First, define the vomitus. Is it bloody, bilious or nonbilious, feculent or posttussive? Hematemesis is seen with gastritis, peptic ulcer disease, gastric and esophageal tumors, and Mallory-Weiss tears. Nonbilious emesis occurs with gastric outlet obstruction, as in patients with pyloric strictures secondary to ulcer disease or infants with pyloric stenosis.
Second, determine what symptoms accompany the vomiting. Is the patient febrile? Fever could point toward an infectious or inflammatory source, or it could represent a toxicologic cause, such as salicylate intoxication. Is there associated abdominal pain, back pain, headache, or chest pain that may point to a specific cause? Pancreatitis, cholecystitis, peptic ulcer disease, appendicitis, and pelvic inflammatory disease typically cause abdominal pain. Back pain usually accompanies aortic dissections, rupturing aortic aneurysms, pyelonephritis, and renal colic. Vomiting is one of the signs of increased intracranial or intraocular pressure and may be a foreboding sign in patients complaining of headache. Finally, the complaint of vomiting associated with chest or epigastric pain might suggest a diagnosis of myocardial ischemia. In female patients, obstetric and gynecologic causes of vomiting should always be considered. In a pregnant woman, epigastric pain and vomiting accompanying hypertension may indicate preeclampsia.
Learning more about the patient is as important as defining the illness. What complicating medical conditions does the patient have? Is the patient diabetic? If so, could the vomiting be a manifestation of diabetic ketoacidosis? In a patient with a history of peripheral vascular disease, vomiting may be a sign of mesenteric ischemia. Patients with a history of multiple abdominal surgeries are at risk for intestinal obstruction due to adhesions. Knowledge of the medications to which the patient has access is also critical, since intentional and unintentional poisonings often present first with emesis. Physicians should be suspicious of drug-induced toxicity in patients taking medicines known to have gastrointestinal toxicity (e.g., lithium, digoxin, or theophylline). The social history provides clues, too. Vomiting in a person who enjoys mushroom hunting may well represent Amanita poisoning.
PHYSICAL EXAMINATION Clinical clues may also assist in making the diagnosis. In addition to evaluating the ABCs, much of the physician's initial attention should be directed toward the assessment of hydration status. Severely volume-depleted patients require immediate intervention, lest circulatory collapse be imminent. The abdominal, genitourinary, and pelvic examinations are often revealing. Physicians should search carefully for tenderness, peritoneal signs, hernias, masses, and evidence of obstruction or torsion. The findings of a careful physical examination may point toward unsuspected causes of vomiting, such as bulimia (scars on the dorsum of hands), pneumonia (consolidative findings on lung examination), or Addison's disease (hyperpigmentation). The rectal examination is important. An anal fistula may be the only clue to Crohn's disease in an otherwise healthy teenager with vomiting, or may demonstrate fecal impaction.
Acquire data selectively and smartly. Order diagnostic tests according to the differential diagnosis. In the vomiting, premenopausal woman, consider pregnancy high on the differential diagnosis, and rule it in or out with a pregnancy test. Other laboratory tests that may be of assistance are determination of blood urea nitrogen, creatinine, and amylase levels; liver function tests; determination of blood alcohol and drug levels; and urinalysis. Addisonian crisis can present with vomiting, and the laboratory results may show hyperkalemia and hyponatremia. An electrocardiogram can help if the physician is considering the diagnosis of myocardial ischemia. Chest and abdominal radiography can assist in the determination of the presence or absence of pneumoperitoneum, pneumonia, or intestinal obstruction.
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