Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Nausea and vomiting of pregnancy (NVP)
History of Present Illness:
Onset, duration, and severity of nausea and vomiting.
Frequency of vomiting episodes (e.g., several times a day, hourly).
Presence of other symptoms (e.g., heartburn, food aversions, ptyalism – excessive salivation).
Impact of symptoms on daily activities (work, school, social life).
Past Medical History:
History of NVP in previous pregnancies (if applicable).
Underlying medical conditions (e.g., gastroesophageal reflux disease – GERD).
History of prior surgeries (especially gastrointestinal surgery).
Medications currently taken (including prenatal vitamins).
Social History:
Dietary habits (identify any potential triggers or aversions).
Alcohol and caffeine intake (both can worsen nausea).
Physical Exam:
General examination: Assess for signs of dehydration (e.g., dry mucous membranes, poor skin turgor).
Abdominal examination: Assess for tenderness or distention.
Laboratory Tests:
In most cases of uncomplicated NVP, laboratory tests are not routinely performed unless concerning for dehydration or underlying medical conditions.
Consider electrolytes (sodium, potassium) and blood urea nitrogen (BUN) if dehydration is suspected.
Thyroid function tests (TSH) may be considered if there is a clinical concern for hyperthyroidism (less common cause of nausea and vomiting).
Assessment:
Nausea and vomiting of pregnancy (NVP): Based on characteristic symptoms occurring during pregnancy.
Dehydration (if present): Based on clinical signs and possibly laboratory findings (electrolytes, BUN).
Differential Diagnoses:
Consider other causes of nausea and vomiting, especially if symptoms are severe or uncontrolled:
Hyperemesis gravidarum (severe NVP)
Gastric ulcer
Appendicitis
Cholecystitis
Hyperthyroidism
Plan:
Dietary modifications:
Frequent small meals and snacks throughout the day.
Bland, easily digestible foods (e.g., crackers, toast, bananas).
Ginger (may help alleviate nausea).
Staying hydrated by sipping fluids throughout the day.
Medications (if symptoms are not adequately controlled by lifestyle modifications):
Vitamin B6 supplementation (may be helpful for some women).
Antihistamines (e.g., doxylamine) – can have drowsiness as a side effect.
Medication specific for nausea and vomiting in pregnancy (prescribed by healthcare provider).
Hydration management:
Oral rehydration solutions if dehydration is present.
Intravenous fluids may be necessary in severe cases.
Education:
Reassurance that NVP is a common pregnancy symptom and usually resolves by mid-second trimester.
Importance of maintaining adequate hydration and nutrition.
When to seek further medical attention (e.g., persistent vomiting, signs of dehydration).