lOMoARcPSD|60399657
1
IHUMAN PEDIATRICS WEEK 7 CASE
STUDY SAMANTHA GRAVES 18-
MONTH-OLD FEMALE WITH VOMITING
AND DIARRHEA – ACUTE VIRAL
GASTROENTERITIS SOAP NOTE
This iHuman Pediatrics Week 7 case study reviews Samantha Graves, an 18-month-old female
presenting with vomiting and diarrhea. Includes a full SOAP note, differential diagnoses,
assessment of dehydration, treatment plan, and clinical reasoning for acute viral gastroenteritis.
iHuman Pediatrics Week 7
Samantha Graves case study
18-month-old vomiting and diarrhea
pediatric gastroenteritis SOAP note
viral gastroenteritis toddler
Name: Samantha Graves
Age: 18 months
Gender: Female
Date of Visit: [Insert date]
Chief Complaint (CC): “Vomiting and diarrhea”
, lOMoARcPSD|60399657
2
S – Subjective
History of Present Illness (HPI)
Samantha Graves is an 18-month-old female brought in by her mother due to vomiting and
diarrhea for the past 2 days. The mother reports that Samantha has had 5 episodes of non-
bloody, non-bilious vomiting and 6–7 episodes of loose, watery stools in the last 24 hours. The
diarrhea is described as yellow and foul-smelling with no blood or mucus.
The mother reports decreased appetite, poor oral intake, and increased fussiness. Samantha
has been drinking small amounts of fluids but often vomits shortly afterward. The mother also
notes decreased wet diapers (only 2 in the past 24 hours). No fever noted at home. No recent
travel. No known sick contacts but attends daycare.
Past Medical History
• Full-term vaginal delivery
• No chronic illnesses
• No prior hospitalizations
Surgical History
• None
Medications
• None
Allergies
• No known drug allergies (NKDA)
Immunizations
• Up to date per mother
Family History
• No significant GI or chronic illnesses
Social History
• Lives with parents
• Attends daycare
• No tobacco exposure
Review of Systems (ROS)
• General: Irritable, decreased activity
• GI: Positive for vomiting and diarrhea
• GU: Decreased urine output
• Respiratory: No cough or SOB
• Skin: No rash
• Neuro: No seizures or lethargy
O – Objective
Vital Signs
, lOMoARcPSD|60399657
3
• Temp: 37.3°C (99.1°F)
• HR: 128 bpm
• RR: 26/min
• BP: 88/54 mmHg
• SpO₂: 99% RA
• Weight: 10.5 kg
Physical Exam
General:
Irritable toddler, appears mildly ill but alert
HEENT:
Dry mucous membranes, sunken eyes, no tears when crying
Cardiovascular:
Tachycardic, regular rhythm
Respiratory:
Clear to auscultation bilaterally
Abdomen:
Soft, mildly distended, hyperactive bowel sounds, no tenderness
Skin:
Poor skin turgor, warm
Neuro:
Alert, responsive
A – Assessment
Primary Diagnosis
Acute Viral Gastroenteritis with Mild–Moderate Dehydration
Differential Diagnoses
1. Bacterial gastroenteritis
2. Food intolerance
3. Urinary tract infection
4. Intussusception (less likely – no severe pain or bloody stools)
P – Plan
Diagnostics
• No labs needed at this time (clinically stable)
• Stool culture if symptoms worsen or blood appears
Treatment
• Oral rehydration therapy (Pedialyte)
• Small frequent sips every 5–10 minutes
, lOMoARcPSD|60399657
4
• Avoid juice and milk temporarily
• Continue age-appropriate diet (BRAT: banana, rice, applesauce, toast)
Medications
• Ondansetron PRN for vomiting (if prescribed)
Education
• Signs of dehydration: no tears, dry mouth, lethargy
• Hand hygiene to prevent spread
• Return if no urination in 8 hours, blood in stool, fever >38.5°C
Follow-Up
• Pediatrician follow-up in 24–48 hours
🩺 VERSION 2 – Bacterial Gastroenteritis with Moderate Dehydration
Identifying Information
Name: Samantha Graves
Age: 18 months
Gender: Female
Chief Complaint: “She keeps throwing up and has diarrhea”
S – Subjective
HPI
Samantha Graves is an 18-month-old female presenting with 3 days of vomiting and diarrhea.
Mother reports 8–10 watery stools daily and frequent vomiting after meals. Stools are green
and foul-smelling. Samantha has had a low-grade fever (100.8°F) and appears very tired.
She recently attended a family picnic where multiple children developed GI symptoms. Oral
intake is minimal, and she has had only one wet diaper in the past 12 hours.
