Fever Clinical Pathway – All Settings – History and Physical

Fever Clinical Pathway – All Settings

History and Physical

The majority of children with fever have a self-limited viral infection. Many patients have a recognizable viral infection and a small proportion have a bacterial illness that is recognizable on physical exam. Careful history and physical examination usually identifies possible bacterial infections. Otherwise, healthy children age > 56 days to 24 months may have occult bacterial infection in the urinary tract or the lung. It is important to review the immunization status of young children as under-immunized children may have an increased risk for invasive bacterial disease.

History

History of Present Illness
  • Onset, duration, method of temperature measurement, height of fever, diurnal variations
  • Associated signs and symptoms
  • Medications, including antipyretics and antibiotics
  • Hydration: intake, output
  • Prior evaluation, treatments during current illness
  • Ill contacts
  • Consider unusual exposures and international travel (e.g., travel history, pet or insect exposures, raw/unusual foods, lifestyle & activities)
Past Medical History
  • Recurrent febrile illnesses (suggestive of, e.g., undiagnosed immunodeficiency, cyclical fever syndromes)
  • Presence of any diseases, medications that may compromise normal host defenses
  • Host Compromise
  • Immunization status
  • Indwelling catheters
  • Other internal devices (e.g., VPS, prosthetic valves, orthopedic hardware, other surgical instrumentation/patches)

Physical

Physical Examination Some Diagnosis Considerations
General
  • Mental status
  • Vital signs, work of breathing, color, perfusion
  • Gross motor functions
HEENT Eyelid swelling, erythema, tenderness Periorbital Cellulitis, Orbital Cellulitis
  • Conjunctival erythema, discharge
  • Rhinorrhea, nasal mucosal inflammation
  • Tympanic membrane redness, bulging, decreased mobility
  • Loss of landmarks and light reflex
  • Air-fluid levels
  • Purulent drainage from a perforation
Rhinorrhea, nasal mucosal inflammation Viral upper respiratory infection (URI)
  • URI symptoms persisting ≥ 10 days
  • or
  • Fever > 39 and purulent nasal discharge for at least 3 consecutive days
 Acute bacterial sinusitis
Barky cough, +/- URI findings, stridor as illness progresses Croup, Croup Clinical Pathway
  • Oropharyngeal erythema, exudate
  • Tonsillar hypertrophy
  • Peritonsillar swelling
Oral ulcers, gingival inflammation Gingivostomatitis
Dental caries, tenderness, gingival inflammation with fluctuance Alveolar abscess
Parotid swelling, tenderness Parotitis
Neck Cervical spinous process tenderness
Meningismus Meningitis, Meningitis Clinical Pathway
Limited extension of neck and/or stridor
Tender lymph nodes may have overlying erythema
  • Bacterial lymphadenitis
  • Bartonella henselae (cat scratch disease)
Chest
  • Tachypnea, fever, and nasal flaring or retractions, hypoxia
  • Rales and evidence of consolidation or pleural effusion
 Pneumonia, Pneumonia Clinical Pathway
Wheezing, tachypnea, and fever in infants Bronchiolitis, Bronchiolitis Clinical Pathway
  • Gallop, friction rub, disproportionate tachycardia
  • Tachypnea, dyspnea
  • Wide pulse pressure, mild hypotension, or other signs of poor perfusion (+/- abnormal CXR, electrocardiogram, hepatomegaly)
 Myocarditis, pericarditis
Abdomen Diffuse mild/moderate pain or tenderness with vomiting and/or diarrhea
  • Viral gastroenteritis
  • Hepatitis or pancreatitis
  • Focal pain, tenderness RLQ
  • Peritoneal signs
Fever with abdominal pain
Suprapubic or costovertebral angle tenderness
(However, young children may manifest only fever) 		UTI/pyelonephritis, UTI Clinical Pathway
Adolescent females with pelvic or abdominal pain and fever
Musculoskeletal Joint swelling, effusion, tenderness, limited range of motion
Bony tenderness, abnormal posture, or limp
Severe muscle tenderness, poor perfusion Pyomyositis, necrotizing fasciitis
Mild muscle tenderness (may have myoglobinuria) Viral myositis (e.g., influenza)
Swollen hands/feet
Neurologic Bulging fontanel (infants), and altered sensorium, convulsion, meningismus, or focal neurologic deficits (older children)
  • Meningitis/encephalitis/meningoencephalitis (including bacterial, HSV, enterovirus, others) Meningitis Clinical Pathway
  • Cerebral abscess
Skin
  • Fever and petechiae
  • Petechiae only above the nipple line
    • Consider labs
    • Normal WBC count and coagulation studies and well-appearance
      • Makes invasive disease less likely
  • Ill appearance, laboratory abnormality, or progressive petechial rash requires full evaluation; consider empiric antibiotic administration
Characteristic febrile exanthems
  • Varicella, rubeola, measles (esp. under-immunized)
  • Scarlet fever
  • Coxsackievirus
  • Fifths disease
Tenderness, erythema, warmth, fluctuance Cellulitis, abscess, Cellulitis Abscess Clinical Pathway
Other Systemic Septic shock with or without rash