Anyone with nausea or vomiting may not be allowed inside a building without a Covid Test. But some patients need to be seen no matter what; every office or clinic has its own mechanism, maybe in a designated exam room, maybe sending them to an Urgent Care or E.R. If there are no other symptoms besides nausea or vomiting, Covid-19 is very unlikely. The rest of this topic assumes Covid is not a possibility.
1. Determine if there’s Dehydration (give IV fluids if significant)
- Not urinating in 6-8 hours (12-24 hours is severe)
- Pulse rate rises from lying down to abrupt standing (see Postural Vital Signs)
- ALERT — If dehydrated patient improves with rehydration (IV fluids), must maintain close follow-up to be sure there’s no subsequent worsening. See Precautionary Tale.
2. Seek Clues to Underlying Cause of N/V by history & exam:
- Diarrhea — Gastroenteritis (see topic Diarrhea)
- Fever — Pneumonia, Kidney Infection, Sepsis, Other Infection (see topic Fever)
- Abdominal pain — see topic Abdominal Pain to structure diagnostic thought process
- Missed / Irregular / Unusually Light Menstrual Period — test for Pregnancy
- Bloody / Coffee-ground-like vomit or Black Stools (“melena”) — Ulcer / Gastritis
- Known Diabetes / Very Thirsty (drinking lots, urinating lots) — Diabetic Ketoacidosis
- Prominent “Other Symptom” (Headache, etc) — use that to structure diagnostic thought process
- Heavy Alcohol — Pancreatitis; Alcoholic Hepatitis
- Immunocompromised — Needs many tests (see #4 below), maybe send to E.R. to rule-out Sepsis
If looks sick / confused, & not dehydrated (or no improvement with IV fluids) → we send to E.R.
xxxx** Needs same-day work-up, see #4 below
3. Diagnosis if no significant symptom or clue except N/V:
- Day #1 of N/V: Gastroenteritis (“Staphylococcal food poisoning”)
- Day #2 of N/V: Gastroenteritis due to Rotavirus / Norovirus
- Day #3, if diarrhea becomes prominent, most likely Rotavirus / Norovirus. BUT…
4. >3 Days of N/V, and no / hardly any diarrhea → needs Work-Up
- Urine Pregnancy Test — please see link for unlikely cases
- Complete Blood Count (CBC) — for various serious infections; Anemia
- Urinalysis (for Kidney Infection; Diabetic Ketoacidosis)
- Comprehensive Metabolic Panel (for Hepatitis, Kidney Failure, many possible causes)
- Lipase (for Pancreatitis)
- If looks sick & seen in ER (see #2 above], we do CT scans & sophisticated tests or hospitalization as indicated
5. Follow-Up in 1-2 weeks (call sooner if above tests abnormal)
If no Diagnosis from above tests:
- If symptoms resolved — lower PPI dose & treat for 8 wks.
- If Weight Loss — Abdominal CT Scan and/or Endoscopy
- Ongoing N/V, No Weight Loss, PPI no help → likely Psychological cause
- Seek clues to Bulimia: erosion of tooth enamel, swelling of parotid glands, calluses on the back of the hand (from self-induced vomiting) [see link]
See Nausea / Vomiting — Full Text for more in-depth explanations and discussions.