Fever Flashcards
A 23-year-old previously healthy man presents to your office for evaluation of fever, cough, sore throat, muscle aches, and headache for the past 4 days. His vital signs include a blood pressure of 122/80 mm Hg, heart rate of 90 bpm, respiratory rate of 22/min, oxygen saturation of 99% on room air, and temperature of 101.4°F. He appears mildly ill but is well hydrated and tolerating oral intake. Rapid influenza diagnostic testing reveals a positive result for influenza B virus. Which of the following is the most appropriate next step in management?
A Initiate course of azithromycin
B Initiate course of oseltamivir
C Initiate course of prednisone
D Refer to the emergency department for evaluation
E Treat with supportive care
E
fever in adults
-38.0˚C (100.4˚F)
-Differential is broad
-Elderly:
-May not present with fever, just decline in mentation or functional status
-Lower baseline body temperatures
-Delayed febrile response
-WBC counts are neither sensitive nor specific for infection
A 24-year-old woman with no significant medical history presents with sore throat, runny nose, and cough for the past 2 days.
An 85-year-old man who has a significant medical history of leukemia and is undergoing chemotherapy presents with one-sided leg swelling, low-grade fevers, and shortness of breath.
A 74-year-old woman who is confused and combative presents from independent living with fever, increased work of breathing, and cough.
- cold
-2. DVT/PE
-3. PNA -> sepsis?
history
-Timing of fever can be helpful to narrow down the source of fever.
-Ex: Recurrent, self-resolving fevers over the course of weeks to months could indicate autoimmune, malignancy, or medication-induced response.
-Ex: Sudden-onset fever and worsening is more likely an infectious source.
-Comorbidities and associated medications
-May assist in identification of risks for infection (eg, recent chemotherapy and possibility of neutropenic fever)
-May explain a blunted physiologic response to fever (eg, beta blocker)
-Events surrounding the start of a fever may assist in determining the etiology.
-Travel hx
-Hx of institutionalization, hospitalization, immobilization, prosthetic indwelling device, recent procedures
-Sick contacts
-Occupational hazards
-Recreational activities
Physical exam
-Vitals: Evaluate for sepsis
-Head: tympanic/mucous membranes, lymphadenopathy, voice changes, posterior oropharynx abnormalities such as erythema, exudates, tonsillar swelling, erythema of tympanic membrane
-Neck: lymphadenopathy, enlarged thyroid or masses, nuchal rigidity
-Lungs: absence or presence of abnormal lungs sounds and/or increased work of breathing
-Cardiac: absence or presence of abnormal cardiac sounds, heart rate, capillary refill time, temperature, and coloring of extremities
-Abdomen: localized tenderness, peritoneal signs, bowel sound dysfunction
-Rectal: consider if concern for source (ie, perirectal abscess or prostatitis)
-Genitourinary (GU): should be considered if concern for pelvic inflammatory disease, epididymitis, tubo-ovarian abscess, Fournier’s gangrene, or sexually transmitted diseases based on history and physical assessment
-Skin and extremities: rash or erythema, capillary refill, swelling of joints, swelling along posterior calf, tenderness along long bones, evaluation of back for decubitus ulcers, abscesses, symmetric joint swelling
-Neurologic: mental status changes, evaluate GCS, focal neurologic findings
investigations into fever
-What to order depends entirely upon clinical picture, some examples:
-Body aches, fevers, chills, cough, rhinorrhea in December. Otherwise, healthy , NAD, clear lung -> viral panel, tylenol, ibuprofen
-Diarrhea and no other source of fever with significant comorbidities -> stool culture, o&p, norovirus, cdiff
-Enlarged thyroid, tachycardia, and fever -> thyroid panel
-Cough, fever, chest pain, rales -> CXR, crackles, viral panel
-RUQ abdominal pain, fever, vomiting -> US
-Hx of cirrhosis, now with fever and generalized abd pain, confusion -> Spontaneous Bacterial Peritonitis (SBP) -> thoracentesis, hepatitis, serum ammonia
-Fever, joint edema, erythema, warmth, pain, limited ROM -> septic arthritis -> arthrocentesis
-Fever, confusion, neck pain and stiffness -> meningitis -> LP
-Fever and focal neuro signs -> brain abscess -> CT
-Dysuria, flank pain, fever -> UTI, UA/Cx, pyelonephritis,
fever differentials
-Viral infections as cause of fever is very common
-MC bacterial infections: Urine, Respiratory tract, Skin/Soft tissue
-Neurologic (Meningitis, encephalitis, brain abscess, malignancy)
-Fungal (Rare, severe immunocompromise)
-Autoimmune (Prolonged fever without source)
-Thromboembolism
-Malignancy
-Thyroid storm
-Toxicologic
-Fever and rash- Meningococcal, Lyme, RMSF, necrotizing fasciitis, toxic shock syndrome, endocarditis .. And more!
