Fever Without a Focus Clinical Presentation

Updated: Sep 01, 2021
  • Author: Saul R Hymes, MD, FAAP; Chief Editor: Russell W Steele, MD  more...
  • Print


Obtaining an accurate history from the parent or caregiver is important when assessing fever without a focus; the history obtained should include the following information:

  • Fever history: What was child's temperature prior to presentation and how was temperature measured? Consider fever documented at home by a reliable parent or caregiver the same as fever found upon presentation. Accept parental reports of maximum temperature.

  • Fever at presentation: If the physician believes the infant has been excessively bundled, and if a repeat temperature taken 15-30 minutes after unbundling is normal, the infant should be considered afebrile. Always remember that normal or low temperature does not preclude serious, even life-threatening, infectious disease.

  • Current level of activity or lethargy

  • Activity level prior to fever onset (ie, active, lethargic)

  • Current eating and drinking pattern

  • Eating and drinking pattern prior to fever onset

  • Appearance: Fever sometimes makes a child appear rather ill

  • Vomiting or diarrhea

  • Ill contacts

  • Medical history

  • Immunization history (especially recent immunizations)

  • Urinary output: Inquire as to the number of wet diapers


Physical Examination

While performing a complete physical examination, pay particular attention to assessing hydration status and identifying the source of infection. [8, 9]  Physical examination of every febrile child should include the following:

Record vital signs as follows:

  • Temperature: Rectal temperature is the standard. Temperature obtained via tympanic, axillary, or oral methods may not truly reflect the patient's temperature.

  • Pulse rate

  • Respiratory rate

  • Blood pressure

Measure pulse oximetry levels as follows:

  • Pulse oximetry may be a more sensitive predictor of pulmonary infection than respiratory rate in patients of all ages, but especially in infants and young children.

  • Pulse oximetry is mandatory for any child with abnormal lung examination findings, respiratory symptoms, or abnormal respiratory rate, although keep in mind that the respiratory rate increases when children are febrile.

Record an accurate weight on every chart:

  • All pharmacologic and procedural treatments are based on the weight in kilograms.

  • In urgent situations, estimating methods (eg, Broselow tape, weight based on age) may be used.

During the examination, concentrate on identifying any of the following:

  • Toxic appearance, which suggests possible signs of lethargy, poor perfusion, hypoventilation or hyperventilation, or cyanosis (ie, shock)

  • A focus of infection that is the apparent cause of the fever

  • Minor foci (eg, otitis media [OM]pharyngitis, sinusitis, skin or soft tissue infection)

  • Identifiable viral infection (eg, bronchiolitis, croup, gingivostomatitis, viral gastroenteritis, varicella, hand-foot-and-mouth disease)

  • Petechial or purpuric rashes, often associated with bacteremia

  • Purpura, which is associated more often with meningococcemia than is the presence of petechiae alone

For all patients aged 2-36 months, management decisions are based on the degree of toxicity and the identification of serious bacterial infection.

The Yale Observation Scale is a reliable method for determining degree of illness. [10, 11]  It consists of 6 variables: quality of cry, reaction to parent stimulation, state variation, color, hydration, and response. A score of 10 or less has a 2.7% risk of serious bacterial infection. A score of 16 or greater has a 92% risk of serious bacterial infection. It is important to remember that this scale was validated in the occult bacteremia era, prior to widespread pneumococcal conjugate vaccination.

Regarding the height of temperature, Hoberman et al found that 6.5% of patients with a temperature of 39.0°C (102.2°F) or more had a urinary tract infection (UTI) and that white females with that temperature had a 17% incidence of UTI. [12]

Table. Summary of the Yale Observation Scale (Open Table in a new window)

Observation Items

1 (Normal)

3 (Moderate Impairment)

5 (Severe Impairment)

Quality of cry

Strong with normal tone or contentment without crying

Whimpering or sobbing

Weak cry, moaning, or high-pitched cry

Reaction to parent stimulation

Brief crying that stops or contentment without crying

Intermittent crying

Continual crying or limited response



Acrocyanotic or pale extremities

Pale or cyanotic or mottled or ashen

State variation

If awake, stays awake; if asleep, wakes up quickly upon stimulation

Eyes closed briefly while awake or awake with prolonged stimulation

Falls asleep or will not arouse


Skin normal, eyes normal, and mucous membranes moist

Skin and eyes normal and mouth slightly dry

Skin doughy or tented, dry mucous membranes, and/or sunken eyes

Response (eg, talk, smile) to social overtures

Smiling or alert (< 2 mo)

Briefly smiling or alert briefly (< 2 mo)

Unsmiling anxious face or dull, expressionless, or not alert (< 2 mo)