An OPD approach to Fever

Welcome back to Med Pods. From the Department of Internal Medicine at AFMC, we bring to you audio podcasts on topics of relevance to undergraduate and postgraduate students. In the 15th of the series of podcasts that we've done till now, today we have a conversation with Major Hari Krishnan, clinical tutor in the Department of Medicine. Clinical tutors are senior residents who have just recently passed out of the MD program that runs in AFMC and the reason they are part of the faculty in the department is because they have come out with flying colors and so has Major Hari Krishnan. He has been the man behind the podcast that you've heard till now and today we have him on the other side of the mic. Welcome Hari. We've had a lot of requests from our students to discuss topics which are common in clinical practice where they have to encounter patients and actually deal with them and the way we teach medicine otherwise in our academics, we often miss out on common things which is very common in our practice and these are the kind of patients we see day in and day out and one of the commonest symptoms that we see in patients is fever and to be a good physician you need to know how to approach fever and I thought the best person to do that would be Major Hari, someone who's done well for himself during his training for post graduation and is now teaching the young students and being not just a teacher or a mentor and he's also a great role model for them. So welcome Hari and let's have this conversation on approach to fever for our undergraduate and post graduate students. I'm truly humbled for that kind introduction sir and thank you for this opportunity and greetings to all the listeners of MedPod FMC and unprecedented initiative. This podcast series is sure to benefit a lot of doctors for which I thank again R. H. O. D. Brigida J. Muthukrishnan. So then for all the E3 batches who have started this great venture of being independent doctors now an idea of F3 batches who must be enjoying the early days of their clinical practice as interns. I believe this session will benefit you mostly in your OPDs and emergency duties. In this podcast, let us always keep the image of that OPD or emergency room where you're attending to a patient of fever and let's not learn any definition here. Let's not learn any table or charts. Let's just talk about fever, one of the common sign and symptoms that you encounter on a day to day basis. The patient came to you with an acute fever can be broadly classified into one of the following categories. Here she can be a case of an acute undifferentiated febrile illness which is an acute onset fever with temperature more than 101 degree Fahrenheit for lasting more than two days and the entire disease course lasting maybe up to 14 days. The catch here is there should not be any organ or system specific science at onset of illness. The common diseases which are associated with this AUFI is malaria, dengue, n-trick fever, chicken gunia, leptospirosis, scrap typhus, etc. The second category of acute fever would be an acute febrile illness due to localized infection with system specific science. You all know these cases when you can probably classify them as respiratory tract infection, patients of urinary tract infections, intraabdominal infections, skin and soft tissue infections. Then you have the third category which is beyond purview of this class, which is something known as fever of unknown origin. So generally means you have worked up patients on an OPD or IPD basis for some, all those obligatory tests have been done and still you are not able to make the diagnosis then you categorize the patient as fever of unknown origin. This we will discuss in maybe one of the future podcast. So what is fever? You to know understand fever is just an elevation of a body temperature above the normal circadian ranges and this results from a change in the thermoregulatory center which is located in our hypothalamus. You should know this. There are specific objective definitions which we will not touch now. So this acute fever or that patient sitting in front of you can have that fever because of a myriad causes. The diverse etiologies often overlap and present a challenge to you and all of us on a day-to-day basis. So knowing the fever and the way to approach fever in a systematic way is extremely important lest you miss out on very crucial things that might have helped you in making the diagnosis and that is exactly what we are going to attempt here, a systematic approach to fever. So the first thing is a thorough history. Anyone can ever replace a thorough history when it comes to fever or for that matter any disease in medicine, history can never be replaced by any of those investigations that have come. So a careful history which includes thorough chronology of the symptoms wherein a detailed complaint of the patient with symptoms which have to be arranged in a chronological way helps you. In this you ask the patient about the pattern of the fever, the timing of the fever, the associated complaints with fever and coming to knowing the patterns of the fever, these patterns of the fever which you must have learned during your medicine classes, theory classes as continuous intermittent and remittent fever had helped the doctors of the years to come to some diagnosis. However, with the inadvertent or unprescribed use of antibiotics, antibiotics, steroids, etc. by the patients before they even present to you, these patterns are not as evident in today's practice as they were in the past. Nevertheless, knowing about them can give you some clues about the possible etiology when combined with a thorough history and examination. So history taking in febrile patients. First is you take history for localizing from where the infection could be arising, what infection the patient could be having and to start with you ask the patient for some common respiratory symptoms like a history of sore throat, nasal discharge, then you can ask patients for headache and pain on the face or the anterior or the forehead or the headache pain which aggravates on bending forward, heaviness in the head etc. suggesting