A 24-year-old woman presents to your urgent care clinic complaining of nausea and vomiting for the past 4 weeks.
- What additional questions should you ask to determine the severity of her condition?
- Can you narrow the differential diagnosis of her “nausea and vomiting” through your use of open-ended questions followed by more focused queries?
Nausea and vomiting are common symptoms experienced across all age groups. Although they are often manifestations of minor self-limited illnesses, these symptoms may also be harbingers of life-threatening disease. Nausea and vomiting cause significant worldwide reductions in worker productivity and increases in healthcare costs, particularly among pregnant women, patients receiving cancer chemotherapy, and patients recovering from surgery. Nausea is frequently, but not always, associated with vomiting.1
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|Chronic nausea and vomiting||The persistence of the symptoms for > 1 month.|
|Early satiety||The sensation of feeling full after eating an unusually small amount of food.|
|Nausea||The unpleasant sensation of the imminent need to vomit that may or may not ultimately lead to actual vomiting.|
|Postchemotherapy nausea and vomiting (PCNV)||3 types: acute, within 24 hours; delayed, after 24 hours later; and anticipatory, just before the next chemotherapy dose.|
|Recurrent vomiting||3 or more episodes.|
|Regurgitation||The passive retrograde flow of esophageal contents into the mouth without the muscular activity associated with vomiting and without antecedent nausea.|
|Retching||The “dry heaves.” Spasmodic respiratory movements against a closed glottis with contractions of the abdominal musculature without expulsion of any gastric contents. Retching often immediately precedes vomiting.|
|Rumination||Chewing and swallowing of regurgitated food that has come back into the mouth through a voluntary increase in intra-abdominal pressure within minutes of eating or during eating.|
|Vomiting||The forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature.|
The initial differential diagnosis of nausea and vomiting is broad but may be narrowed significantly by the clinical context.
The evaluation of an infant or young child who has acute vomiting merits special consideration. For instance, the possibility of a toxic ingestion is much more likely in a child than an adult. Despite a declining incidence, Reye's syndrome remains a consideration in an acutely vomiting child who has had a recent viral infection (and has been given aspirin products).
Similarly, the differential diagnosis for a recurrently vomiting infant or young child should be expanded to include congenital abnormalities (eg, malrotation, pyloric stenosis, esophageal atresia). Remember, vomiting in infants may simply be regurgitation due to physiologic gastroesophageal reflux.
A positive family history along with associated neurologic symptoms should raise suspicion for inherited metabolic dis-orders (eg, urea cycle enzyme deficiencies, Wilson's disease) or neurogastrointestinal disorders (eg, cyclic vomiting syndrome).