A 31-year-old woman, gravida 1 para 0, at 8 weeks gestation is brought to the emergency department for persistent nausea, vomiting,
epigastric pain, and dizziness. The patient has been unable to tolerate any oral intake for the past day. This pregnancy was attained
through intrauterine insemination with donor sperm She has a history of esophageal reflux for which she takes an over-the-counter
antacid. Prior to pregnancy, the patient drank socially but stopped all alcohol use before her insemination. Temperature is 36.7 C (98
F), blood pressure is 90/50 mm Hg, and pulse is 114/min. Her current weight is 55 kg (121 3 lb), a decrease of 3 kg (6.6 lb) from her
prepregnancy weight Physical examination shows dry mucous membranes and decreased skin turgor Cardiac examination shows
tachycardia but a regular rhythm with no murmurs. The thyroid is nonenlarged and has no palpable masses. Abdominal examination
shows epigastric tenderness with deep palpation but no rebound, guarding, or palpable masses. A bedside transvaginal ultrasound
confirms the presence of an 8-week twin intrauterine gestation with 2 normal fetal heartbeats. Which of the following is the best next
step in the evaluation of this patient?
QA 24-hour urine protein collection
0 B. Quantitative 13-hCG level
0 C. Serum T3 and T 4 levels
0 D. Upper endoscopy
0 E. Urinalysis for ketones
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