Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Viral Gastroenteritis
It is an acute, generally self-limited inflammation of the gastrointestinal tract, manifested by a sudden onset of vomiting and diarrhea.
I. Etiology: Most common causative agents are rotavirus, enterovirus, coxsackievirus, adenovirus, astrovirus, and calicivirus.
II. Incidence
A. Seen sporadically in day care, schools, and communities in epidemic proportions.
B. Common in all age groups
C. Seen most frequently in winter
III. Incubation period: 24 to 48 hours
IV. Communicability: Transmissible during acute stage through fecal–oral route
V. Subjective data
A. Vomiting: Assess the duration, frequency, character, and amount of vomitus.
B. Diarrhea: Assess the duration, frequency, consistency of stools, and presence of blood or mucus. Stools are loose with unpleasant odor. Blood or mucus is rarely present.
C. Pertinent subjective data to obtain
1. History of exposure to others with similar symptoms
2. History of illness in the community
3. Urinary output: Frequency and amount
4. Elevated temperature
5. Abdominal pain
6. Weight loss
7. Type and amount of feedings prior to and since onset
D. Pertinent subjective data to rule out other causes
1. Exposure to turtles
2. Exposure to food source outside of home
3. Ingestion of drugs or toxic substances: If history is positive, refer immediately to physician.
4. Exposure to stressful situation
5. Ingestion of home-canned foods: If history is positive, refer immediately to physician.
VI. Objective data
A. Physical examination should include other systems to rule out other infections.
1. Ears
2. Throat
3. Adenopathy
4. Chest
5. CNS for signs of meningeal irritation
a. Nuchal rigidity
b. Fontanelle
c. Kernig’s sign
d. Brudzinski’s signs
e. Irritability, especially paradoxical
f. Level of sensorium
6. Abdomen for distention, visible peristalsis, bowel sounds, tenderness, spasm, organomegaly, masses
7. Assess state of hydration (see Appendix H, p. 534)
8. Weight, pulse, blood pressure, temperature
B. Laboratory tests
1. Urinalysis, include specific gravity to assess state of dehydration.
2. Stool culture
a. It is not necessary to culture stools of all children seen with acute gastroenteritis.
b. Indications for culture
(1) Diarrhea persisting more than 4 days
(2) Infants
(3) Blood in stools
VII. Assessment
A. Diagnosis is made by history of exposure, clinical course, and clinical picture. It is generally a diagnosis of exclusion if the history is not suggestive of other bacterial or parasitic etiologies, and if done, a negative stool culture and the absence of leukocytes on stool exam.
B. Differential diagnosis
1. E. coli: Commonly seen in children younger than 2 years. Gradual onset of diarrheal stools, which are loose, slimy, green, and foul smelling; vomiting and fever are not usually prominent symptoms.
2. Salmonella gastroenteritis (including food poisoning): Incubation period is usually 12 to 24 hours but can range from 6 to 72 hours. Severe abdominal cramps and loose, slimy, green stools with odor of rotten eggs are characteristic; vomiting is common. Diagnosis is confirmed by stool culture.
3. Staphylococcal food poisoning: Explosive onset 2 to 6 hours after ingestion of food contaminated with staphylococci; other people who ingested the same food have a similar illness. Not transmitted from person to person.
VIII. Plan
A. If concurrent infection is found in addition to gastroenteritis (e.g., pneumonia, otitis media, pharyngitis), treat according to protocol. Initially, antibiotics may have to be given parenterally.
B. Dietary management is directed primarily toward fluid and electrolyte management.
1. First 4 hours
a. ORS, Ricelyte, Lytren, Pedialyte, with mild to moderate dehydration: Mild, give 50 to 60 mL/kg over 4-hour period; moderate, give 80 to 100 mL/kg over 4-hour period.
b. To control vomiting, begin with 1 tsp every 1–2 minutes; continue even if vomiting persists initially.
c. When tolerated, gradually increase the amount and decrease the frequency as vomiting subsides. If vomiting recurs, resume giving 1 tsp/min, and again gradually increase amounts.
d. Repeat phase until rehydration occurs. Refer for IV fluids if dehydration worsens or rehydration not accomplished in 4 hours.
e. Toddlers and older children refusing to take ORS may be given Pedialyte freezer pops, water, or sport drinks.
2. Maintenance phase: Generally started within 4 hours of cessation of vomiting
a. Breastfeeding on demand
b. Formula
c. Resume age-appropriate diet with small, frequent feedings once tolerated.
d. Avoid foods high in fat, lactose, simple sugars and roughage.
e. Give 10 mL/kg ORS after each watery stool.
3. Over 90% of infants with vomiting can be hydrated with proper administration of ORS. Vomiting is not a contraindication to oral rehydration therapy.
4. Special diets, such as BRAT, are no longer recommended. Child should be offered foods high in complex carbohydrates, low in fats and simple sugars.
IX. Education
A. Explain that the disease is self-limited. The usual duration of illness is 5 to 7 days. Antidiarrheals and antiemetics are not recommended for acute gastroenteritis.
B. If toddler or child refuses ORS, try Pedialyte freezer pops (2.1 oz per pop)
C. Aim of treatment is to rehydrate and keep child well-hydrated.
1. Vomiting generally resolves with fluid repletion as tissue acidosis is corrected.
2. Clear liquids should be at room temperature.
3. Do not give large amounts. One teaspoon every 1 to 5 minutes is tolerated best.
4. Avoid carbonated beverages with caffeine. May cause stimulation of child and increase severity of diarrhea.
5. Do not use boiled skim milk; it has a high solute load.
D. Once vomiting is under control, increase amount of clear liquids and decrease frequency to avoid too frequent stimulation of the gastrocolic reflex, which might aggravate the diarrhea.
E. Refeeding of usual diet is recommended once rehydration is achieved and vomiting has ceased.
F. If clear liquids only are given for more than 48 hours, reactive loose stools may occur.
G. Starvation stools—scanty, mucous, loose, greenish brown—may mistakenly be construed to be diarrheal stools.
H. Monitor temperature and urinary output.
I. Use petroleum jelly on perianal area to prevent excoriation.
J. Support and encourage parent; treatment is time-consuming.
K. Gastroenteritis may occur in the entire family. It is highly communicable by the fecal–oral or fecal–respiratory route.
1. Careful handwashing technique must be followed to control spread.
2. Do not let other children drink from the sick child’s glass or use the same utensils.
X. Follow-up
A. Close telephone follow-up every 2 to 4 hours if vomiting and diarrhea are frequent
B. Daily weight measurement until weight is stabilized
C. Daily or twice daily telephone contact until all gastrointestinal symptoms have stopped
XI. Complications: The most important complication is dehydration.
XII. Consultation/referral
A. Infants younger than 3 months
B. Vomiting persisting more than 12 hours
C. Diarrhea persisting more than 3 days
D. Any signs or symptoms of dehydration
E. Abdominal pain or tenderness on examination
F. Change in mental status
G. History of chronic illness or immunodeficiency