PEDIATRICS Vol. 76 No. 2 August 1985, pp. 167-171
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Predictive Value of Abnormal Physical Examination Findings in Ill-Appearing and Well-Appearing Febrile Children

Paul L. McCarthy MD1, Robert M. Lembo MD1, Michael A. Baron MD1, Howard D. Fink MD1, and Domenic V. Cicchetti PhD1

1 From the Department of Pediatrics, Yale University School of Medicine, Yale New Haven Hospital, and Veterans' Administration Medical Center, West Haven, Connecticut

In order to study the occurrence and positive predictive value of history and physical examination findings suggestive of serious illness in ill-appearing and well-appearing febrile children, 103 consecutive children aged le24 months with fever ge38.3°C were evaluated from July 1, 1982 to Nov 24, 1982. Patients were initially classified by an attending physician (A) as to whether they appeared ill (Yale Observation Scale score >10) or well (scale score le10). The history was then taken by two attending physicians (A and B) and a resident; the physical examination was performed by attending physician B and the same resident. As history and physical examination findings were elicited, they were scored as to whether they did or did not suggest a serious illness. Serious illness was defined as the presence of a positive laboratory test. Ill-appearing patients had a significantly greater (P < .001, Fisher's exact test) occurrence of physical examination findings suggesting serious illness (14 of 22, 64%) than well-appearing children (12 of 81, 15%). The positive predictive values of abnormal physical examination findings for serious illness in ill-appearing (11 of 14, 79%) and well-appearing children (3 of 12, 25%) were significantly different (P = .02 by Fisher's exact test). The trends for abnormal history findings in ill-appearing and well-appearing children were similar to those for abnormal physical examination findings but did not achieve statistical significance. The results, indicating an important interaction between a febrile child's appearance and physical examination findings, are discussed in terms of probability reasoning in clinical decision making.

Key Words: fever • clinical judgment • diagnosis • toxicity • Bayes theorem

Submitted on April 9, 1984
Accepted on August 27, 1984




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