Presentation A 5-month old boy presented with fever, irritability, and vomiting. His temperature at home was 38.0 rectally. He vomited five times since onset 8 hours ago. He is feeding soy formula. Past medical history is unremarkable. Exam VS T38.0R, P150, R40 (crying), BP unobtainable, wt 50%ile. Fussy, though consolable at times. He doesn't focus or interact well and appears somewhat "toxic" to the examiner. Anterior fontanelle is somewhat full, but he is crying so it is difficult to truly assess. Eyes moist. Pupils reactive. TM's are shiny and slightly red. Oral mucosa moist.
Neck is hard to assess due to crying. Heart regular without murmur. Lungs clear. Abdomen soft on inspiration. No detectable tenderness evident. No hernias. Testes not swollen. CVA tenderness is not apparent. Color slightly pale. Capillary refill time 2-3 seconds. Muscle tone good. A lumbar puncture is done…
