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The vomiting history is similar to cough – it is a symptom which has an onset, timing etc. but also we need details about the physical content of the vomit.
So what are some differentials for vomiting?
Neurological
- Tumour
- Raised ICP
- Idiopathic intracranial hypertension
- Hydrocephalus
- Bleed
Infection
- Gastroenteritis
- Infective colitis
Malignancy
- Gastric cancer
- GI cancer
GI
- Pancreatitis
- Bowel obstruction
- Oesophageal varices
- Peptic ulcers
- Alcohol/gastritis
It is very important to screen the abdominal system right from top to bottom. Notice how vomiting with constipation is more likely to suggest bowel obstruction, compared to with diarrhoea (more likely food poisoning). Unexplained vomiting on its own should prompt checking the neurological system for raised intracranial pressure.
Introduction
- Good afternoon, my name is _______ and I am one of the student doctors here. Is it _______(patient’s name)?
- I just wanted to ask you some questions about how you are feeling and what has brought you in to see the doctor today, and then I’ll take that information, relay it to the consultant and we can go from there.
- Before I start, are you comfortable or would you likely me to get you anything? Do you mind if I take a seat?
- So, what has brought you in to see the doctor today?
(P) Presenting Complaint
- Summarise patient’s answer and ask first screening question) – Apart from this, have you noticed anything else?
- (Ask second screening question) – Ok, anything else?
- (Ask third screening question) – Before talking more about your [symptom], are there any other symptoms?
- (Last screening question) – Are you sure that there is nothing else?
- (Once we are sure there are no other questions, we can now address each symptom in turn) – Now I just want to ask some questions about the symptoms you have been feeling? Go through each symptom using OATES or SOCRATES for pain
- Vomiting – So you mentioned that you have experienced some vomiting, can you tell me a little bit more?
| Onset | When did these this start? Is there anything that triggered this, like something you ate? |
| Associations | Is this associated with any other symptoms? |
| Time | How many times has this happened? |
| Exacerbations | Is there anything which makes this better/worse? |
| Specifics | Quantity: How much did you throw up? Colour: What colour was it? Blood: Are you vomiting any blood? Mucus: Are you vomiting any mucus? |
- Abdominal pain – Ok, so you mentioned that you have experienced some tummy pain, can you tell me a little bit more?
| Site | With regards to the pain, where exactly is it? Can you point with one finger |
| Onset | When did it first begin? Did it come on slowly or quickly? Can you remember what you were doing when it first came on? Is there anything that triggered this? |
| Character | Could you describe the pain for me? |
| Raditation | Does the pain spread anywhere? |
| Associations | Are there any other symptoms which are associated with this pain? |
| Time | Is it there all the time, or does it come and go? (If fluctuates, how long does it last?) |
| Exacerbations | Is there anything which makes it better, like lying still/going to the toilet? Is there anything which makes it worse? Does it hurt when you press it? |
| Severity | If you were to rate it on a scale of 1-10, how bad is the pain? |
(I) Ideas, Concerns, Expectations
- Ok, you have been feeling these symptoms for some time, do you have any idea of what it could be?
- Are you particularly concerned about anything?
- What were you hoping to get out of the visit today?
(S) Systems Review
- (In response to them telling you their expectation from today’s visit) Ok, in order to do that, first I would like to ask you a few more specific questions just to get a more accurate picture of why you might be experiencing these symptoms.
Specific Systems Review
- Upper GI:
Oesophagus: does it hurt when you swallow? Have you experienced any heartburn?
Bowels: Have you got any diarrhoea? Are you constipated?
- Neurological (if signs of raised ICP):
Have you got any headaches?
Any problems in your vision?
Have you had any weakness or changes in sensation in your arms or legs?
General Systems Review: (Ask general questions to rule out red flags):
(Fever) Have you got a fever?
(Glands) Have you got any swollen glands?
(Weight) Have you noticed any weight loss?
(Appetite) Have you noticed any changes in your appetite?
(Bowels) Have you experienced any changes in your bowel movements?
(Waterworks) Are your waterworks all fine?
(Tired) Have you been feeling more tired than usual?
(Travel) Have you travelled anywhere recently?
(Night sweats) Do you wake up in the night drenched in sweat?
(Rash) Have you got any rashes?
(If woman, and abdominal pain, enquire about pregnancy) Are you on the contraceptive pill? Is there a chance you could be pregnant?
(P) Past Medical History
- And now, about your health in general, have you ever seen your doctor about something like this before?
- Do you have any other medical conditions, such as diabetes, blood pressure or asthma?
- Have you ever had any surgeries?
- Have you ever been admitted into hospital before?
(F) Family History
- Is there any incidence of tummy conditions in your family?
- Are there any other conditions which run in your family?
(D) Drug History
- Are you currently taking any prescribed medication?
- Do you take anything else, over the counter?
- Do you have any allergies?
(S) Social History
- (Work) And now, a little but more about yourself in general, do you work at the moment? What do you do?
- (Home) Do you live with any family or friends? Are you married? Do you have any children?
- (Independence) Would you say that you are fairly independent?
And now these are some questions that we ask everyone:
- Do you smoke? (Have you ever smoked? / When did you start? / How many a day?)
- Do you drink? (How much a week? And for how long?)
- Is there any recreational drug use?
