Physical Exam Key Points

1. General appearance. Very important, especially in younger children. Recognition of the "toxic infant" with fever should trigger medical urgency.

2. Vital signs. High degree of fever and its association with other risk indicators in a young child increases the likelihood of bac-teremia. Hypotension should raise concern about hypovolemia, sepsis-induced loss of peripheral vascular resistance, or myocardial dysfunction. Hypotension in the absence of tachycardia raises concern about disturbance of cardiac function or rhythm. Absence of tachycardia with fever is a feature of Salmonella typhi. Tachycardia in the absence of hypotension may be related to fever (10-20 beats/min increase for each degree above normal temperature), incipient vascular collapse (particularly in the setting of narrowed pulse pressure), depressed cardiac function, or an associated rhythm disturbance (eg, supraventricular tachycardia). Elevated respiratory rate, which also may be a response to fever, may signal a pulmonary source of the fever when the rate is elevated disproportionately to heart rate and BP Alternatively, increased

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