ZACHARY LAFONTAINE TODDLER SICK VISIT GI ACTUAL
2026/2027 | Complete SOAP Note Transcript with Clinical
Rationales | GRADED A | Pass Guaranteed
Patient Demographics
Table
Field Documentation
Patient Name Zachary Lafontaine
Age 30 months (2 years 6 months)
Date of Visit March 15, 2026
Mother (Mrs. Amélie Lafontaine), reliable historian; patient non-verbal
Source of Information
but interactive
Chief Complaint "Vomiting and diarrhea for 2 days" [per mother]
Accompanied by Mother and maternal grandmother
Interpreter None required (English primary language)
Section 1: Subjective Data — Complete Transcript
,History of Present Illness (HPI)
[COMPLETE SOLUTION]
Onset: Symptoms began approximately 48 hours prior to presentation (March 13, 2026,
~1400 hours) when Zachary developed sudden non-bilious, non-bloody emesis
approximately 30 minutes after lunch. Initial episode occurred at home without
prodrome.
Duration: Continuous illness course over 48 hours with progressive symptom evolution.
Character of Emesis: Initially described as "food contents" progressing to clear fluid.
Mother reports total of 8-10 episodes in 48 hours, with 3 episodes in past 24 hours.
Emesis characterized as forceful, projectile at times, non-bilious (no green
discoloration), non-bloody. Largest volume estimated "half a cup." No coffee-ground
appearance. Associated with retching and gagging. No relief with attempted oral intake.
Character of Diarrhea: First loose stool noted 6 hours after initial vomiting (March 13,
~2000 hours). Mother describes "watery, no blood, very smelly" stools. Frequency: 6-7
episodes in past 24 hours, increased from 3-4 episodes on Day 1. Stool consistency:
liquid, without mucus or visible blood. Color described as "light brown, sometimes
greenish." No oil droplets or frothy appearance.
Associated Symptoms:
● Fever: Low-grade temperature elevation noted by mother (38.2°C/100.8°F
axillary) on Day 1, resolved with acetaminophen. No fever in past 12 hours per
home monitoring.
● Abdominal Pain: Mother reports Zachary "grabs his tummy" and cries
intermittently, particularly before stooling. Pain appears crampy, relieved
momentarily after diarrhea episode.
● Behavioral Changes: Increased irritability, decreased playfulness, "clingy"
behavior, refusing to walk independently (wants to be carried).
, ● Respiratory: Occasional cough noted Day 1 (post-tussive emesis suspected),
resolved. No nasal congestion, no respiratory distress.
Intake/Output History:
● Fluid Intake: Significantly decreased. Refusing regular milk (normally 16-20
oz/day). Accepting small sips of water and diluted apple juice (mother diluted 1:1
with water). Estimated intake past 24 hours: ~300-400 mL (significantly below
maintenance).
● Urine Output: Mother reports 3 wet diapers in past 24 hours (baseline 6-8), last
void 6 hours prior to arrival. Urine described as "dark yellow, strong smell."
● Tears: Present when crying but "not as many as usual."
Treatments Attempted at Home:
● Acetaminophen 160mg (1 tsp) given twice in past 48 hours for fever/discomfort
(last dose 14 hours ago).
● Attempted oral Pedialyte (mother purchased yesterday) — Zachary refused after
2 oz.
● BRAT diet attempted (banana, rice, applesauce) — minimal intake, vomited rice.
● Probiotic (Culturelle Kids) started yesterday — discontinued after emesis.
Exposures:
● Daycare: Attends "Little Explorers Daycare" 3 days/week (Mon/Wed/Fri). Last
attendance Wednesday March 11. Mother notified by daycare director of
"stomach bug" circulating among toddlers (3 other children sent home with
vomiting this week).
● Sick Contacts: Older sibling (age 5, kindergarten) had similar illness 5 days ago
(resolved). Father had mild diarrhea 2 days ago (working from home).
● Travel: No recent travel outside local area. No camping, lake swimming, or
petting zoo visits in past 2 weeks.
● Food exposures: No new foods introduced. No restaurant meals in past week. No
unpasteurized dairy or undercooked meats.
, Progression: Mother states symptoms "getting worse" with increased stool frequency
and persistent refusal of oral intake. Concerned about dehydration ("he's not himself,
very sleepy").
Review of Systems (ROS) — GI Focus with Complete System Review
[COMPLETE SOLUTION]
Table
System Findings
Positive for fatigue, irritability, decreased activity level. Negative for lethargy
Constitutional
(arousable), syncope, weight loss (acute).
Eyes: Mother notes "eyes look sunken" when crying. No periorbital edema.
HEENT Mouth: Dry lips noted, "tongue looks white." No oral lesions. Throat: Not
examined at home, no drooling, no dysphagia reported.
No chest pain, no palpitations (observed), no cyanosis. Mother notes "heart
Cardiovascular
seems to be beating fast" when child sleeping.
Occasional cough (resolved), no wheezing, no retractions, no nasal flaring.
Respiratory
Breathing "seems faster than usual" per mother.
Positive: Nausea (inferred from food refusal), vomiting (8-10 episodes),
diarrhea (6-7 episodes/24h), abdominal pain (intermittent cramping),
GI
decreased appetite (complete solids refusal today). Negative: No
hematemesis, no hematochezia, no melena, no constipation, no jaundice.
