What should be included in a comprehensive History of Present Illness (HPI) template for a patient presenting with nausea and vomiting?

History of Present Illness Template for Nausea and Vomiting

Onset, Duration, and Pattern

Document whether symptoms are acute (≤7 days) or chronic (≥4 weeks), as this fundamentally changes the differential diagnosis and evaluation approach 1, 2. For chronic symptoms, determine if the pattern is episodic (suggesting cyclic vomiting syndrome) or continuous (suggesting chronic nausea vomiting syndrome) 3. If episodic, ask specifically about stereotypical episodes of acute-onset vomiting lasting <7 days, with at least 3 discrete episodes in the past year and 2 in the prior 6 months, separated by at least 1 week of baseline health 4.

• Timing of episodes: Note if symptoms occur predominantly in early morning hours, as this is classic for cyclic vomiting syndrome 4
• Frequency and severity: For CVS classification, document if <4 episodes/year lasting <2 days (mild) versus ≥4 episodes/year lasting >2 days requiring ED visits or hospitalization (moderate-severe) 4

Prodromal and Associated Symptoms

Approximately 65% of CVS patients experience prodromal symptoms lasting a median of 1 hour before vomiting onset, including an impending sense of doom, panic, or inability to communicate effectively 4.

Document the following constitutional, cognitive, autonomic, and motor symptoms that cluster stereotypically with each episode 4:

• Fatigue, feeling hot or cold, mental fog, restlessness, anxiety
• Headache (personal or family history of migraine is supportive of CVS diagnosis) 4
• Bowel urgency, acute diarrhea or constipation
• Abdominal pain (present in most CVS patients and should not preclude diagnosis) 4
• Diaphoresis, flushing, shakiness or tremulousness

Vomiting Characteristics

• Number of episodes: Document if >4 episodes in 12 hours, as this should prompt immediate HCP contact 4
• Ability to keep fluids down: Inability to maintain oral intake requires urgent evaluation 4
• Retching and unremitting nausea: These are equally disabling as vomiting itself 4
• Compensatory behaviors: Ask if patient drinks large amounts of water or induces vomiting for temporary relief 4

Triggers and Exacerbating Factors

Stress (psychological or physiological) triggers episodes in 70-80% of CVS patients 4. Document:

• Negative stress: death, work/family conflicts
• Positive stress: birthdays, reunions, vacations
• Sleep deprivation
• Hormonal fluctuations (menstrual cycle phase)
• Travel, motion sickness
• Acute infections or surgery
• Prolonged fasting or intense exercise 4

Cannabis and Substance Use History

Cannabis use has a pooled prevalence of 47% in patients with vomiting syndromes and is critical for distinguishing cannabinoid hyperemesis syndrome (CHS) from CVS 5.

• Current and past cannabis use: Type (THC vs CBD), frequency, duration, recent brand changes 6
• Hot water bathing behavior: Compulsive hot showers/baths for symptom relief is pathognomonic for CHS 5
• Cannabinoid withdrawal syndrome: Occurs with cessation of heavy, prolonged use 5
• Other substance use: Vaping products, opioids, alcohol 6

Medication Review

Opioid-induced nausea occurs in 10-50% of patients and worsens gastric emptying 5. Document all medications, particularly:

• Opioids, antibiotics, chemotherapy agents 3
• NSAIDs, which should be stopped during acute illness 4
• Medications affecting gastric emptying: prokinetics, anticholinergics 5
• Recent medication changes or additions 2

Relationship to Food Intake

Worsening symptoms postprandially suggests gastroparesis or gastric outlet obstruction 3.

• Timing: Symptoms during eating, immediately after, or hours later
• Eating behaviors: Eating too quickly, insufficient chewing, overeating (can cause postprandial vomiting) 5
• Dietary triggers: Specific foods, large meals, fatty foods
• Anorexia or decreased intake: Resulting in significant fluid deficit 4

Volume Depletion Signs and Symptoms

Document new or worsening 4:

• Lightheadedness, dizziness, or fainting (particularly orthostatic)
• Decreased urine output
• Weight loss (≥3 kg in 2 days)
• Weakness, lethargy, or fatigue

Severe Symptoms Requiring Immediate Evaluation

The following warrant urgent HCP contact or emergency care 4:

• Reduced level of consciousness or new confusion
• Vomiting >4 times in 12 hours or inability to keep fluids down
• Low blood pressure (SBP <80 mmHg; drop of 20 mmHg SBP or 10 mmHg DBP)
• Increased heart rate (increase by 30 bpm)
• Fever >38°C (101°F) on 2 measurements
• Moderate or high ketones (for patients on SGLT2 inhibitors or insulin)
• Difficulty or rapid breathing 4

COVID-19 Screening

In outpatients with new-onset GI symptoms, monitor for COVID-19-associated symptoms, as GI symptoms may precede respiratory symptoms by several days 4. Document:

• High-risk contact exposure
• Fever, cough, shortness of breath, chills, muscle pain, headache, sore throat
• New loss of taste or smell 4

Comorbid Conditions

Screen for 3, 2:

• Migraine headaches (strongly associated with CVS)
• Anxiety disorders, depression (psychiatric comorbidity in 24-35% of patients with syncope-like symptoms and unexplained vomiting) 4, 3
• Postural orthostatic tachycardia syndrome
• Diabetes mellitus (gastroparesis affects 20-40% of diabetic patients) 5
• Functional dyspepsia (gastroparesis in 25-40% of these patients) 5

Red Flag Symptoms

Document presence or absence of 5, 2:

• Abdominal distention, absent bowel sounds, colicky pain (bowel obstruction)
• Neurologic signs (increased intracranial pressure, CNS tumor)
• Hematemesis, melena (peptic ulcer disease, malignancy)
• Progressive symptoms despite treatment
• Unintentional weight loss
• Age >50 with new-onset symptoms

Duration of Self-Management

SDMG (sick day medication guidance) should only be used for temporary self-management until symptoms resolve or for a maximum of 72 hours, whichever comes first 4. Document:

• When symptoms started
• What self-management measures have been attempted
• Whether patient feels able to cope with self-management 4