Nausea and vomiting (oxford clin cases)

Question 1

What are some vestibular causes of nausea and vomitting?

Answer 1

Menieres
Motion sickness
BPPV
Labyrinthitis

Question 2

What are some chemoreceptor trigger zone causes of nausea and vomiting?

Answer 2

Medication
Alcohol
Hormones
Electrolytes
Toxins

Question 3

What are some CNS causes of nausea and vomiting?

Answer 3

Pain
Anxiety
Raised ICP
Meningitis
Encephalitis

Question 4

What are some abdominal/cardiac causes of nausea and vomiting?

Answer 4

GI obstruction
GI infection
Inflammation of the diaphragm
Inflammation of the liver, gallbladder, pancreas, peritoneum

Question 5

If vomit is undigested what may be the cause?

Answer 5

Oesophageal eg achalasia or pahryngeal puch

Question 6

If vomit is partially digested what may be the cause?

Answer 6

Gastric outlet obstruction

Delayed stomach emptying

Question 7

What patients is delayed stomach emptying seen in?

Answer 7

Those with diabetes

Question 8

If vomit has bile in it what may be the cause?

Answer 8

Small bowel obstruction

Question 9

If vomit is foul looking what may be the cause?

Answer 9

Distal/ colonic obstruction

Question 10

What is the one situation you will see faeces being vomitted?

Answer 10

When someone has a gastrocolonic fistula

Question 11

If vomit is of a very large volume what may be the cause?

Answer 11

It is not likely to be caused functionally

Question 12

What is early morning vomiting typical of?

Answer 12

Pregnancy and raised ICP

Question 13

If someone is vomiting for a long duration what pathology is unlikely?

Answer 13

Bowel obstruction

Question 14

What pathology does vomiting within in hour of eating suggest? What should you ask about if this is the case?

Answer 14

Proximal obstruction of the GI tract- if this is the case ask about peptic ulcer disease as it may have caused scarring or stenosis

Question 15

If someone feels relief after vomiting what does this suggest?

Answer 15

Obstruction

Question 16

What pathology does vomiting after a while of eating suggest?

Answer 16

Distal GI obstruction

Question 17

What does fever with vomitting indicate might be pathologically going on?

Answer 17

Infection or inflammation

Question 18

What neurological symptoms might you see alongside nausea and vomitting?

Answer 18

Headache
Visual disturbance
Limb weakness
Cranial nerve palsy
Paraesthesia

Question 19

What is the likely diagnosis if someone has vertigo alongside nausea and vomiting?

Answer 19

Menieres
BPPV
Labyrinthitis

Question 20

What does a delay or absolute constipation alongside nausea and vomiting suggest?

Answer 20

Bowel obstruction

Question 21

What does diarrhoea alongside vomiting suggest?

Answer 21

Infectious gastroenteritis

Question 22

What should you ask about in terms of bowel movements when someone has nausea and vomitting?

Answer 22

Faeces and flatus
When was the last time they passed any
What did the faeces look like/ was there any change from usual

Question 23

What should you ask about to investigate if the patient has been exposed to infectious bowel pathogens?

Answer 23

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

Question 24

If a young female presents with nausea and vomiting what is the first thing to consider?

Answer 24

Pregnancy

Question 25

What are differentials if someone has nausea and vomiting thats acute, abdominal pain present and fever?

Answer 25

``` Gastroenteritis Food poisoning Appendicitis Cholecystitis Pancreatitis ```

Question 26

What are differentials if someone has nausea and vomiting thats acute, abdominal pain present but no fever?

Answer 26

``` DKA Small bowel obstruction Side effect of drugs Toxins Large bowel obstruction Mesenteric ischaemia MI Pain from kidney stones, testicular etc ```

Question 27

What are differentials if someone presents with chronic nausea and vomiting with weight loss?

Answer 27

Upper GI obstruction- cancer or mechanical | Coeliac disease

Question 28

What are differentials if someone presents with chronic nausea and vomiting without weight loss?

Answer 28

Oesophagitis | Pharyngeal pouch

Question 29

Why may a patient who is vomiting lots loose conciousness?

Answer 29

Due to dehydration

Question 30

What are differentials if someone presents with nausea and vomiting and has altered conciousness?

Answer 30

DKA Meningitis Raised ICP

Question 31

What are differentials when someone presents with nausea/vomiting and haematemesis?

Answer 31

Bleeding peptic ulcer | Oesophageal varices

Question 32

What are the 6 fs that can cause abdominal distention?

Answer 32

``` Fat Fluid Faeces Fetus Fat tumor Flatus ```

Question 33

What will tenderness of the abdomen suggest as opposed to guarding/rigidity?

Answer 33

``` Tenderness= inflammation somewhere Guarding/rigidity= peritonitis ```

Question 34

What are some peripheral signs of dehydration?

Answer 34

Cold peripheries | Reduced cap refil time

Question 35

What happens to urea level when someone is dehydrated and why?

Answer 35

It may be raised due to hypoperfusion of the kidneys

Question 36

What must you always remember when analysing amylase levels?

Answer 36

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

Question 37

What may you see on chest x-ray when someone present with nausea and vomiting and why?

Answer 37

Air under the diaphragm due to perforation of bowel

Question 38

How do you do an erect chest x ray after someone presents with nausea and vomiting?

Answer 38

Sit them up for 10 mins to allow air to migrate upwards then do the x ray

Question 39

What other useful investigations might you do that aren't first line and why

Answer 39

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)

Question 40

What will be seen on abdominal x ray if there is small bowel obstruction?

Answer 40

Centrally located loops of distended small bowel with vulvae conniventes