Skip to main content

Vanderbilt Core Clinical Curriculum

Fever

Across all age groups, febrile illness is quick to prompt a visit to the doctor’s office or emergency department. Fever is not harmful in itself; it is often the symptom of an underlying disease, usually an infection. In children, most fevers are transient, usually of a viral nature and not life threatening. In adults, the diagnosis and prognosis may be less predictable because of greater variability in clinical context, age, travel, occupation, underlying disease, and immune function. Using information obtained from the history, physical examination and, when appropriate, laboratory tests and diagnostic imaging, the student should be able to determine if the fever is caused by a common infection that can be treated as an outpatient, or is due to a serious disease which will require more intensive management and treatment.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with FEVER can include:

Medical Knowledge Learning Topics related to FEVER

1. Signs and symptoms of fever, including common associated signs and symptoms of localized and systemic etiologies
2. Clinical and laboratory features that help distinguish among the common causes of febrile illness
3. Common and less common causes of fever in children and adults, such as:

  • Common: viral and bacterial respiratory and gastrointestinal illnesses
  • Less common conditions: a) osteomyelitis, meningitis, and Kawasaki disease in children; b) pneumonia, pyelonephritis, infectious mononucleosis, acute abdominal disorders, and acute arthritis in adults.

4. Factors that predispose a patient to fever
5. Definition and pathophysiology of fever
6. The impact of age on diagnostic considerations and potential prognosis of febrile illness
7. Indications for and selection of diagnostic tests to assess important causes of fever based on clinical features
8. Rationale for pharmacological management and selection of drugs commonly used to control fever, particularly in children and adolescents
9. Treatment plans and selection of antimicrobial therapy, both empiric and specific, in relation to the clinical syndrome
10. Morbidity and mortality of fever in general and in the context of specific etiologies
11. Epidemiology of fever as a syndrome and in the context of related etiologies, including prevalence, incidence, and socio-economic features

Diagnostic Evaluation Learning Topics related to FEVER

1. Age-appropriate medical history taking, documentation, and presentation from the patient or from the care provider(s) that convey the key elements of the patient’s history, such as:

  • duration and height of fever as well as method of measurement of temperature
  • use of antipyretics
  • change in behavior, appetite, and/or level of activity in a pediatric patient
  • symptoms or signs that may help differentiate syndromes of febrile illness
  • identification of symptoms or signs that may indicate serious infection or other medical conditions

2. Physical examination to determine the likely cause of fever, such as:

  • signs of shock, including changes in vital signs (e.g., tachycardia, tachypnea, apnea, hypotension) and skin changes (e.g., pallor, mottling, cyanosis)
  • respiratory distress
  • nuchal rigidity
  • petechial, purpuric, or rapidly spreading rash
  • specifically in a child
    • change in mental status including reduced or absent awareness of care giver, lethargy, or difficulty arousing
    • high pitched or weak cry; irritability or inconsolability
    • evidence of dehydration (e.g., sunken eyes, lack of tears, dry mucous membranes, decreased skin turgor)
    • full fontanelle in an infant

3. Demonstrate empathy for the concerns of the parent(s), spouse, family
4. Differential diagnosis generation for the cause of fever, based on history and physical examination findings
5. The use and timing of diagnostic and laboratory testing, both prior to and after initiating treatment, in consideration of the differential diagnosis, test performance, cost, and patient preferences
6. Recommendation for an evaluation for sepsis when a serious bacterial infection is suspected:

  • complete blood count, with differential
  • blood culture
  • urinalysis and urine culture
  • lumbar puncture
  • chest radiograph if there are any signs of respiratory distress or disease

7. Communication to patients and families about the working diagnosis, differential diagnosis, and current plan, in a caring and compassionate manner

Management Plan Learning Topics related to FEVER

1. Development of a management plan for fever and underlying diseases based on the patient’s age, history, physical examination, differential diagnosis, and laboratory and imaging results
2. Preventive measures and counseling
3. Treatment measures, such as the appropriate prescribing of antibiotics and antipyretics and the clinical decision whether to manage the patient in the hospital or in the outpatient setting
4. Patient and/or care giver education
5. The use of appropriate information systems to obtain information about health system and community resources
6. Follow-up planning
7. Communication to patients and families about the diagnosis, treatment plan, and prognosis of the disease in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis and its potential impacts
8. Cost-effectiveness of the management plan

