The Pyrexial Patient

Question 1

You are the FY1 on call for the general medical wards. You are asked to review a patient who has spiked a temperature.
Mrs R is a 46 year old patient who was admitted 3 days ago with flu. She has had a positive flu swab. She is currently being treated with tamiflu. She is normally fit and well. Her observations are:
HR 86, BP 129/62, RR 22, Sats 95% on air, Temp 39.6.
On arrival you see she is visibly shaking and is clammy

a) Why has her temp spiked?
b) What other info would you like to know?
c) Investigations
d) Managing the pyrexia

Answer 1

a) - Flu-related
- Secondary bacterial infection?

b) - What did they come in with?
Systems review.
- CV - new murmurs?, chest pain
- Resp - SOB, cough, focal signs
- Urinary - dysuria, haematuria
- Skin - rashes, wounds, ulcers, cellulitis, etc.
- Gastro - abdo pain, diarrhoea, vomiting, jaundice

c) SEPTIC SCREEN.
- Bedside: MSU, sputum culture, ?stool sample
- Bloods: FBC, CRP, cultures, U+Es, lactate, ABG
- Imaging: CXR

d) - Antipyretics
- Cooling measures? (temperature > 41 = dangerous)
- Treat the cause

Question 2

Causes of pyrexia.

Answer 2

• Infection (75% in hospital)
• Inflammation (autoimmune), malignancy
• Drugs - neuroleptic malignant syndrome/ serotonin syndrome
• Ischaemia, brain injury, transfusions, PE, other
• Environmental temperature (very rare) - in heatwave, extremes of age, alcoholics

Question 3

Assessment of pyrexial patient.

Answer 3

Airway.
- patency

Breathing.

• RR, SpO2 (and sats probe attached)
• inspect, percuss, auscultate

Circulation.

• HR, BP (and regular monitoring)
• Auscultate HS
• IV access, septic screen, fluids
• ECG

Disability.

• GCS/AVPU - reduced could indicate poor cerebral perfusion, hypercapnia, etc.
• Glucose
• Pupils

Exposure

• rashes, wounds, ulcers, bleeding
• calves for DVT
• abdomen

Question 4

Spiking temperatures on ABx

Answer 4

Normal in first 48 hours after initiation of ABx

After this, spiking temps could be due to:

• new infection
• inappropriate antibiotic (resistant, etc.)

Question 5

Start Smart - Then Focus.

a) Starting smart

Answer 5

a) Starting smart:
- Obtain cultures prior to starting treatment where appropriate (but treatment should not be delayed).
- Take a drug allergy history.
- Start antimicrobials within ONE hour of recognition of Red Flag sepsis, septic shock or life threatening infections.
- Comply with local antimicrobial prescribing guidelines.
- Document the indication for treatment, severity of the infection, dose, route and frequency on both the prescription and in the medical notes.
- State a review or stop date.
- Consult the Microbiologist/ pharmacist for advice where appropriate.

b) Then focus;
- Review patient at 48 - 72 hours and document new management plan, which may involve…
i) Stop treatment (i.e. if no evidence of infection).
ii) Switch from intravenous to oral treatment
iii) Change the antimicrobial.
iv) Continue current treatment.
v) Refer for OPAT