On September 12, 2007, Wood et al1 presented the case of Mr Q, a 50-year-old man with metastatic esophageal cancer who was admitted to a university hospital through the emergency department with intractable nausea and vomiting. Nausea and vomiting represent a substantial source of physical and psychological distress for patients and families. The authors reviewed the evaluation and treatment of this symptom complex, observing that a thorough history and physical examination are essential because they provide a measure of the severity of the symptoms and clues to their underlying etiology. Once the most likely etiology is determined, the clinician must discern the mechanism, specific transmitters, and receptors by which this etiology is triggering the symptoms. Subsequent pharmacological management focuses on prescribing the appropriate antagonist to the implicated receptors. If symptoms are refractory despite adequate dosage and around-the-clock prophylactic administration, an empirical trial combining several therapies to block multiple emetic pathways should be attempted. Often, oral administration of medication is not feasible and alternate routes such as rectal suppositories, subcutaneous infusions, and orally dissolvable tablets should be considered. Using this stepwise approach, Mr Q's physicians, including a palliative care physician, were able to provide Mr Q relief and discharge him from the hospital.
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The Rational Clinical Examination
3. Presence of Significant Gastrointestinal Symptoms: Anorexia, Nausea, Vomiting, and Diarrhea
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