Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute onset of watery diarrhea (frequency: [x]/day) and non-bilious, non-bloody emesis (frequency: [x]/day). Associated symptoms include low-grade fever, abdominal cramping, and decreased oral intake. No recent travel, antibiotic use, or known sick contacts reported. Current hydration status: [well-hydrated/mildly dehydrated].
Clinical Examination Findings
General: Alert, active, no signs of lethargy. HEENT: Mucous membranes [moist/tacky], anterior fontanelle [flat/sunken], capillary refill [less than 2 seconds/delayed]. Abdomen: Soft, non-distended, hyperactive bowel sounds, non-tender to palpation, no guarding or rebound. Skin: Turgor [brisk/decreased].
Treatment Protocol
Plan: Supportive care. 1. Oral Rehydration Therapy (ORT) with electrolyte solution (e.g., Pedialyte) in small, frequent amounts. 2. Continue age-appropriate diet (BRAT diet or regular diet as tolerated). 3. Avoid anti-diarrheal medications. 4. Monitor for signs of worsening dehydration (decreased urine output, lethargy, dry mucous membranes). 5. Follow up if symptoms persist > 5 days or if blood appears in stool.