NRNP 6541 Week 7 SOAP Note |
Courtney Graham Case Study with
Treatment Flowcharts & Differential
Diagnosis Matrix
Patient Name: Courtney Graham
Age: 18 months
Sex: Female
Length: 81 cm (50th percentile)
Weight: 11.8 kg (75th percentile)
Reason for Encounter: Vomiting and diarrhea
Subjective (S)
• Chief Complaint: Vomiting and loose stools for 2 days.
• History of Present Illness (HPI): An 18-month-old female presents with an acute
48-hour history of non-bilious, non-bloody emesis (5 episodes in the last 24 hours)
and watery, loose diarrhea (6 episodes in the last 24 hours). The mother reports the
illness began abruptly after the child returned from daycare, where multiple children
are reportedly out with similar symptoms.
• Character: The emesis consists of recently ingested fluids and undigested food
particles. The stools are watery, yellow-green, and free of visible blood or mucus.
• Associated Symptoms: The child exhibits intermittent, generalized abdominal
cramping, manifested by brief crying spells and drawing her knees up to her chest.
• Hydration Status: She has had 3 wet diapers over the past 24 hours (decreased
from her baseline of 6). Her fluid intake is minimal; she refuses solids but is tolerating
small, infrequent sips of water. No documented fever at home.
• Past Medical History (PMH): Born full-term via spontaneous vaginal delivery. No
prior hospitalizations or chronic medical conditions. Immunizations are fully up to
date, including the Rotavirus vaccine series.
• Family/Social History: Attends a community daycare 4 days a week. Lives with
both parents and a healthy 4-year-old sibling. No recent travel or unusual food
exposures.
• Review of Systems (ROS):
o General: Positive for mild lethargy and increased irritability. Negative for chills or
documented fever.
o HEENT: Negative for rhinorrhea, otalgia, or conjunctival injection.
o Gastrointestinal: Positive for watery diarrhea, non-bilious vomiting, and intermittent
generalized cramping. Negative for hematochezia or melena.
o Genitourinary: Decreased urine output (3 wet diapers in 24 hours). No hematuria.
o Integumentary: Negative for acute rashes or chronic skin conditions.
Figure 1: Subjective Pediatric Abdominal Pain & Symptom Map
, [ ANTERIOR VIEW ] [ POSTERIOR VIEW ]
\ _ / \ _ /
( o o ) ( . . )
\ _ / \ _ /
| |
.-----+-----. .-----+-----.
/ | | | \ / | | | \
| | R1| | | | | | | |
| +---+---+ | | +---+---+ |
| /| * * * |\ | | | | |
| | | *X* * | | | | | | |
| \| * * * |/ | | | | |
| +-------+ | | +-------+ |
\ | | / \ | | /
`-+-------+-' `-+-------+-'
| | | | | |
| | | | | |
================================= LEGEND
=================================
[ * * ] Shaded Area: Diffuse, poorly localized visceral cramping.
[ X ] Origin Point: Periumbilical cramping that does not radiate.
[ R1 ] Associated Symptom: Epigastric distress leading to active
emesis.
=======================================================================
===
Clinical Description: The visceral pain is diffuse and non-radiating, centered in the
periumbilical region, matching a standard clinical presentation of gut wall distension
and hyperperistalsis.
Objective (O)
• General Appearance: Alert but noticeably tired; clings tightly to her mother. She
cries intermittently during the abdominal exam but is easily consoled by a pacifier
and her mother's presence.
Table 1: Vital Signs and Reference Ranges
Patient Normal Reference Range
Vital Sign Clinical Interpretation
Value (12–24 Months)
Normal (high-normal due to mild
Heart Rate 128 bpm 80 – 130 bpm
dehydration)
Respiratory
28 cpm 24 – 40 cpm Normal
Rate
37.1°C
Temperature 36.5°C – 37.5°C (Axillary) Afebrile
(98.8°F)
Blood Pressure 86/52 mmHg 80––65 mmHg Stable (Low-normal diastolic)
Oxygen 99% on
95% – 100% Normal
Saturation room air
Courtney Graham Case Study with
Treatment Flowcharts & Differential
Diagnosis Matrix
Patient Name: Courtney Graham
Age: 18 months
Sex: Female
Length: 81 cm (50th percentile)
Weight: 11.8 kg (75th percentile)
Reason for Encounter: Vomiting and diarrhea
Subjective (S)
• Chief Complaint: Vomiting and loose stools for 2 days.
