Examination: Causes of Pyrexia

Possible OSCE scenario: You are the doctor covering the medical wards and have been asked to review a patient on the ward with a fever of 38.5 degrees. Please examine the patient and explain to the examiner what you would do next.


Examination Technique
  • Introduce yourself
  • Wash your hands
  • Explain to the patient that you have been asked to review them due to a high temperature
  • Ask for the patients observations – if any signs that patient is unwell/septic advise you would asses using ABCD technique, otherwise continue as below

  • Look at the patient from the end of the bed:
    • Look for any obvious signs of infection or abnormality– e.g. tachypnoea,

  • Review the hands:
    • Peripheral stigmata of infective endocarditis
    • Feel the temperature
    • Capillary refill

  • Feel the pulse:
    • Feel for rate and rhythm, and pulse volume

  • Look at both arms:
    • Look for any areas of erythema or rashes
    • Look at any peripheral access points (cannula’s, PICC lines) – check dates on them and check surrounding skin areas

  • Feel the neck
    • Feel for any enlarged lymph nodes – if any are enlarged note if they are unilateral or bilateral and state what they feel like (rubbery, firm, mobile)
    • Check for neck stiffness

  • Look in the mouth
    • Check for enlarged tonsils
    • Check for any oral infections – e.g. candida, ulcerations
    • Check mucosal membranes
    • Look for any abnormalities in the lips and tongue (Kawasaki disease)

  • Look in the eyes
    • Offer to check the retinae with a fundoscope

  • Look at the rest of the body for a full skin examination (ensure undress patient fully to check all areas)
    • Erythema
    • Scars, wound infections
    • Rashes

  • Explain at this point you would do a full cardiac, respiratory, neurological and abdominal examination but will concentrate on the main points now.
    • Respiratory:
      • Listen to the chest for any signs of infection – crepitations, bronchial breathing
    • Cardiac:
      • Feel the apex beat
      • Listen to the heart sounds for any murmurs
    • Examine the abdomen:
      • Feel for any tenderness
      • Feel for any enlarged organs (spleen)
      • Listen for bowel sounds
    • Neurology examination if indicated:
      • Kernigs sign
      • Any cranial nerve deficits or peripheral neurology

  • Thank the patient
  • Summarise what you have found
  • Explain to the examiner what you would do next:
    • Take a full history
    • Explain you would like to do a full septic screen:
      • Full set of bloods including FBC and CRP
      • Blood cultures
      • Urine dip +/- MC&S
      • Chest X-ray
      • Specific investigations if anything picked up on examination e.g, sputum sample, wound swab
    • Explain you would like to give the patient paracetamol to bring their fever down (check allergies and whether has already had)
    • If the patient had any signs of sepsis or SIRS explain you would resuscitate the patient e.g. IV fluids and treat appropriately e.g. antibiotics
    • Explain you would like to read through the patients notes and drug chart to check if any history of infection or risk factors

Definitions
  • Pyrexia = temperature above the normal range
  • Usually considered > 37.5 degrees
  • Pyrexia of unknown origin = fever of over 38.3 degrees or greater for at least 3 weeks with no identified cause after 3 days of hospital evaluation or three outpatient visits

Differential Diagnosis
  • Most common infections:
    • Bacterial:
      • Chest infection
      • Urinary infection
      • Cellulitis
      • GI – gastroenteritis, cholangitis
    • Viral infections
      • Influenza
  • Rare infections but important to rule out:
    • Infective Endocarditis
    • Meningitis
    • Encephalitis
    • HIV (seroconversion)
  • Non-infective causes:
    • Inflammatory: Inflammatory bowel disease, Kawasaki disease, Juvenile RA
    • Neoplastic: ALL, lymphoma
    • Drugs/toxins

Extras:
download in pdf

written by: naina_mccann,
first posted on: 12/11/15; 12:40

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