-Any many more!!
pediatric fever: presentation, hx, exam
-often acute fever
-± assoc sx: runny nose, cough, rash, vomiting, diarrhea or other
-If young, ask about feeding!!!, arousability, wet diapers since onset of illness
-Other pertinent history includes medical conditions, birth hx and prematurity (if young), sick contacts, vaccination status, timeline of sx, and potential sick contacts/exposures.
-Exam:
-General appearance!! -> if well appearing -> most likely okay
-Fontanelles (normal: flat and soft) (sunken: dehydrated, third spacing sepsis) (bulging: meningitis)
-undress completely
-Skin: look for rash, vesicles, scalp, joints
-Hearts, lungs, tone, ENT
pediatric fevers: key concepts
-Neonate 0-28 days old -> ER
-Young infant 29 - 90 days
-!!Rectal temp is most accurate -> everyone
->105 -> treat aggressive
-Fever is not dangerous
-Mounting a fever may be protective
-Response to antipyretics (or lack of response) does not correlate with severity of illness
-Non-infectious etiologies may be less responsive than bacterial and viral infections
-Most fevers are viral in nature
-Most bacterial infections are UTI
-Most uncomplicated febrile illnesses last a median of 3-4 days.
pediatric fevers: dx, workup
-0-21 days: Sepsis work up!
-Blood cultures and labs (WBC, CRP, and procalcitonin if available)
-UA and urine culture via catheterization
-LP with CSF analysis (WBC, protein, glucose, Gram stain, culture, and available PCR)
-Herpes simplex virus is a significant concern in this age group
-CXR
-Antibiotics
-Hospital admission recommended
-dont need to know details:
-Well-appearing infants aged 22-28 days:
-Obtain blood culture, labs for inflammatory markers (as above), and UA.
-CSF may not be required if all inflammatory markers are neg
-if not undergoing LP -> inpatient observation w/o antibiotics
-However, a strong argument can be made for holding antibiotics initially with a plan to discharge if improvement and perform a LP and start antibiotics if the patient does not improve.
-Antibiotics may be administered even if labs are normal (1%-2% bacteremia risk).
-Home discharge with a 24-hour follow-up and excellent return instructions may be a reasonable management plan for patients with unremarkable inflammatory markers, urine and CSF (or CSF with enterovirus).
-Return for change in appearance/behavior/color, lethargy, inconsolable crying, difficulty feeding, or evidence of distress.
-Well-appearing infants aged 29-60 days:
-Obtain a UA (any method is acceptable). If positive, then send a culture from a suprapubic aspiration or catheterized specimen.
-Circumcised boys have a UTI incidence of <1% and are exempt from this recommendation.
-Obtain a blood culture and labs for inflammatory markers (as above).
-CSF is not required unless the child is ill appearing or inflammatory markers are elevated
kawasaki disease
-ALWAYS consider in child with prolonged fever and rash
-VASCULITIS
-MC in ages 6mo–5yo
-high risk for aneurysm
-Dx criteria:
-5 days of fever (can be shorter if high suspicion) PLUS
-B/L conjunctivitis
-Cervical lymph node >1.5CM
-Polymorphous exanthem
-Cracked lips or strawberry tongue
-Erythema, edema, cracking or peeling of the hands/feet
-NONBLANCHING rash
-Echo- in all pts who meet KD criteria -> inflammation of coronary arteries
-Pediatric rheumatology and infectious disease consults
-Tx- high dose ASA, IVIG, PPI
pediatric fever tx
-Most are self-limited viral infections
-Antipyretics -> pain and discomfort of fever
-Broad spectrum, empiric antibiotics should be given immediately if the child appears ill
-In well appearing children with suspected bacterial infection, antibiotic therapy should be tailored to suspected source
-ALL FEBRILE NEONATES should be admitted for IV antibiotics until cultures are negative
-majority of children can be discharged immediately if H&P do not reveal red flags for a bacterial infection.