• History of Present Illness (HPI): An 18-month-old female presents with an acute
48-hour history of non-bilious, non-bloody emesis (5 episodes in the last 24 hours)
and watery, loose diarrhea (6 episodes in the last 24 hours). The mother reports the
illness began abruptly after the child returned from daycare, where multiple children
are reportedly out with similar symptoms.
• Character: The emesis consists of recently ingested fluids and undigested food
particles. The stools are watery, yellow-green, and free of visible blood or mucus.
• Associated Symptoms: The child exhibits intermittent, generalized abdominal
cramping, manifested by brief crying spells and drawing her knees up to her chest.
• Hydration Status: She has had 3 wet diapers over the past 24 hours (decreased
from her baseline of 6). Her fluid intake is minimal; she refuses solids but is tolerating
small, infrequent sips of water. No documented fever at home.
• Past Medical History (PMH): Born full-term via spontaneous vaginal delivery. No
prior hospitalizations or chronic medical conditions. Immunizations are fully up to
date, including the Rotavirus vaccine series.
• Family/Social History: Attends a community daycare 4 days a week. Lives with
both parents and a healthy 4-year-old sibling. No recent travel or unusual food
exposures.
• Review of Systems (ROS):
o General: Positive for mild lethargy and increased irritability. Negative for chills or
documented fever.
o HEENT: Negative for rhinorrhea, otalgia, or conjunctival injection.
o Gastrointestinal: Positive for watery diarrhea, non-bilious vomiting, and intermittent
generalized cramping. Negative for hematochezia or melena.
o Genitourinary: Decreased urine output (3 wet diapers in 24 hours). No hematuria.
o Integumentary: Negative for acute rashes or chronic skin conditions.
Figure 1: Subjective Pediatric Abdominal Pain & Symptom Map
, [ ANTERIOR VIEW ] [ POSTERIOR VIEW ]
\ _ / \ _ /
( o o ) ( . . )
\ _ / \ _ /
| |
.-----+-----. .-----+-----.
/ | | | \ / | | | \
| | R1| | | | | | | |
| +---+---+ | | +---+---+ |
| /| * * * |\ | | | | |
| | | *X* * | | | | | | |
| \| * * * |/ | | | | |
| +-------+ | | +-------+ |
\ | | / \ | | /
`-+-------+-' `-+-------+-'
| | | | | |
| | | | | |
================================= LEGEND
=================================
[ * * ] Shaded Area: Diffuse, poorly localized visceral cramping.
[ X ] Origin Point: Periumbilical cramping that does not radiate.
[ R1 ] Associated Symptom: Epigastric distress leading to active
emesis.
=======================================================================
===
Clinical Description: The visceral pain is diffuse and non-radiating, centered in the
periumbilical region, matching a standard clinical presentation of gut wall distension
and hyperperistalsis.
Objective (O)
• General Appearance: Alert but noticeably tired; clings tightly to her mother. She
cries intermittently during the abdominal exam but is easily consoled by a pacifier
and her mother's presence.
Table 1: Vital Signs and Reference Ranges
Patient Normal Reference Range
Vital Sign Clinical Interpretation
Value (12–24 Months)
Normal (high-normal due to mild
Heart Rate 128 bpm 80 – 130 bpm
dehydration)
Respiratory
28 cpm 24 – 40 cpm Normal
Rate
37.1°C
Temperature 36.5°C – 37.5°C (Axillary) Afebrile
(98.8°F)
Blood Pressure 86/52 mmHg 80––65 mmHg Stable (Low-normal diastolic)
Oxygen 99% on
95% – 100% Normal
Saturation room air
