Case 1 - Noah

• You are a clinician working in an emergency department in Queensland.
• You are about to review a 3 week old male called Noah who was brought in by his father Patrick and mother Lucy. They tell you the reason they presented was that 'Noah felt warm this morning'.
• History and examination have not identified a source for the fever.
• Noah was a term spontaneous vaginal delivery with no developmental concerns. He has no medical history and is not on any medications. He has no known drug allergies. He had his hepatitis B vaccination and Vitamin K injection at birth. There is no relevant family history. This is Patrick and Lucy’s first child. There are no smokers in the family. Lucy is an airline pilot and Patrick is training as an apprentice carpenter.
• His observations were as follows:
  RR: 40   O2: 100%   T: 38.1   HR: 155   BP: 80/40 (MAP 53)

Questions to discuss about Noah’s case

• What is your differential diagnosis?
• What further history and examination is relevant?
  • What features would suggest a toxic/unwell child?
• What investigations would you do?
  • What are the ways you could collect a urine? Consider the pros/cons of each.
  • What are the contraindications to a lumbar puncture?
• How would you manage this child? Consider the role of antibiotics and antivirals in your discussion.

Normal range for vital signs by age

Case 2 - Riley

• You are a clinician working in an emergency department in Queensland.
• You are about to review a 2 month old female called Riley who was brought in by her father Steven. He tells you the reason they presented was that 'Riley felt warm this morning'.
• History and examination have not identified a source for the fever.
• Riley was born via repeat elective caesarean with no developmental concerns. She has no medical history and is not on any medications. She has no known drug allergies. 6 week vaccinations were provided. There is no relevant family history. This is Steven and Frank’s second child. There are no smokers in the family. Steven is a painter and Frank is a gardener.
• Her observations were as follows:  
  RR: 40   O2: 100%   T: 38.1   HR: 155   BP: 80/40 (MAP 53)

Questions to discuss about Riley’s case

• What is your approach to investigating and managing Riley if she was febrile without any toxic features and no features concerning for an SBI?
• What is your approach to investigating and managing Riley if she was febrile with toxic features or features concerning for an SBI?
• What if Riley had clinical features consistent with bronchiolitis? Should you do any other Ix for her fever?

Normal range for vital signs by age

Case 3 - Elijah

• You are a clinician working in an emergency department in Queensland.
• You are about to review a 18 month old male called Elijah who was brought in by his father Joseph. Joseph tells you that the reason they presented was that 'Elijah felt warm this morning'.
• History and examination have not identified a source for the fever.
• Elijah was born via a vaginal delivery assisted by forceps with no developmental concerns. He has no medical history and is not on any medications. He has no known drug allergies. His vaccinations are up to date. There is no relevant family history. This is Lucy and Joseph’s first child. There are no smokers in the family.
• His observations were as follows:
  RR: 25   O2: 100%   T: 38.1   HR: 130   BP: 100/60 (MAP 73)

Questions to discuss about Elijah’s case

• What is your approach to the investigation and management of this child?
• If you wanted a urine, do they need to wait in the emergency department until one is obtained?
• What advice would you provide the parents on managing the fever itself?
  • What is your view on giving aspirin to this child for analgesia?

Normal range for vital signs by age

Case 4 - Ashraf

• You are a clinician working in an emergency department in Queensland.
• You are about to review a 6 month old male called Ashraf who was brought in by his mother Aisha.
• They tell you the reason they presented was that 'Ashraf feels warm and has a rash'.
• Your examination shows the rash below. It is not blanching.

• Ashraf was born via emergency caesarean due to failure to progress. There are no developmental concerns. He has no medical history and is not on any medications. He has no known drug allergies. His vaccinations are up to date. There is no relevant family history. This is the family’s third child. There are no smokers in the family.
• His observations were as follows:
  RR: 40   O2: 100%   T: 38.9   HR: 155   BP: 90/50 MAP (70)

Questions to discuss about Ashraf’s case

• What is the most concerning differential diagnosis?
• What further information on history would you like to know?
• Would the location of the petechial rash alter your management?
• What would be your investigation and management approach?
• What diagnosis should you consider if Ashraf was a 3 year old with petechial rash (lower limb/buttocks predominance), ankle swelling, and abdominal pain/swelling?

