hyperemesis gravidarum

no PMH/PSH p/w n/v in context of pregnancy.
EGA 6 wks by LMP and corrolorated by US
Has already had US confirming IUP per pt.
Emesis nb/nb.
Denies other infectious sx suggesting focal infectioun. Also denies dysuria, denies vaginal discharge.
Denies abd pain/vaginal bleeding.
Has OB f/u
Initial Impression/Empiric management: Suspected hyperemesis gravidarum
Preg test positive
No electrolyte derangements.
PO trial – pt tolerated POs after treatment.
Therapeutically: Patient given B6. Pt given Zofran from triage. I explained unknown definitive evidence of teratrogenicity of Zofran. Pt adamentaly still requests Zofran stating that is what works. As such, will obligue patient’s wishes.
ED Course/Reevaluation: Tolerated POs. Repeat abd exam benign.
Presentation is most consistent with hyperemesis gravidarum
DDx – Considered the following diagnoses though based upon evaluation, pt does not meet reasonable level of consistency with characteristic findings/likelihood for further pursuit at this time (risks/outweigh benefits of non-indicated testing). Shared decision making with with pt attempted to the extent possible.
Not c/w pregnancy related complication (molar pregnancy) given US showed normal IUP per pt.
Not c/w infectioius preciipitant given no infectiouos sx on ROS.
Not c/w ectopic given US showed IUP, no vaginal bleeding, no abd pain.
Disposition: home w/ prompt OB f/u. Pt given rx for B6 (preg class A). Given breakthrough rx for rectal compazine (preg class B) and zofran ODT (preg class C) and patient counseled extensively on the importance to try B6 and the risks of taking the other medications.
Pt advised of return precautions, specifically inability to tolerate POs. 
Counseling: Patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with proposed plan. All questions and concerns answered and addressed.
Supervision: Discussed and obtained approval/confirmation of evaluation (history/exam/diagnostics) and plan (assessment/interventions/disposition) with ED attending physician

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