Presentations
Approach to fever in the hospital
The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.
Immediate threats
- Septic shock physiology
- Neutropenic fever: antibiotics within the hour
- Meningitis; necrotizing soft tissue infection
- The non-infectious killers wearing fever: PE, drug fever syndromes
History that discriminates
- Localizing symptoms walked head to toe
- Lines, catheters, devices, recent procedures: each one a suspect
- Immunosuppression inventory; travel and exposures
- New drugs (drug fever, serotonin and neuroleptic syndromes)
Examination
- Every line site and every drain, uncovered and looked at
- Lungs, abdomen, skin folds, joints, calves
- The back: sacral wounds hide from busy teams
Problem representation
New fever on ward day 3 in a stented, recently instrumented urinary system (urosepsis weight, source-control question) versus fever with a new murmur and split hands (endocarditis weight).
Differential, by mechanism
Infectious
- Urinary (catheter)
- Pneumonia (aspiration weight in the frail)
- Line infection
- Surgical site and collections
- C. difficile
- Endocarditis
Non-infectious
- VTE
- Drug fever
- Gout flare
- Transfusion reactions
- Malignancy and connective tissue disease
Investigations
- Cultures before antibiotics: blood times two, urine, and anything drainable
- Directed imaging over reflex pan-scanning, but a low threshold in the deteriorating
- Lactate as the severity meter
Interpretation
- Fever plus hypotension runs the sepsis clock regardless of the eventual source
- A fever without localization on day one localizes on day two: re-examine
Next steps
- Empiric coverage matched to the suspected source and local patterns, de-escalated on data
- Source control is asked about early and out loud
What the images look like
Connected
Take it further
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