Essay Elements:

One to three pages of scholarly writing in paragraph format, not counting the title page or reference page

Brief introduction of the case

• Identification of the main diagnosis with supporting rationale
• Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
• Diagnostic plan with supporting rationale or references
• A specific treatment plan supported by recent clinical guidelines
• Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.
• Patient Name: Amelia Arlington
• Age: 4-week-old infant

Sex assigned at birth: female

Gender identity: female

Pronouns: she/her/hers

• You are working at Dr. Nayar’s family medicine office.

The schedule says the next patient is “Amelia Arlington — 4-week-old infant — fussiness.”

• Dr. Nayar fills you in on the history: “Amelia is the first child born to the Arlingtons, whom I saw throughout the pregnancy for prenatal care. This was a planned pregnancy, and they were both very excited about becoming parents. The pregnancy was uncomplicated and went to 39 weeks, five days; mom’s test for Group B streptococcus (GBS) infection was negative. Labor was uneventful.

“Second stage was two hours long and the baby was delivered without difficulty. They had a 7-pound, 8-ounce (3,400 g) female with Apgars of 7 and 9, and height of 20.5 inches (52 centimeters).

• “Ms. Arlington and the baby were discharged home on the second postpartum day with plans to breastfeed. The baby’s discharge weight was 7 pounds 3 ounces.

“Generally we see newborns two or three days after discharge from the hospital to check that breastfeeding is going well, to ensure that there is not excessive neonatal jaundice, and to do a weight check. When I saw Amelia at this visit she looked great and breastfeeding seemed to be off to a good start. Somehow we haven’t gotten the baby’s growth chart filled out yet. Can you fill out a growth chart for Amelia today?”

• 60th percentile for weight, 90th percentile for height.

4 WEEK VISIT

Dr. Nayar continues, “I next saw Amelia at two weeks of life. Both parents had come in for that visit and they were tired, like so many parents of newborns are, but they seemed to be doing all right. The baby was breastfeeding fairly well, though Ms. Arlington was nervous that she might not be getting enough. This is a very common concern of first-time breastfeeding mothers. Her weight was 7 pounds 6 ounces. How would you assess this weight at two weeks of age, given that her birth weight was 7 pounds 8 ounces?”

Dr. Nayar continues, “That was two weeks ago. Now the baby is four weeks old. I asked the nurse to give the Arlingtons an appointment today because Ms. Arlington called this morning and said that Amelia was ‘really fussy and crying a lot.’ By taking a look at her vitals and growth curve, you can get a quick sense of her health status today before you start the visit.”

You look in the EMR and notice that her vital signs today are:

Vital signs:

Temperature is 37.5 °C (99.5 °F) (rectal)

Pulse is 132 beats/minute

Respiratory rate is 42 breaths/minute

Oxygen saturation is 98% to 99%

Weight is 3.8 kg (8 lbs, 6 oz)

You recognize this as a set of normal vital signs for a four-week-old infant and plot the baby’s new weight. You are pleased to see that her weight is now in the 60th percentile range.

When you report this to Dr. Nayar, he is also pleased. He says, “Now, the last thing we should review before you go meet the Arlingtons is normal growth and developmental milestones for a four-week-old infant.”

NEWBORN EXAM

You have finished gathering your history and ask Ms. Arlington, “Do you mind if I take a look at Amelia? I am sorry to wake her up.” She tells you that’s fine, as she’s close to feeding time and would probably wake on her own soon.You take the infant to the exam table just as Dr. Nayar knocks and asks to join the visit. After greeting Ms. Arlington and asking how she is doing, he turns his attention to Amelia lying on the exam table. You summarize the history that you have learned for Dr. Nayar:

“Amelia is now four weeks of age and has been very fussy late in the day for about the last week to 10 days. Mom is quite concerned that she might be in pain because she screams and cries often for two or three hours, drawing her legs up. Nothing she does to soothe her has seemed to help. I did a review of systems looking for other signs or symptoms of illness, and really can’t find any. She has gained a full pound since you saw her at two weeks of age.”

