Clinical approach to a child with feverA good clinical history and a thorough physical examination should form the basis of making a provisional diagnosis. Laboratory tests should only be supportive and not an alternative to clinical diagnosis. A) History 1. Age: Fever in infants < 3 months of age should be considered as evidence of serious bacterial infection until proven otherwise. 2. Duration of fever: Fever lasting for more than 4-7 days is rarely due to self limiting viral illness and needs investigation. Fever lasting for more than 2 weeks indicates serious underlying problem and needs thorough investigation. 3. Chills and rigors: both are non specific and suggest no definite etiology. 4. Pattern of fever: The wide use of the antipyretics modifies the natural pattern of fever. Nausea may indicate hepatic disease. Persistence of headache and vomiting may indicate meningitis.5. Contact with similar diseases: Knowledge of the epidemiology of a prevailing illness helps in suspecting the illness.6. Past history of similar illness: Recurrent viral infections are common in children especially in the first year of school. Children between 2 months to 6 years of age are also susceptible to recurrent viral infections. Malaria may often recur, as the therapy is merely suppressive.7. Drugs used in the treatment and its response: Hence the inter febrile state helps in the evaluation of the probable cause of fever. Patterns of fever have limited value in predicting the etiology of fever.8. Progress of fever: Fever due to viral infection peaks over a day or two and gradually declines in 3-4 days. Bacterial fever worsens if left untreated. Malarial fever develops suddenly and declines swiftly.9. Accompanying symptoms: specific symptoms help in localising the site of infection such as cough/cold in respiratory illness, diarrhea/vomiting in GI infection, dysuria in UTI, drowsiness or convulsions in meningitis. Non specific symptoms include bodyache, headache, anorexia, vomiting and irritability. These usually disappear with the reduction of fever. Persistence of anorexia and Therapeutic response to an antibiotic is very difficulty to assess accurately. Natural remission of a viral fever may be interpreted as response to an antibiotic. Typically, fever due to bacterial infection responds to antibiotic in 2-3 days. Typhoid fever takes longer duration to normalize. 10. Immunization: Vaccine preventable diseases are rare in immunized children. Clinical manifestations of the disease are often modified in immunized children. Vasoconstrictors Adrenocepto Reactivity Onset (minutes) Duration of action(hours) Dosage Sympathomimetic amines Phenylephrine Alpha1 1 to 9 1 to 4 2 to 3 sprays in each nostril every 3 to 4 hours Imidazoline derivatives Naphazoline Alpha2 1 to 3 2 to 6 1 to 2 sprays in each nostril not more than every 6 hours Oxymetazoline Alpha2 1 to 3 5 to 12 2 to 3 sprays daily Xylometazoline Alpha2 1 to 3 6 to 12 2 to 3 drops or 2 to 3 sprays every 8 to 10 hours Phenylpropanolamine Alpha1 and alpha2, beta1 and beta3 15 to 30 8 to 12 1 tablet every 12 hours Pseudoephedrine Alpha1 and alpha2, beta1 and beta2 15 to 30 4 to 8 8 to 12 60 mg every 4 to 6 hours, 120 mg every 12 hours B. Physical examination: 1. Assess seriousness: Presence of the following signs suggests the possibility of serious underlying diseases: a) Respiratory distress b) Drowsiness / meningeal signs c) Signs of impending shock d) Purpuric spots e) Faucial membrane f) Abdominal guarding / rigidity 2. General examination: i) General appearance: Toxic/ill look indicates serious illness. Irritability or discomfort may either be due to pain or respiratory distress. A comfortable child indicates that a benign illness is likely. ii) Body temperature: Must be quickly judged by merely touching the skin over the central and peripheral parts of the body. Differential body temperature: warm chest/abdomen and cool periphery-indicates severe illness.iii) Pulse rate: With every degree Fahrenheit rise in the fever, pulse rate goes up by 10 beats/min. Disproportionate increase in the pulse rate may suggest early sepsis or primary cardiac disease. iv) Respiratory rate: Normal ratio of pulse and respiration in health is 4:1. The ratio is increased in primary cardiac disease and decreased in respiratory pathology.v) Skin rash vi) Lymphadenopathy vii) ENT examination3. Systemic examination i. Respiratory system ii.Cardiovascular system iii. Central nervous system iv. Abdomen Good clinical history and thorough physical examination form the first step in the management of fever in children. Interfebrile clinical state is the best predictor of fever etiology. Beware of warning signs that may suggest serious underlying illness in a febrile child. C. Clinical approach to fever in relation to the duration of the fever: Algorithm I-A : Fever of 1-3 days Note: Every febrile child should have a CBC at least by the 4th day; more so if no definite diagnosis is possible by then.