Nausea / Vomiting
Nausea is the unpleasant sensation of an urge to vomit, while vomiting is the forceful expulsion of gastric contents through the mouth, both mediated by the brainstem vomiting center in response to various peripheral or central stimuli.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Acute gastroenteritis | Acute onset + diarrhoea + sick contacts / food Hx | 「有冇屙肚？身邊有冇人有同樣嘅情況？食過啲咩嘢？」 | ~35% |
| Drug-induced N/V | Temporal relationship with new medication | 「最近有冇食新藥或者加藥？食咗藥之後幾耐開始嘔？」 | ~15% | |
| Early pregnancy | Reproductive-age female + missed period | 「月經有冇遲到？有冇可能懷孕？」 | ~10% | |
| Serious Not To Miss | Intestinal obstruction (SBO) | Colicky abdominal pain + distension + absolute constipation | 「個肚有冇脹起？有冇放到屁？有冇大便到？」 | ~2% |
| Ectopic pregnancy | Missed period + unilateral pelvic pain + vaginal bleeding | 「月經遲咗，有冇肚痛或者出血？」 | ~1% | |
| Raised ICP (tumour/meningitis) | Projectile vomiting + headache ± papilloedema | 「嘔嘅時候有冇頭好痛？朝早起身特別辛苦？」 | ~1% | |
| Acute MI | Chest pain + nausea + diaphoresis; Bezold-Jarisch reflex [2] | 「有冇胸口痛/翳住？有冇標冷汗？」 | ~1% | |
| DKA | Known DM + polyuria + Kussmaul breathing + ketotic breath | 「你有冇糖尿？有冇飲多咗水、去多咗廁所？」 | ~1% | |
| Acute pancreatitis | Epigastric pain radiating to back + vomiting [3] | 「肚痛有冇攝到去背脊？」 | ~1% | |
| Pitfalls | Gastroparesis | Chronic post-prandial vomiting of undigested food in DM patient | 「食完好耐先嘔出嚟，啲嘢仲未消化？你有冇糖尿？」 | ~3% |
| Bulimia nervosa | Self-induced vomiting, Russell's sign, dental erosion | 「食完嘢之後有冇自己扣喉嘔返出嚟？」 | ~2% | |
| Hypercalcaemia | "Stones, bones, groans, moans" [4] | 「有冇骨痛？便秘？覺得好攰好渴？」 | < 1% | |
| Addison's disease | Fatigue + hypotension + hyperpigmentation + hypoNa/hyperK [5] | 「有冇成日覺得好攰？皮膚有冇變深色？」 | < 1% | |
| Masquerades | Drugs (opioids, digoxin, chemo) | Temporal link to medication | 「食緊嘅藥裏面有冇止痛藥/心臟藥/化療藥？」 | ~15% |
| Depression | Low mood, anhedonia, poor appetite mimicking nausea | 「心情點樣？有冇開心唔到？」 | ~5% | |
| Thyrotoxicosis | Weight loss + heat intolerance + tremor + N/V [7] | 「有冇瘦咗？怕唔怕熱？手有冇震？」 | ~2% | |
| Uraemia (CKD) | Advanced CKD → nausea + anorexia [6] | 「你有冇腎病？」 | ~1% | |
| Trying to Tell Me Something? | Anxiety / psychosocial stress | Work/exam pressure, relationship problems, health anxiety | 「最近有冇咩嘢令你好大壓力？你覺得有冇可能同壓力有關？」 | ~10% |
| Eating disorder | Body image concerns, fear of gaining weight | 「你覺得自己肥唔肥？有冇刻意減肥？」 | ~3% |
Nausea / Vomiting — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport | 「你好，我係X醫生，今日由我同你傾吓，你可以慢慢講，唔使急。」(Hello, I'm Dr X, take your time.) | Interpersonal marks: warm greeting, introduce self |
| 0:30–1:30 | Open-ended chief complaint + HPI | 「咩嘢事嚟睇醫生呀？」→「作嘔定有嘔到出嚟？幾時開始？嘔咗幾多次？嘔出嚟係咩嘢嘅樣？」 | Elicit onset, frequency, nature of vomitus; shows structured history |
| 1:30–3:00 | Symptom analysis + red flags | 「個肚有冇痛？有冇屙血/黑色大便？有冇頭痛/頭暈/眼矇？有冇瘦咗？經期正唔正常？」 | Covers GI, CNS, metabolic, pregnancy red flags |
| 3:00–4:00 | PMHx, drugs, allergy, FHx, social Hx | 「你有冇長期病？食緊咩藥？有冇藥物敏感？屋企人有冇類似嘅病？你有冇飲酒/食煙？做咩工？」 | Completeness of history; drug-induced vomiting is a masquerade |
| 4:00–5:00 | ICE + hidden agenda | 「你自己覺得係咩原因呢？（Idea）最擔心係咩嘢？（Concern）你嚟到係想我幫你做啲咩？（Expectation）」 | Direct ICE marks; uncovers hidden agenda |
| 5:00–5:30 | Summarise + check understanding | 「等我總結一下你嘅情況…我講得啱唔啱？有冇補充？」 | Shows active listening; confirms accuracy |
| 5:30–6:00 | Close: plan + safety net | 「我會幫你安排檢查…如果你嘔血、嘔到食唔到嘢、頭好痛、或者暈咗，就要即刻返急症室。」 | Safe closure; demonstrates safety-netting |
Uncovering the hidden agenda: The patient may present with vomiting but their real worry could be pregnancy, cancer fear, eating disorder, medication side-effects, or work-related stress. Always ask: 「其實今日特別嚟係有冇咩嘢令你好擔心？」(Is there something specific worrying you today?)
