IHUMAN CASE STUDY. LAYLA
STEVENS, 18-MONTHS-OLD.
REASON FOR ENCOUNTER:
VOMITTING AND DIARRHEA.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
, 1. HISTORY
Patient Identification
• Name: Layla Stevens
• Age: 18 months
• Gender: Female
• Accompanied by: Mother
• Source of History: Mother (reliable historian)
Chief Complaint (CC)
"My daughter has been vomiting and has diarrhea."
History of Present Illness (HPI)
Layla Stevens is an 18-month-old female brought to the clinic by her mother
with complaints of vomiting and diarrhea for the past two days. The mother
reports that Layla was in her usual state of health until two days ago when she
suddenly began vomiting after meals. Since then, she has had approximately
four episodes of non-bloody, non-bilious vomiting and seven episodes of
watery diarrhea. The stools are loose, yellowish-brown, and contain no blood
or mucus.
The child has had a decreased appetite and has been refusing most solid foods,
although she is able to tolerate small amounts of oral fluids. The mother
reports that Layla has become less playful, more irritable, and appears tired.
She has noticed fewer wet diapers than usual during the last 24 hours. A low-
grade fever was recorded at home, reaching 100.9°F (38.3°C), and improved
after administration of acetaminophen.
The mother denies any history of severe abdominal pain, abdominal swelling,
persistent crying, seizures, cough, difficulty breathing, skin rash, or recent
trauma. There has been no recent travel or exposure to untreated water.
STEVENS, 18-MONTHS-OLD.
REASON FOR ENCOUNTER:
VOMITTING AND DIARRHEA.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
, 1. HISTORY
Patient Identification
• Name: Layla Stevens
• Age: 18 months
• Gender: Female
• Accompanied by: Mother
• Source of History: Mother (reliable historian)
Chief Complaint (CC)
"My daughter has been vomiting and has diarrhea."
History of Present Illness (HPI)
Layla Stevens is an 18-month-old female brought to the clinic by her mother
with complaints of vomiting and diarrhea for the past two days. The mother
reports that Layla was in her usual state of health until two days ago when she
suddenly began vomiting after meals. Since then, she has had approximately
four episodes of non-bloody, non-bilious vomiting and seven episodes of
watery diarrhea. The stools are loose, yellowish-brown, and contain no blood
or mucus.
The child has had a decreased appetite and has been refusing most solid foods,
although she is able to tolerate small amounts of oral fluids. The mother
reports that Layla has become less playful, more irritable, and appears tired.
She has noticed fewer wet diapers than usual during the last 24 hours. A low-
grade fever was recorded at home, reaching 100.9°F (38.3°C), and improved
after administration of acetaminophen.
The mother denies any history of severe abdominal pain, abdominal swelling,
persistent crying, seizures, cough, difficulty breathing, skin rash, or recent
trauma. There has been no recent travel or exposure to untreated water.
