IHUMAN LAYLA STEVENS CASE STUDY |
PEDIATRIC VOMITING & DIARRHEA |
COMPREHENSIVE CLINICAL REVIEW | HISTORY
& PHYSICAL EXAM | DIFFERENTIAL DIAGNOSIS,
SOAP NOTE & TREATMENT PLAN | PREMIUM
NURSING STUDY GUIDE
SECTION 1: PATIENT DEMOGRAPHICS & IDENTIFYING DATA
Demographic
Information
Patient Name
Layla Stevens
,Demographic
Information
Age
18 months
Sex
Female
Weight
10.2-10.5 kg (current); 11.0-11.8 kg (pre-illness baseline)
Height
81 cm (2' 8")
BMI
~15.6 (pre-illness 50th percentile)
Race/Ethnicity
Not specified
Date of Encounter
[Insert current date]
Setting
Emergency Department / Outpatient Clinic
Source of Information
Mother (primary informant), patient examination
Growth Trajectory: Previously on normal growth trajectory at the 50th percentile for weight and height. Current
estimated weight loss of 3.7-7.3% from baseline, consistent with mild-to-moderate dehydration .
SECTION 2: CHIEF COMPLAINT (CC)
"My daughter has been throwing up and having diarrhea for the past two to three days. She can't keep anything
down and seems really tired. "
Duration: 2-3 days
SECTION 3: HISTORY OF PRESENT ILLNESS (HPI) – The OLD CARTS Method
, OLD CARTS Component
Assessment
Onset
Acute, began 2-3 days ago
Location
Gastrointestinal tract (vomiting, diarrhea)
Duration
Continuous for 2-3 days; symptoms persisting
Character
Non-bilious, non-bloody emesis (initially partially digested food, now clear fluid); watery, yellow-brown diarrhea without
blood or mucus
Aggravating Attempts to feed solids or offer larger amounts of fluids worsen vomiting; eating/drinking
Factors anything aggravates symptoms
Relieving Factors
Small sips of Pedialyte briefly tolerated; nothing provides significant relief
Timing
Continuous symptoms over 2-3 days; worsening over the past 24 hours
Severity
Moderate. Vomiting: 8-10 episodes/day; Diarrhea: >10 episodes/day ; Decreased urine output (only 2 wet diapers in 24
hours, down from 6-8), increased fussiness and lethargy
Associated Symptoms
Low-grade fever, abdominal cramping, dizziness/weakness, chills
Contextual Factors:
• Daycare Exposure: Attends daycare 3-5 days per week; several children recently ill with similar "stomach bug"
symptoms
• Birthday Party: Attended a party 4 days ago
• Diet: No new foods introduced
• Immunizations: Up-to-date, including completed rotavirus vaccine series
SECTION 4: PAST MEDICAL HISTORY (PMH)
PEDIATRIC VOMITING & DIARRHEA |
COMPREHENSIVE CLINICAL REVIEW | HISTORY
& PHYSICAL EXAM | DIFFERENTIAL DIAGNOSIS,
SOAP NOTE & TREATMENT PLAN | PREMIUM
NURSING STUDY GUIDE
SECTION 1: PATIENT DEMOGRAPHICS & IDENTIFYING DATA
Demographic
Information
Patient Name
Layla Stevens
,Demographic
Information
Age
18 months
Sex
Female
Weight
10.2-10.5 kg (current); 11.0-11.8 kg (pre-illness baseline)
Height
81 cm (2' 8")
BMI
~15.6 (pre-illness 50th percentile)
Race/Ethnicity
Not specified
Date of Encounter
[Insert current date]
Setting
Emergency Department / Outpatient Clinic
Source of Information
Mother (primary informant), patient examination
Growth Trajectory: Previously on normal growth trajectory at the 50th percentile for weight and height. Current
estimated weight loss of 3.7-7.3% from baseline, consistent with mild-to-moderate dehydration .
SECTION 2: CHIEF COMPLAINT (CC)
"My daughter has been throwing up and having diarrhea for the past two to three days. She can't keep anything
down and seems really tired. "
Duration: 2-3 days
SECTION 3: HISTORY OF PRESENT ILLNESS (HPI) – The OLD CARTS Method
, OLD CARTS Component
Assessment
Onset
Acute, began 2-3 days ago
Location
Gastrointestinal tract (vomiting, diarrhea)
Duration
Continuous for 2-3 days; symptoms persisting
Character
Non-bilious, non-bloody emesis (initially partially digested food, now clear fluid); watery, yellow-brown diarrhea without
blood or mucus
Aggravating Attempts to feed solids or offer larger amounts of fluids worsen vomiting; eating/drinking
Factors anything aggravates symptoms
Relieving Factors
Small sips of Pedialyte briefly tolerated; nothing provides significant relief
Timing
Continuous symptoms over 2-3 days; worsening over the past 24 hours
Severity
Moderate. Vomiting: 8-10 episodes/day; Diarrhea: >10 episodes/day ; Decreased urine output (only 2 wet diapers in 24
hours, down from 6-8), increased fussiness and lethargy
Associated Symptoms
Low-grade fever, abdominal cramping, dizziness/weakness, chills
Contextual Factors:
• Daycare Exposure: Attends daycare 3-5 days per week; several children recently ill with similar "stomach bug"
symptoms
• Birthday Party: Attended a party 4 days ago
• Diet: No new foods introduced
• Immunizations: Up-to-date, including completed rotavirus vaccine series
SECTION 4: PAST MEDICAL HISTORY (PMH)
