Associated History for Nausea and Vomiting
When evaluating nausea and vomiting, obtain a detailed history focusing on temporal patterns, triggers, associated symptoms, medication use, and red flag features to guide diagnosis and treatment.
Critical Historical Elements to Obtain
Temporal Pattern and Duration
- Determine if symptoms are acute (≤7 days) or chronic (≥4 weeks), as this fundamentally changes the diagnostic approach and urgency of evaluation 1, 2.
- Document episode frequency and duration: Ask specifically about number of episodes per year, length of each episode, and whether there are symptom-free intervals between episodes 3.
- Identify episodic versus continuous patterns: Episodic vomiting with well periods suggests cyclic vomiting syndrome, while continuous symptoms suggest metabolic, medication-induced, or coalescent disease 3.
- For cyclic vomiting syndrome specifically, classify severity: mild CVS is <4 episodes/year lasting <2 days without ED visits; moderate-severe CVS is ≥4 episodes/year lasting >2 days requiring ED visits or hospitalization 3.
Relationship to Food and Vomiting Pattern
- Ask about timing relative to meals: Nausea relieved by vomiting or induced by eating suggests gastroparesis, gastric outlet obstruction, or small bowel obstruction 4.
- Continuous severe nausea unrelieved by vomiting typically indicates medication toxicity or metabolic abnormalities 4.
- Document any recent foodborne illness or gastroenteritis exposure 1, 5.
Medication and Substance Use History
- Obtain complete medication list and recent changes, as medication adverse effects are among the most common causes of nausea and vomiting 3, 1.
- Specifically ask about opioid use, as this commonly causes gastroparesis and requires opioid rotation or dose reduction 3.
- Check therapeutic drug levels if patient takes digoxin, phenytoin, carbamazepine, or tricyclic antidepressants 3.
- Cannabis use history is critical, especially in younger patients, as Cannabis Hyperemesis Syndrome should be suspected with heavy cannabis use preceding symptom onset 6.
Associated Symptoms and Comorbidities
- Screen for alarm features requiring urgent evaluation: hematemesis, severe abdominal pain, signs of obstruction, neurological symptoms, or severe dehydration 1, 2.
- Document presence of constipation or fecal impaction, which can cause nausea and vomiting 3.
- Ask about anxiety, migraine headaches, and autonomic dysfunction, as these are common comorbidities with cyclic vomiting syndrome and guide management 3.
- In cancer patients, assess for CNS involvement, hypercalcemia, bowel obstruction, or gastric outlet obstruction from tumor burden 3.
Triggers and Relieving Factors
- Identify specific triggers such as stress, anxiety, certain foods, or physical exertion that precipitate episodes 3, 2.
- Document any factors that relieve symptoms, including hot showers (suggestive of Cannabis Hyperemesis Syndrome) 6.
- Ask about vestibular symptoms or motion sensitivity 1, 2.
Pregnancy and Metabolic Risk Factors
- Always consider pregnancy in women of childbearing age as a common cause of acute nausea and vomiting 1, 5.
- Screen for symptoms of metabolic disorders: polyuria/polydipsia (diabetes, hypercalcemia), cold intolerance (hypothyroidism), or orthostatic symptoms (Addison's disease) 6, 2.
Common Pitfalls to Avoid
- Do not dismiss episodic patterns in patients with daily symptoms: Patients with coalescent cyclic vomiting syndrome may have lost their well periods but universally endorse years of prior episodic patterns—a careful history identifies this 3.
- Never assume functional disease based on symptom pattern alone: Symptoms are poor predictors of functional versus pathological illness, and organic causes must be excluded 5.
- In cancer patients, recognize that nausea and vomiting may be secondary to cachexia syndrome (chronic nausea, anorexia, asthenia, changing body image, and autonomic failure) 3.
- Do not stigmatize patients with cannabis use: Offer treatment even with ongoing use, as therapies can still be effective 6.