Presenting Complaints

The patient presents with a chief complaint of vomiting for the past 2 days.

History of Presenting Complaint

The patient, a 28-year-old male, reports that he started experiencing nausea and vomiting 2 days ago. He states that he has been vomiting 3-4 times per day, with the vomitus containing partially digested food. He also complains of mild abdominal discomfort, mostly in the epigastric region, but denies any diarrhea, fever, or chills. He mentions that he recently returned from a weekend trip to a rural area in Malaysia, where he ate some local street food.

Significant Positives & Negatives For Differentials

Viral Gastroenteritis

Positives:

• Recent travel to rural area
• Acute onset of vomiting

Negatives:

• No known exposure to other sick individuals
• Absence of other viral symptoms (e.g., myalgia, headache)

Bacterial Gastroenteritis (e.g., Salmonella, Shigella, Campylobacter)

Positives:

• Recent travel to rural area
• Consumption of local street food
• Acute onset of vomiting

Negatives:

• Lack of diarrhea or fever
• Absence of bloody stool

Medication-induced Nausea and Vomiting

Positives:

• Acute onset of vomiting

Negatives:

• No recent medication use
• History of recent travel and consumption of local food

Peptic Ulcer Disease

Positives:

• Epigastric abdominal discomfort

Negatives:

• Lack of history of peptic ulcer disease
• Absence of other typical symptoms (e.g., heartburn, dyspepsia)

Bowel Obstruction

Positives:

• Vomiting of partially digested food

Negatives:

• Lack of severe abdominal pain or distension
• Absence of constipation

Past Medical History

The patient reports no significant past medical history. He has no known allergies and is not taking any regular medications.

Drug/Medication History

The patient denies any recent use of medications, including over-the-counter drugs or supplements.

Social History

The patient is single and works as an office administrator. He denies any alcohol, tobacco, or recreational drug use.

Family History

The patient's family history is unremarkable, with no history of gastrointestinal disorders or other significant medical conditions.

Systems Review

Apart from the gastrointestinal symptoms, the review of other systems is unremarkable. The patient denies any respiratory, cardiovascular, neurological, or genitourinary symptoms.

Ideas, Concerns & Expectations

The patient is concerned that he may have contracted a foodborne illness from the street food he consumed during his recent trip. He expects to receive appropriate treatment to alleviate his symptoms and recover quickly.

Case Presentation

Based on the patient's history, the most likely diagnosis is acute gastroenteritis due to food poisoning. The recent travel to a rural area, consumption of local street food, and the acute onset of vomiting without diarrhea or fever strongly suggest a foodborne illness as the primary cause of the patient's symptoms. While other differentials should be considered, the clinical presentation and epidemiological factors point towards a diagnosis of food poisoning as the most likely explanation for the patient's condition.