Nausea
Age: years old
Gender:
HISTORY:
Presents with a - history of nausea
Severity of nausea is
Occurs most frequently during the
Worsening factors:
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, , ,
, episodes ,
, over ,
, up to °, over
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Contributing factors:
no history of: , , , , ,
no use of: , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Anorectal: DRE , prostate , , , anus
Extremities: , , cap refill sec, pulses , ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
ASSESSMENT:
DDx: gastroenteritis, food poisoning, appendicitis, gastritis, GERD, pyloric stenosis, small bowel obstruction, urinary tract infection, concussion, intracranial pressure, metabolic disorders, medication side effects, toxin exposure, motion sickness, migraine, intussusception, pancreatitis, diabetic ketoacidosis, adrenal insufficiency, sepsis, meningitis, COVID-19, psychogenic vomiting, cannabinoid hyperemesis syndrome, pregnancy, hepatic disorders, renal disorders, psychological factors
PLAN:
Investigations:
- Blood work: , , , , , , ,
- Urinalysis
- Abdominal ultrasound
- Upper GI endoscopy
- CT scan of the abdomen
Treatments:
- Dietary modifications: , , , ,
- Stop offending medications
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-
-
-
Further care:
- Referral to gastroenterologist
- Follow-up in
- Return if nausea persists, if new symptoms develop such as vomiting, weight loss, or abdominal pain, or if condition worsens
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: