FormalPara Learning Objectives

  • How to perform a focused history and physical examination for children presenting with fever?

  • How to demonstrate a good understanding of common and potential differential diagnosis for children presenting with fever?

  • How to perform a focused exam for children presenting with fever?

  • How to provide management for infant and children presenting with fever?

Focus areas on infectious causes (viral respiratory or gastrointestinal infections, bacterial infections like otitis media, pneumonia, urinary tract infections, tuberculosis, cytomegalovirus, Epstein–Barr virus, meningitis), versus noninfectious causes (Kawasaki disease, post vaccination fever, inflammatory bowel disease, juvenile idiopathic arthritis, systemic lupus erythematosus, lymphoma, leukemia).

  1. 1.

    Introduce yourself and establish a good rapport with the parents.

  2. 2.

    Identify the complaint:

    1. (a)

      “What is the temperature and where was it measured?” (rectal, axillary, or tympanic).

    2. (b)

      Onset, duration, and pattern.

    3. (c)

      Recent regular use of medication: new medication exposure or recent antibiotic use (can mask the infection).

    4. (d)

      Associated symptoms: reduced oral intake, irritability, lethargy, swollen glands, red conjunctiva, swollen eyes, dry eyes, sore throat, dental problems, mouth sores, epistaxis, flu-like symptoms, vomiting, diarrhea, abdominal pain, dysuria, urinary incontinence, flank pain, scrotal pain, bone pain, joint pain, decreased range of movement, and rash.

    5. (e)

      Possible provoking factors: incidental drug ingestion, indwelling devices, recent vaccine, transfusion, surgery, travel, high-risk diet (tap water, unpasteurized dairy products, or uncooked food), history of contact with infected human or unvaccinated animals.

  3. 3.

    Past medical history: immunization status, previous febrile illness, or immune compromised status (using steroids, immune deficiency syndromes, or cancer).

  4. 4.

    Family history: immune deficiency syndromes, recurrent infection, history of periodic fever disorder or Familial Mediterranean Fever.

  5. 5.

    Explore parent’s ideas, concerns and expectations (ICE).

  6. 6.

    Examination:

    1. (a)

      General: general appearance (well-appearing or toxic) and vital signs.

    2. (b)

      Skin: dry cracked lips, color of skin, turgor, rash, and capillary refill (normally less than 3 seconds).

    3. (c)

      Eye: bilateral conjunctival injection.

    4. (d)

      Neck: neck rigidity, cervical lymphadenopathy, torticollis.

    5. (e)

      Ear, nose, and throat: strawberry tongue, bulging tympanic membrane, tonsillar exudate or enlargement, petechial rash on soft palate.

    6. (f)

      Extremities: limb or joint swelling, refusal to bear weight.

    7. (g)

      Lung and cardiac examination: tachycardia or rales.

    8. (h)

      Abdomen examination: suprapubic tenderness, abdominal guarding, or rigidity.

  7. 7.

    Order investigation if there was no source of infection identified and if temperate above 38:

    1. (a)

      Patient less than 28 days old: complete blood count (CBC) with deferential, urine analysis with culture, stool for white blood count (WBC) and culture if diarrhea present, chest X-ray, and lumbar puncture.

    2. (b)

      Patient is 1–3 months old: CBC with deferential, urine analysis with culture, stool for WBC and culture if diarrhea present, Chest X-ray (if fever is 39 degrees, white blood cells is more than or equal to 20,000/mm2, or respiratory signs are present), Lumbar puncture (if ill appearing).

    3. (c)

      Patient is 3–36 months old: CBC with deferential, urine analysis with culture, stool for white blood cells and culture if diarrhea present, chest X-ray (if fever is 39°, white blood cells is more than or equal to 20,000/mm2, or respiratory signs are present), lumbar puncture (if neurological or meningeal signs are present).

  8. 8.

    Management and education: share differential diagnosis and prognosis.

    1. (a)

      Educate the patient on the following: the correct way of monitoring body temperature (rectal is the most accurate in infants and toddlers), the correct dose of antipyretic medication, and physical means of fever control. Examples of these are: wearing light clothing, taking a shower or bath in room-temperature water, and applying water compresses (made with room-temperature water) to the neck, axillae, and inguinal regions, where blood vessels are bigger, will help promote evaporation.

    2. (b)

      Patient less than 28 days old: begin empiric antibiotic treatment after cultures have been obtained : ampicillin and gentamicin, or ampicillin and cefotaxime.

    3. (c)

      Older children: manage according to the symptoms or investigation findings.

  9. 9.

    Arrange referral and follow up as needed:

    1. (a)

      Consider admission for all neonates and any child with no focus found.

  10. 10.

    Give reading educational materials if any.

  11. 11.

    Discuss health maintenance and screening for age.

  12. 12.

    Communication skills: organized approach, mixed questioning styles (open- and close- ended questions), active listening, clear language, and reflection on patient’s ICE.