The febrile child

Probabiglity diagnosis

Viral URTI infection incl. common cold, pharyngitis, tonsillitis

Otitis media

Acute bronchitis

Roseola

Gastroenteritis

Post immunisation

Serious disorders not to be missed

Infection:

• Bacterial

• Meningitis/encephalitis

• Septicaemia/bacteraemia

• Epiglottitis

• Pneumonia

• Oteomyelitis/septic arthritis

• Tuberculosis

• Orbital cellulitis

• Abscess

• Viral

• Epstein—Barr mononucleosis

• Exanthemata eg measles, varicella e.g. fifth disease, hand-foot-mouth disease

• Bronchiolitis/croup

• HIV/AIDS

Cancer:

• Leukaemia/lymphoma

• Neuroblastoma/sarcoma

Other:

• Acute appendicitis

Pitfalls (often missed)

Tuberculosis

Rheumatic fever

Endocarditis

Tropical infections e.g. malaria

Atypical infections e.g. zoonoses

Henoch Schonlein purpura

Kawasaki disease (persistent fever)

Heatstroke/hot car

Masquerades checklist

Drugs e.g. penicillin, antihistamines

Urinary tract infection

Is the patient trying to tell me something?

?parental ?Munchaussen by proxy

Key history

Obtain detailed account from parents of the symptoms and circumstances, esp. associations such as vomiting, diarrhoea, sweating, cough, wheeze, headache, other pain, cognition, photophobia and urinary symptoms. Ask about immunisation (past and recent), infectious contacts, animal contact and travel. Past history: ?splenectomy.

Key examination

• General features: appearance of the child, interaction and level of activity, colour, hydration, chest movement and vital signs including peripheral perfusion.

• Examine skin looking for evidence of rashes, vesicles and purpura.

• Examine the ears and throat.

• Basic neurological signs, esp. neck stiffness and fontanelles.

Key investigations (only if necessary)

First line:

• FBE/ESR

• urinalysis

• MCU

Consider:

• CXR

• blood culture

• lumbar puncture

Diagnostic tips

Fever is regarded as a temperature >38° (rectal or tympanic). Most fevers in children are caused by viruses and are self limiting. Distinguish between focal causes, e.g. tonsillitis, and no apparent focus when a more detailed history and examination is required. Be very mindful of septicaemia and endocarditis.