Pharmacotherapy Case Study 7: Nausea and Vomiting By: Dr. Nehad Ahmed

 

Pharmacotherapy Case Study 7: Nausea and Vomiting By: Dr. Nehad Ahmed

Chief Complaint:

A 45-year-old male presents with a 3-day history of persistent nausea and vomiting. He reports feeling nauseous throughout the day, with frequent episodes of vomiting, primarily in the morning.

Subjective Data:

History of Present Illness (HPI):

·        The patient states that for the past 3 days, he has been experiencing constant nausea, which is worse in the morning, often leading to vomiting. Vomiting consists of food and bile, with no blood or coffee-ground appearance.

·        He reports a lack of appetite, which has contributed to mild weight loss of approximately 4 pounds over the past 3 days.

·        The nausea is accompanied by mild abdominal discomfort but no significant pain. He describes the abdominal discomfort as a feeling of fullness and bloating.

·        He has not been able to keep much food or fluid down, which has led to some dehydration symptoms, including dry mouth and dark-colored urine.

·        No history of diarrhea, fever, or chills. He denies any recent trauma or travel history.

·        The patient is concerned that the nausea and vomiting are related to an illness or the stress at work, as he has been dealing with increased workload pressures recently.

·        He denies alcohol use, smoking, or illicit drug use.

Past Medical History (PMH):

·        Hypertension: Diagnosed 3 years ago, well-controlled on medication.

·        Gastroesophageal reflux disease (GERD): Diagnosed 5 years ago, managed with omeprazole 20 mg daily.

·        No history of gastrointestinal surgeries, malignancy, or chronic conditions besides hypertension.

Medications:

·        Omeprazole 20 mg orally once daily for GERD.

·        Lisinopril 10 mg orally once daily for hypertension.

·        Acetaminophen 500 mg as needed for headaches.

Allergies:

·        No known drug allergies (NKDA).

Social History:

·        Non-smoker.

·        Occasional alcohol use (1-2 drinks per week).

·        Works as a project manager with high stress and long hours.

·        No significant recent changes in diet, except for increased consumption of caffeine due to work demands.

Family History:

·        Father with a history of type 2 diabetes and hypertension.

·        Mother with a history of gallbladder disease (cholecystectomy at age 50).

·        No family history of gastrointestinal cancers or chronic GI disorders.

Review of Systems (ROS):

·        Gastrointestinal: Persistent nausea, vomiting (no blood), mild abdominal discomfort. Denies diarrhea, constipation, or recent changes in bowel habits.

·        Cardiovascular: No chest pain, palpitations, or edema.

·        Respiratory: No shortness of breath or cough.

·        Neurological: No dizziness, headaches, or visual changes.

·        Musculoskeletal: No significant muscle or joint pain.

 

Objective Data:

Vital Signs:

·        Blood Pressure: 120/78 mmHg

·        Heart Rate: 88 bpm

·        Respiratory Rate: 16 breaths/min

·        Temperature: 98.4°F (36.9°C)

·        Weight: 185 lbs (83.9 kg) (4 lbs weight loss in the past 3 days)

·        Height: 5'10" (178 cm)

Physical Exam:

·        General: Alert and oriented, appears fatigued but not in acute distress. Mild dry mucous membranes noted.

·        Abdomen: Soft, non-distended. Mild epigastric tenderness on palpation. No rebound tenderness or guarding. Bowel sounds are normal.

·        Cardiovascular: Regular rate and rhythm, no murmurs or gallops.

·        Respiratory: Clear to auscultation bilaterally.

·        Neurological: Alert and oriented with no focal deficits.

·        Skin: Dry, no rashes or signs of jaundice.

