What is the most likely finding on a physical exam for a female patient presenting with intermittent nausea and vomiting for 2 weeks, without abdominal pain, diarrhea, or dysuria, and whose last menstrual period began 8 weeks ago?

Most Likely Physical Exam Finding: Enlarged Uterus

The most likely finding on physical examination is an enlarged uterus consistent with approximately 8 weeks of gestation, as this patient's presentation is classic for nausea and vomiting of pregnancy (NVP). 1, 2

Clinical Reasoning

Why This is Pregnancy-Related Nausea and Vomiting

The clinical presentation strongly suggests early pregnancy:

• Last menstrual period 8 weeks ago places the patient at the peak timing for NVP, which typically begins at 4-6 weeks gestation and peaks at 8-12 weeks 2
• Intermittent nausea and vomiting for 2 weeks aligns perfectly with the expected symptom onset (starting around 6 weeks gestation) 2
• Absence of abdominal pain, diarrhea, or dysuria makes gastrointestinal infection, inflammatory conditions, or urinary tract pathology unlikely 3, 4
• NVP affects 30-90% of pregnant women, making it the most common cause of nausea and vomiting in women of childbearing age with amenorrhea 2

Expected Physical Examination Findings

At 8 weeks gestation, the physical examination would reveal:

• Enlarged, softened uterus palpable on bimanual pelvic examination, approximately the size of an orange or small grapefruit 1, 2
• Closed cervical os (in normal early pregnancy)
• Possible breast tenderness and enlargement due to elevated estrogen and progesterone 2
• The patient should otherwise appear well-hydrated if NVP has not progressed to hyperemesis gravidarum 1

Pathophysiology Supporting This Diagnosis

The timing and symptoms are explained by pregnancy-specific hormonal changes:

• Elevated human chorionic gonadotropin (hCG) rises dramatically in early pregnancy and is directly associated with nausea and vomiting 1, 2
• Elevated estrogen levels contribute to NVP 1, 2
• Progesterone-induced delayed gastric emptying causes gastric stasis, worsening nausea 1, 2

Critical Differential Considerations

While pregnancy is most likely, other causes warrant brief consideration but are less probable given the clinical context:

• Cyclic vomiting syndrome (CVS) typically presents with more severe, stereotypical episodes lasting hours to days with complete resolution between episodes, not the continuous intermittent pattern described here 5
• Gastroparesis would typically present with postprandial fullness and bloating in addition to nausea 5
• Gastroenteritis would be expected to include diarrhea and resolve within 7 days 3, 4

Immediate Next Steps

Pregnancy must be considered in any woman of childbearing age presenting with nausea and vomiting 4, 6:

• Obtain urine or serum β-hCG to confirm pregnancy 4, 6
• If pregnancy is confirmed, initiate dietary modifications immediately to prevent progression to hyperemesis gravidarum 1
• Recommend small, frequent meals with bland carbohydrates (BRAT diet), high-protein/low-fat foods, and avoidance of spicy, fatty, or acidic triggers 1
• Consider vitamin B6 (pyridoxine) 10-25 mg every 8 hours if dietary modifications are insufficient 1