IHUMAN CASE STUDY, LAYLA
STEVENS; 18-MONTHS-OLD; REASON
FOR ENCOUNTER: VOMITING AND
DIARRHEA.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 Patient Demographics & Identifying Data
2 Chief Complaint (CC)
3 History of Present Illness (HPI) – The OLD 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
, 1. Patient Demographics & Identifying Data
• Name: Layla Stevens
• Age: 18 months old
• Gender: Female
• Date of Visit: __________________
• Source of History: Mother (reliable historian)
• Accompanied By: Mother and father
• Race/Ethnicity: Not specified
• Primary Language: English
• Chief Concern: Repeated episodes of vomiting and diarrhea over the
past two days with decreased oral intake.
• Reason for Encounter: Vomiting and diarrhea.
• Mode of Arrival: Brought to the pediatric clinic by her parents for
evaluation of persistent vomiting, diarrhea, and concerns about
dehydration.
• Birth History: Full-term vaginal delivery without complications. Normal
newborn course and discharged home with mother.
• Developmental Status: Growth and developmental milestones are
appropriate for age. Walking independently, says several single words,
follows simple commands, and interacts appropriately with parents.
• Immunization Status: Immunizations are current according to the
recommended childhood vaccination schedule.
• General Appearance: Alert but tired-appearing toddler who appears
mildly ill. She is sitting quietly on her mother's lap and is less playful than
usual. She becomes fussy during the examination but is easily comforted
by her parents. No acute respiratory distress is observed.
• Reliability of Information: History is obtained from the patient's mother,
who provides a clear and consistent description of the illness. Both
STEVENS; 18-MONTHS-OLD; REASON
FOR ENCOUNTER: VOMITING AND
DIARRHEA.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 Patient Demographics & Identifying Data
2 Chief Complaint (CC)
3 History of Present Illness (HPI) – The OLD 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
, 1. Patient Demographics & Identifying Data
• Name: Layla Stevens
• Age: 18 months old
• Gender: Female
• Date of Visit: __________________
• Source of History: Mother (reliable historian)
• Accompanied By: Mother and father
• Race/Ethnicity: Not specified
• Primary Language: English
• Chief Concern: Repeated episodes of vomiting and diarrhea over the
past two days with decreased oral intake.
• Reason for Encounter: Vomiting and diarrhea.
• Mode of Arrival: Brought to the pediatric clinic by her parents for
evaluation of persistent vomiting, diarrhea, and concerns about
dehydration.
• Birth History: Full-term vaginal delivery without complications. Normal
newborn course and discharged home with mother.
• Developmental Status: Growth and developmental milestones are
appropriate for age. Walking independently, says several single words,
follows simple commands, and interacts appropriately with parents.
• Immunization Status: Immunizations are current according to the
recommended childhood vaccination schedule.
• General Appearance: Alert but tired-appearing toddler who appears
mildly ill. She is sitting quietly on her mother's lap and is less playful than
usual. She becomes fussy during the examination but is easily comforted
by her parents. No acute respiratory distress is observed.
• Reliability of Information: History is obtained from the patient's mother,
who provides a clear and consistent description of the illness. Both