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & duration | Acute ( < 1 wk) or chronic? | 「幾時開始？超過一個星期未？」 | Acute vs chronic frames entire DDx [1] | Acute → gastroenteritis, drugs, pregnancy; Chronic → GOO, gastroparesis, ↑ICP |
| Timing | Empty stomach or after eating? | 「空肚嘔定食完嘢先嘔？」 | Timing of vomiting [1] | Post-prandial → GOO, gastroparesis; Morning → pregnancy, ↑ICP |
| Nature of vomitus | What does it look like? Food/bile/blood/coffee ground? | 「嘔出嚟係啲咩嘢？有冇血？有冇好似咖啡渣咁？」 | Nature of vomitus (undigested vs acidic vs bilious) [1] | Coffee ground → UGIB; Bilious → SBO; Feculent → distal obstruction |
| Projectile? | Any forceful vomiting without nausea? | 「有冇嗰種好大力咁射出嚟，之前又唔覺得作嘔？」 | Absent nausea = projectile, suggests direct emetic centre stimulation [1] | ↑ICP (tumour, meningitis); pyloric stenosis in neonates |
| Abdominal pain | Any belly pain? Where? | 「個肚有冇痛？邊度痛？」 | Localises intra-abdominal cause | Epigastric → PUD/pancreatitis; RUQ → cholecystitis; Diffuse → SBO |
| GI red flags | Blood in vomit / black stool / weight loss? | 「有冇嘔血？大便有冇黑色/紅色？有冇瘦咗？」 | UGIB, malignancy | GI malignancy, PUD with bleed |
| CNS symptoms | Headache / blurred vision / neck stiffness? | 「有冇頭痛？視嘢有冇矇？條頸有冇硬？」 | ↑ICP, meningitis | Brain tumour, SAH, meningitis |
| Vestibular | Dizziness / spinning / hearing loss? | 「有冇頭暈？周圍嘢係咪轉嚟轉去？聽嘢有冇唔清楚？」 | Peripheral vs central vertigo | BPPV, Ménière's, vestibular neuronitis |
| LMP / pregnancy | When was your last period? Could you be pregnant? | 「最後一次月經幾時？有冇可能懷孕？」 | LMP for female [1] — MUST ASK | Early pregnancy, hyperemesis gravidarum, ectopic |
| Constitutional | Fever / night sweats / fatigue? | 「有冇發燒？夜晚有冇出汗？覺唔覺得好攰？」 | Infection, malignancy, Addison's | Gastroenteritis, hepatitis, lymphoma |
| PMHx | DM? Previous surgery? Psychiatric Hx? | 「你有冇糖尿？做過手術未？有冇情緒方面嘅問題？」 | DM → DKA, gastroparesis; Surgery → adhesive SBO; Psych → bulimia [1] | DKA, adhesive SBO, bulimia nervosa |
| Drug history | Any new medications? NSAIDs? Chemo? | 「最近有冇食新藥？止痛藥？」 | Drug-induced N/V is very common | Opioids, NSAIDs, antibiotics, chemo, digoxin |
| Allergy | Any drug allergy? | 「有冇藥物敏感？」 | Safety; completeness | — |
| FHx | Family history of cancer / GI disease? | 「屋企人有冇生過癌症或者腸胃病？」 | GI malignancy risk | Gastric/colorectal CA |
| Social / alcohol | Alcohol? Smoking? Occupation? | 「有冇飲酒？食煙？做咩工？」 | Alcoholism, pancreatitis; occupation → toxin exposure | Alcoholic gastritis/pancreatitis/hepatitis |
| Eating behaviour | Any binge eating / self-induced vomiting? | 「你食嘢方面有冇特別嘅習慣？有冇食完之後自己扣喉？」 | Bulimia nervosa — a pitfall | Russell's sign, dental erosion, hypokalaemia |
| Functional impact | Can you eat/drink? How is work/school? | 「你而家食到嘢飲到水嗎？返唔返到工？」 | Dehydration risk; social impact for case report | Dehydration, inability to work |
Case Report Form Answer Builder
- CC: "Nausea and vomiting for [duration]"
- HPI high-yield points: onset (acute vs chronic); frequency and volume; timing (fasting vs post-prandial vs morning); nature of vomitus (undigested / acidic / bilious / bloody / coffee ground) [1]; presence or absence of preceding nausea (projectile = no nausea) [1]; associated symptoms (abdominal pain, diarrhoea, headache, vertigo, chest pain); aggravating/relieving factors; oral intake tolerance; LMP [1]; relevant PMHx and drugs
Choose the single best reason the patient came today, not just the symptom:
- e.g. "Persistent vomiting preventing oral intake for 3 days" or "Worried about pregnancy" or "Wife asked her to see doctor because vomiting blood"
- Frame as: symptom + impact/trigger that prompted visit TODAY
| Component | Example Wording |
|---|---|
| Idea | "Patient thinks the vomiting is due to something she ate" / "Patient thinks she might be pregnant" |
| Concern | "Patient is worried about stomach cancer as her mother had it" / "Patient worried about dehydration as she cannot keep fluids down" |
