FEVER

MR SUNEIL RAMNANI
CONSULTANT IN EMERGENCY MEDICINE
PRINCESS ALEXANDRA HOSPITAL
OBJECTIVES

 Define Fever
 Discuss Causes
 Assessment
 Investigations
 Management
 Red Flags and Pitfalls
 Summary
WHAT IS FEVER?

 ‘A temporary increase in the core body

temperature above the normal range caused by
elevation of the hypothalamic set point’
 No single agreed upper limit for normal
temperature.
 Normal core body temperature in healthy people
is 35.6˚c – 38.2˚c (mean 36.8˚c)
 In adults, a temperature of 38.3˚c is a fever.
 In infants, a rectal temperature of 38˚c is a fever.
 A temperature over 41.5˚c is not a true fever.
FEVER FACTS
 Common complaint – 6% of adult ED attendances
and 20-40% of paediatric attendances.
 Same as Pyrexia!
 Rectal temperature is most accurate measurement.
 Generally a response to disease or illness but can be
‘physiological’.
 Can indicate serious or life threatening illness.
 No relationship between magnitude of temperature
and severity of illness.
FEVER-CAUSES

 Hundreds!
 Mostly caused by self limiting viral infections.
 Infections are the most common cause (acutely!).
30-40%
 Cause usually apparent in ED. (pneumonia, UTI
etc)
 FUO/PUO (fever >38.3˚c documented on several
occasions during a period of more than 3 weeks
with uncertain diagnosis after 1 week of
evaluation in hospital).
FEVER OF UNKNOWN ORIGIN (FUO)

 Infections/Infectious diseases 20-40%

 Neoplastic/Malignancy 10-30%
 Non-infectious Inflammatory diseases (eg
collagen vascular diseases, connective tissue
diseases) 20-35%
 Miscellaneous (including drug fever) 10-20%
 No diagnosis 20-30%
ASSESSMENT: HISTORY
 Key to Assessment
 Associated Symptoms: Cough, SOB, pain, dysuria, diarrhoea,
weight loss, sweats, rigors, fever, rash, lumps/itching.
 Duration
 Ill contacts, pets, animal contacts
 Occupation
 Travel history
 Medication
 History/risk of immunocompromise
 Sexual History, IVDU
 Bites, Cuts, Surgery
ASSESSMENT: EXAMINATION

 General appearance: sick Vs well

 Vital signs
 Subtle mental state changes
 Rashes
 Skin, eyes, lymph nodes, throat, teeth
 Liver and spleen
 Occult sites of infection: nose/sinuses
 PR exam (prostatitis, perirectal abscesses)
 Pelvic exam
 Nails, joints, temporal arteries
INVESTIGATONS
 Guided by history and examination.
 No tests that are always needed for every patient.
 Clinical judgement required.
 Consider:
 Bloods:
▪ FBC and differential. Blood film.
▪ Renal profile
▪ LFTs
▪ CRP, ESR
▪ VBG
 Urine dip
 Cultures – urine, sputum, blood, stool.
 ECG
 CXR
 Thick and thin blood films.
INVESTIGATIONS 2

 Other tests for the medics!

 Serology/virology (EBV,CMV,HIV),
Rheumatoid factor, ANA, protein
electrophoresis, Mantoux, CT scans,
LP,ECHO.
FEVER RED FLAGS

 Systemic upset/symptoms
 ‘Unwell’
 Abnormal vitals
 Abnormal bloods/investigations (eg CRP,
WBC, lactate)
 Immunocompromised
 Admit/refer the above
FEVER - MANAGEMENT

 Depends on the cause

 Resuscitate!
 Antipyretics?
 Antibiotics?
 Admission/Followup?
SUMMARY

 Relatively common presentation.

 Many causes (not just infections!)
 May be serious (but usually not!)
 History and examination are paramount
 Treat the cause
 Admit the ill!
 Arrange followup for FUOs
QUESTIONS?