Case 5: Nausea

Opening scenario

Sophia Benedikt, a 19-year-old female; , comes to the physician's office because of nausea.

Vital signs

• Temperature: 98.6°F (37°C)
• Blood pressure: 122/68 mm Hg
• Heart rate: 75/min
• Respirations: 16/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• You think doctors are overrated and do not really believe the conclusions the examinee reaches about your condition.
• When the examinee presses on the right and left lower parts of your abdomen, say that it hurts a little bit.
• You are not aware of the meanings of medical terms (e.g., ultrasound) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: If the examinee says you may be pregnant, act upset and say that it is not possible.

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• I just feel sick to my stomach all time.
  • Vomiting
  • I have to throw up 1–2 times most days.
    • Color
    • It happens more when my stomach is empty, so it is usually clear.
    • Blood
    • No.
• Onset
• It has been going on for 10 days or so.
• Constant/intermittent
• It is worst in the morning, but I would say I feel pretty consistently bad all day.
• Precipitating events
• None.
• Progression
• I think it is getting worse.
• Previous episodes
• No never.
• Alleviating factors
• It actually helps if I eat a little something when I feel the sickness coming on. Is that not strange?
• Aggravating factors
• Strong smells seem to make it worse.
• Associated symptoms
• Yes actually, now that you ask. I have had to pee all the time for the last 1–2 weeks and really suddenly sometimes.
  • Urinary discomfort
  • No.

Review of systems specific to nausea and increased urinary frequency

• Recent travel
• No.
• Swelling of the ankles
• What? No.
• Fever/chills
• No.
• Fatigue
• Yes, I have been really tired.
• Rash/skin changes
• No.
• Pain in joints
• No.
• Bowel problems
• No.
• Appetite
• I have no appetite, but if I eat, I feel better. The only thing I have really been craving for some reason are bananas.
• Weight changes
• I am not sure. I do not have a scale, but I feel bloated.
• Recent infections
• No.
• Abdominal pain
• Hmm, my stomach has been hurting a little for the past 4–5 days. It is almost like menstrual cramps, but I am not on my period.
• Back pain
• No.
• Breast enlargement/tenderness
• I wish.

Past medical history, family history, and social history

• Past medical history
• None.
• Allergies
• I cannot wear jewelry with nickel in it because it gives me a bad rash.
• Medications
• None.
• Hospitalizations
• No.
• Ill contacts
• My roommate got really sick to her stomach 3 weeks ago for about 2 days. I probably have what she had.
• Past surgical history
• None.
• Family history
• My parents are both fine. My little sister has Down syndrome.
• Work
• I am getting my bachelor's in mathematics.
• Home
• I live in an apartment with a roommate.
• Alcohol
• I do not like to drink. Alcohol always gives me a bad headache.
• Recreational drugs
• No, I think that stuff is stupid.
• Tobacco
• No.
• Diet
• I mostly eat in the cafeteria at my school.

Sexual history, OB/Gyn

• Sexually active
• Yes.
• With whom
• My boyfriend.
• Men or women
• Men.
• Number of partners over the past year
• Five.
• Protection
• Sometimes. But I have a contraceptive implant so it does not really matter.
  • When was the implant placed
  • About 4 years ago or so.
  • History of sexually transmitted infection
  • No.
  • Pain during sex
  • Hmm, a little last time I had sex.
• Last menstrual period
• I would say about 6 weeks ago? Maybe a little longer.
• Menarche
• When I was 12 years old.
• Duration of period
• 2–3 days.
• Period regular
• Yes. Usually every 4 weeks, but I guess this time it is not as regular.
• How many tampons per day
• I use pads. But maybe 3 of those?
• Vaginal discharge
• A little more than the usual amount lately. But it is the same color still.
• Vaginal itching
• No.
• Pregnancies
• Never!

Always evaluate for genitourinary causes of nausea/vomiting in sexually active patients.

• Washed hands
• Used respectful draping
• Back examination
  • Examination for costovertebral angle tenderness
• Cardiovascular examination
  • Auscultation of the heart
• Chest examination
  • Auscultation of the lungs
• Abdominal examination
  • Inspection of the abdomen
  • Auscultation of the abdomen
  • Percussion of the abdomen
  • Palpation of the abdomen
    • Mild tenderness to palpation in the right and left lower quadrant
  • Signs of appendicitis
• Skin examination

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee did not repeat painful maneuvers during physical examination
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on safer sex practices.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Ms. Benedikt, I understand your shock and surprise at being told that you might be pregnant. I can see that it is not something you expected to hear. Since it is only one of several possible explanations for your symptoms, let's run a few tests first before jumping to conclusions and then look at the results together. I can assure you that no matter what the results are I will be with you to decide what steps to take.”

Patient note

Differential diagnoses

1. Normal pregnancy: Although this patient has a contraceptive implant, her history of unprotected sexual intercourse and last menstrual period 6 weeks ago (with an otherwise regular 4-week cycle in the past), as well as the implant placement that occurred 4 years ago, should raise suspicion of pregnancy. Her symptoms of morning sickness (nausea and vomiting that is worst in the morning), increased urinary frequency, cravings for specific foods, fatigue, and feeling bloated are all consistent with the diagnosis. Although pelvic pain is not a typical sign of a pregnancy, mild pain can occur. Her otherwise stable vitals and normal physical examination make a normal pregnancy the most likely diagnosis in this case.
2. Pelvic inflammatory disease (PID): A history of unprotected sexual intercourse with multiple sexual partners put this patient at risk for sexually transmitted infections. Nausea and vomiting, increased urinary frequency, urgency, dyspareunia, increased vaginal discharge, and pelvic pain are all consistent with PID. Bilateral lower abdominal or pelvic tenderness further support this diagnosis. However, the fact that this patient has had nausea and vomiting for an extended period as well as the lack of fever or more pronounced abdominal pain make PID only the second differential diagnosis.
3. Ectopic pregnancy: The symptoms of an ectopic pregnancy are usually similar to those of an early pregnancy and therefore consistent with this case. Although lower abdominal pain or pelvic pain is seen in ectopic pregnancies, the pain is usually unilateral and limited to the side of the ectopic pregnancy. Although this patient does have a contraceptive implant, which increases the risk of ectopic pregnancy slightly, she does not have any other risk factors for ectopic pregnancy, such as a history of PID, endometriosis, or past surgeries involving the fallopian tubes, making it the least likely of the three differential diagnoses.

Diagnostic studies

• Pelvic exam: mandatory in all female patients with gynecological complaints
• Cervical and urethral swab for gonococcal and chlamydial DNA (PCR) and cultures: confirms the most likely causative organisms for PID
• Urinalysis: to rule out a urinary tract infection
• Abdominal ultrasound: to assess for a normal and ectopic pregnancy and other causes of lower abdominal pain (i.e., abscess, appendicitis)
• Transvaginal ultrasound: to assess for a normal and ectopic pregnancy
• Serum β-hCG: can detect a pregnancy 6–9 days (on average) after fertilization and has a higher sensitivity than urine β-hCG testing
• CBC, ESR, electrolytes: Leukocytosis and an elevated ESR may indicate an infectious cause. The patient also has recurrent vomiting, which means that electrolyte disturbances should be ruled out.

Other differential diagnoses to consider

• Urinary tract infection
• Cervicitis
• Appendicitis
• Hyperemesis gravidarum
• See also differential diagnoses of pelvic inflammatory disease.