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 of the western world, 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 acquired immunodeficiency states. 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.
Describe and discuss:
- basic principles of microbiology
- basic principles of physiology
- basic elements of fever
- basic interview and history-taking skills
- basic communication skills
- basic physical examination
Apply Medical Knowledge in the Clinical Encounter
1. Describe and discuss clinical presentation, signs and symptoms of fever, including common localized and systemic infectious syndromes.
2. Describe and discuss the clinical and laboratory features that help distinguish among the common causes of febrile illness.
3. Describe and discuss the causes of fever including:
- common conditions, such as viral and bacterial respiratory and gastrointestinal illnesses
- less common conditions: a) in children such as osteomyelitis, meningitis, and Kawasaki disease; b) in adults such as pneumonia, pyelonephritis, infectious mononucleosis, acute abdominal disorders, and acute arthritis.
- the causes of high fever in an infant or young child; including serious bacterial infections
4. Describe and discuss factors that predispose a patient to fever.
5. Describe and discuss etiology, pathophysiology, and definition of fever.
6. Describe and discuss how age affects diagnostic considerations and potential severity of febrile illness.
7. Describe and discuss indications for and selection of diagnostic tests to assess important causes of fever based on clinical features.
8. Describe and discuss rationale for pharmacological management, and selection of drugs commonly used to control fever, particularly in children and adolescents.
9. Describe and discuss appropriate treatment plans and selection of antimicrobial therapy, both empiric and specific, in relation to the clinical syndrome.
10. Describe and discuss the morbidity and mortality of fever.
11. Describe and discuss the epidemiology of fever, including prevalence, incidence, and socio-economic features.
1. Demonstrate ability to obtain, document, and present an age-appropriate medical history from the parent(s), or adult patient, that conveys the key elements of the patient’s history, in order to:
- establish the duration and height of fever as well as method of measurement of temperature
- determine if antipyrectics have been used
- determine, in the case of a child, change in behavior, appetite, level of activity
- differentiate among the different syndromes of febrile illness
- identify the febrile child (or adult) at risk for occult bacteremia or serious bacterial infection
2. Perform a thorough physical exam and review of systems to determine the likely cause of fever, with particular emphasis on:
- a change in mental status; in young children a reduced or absent awareness of the parent or environment, lethargy or difficulty arousing the child
- in children: high pitched or weak cry; irritability or inconsolability
- signs of shock, including changes in vital signs (tachycardia, tachypea, apnea, hypotension); skin changes such as pallor, mottling or cyanosis
- evidence of dehydration (e.g. in children: sunken eyes, lack of tears, dry mucous membranes, decreased skin turgor)
- respiratory distress
- in an infant, full fontanelle; in an older child > 18 months of age (or adult), nuchal rigidity
- petechial, purpuric, or rapidly spreading rash
3. Demonstrate empathy for the concerns of the parent(s), spouse, family.
4. Generate an appropriate differential diagnosis for the cause of fever, based on the history and physical examination findings.
5. Recommend appropriate laboratory and diagnostic tests and /or imaging studies, both prior to and after initiating treatment, justify ordering the tests and interpret the results, based on the differential diagnosis and age of the patient.
6. Recommend a sepsis work-up 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
7. Determine the patient’s problem from all the problems listed in the differential diagnosis; present and record an explanation of how the determination was made citing medical knowledge, information obtained in the clinical encounter, and collective experience with other, similar patients that the student, the team, and the attending have seen.
8. Communicate the working diagnosis to the patient or parent(s) and older child.
9. Record, present, critique and manage clinical information.
Develop a Management Plan
Demonstrate ability to develop a management plan for fever and underlying disease based on the patient’s age, history, physical examination, differential diagnosis and laboratory/imaging results. Make decisions about what to include from the following items and explain why each item selected should be included:
1. Discuss preventive measures.
2. Consider treatment measures such as the appropriate prescribing of antibiotics and antipyretics, including characteristics of the patient and the fever that must be considered in the decision to manage the patient in the hospital or in the outpatient setting.
3. Provide patient and family education.
4. Access and utilize appropriate information systems to obtain information about health system and community resources.
5. Plan for follow-up.
6. Formulate and communicate a prognosis for the patient with fever and underlying disease to the patient and parent(s) and older child.
7. Consider the cost-effectiveness of the management plan.
In Children (ACUTE)
- serious bacterial infections
- occult bacteremia
- urinary tract infections / pyelonephritis
- septic arthritis
- bacterial gastroenteritis
- other bacterial infections
- otitis media
- Group A streptococcal pharyngitis
- cellulitis / abscess
- respiratory-RSV, influenza, parainfluenza
- visceral larva migrans
- tick borne
- Rocky Mountain spotted fever
Autoimmune diseases / Vasculitic
- acute rheumatic fever
- dermatomyositis / polymyositis
- Henoch-Schonlein purpura
- juvenile rheumatiod arthritis
- Kawasaki disease
- mixed connective tissue disorder
- polyarteritis nodosa
- Steven’s Johnson
- Systemic lupus erythematosus
- ewing’s sarcoma
Drug Fever-Antibiotics, antihistamines
- recent immunizations
- high external temperature
- over bundling, especially in cold weather
- inflammatory bowel disease
- infectious mononucleosis (EBV, CMV)
- bacterial-localized / systemic infrections
- streptococcal pharyngitis
- urinary tract infection (pyelonephritits, prostatitis)
- bacteremia (staph aureus, GN Bacillary)
- fungal – candidemia
- parasitic – malaria
- tick borne
- Rocky Mountain spotted fever, ehrlichiosis
- rheumatoid arthritis
- systemic lupus erythematosis
- vasculitis (e.g. Wegener’s)
Drug fever-antibiotics, antiepileptic medications, etc.
Miscellaneous causes (infectious and noninfectious)
- pulmonary embolism/infarction
- gout / pseudogout
- nosocomial (post-op wound, catheter-associated, pneumonia, drug fever)
- spontaneous bacterial peritonitis (SBP) – cirrhosis with ascites
Risk factor/immunocompromised states
- neutropenia (leukemia, cancer chemotherapy)
- organ transplantation – immunomodulating therapy
- prolonged steroid use
- age over 65
- heavy alcohol or drug use
- malnutrition / bed-fast states (pressure sores)
In Adults – Subacute/Chronic and Fever of Unknown Origin (FUO)
- Epstein Barr virus (EBV)
- cytomegamovirus (CMV)
- localized Bacterial infection:
- abdominal abscess
- pelvic abscess
- dental abscess
- systemic bacterial and fungal infection
- mycobacterial – tuberculosis
- histo / crypto / blasto
- salmonellosis (typhoid / paratyphoid)
- zoonoses (tularemia, leptospirosis, brucellosis)
- tick-borne – lyme disease
- adult Still’s disease (juvenile RA)
- temporal arteritis
- rheumatoid arthritis
- rheumatic fever
- inflammatory bowel disease
- reiter’s syndrome
- systemic lupus erythematosus
- lymphoma (Hodgkin’s disease)
- renal cell carcinoma
- carcinomas complicated by obstruction/perforation of hollow organs
- drug fever
- hepatitis (alcoholic, granulomatous, or lupoid)
- deep venous thrombophlebitis
- factitious fever