CASE
COMPREHENSIVE IHUMAN CASE STUDY, 18-MONTHS-OLD LAYLA STEVENS;
REASON FOR ENCOUNTER: VOMITING AND DIARRHEA.
, CASE
COMPREHENSIVE IHUMAN CASE STUDY, 18-MONTHS-OLD LAYLA STEVENS;
REASON FOR ENCOUNTER: VOMITING AND DIARRHEA.
Layla Stevens is an 18-month-old female who presents to the outpatient pediatric clinic
with a 48-hour history of forceful, non-bilious vomiting and frequent watery diarrhea.
Her mother reports that Layla has had approximately 8-10 episodes of vomiting and 6-8
watery stools per day over the past two days. She has had decreased oral intake,
increased irritability, reduced urine output (only two wet diapers in the past 24 hours
compared to her usual 6-8), and a low-grade fever. The mother reports that several
children at Layla's daycare have had similar symptoms recently.
Physical examination reveals an irritable but consolable toddler with tachycardia (HR 142
bpm), dry mucous membranes, sunken eyes, delayed capillary refill (3 seconds),
decreased skin turgor, and a 4.2% weight loss from her baseline. These findings are
consistent with moderate dehydration (estimated 6-9% fluid deficit) secondary to acute
viral gastroenteritis.
The case is structured using a comprehensive SOAP format, including patient
demographics, chief complaint, history of present illness (OLD CARTS), past medical
history, review of systems, social and family history, physical examination findings,
diagnostic considerations, a prioritized differential diagnosis, and an evidence-based
management plan.
SUBJECTIVE (SOAP NOTE)
Patient Demographics & Identifying Data
Field Information
Patient Name Layla Stevens
Age 18 months
Sex Female
Race/Ethnicity [As specified in case]
Date of Birth [Redacted]
, CASE
COMPREHENSIVE IHUMAN CASE STUDY, 18-MONTHS-OLD LAYLA STEVENS;
REASON FOR ENCOUNTER: VOMITING AND DIARRHEA.
Field Information
Date of Visit [Current Date]
Encounter Type Outpatient Pediatric Clinic Visit
Source of Information Mother (primary caregiver)
Reliability Reliable
Chief Complaint (CC)
Mother's Statement: "Layla has been throwing up and having diarrhea for the past two
days. She won't drink much and seems really tired."
History of Present Illness (HPI) — OLD CARTS Format
Component Finding
Onset Acute onset approximately 48 hours ago
Location Gastrointestinal (vomiting, diarrhea)
Duration 48 hours of symptoms
Character Forceful, non-bilious, non-bloody vomiting; frequent watery, non-bloody diarrhea
Aggravating
Oral intake (stimulates vomiting), activity
Factors
Relieving Factors Rest, being held by mother
COMPREHENSIVE IHUMAN CASE STUDY, 18-MONTHS-OLD LAYLA STEVENS;
REASON FOR ENCOUNTER: VOMITING AND DIARRHEA.
, CASE
COMPREHENSIVE IHUMAN CASE STUDY, 18-MONTHS-OLD LAYLA STEVENS;
REASON FOR ENCOUNTER: VOMITING AND DIARRHEA.
Layla Stevens is an 18-month-old female who presents to the outpatient pediatric clinic
with a 48-hour history of forceful, non-bilious vomiting and frequent watery diarrhea.
Her mother reports that Layla has had approximately 8-10 episodes of vomiting and 6-8
watery stools per day over the past two days. She has had decreased oral intake,
increased irritability, reduced urine output (only two wet diapers in the past 24 hours
compared to her usual 6-8), and a low-grade fever. The mother reports that several
children at Layla's daycare have had similar symptoms recently.
Physical examination reveals an irritable but consolable toddler with tachycardia (HR 142
bpm), dry mucous membranes, sunken eyes, delayed capillary refill (3 seconds),
decreased skin turgor, and a 4.2% weight loss from her baseline. These findings are
consistent with moderate dehydration (estimated 6-9% fluid deficit) secondary to acute
viral gastroenteritis.
The case is structured using a comprehensive SOAP format, including patient
demographics, chief complaint, history of present illness (OLD CARTS), past medical
history, review of systems, social and family history, physical examination findings,
diagnostic considerations, a prioritized differential diagnosis, and an evidence-based
management plan.
SUBJECTIVE (SOAP NOTE)
Patient Demographics & Identifying Data
Field Information
Patient Name Layla Stevens
Age 18 months
Sex Female
Race/Ethnicity [As specified in case]
Date of Birth [Redacted]
, CASE
COMPREHENSIVE IHUMAN CASE STUDY, 18-MONTHS-OLD LAYLA STEVENS;
REASON FOR ENCOUNTER: VOMITING AND DIARRHEA.
Field Information
Date of Visit [Current Date]
Encounter Type Outpatient Pediatric Clinic Visit
Source of Information Mother (primary caregiver)
Reliability Reliable
Chief Complaint (CC)
Mother's Statement: "Layla has been throwing up and having diarrhea for the past two
days. She won't drink much and seems really tired."
History of Present Illness (HPI) — OLD CARTS Format
Component Finding
Onset Acute onset approximately 48 hours ago
Location Gastrointestinal (vomiting, diarrhea)
Duration 48 hours of symptoms
Character Forceful, non-bilious, non-bloody vomiting; frequent watery, non-bloody diarrhea
Aggravating
Oral intake (stimulates vomiting), activity
Factors
Relieving Factors Rest, being held by mother
