Patient presents with acute gastroenterocolitis, characterized by symptoms of diarrhea, nausea, and vomiting.  Onset of symptoms began approximately [number] [time unit] prior to presentation.  Frequency of diarrhea is described as [frequency description, e.g., three times per day, watery and loose].  Nausea is [severity, e.g., constant, intermittent] and emesis has occurred [number] times, described as [character of emesis, e.g., bilious, non-bloody].  Patient reports [presence or absence] of abdominal pain or cramping, localized to [location if present].  Fever is [present or absent], measured at [temperature if present].  Patient denies recent travel history.  Recent dietary intake includes [brief description of recent food intake].  Hydration status appears [assessment of hydration, e.g., well-hydrated, mildly dehydrated].  Vital signs:  Heart rate [heart rate], blood pressure [blood pressure], respiratory rate [respiratory rate], temperature [temperature].  Physical examination reveals [relevant findings, e.g., mild diffuse abdominal tenderness, hyperactive bowel sounds].  Differential diagnosis includes viral gastroenteritis, bacterial gastroenteritis, and food poisoning.  Assessment:  Acute gastroenterocolitis likely secondary to [presumed etiology, e.g., viral infection]. Plan:  Patient education regarding oral rehydration therapy and dietary modifications.  Prescribed antiemetic medication [medication name and dosage].  Stool studies not indicated at this time given likely viral etiology.  Follow-up recommended if symptoms worsen or persist beyond [timeframe].  Return precautions reviewed, including signs of dehydration and persistent vomiting.  ICD-10 code:  [appropriate ICD-10 code, e.g., A08.4].