Patient presents with intractable nausea and vomiting, refractory to standard antiemetic therapy.  The patient reports persistent nausea and frequent episodes of emesis, significantly impacting their quality of life and nutritional status.  Onset of symptoms was [timeframe] and potential contributing factors include [list potential etiologies e.g., chemotherapy, gastroparesis, cyclic vomiting syndrome, hyperemesis gravidarum, bowel obstruction, medication side effects].  The patient describes the nausea as [character of nausea e.g., constant, intermittent, wave-like] and the vomitus as [character of vomitus e.g., bilious, non-bilious, bloody, food particles].  Current medications include [list current medications, including antiemetics].  Physical examination reveals [relevant findings e.g., dehydration evidenced by dry mucous membranes and decreased skin turgor, abdominal distension or tenderness].  Differential diagnosis includes [list differential diagnoses].  Assessment includes intractable nausea and vomiting, with associated symptoms of [list associated symptoms e.g., dehydration, weight loss, electrolyte imbalance, malnutrition].  Plan includes further investigation with [diagnostic tests e.g., complete metabolic panel, complete blood count, abdominal imaging, upper endoscopy] to identify the underlying etiology.  Treatment plan includes initiation of [antiemetic regimen e.g., ondansetron, metoclopramide, prochlorperazine] and supportive care with intravenous fluids for hydration and electrolyte correction.  Patient education provided regarding medication management, dietary modifications, and potential complications.  Follow-up scheduled in [timeframe] to assess treatment response and adjust management as needed.  Medical coding considerations include ICD-10 code R11.2 for nausea and vomiting, unspecified, with additional codes for underlying conditions and complications as appropriate.  Billing considerations include documentation of medical necessity for diagnostic testing and treatment interventions.