Patients often experience abdominal pain in conjunction with other symptoms. Begin by asking "How is your appetite?" then pursue symptoms such as indigestion, nausea, vomiting, and anorexia. Indigestion is a general term for distress associated with eating that can have many meanings. Urge your patient to be more specific.

■ Nausea, often described as "feeling sick to my stomach," may progress to retching and vomiting. Retching describes involuntary spasm of the stomach, diaphragm, and esophagus that precedes and culminates in vomiting, the forceful expulsion of gastric contents out of the mouth.

Some patients may not actually vomit but raise esophageal or gastric contents without nausea or retching, called regurgitation.

Ask about any vomitus or regurgitated material and inspect it if possible, noting the color, odor, and quantity. Help the patient to specify the amount: a teaspoon? Two teaspoons? A cupful?

Ask specifically if the vomitus contains any blood, and quantify the amount. Gastric juice is clear and mucoid. Small amounts of yellowish or greenish bile are common and have no special significance. Brownish or blackish vomitus with a "coffee grounds" appearance suggests blood altered by gastric acid. Coffee ground emesis or red blood is called hematemesis.

Is there any dehydration or electrolyte imbalance from prolonged vomiting or significant blood loss? Do the patient's symptoms suggest any complications of vomiting, such as aspiration into the lungs, seen in debilitated, obtunded, or elderly patients?

■ Anorexia is loss or lack of appetite. Find out if it arises from intolerance to certain foods, fear of abdominal discomfort (or "food fear"), or distortions in self-image. Check for associated nausea and vomiting.

Patients may complain of unpleasant abdominal fullness after light or moderate meals, or early satiety, the inability to eat a full meal. A dietary assessment or recall may be warranted.

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