I -HUMAN PEDIATRIC CASE STUDY: SAMANTHA GRAVES
(18-MONTH-OLD WITH VOMITING & DIARRHEA) | ACUTE
GASTROENTERITIS + DEHYDRATION MANAGEMENT &
FULL SOAP NOTE
Table of Contents
1 . Case Overview & Problem Statement
2. Patient Demographics & Vitals
3. Chief Complaint & History of Present Illness
4. Recommended Interview Questions & Rationale
5. Past Medical, Family & Social History
6. Review of Systems (ROS)
7. Physical Examination
8. Key Findings Summary
9. Clinical Assessment
10.Diagnostic Tests & Lab Interpretation
11.Differential Diagnosis
, 1 2.Final Diagnosis & Classification
13.Pathophysiology of Atopic Dermatitis
14.SOAP Note (Full and Comprehensive)
15.Treatment & Management Plan
16.Patient & Caregiver Education
17.Follow-Up & Monitoring Plan
1. Case Overview & Problem Statement
amantha Graves is an 18-month-old toddler brought to the clinic by her mother
S
for vomiting and diarrhea that began two days ago. The child has had multiple
loose stools, decreased oral intake, and fewer wet diapers than usual. The primary
clinical concern is acute gastroenteritis with possible mild to moderate
dehydration. The immediate priorities are hydration assessment, identification of
warning signs, ruling out serious bacterial or surgical causes, and developing a safe
outpatient management plan.
his case focuses on evaluating the severity of fluid loss, determining the likely
T
infectious etiology, and educating the caregiver on home care and when to seek
urgent medical attention.
2. Patient Demographics & Vitals
atient Name:Samantha Graves
P
Age:18 months
Sex:Female
Weight:11.2 kg
Height:80 cm
Setting:Pediatric clinic / urgent care
Vital Signs
T
● emperature: 37.8°C (100.0°F)
● Heart Rate: 132 bpm
● Respiratory Rate: 28 breaths/min
, B
● lood Pressure: 88/54 mmHg
● Oxygen Saturation: 99% on room air
Hydration-related observations
● ucous membranes mildly dry
M
● Tears decreased
● Capillary refill 2–3 seconds
● Mildly decreased urine output
● Alert but irritable
3. Chief Complaint & History of Present Illness
Chief Complaint:“She has been vomiting and having diarrhea.”
istory of Present Illness:
H
Samantha is an 18-month-old previously healthy child who presents with 2 days of
vomiting and diarrhea. According to her mother, the vomiting began first and
occurred 3–4 times on the first day, with non-bilious, non-bloody emesis after
feeding. Loose stools began later the same day and have continued, occurring
about 5–6 times per day. The stools are watery, without visible blood or mucus.
he has had reduced appetite and is drinking small amounts of water and diluted
S
juice, but she vomits some feeds. Her mother reports she is less active than usual
and has had fewer wet diapers, with only 2 wet diapers in the last 24 hours. No
known sick contacts are confirmed, but she attends daycare. No recent travel, no
ingestion of suspicious food, and no exposure to antibiotics is reported.
here is no history of bilious vomiting, projectile vomiting, severe abdominal
T
distention, bloody stool, high fever, seizure, or lethargy. The presentation most
strongly suggests viral gastroenteritis with early dehydration.
4. Recommended Interview Questions & Rationale
(18-MONTH-OLD WITH VOMITING & DIARRHEA) | ACUTE
GASTROENTERITIS + DEHYDRATION MANAGEMENT &
FULL SOAP NOTE
Table of Contents
1 . Case Overview & Problem Statement
2. Patient Demographics & Vitals
3. Chief Complaint & History of Present Illness
4. Recommended Interview Questions & Rationale
5. Past Medical, Family & Social History
6. Review of Systems (ROS)
7. Physical Examination
8. Key Findings Summary
9. Clinical Assessment
10.Diagnostic Tests & Lab Interpretation
11.Differential Diagnosis
, 1 2.Final Diagnosis & Classification
13.Pathophysiology of Atopic Dermatitis
14.SOAP Note (Full and Comprehensive)
15.Treatment & Management Plan
16.Patient & Caregiver Education
17.Follow-Up & Monitoring Plan
1. Case Overview & Problem Statement
amantha Graves is an 18-month-old toddler brought to the clinic by her mother
S
for vomiting and diarrhea that began two days ago. The child has had multiple
loose stools, decreased oral intake, and fewer wet diapers than usual. The primary
clinical concern is acute gastroenteritis with possible mild to moderate
dehydration. The immediate priorities are hydration assessment, identification of
warning signs, ruling out serious bacterial or surgical causes, and developing a safe
outpatient management plan.
his case focuses on evaluating the severity of fluid loss, determining the likely
T
infectious etiology, and educating the caregiver on home care and when to seek
urgent medical attention.
2. Patient Demographics & Vitals
atient Name:Samantha Graves
P
Age:18 months
Sex:Female
Weight:11.2 kg
Height:80 cm
Setting:Pediatric clinic / urgent care
Vital Signs
T
● emperature: 37.8°C (100.0°F)
● Heart Rate: 132 bpm
● Respiratory Rate: 28 breaths/min
, B
● lood Pressure: 88/54 mmHg
● Oxygen Saturation: 99% on room air
Hydration-related observations
● ucous membranes mildly dry
M
● Tears decreased
● Capillary refill 2–3 seconds
● Mildly decreased urine output
● Alert but irritable
3. Chief Complaint & History of Present Illness
Chief Complaint:“She has been vomiting and having diarrhea.”
istory of Present Illness:
H
Samantha is an 18-month-old previously healthy child who presents with 2 days of
vomiting and diarrhea. According to her mother, the vomiting began first and
occurred 3–4 times on the first day, with non-bilious, non-bloody emesis after
feeding. Loose stools began later the same day and have continued, occurring
about 5–6 times per day. The stools are watery, without visible blood or mucus.
he has had reduced appetite and is drinking small amounts of water and diluted
S
juice, but she vomits some feeds. Her mother reports she is less active than usual
and has had fewer wet diapers, with only 2 wet diapers in the last 24 hours. No
known sick contacts are confirmed, but she attends daycare. No recent travel, no
ingestion of suspicious food, and no exposure to antibiotics is reported.
here is no history of bilious vomiting, projectile vomiting, severe abdominal
T
distention, bloody stool, high fever, seizure, or lethargy. The presentation most
strongly suggests viral gastroenteritis with early dehydration.
4. Recommended Interview Questions & Rationale
