1. FEVER MR SUNEIL RAMNANI CONSULTANT IN EMERGENCY MEDICINE
PRINCESS ALEXANDRA HOSPITAL

2. OBJECTIVES Define Fever Discuss Causes Assessment Investigations
Management
Red Flags and Pitfalls
Summary

3. WHAT IS FEVER?
‘A temporary increase in the core body temperature above the normal range caused by elevation of the hypothalamic set point’
No single agreed upper limit for normal temperature.
Normal core body temperature in healthy people is 35.6˚c – 38.2˚c (mean 36.8˚c)
In adults, a temperature of 38.3˚c is a fever.
In infants, a rectal temperature of 38˚c is a fever.
A temperature over 41.5˚c is not a true fever.

4. FEVER FACTS
Common complaint – 6% of adult ED attendances and 20-40% of paediatric attendances.
Same as Pyrexia!
Rectal temperature is most accurate measurement.
Generally a response to disease or illness but can be ‘physiological’.
Can indicate serious or life threatening illness.
No relationship between magnitude of temperature and severity of illness.

5. FEVER-CAUSES Hundreds!
Mostly caused by self limiting viral infections.
Infections are the most common cause (acutely!) %
Cause usually apparent in ED. (pneumonia, UTI etc)
FUO/PUO (fever >38.3˚c documented on several occasions during a period of more than 3 weeks with uncertain diagnosis after 1 week of evaluation in hospital).

6. FEVER OF UNKNOWN ORIGIN (FUO)
Infections/Infectious diseases 20-40%
Neoplastic/Malignancy 10-30%
Non-infectious Inflammatory diseases (eg collagen vascular diseases, connective tissue diseases) 20-35%
Miscellaneous (including drug fever) 10-20%
No diagnosis 20-30%

7. ASSESSMENT: HISTORY Key to Assessment
Associated Symptoms: Cough, SOB, pain, dysuria, diarrhoea, weight loss, sweats, rigors, fever, rash, lumps/itching.
Duration
Ill contacts, pets, animal contacts
Occupation
Travel history
Medication
History/risk of immunocompromise
Sexual History, IVDU
Bites, Cuts, Surgery

8. ASSESSMENT: EXAMINATION
General appearance: sick Vs well
Vital signs
Subtle mental state changes
Rashes
Skin, eyes, lymph nodes, throat, teeth
Liver and spleen
Occult sites of infection: nose/sinuses
PR exam (prostatitis, perirectal abscesses)
Pelvic exam
Nails, joints, temporal arteries

9. INVESTIGATONS Guided by history and examination.
No tests that are always needed for every patient.
Clinical judgement required.
Consider:
Bloods:
FBC and differential. Blood film.
Renal profile
LFTs
CRP, ESR
VBG
Urine dip
Cultures – urine, sputum, blood, stool.
ECG
CXR
Thick and thin blood films.

10. INVESTIGATIONS 2 Other tests for the medics!
Serology/virology (EBV,CMV,HIV), Rheumatoid factor, ANA, protein electrophoresis, Mantoux, CT scans, LP,ECHO.

11. FEVER RED FLAGS Systemic upset/symptoms ‘Unwell’ Abnormal vitals
Abnormal bloods/investigations (eg CRP, WBC, lactate)
Immunocompromised
Admit/refer the above

12. FEVER - MANAGEMENT Depends on the cause Resuscitate! Antipyretics?
Antibiotics?
Admission/Followup?

13. SUMMARY Relatively common presentation.
Many causes (not just infections!)
May be serious (but usually not!)
History and examination are paramount
Treat the cause
Admit the ill!
Arrange followup for FUOs

14. QUESTIONS?