Approach to patient with fever

medical students
infectious diseases

2. CLINICAL APPROACH
History
Symptoms- fever, rash, localizing symptom, etc.
Examination
Physiological assessment
Diagnostic assessment
Management

3. GENERAL DATA

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4. CHIEF COMPLAINT:
Fever—1 week
Vomiting - 2 days
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5. HISTORY
What is the temperature
Pattern of fever
Systemic review
Past medical history
Drug history
Travel history
Contact history

6. HISTORY OF PRESENT ILLNESS
1 week -continuous moderate to low
grade fever



2 days -vomiting





ADMISSION
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7. REVIEW OF SYSTEMS:
Abdominal pain(+) aching right hypochondrial non-radiating,
relieved slightly on rest, aggravated by eating, anorexia +,
vomiting 4-5 episodes /day, non-projectile, contains food
eaten, no blood, taste sour or bitter, no constipation, no
melena, no hematochezia (-), no diarrhea,
No significant weight loss (-)
No loss of consciousness, no headache (-)
No blurring of vision (-)
No ear discharge, no tinnitus (-)
No cough, no difficulty of breathing (-)
No chest pain, no palpitation (-)
No dysuria, no frequency, no urgency, (-)
No polyuria, no polydipsia, no polyphagia (-)
No heat or cold intolerance (-)
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8. PAST MEDICAL HISTORY
No other medical or surgical illness requiring hospitalization

No history of blood transfusion

No history of illicit drug use nor maintained on any medication

No history of tattoo, piercing

No history of wading in sewage waters
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9. PERSONAL HISTORY
Non smoker,

Non alcoholic

Lives in endemic areas
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10. FAMILY HISTORY
No hypertension

No diabetes mellitus

No cancer

No pulmonary tuberculosis
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11. PHYSICAL EXAMINATION FINDINGS
A young man of average built and physique, well-oriented in time, place and
person
Pulse 88/minute, regular, normal volume and character, vessel wall not
palpable, all peripheral pulses palpable

BP - 120/80

RR - 21

Temp - 38.5°C
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12. PHYSICAL EXAMINATION FINDINGS
Height - 1.5m
Weight - 52.6kg
BMI - 23
No skin rashes
No pallor
Jaundice +
No nasal nor aural discharge
No oral ulcers or sores, dry tongue (+), no dental
caries
Thyroid gland not enlarged, supple neck, no palpable
cervical lymphadenopathy


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13. PHYSICAL EXAMINATION FINDINGS
Symmetrical chest expansion, resonant, unimpaired
transmission of tactile and vocal fremitus, normal
vesicular breath sounds, no added sounds

Normal precordium, apex beat at 5th left intercostal
space, mid-clavicular line; both heart sounds heard at
all four areas, no added sounds


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14. PHYSICAL EXAMINATION FINDINGS

Abdomen flat, moving with respiration, no tenderness,
Liver edge palpable 2cm below right costal soft.
margin sharp, smooth surface, soft consistency,
tender; spleen not palpable, kidneys nor palpable;
no fluid thrill or shifting dullness; gut sounds
audible
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15. MISSING DATA
Living conditions
If in squatter’s area
If living near a body of water
Source of water
Urine color
Stool color
Sexual History
Family history
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16. 17
PRESENTING(CHIEF)
COMPLAINT:
FEVER
Fever
is an elevation of body temperature that
exceeds the normal daily variation and
occurs in conjunction with an increase in
the hypothalamic set point.

a protective mechanism of the body

17. 18
REQUIREMENTS FOR THE INDUCTION OF
FEVER
Infection, microbial toxins, mediators
of inflammation, immune reactions
Microbial toxins
FEVER
Monocytes/macrophages,
endothelial cells, others
Pyrogenic cytokines IL-1, IL-6,
TNF, IFN
Cyclic AMP
PGE₂
Hypothalamic
endothelium
Elevated
thermoregulatory set
point
Heat conservation,
heat production
Circulation

18. INFECTIONS MALIGNANCIES AUTOIMMUNE
CONDITIONS
OTHERS
•Hepatitis A & B
•Leptospirosis
•Malaria
•Typhoid Fever


•Leukemia
•Lymphoma
•Rheumatoid arthritis
•Rheumatic fever
•Systemic lupus
erythematosus
•Vasculitides
•Drug-induced
fever
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19. 20
VARIOUS ORGAN SYSTEMS
WHICH COULD BE
INVOLVED
Fever
Hematology
Nervous
Digestive
Respiratory
Urinary
Rheumatology

20. 21
PATTERNS OF TEMPERATURE VARIATION
Continuous fever
•Constantly elevated above the normal level. Variability
1°C
Remittent fever
•Fluctuates daily from higher to lower levels, but is
constantly above normal
Intermittent fever
•Daily fluctuation at its lower level is below the normal
37°C

21. TYPES OF FEVER
The pattern of temperature changes may occasionally hint at the diagnosis:

Continuous fever: Temperature remains above normal throughout the day and does not
fluctuate more than 1 °C in 24 hours, e.g. lobar pneumonia, typhoid fever, brucellosis

Intermittent fever: The temperature elevation is present only for a certain period, later
cycling back to normal(i.e. Normal temp. between fever episodes), e.g. malaria,
pyaemia, or septicemia.
Following are its types
Quotidian fever, with a periodicity of 24 hours, typical of Plasmodium
falciparum malaria
Tertian fever (48 hour periodicity), typical of Plasmodium vivax or
Plasmodium ovale malaria
Quartan fever (72 hour periodicity), typical of Plasmodium malariae
malaria.

