HISTORY:
for
Vomiting episodes: times
Vomitus:
Worsening factors:
Treatments tried: ,
, , ,
, episodes ,
, over ,
, up to °, over
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Extremities: , , cap refill , pulses ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , ,
- Urinalysis
- Abdominal ultrasound
- Upper GI endoscopy
- CT scan of the abdomen
- CT scan of the head
- Dietary modifications: , , , ,
- Stop medications that may contribute to nausea
-
-
-
-
- Vestibular rehabilitation exercises
- Stop cannabis (hyperemesis syndrome)
- Referral to gastroenterologist
- Follow-up in
- Return if develops persistent vomiting, weight loss, or abdominal pai