2026/2027 | Complete SOAP Note Transcript with Clinical
Rationales | GRADED A | Pass Guaranteed
Patient Demographics
Table
Field Documentation
Patient Name Zachary Lafontaine
Age 30 months (2 years 6 months)
Date of Visit March 15, 2026
Mother (Mrs. Amélie Lafontaine), reliable historian; patient non-verbal
Source of Information
but interactive
Chief Complaint "Vomiting and diarrhea for 2 days" [per mother]
Accompanied by Mother and maternal grandmother
Interpreter None required (English primary language)
Section 1: Subjective Data — Complete Transcript
,History of Present Illness (HPI)
[COMPLETE SOLUTION]
Onset: Symptoms began approximately 48 hours prior to presentation (March 13, 2026,
~1400 hours) when Zachary developed sudden non-bilious, non-bloody emesis
approximately 30 minutes after lunch. Initial episode occurred at home without
prodrome.
Duration: Continuous illness course over 48 hours with progressive symptom evolution.
Character of Emesis: Initially described as "food contents" progressing to clear fluid.
Mother reports total of 8-10 episodes in 48 hours, with 3 episodes in past 24 hours.
Emesis characterized as forceful, projectile at times, non-bilious (no green
discoloration), non-bloody. Largest volume estimated "half a cup." No coffee-ground
appearance. Associated with retching and gagging. No relief with attempted oral intake.
Character of Diarrhea: First loose stool noted 6 hours after initial vomiting (March 13,
~2000 hours). Mother describes "watery, no blood, very smelly" stools. Frequency: 6-7
episodes in past 24 hours, increased from 3-4 episodes on Day 1. Stool consistency:
liquid, without mucus or visible blood. Color described as "light brown, sometimes
greenish." No oil droplets or frothy appearance.
Associated Symptoms:
● Fever: Low-grade temperature elevation noted by mother (38.2°C/100.8°F
axillary) on Day 1, resolved with acetaminophen. No fever in past 12 hours per
home monitoring.
● Abdominal Pain: Mother reports Zachary "grabs his tummy" and cries
intermittently, particularly before stooling. Pain appears crampy, relieved
momentarily after diarrhea episode.
● Behavioral Changes: Increased irritability, decreased playfulness, "clingy"
behavior, refusing to walk independently (wants to be carried).
, ● Respiratory: Occasional cough noted Day 1 (post-tussive emesis suspected),
resolved. No nasal congestion, no respiratory distress.
Intake/Output History:
● Fluid Intake: Significantly decreased. Refusing regular milk (normally 16-20
oz/day). Accepting small sips of water and diluted apple juice (mother diluted 1:1
with water). Estimated intake past 24 hours: ~300-400 mL (significantly below
maintenance).
● Urine Output: Mother reports 3 wet diapers in past 24 hours (baseline 6-8), last
void 6 hours prior to arrival. Urine described as "dark yellow, strong smell."
● Tears: Present when crying but "not as many as usual."
Treatments Attempted at Home:
● Acetaminophen 160mg (1 tsp) given twice in past 48 hours for fever/discomfort
(last dose 14 hours ago).
● Attempted oral Pedialyte (mother purchased yesterday) — Zachary refused after
2 oz.
● BRAT diet attempted (banana, rice, applesauce) — minimal intake, vomited rice.
● Probiotic (Culturelle Kids) started yesterday — discontinued after emesis.
Exposures:
● Daycare: Attends "Little Explorers Daycare" 3 days/week (Mon/Wed/Fri). Last
attendance Wednesday March 11. Mother notified by daycare director of
"stomach bug" circulating among toddlers (3 other children sent home with
vomiting this week).
● Sick Contacts: Older sibling (age 5, kindergarten) had similar illness 5 days ago
(resolved). Father had mild diarrhea 2 days ago (working from home).
● Travel: No recent travel outside local area. No camping, lake swimming, or
petting zoo visits in past 2 weeks.
● Food exposures: No new foods introduced. No restaurant meals in past week. No
unpasteurized dairy or undercooked meats.
, Progression: Mother states symptoms "getting worse" with increased stool frequency
and persistent refusal of oral intake. Concerned about dehydration ("he's not himself,
very sleepy").
Review of Systems (ROS) — GI Focus with Complete System Review
[COMPLETE SOLUTION]
Table
System Findings
Positive for fatigue, irritability, decreased activity level. Negative for lethargy
Constitutional
(arousable), syncope, weight loss (acute).
Eyes: Mother notes "eyes look sunken" when crying. No periorbital edema.
HEENT Mouth: Dry lips noted, "tongue looks white." No oral lesions. Throat: Not
examined at home, no drooling, no dysphagia reported.
No chest pain, no palpitations (observed), no cyanosis. Mother notes "heart
Cardiovascular
seems to be beating fast" when child sleeping.
Occasional cough (resolved), no wheezing, no retractions, no nasal flaring.
Respiratory
Breathing "seems faster than usual" per mother.
Positive: Nausea (inferred from food refusal), vomiting (8-10 episodes),
diarrhea (6-7 episodes/24h), abdominal pain (intermittent cramping),
GI
decreased appetite (complete solids refusal today). Negative: No
hematemesis, no hematochezia, no melena, no constipation, no jaundice.
