History
A detailed history and physical exam are crucial in evaluating patients with nausea and vomiting and in determining the underlying cause of nausea and vomiting. Acute vomiting without abdominal pain is usually self-limiting and does not require further evaluation.
Nausea & Vomiting_Initial Assesment
Determine the duration, frequency, and severity of nausea and vomiting. Nausea and vomiting are considered chronic when they last >1 month. Determine when vomiting occurs during the day (timing) and the characteristics of the vomiting process itself. An example is projectile vomiting, which may suggest an increased intracranial pressure (ICP) resulting from an intracranial problem. Elicit information about the onset of vomiting, ie relation to meals. Investigate the quantity and quality of the vomitus. Ask if vomitus consists of undigested, partially digested, or bilious material, which suggests gastric obstruction or gastroparesis. Ask about a possible fecaloid character of the vomitus or a putrid odor, which is characteristic of small intestinal obstruction.
Ask about associated symptoms, as these may assist in localizing the underlying disease process, such as: Abdominal pain, diarrhea, fever, weight loss, and CNS symptoms such as headache, focal neurologic deficits, neck stiffness, or vertigo. Inquire on the presence of a similar illness in the patient’s family and/or friends. Ask about concomitant illnesses. The patient may be suffering from nausea and vomiting related to treatment, ie chemotherapy-related nausea and vomiting. Pregnancy should be excluded.
Physical Examination
Search for signs of dehydration or weight loss, such as orthostatic hypotension and postural increase in pulse rate. Search for findings that may suggest autonomic neuropathy, such as postural decrease in blood pressure (BP) without a concomitant increase in pulse rate. Conduct a careful abdominal examination. Ascertain if there is abdominal tenderness, together with its specific location. Listen for decreased bowel sounds and palpate for abdominal masses.
Conduct a detailed neurologic and psychiatric exam. Check for cranial nerve abnormalities, gait problems, funduscopic changes, and other relevant information. The rest of the systemic physical exam may also provide other helpful information with regard to the etiology of nausea and vomiting. Findings suggestive of autonomic neuropathy may be found. A thorough exam may reveal signs of systemic diseases causing nausea and vomiting. Evidence of self-induced vomiting may also be apparent.
Screening
Categories of Vomiting by Clinical Course and Presence of Abdominal Pain
Acute with Severe Abdominal Pain
Exclude surgical disorders such as gastric or intestinal obstruction, perforated viscus, appendicitis, biliary disease, pancreatitis, mesenteric ischemia, and acute ischemia (cardiac).
Acute without Abdominal Pain
Consider non-surgical disorders such as pregnancy, myocardial infarction, food poisoning, viral or bacterial gastroenteritis, hepatitis, upper GI bleeding, hyperglycemia, diabetic ketoacidosis, acute renal failure, adrenal insufficiency, hypothyroidism, CNS trauma, acute CNS disease, meningitis, migraine headache, vestibular neuritis, motion sickness, postoperative ileus, and medications (including chemotherapy).
Chronic with Intermittent or Recurrent Abdominal Pain
Exclude disorders causing intermittent or partial luminal obstruction, such as peptic disease, gastric or pancreatic malignancy, Crohn's disease, radiation, neoplasm, and chronic intestinal pseudo-obstruction.
Chronic without Intermittent or Recurrent Abdominal Pain
Consider non-surgical disorders such as chronic renal failure, cardiac disease, hypothyroidism, diabetes, neuromuscular disorders, labyrinth disorders, subdural hematoma, tumors, hydrocephalus, psychiatric disease, eating disorders, gastroparesis, cyclical vomiting syndrome, functional disorders, medications, cannabinoids, and pregnancy.