Infant
Case 2: A 5-month-old male presented
with fever and fussiness. The patient
was seen fi ve days earlier with fever and
URI, diagnosed with otitis media and
discharged home with amoxicillin. Prior to
arrival, the patient had multiple episodes
of vomiting and decreased urine output.
Initial assessment revealed an illappearing,
febrile infant. While observing
the infant and beginning the physical
exam, it is important to place your hand on
the infant’s head and assess the fontanelle.
A fontanelle is measured as full, fl at, or
depressed. Cup your palm on the back of
the baby’s head and then move forward.
The curve of your palm should touch the
fontanelle if it is normal. If the fontanelle
doesn’t touch, it is depressed; if it pushes
your hand up, it is full.
In young infants, a bulging fontanelle may
be seen with meningitis, but meningismus
is rare before one year of age. Another
possible exam fi nding in infants with
meningitis is a paradoxical response
to consoling maneuvers like cuddling.
When a caregiver “cuddles” an infant,
the meninges are stretched and irritated
making the infant more fussy. By contrast,
the same infant will calm when laid fl at.
This infant’s fontanelle was full and
tense. Throughout the exam, the patient
was irritable and diffi cult to console. The
infant was appropriately resuscitated and
underwent a full septic work-up, revealing
pneumococcal meningitis.