CHART NOTE
This 24-year-old female relates a history of having her first pregnancy complicated with severe hyperemesis. She stated she was hospitalized for 6 weeks because of this. The patient relates she had been vomiting persistently for almost a week to a week and a half with this pregnancy. The patient had 1+ bacteria in the catheterized urine specimen. She had no CVA tenderness on examination.
In view of the persistent vomiting and urinary tract infection, the mild dehydration, it was elected to admit the patient for IV hydration and parenteral antibiotic therapy.
IMPRESSION
My impression is intrauterine pregnancy, 7+ weeks’ gestation by dates confirmed clinically, with hyperemesis gravidarum and urinary tract infection.
FOOTNOTE
Line 12. The slang term cath’d was expanded to catheterized. The abbreviation CVA was expanded to (costovertebral angle).
Line 16. Alternative: I.V.
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