SAMANTHA GRAVES CASE STUDY: 18-MONTH-OLD WITH
VOMITING AND DIARRHEA | PEDIATRIC DEHYDRATION
ASSESSMENT & ORAL REHYDRATION PROTOCOL |
CHAMBERLAIN MSN ASSIGNMENT
, Table of Contents
1. Reason for Encounter
2. OLD-CARTS for the HPI
3. Past Medical History
4. Family History
5. Social History
6. Review of Systems
7. Vital Signs
8. Physical Examination
9. Differential Diagnosis
10. Diagnostic Workup
11. Laboratory Results
12. Imaging Results
13. Final Diagnosis
14. Pathophysiology
15. Management Plan
16. Monitoring Plan
17. Patient Education
18. Prognosis
19. Potential Complications
20. Follow-Up Plan
21. SOAP Note Summary
, Patient: Samantha Graves
Age: 18 months
Sex: Female
Height: 2' 6" (76 cm)
Weight: 26.0 lb (11.8 kg)
Setting: Outpatient clinic with laboratory capabilities
Chief Complaint: Vomiting and diarrhea
Reason for Encounter
Graded Approach Question Response Information Obtained /
Clinic Notes
%Ï Open-ended What brings you and She has been vomiting Parent is here for
Samantha in today? and has diarrhea, and she evaluation of vomiting
just seems so sick. and diarrhea in her
18-month-old daughter.
%Ï CC Sx Can you tell me more She just can't keep Vomiting is a primary
about her vomiting? anything down. complaint.
%Ï CC Sx Can you tell me more She's had several watery Diarrhea is also a
about her diarrhea? diapers since yesterday. primary compliant.
%Ï Assoc Sx Has she had a fever? Yes, she feels really Associated symptom of
warm. fever.
%Ï Assoc Sx How is her energy level? She is very sleepy and Associated symptom of
not playing at all. lethargy.
%Ï Assoc Sx How has her eating and She doesn't want to eat Associated poor oral
drinking been? or drink anything. intake and anorexia.
OLD-CARTS for the HPI
Graded Approach Question Response Information Obtained /
Clinic Notes
%Ï Onset When did the vomiting She started throwing up Symptoms began
and diarrhea start? yesterday morning, and approximately 24-30
the diarrhea started a few hours ago.
hours later.
VOMITING AND DIARRHEA | PEDIATRIC DEHYDRATION
ASSESSMENT & ORAL REHYDRATION PROTOCOL |
CHAMBERLAIN MSN ASSIGNMENT
, Table of Contents
1. Reason for Encounter
2. OLD-CARTS for the HPI
3. Past Medical History
4. Family History
5. Social History
6. Review of Systems
7. Vital Signs
8. Physical Examination
9. Differential Diagnosis
10. Diagnostic Workup
11. Laboratory Results
12. Imaging Results
13. Final Diagnosis
14. Pathophysiology
15. Management Plan
16. Monitoring Plan
17. Patient Education
18. Prognosis
19. Potential Complications
20. Follow-Up Plan
21. SOAP Note Summary
, Patient: Samantha Graves
Age: 18 months
Sex: Female
Height: 2' 6" (76 cm)
Weight: 26.0 lb (11.8 kg)
Setting: Outpatient clinic with laboratory capabilities
Chief Complaint: Vomiting and diarrhea
Reason for Encounter
Graded Approach Question Response Information Obtained /
Clinic Notes
%Ï Open-ended What brings you and She has been vomiting Parent is here for
Samantha in today? and has diarrhea, and she evaluation of vomiting
just seems so sick. and diarrhea in her
18-month-old daughter.
%Ï CC Sx Can you tell me more She just can't keep Vomiting is a primary
about her vomiting? anything down. complaint.
%Ï CC Sx Can you tell me more She's had several watery Diarrhea is also a
about her diarrhea? diapers since yesterday. primary compliant.
%Ï Assoc Sx Has she had a fever? Yes, she feels really Associated symptom of
warm. fever.
%Ï Assoc Sx How is her energy level? She is very sleepy and Associated symptom of
not playing at all. lethargy.
%Ï Assoc Sx How has her eating and She doesn't want to eat Associated poor oral
drinking been? or drink anything. intake and anorexia.
OLD-CARTS for the HPI
Graded Approach Question Response Information Obtained /
Clinic Notes
%Ï Onset When did the vomiting She started throwing up Symptoms began
and diarrhea start? yesterday morning, and approximately 24-30
the diarrhea started a few hours ago.
hours later.
