Nausea and vomiting (oxford clin cases) Flashcards
What are some vestibular causes of nausea and vomitting?
Menieres
Motion sickness
BPPV
Labyrinthitis
What are some chemoreceptor trigger zone causes of nausea and vomiting?
Medication Alcohol Hormones Electrolytes Toxins
What are some CNS causes of nausea and vomiting?
Pain Anxiety Raised ICP Meningitis Encephalitis
What are some abdominal/cardiac causes of nausea and vomiting?
GI obstruction
GI infection
Inflammation of the diaphragm
Inflammation of the liver, gallbladder, pancreas, peritoneum
If vomit is undigested what may be the cause?
Oesophageal eg achalasia or pahryngeal puch
If vomit is partially digested what may be the cause?
Gastric outlet obstruction
Delayed stomach emptying
What patients is delayed stomach emptying seen in?
Those with diabetes
If vomit has bile in it what may be the cause?
Small bowel obstruction
If vomit is foul looking what may be the cause?
Distal/ colonic obstruction
What is the one situation you will see faeces being vomitted?
When someone has a gastrocolonic fistula
If vomit is of a very large volume what may be the cause?
It is not likely to be caused functionally
What is early morning vomiting typical of?
Pregnancy and raised ICP
If someone is vomiting for a long duration what pathology is unlikely?
Bowel obstruction
What pathology does vomiting within in hour of eating suggest? What should you ask about if this is the case?
Proximal obstruction of the GI tract- if this is the case ask about peptic ulcer disease as it may have caused scarring or stenosis
If someone feels relief after vomiting what does this suggest?
Obstruction
What pathology does vomiting after a while of eating suggest?
Distal GI obstruction
What does fever with vomitting indicate might be pathologically going on?
Infection or inflammation
What neurological symptoms might you see alongside nausea and vomitting?
Headache Visual disturbance Limb weakness Cranial nerve palsy Paraesthesia
What is the likely diagnosis if someone has vertigo alongside nausea and vomiting?
Menieres
BPPV
Labyrinthitis
What does a delay or absolute constipation alongside nausea and vomiting suggest?
Bowel obstruction
What does diarrhoea alongside vomiting suggest?
Infectious gastroenteritis
What should you ask about in terms of bowel movements when someone has nausea and vomitting?
Faeces and flatus
When was the last time they passed any
What did the faeces look like/ was there any change from usual
What should you ask about to investigate if the patient has been exposed to infectious bowel pathogens?
Have any of their close contacts been vomiting eg family/ housemates/ friends
Have they travelled anywhere foreign recently
Do they live in close quarters eg hospitals, army barracks
Have they had any unusual meals recently
If a young female presents with nausea and vomiting what is the first thing to consider?
Pregnancy
What are differentials if someone has nausea and vomiting thats acute, abdominal pain present and fever?
Gastroenteritis Food poisoning Appendicitis Cholecystitis Pancreatitis
What are differentials if someone has nausea and vomiting thats acute, abdominal pain present but no fever?
DKA Small bowel obstruction Side effect of drugs Toxins Large bowel obstruction Mesenteric ischaemia MI Pain from kidney stones, testicular etc
What are differentials if someone presents with chronic nausea and vomiting with weight loss?
Upper GI obstruction- cancer or mechanical
Coeliac disease
What are differentials if someone presents with chronic nausea and vomiting without weight loss?
Oesophagitis
Pharyngeal pouch
Why may a patient who is vomiting lots loose conciousness?
Due to dehydration
What are differentials if someone presents with nausea and vomiting and has altered conciousness?
DKA
Meningitis
Raised ICP
What are differentials when someone presents with nausea/vomiting and haematemesis?
Bleeding peptic ulcer
Oesophageal varices
What are the 6 fs that can cause abdominal distention?
Fat Fluid Faeces Fetus Fat tumor Flatus
What will tenderness of the abdomen suggest as opposed to guarding/rigidity?
Tenderness= inflammation somewhere Guarding/rigidity= peritonitis
What are some peripheral signs of dehydration?
Cold peripheries
Reduced cap refil time
What happens to urea level when someone is dehydrated and why?
It may be raised due to hypoperfusion of the kidneys
What must you always remember when analysing amylase levels?
They might not be raised even if someone does have pancreatitis, therefore it cannot be used to diagnose or rule out but it is used to support your differentials
What may you see on chest x-ray when someone present with nausea and vomiting and why?
Air under the diaphragm due to perforation of bowel
How do you do an erect chest x ray after someone presents with nausea and vomiting?
Sit them up for 10 mins to allow air to migrate upwards then do the x ray
What other useful investigations might you do that aren’t first line and why
Pregnancy test- if the patient is female, fertile and sexually active
Contrast studies- to find the location of a bowel obstruction if not visible on x ray
Head CT- to look for dilated ventricles or fluid if raised ICP is suspected
Toxicology screen- if accidental or purposeful drug overdose is suspected (remember it has to be drug specific as there is no general toxicology screen)
What will be seen on abdominal x ray if there is small bowel obstruction?
Centrally located loops of distended small bowel with vulvae conniventes
