IHUMAN LAYLA STEVENS PEDIATRIC CASE STUDY |
CLINICAL SIMULATION & COMPLETE CASE
WALKTHROUGH | PATIENT ASSESSMENT, DIAGNOSIS &
SOAP DOCUMENTATION | EVIDENCE-BASED
MANAGEMENT | ULTIMATE NURSING SUCCESS GUIDE
,Table of Contents
Section Title
Page
Patient Demographics & Identifying Data
1
,Section Title Page
Chief Complaint (CC) 2
History of Present Illness (HPI) – The OLD 3
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
Patient Demographics & Identifying Data
Patient Name: Layla Stevens
Age: 18 months old
Sex: Female
Date of Birth: 02/14/2024
, Date of Encounter: 08/07/2026
Race/Ethnicity: Caucasian
Weight: 10.2 kg (22.5 lbs) – 50th percentile
Height: 79 cm (31.1 inches) – 50th percentile
BMI: 16.3 – 50th percentile
Vital Signs:
• Temperature: 101.8°F (38.8°C) – Tympanic
• Heart Rate: 148 bpm (elevated for age)
• Respiratory Rate: 32 breaths/min
• Blood Pressure: 98/62 mmHg
• Oxygen Saturation: 98% on room air
Immunization Status: Up to date per CDC schedule
• DTaP, IPV, Hib, PCV13, MMR, Varicella, Hepatitis A, Hepatitis B (all completed as
scheduled)
Primary Care Provider: Dr. Sarah Chen, MD, Pediatrics
Insurance: Medicaid
Preferred Language: English
Interpreter Needed: No
Accompanying Person: Mother – Jessica Stevens (age 28)
Reliability of Informant: Mother appears reliable, provides clear and consistent history
Mode of Arrival: Walk-in appointment at pediatric clinic
Triage Priority: Urgent – potential dehydration risk
Chief Complaint (CC)
CLINICAL SIMULATION & COMPLETE CASE
WALKTHROUGH | PATIENT ASSESSMENT, DIAGNOSIS &
SOAP DOCUMENTATION | EVIDENCE-BASED
MANAGEMENT | ULTIMATE NURSING SUCCESS GUIDE
,Table of Contents
Section Title
Page
Patient Demographics & Identifying Data
1
,Section Title Page
Chief Complaint (CC) 2
History of Present Illness (HPI) – The OLD 3
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
Patient Demographics & Identifying Data
Patient Name: Layla Stevens
Age: 18 months old
Sex: Female
Date of Birth: 02/14/2024
, Date of Encounter: 08/07/2026
Race/Ethnicity: Caucasian
Weight: 10.2 kg (22.5 lbs) – 50th percentile
Height: 79 cm (31.1 inches) – 50th percentile
BMI: 16.3 – 50th percentile
Vital Signs:
• Temperature: 101.8°F (38.8°C) – Tympanic
• Heart Rate: 148 bpm (elevated for age)
• Respiratory Rate: 32 breaths/min
• Blood Pressure: 98/62 mmHg
• Oxygen Saturation: 98% on room air
Immunization Status: Up to date per CDC schedule
• DTaP, IPV, Hib, PCV13, MMR, Varicella, Hepatitis A, Hepatitis B (all completed as
scheduled)
Primary Care Provider: Dr. Sarah Chen, MD, Pediatrics
Insurance: Medicaid
Preferred Language: English
Interpreter Needed: No
Accompanying Person: Mother – Jessica Stevens (age 28)
Reliability of Informant: Mother appears reliable, provides clear and consistent history
Mode of Arrival: Walk-in appointment at pediatric clinic
Triage Priority: Urgent – potential dehydration risk
Chief Complaint (CC)
