How to approach fever?

Approach Fever T-note

Two groups:
infectious inflammation: bacteria(TB), virus, fungus, abscess, meningitis  

non-infectious inflammation:META (hypothyroidism, adrenal insufficiency), malignant tumor, immune disease

FUO approaches

History and Physical Examination (Reassess the patient frequently )
Laboratory Investigation 

Invasive Procedures
Therapeutic trials

History taking:

1. Verify the presence of fever

2. Fever pattern

3. Localizing symptoms

4. Residence and recent travel

5. Exposure to pets and other animal

6. The work environment

7. The family history

8. Recent contact with persons exhibiting similar symptoms

9. The past medical history--

A complete list of the patient’s medications, not just last admission

Sexual exposure and blood transfusion or blood donation

Physical Examination:

Head: sinus tenderness – Sinusitis

Orophaynx: tender tooth – Periapical abscess

Conjunctivae: petechiae, Roth’s spot – Endocarditis

Fundi: CMV retinitis, K. pneumoniae endophthalmitis

Thyroid : enlargement, tenderness – thyroiditis

Heart: murmur – Endocarditis

Abdomen:

Enlargement iliac crest lymph node –

lymphoma, disseminated granulomatosis

RUQ tenderness – liver abscess

Rectum:

Perirectal and prostatic tenderness – abscess

Skin and nail:

Petechiae, splinter hemorrhages, subcutaneous nodules – Endocarditis

Laboratory Investigation:

1. Blood routine: some hints

# Leukocytosis & shift to left – bacterial infection or viral infection

# Normal or leukopenia – atypical bacterial infection or viral infection

# Thrombocytopenia, leukemia & hemoconcentration –dengue

# Eosinophillia – parasite infection

2. BUN and Cr elevated – septicemia

3. GOT, GPT elevated – hepatitis, virus or atypical

4. ALP elevated – liver abscess, bone metastasis

5. Hyponatremia ( SIADH ) – chronic meningitis

6. Hypercalcemia – disseminated granulomatosis,malignancy

7. LDH & bilirubin elevated – hemolysis, malaria, hemophagocytosis *ALP: alkaline phosphatase

8. C-reactive protein (CRP) elevated – acute or chronic bacterial infection

9. Erythrocyte sedimentation rate (ESR) elevated – chronic inflammaion or infection

10.Antinuclear antibody – autoimmune disease

11.Ferritin elevated – Adult Still’s disease

Imaging study:

1. X-ray film

2. Echogram

3. Computed tomography

4. Gallium scan/ bone scan

5. Upper and lower GI series

6. Magnetic resonance imaging

Invasive Procedures:

1. Lumbar puncture

2. Bone marrow examination

3. Liver biopsy

4. Skin biopsy

5. Lymph node biopsy

6. Pleural biopsy

7. Echo or CT guide biopsy

Theraputic trials:

1. All other approaches have failed

2. Critical condition for therapy

3. Anti-TB drugs – Tuberculosis

Tetracycline – Rickettsial disease

Anti-malaria drugs – Malaria

Naproxen – Tumor fever
Steroid – Malignancy and autoimmune disease