Cranial nerves II–XII intact. No focal deficits. Assessment (A) Diagnosis: Acute viral gastroenteritis with mild-to-moderate dehydration.
Tachycardic, regular rhythm, no murmurs, rubs, or gallops. Capillary refill ~2–3 seconds. soap note gastroenteritis
Low-grade fever (100.8°F subjective at home), mild generalized weakness, dry mouth, decreased urine output (only once in past 12 hours, dark yellow). Denies hematemesis, hematochezia, jaundice, dysuria, headache, or stiff neck. Cranial nerves II–XII intact
None. No recent antibiotics.
Generalized abdominal cramping, diffuse without radiation. mild generalized weakness
None. No chronic GI disorders.