08.09 ID
08.09 Infectious disease [PDF link]: Animal & human bites, Cellulitis, Sepsis, Necrotising fasciitis, Nematode infections (Ancylostoma braziliense, Strongyloides stercoralis, Toxocara canis), Threadworms (Enterobius vermicularis), Lemierre's syndrome, Post-splenectomy sepsis, Pyrexia of unknown origin (fever of unknown origin, PUO, FUO), Spinal epidural abscess, Side effects of antimicrobials
Other notes
Sepsis 6: Blood cultures, urine output, VBG for lactate + antibiotics, IV fluids (bolus if in shock), oxygen if needed
Fever of unknown origin
Defined as
Fever for ≥3 weeks, AND
Fever ≥38.3ºC on at least 3 occasions
No cause identified from minimum set of investigations
Clerking
Age & sex
PC: Fever
HPC:
- ?Measured or just “feeling hot/cold”
- Total duration in days
- Intermittent or all the time? Any pattern (eg diurnal or every other day, etc)
- Any one else in the family unwell?
- Any recent travel?
> Consumption of food ?sources. Any unpasturised milk? Undercooked meat?
- Any associated symptoms? (Do full systems review – see here)
PMH:
- Previous cancers?
- Rheumatic fever?
- Surgical history? – indwelling foreign devices?
- If female – OBGYN history as well
DHx:
- Any recent changes in medication?
FHx:
- Cancers?
- Ethnicity (may be important in conditions like Familial Mediterranean Fever)
SHx:
- Alcohol & smoking
- Illicit drug use – esp IVDU
- Travel history
- Occupational history
- Sexual history
Ix:
- Bloods
- ECG
- CXR
- Other imaging
O/E
(Physical exam)
Imp:
Plan
Investigations for fever of unknown origin
Bloods (generic): FBC, U&Es, LFTs, bone profile, CRP, ESR, ferritin, TSH
Bloods (rheum): rheumatoid factor, ANA, ANCA
Bloods (ID): blood cultures (usually require serial sets), HIV 1/2 serology, Hep B, Hep C,
Other tests: TB PCR
Imaging: CXR as minimum, abdominal US may be helpful, and depending on indication may require CTTAP
Further investigations
This BMJ article has a good summary on suggested investigations for suspected causes
Treatment for fever of unknown origin
Where possible, withhold treatment until cause is identified as treatment may mask cause or derail investigations
There are some situations in which this will not be possible, eg neutropenic sepsis, risk of developing into sepsis, rheumatological conditions where sight is threatened (eg GCA)