a sinusitis, then you can elicit symptoms or lower tract respiratory tract like productive cough, the patient can have breathlessness, tachypnea, etc. Moving on to symptoms pertaining to the genitourinary system, you can ask specifically about frequency of maturation, you can ask history of dysuria, any loin pain, any peri-euteryl discharge, any vaginal discharge, these things suggest a possible urinary tract infection, pelvic inflammatory disorders and sexually transmitted infections. You can also ask history for intraabdominal infections, ask the patient about the patient has diarrhea, if the patient has diarrhea ask if there is admix blood with the stool, if there is presence of mucus coming with the stool, vomiting and you can ask history of pain abdomen and these abdominal symptoms give you a hint towards a possible intraabdominal cause for the fever which can be commonly gastrointritis, it can be any other intraabdominal sepsis and in a long-standing patient with diarrhea and blood coming in the stool, you think of non-infectious causes like inflammatory bowel disease, you think of a possible GI malignancy. Now you move on to other systems like joint and soft tissue involvement, you ask the patient if the patient has any joint pain, swelling, any limitation of movement and again skin ends up to ask if there are any abscesses in the body, any redness involving the skin with increased temperature, local temperature. You also take a thorough drug history because drug fever is uncommon and therefore can easily be missed, so the culprit drugs being commonly available to over the counter drugs like cephalosporins can cause anti-tubricular drugs are known to cause drug fever and anticonvulsants particularly phenytoin is known to cause a drug fever. This history will help you localize to a particular system whenever you are taking history, apart from these histories you should always ask for any recent surgical procedure or dental procedure that your patient must have undergone, then you can ask history for any occupational possible exposure to animals like brucellosis is known to be associated with exposure to animals like mostly cattle drinking unpasteurized milk exposure to animals, this history can help you in coming to some etiologies. Another important history would be the geographic area of living like for India is having endemic areas for various infections like for example the north is in part of our country is known to have malaria then we have Bihar and the area surrounding Bihar, Jharkhand, Bengal etc. The patient can have kalas are apart from that history of travel helps you then eating from outside food and waterborne infection etc. So these history points in history should always be brought out then other supporting history points like presence of household pets then unprotected sexual practices, IV drug abuse, prior transfusion or immunization history, drug allergy, these are things that should be asked in history of any patient who comes to you with fever. After a thorough history that you've taken now the next step in your management or approach to this patient who is sitting in front of you would be to do a thorough physical examination of this patient. So starting with the general examination part where you start with the temperature first you document the temperature it's not necessary that the patient might be having fever when he is presenting to you but again make it a point to ask the patient if possible to get the temperature recorded at home or maybe next time he has fever come to the hospital get the temperature recorded that helps you document the presence of fever. And then moving on to pulse, in pulse you can look for tachycardia which indicates one of the signs of SARS and also make it a point to look for temperature pulse dissociation also known as relative bradycardia whereby the pulse rate is slower for the expected body temperature which can hint towards certain etiology. Roughly for you to remember for a temperature of 102 degree Fahrenheit pulse should be around 110, 103 it's 120 for a temperature of 104, 130, 105, 140 so on so forth. And any pulse difference which is lesser by 10 beats that means for a patient having temperature of 10 to you if pulse rate is less than 100 then you label the patient to have a relative bradycardia and the point is this is applicable only for an adult patient and the temperature as well as the pulse have to be recorded the same time. Now moving on from pulse you record the BP of the patient you see if the patient has features of sepsis or shock and then from there you move on to respiratory rate look for any features of respiratory distress or increased work of breathing in the form of nasal flare you look for tachypnea and then again this indicates presence of SIRS and also may hint towards possible involvement of the lungs and the pulmonary system. After this general vital examination now you should make it a practice to do a thorough head to toe examination in a patient who comes to you with fever this includes starting from the eyes you look for any jaundice in this you can even find features like a conjunctival pettice which may suggest a sinister disease like meningococcal meningitis jaundice suggesting acute hepatitis then you look for in the mouth you can look for presence of for tonsillar enlargement hyperemia of the tonsillar pillars posterior pharyngeal wall which may indicate an acute pharyngeitis also look for presence of features of bacterial co-infection the form of any pustule in the oral cavity you can also look for presence of candidiasis which can indicate towards a possible immune deficiency in the patient and then you can actually do a more focused investigation in that line may be sent for HIV testing in this patient. Then another important aspect while looking at a patient who has fever is to look at the skin skin helps you immensely an HR to look for an HR you have to see the patient so thoroughly may strip the patient if required if you suspect a possible Rickettsial infection look for an HR in hidden areas like the groin between the toes then the anal cleft and in the groin it HR can be hidden by the pubic hair so make sure you're