Pyrexia (Adult)

Question 1

HPC

Answer 1

Clarify- what do you mean by feverish?
Timeline- how did this symptom start from the beginning
How are you feeling generally- nausea or pain or night sweats
Timing and triggers- does it come and go or is it constant? Anything bring it on

Question 2

3 main causes of a fever

Answer 2

Infection
Malignancy
Autoimmune/ others

NB- fever is usually due to a self limiting viral infection or uncomplicated bacterial infection. If no cause after 3 weeks and investigations= pyrexia of unknown origin

Question 3

Systems review for a fever

Answer 3

Cancer- (F)WARJLN
Respiratory- cough, SOB, sputum, haemoptysis
Cardiac- chest pain
GUT- pain on urination, going more frequently, haematuria, unprotected sex with a new partner
Neurological- headache, neck stiffness, rash, vision changes, jaw claudication
GIT- d and v, changes in bowel habit
Tropical- been abroad recently, insect bites
Haematological- bruising more easily, getting lots of infections
DVT- legs swollen, painful or hot
Breast- any lumps or changes
MSK- skin lesions or ulcers, dry eyes and mouth, do hands change colour in the cold

Question 4

Friends and family

Answer 4

Any of them have infections at the moment

Question 5

TB

Answer 5

Weight loss, night sweats, lymphadenopathy, haemoptysis

Risks- previous TB, alcoholism, homeless, IVDU, compromised immune system

Question 6

IE

Answer 6

Malaise and flu like illness, cardiac and embolus phonomenae like SOB/ systemic infractions
Classically, pt goes to dentist (infection into bloodstream occurs), may or may not have pre existing heart condition

Question 7

Haematological malignancy

Answer 7

Fever, bruising, recurrent infections, anaemia

Question 8

Drug induced fever

Answer 8

Some patients have drug hypersensitivities

Consider if no other Sx and they developed the fever after starting/ increasing dose of a drug

Question 9

Patient perspective

Answer 9

Feelings and effect on life
Ideas
Concerns
Expectations - “I understand you have come here for medical advice but is there anything else you were hoping for today”

Question 10

PMH

Answer 10

HIV
Previous malignancy
Inflammatory conditions
Recent surgery

Question 11

DH

Answer 11

Any medications and recent changes

Any allergies

Question 12

FH

Answer 12

Do any conditions run in the family esp. autoimmune disease and malignancy
Have family and friends been unwell recently

Question 13

SH

Answer 13

Working currently- impact of fever on job
Tell me about home occupants difficulties etc.
Smoking/alcohol/ recreational drugs

Question 14

Abscesses

Answer 14

May be no localised Sx

Consider if patient has had recent surgery trauma or PMH of diverticulosis

Question 15

Cancer

Answer 15

Weight loss and cachexia, as well as other red flags

Question 16

Rheumatoid arthritis

Answer 16

Symmetrical poly arthritis typically affecting small joints
More common in females
Hot swollen tender joints with morning stiffness

Question 17

Connective tissue disease eg. SLE

Answer 17

Sicca Sx (raynauds, dry eyes, dry mouth) and fatigue 
Arthralgia, rashes, renal and limb involvement

Question 18

Vasculitis

Answer 18

Skin lesions, urticaria, oedema, arthralgia, other systemic features

Question 19

Familial Mediterranean fever

Answer 19

An inherited condition usually in Mediterranean ethnicities particularly subsets of Jewish communities
Recurrent bouts of fever, abdominal pain, pleuritic chest pain, joint pains etc.

Question 20

Investigations

Answer 20

Bloods- FBC UE LFT TFT ESR CRP serum ferritin HIG screen
Autoimmune screen
Blood cultures
Urinalysis, urine microscopy, culture and sensitivity
CXR
Mantoux test and quantiferon TB gold for TB
CT MRI USS if cancer or abscess suspected (and colonoscopy upper GI endoscopy)
Doppler or echo if cardiac involvement

Question 21

COVID19

Answer 21

COVID is now a differential for anyone who presents with a fever
Ask about vaccines, loss of sense of taste and smell
May see COVID pneumonitis on an XRay