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-=-=-=-=-=> [這篇文章最後由JuanFe在 2018/05/11 07:13pm 第 1 次編輯] VOMITING doorway information about patient Patient is a 25-year-old woman who comes to the clinic due to vomiting vital signs . Temperature : 36.7’C . Blood pressure 110/70 mmHg . Pulse : 80 / min . Respirations : 14/ Min Approach to the patient Vomiting is the involuntary , forceful expulsion of gastric contents . when evaluating a patient with vomiting ,, first clarify the patient is not expecting reflux (non forceful retrograde passage of gastric contents) or regurgitation (pharyngeal return of esophageal contents ) Chronic or severe vomiting can impair adequate intake of food an fluid m and lead to complications . However , many cases of acute vomiting are self-limited and may require minimal or no diagnostic testing . Therefore , the objective of the evaluation is to identify associated symptoms (eg. abdominal pain , fever , gastrointestinal bleeding ) or complications (eg, dehydration , acidosis) that may necessitate additional evaluation. Be ware of that the evaluation of vomiting differs significantly by the setting of care. Patient with chronic or mild intermittent vomiting are more likely to be seen in the clinic whereas with severe , acute vomiting are more likely to come to the emergency department. Differential diagnosis Acute vomiting with diarrhea is usually due to either acute (vial ) gastroenteritis or food-borne enteric illness (eg. staphylococcal or Bacillus cereus food poisoning) . However , vomiting can be due to disorders in virtually any system , and a detailed medical history and review of system any be needed to identify the sources . other common darers that cause vomiting in adults include : . Gastrointestinal : gastric outlet or intestinal obstruction , cholecystitis , appendicitis , pancreatitis , peptic ulcer , liver disease. . Cardiovascular : acute myocardial ischemia , mesenteric ischemia . respiratory : legionnaire’s disease . Genitourinary/ reproductive : pyelonephritis , kidney failure , pregnancy . Endocrine : adrenal insufficiency , diabetic ketoacidosis . Ophthalmic : ankle - closure glaucoma . Vestibular : motion sickness , vestibular neuritis . Psychiatric ; anxiety , eating disorders . Multisystem : toxin ingestion , medication History an physical examination HISTORY . please describe what you are experiencing . . When did the vomiting start ? . Are you throwing up any blood ? are you passing any blood in your stool ? . Do you have any abdominal pain ? . Any diarrhea or constipation ? . Any fever or chills? Headache? . Any burning with urination ? . Have you lost any weight recently ? . Have you had problems like this before ? . Did you eat at a restaurant or eat leftover food prior to this illness ? Is anyone else who ate the same thing sick? . Is anyone around you sick ? . When was your last menstrual period ? is there a chance you could be pregnant? PAST MEDICAL HISTORY . Have you been diagnosed with any other medical conditions? . Have you had any surgeries (especially abdominal surgeries )? MEDICATIONS . Do you take any medications (prescription and over-the counter)? SOCIAL HISTORY . Do you smoke ? at what age did you start, and how much do you smoke ? . Do you drink alcohol ? How much , and how often ? . Have you used recreational drugs ? PHYSCIAL EXAMINATIONS General . Assess level of alertness Vital signs . Check for orthostatic hypotension if not already given in vital signs. HEENT . Examine oropharynx for dry mucous membranes . . Examine funds suspecting increased intracranial pressure . Heart . Auscultation for murmurs , gallops , and rubs Abdomen . Inspect ofr distension . Auscultate for bowel sounds. . Percuss for bowel gas pattern. . Palpate for tenderness . . Examine for costovertebral tendernes Colin the encounter At the conclusion of the encounter , describe any notable examination findings , discuss the differential diagnosis ,and explain the need for any diagnostic testing . If invasive studies 9eg. esophagogastroduodenoscopy) are needed. explain the procedure and obtain the patient’s permission before proceeding . be sure to leave adequate time to answer patient questions . Diagnostic studies Stable patients with gastroenteritis or otters benign cases of vomiting (eg, migraine ) may require no diagnostic testing . Woman of child-bearing potential should have pregnancy test .other studies to consider include: . Complete bold count ( and differential ) . Serum electrolytes . Blood glucose . Blood era nitrogen and creatinine . Liver function panel . Lipase (prefer over amylase ) . Urinalysis (and culture) . Abdominal x-rays (flat and upright if obstruction is suspected ) -=-=-=-=-=>
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