During the exam, Dr. Nayar describes what he is doing to both you and Ms. Arlington, and he comments frequently throughout the exam about normal healthy findings.

• Physical Exam

General: Vigorous-appearing infant lying on back on the exam table, moving all extremities.

• Head: Sutures non-overlapping, no facial or cranial deformity appreciated; anterior fontanelle is soft, flat (not sunken).

Eyes: Tears when crying, no discharge, erythema, or edema. The eyes do not appear dry or sunken; there is no scleral icterus.

• Ears: Tympanic membranes are gray, with normal mobility and normal landmarks visualized.

Nares: Patent, no flaring, normal anatomy.

• Oral mucosa: Pink, moist, no exudates.

Respiratory: Symmetric chest excursions, breath sounds clear bilaterally.

• Cardiovascular: Regular rate, normal S1, and S2, no murmur. Femoral pulses are symmetric.

Abdomen: Bowel sounds present, soft abdomen, not distended, no palpable masses, no hepatosplenomegaly, non distended.

GU: Wet diaper; normal external female genitalia.

Skin: Pink without evidence of jaundice, well-perfused throughout, normal turgor, w/o tenting. Capillary refill: ? 2 seconds.

Neuro: Calm and consolable. Normal tone, moving all extremities spontaneously; positive suck and Moro reflexes elicited

FEEDING

Amelia is awake and crying at this point. Dr. Nayar asks you how to elicit the rooting reflex, and you demonstrate. Ms. Arlington immediately responds to Amelia’s signals that she is hungry and Dr. Nayar hands the baby to her.

Dr. Nayar asks, “Is it okay if we watch Amelia feed for a minute so we can get a sense of how breastfeeding is going?”

Ms. Arlington agrees and appropriately strokes Amelia’s cheek so she turns towards her nipple. She latches quickly and fully and begins making gulping and swallowing noises. Dr. Nayar points these out to you as evidence that there has been a good letdown and good volume of milk flow while commenting also to Ms. Arlington that she appears to have a great milk supply and has developed a lot of confidence in her breastfeeding.

After a minute of observation, you and Dr. Nayar excuse yourselves to allow the Arlingtons some privacy while you go out in the hallway to discuss the case further.

Dr. Nayar tells you that good knowledge and supportive counseling skills are very important for the family physician who is helping to support breastfeeding families, but there is also a wealth of readily accessible information available. He gives you a reference for an American Family Physician article on successful strategies for breastfeeding that he suggests you read.

DIFFERENTIAL DIAGNOSIS

You and Dr. Nayar go to the preceptor room to discuss the Arlingtons. He asks you, “What do you think about little Amelia?”

You reply, “Well, I think she is a healthy baby but I don’t know. Can’t young babies have reflux? Could that be why she cries every evening? And maybe the dad is right and she has a milk allergy? Is there some kind of testing you could do to figure that out?”

Dr. Nayar suggests that you have already begun to compose a differential and asks you, given the information you now have, to think about what else might explain Amelia’s presentation and physical exam.

Differential of Fussy Infant

Most Likely Diagnosis

Colic affects approximately 20%–25% of all infants. Symptoms typically begin around the age of two weeks, peak at about six weeks, and gradually improve over the next several weeks, with most infants free of symptoms by twelve weeks of life.

After considering the list of potential diagnoses, you realize that Amelia must have colic, a condition you do not really understand. You ask Dr. Nayar to explain it to you, and he laughs, “I wish I could, and so do many others. Colic is a funny thing that medical science has never really been able to satisfactorily explain, though many have tried. Over my years of practice, I have developed a way to explain it to parents that seems to help; we’ll go back in and see Ms. Arlington and we’ll talk about it. You let me know if you think my explanation helps her or just confuses her more, and please feel free to add your ideas to our discussion.”

You and Dr. Nayar talk about what we do know about the definition and etiology of colic.

