Nausea and Vomiting Flashcards Preview

Y3 z Oxford Clinical Cases > Nausea and Vomiting > Flashcards

Flashcards in Nausea and Vomiting Deck (38)
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1
Q

Where is the vomiting centre located?

A

Medulla oblongata

2
Q

What are the two main types of receptors found within the vomiting centre?

A

Histamine receptors

Acetylcholine receptors

3
Q

What are the four main inputs to the vomiting centre?

A

Vestibular system
CNS
Chemoreceptor Trigger Zone (CTZ)
Cranial Nerves IX & X

4
Q
List some causes of nausea and vomiting for each of the four mechanisms below:
Vestibular system 
CNS
Chemoreceptor Trigger Zone (CTZ)
Cranial Nerves IX & X
A
- Vestibular System - vertigo
BPPV
Meniere’s disease 
Labyrinthitis 
Motion sickness
- CNS – brain problems 
Pain 
Anxiety
Raised ICP 
Meningitis/Encephalitis
- CTZ – chemicals in the blood  
Alcohol
Drugs 
Toxins
Electrolytes 
Hormones 
- CN IX & X – abdomen and heart problems 
GI obstruction
GI infection
Inflammation of the diaphragm
Infection/Inflammation of organs (e.g. hepatitis, pancreatitis)
5
Q

List some key features of the history of presenting complain that you should ask about.

A

Contents
Timing
Association with eating
Pain

6
Q

Describe different types of vomit and how they relate to their aetiology.

A

Undigested – the food hasn’t reached the stomach, probably an oesophageal problem
Partially digested – gastric outlet obstruction, gastroparesis
Bile – SBO distal to ampulla of Vater
Faeculent – distal intestinal or colonic obstruction
Blood/coffee-ground – haematemesis causes

7
Q

Which causes of nausea and vomiting are associated with early-morning vomiting?

A

Raised ICP

Pregnancy

8
Q

Explain how the association between the nausea/vomiting and eating helps narrow down the differential diagnosis.

A

Within 1 hr of eating = high GI obstruction (proximal to gastric outlet)
Longer, post-prandial delay = lower GI obstruction
Early satiety, post-prandial bloating and abdominal discomfort = gastroparesis or outlet obstruction

9
Q

List some important associated symptoms to ask about.

A

Fever
Headache, visual disturbance, focal neurological deficits
Vertigo

10
Q

Explain how asking about the patient’s bowel movements can help narrow the differential diagnosis.

A

Absolute constipation – bowel obstruction

Diarrhoea – suggests gastroenteritis

11
Q

List some risk factors for infectious diarrhoea.

A

Close contacts with similar symptoms
Living in close quarters
Unusual meals
Recent travel

12
Q

List some drugs/toxins that are associated with causing nausea and vomiting.

A

Medications (e.g. opiates, chemotherapy)
Industrial chemicals (e.g. arsenic, organophosphates)
Alcohol and drugs

13
Q

Why is it important to enquire about previous abdominal surgery?

A

Previous abdominal surgery increases the risk of forming adhesions, which can lead to bowel obstruction

14
Q

How can the causes of chronic nausea and vomiting be subdivided?

A
- Weight loss 
Upper GI obstruction (e.g. cancer) 
Functional dysphagia (e.g. achalasia)
Coeliac disease 
- No weight loss 
Oesophagitis 
Pharyngeal pouch
15
Q
List some causes of nausea and vomiting that are associated with:
Abdominal Pain
Headache
Vertigo
Onset shortly after eating food
None of the above
A
- Abdominal Pain
With fever: infection (e.g. gastroenteritis), inflammation (e.g. appendicitis, cholecystitis) 
Without fever: DKA, SBO, drug side-effects, toxins
- Headache
Meningitis 
Raised ICP 
Migraine 
- Vertigo
Labyrinthitis 
Meniere’s disease 
BPPV
Motion sickness
- Onset shortly after eating food
Gastric outlet obstruction
- None of the above
Drug side-effect 
Psychogenic 
Hyperthyroid
Renal failure + uraemia
16
Q

List some particularly worrying signs that are associated with nausea and vomiting.

