I-HUMAN CASE STUDY LAYLA STEVENS – AN 18-MONTH-
OLD WITH ACUTE VIRAL GASTROENTERITIS AND
MODERATE DEHYDRATION A COMPREHENSIVE SOAP
NOTE AND EVIDENCE-BASED MANAGEMENT (2026/2027)
,
,Part 1: Patient Bio Data & Initial Data Gathering
Category Details
Name Layla Stevens
Age 18 months old
Gender Female
Height 2'8" (81 cm) – 50th-75th percentile
Weight (current) 10.2-10.5 kg (22.4-23.1 lb)
Weight (pre-illness) 11.0-11.8 kg (24.2-26.0 lb)
Weight Loss 0.4-0.8 kg (3.7-7.3% – mild-moderate dehydration)
Setting Outpatient clinic
Source Mother (reliable historian)
Allergies No Known Drug Allergies (NKDA)
Chief Complaint: Vomiting and diarrhea – mother reports it has been
going on for two days.
Reason for Encounter: "My 18-month-old has been throwing up and
having diarrhea for the past two days. She doesn't really want to eat
anything either and I'm pretty worried."
Part 2: Past Medical History (PMH)
, Category Details
Full-term (39 weeks), spontaneous vaginal delivery, birth weight
Birth History
lb 2 oz (3.2 kg), no NICU stay, no complications
Two prior episodes of acute otitis media (6 months and 12 month
Childhood
– treated with amoxicillin; one prior episode of viral gastroenteriti
Illnesses
9 months
Hospitalizations None
Surgeries None
ER Visits None
Current None daily. Acetaminophen 160 mg PRN for fever/teething (last
Medications dose 36 hours ago)
Up-to-date per CDC schedule – DTaP #4, Hib #4, PCV13 #4, IPV
Immunizations #3, MMR #1, Varicella #1, Hep A #1, rotavirus vaccine series
completed
Previously on normal trajectory (50th percentile for weight and
Growth
height)
Part 3: Developmental History (18 Months)
Milestone Achieved
Social smile 2 months
Rolls over 5 months
OLD WITH ACUTE VIRAL GASTROENTERITIS AND
MODERATE DEHYDRATION A COMPREHENSIVE SOAP
NOTE AND EVIDENCE-BASED MANAGEMENT (2026/2027)
,
,Part 1: Patient Bio Data & Initial Data Gathering
Category Details
Name Layla Stevens
Age 18 months old
Gender Female
Height 2'8" (81 cm) – 50th-75th percentile
Weight (current) 10.2-10.5 kg (22.4-23.1 lb)
Weight (pre-illness) 11.0-11.8 kg (24.2-26.0 lb)
Weight Loss 0.4-0.8 kg (3.7-7.3% – mild-moderate dehydration)
Setting Outpatient clinic
Source Mother (reliable historian)
Allergies No Known Drug Allergies (NKDA)
Chief Complaint: Vomiting and diarrhea – mother reports it has been
going on for two days.
Reason for Encounter: "My 18-month-old has been throwing up and
having diarrhea for the past two days. She doesn't really want to eat
anything either and I'm pretty worried."
Part 2: Past Medical History (PMH)
, Category Details
Full-term (39 weeks), spontaneous vaginal delivery, birth weight
Birth History
lb 2 oz (3.2 kg), no NICU stay, no complications
Two prior episodes of acute otitis media (6 months and 12 month
Childhood
– treated with amoxicillin; one prior episode of viral gastroenteriti
Illnesses
9 months
Hospitalizations None
Surgeries None
ER Visits None
Current None daily. Acetaminophen 160 mg PRN for fever/teething (last
Medications dose 36 hours ago)
Up-to-date per CDC schedule – DTaP #4, Hib #4, PCV13 #4, IPV
Immunizations #3, MMR #1, Varicella #1, Hep A #1, rotavirus vaccine series
completed
Previously on normal trajectory (50th percentile for weight and
Growth
height)
Part 3: Developmental History (18 Months)
Milestone Achieved
Social smile 2 months
Rolls over 5 months