-Young infants >1mo may be discharged if deemed low risk by criteria including eval of blood and urine with or w/o CSF -> Close f/u (~24 hours) must be ensured
An 84-year-old African American man presents to the local emergency department (ED) from a skilled nursing facility for fever, generalized malaise, and altered mentation for the past 12 hours.
On arrival, the patient is answering questions appropriately but does appear increasingly somnolent.
Pt has a history of hypertension, coronary artery disease and past CVA.
Vital signs: Temp 39.4 C (103° F), HR 125 bpm, BP 92/55 mmHg, RR 22 per min, SpO2 99% on RA.
Physical exam is significant for dry mucous membranes, tachycardic regular rhythm, tachypnea but otherwise clear breath sounds.
Pt has mild lower abdominal tenderness to palpation with an indwelling Foley catheter in place. Pt has brisk lower extremity pulses.
The nurses ask “What are your initial orders doc?”
-UA and Urine cx, blood culture
-fluids
-prob infection from folley cath
-empiric antibiotics
-take out the catheter
-CXR
-can be multiple sources
-viral panel
-sputum if there is a cough
-CBC, CMP, lactate, LFTs
SIRS
-SIRS criteria:
-temp >38 (100.4) or <36 (96.8)
-HR > 90
-RR > 20 or CO2 < 32
-WBC > 12,000 or < 4,000 or >10% bands
-qSOFA score:
-systolic BP <= 100
-RR >= 22
-GCS <15
-scores >= 2 have increased risk of mortality
sepsis presentation
-Classic: Fever, tachycardia, tachypnea, ± hypotension, with delirium
-Variability in presentation
-Factors that increase risk of sepsis
-Age >65
-Social: Nursing home or LTC, prisoners, homeless, alcoholism
-Co-morbidities: Diabetes, CHF, COPD, Liver disease, Cancer, CKD
-Immunosuppression: Chemotherapy, daily steroid use, immune modulating drugs or immune blocking drugs
approach to critical pt in sepsis (hour 1)
-Recognize S&S of sepsis (also, core temperature)
-ABCs
-Vascular access
-Peripheral IV or IO access
-Central (Line) venous catheters
-Arterial line- check MAP
-Empiric antibiotic therapy*
-Attempt collection of cultures before antibiotics, within first hour
-Lactated ringers at 30mL/kg (less if heart or oliguric renal failure)
-Vasopressors to maintain goal MAP >65mmHg!!:
-Norepinephrine 0.01-3.0 μg/kg/min (generally first line)- through central line
-Vasopressin 0.03 units/min
-Addition of vasopressin generally utilized once norepinephrine dose is ≥15 μg/min.
-Use caution or avoid vasopressin use in cases of mesenteric or cardiac ischemia.
-Epinephrine 0.01-2 μg/kg/min
-find and control source of infection:
-remove indwelling foley catheters if possible
-full PE
-CXR
-ECG if tachy
-labs:
-CBC, CMP, UA, VBG (for lactate), cultures (blood + urine), other as indicated -> CT, CSF, SSTI wound cultures, joint cx
-serial exams:
-repeat vitals and PE
-urine output
-trend lactate
-Dispo:
-admit, usually ICU
hospital measures and sepsis bundles (dont memorize)
-Center for Medicaid and Medicare services (CMS)
-Surviving sepsis campaign 2018
-1 hour bundle (SEP-1)
-Hour-1 Bundle
-Measure lactate level* remeasure if >2mmol/L
-Obtain blood cultures before administering antibiotics
-Administer broad-spectrum antibiotics
-Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L
-Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg
-3 hour bundle (SEP-3)
-Lactate measurement
-Blood cultures done before antimicrobial initiation
-Broad spectrum antibiotics
-Administration of 30ml/kg crystalloid for hypotension or lactate ≥4 mmol/L
-6 hour bundle
-Administration of vasopressors for hypotension that does not respond to fluids to achieve a MAP ≥ 65 mm Hg
-Reassess and document volume status after fluid administration for patients with hypotension that does not respond to fluids or lactate ≥ 4 mmol/L
-Repeat lactate measurement for patients with initial lactate ≥ 4 mmol/L
cellulitis
-Infection of skin (dermis + subcutaneous tissue)
-MCC- group A beta-hemolytic strep (Strep pyogenes) or Staph aureus (rising rates of MRSA)
