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Fever Krista A. Grandey, DO Key Points ‘© Fever i a symptom, rot a disease, ‘+ Fever should not be confused with hyperthermia. Temperatures higher than 41°C (105.8°F) are almost always due to hyperthermia and not feve. ‘© be thoughtful a your evaluation of fever to avoid ‘misdiagnosing 2 Serious bacterial illness as “just another vil syndrome.” INTRODUCTION, ‘The human body temperature is controlled within a nar- row range between 36 nd 37.8 °C (96.8 -100.4°F). Fever is defined as a core teraperature >38° C (100.4 °F) in infants and >38.3°C (100.9°F) in adults. It's the result ofthe body resetting the temperature control center, the hypothala- ‘mus, in response to infection. Endogenous (cytokines) and exogenous (hacterial and viral) pyrogens trigger produc- tion of prostaglandin F2 (PGE2) in the hypothalamus PGE2 raises the hypothalamic temperature set point. The body then generates and conserves heat to reach this new hypothalamic set point, thereby raising the body tempera~ ture, Fever is sustained aslong as the levels of pyrogens andl PGE2 are elevated. Cyclooxygenase inhibitors decrease fever by blocking the production of PGE2. Fever is one of the most common presenting com- plaints in the emergency department (ED). It accounts for 5H of adult visits, 1596 of elderly visits and 40% af pediat- ric visits tothe ED. The most important thing to recognize about fever is that it isa symptom, not a disease, and it represents an underlying problem that must be evaluated and treated. The most commen sites of infection vary based on age and immune system status In the elderly and immunosuppressed, respiratory, genitourinary, and bacterial '* Provide empiric antibiotics early for moderate to severely il patients witha possible infectious etiology. Give directed antibotic reatment nthe emergency department to patients with serious focal bacterial infections. ‘kin infections predominate. Ia younger ptientsthe cause ‘of fever is often self-limited and benign (eg, upper respira tory infection), but serious focal bacterial infections (eg meningitis) requiring antibiotics, diagnostic procedures, and admission, must be detected. CLINICAL PRESENTATION. > History ‘Thediferential diagnosis for feverisquite broad, but in 85% of cases the cause is identified by a thorough history and. physical examination, Important historical information includes the onset, magnitude, duration, pattern, any associ- ‘ated symptoms, travel within the past yea, chronic illnesses, recent medication changes, recent hospitalizations, chemo- therapy, radiotherapy, or the presence ofindwelling vascular access deviees or artifical heart valves. The age and overall health ofthe patient must be taken into account when tak- ‘ng the history and making medical decisions. > Physical Examination ‘The site of temperature recording should be noted, as rec- tal temperatures are more accurate and usually 1°C higher than oral temperatures, Rectal temperature should be 138 Table 33-1. Physical examination in fever. “athna or oer sigs of Gon ness Perform a bet mental status eamination. In ‘the edery, ANS may be the aly son ofan occaltinfecion. ‘aie the tympaic membranes ad payne {or evdonce of onts meta or ensate phar ats Assess the neck foc hyd erage ‘met, iymphaderoaty, and meningismes. est ‘Auscutae for evidence of preumona (eg. aes ‘ot orci), new murmurs suggesting endo- cats, othe nb of aate fr signs of focal ox generated perter ‘its. Check for cotovertbral ane tender ‘ess, Perform 2 genituinay exaiatio in ‘males and a pelvic examination in females with abdominal pin, skin Disrebe the patont and examine for rashes (petechiae af menngoceccema) or fecal infecton (int inflanmatin, clus, infected ules, o abscess). “Genera Neurologic ay nose, and that taken in infants, children, and adults with significant tachypnea, tachycardia, or altered mental status (AMS). Heart rate (HR) and respiratory rate (RR) increaseas fever rises, An increase in temperature of I°C results in an increase in HR by approximately 10 bpm. The RR may also inerease 2-4 breaths/minute per degree Celsius. The elderly and immunosuppressed patients may not mount a febrile response despite serious infection. In most patients, the examination is directed by the patient's symptoms (Table 33-1). Patients with significant alterations in mental status, respiratory distress, and car- diovascular instability require rapid assessment and stabi~ lization. Once the patient has been stabilized, assess for infectious causes that may be a threat to life (eg, toxic shock, septic shock, meningitis, peritonitis). DIAGNOSTIC STUDIES > Laboratory In