Subjective and objective information that needs to be elicited from the patient presenting with nausea or vomiting
| Subjective | Objective |
|---|---|
| The symptom | General |
| How long has the symptom been present? | Baseline vital signs are measured. |
| How long have the symptoms been a problem? | Is there any evidence of dehydration? |
| How often has the person vomited in the past few hours? | Look in the mouth/ears. Check lymph glands. |
| Is there any blood or mucus in the vomit? | Look for evidence of jaundice. |
| What colour is the vomit? | Is there a rash or wide-spread muscle tenderness? |
| Associated symptoms | Systems exam as indicated by history |
| Is there any associated pain? – where is it and does it radiate anywhere? | Neurological |
| Is there any diarrhoea – if so is there any blood or mucus in it? | Is there any headache, visual symptoms, altered level of consciousness, or neurological signs including abnormal tone in children? |
| Possible infective contacts/travel | Chest – as indicated by the history. |
| Does anyone else in the family have the same problems? | Abdomen |
| What does the patient/family think is the cause? Have they been abroad, if so where? | Is there any abdominal pain? – if so the abdomen should be palpated and listened to for signs of bowel disease or obstruction and the renal angles palpated for tenderness. |
| Past History | Are there any urinary or gynaecological symptoms e.g. dysuria and frequency or vaginal discharge? |
| Is there a significant past medical history of similar episodes or recent illness/surgery? Is the patient immunocompromised by pre-existing illness or recent treatment – they will usually have a letter from hospital explaining the risks if this is likely. | Tests |
| Has the patient taken any drugs prescribed or otherwise? – if not should they have? | Check a urine specimen if possible (nephur test or combistix) checking for nitrites or cells. |
| Is the patient pregnant? – if so how pregnant? | Check a BM test in the very young and the elderly even if there is no history of diabetes. |