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acidosis resulting from the underlying etiology of the fever.

3. Skin. Rashes frequently accompany viral syndromes (viral exanthemas). The critical distinction in assessing rash in a febrile child is whether or not the rash blanches with pressure. Nonblanching rash may indicate a vasculitic injury with extravasation of blood into the surrounding dermis. It should raise suspicion of infecting organisms that are tropic to vascular structures, which includes enteroviruses, Neisseria meningi-tides (meningococcemia), and Rickettsia rickettsiae (Rocky Mountain spotted fever [RMSF]). Distribution of rash can be useful in distinguishing source of infection. Varicella starts centrally (truncal) and moves out, whereas variola begins peripherally. Palms are more often involved in RMSF.

4. HEENT. Acute otitis media is the most frequent diagnosis in children presenting with fever. Diagnosis in a screaming child requires diagnostic skill beyond mere assessment of tympanic membrane erythema. Drum appearance and membrane mobility are important signs. Conjunctival suffusion may be one of the diagnostic clues to Kawasaki disease. It is important to evaluate for pharyngitis (eg, group A streptococcus, EBV), peritonsillar abscess, retropharyngeal abscess, and rhinosi-nusitis (eg, upper respiratory allergic diathesis). Drooling may suggest upper airway obstruction, including retropharyngeal abscess.

5. Neck. Assess for nuchal rigidity, including Brudzinski and Kernig signs. Note that these signs become progressively less reliable in children younger than 15 months of age. Tilted head due to torticollis may indicate an inflamed node in contact with the sternocleidomastoid (eg, peritonsillar abscess).

6. Lymph nodes. Suppurative nodes are usually caused by either Staphylococcus aureus or group A streptococcus. Cat-scratch fever usually is associated with a cold lymphadenitis. Often an entry punctum can be found on skin in the anatomic area associated with the abnormal node. Generalized adenopathy directs clinician away from focal infections with considerations of certain viral, rheumatologic, or malignant processes.

7. Lungs. Respiratory tract is the most frequent site of infection in children with fever. Altered pattern of normal breath sounds is a clue (especially tachypnea). Rales may direct clinician to a pulmonary infiltrate. Diffuse wheezes can be heard in bron-chospastic processes and lower airway infection (bronchiolitis). Unilateral or segmental wheezes suggest foreign body aspiration.

8. Heart. New murmur, particularly mitral or aortic regurgitant, should raise suspicion of acute rheumatic fever. Occasionally this will only be heard on serial exams, because it may not be present at onset of fever. Muffled or distant heart sounds may be a clue to pericardial effusion as part of viral pancarditis or due to septic pericardial effusion.

9. Abdomen. Examination often requires diversionary tactics. Exam findings such as localized tenderness often need to be repeated from different approaches to validate finding. Rupture of the appendix before operative treatment is the rule in infants and young toddlers. Tenderness at McBurney point, if elicited, is reliable as a sign of appendicitis. Liver size, as measured by distance of the edge below the right costal margin at the mid-clavicular line (MCL), requires knowledge of changing anatomic ratios with growth. A liver edge 3 cm below the right costal margin at the MCL may be normal in a newborn but marks hepatomegaly in a 10-year-old child. Tenderness of the costovertebral angle (CVA) in older toddlers and children points to a renal source of infection.

10. GU system. Perform a GU exam to evaluate for pelvic inflammatory disease in a sexually active febrile adolescent. Consider UTI in a febrile girl without other evidence of an infectious focus. Physical findings (eg, CVA tenderness) are less reliable in younger children. Male adolescents must be assessed for testicular tenderness of epididymitis.

11. Extremities. Trauma from childhood play can be noted on the extremities, and evidence of infecting cellulitis should be sought. The punctum of cat-scratch disease is most often seen on extremities (upper > lower) as this is the site of most human contact with cats. Extremity findings can be seen in Kawasaki disease, dermatomyositis, SLE, and vasculitic syndromes (eg, septic vasculitis).

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