MERCK MANUAL

Professional Version
 Examination of the Febrile Child

Area Finding Possible Cause

Area Finding Possible Cause

Skin Variety of infections including

Nonblanching rash (ie,
petechiae or purpura)
enterovirus, meningococcemia, and Rocky
Mountain spotted fever
Disseminated intravascular coagulation
due to sepsis

Vesicular lesions Varicella virus, herpes simplex virus

Lacelike maculopapular rash

on trunk and extremities with Erythema infectiosum
slapped-cheek appearance

Focal erythema with swelling,

Cellulitis, skin abscess
induration, and tenderness

Evanescent erythematous
morbilliform rash on trunk and Juvenile idiopathic arthritis
proximal extremities

Bull’s-eye erythematous rash,

Lyme disease
single or multiple lesions

Erythematous, sandpaper-like Scarlet fever (group A streptococcal

rash infection)

*Meningismus is not consistently present in children < 2 yr with meningitis.

Area Finding Possible Cause

Toxic shock syndrome, toxin-mediated

Erythroderma
disease

Fontanelle
Bulging Meningitis or encephalitis
(infants)

Red, bulging tympanic

Ears membrane, loss of landmarks Otitis media
and mobility

URI
Congestion, discharge
Sinusitis
Nose

Nostril flaring with inspiration Lower respiratory infection

Redness Pharyngitis (URI or strep infection)

Throat Sometimes exudate or swelling Retropharyngeal abscess

Sometimes drooling Peritonsillar abscess

Neck Focal adenopathy with Lymphadenitis secondary to

overlying redness, warmth, and Staphylococcus aureus or group A
tenderness; possible torticollis streptococcal infection

*Meningismus is not consistently present in children < 2 yr with meningitis.

Area Finding Possible Cause

Focal adenopathy with limited

or no redness, warmth, or Cat-scratch disease
tenderness

Lymphoma
Generalized cervical
adenopathy Viral infection (particularly Epstein-Barr
virus)

Pain or resistance to flexion

Meningitis
(meningismus*)

Coughing, tachypnea, crackles, Lower respiratory infection (eg,

Lungs rhonchi, decreased breath pneumonia, bronchiolitis, chronic foreign
sounds, wheezing body aspiration)

New murmur, particularly Acute rheumatic fever

Heart
mitral or aortic regurgitant Endocarditis

Abdomen Gastroenteritis

Tenderness, distention Appendicitis

Absent bowel sounds Pancreatitis

Abdominal abscess

Mass Tumor

Hepatomegaly Hepatitis

*Meningismus is not consistently present in children < 2 yr with meningitis.

Area Finding Possible Cause

In neonate, Epstein-Barr virus infection,

TORCH infections (toxoplasmosis, syphilis,
varicella, coxsackievirus, HIV, parvovirus
B19)

Leukemia, lymphoma
Splenomegaly

Costovertebral tenderness (less

Pyelonephritis
reliable in younger children)
Genitourinary

Testicular tenderness Epididymitis, orchitis

Septic arthritis (very tender)

Joint swelling, erythema,
warmth, tenderness, decreased Lyme arthritis
range of motion
Rheumatoid or inflammatory disorder
Extremities

Focal bone tenderness Osteomyelitis

Swelling of the hands or feet Kawasaki disease

*Meningismus is not consistently present in children < 2 yr with meningitis.

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