| Expectation | "Patient wants blood tests / wants anti-vomiting medication / wants to know if she is pregnant" |
- In FM primary care: Acute gastroenteritis is the most common cause if acute onset + diarrhoea + food exposure history
- If reproductive-age female: always exclude early pregnancy / hyperemesis gravidarum
- If on new drugs: drug-induced nausea/vomiting
- Minimum supporting evidence: acute onset, associated diarrhoea, oral exposure history, sick contacts, self-limiting course
| DDx | Key Discriminator |
|---|---|
| Drug-induced N/V | Temporal relationship with medication (e.g. NSAID, antibiotic, opioid) |
| Early pregnancy / Hyperemesis gravidarum | Reproductive-age female + missed period + positive UPT |
| Peptic ulcer disease / Gastritis | Epigastric pain, relationship to meals, NSAID use, H. pylori |
(Adapt to the stem: if headache → consider ↑ICP; if DM → consider DKA/gastroparesis)
| Domain | Example |
|---|---|
| Biological | Dehydration and electrolyte imbalance (hypokalaemia, metabolic alkalosis) from persistent vomiting |
| Psychological | Anxiety about underlying serious illness (e.g. cancer) / depressed mood / health anxiety |
| Social/Functional | Unable to work or attend school; unable to care for children; financial worry from sick leave |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Acute gastroenteritis | Dry mucous membranes / reduced skin turgor | Inspect oral mucosa; pinch skin on dorsum of hand | Indicates dehydration from vomiting ± diarrhoea |
| Intestinal obstruction | Abdominal distension with high-pitched / tinkling bowel sounds | Inspect abdomen; auscultate all four quadrants | Mechanical obstruction causes proximal dilatation and hyperactive bowel sounds |
| Early pregnancy | Soft, enlarged uterus on bimanual exam (may not be detectable early) | Bimanual pelvic exam (unlikely in FM station) — best exam clue: positive UPT | UPT is the most reliable rapid bedside test |
| Raised ICP | Papilloedema on fundoscopy | Ophthalmoscope, examine optic disc | Swollen disc margins = raised ICP → urgent referral |
| DKA | Kussmaul (deep, rapid) breathing + ketotic (fruity) breath | Observe respiratory rate and pattern; smell breath | Metabolic acidosis compensation; ketone production |
| Peptic ulcer / Gastritis | Epigastric tenderness on palpation | Palpate epigastrium; watch for guarding/rebound | Localises pathology to upper GI |
| Gastroparesis | Succussion splash > 3 hours post-meal | Shake patient gently by hips and auscultate over stomach | Delayed gastric emptying retains fluid |
| Bulimia nervosa | Russell's sign (calluses on knuckles) + dental erosion [8] | Inspect dorsum of hands; examine teeth | Pathognomonic of self-induced vomiting |
| Addison's disease | Hyperpigmentation (palmar creases, buccal mucosa) | Inspect palms, look inside mouth | ↑ACTH/MSH causes melanocyte stimulation [5] |
| Hypercalcaemia | No reliable physical sign in brief FM station — best clue: elevated serum calcium | Blood test | Confirm with corrected Ca level [4] |
Must-Not-Miss Red Flags — Refer Urgently
- Haematemesis / coffee ground vomitus → UGIB; urgent OGD [9]
- Projectile vomiting + severe headache ± papilloedema → ↑ICP; urgent CT brain
- Bilious vomiting in a neonate → surgical emergency (malrotation/volvulus) [10]
- Signs of peritonism (rigid abdomen, rebound tenderness) → acute abdomen; surgical referral
- Severe dehydration / unable to keep fluids down → admit for IV rehydration
- Positive UPT + unilateral pelvic pain → ectopic pregnancy until proven otherwise
- DM patient with vomiting + drowsy → check glucose, ketones → DKA
Top traps that lose marks:
- Forgetting LMP / pregnancy in any reproductive-age female — this is specifically listed on GC lecture slides [1] and is an automatic penalty if omitted.