A
Peritonitis (guarding, motionless, rigid abdomen, absent bowel sounds)
Signs of bowel obstruction
High fever (infection)
Signs of raised ICP 
Signs of MI 
Signs of meningitis 
Reduced consciousness 
Haematemesis
17
Q

List some signs of meningitis.

A

Photophobia
Neck stiffness
Headache
Kernig’s sign (when the hip is flexed, there is resistance against knee extension)
Brudzinski’s sign (flexion of the neck causes flexion of the hip)

18
Q

List some key features of inspection when performing an abdominal examination on a patient presenting with nausea and vomiting.

A
Hydration status (vomiting can lead to dehydration)
Abdominal distension 
Scars 
Hernias 
Jaundice
19
Q

List two important signs that may be picked up on auscultation of the abdomen.

A

Absent bowel sounds –> ileus

Tinkling bowel sounds –> obstruction

20
Q

List some blood tests that would be undertaken in a patient presenting with nausea and vomiting and explain why they would be performed.

A

FBC and CRP – high WCC and CRP in infection
U&Es – vomiting can cause derangement of electrolyte levels
LFTs – check for hepatobiliary cause of nausea/vomiting
VBG – check lactate and pH to get an idea of how sick the patient is
Amylase – rule out pancreatitis
Group and save

21
Q

List two forms of imaging that may be useful in patients with nausea and vomiting.

A

AXR

Erect CXR

22
Q

How are the small and large bowel differentiated on an AXR?

A

Small bowel – valvulae conniventes, 3 cm diameter

Large bowel – haustra, 6 cm diameter

23
Q

Which test is important to consider in young female patients presenting with nausea and vomiting?

A

Pregnancy test

24
Q

Outline the management of a patient with acute abdomen.

A

Nil-by-mouth
Drip and suck
Analgesia
Anti-emetics

25
Q

Which anti-emetic must you take caution with when using in a patient with acute abdomen?

A

Metoclopramide – it has a prokinetic effect on the GI tract

26
Q

Which form of imaging is useful in a patient with suspected bowel obstruction?

A

CT scan – allows localisation of the obstruction and identification of a cause

27
Q

Under what circumstances is surgery indicated in patients with bowel obstruction?

A

Signs of strangulation or peritonism
After 48 hrs if it hasn’t resolved
No history of previous abdominal surgery – this suggests that there may be a more sinister cause (not adhesions)

28
Q

Describe the typical presentation of gastroenteritis.

A

Nausea, vomiting, diarrhoea, fever and abdominal pain

Last a matter of days and resolves by itself

29
Q

What does ketonuria in a patient without diabetes suggest?

A

Starvation

30
Q

How can food poisoning be differentiated from gastroenteritis?

A

Food poisoning is caused by bacterial toxins

Symptoms don’t tend to persist longer than 24 hrs

31
Q

Describe the typical presentation of DKA.

A
Drowsy
Polyuria/Polydipsia
Abdominal pain
Nausea and vomiting 
If severe: Kussmaul breathing, reduced consciousness
32
Q

Outline the management of DKA.

A

IV fluids to rehydrate
IV insulin (sliding scale)
Monitor capillary ketones and serum K+ concentration
Switch to subcutaneous insulin once pH and capillary ketones have normalised

33
Q

When does morning sickness typically affect pregnant women?

A

First trimester

34
Q

Outline the management of morning sickness.

A

Advise dietary changes (e.g. avoiding spicy food)
Anti-emetics (e.g. promethazine)
Electrolyte replacement
Thiamine supplementation

35
Q

What term is used to describe severe morning sickness?

A

Hyperemesis gravidarum

36
Q

List some strong anti-emetics that may be used in such cases of severe morning sickness.

A

Prochlorperazine
Chlorpromazine
Ondansteron
Metoclopramide

37
Q

Describe the distinguishing clinical features of raised ICP.

A

Early morning nausea and vomiting

Headaches worse when lying down

38
Q

Which cranial nerve palsy is most commonly involved in raised ICP and why?

A

CN VI – it has the longest intracranial course