LAYLA STEVENS IHUMAN CASE STUDY | 18-MONTH-OLD
WITH VOMITING & DIARRHEA | COMPLETE PEDIATRIC
ASSESSMENT & MANAGEMENT GUIDE | HIGH-YIELD SOAP
NOTE | DIFFERENTIAL DIAGNOSIS & CLINICAL REASONING
| 2026 EDITION
, Page
Section Title
Patient Demographics & Identifying Data 1
Chief Complaint (CC) 2
History of Present Illness (HPI) – The OLD 3
CARTS Method
4
Past Medical History (PMH)
5
Review of Systems (ROS)
6
Social and Family History
7
Physical Examination (PE) – Objective Findings
8
Key Findings & Problem Statement
9
Diagnostic Tests (Labs & Imaging)
10
Differential Diagnosis (DDx)
11
Management Plan (Plan of Care)
12
SOAP Note
,Patient Demographics & Identifying Data
Field Information
Patient Name Layla Stevens
Age 18 months
Gender Female
Reason for Encounter Vomiting and Diarrhea
Source of Information Mother (reliable historian)
Date of Visit [Current Date]
Setting Pediatric Outpatient Clinic
Chief Complaint (CC)
"My daughter has been throwing up and having diarrhea for the past three days. She can't keep
anything down and seems really weak."
History of Present Illness (HPI) – The OLD CARTS Method
Onset
Acute onset approximately 3 days ago
Location
• Gastrointestinal tract: nausea, vomiting, diarrhea
• Abdominal cramping noted
Duration
, • Continuous symptoms for 3 days with progressive worsening
Character/Quality
• Vomiting: Non-bilious, non-bloody; started with partially digested food, now clear fluid
• Diarrhea: Watery, yellow-brown stools; no blood or mucus visible
• Frequency: Vomiting 8–10 times per day; diarrhea >10 times per day
Aggravating Factors
• Attempts to feed solids worsen vomiting
• Eating or drinking anything aggravates symptoms
• Standing/activity increases discomfort
Relieving Factors
• Nothing provides significant relief
• Small sips of Pedialyte occasionally tolerated briefly
• Lying down provides minimal relief
Timing
• Symptoms are continuous and have been worsening over the past 24 hours
Severity
• Moderate to severe based on clinical signs:
o Decreased urine output: only 2 wet diapers in 24 hours (baseline 6–8)
o Increased fussiness and lethargy
o Mother reports child is "more sleepy than usual"
Associated Symptoms
• Nausea
• Abdominal cramping
• Dizziness and weakness
• Low-grade fever (mother reports 100.4°F at home)
• Chills
• Increased clinginess
Contextual Factors
• Attends daycare where other children recently had similar "stomach bugs"
WITH VOMITING & DIARRHEA | COMPLETE PEDIATRIC
ASSESSMENT & MANAGEMENT GUIDE | HIGH-YIELD SOAP
NOTE | DIFFERENTIAL DIAGNOSIS & CLINICAL REASONING
| 2026 EDITION
, Page
Section Title
Patient Demographics & Identifying Data 1
Chief Complaint (CC) 2
History of Present Illness (HPI) – The OLD 3
CARTS Method
4
Past Medical History (PMH)
5
Review of Systems (ROS)
6
Social and Family History
7
Physical Examination (PE) – Objective Findings
8
Key Findings & Problem Statement
9
Diagnostic Tests (Labs & Imaging)
10
Differential Diagnosis (DDx)
11
Management Plan (Plan of Care)
12
SOAP Note
,Patient Demographics & Identifying Data
Field Information
Patient Name Layla Stevens
Age 18 months
Gender Female
Reason for Encounter Vomiting and Diarrhea
Source of Information Mother (reliable historian)
Date of Visit [Current Date]
Setting Pediatric Outpatient Clinic
Chief Complaint (CC)
"My daughter has been throwing up and having diarrhea for the past three days. She can't keep
anything down and seems really weak."
History of Present Illness (HPI) – The OLD CARTS Method
Onset
Acute onset approximately 3 days ago
Location
• Gastrointestinal tract: nausea, vomiting, diarrhea
• Abdominal cramping noted
Duration
, • Continuous symptoms for 3 days with progressive worsening
Character/Quality
• Vomiting: Non-bilious, non-bloody; started with partially digested food, now clear fluid
• Diarrhea: Watery, yellow-brown stools; no blood or mucus visible
• Frequency: Vomiting 8–10 times per day; diarrhea >10 times per day
Aggravating Factors
• Attempts to feed solids worsen vomiting
• Eating or drinking anything aggravates symptoms
• Standing/activity increases discomfort
Relieving Factors
• Nothing provides significant relief
• Small sips of Pedialyte occasionally tolerated briefly
• Lying down provides minimal relief
Timing
• Symptoms are continuous and have been worsening over the past 24 hours
Severity
• Moderate to severe based on clinical signs:
o Decreased urine output: only 2 wet diapers in 24 hours (baseline 6–8)
o Increased fussiness and lethargy
o Mother reports child is "more sleepy than usual"
Associated Symptoms
• Nausea
• Abdominal cramping
• Dizziness and weakness
• Low-grade fever (mother reports 100.4°F at home)
• Chills
• Increased clinginess
Contextual Factors
• Attends daycare where other children recently had similar "stomach bugs"
