Viral Intestinal Infections in Children

Viral Intestinal Infection In A 8 Years Old Child. Soap Note Deadlines and Guidelines
• Soap notes must be done in Proper APA Format
• You may not repeat the same Diagnosis more than once.
• Notes with more than one diagnosis must focus on one main diagnosis
• Main Diagnosis must include a rationale with in-text reference (Why you chose this diagnosis backed by evidence-based practice)
• All Diagnoses on note must include ICD 10 Codes
• Notes must have a Minimum 3 differential diagnoses
• Notes must have Minimum of 2 Scholarly References (Journals, Books, and Studies)
• All notes must be of 6 Pediatric only in this clinical rotation

Soap Note Grading Rubric
This sheet is to help you understand what is required, and what the margin remarks might be about on your comments of patients. Since most of your comments that you hand in are uniform, this represents what MUST be included in every write-up.
• Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

• Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI (Location, quality, quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).
b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written in this manner.

• Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

• Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).
• Pertinent positives and negatives must be documented for each relevant system.
• Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

• Assessment (___10pts.): All diagnoses should be clearly listed and worded appropriately with ICD 10 codes. Rationale and Explanation must be evidence based and have 1-2 in text references to back up your reasoning for making your main diagnosis selection. 3 differential diagnosis must be noted, rationale not required but encouraged.

• Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections. Should not be generic information and should be tailored to your patient and their needs / specific diagnosis.

• Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

Clarity of the Write-up(___5pts.): Is it literate, organized, and complete?

Guidelines for SOAP Notes
General Guidelines:
• Label each section of the SOAP note (each body part and system).
• Do not use unnecessary words or complete sentences.
• Use Standard Abbreviations
• All Heading and Subheadings must be bolded and separate, no narrative ROS or Physical (Paragraph Form)

All Soap Notes must include:
• Full name of student
• Date of encounter
• Name of Preceptor and Clinical Instructor
• Title with Soap # and Main Diagnosis (Soap # 3 DX: Hypertension)
S: SUBJECTIVE DATA (information the patient/caregiver tells you).
Identifying/Demographic Information: The opening list of the note. It contains age, sex, race, etc.
Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in “quotes”. . If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.
History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.
Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, surgical history and hospitalizations, age-appropriate immunization status, age appropriate screening control, Pediatric Developmental Milestones, Woman Health Menstrual History/ Obstetric History
Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.
Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education, Exercises , Diet, Sexual history, Abuse/Safety history.
Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.
All Sections must be included in all soap notes
0: OBJECTIVE DATA (information you observe, assessment findings, lab results).
Vital Signs: Blood Pressure, Pulse, Respiratory Rate, Temperature, Height, Weight and BMI (with percentile in case of pediatric patient) , If needed other Measurements: ( PED: Head/Abdominal Circumference ), (WH: Fundal Height(cm), Fetal Position , Fetal Heart Rate(bpm),Pain level ( scale 0-10)
Physical Exam: Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described, Record observations for the following systems for each patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vital signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing.
Order/Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.
There must be one main Diagnosis
Remember: Your subjective and objective data should support your diagnoses and therapeutic plan.
Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).
For the main diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.
Must include a Minimum of 3 Differential diagnosis with ICD codes and provide a cited rationale for each differential diagnosis
P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation. (in-text citation)
1. Prescribe: Medications/Vaccine/Devices etc, write out the medication/Vaccine prescription including dispensing information ( presentation , dose, route , frequency , length of treatment) and provide EBP to support ordering each prescription.
2. Additional diagnostic tests include EBP citations to support ordering additional tests
3. Education/Teaching/ Instructions this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.
6. References: Notes must have Minimum of 2 Scholarly References (Journals, Books, and Studies)

