A 6-month-old male patient presents to your clinic with his mother. The mothers 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?(Include rationales for questions)
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? (Include ICD codes and rationales)


Sample Answer

Sample Answer


Questions for the Mother:

1. How often is your baby having diarrhea, and what does it look like?

– Rationale: Frequency and consistency of diarrhea can indicate the severity of the issue and help assess for dehydration.

2. Have you noticed any blood or mucus in your baby’s stool?

– Rationale: Presence of blood or mucus in stool can indicate underlying infections or gastrointestinal issues that may require immediate attention.

3. Is your baby urinating less than usual?

– Rationale: Decreased urine output can be a sign of dehydration, which is a concern in infants with fever and diarrhea.

4. Has your baby been vomiting, and if so, how frequently?

– Rationale: Vomiting along with fever and diarrhea can exacerbate dehydration and may indicate a more serious condition.

5. Is your baby showing any signs of irritability, lethargy, or difficulty breathing?

– Rationale: These symptoms, along with fever and diarrhea, could suggest a systemic illness requiring urgent medical attention.

Additional Signs/Symptoms for ER Transfer:

– Persistent high fever (above 100.4°F or 38°C)
– Severe dehydration (sunken fontanelle, dry mouth, no tears when crying)
– Excessive vomiting leading to inability to keep fluids down
– Persistent diarrhea with blood or mucus
– Lethargy, irritability, or difficulty breathing

Top 3 Differential Diagnoses:

1. Gastroenteritis (ICD-10: A09):

– Rationale: Common viral or bacterial infection causing fever, diarrhea, and vomiting in infants.

2. Urinary Tract Infection (ICD-10: N39.0):

– Rationale: Fever along with decreased urine output could indicate a UTI, especially in young infants.

3. Rotavirus Infection (ICD-10: A08.0):

– Rationale: Highly contagious viral infection common in infants causing severe diarrhea and dehydration.

In this clinical scenario, prompt evaluation and management are essential to determine the underlying cause of the infant’s symptoms and ensure appropriate treatment to prevent complications.



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