PMH
• Healthy toddler
Medications
• Acetaminophen given once
Allergies
• NKDA
ROS
• General: Fatigue, poor feeding
• GI: Severe diarrhea, vomiting
• GU: Oliguria
• Skin: Dry lips
• Neuro: Less active than normal
1
IHUMAN PEDIATRICS WEEK 7 CASE
STUDY SAMANTHA GRAVES 18-
MONTH-OLD FEMALE WITH VOMITING
AND DIARRHEA – ACUTE VIRAL
GASTROENTERITIS SOAP NOTE
This iHuman Pediatrics Week 7 case study reviews Samantha Graves, an 18-month-old female
presenting with vomiting and diarrhea. Includes a full SOAP note, differential diagnoses,
assessment of dehydration, treatment plan, and clinical reasoning for acute viral gastroenteritis.
iHuman Pediatrics Week 7
Samantha Graves case study
18-month-old vomiting and diarrhea
pediatric gastroenteritis SOAP note
viral gastroenteritis toddler
Name: Samantha Graves
Age: 18 months
Gender: Female
Date of Visit: [Insert date]
Chief Complaint (CC): “Vomiting and diarrhea”
, lOMoARcPSD|60399657
2
S – Subjective
History of Present Illness (HPI)
Samantha Graves is an 18-month-old female brought in by her mother due to vomiting and
diarrhea for the past 2 days. The mother reports that Samantha has had 5 episodes of non-
bloody, non-bilious vomiting and 6–7 episodes of loose, watery stools in the last 24 hours. The
diarrhea is described as yellow and foul-smelling with no blood or mucus.
The mother reports decreased appetite, poor oral intake, and increased fussiness. Samantha
has been drinking small amounts of fluids but often vomits shortly afterward. The mother also
notes decreased wet diapers (only 2 in the past 24 hours). No fever noted at home. No recent
travel. No known sick contacts but attends daycare.
Past Medical History
• Full-term vaginal delivery
• No chronic illnesses
• No prior hospitalizations
Surgical History
• None
Medications
• None
Allergies
• No known drug allergies (NKDA)
Immunizations
• Up to date per mother
Family History
• No significant GI or chronic illnesses
Social History
• Lives with parents
• Attends daycare
• No tobacco exposure
Review of Systems (ROS)
• General: Irritable, decreased activity
• GI: Positive for vomiting and diarrhea
• GU: Decreased urine output
• Respiratory: No cough or SOB
• Skin: No rash
• Neuro: No seizures or lethargy
O – Objective
Vital Signs
, lOMoARcPSD|60399657
3
• Temp: 37.3°C (99.1°F)
• HR: 128 bpm
• RR: 26/min
• BP: 88/54 mmHg
• SpO₂: 99% RA
• Weight: 10.5 kg
Physical Exam
General:
Irritable toddler, appears mildly ill but alert
HEENT:
Dry mucous membranes, sunken eyes, no tears when crying
Cardiovascular:
Tachycardic, regular rhythm
Respiratory:
Clear to auscultation bilaterally
Abdomen:
Soft, mildly distended, hyperactive bowel sounds, no tenderness
Skin:
Poor skin turgor, warm
Neuro:
Alert, responsive
A – Assessment
Primary Diagnosis
Acute Viral Gastroenteritis with Mild–Moderate Dehydration
Differential Diagnoses
1. Bacterial gastroenteritis
2. Food intolerance
3. Urinary tract infection
4. Intussusception (less likely – no severe pain or bloody stools)
P – Plan
Diagnostics
• No labs needed at this time (clinically stable)
• Stool culture if symptoms worsen or blood appears
Treatment
• Oral rehydration therapy (Pedialyte)
• Small frequent sips every 5–10 minutes
, lOMoARcPSD|60399657
4
• Avoid juice and milk temporarily
• Continue age-appropriate diet (BRAT: banana, rice, applesauce, toast)
Medications
• Ondansetron PRN for vomiting (if prescribed)
Education
• Signs of dehydration: no tears, dry mouth, lethargy
• Hand hygiene to prevent spread
• Return if no urination in 8 hours, blood in stool, fever >38.5°C
Follow-Up
• Pediatrician follow-up in 24–48 hours
🩺 VERSION 2 – Bacterial Gastroenteritis with Moderate Dehydration
Identifying Information
Name: Samantha Graves
Age: 18 months
Gender: Female
Chief Complaint: “She keeps throwing up and has diarrhea”
S – Subjective
HPI
Samantha Graves is an 18-month-old female presenting with 3 days of vomiting and diarrhea.
Mother reports 8–10 watery stools daily and frequent vomiting after meals. Stools are green
and foul-smelling. Samantha has had a low-grade fever (100.8°F) and appears very tired.
She recently attended a family picnic where multiple children developed GI symptoms. Oral
intake is minimal, and she has had only one wet diaper in the past 12 hours.
PMH
• Healthy toddler
Medications
• Acetaminophen given once
Allergies
• NKDA
ROS
• General: Fatigue, poor feeding
• GI: Severe diarrhea, vomiting
• GU: Oliguria
• Skin: Dry lips
• Neuro: Less active than normal
