A 24 yo G1P0 at 9 weeks gestation presents to the emergency department for evaluation of a picc line

Clinical Case Question:

A 24 yo G1P0 at 9 weeks gestation presents to the emergency department for evaluation of a picc line.

She was diagnosed with hyperemesis gravidarum and failed diclectin and oral therapy and this led to a PICC line being placed one week prior to her admission.

She indicates that there has been some slight itching at the sight of the PICC line. She continues to have nausea and vomiting and feels a bit better with iv fluids and gravol.

Her past medical history is unremarkable. She has a stated medical tape allergy, and is currently receiving IV hydration at home with gravol through her picc line at home since she did not tolerate oral medication well.

She complains of some itching on the right arm at the picc line insertion site. On exam her GCS is 15, she is AAOx3, and complains of some abdominal discomfort and back pain. She complains of Some mild chest discomfort. She indicates she has some redness, tenderness and discomfort at the tips of her fingers which is new. Her temperature is 38.1, heart rate 108, and BP 117/74. Due to the COVID pandemic the resident defers auscultation of the chest, lungs and abdomen but abdominal palpating is unremarkable.

In addition a CBC, picc line inspection, and chemistry panel, And HCG level are ordered. Only the CBC is back so far with a WBC of 13.8, and hemoglobin of 107, with platelets of 372k.

The first year emergency medicine resident discusses this with her staff, who points out that it would be important to arrange and consider the following:

1: Refractory hyperemesis gravidarum

Not responding to IV medication and hydration

2: Potential Mallory Weiss given the repeated episodes of vomiting

3: A stat ultrasound to evaluate the pregnancy

4: 2 stat blood cultures and empiric antibiotics with admission to hospital

5: Reassure the patient if the labs are abnormal to take Tylenol for fever and call their family doctor for a follow up

Please post your answer and explanation below

Thanks