A 6-month-old male patient presents to your clinic with his mother. The mother’s chief complaint is that the baby has had a fever and diarrhea for several days and is not nursing as much as usual. The infant is quiet and warm, lung sounds are clear, heart sounds normal. No medical history, born healthy at 39 weeks 5 days via uncomplicated vaginal delivery, he is exclusively breastfed and is up-to-date on his vaccinations.
What are 5 questions you would ask the mother next?
What additional signs/symptoms would alert you that this infant may need to be transferred to the ER?
What are your top 3 differential diagnoses
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Questions to ask the Mother
The first question that I Will ask is if the child is experiencing any problems with sleep. Next, I will ask if the patient may be experiencing high temperatures, especially at night. Also, I will ask if the child experiences diarrhea after eating specific food or if it is just prevalent regardless of the food taken. In addition, I will ask the mother if the child has taken any fever medication and whether they were prescribed. Finally, I will ask if the child has had any exposure to a sick person, either a family member or anyone else, and if yes, whether the complications started after the exposure.
Additional Signs/Symptoms Necessitating ER Transfer
Several signs and symptoms could necessitate the patient to be transferred to emergency care. These include shortness of breath, extreme diarrhea, continuous vomiting and labs, and failure to thrive. Also, if the infant is not producing any dry mucus membranes, has increased or decreased respiration, poor muscle tone, decreased urine output, and sunken eyes, it will be necessary to transfer him to the emergency care (Hartman et al., 2019). In addition, the patient may be transferred to the emergency department if he is crying with positional changes or has a high fever of more than 39C.
Top Three Differential Diagnosis
The top three differential diagnoses include Acute Gastroenteritis, upper respiratory tract infection, and Rotavirus. Acute Gastroenteritis is an intestinal infection characterized by nausea, fever, vomiting, and diarrhea, while Rotavirus is a health condition causing diarrheas among young children and infants (Lugonja et al., 2020). Upper respiratory tract infection is a health condition fever, cough, runny nose, and sore throat. The condition is contagious, passing from one person to another and common among the children.
Hartman, S., Brown, E., Loomis, E., & Russell, H. A. (2019). Gastroenteritis in children. American family physician, 99(3), 159-165. https://www.aafp.org/afp/2019/0201/p159.html?cmpid=em_AFP_20190201
Lugonja, S., Zivic, J., & Zdravkovic, N. (2020). Clinical characteristics of rotavirus-induced Gastroenteritis in infants. Serbian Journal of Experimental and Clinical Research, 21(4), 291-297. https://sciendo.com/pdf/10.2478/sjecr-2020-0003