Normal range for vital signs by age

Case 5 - Penelope

• You are a clinician working in an emergency department in Queensland.
• You are about to review a 2 year old female called Penelope who was brought in by her mothers Scarlett and Chloe. They tell you the reason they presented was that 'Penelope felt warm'.
• Your history and examination did not reveal a source. Penelope has been having fevers for 2 days.
• Penelope was a term spontaneous vaginal delivery with no developmental concerns. She has no medical history and is not on any medications. She has no known drug allergies. Her vaccinations are up to date. There is no relevant family history. This is Scarlett and Chloe’s first child. There are no smokers in the family. Scarlett is an anaesthetics registrar and Chloe works as an educator in childcare.
• Her observations were as follows:
  RR: 23   O2: 100%   T: 39.5   HR: 190   BP: 95/60 (MAP 72)
• Her investigations are as follows:
  Urine M/C/S: 500/<10/<10 Bacteria 2+. Culture pending

Questions to discuss about Penelope’s case

• How would you interpret this patient’s results?
  • What is the diagnosis?
• Which children are at increased risk of urinary tract infection (UTI)?
• What are some symptoms/signs of a UTI in children?
  • Does it change by age?
• When would you consider a presumptive diagnosis of UTI? When is it a definitive diagnosis?
• How would you manage Penelope (well and unwell)?
  • What if she was a 6 week old?

Normal range for vital signs by age

Case 6 - Ivy

• You are a clinician working in an emergency department in Queensland.
• You are about to review a 3 week old female called Ivy who was brought in by her mother Alice. She tell you the reason they presented was that 'Ivy felt warm this morning'.
• Your history and examination did not reveal a source.
• Ivy was a term spontaneous vaginal delivery. There were no perinatal complications. Maternal GBS status is not known. There are no HSV contacts.
• There are no developmental concerns. She has no medical history and is not on any medications. She has no known drug allergies. At birth, Ivy had her hepatitis B vaccination and vitamin K injection. There is no relevant family history. Alice is a single mother. Ivy’s father does not routinely see her. There are no domestic violence concerns. There are no smokers in the family. Alice works in retail and is currently on maternity leave.
• Her observations were as follows:
  RR: 50   O2: 100%   T: 38.1   HR: 155   BP: 80/40 (MAP 53)
• You proceed with a full septic work-up including FBC, CRP, Chem 20, blood culture, urine M/C/S, lumbar puncture. You commence empiric antibiotics in accordance with the guidelines.

Her investigations are as follows:

• FBC: Normal WCC, Neutrophils.
• Chem 20: Nil abnormalities; serum glucose 4.2.
• CRP: 45.
• Blood culture pending.
• Urine M/C/S: 20/<10/<10 no bacteria seen. Culture pending.
• CSF:
  • WCC: 250 (x10⁶/L) monomorphs 90%, polymorphs 10%.
  • RCC: 200 (x10⁶/L).
  • Protein: 0.8 (g/L) (normal range: <1.0 g/L).
  • Glucose: 3.9 mmol/L (range: 3.3-4.5).

Questions to discuss about Ivy’s case

• What is the diagnosis? Consider if this more likely to be bacterial or viral.
• What are symptoms/signs of meningitis in a child less than 3 months old? What about in older children?
• How do you interpret a traumatic tap (where WCC is able to be provided)?
• What is the normal WCC count in the CSF of a neonate? What about if a child is over 1 month old?
• How would you manage Ivy? Include discussion on fluid management, aciclovir and dexamethasone.

Normal range for vital signs by age

Case 7 - Abhishek

• You are a clinician working in an emergency department in Queensland.
• You are about to review a 4 year old male called Abhishek who was brought in by his father Harsh and mother Ananya. They tell you the reason they presented was that 'Abhishek felt warm this morning'.
• Abhishek was a term spontaneous vaginal delivery with no developmental concerns. He has no medical history and is not on any medications. He has no known drug allergies. His vaccinations are up to date. There is no relevant family history. This is family’s first child. There are no smokers in the family.
• His observations were as follows:
  RR: 40   O2: 98%   T: 38.1   HR: 200   BP: 100/65  MAP (77)
• History did not reveal the source of the fever.
• On examination, Abhishek appears lethargic, pale, and unwell. He has a CRT of 4 seconds. He has cool peripheries. His ENT, cardiovascular, respiratory, abdominal, and neurological examinations are otherwise normal.

Questions to discuss about Abhishek’s case

• What is the most likely diagnosis?
• How do you diagnose sepsis?
  • Which children are at high risk of developing sepsis?
  • What are the different types of septic shock?
• What investigations would you like to perform?
• What is your management of Abhishek?

Normal range for vital signs by age