Physical examination General HEENT Diagnosis to consider Alertness, responsiveness Work of breathing, color, feeding activity Eyelid swelling, erythema, tenderness Conjunctival erythema, +/− discharge +/− rhinorrhea (i.e., +/− URI) Periorbital, orbital cellulitis Conjunctivitis, viral syndrome, Kawasaki disease (if limbic sparing) Otitis media Tympanic membrane erythema, bulging, decreased mobility, loss of landmarks/light reflex, air–fluid level behind, or purulent drainage from a perforation Rhinorrhea, nasal Viral upper respiratory congestion infection (URI) URI symptoms persisting Acute bacterial sinusitis ≥10 days OR severe onset of fever >39°C and purulent nasal discharge ≥3 days Stridor, excessive drooling, Epiglottitis, a bacterial and tripod positioning tracheitis, a diphtheria (rare) a ; retropharyngeal abscess Barky cough, +/− URI Croup findings, stridor Oropharyngeal erythema, Acute pharyngitis (viral or exudate, tonsillar streptococcal), tonsillitis, hypertrophy, peritonsillar peritonsillar abscess swelling Neck Chest Abdomen Oral ulcers, gingival inflammation Caries, tenderness, gingival inflammation Parotid swelling, tenderness Erythematous and cracked lips, strawberry tongue, erythematous oral mucosa Tender or swollen cervical lymph nodes Cervical spinous process tenderness Meningismus Wheezing, tachypnea, fever in infants/toddlers Tachypnea, fever, hypoxia, work of breathing; auscultatory rales/focal asymmetry, cyanosis if severe Disproportionate tachycardia, +/− mild hypotension, or poor perfusion, hepatomegaly, rales, new murmur or gallop (+/− abnormal CXR and ECG) Pain or tenderness, vomiting, and/or diarrhea Pain, tenderness (severe, focal right lower quadrant tenderness +/− peritoneal signs) fever with abdominal pain Stomatitis Tooth abscess Parotitis Kawasaki disease Adenitis, Kawasaki disease Osteomyelitis, discitis Meningitis a Bronchiolitis Pneumonia Myocarditis, a pericarditis; bacterial endocarditis, sepsis, a septic shock a Viral gastroenteritis, early hepatitis, or pancreatitis Appendicitis peritonitis/intraabdominal abscess from other sources Lower lobe pneumonia, without focality may also represent: Musculoskeletal Neurologic Skin Suprapubic/costovertebral angle tenderness (or fever alone in young children) Adolescent females with pelvic or abdominal pain and fever Joint swelling, effusion, tenderness, limited range of motion Bony tenderness, abnormal posture, or limp Severe muscle tenderness, poor perfusion streptococcal pharyngitis, or urinary tract infection (UTI) UTI Pelvic inflammatory disease, UTI Septic arthritis, Lyme disease; rheumatologic disease Osteomyelitis, discitis, etc Myositis, pyomyositis, necrotizing fasciitis, a sepsis, a septic shock a Bulging fontanel, irritability, Meningitis, a encephalitis, a lethargy (infants) and sepsis, a septic shock a altered sensorium, convulsion, meningismus, or focal neurologic deficits (older children) Characteristic febrile Varicella, rubeola, scarlet exanthems fever, and coxsackievirus; Kawasaki disease (in association with other Kawasaki stigmata) Fever and full-body Meningococcemia, a other petechiae, esp if ill or bacteremia, a Rocky abnormal lab values Mountain spotted fever a Petechiae only above the Viral infection, or nipple line, normal labs, streptococcal pharyngitis and well appearance make invasive disease less likely Diffuse erythroderma, especially with multiorgan dysfunction and/or hemodynamic instability a Represents life-threatening condition Toxic shock syndrome, a other toxin-mediated illness a