Layla Stevens (18-Month-Old Female) – Acute Vomiting and
Diarrhea: Comprehensive i-Human Pediatric Case Study with
Clinical Assessment, Differential Diagnosis, SOAP Note,
Evidence-Based Management, and Follow-Up Guide (2026)
, 1. Patient Demographics & Chief Complaint
• Patient Name: Lucas Vance
• Age/Gender: 6-month-old male
• Chief Complaint: Increasing respiratory difficulty, persistent cough, and nasal congestion
for the past 3 days.
• History of Present Illness (HPI): Lucas is brought to the pediatric urgent care clinic by his
father, who reports that the infant began with mild upper respiratory symptoms—clear
rhinorrhea and a low-grade fever—three days ago. Over the last 24 hours, the cough has
worsened, becoming tight and wheezy, accompanied by rapid breathing and noticeable
chest retractions. The father notes that Lucas has experienced a marked decrease in
feeding efficiency, taking only about half of his usual formula volume per feed, and has
had fewer wet diapers over the past 12 hours. There is a 3-year-old sibling at home who
recently recovered from a mild cold. No known sick contacts outside the household, no
history of foreign body aspiration, and up-to-date on routine immunizations.
Diarrhea: Comprehensive i-Human Pediatric Case Study with
Clinical Assessment, Differential Diagnosis, SOAP Note,
Evidence-Based Management, and Follow-Up Guide (2026)
, 1. Patient Demographics & Chief Complaint
• Patient Name: Lucas Vance
• Age/Gender: 6-month-old male
• Chief Complaint: Increasing respiratory difficulty, persistent cough, and nasal congestion
for the past 3 days.
• History of Present Illness (HPI): Lucas is brought to the pediatric urgent care clinic by his
father, who reports that the infant began with mild upper respiratory symptoms—clear
rhinorrhea and a low-grade fever—three days ago. Over the last 24 hours, the cough has
worsened, becoming tight and wheezy, accompanied by rapid breathing and noticeable
chest retractions. The father notes that Lucas has experienced a marked decrease in
feeding efficiency, taking only about half of his usual formula volume per feed, and has
had fewer wet diapers over the past 12 hours. There is a 3-year-old sibling at home who
recently recovered from a mild cold. No known sick contacts outside the household, no
history of foreign body aspiration, and up-to-date on routine immunizations.