- Not distinguishing vomiting from regurgitation — the GC slide explicitly differentiates them [1]. Clarify this early: 「係嘔出嚟定係湧返上嚟？」
- Missing drug history — drug-induced N/V is extremely common and a classic masquerade. Always ask about new medications, OTC drugs, and supplements.
- Not asking about CNS symptoms — missing ↑ICP or meningitis is a serious-diagnosis-not-to-miss error.
- Overlooking eating disorders — especially in young females; look for Russell's sign and ask sensitively.
- Ignoring metabolic causes — DKA, uraemia, hypercalcaemia, Addison's, thyrotoxicosis can all present as isolated vomiting.
- Poor safety-netting at close — always give return advice: 「如果你嘔血、食唔到飲唔到嘢超過24小時、頭好痛、或者暈咗，就要即刻嚟返急症。」
Key GC slide point: "Salient clinical features at history taking" include onset (acute vs chronic), timing, nature of vomitus, preceding nausea, constitutional symptoms, associated GI/CNS/vestibular/cardiac symptoms, LMP, PMHx (DM, psych, surgical), drug history [1]
Shortest safe management line for closing:
- Oral rehydration if tolerating fluids; antiemetics PRN (e.g. metoclopramide); investigate cause; safety-net as above.
High Yield Summary
What to ASK: Onset/duration, timing, nature of vomitus, projectile?, associated symptoms (GI + CNS + vestibular + cardiac), LMP (MUST), PMHx (DM/surgery/psych), drug history, ICE, hidden agenda.
What to WRITE: CC with duration; HPI with symptom analysis and negatives; ONE clear RFC; ICE verbatim; most likely Dx with evidence; 3 DDx with discriminators; 3 biopsychosocial problems; 1 physical sign.
What NOT TO MISS: Pregnancy in reproductive-age female; haematemesis; projectile vomiting (↑ICP); bilious vomiting in neonates; DKA in DM; drug-induced cause; bulimia; Addison's.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 068. Indigestion and 'heartburn'.pdf (p27, p32 — Nausea and Vomiting; Salient clinical features at history taking) [2] Senior notes: Block A - Sudden severe chest pain_ acute myocardial infarction; aortic dissection.pdf (Bezold-Jarisch reflex, nausea/vomiting as AMI associated symptom) [3] Senior notes: Block A - Upper abdominal pain_ peptic ulcer; pancreatitis and gallstone.pdf (Epigastric pain + vomiting DDx) [4] Senior notes: Ryan Ho Chemical Path.pdf (p22 — Hypercalcaemia: stones, bones, groans, moans) [5] Senior notes: Ryan Ho Endocrine.pdf (p71 — Addison's disease: nausea, vomiting, hyperpigmentation) [6] Senior notes: Block A - Introduction to Renal Investigations (RFT, urine tests and US kidneys).pdf (Advanced CKD → nausea and vomiting) [7] Senior notes: Ryan Ho Fundamentals.pdf (p260 — Causes of nausea and vomiting table: thyrotoxicosis, Addison's) [8] Senior notes: Block A - Indigestion and 'heartburn'_ nausea and vomiting; gastric motility problems; benign esophageal lesions.pdf (p22 — Russell's sign; p24 — workup for acute/chronic vomiting) [9] Senior notes: Block A - Coffee ground vomitus tarry stool upper GI bleeding.pdf (Coffee ground vomiting mechanism) [10] Senior notes: Maksim Surgery Notes.pdf (p330 — Bilious vomiting in neonate = surgical emergency)
Localised Lump
A localized lump is a discrete, palpable mass confined to a specific anatomical area, arising from abnormal growth or swelling of tissue such as a cyst, abscess, lipoma, or neoplasm.
Shortness Of Breath / Dyspnoea
Dyspnoea is the subjective sensation of difficult, labored, or uncomfortable breathing arising from interactions among physiological, psychological, and environmental factors.