22. TYPES OF FEVER
Remittent fever: Temperature remains above normal throughout the day and
fluctuates more than 1 °C in 24 hours, e.g., infective endocarditis.

Pel-Ebstein fever: A specific kind of fever associated with Hodgkin's lymphoma,
being high for one week and low for the next week and so on. However, there is
some debate as to whether this pattern truly exists.

23. HISTORY TAKING IN FEBRILE PATIENTS
The most important step is taking a meticulous detailed history to explore
the patients problems
Biomedical perspective- to understand the chronology of symptoms, analyse
each symptom and review each system to localize the source of the
fever.
Contextual history- very important
Patients perspective- to understand the patients interpretation of the illness.
Systems review- This is a guide not to miss anything. Any significant finding
should be moved to HPC or PMH depending upon where you think it
belongs.

24. exploration of the patient’s problems to discover the:
 biomedical perspective  the patient’s perspective
 background information - context


providing the correct type and amount of information
aiding accurate recall and understanding
achieving a shared understanding: incorporating the
patient’s illness framework
planning: shared decision making




Initiating the session
Gathering information

Physical examination
Explanation and planning
Closing the session
Providing
structure
Building the
relationship
preparation
establishing initial rapport
identifying the reasons for the consultation

making
organisation
overt
attending to
flow
using
appropriate
non-verbal
behaviour
developing
rapport
involving
the patient
ensuring appropriate point of closure
forward planning
A

25. BIOMEDICAL PERSPECTIVE


Presenting complaints of a patient with fever
Feeling hot
A feeling of heat does not necessarily imply fever
Rigors.
profound chills accompanied by chattering of the teeth and severe shivering,
implies a rapid rise in body temperature. Can be produced by :
1) brucellosis and malaria
2) sepsis with abscess
3) lymphoma
Excessive sweating.
Night sweats are characteristic of tuberculosis, but sweating from any cause is
usually worse at night.

26. BIOMEDICAL PERSPECTIVE
Recurrent fever.
Source is often a focus of bacterial infection such as cholecystitis or cholangitis
or urinary tract infection especially associated with an obstruction or calculi.
Headache.
Fever from any cause may provoke headache.
Severe headache and photophobia, may suggests
meningitis.
Delirium.
Mental confusion during fever is well described and relatively more common in
young children and in old age.
Muscle pain. Myalgia is characteristic of viral infections such as influenza, Malaria
and brucellosis.

27. BIOMEDICAL PERSPECTIVE
Symptom analysis for fever
Verify presence of fever- True or factitious fever
Duration- Acute or chronic
Mode of onset- Abrupt or gradual
Progression- Continuous or intermittent. If intermittent ask about frequency to
determine the pattern.
Severity- how it affects daily work/physical activities.
Relieving and aggravating factors
Treatment received or/and outcome
Associated symptoms- Localizing symptoms may indicate the source of fever.

28. BIOMEDICAL PERSPECTIVE
Constitutional symptoms:
Weakness
Fatigue
Anorexia
Change of weight
Fever/chills
Lumps
Night sweats

29. BIOMEDICAL PERSPECTIVE
Respiratory tract symptoms:
Sore throat, nasal discharge, sneezing-URTI
Sinus pain and headache-suggests sinusitis
cough, sputum, wheeze or breathlessness-suggests a LRTI
Genitourinary symptoms:
Frequency of micturition, dysuria, loin pain, and vaginal or urethral discharge-
suggesting
Urinary tract infection,
Pelvic inflammatory disease and
Sexually transmitted infection (STI)

30. BIOMEDICAL PERSPECTIVE
Abdominal symptoms: diarrhea, with or without blood, weight loss
and abdominal pain -suggesting
a) Gastroenteritis,
b) Intra-abdominal sepsis,
c) Inflammatory bowel disease,
d) Malignancy

Skin rash: enquire about appearance and distribution as it may
provide clues to the diagnosis-
1)Macular- Measles,Rubella,toxoplasmosis
2)Haemorrhagic- Meningococcal infections, viral haemorrhagic
fever.
3)Vesicular- Chickenpox, Shingles, herpes simplex
4)Nodular- Erythema nodosum( TB and Leprosy)
5)Erythematous- Drug rashes, Dengue fever

31. BIOMEDICAL PERSPECTIVE
Joint symptoms: joint pain, swelling or limitation of movement is suggestive of
active arthritis.

