IHUMAN LAYLA STEVENS CASE STUDY | 18-MONTH-OLD WITH VOMITING &
DIARRHEA | A+ CLINICAL STUDY GUIDE | PEDIATRIC ASSESSMENT, SOAP
NOTE, DIAGNOSIS & TREATMENT PLAN | 2026
,Demographic
Information
Name
Layla Stevens
Age
18 months
Sex
Female
Weight
10.2–10.5 kg (current); 11.0–11.8 kg (pre-illness)
Height
81 cm (2'8")
BMI
~15.6 (based on current weight)
Race/Ethnicity
Not specified
Primary Language
English
Parents/Guardians
Mother (28) and Father (30), both healthy
Living Situation
Lives with mother and father in a single-family home
CHIEF COMPLAINT (CC)
"Layla has been throwing up and having diarrhea for the past two days. She can't
keep anything down and seems really tired."
Reason for Encounter: Vomiting and diarrhea
, HISTORY OF PRESENT ILLNESS (HPI) – The OLD CARTS Method
OLD CARTS
Component
Findings
Onset
Acute, 2–3 days ago
Location
Gastrointestinal tract (vomiting and diarrhea); abdominal cramping
Duration
Continuous for 2–3 days; worsening over past 24 hours
Character
Non-bilious, non-bloody vomiting (partially digested food → clear fluid); watery, yellow-brown diarrhea without blood or
mucus
Aggravating Factors
Attempts to eat or drink anything; feeding solids worsens vomiting; standing
Relieving Factors
Nothing provides significant relief; small sips of Pedialyte briefly tolerated; lying down (minimal)
Timing
Continuous symptoms; vomiting ~8–10×/day; diarrhea >10×/day
Severity
Moderate; decreased urine output (only 2 wet diapers in 24 hours, down from 6–8); increased fussiness and lethargy;
estimated weight loss 3.7–7.3%
Associated Symptoms
Nausea, abdominal cramping, dizziness, weakness, chills, low-grade fever
Additional HPI Details:
• Contextual Factors: Attends daycare 3–5 days per week; several children at daycare recently ill with similar
symptoms; attended a birthday party 4 days ago
• No recent travel
• No new foods introduced
DIARRHEA | A+ CLINICAL STUDY GUIDE | PEDIATRIC ASSESSMENT, SOAP
NOTE, DIAGNOSIS & TREATMENT PLAN | 2026
,Demographic
Information
Name
Layla Stevens
Age
18 months
Sex
Female
Weight
10.2–10.5 kg (current); 11.0–11.8 kg (pre-illness)
Height
81 cm (2'8")
BMI
~15.6 (based on current weight)
Race/Ethnicity
Not specified
Primary Language
English
Parents/Guardians
Mother (28) and Father (30), both healthy
Living Situation
Lives with mother and father in a single-family home
CHIEF COMPLAINT (CC)
"Layla has been throwing up and having diarrhea for the past two days. She can't
keep anything down and seems really tired."
Reason for Encounter: Vomiting and diarrhea
, HISTORY OF PRESENT ILLNESS (HPI) – The OLD CARTS Method
OLD CARTS
Component
Findings
Onset
Acute, 2–3 days ago
Location
Gastrointestinal tract (vomiting and diarrhea); abdominal cramping
Duration
Continuous for 2–3 days; worsening over past 24 hours
Character
Non-bilious, non-bloody vomiting (partially digested food → clear fluid); watery, yellow-brown diarrhea without blood or
mucus
Aggravating Factors
Attempts to eat or drink anything; feeding solids worsens vomiting; standing
Relieving Factors
Nothing provides significant relief; small sips of Pedialyte briefly tolerated; lying down (minimal)
Timing
Continuous symptoms; vomiting ~8–10×/day; diarrhea >10×/day
Severity
Moderate; decreased urine output (only 2 wet diapers in 24 hours, down from 6–8); increased fussiness and lethargy;
estimated weight loss 3.7–7.3%
Associated Symptoms
Nausea, abdominal cramping, dizziness, weakness, chills, low-grade fever
Additional HPI Details:
• Contextual Factors: Attends daycare 3–5 days per week; several children at daycare recently ill with similar
symptoms; attended a birthday party 4 days ago
• No recent travel
• No new foods introduced
