Clinical Presentation & Protocol
Patient Usually Complains Of
Patient is a [G_P_] at [weeks] gestation presenting with intractable nausea and vomiting. Reports inability to tolerate oral intake for [number] days, associated with weight loss of [kg], dizziness, and decreased urine output. Denies fever, abdominal pain, or diarrhea. No history of thyroid disease or molar pregnancy.
Clinical Examination Findings
Vitals: BP [value], HR [value], Temp [value]. General: Patient appears dehydrated, dry mucous membranes, poor skin turgor. HEENT: No thyromegaly. Cardiovascular: Tachycardic, regular rhythm. Abdominal: Soft, non-tender, no guarding or rebound. Neurological: Alert and oriented, no focal deficits.
Treatment Protocol
Plan: 1. Admit for IV fluid resuscitation (Lactated Ringerโs). 2. NPO for bowel rest. 3. Antiemetic therapy: Ondansetron [dose] IV q8h, Metoclopramide [dose] IV q6h. 4. Thiamine supplementation [dose] IV. 5. Monitor electrolytes, BUN/Cr, and urine ketones. 6. Daily weights and strict I/O monitoring.