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Fever

  • Approach

    • infectious
      • labs: CBC, blood smear, blood culture, UA
      • locate source (pick tests based on clinical suspicions)
        • localization of pain
        • LP (meningismus)
        • STD panel (HIV)
        • CXR (TB, pneumonia)
        • echo (endocarditis)
        • monospot (mono), viral panel
        • hepatitis panel if elevated LFTs
        • strep test (strep throat)
        • tick panel, ID consult (foreign travel, animal exposure)
        • CT (appy), US (cholecystitis)
    • inflammatory
      • labs: CRP, ESR, ANA, RF, biopsy for vasculitis
      • DAT coombs test (transfusion reaction)
      • CT (appy), US (cholecystitis)
      • doppler (venous thrombosis)
    • meds, vaccines, IV drugs and exposures
      • discontinue drug
    • malignancy
      • CBC with smear, CT, PET, bone marrow biopsy (lymphoma)
    • dysregulation
      • hypothalamic injury (prior stroke)
      • hyperthyroidism (TSH)
      • adrenal insufficiency (Na, K, aldosterone)
    • hereditary cyclic fevers (family history, early onset)
  • Ddx

    • Common: flu, common cold, strep throat, sinusitis, gallstone, mono
    • Serious: endocarditis, pneumonia, TB, RSV, appendicitis, pyelonephritis, meningitis, RMSF, sepsis, malignancy, HIV, DVT, transfusion reaction
    • Fever of unknown origin criteria:
      • temp > 38.3 C on several occasions
      • duration > 3 weeks
      • despite at least 1 week of evaluation
  • Admission order

    • Admit: Floor
    • Diagnosis: Fever of unknown origin
    • Condition: Stable or guarded
    • Vital Signs: q4 hours
    • Allergies:
    • Nursing:
    • Diet: Regular
    • Activity: As tolerated
    • Labs: see approach
    • IV: None if can tolerate PO
    • Special:
    • Medications:
      • withhold antipyretics to document true fever
      • withold drugs to r/o drug fever
      • if opiate abuse: Methadone 30-40 mg PO q 12 hours - hold for sedation.
      • if severe pain, Oxycodone 15-30 mg PO q 4 hours prn pain
      • Ibuprofen 600 mg PO tid
      • if smoker: Nicotine patch 21 mg transdermal daily
    • Call HO: temp > 38
    • Discharge
      • criteria: stable, close outpatient f/u arranged
      • education: take temperature several times per day, return if new symptoms
      • if drug abuse: drug/STD education, social work, methadone clinic

  • Print | Citations

    Disclaimer: MDHero Workups is for educational use only, and is not meant to replace the clinical judgement of a professional. We do not guarantee the accuracy of any information on this website.