FEVER
A. HISTORY
a. HISTORY OF PRESENT ILLNESS
i. Patient-centered interviewing techniques and open-ended questions
1. Tell me about your fever
Time Course Possible Diagnosis
Have you had any sick contacts?
Have you recently been in the hospital?
Infection
Did you travel recently?
Have you had any recent procedures?
Have you lost weight?
Malignancy
Do you have any bone pain?
Do you have arthritis or a rash?
Inflammatory disorders
Personal or family history of vasculitis or other inflammatory disease?
ii. Timing: acute or chronic, constant vs intermittent, accelerating; why presenting today?
Time Course Possible Diagnosis
Fever > 3 weeks with temp >38°C Fever of unknown origin (FUO) if initial work-up is negative
Patterns
Continuous/sustained CNS disease / gram-negative rod bacteremia
Diurnal (regular rise and fall in temp, Absence of diurnal variation = associated with, but does
between 4 PM and midnight) not establish a noninfectious cause
Tertian fever (48 hours) Malaria (P. vivax or P. ovale)
Quartan fever (72 hours) Malaria (P. malariae)
iii. Associated symptoms
iv. Warning/alarm symptoms
Alarm Symptoms Serious Causes Benign Causes
• CNS Infection
High fever (>41°C) • NMS (Neuroleptic malignant syndrome)
• Heat stroke
• Meningitis
• Bacteremia with septic shock • Viral exanthem
Rash
• Rickettsial disease • Drug fever
• Bacterial endocarditis
• Meningitis
• Encephalitis
Change in mental status
• NMS
and level of sensorium
• Heat stroke
• Bacterial infection with septic shock
• Bacterial infection with septic shock
Viral infxn with
Dizziness or light-headedness • Adrenal insufficiency
labyrinthitis
• PE
Recent chemotherapy • Nosocomial infection with neutropenia
• PE
Shortness of breath and chest pain • Pneumonia
• Empyema
b. PAST MEDICAL HISTORY
• Comorbidities • Viral infections in the past (esp those that confer
• Confinements permanent immunity e.g. chicken pox/measles)
• History of invasive manipulations (e.g. use of • Medications
indwelling Foley catheters, IV lines) or surgeries • Vaccinations
in the recent past • Allergies ALWAYS
c. FAMILY HISTORY: Familial disorders that may relate to the acute problem
d. SOCIAL HISTORY
• Occupation • Exposure to mosquitoes or other insect vectors,
• Hobbies stagnant water
• Travel • Wading in flooded areas
• Source of drinking water • Details on garbage and toilet/sewerage
• Consumption of street food / meals that aren’t • Smoking and intake of alcoholic beverage intake
home-cooked ALWAYS
• Exposure to people with similar manifestations
e. SEXUAL HISTORY (Ask if fever is associated with genitourinary symptoms)
• Last sexual contact
• Last menstrual period for females
• Number of sex partners
• Use of barriers like condoms
• Sexual practices
B. PHYSICAL EXAMINATION
a. General survey and vital signs ALWAYS; check weight especially in patients with prolonged fever
b. Skin
• Rashes - viral exanthematous diseases
• Dry skin and skin turgor – dehydration
• Jaundice - hepatitis
• Open wounds or ulcers with erythematous borders and discharges
• Pustules
c. HEENT
• Icteric sclerae – hepatitis
• Sunken eyeballs – dehydration
• Congested nasal turbinates – rhinitis
• Ear discharge on otoscopy - ear infection
• Enlarged and congested tonsils with or without exudates – viral or bacterial tonsillitis
• Dry lips, buccal mucosa, and tongue – dehydration
• Dental caries
• Cervical lymphadenopathies - reactive or lymphoma especially in patients with FUO
• Nuchal rigidity – meningitis
d. Chest and Lungs
• In patients with cough, complete lung examination anteriorly and posteriorly
• Check for symmetry of chest expansion, palpate fremitus, do chest percussion, auscultate for
abnormally located breath sounds and adventitious breath sounds (crackles, wheezes, rhonchi)
e. Heart: Cardiac auscultation on all valvular areas
f. Abdomen
• Inspect for surgical incisions with erythematous borders and discharge
• Palpate for abdominal tenderness
• Hepatomegaly – hepatitis
• Splenomegaly
• CVA tenderness – pyelonephritis
g. Upper and lower extremities
• Check for swollen joints, skin examination
• Check for axillary and inguinal lymphadenopathies in patients with prolonged fever.
h. Genital examination
• In patients with fever and genitourinary symptoms, and patient consents, check external genitalia
for discharges – sexually transmitted infection
• In women, do internal examination - pelvic inflammatory disease
