Andrew Shaffer, MS3

05/20/16
H&P 4
CC: Vomiting
HPI: Patient is a 70 y.o. female who presents with a 6 day history of nausea
and vomiting in association with Bactrim administration. She recently
underwent a ventral hernia repair with mesh 2 weeks before admission. Nine
days before admission the patient was started on empiric ciprofloxacin due to
a complaint of new onset dysuria. An outpatient urinalysis and culture was
performed, which was positive for extended-spectrum beta lactamase E. coli
and K. pneumonia. At that time, six days before admission, the patient's
antibiotics were changed from ciprofloxacin to Bactrim. The next day the
patient reported that she began to experience nausea and vomiting. She says
that she "was unable to keep anything down". She noticed that the nausea
and vomiting usually began after she took her Bactrim. She describes the
vomitus as appearing like "whatever I ate beforehand", and that it was not
green, brown or blood-containing. She denies abdominal pain and chills. She
is still experiencing painful urination, despite her reported compliance with
Bactrim. Her bowel function has remained unchanged; she denies diarrhea
and constipation.
PMH:
-Diabetes mellitus
-Hypertension
-Arthritis
PSH:
-Laparascopic ventral hernia repair (04/29/2016)
-Ventral hernia repair x2 (2009)
-Cholecystectomy
-Colonoscopy (2014)
Medications:
Bactrim 160-800 mg BID
Sitagliptin 100 mg once daily
Oxycodone 10 mg q4h PRN pain
Fluticasone nasal spray once daily
Hydrocholorthiazide 12.5 mg once daily
Ezetimibe 10 mg once daily
Metformin 500 mg two tabs once daily
Nadolol 20 mg once daily
Ibuprofen 800 mg q8h PRN pain
Losartan 50 mg once daily
Omeprazole 40 mg once daily
Aspirin 81 mg once daily

Allergies:
Latex- mild rash/itching
Cefaclor- chest pain
Meperidine- hives
Morphine- mild rash/itching
Iodine- itching
Lipitor- muscle/joint pain
Statins- muscle/joint pain
FH:
Father: Colon cancer, heart disease
Mother: Diabetes, high cholesterol, heart failure, osteoarthritis.
Sister: Dementia, heart disease
Brother: Heart disease
No known FH of adverse reactions to anesthesia, clotting/bleeding disorders
SH:
Former smoker- 28 pack year history. Last smoked 1987
Denies alcohol use
Denies recreational drug use
She is currently retired
ROS:
Constitutional: No chills, fever, diaphoresis, night sweats, weight loss
HEENT: No congestion, ear discharge, sore throats, headaches, hearing loss,
nose bleeds
CV: No chest pain, palpitations, orthopnea, leg swelling
Resp: No cough, shortness of breath, wheezing
GI: Endorses nausea and vomiting. No blood in stool, abdominal pain
GU: Endorses dysuria. No flank pain, frequency, hematuria or urgency
MSK: No joint pain, myalgias, back or neck pain
Neuro: No dizziness, weakness, seizure-like activity or sensory changes
Skin: No itching, bruising or rashes
Endo: No cold intolerance, heat intolerance, polydipsia, polyuria
Psych: No depression, anxiety or suicidal ideation
Vitals: Tc 98.7
BMI 25.12

HR 79 BP 125/43

RR 16

O2 94% in RA

WT 81.6 kg

Physical Exam:
Gen: well-developed, well-nourished female in no acute distress. Oriented
with normal affect
HEENT: PERRL, EOMI, no scleral icterus or conjunctivitis, hearing grossly
intact, oropharynx clear, no JVD, trachea midline
CV: RRR, no murmurs, rubs or gallops, peripheral pulses intact and
symmetric, no pedal edema
Resp: Clear to auscultation bilaterally, normal respiratory effort, no wheezes
or crackles
Abd: soft, non-tender, non-distended. Bowel sounds normal.

Laparascopic surgical sites clean, dry and intact.

