What is the approach to taking a history and performing a physical examination on a patient with fever?

Approach to Taking History and Examination from a Patient with Fever

The most effective approach to evaluating a patient with fever requires a detailed travel history, assessment of risk factors, and systematic physical examination focusing on potential infectious sources, with special attention to high-mortality conditions such as malaria in returning travelers. 1

Initial Assessment

History Taking

• Travel history:

  • Detailed geographical locations visited (specific countries and regions)
  • Duration of stay in each location
  • Time of onset of symptoms relative to travel
  • Activities during travel (swimming, hiking, animal contact)
  • Accommodations (urban hotels, rural settings, camping)
  • Food and water consumption patterns 1

• Fever characteristics:

  • Onset (sudden vs. gradual)
  • Pattern (continuous, intermittent, relapsing)
  • Duration (acute vs. persistent)
  • Associated symptoms before, during, and after fever
  • Response to antipyretics 1

• Risk factors and exposures:

  • Insect bites
  • Animal contacts
  • Sexual contacts
  • Fresh water exposure
  • Consumption of unpasteurized dairy products or undercooked meat
  • Contact with ill individuals 1

• Medical history:

  • Pre-existing conditions
  • Immunization status
  • Current medications
  • Chemoprophylaxis (e.g., malaria prophylaxis)
  • Recent procedures or surgeries
  • Indwelling devices (catheters, prosthetics) 1

Physical Examination

• Vital signs:

  • Temperature measurement (preferably oral or rectal for accuracy)
  • Heart rate, respiratory rate, blood pressure
  • Oxygen saturation 1

• General appearance:

  • Level of consciousness
  • Signs of toxicity or distress
  • Hydration status 1

• Systematic examination:

  1. Skin: Rashes (maculopapular, petechial, vesicular), eschar, purpura, jaundice
  2. Head and neck: Conjunctival injection, pharyngeal erythema, cervical lymphadenopathy
  3. Respiratory: Breath sounds, evidence of consolidation
  4. Cardiovascular: Murmurs, pericardial rub
  5. Abdominal: Hepatosplenomegaly, tenderness, masses
  6. Musculoskeletal: Joint swelling, tenderness, range of motion
  7. Neurological: Mental status, meningeal signs, focal deficits 1

Diagnostic Approach

Initial Investigations

• Blood tests:

  • Complete blood count with differential
  • Malaria films and rapid diagnostic tests (for travelers to endemic areas)
  • Blood cultures (at least two sets from different sites)
  • Liver function tests
  • Renal function tests 1

• Imaging:

  • Chest radiograph (recommended for all patients with fever during hospitalization) 1
  • Abdominal ultrasound (if abdominal symptoms, abnormal liver function, or recent abdominal surgery) 1

Syndrome-Based Approach

Based on presenting symptoms, focus additional investigations on:

1. Respiratory symptoms:

   • Sputum culture
   • Respiratory viral panel
   • Consider thoracic ultrasound if chest X-ray abnormal 1

2. Gastrointestinal symptoms:

   • Stool cultures
   • Ova and parasite examination
   • C. difficile testing if relevant 1

3. Urinary symptoms:

   • Urinalysis and urine culture
   • If catheterized, replace catheter before obtaining specimen 1

4. Neurological symptoms:

   • Consider lumbar puncture
   • Brain imaging if focal deficits 1

Special Considerations

Returning Travelers

• Prioritize potentially fatal tropical infections:

  • Malaria (perform thick and thin blood films and rapid diagnostic tests)
  • Dengue fever
  • Typhoid fever
  • Viral hemorrhagic fevers 1

• Timing considerations:

  • Most tropical infections become symptomatic within 21 days of exposure
  • Majority of febrile returning travelers present within one month of leaving endemic areas 1

Fever Without Obvious Source

• If initial workup is unrevealing:
  • Consider inflammatory markers (ESR, CRP)
  • Consider procalcitonin if bacterial infection probability is low to intermediate 1
  • Consider advanced imaging (CT, MRI) if fever persists 1
  • For persistent fever of unknown origin, consider 18F-FDG PET/CT if other tests have failed to establish etiology 1, 2

Common Pitfalls to Avoid

1. Incomplete travel history: Failing to obtain detailed information about all locations visited, activities, and exposures

2. Premature closure: Attributing fever to common conditions without considering serious tropical diseases in returning travelers

3. Inadequate malaria testing: Not performing repeated malaria tests (three thick films/RDTs over 72 hours) to confidently exclude malaria in travelers from endemic regions 1

4. Inappropriate antibiotic use: Starting empiric antibiotics without adequate diagnostic workup (except in critically ill patients)

5. Overlooking non-infectious causes: Not considering non-infectious etiologies such as drug reactions, thromboembolism, or malignancy 2

6. Relying on fever pattern alone: While helpful, fever patterns are rarely pathognomonic and should not be used in isolation for diagnosis

7. Inadequate blood cultures: Not collecting sufficient volume (at least 60 mL total) or not obtaining cultures before starting antibiotics 1