-Infection begins at a site of trauma: cut, puncture, surgical wound, bites, shaving
-unilateral normally
-!!Pain, redness, swelling, warmth, tenderness in the affected area
-firm
-May have associated fevers, chills, sweats, swollen lymph nodes, streaking (ascending lymphangitis)
-Prognosis: Good w/ outpatient treatment
-Dx: CLINICAL
-US- adjunct -> cobble stoning and edematous fluid
-Tx for non-purulent cellulitis: -Antibiotics
-!!Cephalexin 500 mg PO Q6 hours X 5-7 days or
-!Doxycycline 100 mg PO BID X 5-7 days if true PCN allergy
-High risk for MRSA: Empiric addition of trimethoprim-sulfamethoxazole (TMP-SMX)- bactrim
cellulitis considerations
-in in dirty water -> vibrio- will blister too -> doxy
-cats, dogs -> Augmentin
-fight bite (punch face and tooth gets you) -> augmentin
cellulitis mimics
-Stasis dermatitis: MC misdiagnosis as cellulitis! Often !bilateral and chronic! Presence of telangiectasia, varicose veins, hyperpigmentation, edema subsides with recumbency
-send to wound clinic, elevate, NO antibiotics
-Contact dermatitis – itchy!
-Allergic reactions – itchy!
-Peripheral arterial disease
-DVT: venous cord, can check Homan’s sign (discomfort behind the knee on forced dorsiflexion of foot), duplex ultrasound
-Mono-arthritis (septic/gout): suspect when cellulitis overlies a joint
abscesses
-Localized infection causing !pocket of pus within the dermis!
-can be complication of cellulitis -> warm, firm, with fluctuant center
-Painful, tender, !fluctuant, surrounding induration! ± erythema
-DX- clinical
-US- swish sign
-CT- for perianal abscess -> surgeon bc can cause fistula
-pilonidal abscess -> surgeon bc reoccur usually
-psoas- common
-bartholin cyst - word catheter
-breast- needle aspiration by surgeon
-Tx: Simple linear !I&D! with #11 blade
-ED performs at uncomplicated sites (limbs, back, axilla)
-Must break loculations! through probing
-But Sarah.. Are the following needed?
-Wound culture swabs?
-Packing?
-Antibiotics? -> abscess + cellulitis =I&D + antibiotics
-just abscess = I&D
abscess discharge instructions- dont memorize
-Apply warm and dry compresses, a heating pad set on low, or a hot water bottle 3 or 4 times a day for pain. Keep a cloth between the heat source and your skin.
-Keep your bandage clean and dry. Change the bandage whenever it gets wet or dirty, or at least one time a day.
-If the abscess was packed with gauze:
-Keep follow-up appointments to have the gauze changed or removed. If the doctor instructed you to remove the gauze, follow the instructions you were given for how to remove it.
-After the gauze is removed, soak the area in warm water for 15 to 20 minutes 2 times a day, until the wound closes.
-Take prescribed antibiotics as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.
-Take pain medicines exactly as directed.
skin and soft tissue summary
-Abscess and cellulitis are 2 MC soft tissue infections in the ER
-They can occur together requiring different treatments
-Cellulitis requires antibiotics alone
-Abscessesrequire tx with I&D
-May also require antibiotics if surrounding cellulitis
-Caveat: If US shows a very small abscess <1cm diameter, may choose tx with antibiotics and warm compresses instead, with 2 day f/u for reassessment
necrotizing soft tissue infection (NSTI)
-Rapidly progressive infection of the deep fascia causing necrosis of the subcutaneous tissue
-“Flesh eating disease”
-Early signs and symptoms like cellulitis
-Swelling and severe pain
-Can also have:
-Margins are poorly defined (tenderness extends beyond apparent area of involvement)
-Edema extending beyond margin of erythema
-!!Bullae
-!!Gangrenous skin
-Crepitus (13-31%)
-Wooden feel to the subq tissue
-!!Severe pain out of proportion to exam
-Dx: clincial
-X-ray- NF showing ectopic air in the subcutaneous tissue
-Do not rely on imaging
-Tx:
-Broad spectrum antibiotics
-Prompt surgical debridement
