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Probability diagnosis

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All ages: acute gastroenteritis, motion sickness, drugs, various infections

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Neonates: feeding problems

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Children: viral infections/fever, otitis media, UTI

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Adults: gastritis, alcohol intoxication, pregnancy, migraine

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Serious disorders not to be missed

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Bowel obstruction:

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  • oesophageal atresia (neonates)

  • pyloric obstruction <3 months

  • intestinal malrotation

  • intussusception

  • malignancy (e.g. oesophagus, stomach)

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Infection:

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  • botulinum poisoning

  • septicaemia

  • meningitis/encephalitis

  • infective endocarditis

  • others (e.g. acute viral hepatitis)

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Malignancy

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Intracranial disorders: malignancy, cerebellar

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haemorrhage, PICA infarction

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Acute appendicitis

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Acute pancreatitis

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Acute myocardial infarction (e.g. painless)

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Pitfalls (mainly adults)

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Pregnancy (early)

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Organ failure: liver, kidney (uraemia), heart, respiratory

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Labyrinthine disorders: Meniere syndrome, labyrinthitis

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Poisoning: food, chemicals

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Gut motility disorders: achalasia

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Paralytic ileus

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Substance abuse (e.g. opioids, ecstasy)

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Radiation therapy

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Hypercalcaemia

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Functional obstruction: diabetic gastroparesis, idiopathic gastroparesis

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Masquerades checklist

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Depression (possible)

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Diabetes (ketoacidosis)

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Drugs (multiple)

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Anaemia (possible)

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Thyroid and other endocrine disorders (Addison disease)

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UTI esp. pyelonephritis

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Is the patient trying to tell me something?

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Possibly: extreme stress and anxiety (e.g. panic attacks). Consider bulimia (self-induced vomiting) and functional (psychogenic).

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Key history

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Nausea and vomiting have a wide range of potential causes emanating from every body system. A careful history is essential with an emphasis on drug intake, possible psychogenic factors including self-induced emesis, weight loss, other GIT symptoms or symptoms suggestive of systemic disease.

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Key examination

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  • If fever is present possible sources of infections (e.g. middle ear, urinary tract and meninges) should be checked

  • A careful abdominal examination is appropriate in most instances, searching for scars indicative of previous surgery

  • Consider a neurological examination

  • Be mindful of the possibility of pregnancy

  • Always assess the patient’s condition including the level of hydration

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Key investigations

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Look for the cause and also consider biochemical abnormalities resulting from fluid and electrolyte loss. Consider:

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  • pregnancy test

  • urine analysis and MC

  • stool MC

  • endoscopy

  • drug toxicity studies

  • blood glucose

  • radiology of GIT.

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Diagnostic tips

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The common cause of acute nausea and vomiting in most age groups is gastroenteritis.

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  • Drug ingestion is a common cause of nausea and vomiting so check for prescribed drugs and illicit street drugs such as heroin and ecstasy.

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