Tx Plan Toddler Sick Visit: Gastrointestinal. Zachary Lafontaine 30 months old
, Treatment Plan – Toddler Sick Visit: Gastrointestinal
Patient: Zachary Lafontaine
Age: 30 months
Date: [Insert Date]
Reason for Visit: Gastrointestinal symptoms (vomiting, diarrhea,
abdominal pain, possible dehydration)
1. Assessment
• Likely acute gastroenteritis (viral most common in toddlers).
• Evaluate hydration status (mild, moderate, severe).
• Rule out red flags: persistent vomiting, bloody diarrhea, severe
dehydration, lethargy, abdominal distension, high fever.
2. History & Physical Exam Focus
• Onset, frequency, and duration of vomiting/diarrhea.
• Stool characteristics: watery, bloody, mucus.
• Oral intake and urine output.
• Associated symptoms: fever, abdominal pain, irritability.
• Past medical history, medications, allergies, vaccination status.
• Physical exam: vital signs, capillary refill, mucous membranes,
fontanelle (if still present), abdominal tenderness, bowel sounds.
3. Diagnostic Tests (if indicated)
• Rapid stool testing for pathogens (if bloody or severe diarrhea).
, Treatment Plan – Toddler Sick Visit: Gastrointestinal
Patient: Zachary Lafontaine
Age: 30 months
Date: [Insert Date]
Reason for Visit: Gastrointestinal symptoms (vomiting, diarrhea,
abdominal pain, possible dehydration)
1. Assessment
• Likely acute gastroenteritis (viral most common in toddlers).
• Evaluate hydration status (mild, moderate, severe).
• Rule out red flags: persistent vomiting, bloody diarrhea, severe
dehydration, lethargy, abdominal distension, high fever.
2. History & Physical Exam Focus
• Onset, frequency, and duration of vomiting/diarrhea.
• Stool characteristics: watery, bloody, mucus.
• Oral intake and urine output.
• Associated symptoms: fever, abdominal pain, irritability.
• Past medical history, medications, allergies, vaccination status.
• Physical exam: vital signs, capillary refill, mucous membranes,
fontanelle (if still present), abdominal tenderness, bowel sounds.
3. Diagnostic Tests (if indicated)
• Rapid stool testing for pathogens (if bloody or severe diarrhea).
