What are the essential components to include when writing a case sheet for a patient with fever?

Essential Components for Writing a Case Sheet for a Fever Patient

A comprehensive case sheet for a fever patient should include detailed history, physical examination findings, diagnostic investigations, and management plan to ensure proper diagnosis and treatment of the underlying cause.

Patient History

• Document the date of onset of fever and its progression over time 1
• Record the pattern of fever (continuous, intermittent, remittent), maximum temperature, and associated symptoms 1
• Note any prodromal symptoms such as malaise, upper respiratory tract symptoms, or flu-like illness 1
• Document all medications taken over the previous 2 months, including over-the-counter and complementary therapies 1
• Record travel history, especially to areas with endemic infectious diseases 1, 2
• Document any history of contact with sick individuals or exposure to infectious agents 1
• Note any previous history of similar episodes or known medical conditions 1

Physical Examination

• Record vital signs including temperature, pulse, respiratory rate, blood pressure, and oxygen saturation 1, 3
• Document the general appearance of the patient and level of consciousness 1
• Perform a systematic examination of all body systems with special attention to:
  • Skin for rashes, petechiae, or signs of infection 1, 4
  • Mucous membranes (oral, ocular, genital) for signs of inflammation or ulceration 1
  • Lymph nodes for enlargement or tenderness 4
  • Respiratory system for signs of pneumonia or respiratory distress 1
  • Cardiovascular system for murmurs or signs of endocarditis 4
  • Abdomen for hepatosplenomegaly or tenderness 4, 2
  • Neurological system for signs of meningitis or encephalitis 4

Laboratory and Diagnostic Investigations

• Complete blood count with differential 1
• C-reactive protein and erythrocyte sedimentation rate 5
• Blood cultures (at least two sets from different sites) 1
• Urine analysis and culture 1
• Liver function tests and renal function tests 1
• Chest X-ray 1
• Specific tests based on clinical suspicion:
  • Malaria smear if travel to endemic area 1, 2
  • Dengue serology if appropriate travel history 1, 2
  • PCR for specific pathogens when indicated 1
  • Procalcitonin level if sepsis is suspected 6, 5

Assessment and Differential Diagnosis

• Document the most likely diagnosis based on history, examination, and initial investigations 7, 4
• List alternative diagnoses in order of probability 7, 2
• Consider common causes of fever based on patient demographics and risk factors 1, 2
• Note if the patient meets criteria for fever of unknown origin (temperature >38.3°C for ≥3 weeks without diagnosis after 1 week of investigation) 7

Management Plan

• Specify antimicrobial therapy if indicated, including drug, dose, route, and duration 1
• Document supportive measures such as hydration and antipyretics 8
• Note infection control measures if required (isolation, droplet precautions) 1, 3
• Outline monitoring parameters (vital signs, laboratory tests) 3, 6
• Specify criteria for escalation of care or specialist consultation 3
• Document patient education regarding warning signs that require immediate attention 8

Follow-up Plan

• Schedule for reassessment of clinical status 7, 4
• Plan for review of investigation results 1
• Criteria for discontinuation of therapy or discharge from care 8
• Indications for specialist referral if the fever persists 7

Special Considerations

• For elderly patients, note that fever may be defined differently (single oral temperature ≥37.8°C or increase of ≥1.1°C over baseline) 3, 6
• In immunocompromised patients, document the nature and degree of immunosuppression 6, 5
• For patients with cancer, consider both infectious and non-infectious causes of fever 5
• For returned travelers, document specific exposures and incubation periods of potential pathogens 1, 2