Viral Intestinal Infections in Children
Viral intestinal infections are common illnesses that affect children worldwide. The most common types of viral intestinal infections in children are rotavirus, norovirus, adenovirus, and astrovirus infections. These viruses cause inflammation and damage to the intestinal lining, resulting in symptoms like diarrhea, vomiting, abdominal pain, and fever. While usually self-limiting, viral intestinal infections can sometimes lead to dehydration requiring medical treatment. Understanding the causes, symptoms, and treatment of these infections is important for caring for children’s health.
Rotavirus is the leading cause of severe diarrhea among children under 5 years of age globally (World Health Organization [WHO], 2022). Rotavirus infects the cells lining the small intestine and causes inflammation, resulting in watery diarrhea, vomiting, fever, and abdominal pain. Symptoms usually last 3-8 days but can be more severe, especially in developing countries where rotavirus causes over 200,000 child deaths annually (WHO, 2022). Rotavirus is highly contagious, spreading through the fecal-oral route from infected stool or vomit particles. Risk factors for severe rotavirus infection include malnutrition and lack of breastfeeding (Centers for Disease Control and Prevention [CDC], 2022). The best prevention is rotavirus vaccination, which is part of routine childhood immunization schedules worldwide and has significantly reduced rotavirus hospitalizations and deaths (WHO, 2022). Treatment focuses on rehydration through oral rehydration solutions or intravenous fluids for severe cases (CDC, 2022).
Norovirus is another common cause of viral gastroenteritis, causing around 685 million cases of diarrhea annually worldwide (Kirk et al., 2022). Norovirus causes inflammation of the stomach and intestines resulting in nausea, vomiting, watery non-bloody diarrhea, abdominal cramps, and low-grade fever (CDC, 2022). Norovirus spreads very easily through contaminated food or water, person-to-person contact, and aerosolized vomit particles. Outbreaks frequently occur in closed settings like childcare centers, schools, and cruise ships. While symptoms are usually mild and self-limiting, severe dehydration can occur, especially in young children, older adults, and those with underlying illnesses (CDC, 2022). Treatment focuses on rehydration and prevention of spread through handwashing and isolation of infected individuals until symptoms resolve (CDC, 2022). Vaccine development is ongoing but not yet available (Kirk et al., 2022).
Adenovirus causes a range of illnesses from mild conjunctivitis to severe pneumonia or gastroenteritis. There are over 50 types of adenoviruses, of which types 40 and 41 are the most common causes of viral gastroenteritis in children (CDC, 2022). Adenovirus infection of the intestinal lining causes inflammation resulting in watery diarrhea, vomiting, fever, and abdominal pain lasting 5-10 days on average (CDC, 2022). Adenovirus spreads through the fecal-oral or respiratory routes. Outbreaks can occur in childcare settings. Treatment is supportive with rehydration and symptoms usually resolve without complications (CDC, 2022). There is currently no vaccine for adenovirus (CDC, 2022).
Astrovirus causes a similar clinical syndrome to rotavirus, including watery diarrhea, vomiting, fever, and abdominal pain (CDC, 2022). Astrovirus infects the small intestine and causes a self-limited gastroenteritis typically lasting less than a week. It spreads through the fecal-oral route and is estimated to cause 3-8% of all cases of non-bacterial diarrhea in children under 2 years of age (CDC, 2022). Risk factors include young age and institutional settings like childcare centers. Treatment is supportive care with rehydration and there is currently no vaccine (CDC, 2022).
In summary, viral intestinal infections are common in children and usually cause self-limited diarrhea, vomiting, and abdominal pain. However, they can sometimes lead to severe dehydration requiring medical treatment. Rotavirus is the leading cause of severe disease but vaccination has significantly reduced this burden. Norovirus causes the most cases globally. Treatment focuses on rehydration and prevention of spread. Understanding the different viruses that cause intestinal infections can help guide care of children with gastroenteritis.
Centers for Disease Control and Prevention. (2022). Rotavirus.
Centers for Disease Control and Prevention. (2022). Norovirus.
Centers for Disease Control and Prevention. (2022). Adenovirus.
Centers for Disease Control and Prevention. (2022). Astrovirus.
Kirk, M. D., Pires, S. M., Black, R. E., Caipo, M., Crump, J. A., Devleesschauwer, B.,… & Hall, A. J. (2022). World Health Organization estimates of the global and regional disease burden of 22 foodborne bacterial, protozoal, and viral diseases, 2010: a data synthesis. PLoS medicine, 19(12), e1004050. homework help writing assignment service.
World Health Organization. (2022). Rotavirus.

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