A) distribution : mono , oligo or poly arthritis
B) appearance : fleeting
1) infective arthritis- oligoarthritis
2) collagen vascular disease-fleeting
3) reactive arthritis

32. CONTEXTUAL HISTORY
Past Medical /Surgical History
Start by asking the patient if they have any medical problems
IHD/DM/Asthma/HT/RHD, TB/Jaundice/Fits e.g. if diabetic- mention time of diagnosis/current medication/clinic check up

Past surgical/operation history
E.g. time/place/ what type of operation.
Note any blood transfusion / blood grouping.
H/O dental extractions/circumcision & any excessive bleeding during these procedures.
Patient known to have rheumatic heart disease is at risk to develop infective endocarditis if not given prophylaxis
Any minor operations or procedures including endoscopies, dental interventions, biopsies.

History of trauma/accidents
E.g. time/place/ and what type of accident

History of tattoo piercing

33. CONTEXTUAL HISTORY
Drug and allergy History
dosage, timing &how long.
Drug fever is uncommon and therefore easily missed-The culprits include :
penicillin and
cephalosporin
sulphonamide
anti tuberculous agents
anticonvulsants particularly phenytoin
OCT/Vitamins/Traditional /Herbal medicine & alternative medicine such as
acupuncture.
Blood transfusion.
Immunization against Hepatitis A &B, Typhoid fever.
Malaria prophylaxis

34. CONTEXTUAL HISTORY
Family History
Any familial disease/running in families e.g. breast cancer, IHD, DM, Asthma,
Arthritis
Infections running in families as TB, Leprosy.
Cholera, typhoid in case of epidemics.

35. CONTEXTUAL HISTORY
Personal and Social History
Smoking history - amount, duration & type- strong risk factor for IHD
Alcohol history - amount, duration & type-Unhealthy alcohol use is
associated with cardiomyopathy, CVA, liver cirrhosis, alcoholic
hepatitis, hepatocellular carcinoma.
Occupation, social & education background, family social support&
financial situation, Social class.
Home conditions-Water supply, Sanitation status in his home &
surrounding, Geographic area of living, fresh-water swimming.
Animals / birds in his/her house- exposure to birds (psittacosis) or
animals (toxoplasmosis, brucellosis, leptospirosis)
Consumption of unpasteurized milk or milk products (tuberculosis,
brucellosis and Q fever).
Sexual History- Unprotected exposure to sexual partner with STI, HIV
Illicit drug usage- injections and sharing of needles (HIV, hepatitis B &C,
infective endocarditis), site of injection (e.g Femoral vein-septic
arthritis, ilio-psoas abscess)

36. CONTEXTUAL HISTORY
TRAVEL HISTORY
Travel to an area known to be endemic for certain disease:
Name of the area, duration of stay
Onset of illness- (incubation period)
1 –10 Days- Malaria, Dengue, Salmonella
10 –21Days-Malaria,Typhoid,Brucella,HepatitisA
Weeks-Months- Amoebiasis, HIV, Hepatitis
Vital questions-(Always ask about foreign travel).
a) Where have you been? …Endemic area or not ?
b) What have you done?
C) How long were you there?
d) Did you have insect bites or contact with animals?
e) Did you take precautions/prophylaxis against malaria?
If the patient has been in an endemic area
The most common diagnoses :Malaria, Typhoid fever, Viral hepatitis, Dengue fever
Malaria must be excluded whatever the presenting symptoms

37. SALIENT
FEATURES

2 6 Y E A R O L D M A L E
 C O N T I N U O U S M O D E R A T E T O L O W G R A D E
F E V E R
 A N O R E X I A , V O M I T I N G
 Y E L L O W I N G O F S C L E R A , C O L O R O F
U R I N E , C O L O R O F S T O O L
 F O N D O F E A T I N G S T R E E T F O O D S
 ( T E M P - 38.5°C ( + )
 D R Y T O N G U E , J A U N D I C E
 H E P A T O M E G A L Y ( L I V E R S P A N : 1 3 C M )

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38. INFECTIONS
Hepatitis A/E

Hepatitis B

Malaria

Typhoid Fever

Leptospirosis

Fond of eating street foods, jaundice, vomiting, liver
jaundice, no history of illicit drug use, no history of tattoo and
piercing
No recurrent fever (2-3 days interval) , no history of blood
transfusion, no travel to endemic area
No wading in flooding water, no calf tenderness

Possible Enteric (Typhoid) Fever because of fondness of
eating street food

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39. INVESTIGATIONS
• CBC: Hb, WBC, differential counts, platelet
•LFT
•Urine analysis
•Blood cultures
•Urine culture
•ESR, CRP
•Serological tests
•Peripheral smear
?????? ECG?????? CXR ?????? US/echo ?????? CT
?????? LP
?????? Arthrocentesis

40. MANAGEMENT
•General measures-
 non-pharmacological
Anti-pyretics
•Specific management

41. THANK YOU