children and the elderly. the highest yield laboratory test will be the urinalysis. Its highly accurate for urinary tract, infection. In most cases, a complete blood count (CEC) will be sent tolook for an clevated white blood cell (WBC) count, but this test lacks specificity and sensitivity. The WBC count can be normal in eases of severe infection oF falsely clevated when no infection is present. The most helpful component of the CBC is the neutrophil count, as it ean provide a measure of response to infection or deter ‘mine whether a patient is neutropenic and unable to, ‘mount a response to infection (eg. immunocompromised chemotherapy patient). Gram stains, blood, urine, and re Ye ‘wound cultures can be obtained in the ED. Although not helpful in the ED management of the patient,these studies direct targeted antibiotic therapy in the future. p> Imaging ‘The ches x-rays hepfl in patients with suspected preamo- ‘ia, butmay be dffcultto interpret inthe dehydrated patient ‘or those with underlying pulmonary or cardiovascular disor ers. For patients with abdominal pain, a computed tomog raphy (CT) sean of the abdomen can be performed to ‘evaluate for appendicitis, diverticulitis, choleystts, and intra abdominal absces. A head CT should be performed for patients with focal neurologic ndings, seizures, AMS, human, ‘immunodeficiency virus (HIV Vacquired immune deRiciency syndrome or signs of increased intracranial pressure. The administration of antibiotics should not be delayed in patients with suspected meningitis awaiting CT scan results. PROCEDURES For patients with altered mental status or meningismus, 4 lumbar puncture should be performed to evaluate the ‘cerebrospinal fuid for infectious causes (see Chapter 5). MEDICAL DECISION MAKING ‘The differential diagnosis for fevers extensive, and the cause ‘can be infectious or noninfectious. The majority of causes of | fever are infectious (Table 33-2). Noninfectious causes include pulmonary embolism, intracranial hemorthage, cerebrovascular accident, neuroleptic malignant syndrome! serotonin syndrome, malignant hyperthermia, thyroid Table 33-2. Differential diagnosis of infectious causes of fever. Nex dogie Replay; we, end gat, egress, ‘eumori, ertonirabses, ois med, pharyngitis, sins upper espatry infection Indocardis, myocatts, or prcardts ‘eons, colangts, appends, cho. ests, dete rreebdorinl a2, cots Fens Ado aes) Stable vital signs, othe healthy ‘No obvious source: History & physical exam antipyretics, hydration, Cte Eee tet ea antipyretics, admission Unstable vital signs, seriou signs (stiff neck, AMS, Reet ae) or very old, immunosuppressed, Cee Ret tay Pee Cy Ce aC as ei iess Figure 33-1. Fever diagnostic algorithm. AMS, altered mental status; CBC, complete blood count; CSF, cerebro - spinal fluid; OX, chest x~iay; UA, urinalysis. storm, transfusion reaction, malignaney, autoimmune dis- onder, or drug fever. Use the history and physical examination to make deci- sions about testing and treatment Ifthe patients stable and there ian obvious soures of infection, antipyretics should bbe given and antibiotics when appropriate In the hemody- namicaly unstable patient, intravenous fhid resuscitation should be initiated along with monitoring, respiratory sup- port, and antipyretics (see Chapter 34). Empiric antibiotic treatment with broad-spectrum antibiotics should be started immediately in the ED for unstable patients if an obvious source cannot be found (Figure 33-1). TREATMENT Antipyretics (eg, acetaminophen or ibuprofen) ate adminis tered to increase patient comfort and reduce the metabolic demand. Patients who are stable can be treated with hydra- tion and appropriate antibiotics. Patients with signs and symptoms of shock (eg, AMS, hypotension, tachycardia) require monitoring and aggressive fluid resuscitation, Patients with signs of respiratory compromise or airway ‘obstruction may require intubation. In critically il or immunocompromised patients, administer antibiotic ther- ‘apy early. If there is no known source of infection, adminis- ter broad-spectrum antibiotic therapy to cover aerobic (gram-postive and gram-negative) and anaerabie organ- isms. The choice of antibiotic is based on the most likely ‘cause of the fever as well as patient considerations such as neutropenia. Antibiotic dosing may be altered in patients with renal insufficiency or in patients with specific condi tions (cg, bacterial meningitis) DISPOSITION > Admission Patients who are unstable, immunocompromised (eg, HIV, cerly, neonate), have serious localized infection (eg, ‘meningitis, or have serious comorbidities (pneumonia

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