Potential Differential Diagnosis Topics Include:

Acute Fever In Children

Infections

  • serious bacterial infections
    • meningitis
    • occult bacteremia
    • urinary tract infections, including pyelonephritis
    • pneumonia
    • osteomyelitis
    • septic arthritis
    • bacterial gastroenteritis
  • other bacterial infections
    • otitis media
    • Group A streptococcal pharyngitis
    • sinusitis
    • cellulitis / abscess
  • viral
    • respiratory (e.g. RSV, influenza, parainfluenza)
    • enterovirus (e.g. coxsackie)
    • herpes virus (e.g. varicella, EBV, CMV)
  • mycobacterial
  • fungal
    • histoplasmosis
    • blastomycosis
  • parasitic
    • malaria
    • toxoplasmosis
  • tick borne
    • Rocky Mountain Spotted Fever
    • Lyme disease

Autoimmune diseases

  • acute rheumatic fever
  • dermatomyositis / polymyositis
  • Henoch-Schoenlein purpura
  • juvenile rheumatoid arthritis
  • Kawasaki disease
  • mixed connective tissue disorder
  • polyarteritis nodosa
  • Stevens-Johnson syndrome
  • Systemic lupus erythematosus

Malignancy

  • leukemia
  • lymphoma
  • neuroblastoma
  • Ewing’s sarcoma
  • osteosarcoma

Drug Fever

  • antibiotics
  • anticonvulsants
  • antihistamines
  • non-steroidal anti-inflammatory drugs

Miscellaneous

  • recent immunizations
  • high external temperature
  • over bundling, especially in cold weather
  • inflammatory bowel disease
  • factitious

Acute Fever In Adults

Infections

  • viral
    • influenza
    • viral gastroenteritis
    • infectious mononucleosis (e.g. EBV, CMV)
  • bacterial
    • streptococcal pharyngitis
    • pneumonia
    • endocarditis
    • meningitis
    • urinary tract infection (e.g. pyelonephritis, prostatitis)
    • appendicitis
    • cholecystitis
    • pancreatitis
    • diverticulitis
    • bacteremia
    • nosocomial
      • post-operative wound infection
      • catheter-associated urinary tract infection
    • spontaneous bacterial peritonitis (SBP)
  • fungal
    • Candidemia
  • parasitic
    • malaria
  • tick borne
    • Rocky Mountain spotted fever
    • Lyme disease
    • Ehrlichiosis

Autoimmune diseases

  • rheumatoid arthritis
  • systemic lupus erythematosus
  • vasculitis

Drug Fever

  • antibiotics
  • anticonvulsants
  • antihistamines
  • Non-steroidal anti-inflammatory drugs

Miscellaneous causes

  • pulmonary embolism and related infarction
  • gout
  • pseudogout

Risk factors and Immunocompromised States

  • neutropenia (e.g., leukemia, cancer chemotherapy)
  • organ transplantation with immunomodulating therapy
  • prolonged corticosteroid use
  • HIV
  • age over 65
  • cirrhosis
  • sarcoidosis
  • systemic lupus erythematosus
  • diabetes
  • alcohol or substance use
  • asplenia
  • malnutrition

Subacute/Chronic Fever and Fever of Unknown Origin In Adults

Infections

  • viral
    • Epstein Barr virus (EBV)
    • cytomegalovirus (CMV)
    • HIV
  • bacterial infection:
    • abdominal abscess
    • pelvic abscess
    • dental abscess
    • endocarditis
    • osteomyelitis
    • sinusitis
  • Atypical infection
    • non-tuberculosis mycobacterial infections
    • tuberculosis
    • Histoplasmosis
    • Cryptococcosis
    • Blastomycosis
    • Salmonellosis
    • Tularemia
    • Leptospirosis
    • Brucellosis

Autoimmune disease

  • adult Still’s disease
  • temporal arteritis
  • rheumatoid arthritis
  • inflammatory bowel disease
  • Reiter’s syndrome
  • systemic lupus erythematosus
  • vasculitis

Malignancy

  • lymphoma (e.g. Hodgkin’s disease, non-Hodgkin’s lymphoma)
  • renal cell carcinoma
  • hepatoma
  • carcinomas complicated by obstruction/perforation of hollow organs

Miscellaneous

  • drug fever
  • gout
  • non-infectious hepatitis
  • deep venous thrombophlebitis
  • sarcoidosis
  • factitious fever