Labs and Imaging:

·        Complete Blood Count (CBC):

o   Hemoglobin: 14.2 g/dL (normal)

o   Hematocrit: 41% (normal)

o   White Blood Cell Count: 6,500/mm³ (normal)

o   Platelets: 220,000/mm³ (normal)

·        Basic Metabolic Panel (BMP):

o   Sodium: 138 mEq/L (normal)

o   Potassium: 3.9 mEq/L (normal)

o   Chloride: 101 mEq/L (normal)

o   Bicarbonate: 23 mEq/L (normal)

o   Blood Urea Nitrogen (BUN): 16 mg/dL (normal)

o   Creatinine: 0.9 mg/dL (normal)

o   Glucose: 98 mg/dL (normal)

·        Liver Function Tests (LFTs):

o   Alanine aminotransferase (ALT): 25 U/L (normal)

o   Aspartate aminotransferase (AST): 22 U/L (normal)

o   Total bilirubin: 0.4 mg/dL (normal)

·        Urinalysis:

o   Specific gravity: 1.030 (slightly concentrated, suggestive of mild dehydration)

o   No protein, glucose, or blood detected.

·        Abdominal Ultrasound: No evidence of gallstones, liver, or pancreatic abnormalities. Normal findings.

·        Electrocardiogram (ECG): Normal sinus rhythm.

Assessment:

The patient is presenting with acute nausea and vomiting of unclear etiology, with associated mild dehydration, weight loss, and epigastric discomfort. The differential diagnosis includes:

·        Gastritis or peptic ulcer disease: Given the patient's history of GERD and epigastric tenderness, these could be contributing factors, although no overt gastrointestinal bleeding is present.

·        Gastroenteritis: Less likely given the lack of fever and diarrhea.

·        Medication side effects: Although the patient is on omeprazole, nausea and vomiting are not common side effects. However, overuse or misuse of NSAIDs, though not currently reported, could be a factor.

·        Stress-related nausea: Increased stress and lack of appetite could be contributing to his symptoms.

·        Gallbladder disease: The patient's family history of gallbladder disease raises the possibility of biliary issues, but ultrasound findings are normal.

·        Peptic ulcer disease: Could be considered given the patient's history of GERD, but no severe symptoms of bleeding or perforation are present.

Plan:

Pharmacologic Treatment:

1.     Antiemetic Therapy:

o   Ondansetron 4 mg orally every 8 hours as needed for nausea.

2.     Antacid Therapy:

o   Ranitidine 150 mg orally twice daily (H2 blocker) to help manage potential gastritis or reflux contributing to nausea.

3.     Rehydration:

o   Encourage oral rehydration solutions (ORS) for fluid replacement due to dehydration. If vomiting persists, consider IV fluids.

4.     Proton Pump Inhibitor (PPI):

o   Continue omeprazole 20 mg daily for GERD, but ensure patient is adhering to the medication as prescribed.

Non-Pharmacologic Treatment:

·        Dietary modifications: Recommend a bland, low-fat diet to minimize irritation to the stomach. Avoid spicy or acidic foods.

·        Hydration: Encourage adequate fluid intake, particularly water and oral rehydration solutions to combat dehydration.

·        Stress management: Suggest relaxation techniques such as deep breathing exercises, meditation, or mindfulness practices.

Monitoring and Follow-Up:

·        Follow-up in 2-3 days to evaluate symptom control and fluid intake. If vomiting continues or worsens, consider further diagnostic testing (e.g., upper GI endoscopy).

·        If symptoms do not improve or if there is evidence of a more serious condition (e.g., worsening pain, signs of GI bleeding), further investigation may include endoscopy, CT abdomen, or referral to a gastroenterologist.

Patient Education:

·        Educate the patient on the importance of maintaining hydration and eating small, frequent meals to manage nausea.

·        Explain the possible side effects of ondansetron and ranitidine (e.g., constipation, dizziness) and advise the patient to contact healthcare providers if any new symptoms arise.

·        Discuss stress management techniques and the potential impact of stress on gastrointestinal health.

Referral:

·        If symptoms persist or worsen, referral to a gastroenterologist for further evaluation may be warranted, particularly if peptic ulcer disease or other GI disorders are suspected.

Long-Term Management:

·        If the cause is determined to be stress or anxiety-related, further management with counseling or stress management techniques may be beneficial.