Then Dr. Nayar tells you, “My approach is to try to strongly encourage all my pregnant patients to breastfeed and, once initiated, to keep at it. Some may need a lot of support to do this but it’s well worth the time and effort to provide for both mom and baby’s well-being. Let’s go see Amelia and Ms. Arlington.”

Dr. Nayar asks you, “What if everything about Amelia’s presentation were the same but we found she had a fever of 101 degrees? Would that make any difference in your thinking about her?”

You are alarmed at the question. “Well, it sure would. Fever in a 4-week-old infant is a potentially serious sign of life-threatening infection and our differential would be entirely different in that case.”

MS. ARLINGTON

Just then, a knock at the door calls Dr. Nayar out of the room for a phone call from the hospital. You leave to get the patient information sheet and when you return, Ms. Arlington is crying quietly with the baby asleep in her arms.

You sit down next to her and gently ask, “So, how are you doing?”

She begins to cry even more. “I am so relieved that nothing is seriously wrong with Amelia. I really didn’t think so but it is so scary when she cries for so long and so hard and I feel so helpless. My husband is really upset about it too, and he sometimes just slams out of the house. I know it’s just that he is frustrated, but sometimes I get tired after being with the baby all day without any adults to talk to, and it seems like he finally gets home from work, and then the baby starts crying and I feel like I can’t take it anymore and I must be a bad mother.”

You reply to Ms. Arlington, “It must be really hard. I wonder, what do you do when it gets really bad like that?”

“Well, sometimes I pack the baby up and just go for a long walk. Sometimes I call my friend who is at home with her six-month-old and go over there, and sometimes I just lay Amelia in her crib and let her cry until I can calm myself down.”

You reply, “Those all sound like really constructive solutions. I am impressed that you’ve figured out so many ways to hold on during these hard times. Do you ever fear that you might hurt the baby because you are so upset?”

Ms. Arlington, looking very frightened, tells you, “You know, I think that’s when I realized that it’s okay to lie her down in her crib and just take a break. Because sometimes you think you will go crazy when they just scream and cry and there’s nothing you can do about it.”

You are thinking about the screening tools for depression and find yourself wondering how these apply to postpartum women.You and Dr. Nayar return to Ms. Arlington’s room.

Dr. Nayar begins, “Hi again. Have you had a chance to fill out that questionnaire?”

“Yes, I did. And I have been reading through some of the handouts on treatments for calming a fussy baby and I think there are some good ideas in here that I hadn’t thought of. I feel so relieved to read more of these descriptions in the handout; it sounds so much like what Amelia goes through that I feel less worried that something really bad is happening.”

Dr. Nayar replies, “Good. In reviewing your questionnaire here, I feel pretty comfortable that you don’t have depression. Your score is 10 and we consider that pretty much in the normal range. I am wondering if the worry about Amelia and all the changes that having a new baby has brought to your life has been really stressful and that has left you sometimes feeling pretty overwhelmed. That is a common feeling for new parents. What do you think?”

Ms. Arlington agrees, “Well, no question we all have been feeling pretty overwhelmed. I’m thinking that this adjustment has been much more complicated than any of us have imagined, including for my husband.”

“Yes, often new fathers can feel left out and pushed aside given all the demands made by the baby.” Dr. Nayer then asks, “Do you think this has happened for Mr. Arlington?”

“Yep, I think maybe it has. I feel bad about it too. But you know, at the end of the day, I am pretty much out of energy.”

Dr. Nayar reassures her, “I think that’s quite understandable, and yet it’s important for new families to think about ways to include Dad in the intense early months. I would like to check in with both you and Amelia in two weeks to make sure things are going okay. How would it be if we rescheduled you for a visit in two weeks, and perhaps Mr. Arlington could come along? This would give us all a chance to talk a little more about some of these concerns, and it would be great if we could hear how he’s feeling too.”

“OK, I’ll invite him to come,” Ms. Arlington says.

You add, “And if you have a couple more minutes I want to answer any questions you have about the handouts and go over this new one too about postpartum blues and depression.”

“That’s fine, and thank you both for all your help,” smiles Ms. Arlington.

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