MSK: Moving all extremities spontaneously, no gross motor abnormalities
Skin: Warm, dry and intact. No lesions, rashes or alopecia
Neuro: awake and alert, CN II-XII intact, no focal deficits, sensation intact
GU: Normal female genitalia.
Labs:
CBC: 5.9 / 12.1 / 37.4 / 383
54 segs
BMP: 137 / 3.7 / 96 / 23 / 22 / 1.6 / 102 / 8.7
Hepatic Function: Albumin 4.0
AST 12
ALT 7
Alk Phos 62
Lipase 37
Total Bili 0.4
Direct Bili <0.2
Urinalysis: Negative for glucose, bilirubin, ketones, occult blood.
Moderate leukocyte esterase, positive for urine nitrites, wbc 50-100, rbc 3-5,
bacteria present, 0-2 squamous cells.
Imaging:
CT Scan Abdomen:
Residual versus recurrent low abdominal wall hernia defect contains fluid,
dots of air, and bowel but no additional intraperitoneal air is seen.
Significance of this air is uncertain. It could represent an infected fluid
collection within the hernia sac. Bowel perforation less likely. No associated
bowel obstruction.
Assessment:
1. Medication side effect
-Isolated nausea and vomiting without abdominal pain, altered bowel
function,
leukocytosis or peritoneal signs most likely due to a medication.
These can be side effects of Bactrim. Time course fits this diagnosis.
2. Obstruction secondary to recurrent or unresolved ventral hernia
-CT scan suggests hernia, but not bowel obstruction. Given normal
bowel function
(lack of constipation), non-tender and non-distended
abdomen, this diagnosis is less likely
3. Emesis gravidarum
-Unlikely given patient age, acute onset, lack of morning-time
exacerbation of
symptoms
4. Gastroenteritis
-Less likely given lack of diarrhea, abdominal pain, leukocytosis or
fever
Plan:
1. Will admit patient to floor for observation and treatment
2. Switch from PO ciprofloxacin to IV meropenem

3. Rehydrate patient with IVF

4. Repeat urine culture to assess for more narrow-spectrum agent
susceptibility
5. On regular diet. Encourage good PO intake as tolerated
6. PRN Zofran for nausea
7. Consider pregnancy test

Discussion:
DDX: The causes of nausea and vomiting can be broadly divided into
medication-related, infectious, disorders of the gut and peritoneum, CNS
etiologies, endocrinologic causes. Some causes that do not fit into the
aforementioned categories include post-op nausea and cyclic vomiting
syndrome. Drugs that can cause nausea and vomiting as a side effect include
chemotherapy agents, analgesics, antigout drugs, hormonal agents,
antibiotics and ethanol abuse. Infectious causes are viral and bacterial
gastroenteritis, although otitis media can also induce nausea. Gut disorders
including obstruction, gastroparesis, irritable bowel syndrome, cholecystitis,
appendicitis, pancreatitis and hepatitis can all induce vomiting. CNS causes
include migraines, increased ICP of any etiology, seizures, psychiatric
disorders (anxiety, depression, bulimia). Hormonal causes like pregnancy,
diabetic ketoacidosis and hyperthyroidism can all result in vomiting.
Appropriate Workup and Therapy (Pharmacologic/surgical): When presented
with acute onset vomiting, it is most important to first rule out potentially lifethreatening disorders, including bowel obstruction and acute pancreatitis.
Any consequences of vomiting, such as hypokalemia, metabolic alkalosis and
fluid depletion should be identified with a BMP and corrected with intravenous
fluids as soon as possible. Patients with bowel obstruction should be given
surgical intervention when possible. Certain clinical features can be
particularly helpful in narrowing the diagnosis; abdominal pain often indicates
an organic etiology, wheras abdominal distension and tenderness suggest
bowel obstruction. If a patient vomits soon after eating and a succussion
splash is detected on abdominal exam, gastric obstruction or gastroparesis is
suspected. Early morning vomiting suggests a pregnancy etiology.
Pathophysiology: Nausea is associated with and proportional to increased
gastric myoelectrical activity (tachygastria), as well as elevated levels of
plasma cortisol, beta endorphin, epinephrine and norepinephrine. Vomiting is
induced by multiple pathways in the brain. The area postrema is located in
the floor of the fourth ventricle and contains a chemoreceptor trigger zone,
which is sensitive to drugs, toxins and neurotransmitters, and is likely the
area affected when vomiting is experienced as a side effect of a medication.
Certain neurotransmitters are responsible for mediating vomiting and are
likely affected by medications which induce emesis; they include M1
muscarinic, D2 dopamine, H1 histamine, HT3 serotonin and substance P

receptors.