Clinical Decision-Making Case: Febrile Infant

This clinical decision-making (CDM) case is intended for emergency medicine residents of all levels, medical students, and fellows preparing for standardized oral board exams.

Fever in a neonate (infant <28 days old) is a medical emergency due to the high risk of serious bacterial infections (SBIs) like meningitis, sepsis, or urinary tract infections (UTIs).1-3 Compared with older infants and children, neonates have immature immune responses, reduced ability to localize infection, and limited physiologic reserve, which contribute to rapid clinical deterioration and increased morbidity and mortality when invasive infection is present.1,3Importantly, clinical presentation in this age group is often subtle and nonspecific. Neonates with life-threatening infections may appear well or only mildly ill on initial examination, with symptoms such as poor feeding, irritability, or decreased urine output serving as early but easily overlooked warning signs.1,4 As a result, reliance on appearance or focal examination findings alone is insufficient to safely exclude SBI in febrile neonates.Current evidence supports a standardized approach to the evaluation of neonatal fever. This includes a complete sepsis workup-consisting of blood, urine, and cerebrospinal fluid studies-along with early administration of empiric, age-appropriate intravenous antibiotics and hospital admission for close monitoring.1-3This clinical decision-making case is designed to reinforce these foundational principles within the context of an emergency department presentation. It emphasizes early recognition of neonatal fever as a high-risk condition, systematic diagnostic reasoning, timely initiation of empiric therapy, and appropriate disposition to a higher level of care. Learners are challenged to clearly articulate their clinical reasoning and management decisions in a high-stakes environment that mirrors real-world emergency medicine practice.

By the end of this CDM case, learners will be able to: 1) demonstrate familiarity with the CDM case format, 2) recognize the critical importance of fever in a neonate and initiate a thorough evaluation, 3) develop an appropriate differential diagnosis and understand the workup for febrile neonates, 4) identify and justify the appropriate diagnostic studies and interpret their findings in the context of a neonate with fever, 5) justify a treatment plan and understand the critical disposition of a neonate with fever.

The case will be presented as a CDM case with questions posed by the examiner. Learners will be asked to list the history, physical exam findings, differential diagnosis, diagnostic studies, treatments, and final diagnosis in response to the examiner's prompts.

Learners' performance will be evaluated using standardized oral board scoring guidelines. Efficacy will be assessed through feedback from both learners and faculty, focusing on knowledge acquisition and application in a high-stakes environment. Pre- and post-case surveys or performance scoring may be used for evaluation.

Preliminary assessments from learners demonstrated improved confidence in managing febrile neonates after completing the case, with a focus on early recognition and appropriate escalation of care.

Neonatal fever is a high-risk scenario requiring prompt, appropriate management. This case reinforced the importance of early sepsis recognition, comprehensive evaluation, and timely treatment. Learners benefited from exposure to the CDM Case format aiding in their exam preparation.

Neonatal fever, sepsis, meningitis, pediatric emergency management, antibiotic management, ABEM Certifying Exam, clinical decision-making case.