6-Year-Old Male with Acute Gastroenteritis and Dehydration Concerns

Case at a Glance

A 6-year-old male with small stature (18.1 kg) presents with acute onset gastroenteritis characterized by vomiting, diarrhea, fever, and significant fatigue following a viral illness.

Patient's Story

The patient's mother reports that her son began experiencing multiple episodes of vomiting the previous evening, followed by diarrhea the next day. He developed accompanying symptoms including rhinorrhea and fever peaking at 38.5°C (101.3°F). The child, normally active and energetic, became notably lethargic and preferred to remain recumbent rather than engage in typical play activities. The mother describes him as 'floppy' and having markedly reduced energy levels, which represents a significant departure from his baseline behavior.

Initial Assessment

The patient has a history of recurrent vomiting episodes during previous viral illnesses, for which his pediatrician had previously prescribed ondansetron 4mg PRN. Current symptoms include gastrointestinal distress with associated upper respiratory symptoms and constitutional symptoms of viral illness. The child is maintaining adequate oral intake of clear fluids and bland foods including applesauce, popsicles, and toast. Urine output remains normal, and diarrhea frequency has decreased from initial presentation.

The Diagnostic Journey

Clinical presentation is consistent with viral gastroenteritis, likely accompanied by an upper respiratory tract infection. The combination of gastrointestinal symptoms, fever, and rhinorrhea in the context of current seasonal viral circulation supports this diagnosis. The patient's known tendency toward prolonged vomiting episodes during viral illnesses aligns with the current presentation.

Final Diagnosis

Acute viral gastroenteritis with concurrent upper respiratory tract infection

Treatment Plan

Symptomatic management with ondansetron 4mg as needed for nausea and vomiting (as previously prescribed by pediatrician), alternating acetaminophen and ibuprofen for fever and comfort per package dosing guidelines. Continued emphasis on fluid replacement with clear liquids and gradual advancement to bland diet as tolerated (BRAT diet approach). Environmental hygiene measures including surface disinfection, frequent handwashing, and isolation of contaminated materials.

Outcome and Follow-up

Patient showing signs of clinical improvement with decreased diarrhea frequency and maintained hydration status. Continued monitoring for resolution of symptoms expected over 3-5 days. Mother counseled that current level of lethargy and decreased activity is typical for viral gastroenteritis in pediatric patients and should gradually improve as the illness resolves. Follow-up recommended if symptoms worsen, signs of dehydration develop, or illness persists beyond expected timeframe.