You are seeing Mrs. Bosco, a 25 year old female who recently gave birth to a baby named Michael six weeks ago. Today, she presents to your office because she is concerned about the baby’s health. Take a focused history of Mrs. Bosco’s complaint.
History
- Determines chief complaint is diarrhea
- Volume of diarrhea (i.e. frequency of diaper change)
- Appearance of diarrhea (appears brown, with no blood)
- Associated nausea/vomiting
- Lethargy
- Child’s level of activity
- Fever and peak temperature
- Changes in urination, including odor
- New rashes
- Symptoms of URTI
- Recent weight loss
- Volume of oral intake
- Infectious contacts
- Past medical history (none)
- Asks about developmental milestones appropriate for child’s age
- Pregnancy history (normal)
- Vaccinations to date
- Allergies (none)
- Current medications (none)
- Inquires about mother’s stress, caregiver burden
- Inquires about mother’s support for the care of the infant
- Inquires about post-partum depression
- Inquires about mother’s other concerns related to raising her infant
Case 2 – Infant Diarrhea