Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
Severity and frequency of nausea and vomiting
Inability to keep fluids down
Weight loss
Fatigue, weakness
Electrolyte imbalance symptoms (dizziness, heart palpitations)
History of Present Illness:
Onset and duration of nausea and vomiting
Frequency and severity of vomiting episodes (projectile vs. non-projectile)
Presence of other GI symptoms (constipation, diarrhea)
Changes in appetite and food intake
Liquid intake and ability to keep fluids down
Past attempts at home management (diet changes, ginger, medications)
Past Medical History:
History of hyperemesis gravidarum in previous pregnancies (if applicable)
Other medical conditions (e.g., gastroesophageal reflux disease, peptic ulcer disease)
Prior surgeries
Medications (current and recent) – including prenatal vitamins
Family History:
Family history of hyperemesis gravidarum (first-degree relatives)
Social History:
Pre-pregnancy weight and current weight
Dietary habits
Psychological stressors
Physical Examination:
Vital signs (orthostatic hypotension may be present with dehydration)
General appearance (dehydration, malnutrition)
Oral exam (dehydration signs like dry mucous membranes)
Abdominal exam (organomegaly unlikely)
Neurologic exam (orientation, mental status)
Laboratory Tests:
Complete blood count (CBC) – may show anemia
Electrolytes (sodium, potassium, chloride) – to assess for imbalances
Liver function tests – to rule out other causes of nausea and vomiting
Thyroid function tests (TSH) – to rule out hyperthyroidism
Urinalysis – to assess for dehydration and ketones (may indicate breakdown of muscle for energy)
Human chorionic gonadotropin (hCG) level (if pregnancy not confirmed)
Imaging Studies:
Imaging studies are typically not needed for diagnosis unless other conditions are suspected (e.g., appendicitis).
Diagnosis:
Hyperemesis gravidarum (based on clinical presentation)
Treatment Plan:
Dietary modifications (small frequent meals, bland foods, ginger may be helpful)
Hydration management:
Intravenous fluids (if unable to keep fluids down orally)
Oral rehydration solutions (if tolerated)
Anti-emetic medications (various options available, chosen based on severity and side effects)
Vitamin supplementation (prenatal vitamins and electrolytes as needed)
Psychological support (counseling, relaxation techniques)
Prognosis:
Discuss the expected course of hyperemesis gravidarum, which typically improves by the second trimester.
Importance of monitoring for improvement and potential complications of dehydration and malnutrition.
Patient Education:
Importance of maintaining hydration (even if small amounts at a time)
Dietary modifications to manage nausea and vomiting
Importance of prenatal vitamins and potential need for electrolyte replacement
Warning signs of worsening dehydration (dizziness, decreased urination)
Stress management techniques
Next Follow-up:
Schedule for the next appointment depends on the severity of symptoms and response to treatment.
Close monitoring of weight, hydration status, and laboratory tests.
Earlier follow-up if symptoms worsen or dehydration develops.