Clinical scenario 1 - Simon

Simon, an eight week old infant, presents with fussiness and poor feeding for two days. Simon’s older siblings have had an URTI recently and have been exposed to him. On examination he handled well but mostly is unsettled and grizzly.

The following three questions refer to Simon’s clinical scenario.

Question 01

On the basis of this history, which ONE of the following is the most likely diagnosis?
URTI (upper respiratory tract infection)
Meningitis
UTI (urinary tract infection)
Sepsis
Not possible to determine
Check answer

Explanation

The correct answer is: Not possible to determine.

Question 02

What is the most appropriate plan for investigations in this infant? Which ONE of the following investigations, if any, would you perform?
None required
FBC, BC, urine MC&S
Urinalysis
FBC,UEC,CRP, BC
FBC, blood culture, CXR, LP, urine MC&S
Check answer

Explanation

The correct answer is: FBC, blood culture, CXR, LP, urine MC&S.

Question 03

Which ONE of the following is the most appropriate management plan, pending any results?
Reassure and discharge
Admit for observation
Oral augmentin
IV ampicillin and gentamicin
IV cefotaxime
Check answer

Explanation

IV ampicillin and gentamicin. Given the history of exposure to an URTI it is possible that Simon has an URTI. However, in children of this age, it can be very difficult to determine a localizing source. Presenting features of sepsis and other serious illness are generally non-specific. Neonates and young infants may not have the characteristic signs of serious infection (temperature can be high or low). Localising features may be absent. They can deteriorate rapidly and may be infected with organisms from the birth canal.

Young infants with fever, especially those under three months of age, need rapid assessment and investigation and admission to hospital. Consult a senior colleague about the extent of investigations (full blood count, cultures of blood, urine and CSF, chest x-ray) and the administration of antibiotics. If there is any doubt, you should proceed to a full septic screen and commence antibiotics for a fever without a focus (ampicillin and gentamicin in this age group). The younger the febrile infant, the greater the incidence of serious bacterial infections, particularly those less than one month of age.

A full septic screen includes all of those items listed. In most units it is routine to include UEC as a measure of hydration. Many departments will also perform a CRP +/- procalcitonin, although the utility of these in the acute setting as a single measure is a matter of debate. You should refer to your local guidelines for more information. A CXR may not be performed in the first instance in the complete absence of respiratory symptoms.

For more information, please see

NSW Health guidelines:Children and Infants with Fever - Acute Management
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