Date:
Patient:
MRN:
Clinician: (Pediatrician, Emergency Physician)
Reason for Visit:
Febrile infant evaluation (temperature > 100.4°F (38°C) rectally)
(Optional) Specific reason for concern (e.g., cough, vomiting, irritability)
History of Present Illness:
Age and gestational age at presentation
Onset, duration, and pattern of fever (continuous, intermittent)
Associated symptoms (cough, congestion, vomiting, diarrhea, irritability, poor feeding, lethargy)
Immunization history (up-to-date or not)
Prenatal history (maternal infections, medications)
Delivery history (term or preterm birth, complications)
Past Medical History:
Any previous hospitalizations or surgeries
Chronic medical conditions (if applicable)
Family History:
Presence of fever or illness in household contacts
Social History:
Living situation (daycare, exposure to other children)
Travel history (recent or planned)
Physical Exam:
Vital Signs: Temperature, heart rate, respiratory rate, oxygen saturation
General Appearance: Illness severity (irritable, lethargic), hydration status
HEENT (Head, Ears, Eyes, Nose, Throat): Signs of otitis media (ear infection), upper respiratory infection (URI), conjunctivitis
Neck: Lymphadenopathy (swollen lymph nodes)
Chest: Auscultation for wheezing, crackles
Abdomen: Soft, distended, tenderness
Genitourinary: Normal urination
Neurological: Fontanelle (soft spot on head) full or bulging, lethargy, irritability
Mucous membranes: Moist or dry
Labs:
Consider mentioning specific labs ordered based on presentation:
Complete blood count (CBC) – to assess for white blood cell count and differential (may indicate infection)
Urinalysis and urine culture (if UTI suspected)
Respiratory viral panel (rapid test for common respiratory viruses)
Blood culture (if high fever and appears very ill)
Lumbar puncture (spinal tap) – may be indicated in specific situations to rule out meningitis
Imaging:
Imaging studies are not routinely performed for all febrile infants.
Chest X-ray – may be obtained if pneumonia is suspected.
Assessment:
Identify the source of fever (if possible) based on history, physical exam, and laboratory findings.
Consider differential diagnoses:
Urinary tract infection (UTI)
Otitis media (ear infection)
Upper respiratory infection (URI)
Bronchiolitis
Pneumonia
Bacteremia (bloodstream infection)
Meningitis
Plan:
Outline the treatment plan based on the suspected source of infection:
Antibiotics: If a bacterial infection is suspected, administer antibiotics based on culture results and sensitivities.
Antipyretics: Medications to reduce fever (e.g., acetaminophen, ibuprofen) as needed for comfort.
Supportive care: Fluids for hydration, comfort measures
Disposition:
Admission to the hospital – for infants with concerning symptoms, high fever, or dehydration.
Discharge home – with close follow-up and specific instructions based on the diagnosis.
Prognosis:
Briefly discuss the prognosis, which depends on the underlying cause of fever and the infant’s overall health. Most febrile infants recover quickly with appropriate treatment.
Education:
Document any education provided to the parents/caregivers regarding:
Warning signs of a serious illness in an infant (persistent fever, poor feeding, lethargy, bulging fontanelle)
Importance of close follow-up and returning for re-evaluation if symptoms worsen
Fever management strategies (appropriate medication dosing)
Importance of good hydration
Notes:
Include any additional relevant information not covered above, such as parental concerns and understanding of the plan.
Consider mentioning the need for potential re-evaluation if the infant’s condition worsens.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis and treatment recommendations.