Key elements of the history and physical examination in a pediatric patient with nausea or vomiting

Symptoms	Diagnostic considerations
History
Contacts with vomiting or diarrhea	Gastroenteritis
Acute onset of diarrhea and fever	Viral gastroenteritis (if typical features) Infection (sepsis, infectious enteritis/colitis, appendicitis, IBD) Hirschsprung-associated enterocolitis
Early morning vomiting	Pregnancy (adolescent females), increased ICP, or cyclic vomiting syndrome
Vomiting without nausea	Increased ICP
Effortless vomiting/regurgitation	Gastroesophageal reflux Rumination syndrome
Chronic or recurrent infections	Immunodeficiency Tracheoesophageal fistula (infant with recurrent pneumonia)
Periodic episodes of vomiting	Cyclic vomiting syndrome Inborn error of metabolism Migraine (usually with headache and family history) Cannabis hyperemesis syndrome Porphyria, carcinoid, pheochromocytoma, familial dysautonomia
Vomiting triggered by specific foods
Vomiting begins within minutes to 2 hours of ingesting the food, usually with cutaneous or respiratory symptoms	Food allergy (eg, anaphylaxis)
Subacute or chronic, with diarrhea	Food protein-induced enteropathy or chronic FPIES
Triggered by introduction of lactose	Galactosemia
Triggered by introduction of fructose or sucrose	Hereditary fructose intolerance
Undigested food in vomitus	Can be seen with vomiting from any cause that occurs immediately after eating Achalasia* Other esophageal obstructions (eg, foreign body in the esophagus)
Heartburn	Esophagitis (peptic or eosinophilic)
Physical examination
One or more of these findings: Marked abdominal distension Visible bowel loops Vomitus bilious (green or yellow) or feculent (with the odor of feces) Bowel sounds either absent, or increased and high-pitched	Intestinal obstruction
Focal tenderness	RLQ – Appendicitis or Crohn disease RUQ – Gallbladder disease, pancreatitis Costovertebral angle – Pyelonephritis Epigastric – Pancreatitis, peptic ulcer disease/gastritis
Hepatomegaly, splenomegaly, jaundice	Viral hepatitis, viral infection (eg, EBV), metabolic disorders
Ataxia, dizziness, nystagmus	Vestibular neuronitis or acute cerebellar ataxia
Papilledema	Increased ICP
Atypical genitalia	Congenital adrenal hyperplasia with vomiting due to adrenal crisis (infants)
Unusual odor	Inborn error of metabolism
Enlarged parotid glands	Bulimia (adolescents)

IBD: inflammatory bowel disease; ICP: intracranial pressure; FPIES: food protein-induced enterocolitis syndrome; RLQ: right lower quadrant; RUQ: right upper quadrant; EBV: Epstein-Barr virus.

* Typical symptoms of achalasia include gradual onset of recurrent nonforceful regurgitation of bland undigested food or saliva, sometimes with a sensation of retrosternal fullness after a meal.

Courtesy of Carlo Di Lorenzo, MD.

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Key elements of the history and physical examination in a pediatric patient with nausea or vomiting