looking for the HR is very thorough and make a note of the same in your in your case sheet or maybe the OPD book which will help subsequent doctors to make their decisions from here on other than the HR also look for other rash may be an arithmetic rash on the body which easily blanches on pressure gives you a clue that the possibly patient might be having a possible viral infection measles if it is company by features of upper respiratory tract infection conjunctivitis even any common viral infections can be associated with a blanchable erudima a perpuric or a particular rash which do not blanch on pressure can point towards possibilities of vasculitis again patients with many gococcal septicine but these patients will be more sick then your diagnosis will vary based on the general status and other supporting symptoms of this patients also if you find a vesicular rash it may be caused by chickenpox a common infection in our country then looking for enlarged lymph nodes another important aspect of evaluating or approaching a patient of fever lymph nodes can be enlarged in systemic infections any hematolymphoid malignancy chronic infections like HIV, TB etc. so make it point to not miss this part of examination it should have come as a habit that any patient coming to your with fever you do examine that patients for their presence of any lymphadenopathy also have a look at their joints look for any redness or any swelling in the large joints any local rise of temperature you do not want to miss out on and septic arthritis but again in such cases the patient will have specific symptoms which can help you identify these conditions. Now coming to specific systems in the abdomen looks for any tendon as any free fluid and see liver abscess, cholangitis, cholecystitis etc. can be causes of fever and never ever send back your patient without palpating the abdomen as a liver abscess can be easily missed patient can have non-specific symptoms like fever with myalgia with reduced appetite easily tend to think in lines of maybe a possible viral infection also since it's easy to miss if you make this as a habit that you will definitely go and touch the patient's abdomen before you send back your chances of picking a liver abscess increase and you can manage your patient better then in the chest you look for a science of consolidation where you look for a bronchial breath sound you can look for a presence of crackles and absent breath sound can indicate a pleural effusion fresh onset cardiac murmur can be indicating endocarditis or maybe an acute rheumatic fever and after this another part of clinical examination which we almost always miss out and this is the per rectal examination very crucial part of investigation a patient of fever and generally I would suggest you go ahead and do a peractal examination if you were not able to find any localizing sign or symptoms in the patient and then you do a peractal examination to look for a perineal abscess or maybe an acute prostatitis and so these components of examination which on a busy OPD tend to get missed I would recommend you to start bringing this to your practice so that you don't miss out a potential killer once you've done this thorough examination of your patient now the third step in your approach to your patient with fever would be you assess the severity and since you now have the general outlook about this patient look for the red flags this helps you to decide urgency of management and an important decision of inpatient vessels outpatient management of a patient few red flag signs that you should remember is severe prostration of your patient that is the patient is unable to stand sit his severe patient has that sick look and needs support to walk that's severe prostration please admit such patients don't send them back then temperature say hyperpyrexia indicates hyperpyrexia presence of rigour indicates possible again bacterial infection severe bacterial sepsis you should not be sending such patients back respiration in any patient who is testing who stack ethnic more than respiratory rate of 22 per minute has sinosis has a dip in saturation SPO2 less than 92% in rumour and then you have systolic BP less than 100 the extremities are cold with increase capillary free time in neurological examination you find that the patient has an altered mental status history of convulsions you find positive meningal signs then in abdomen the patient has persistent vomiting a severe abdominal pain which is disproportionate to your clinical finding then any rash any purpura etc please admit such patients now that you have taken a detailed history and have thoroughly examined your patient based on the clinical clues that you got from it time for you to write some investigations for your patient for the preliminary investigations you should be focusing on include a complete blood count in CBC you should look at individual parameters which can give certain clues like for example anemia can be seen in complicated malaria increasing hematocrit can be seen in severe dengue leukocytosis indicate bacterial infection and should be augmented using a peripheral blood smear examination in PBS supposed to look for a presence of toxic granules toxic vacuoles left shift band forms all indicating features of sepsis next is leukopenia which can be seen in early phases of dengue and also other viral infections lymphocytosis is seen in viral infections and may be seen in rickettsial infections also eosinophilia can indicate parasitic infection like pylaryasis coming to platelets thrombocytopenia may be seen in many acute undifferentiated febrile illnesses with very little discriminatory value but with other clinical features it may point to a specific etiologist like for example thrombocytopenia with splenomegaly can be seen in patients of malaria thrombocytopenia with bleeding manifestation can be seen in patients of dengue and other viral hemorrhage fevers next is urine examination which can provide valuable information other than UTI it can also help in diagnosing malaria where patient can have hemoglobinuria, leptospirosis where patient can have proteinuria, hematuria etc. sexually active lady coming to you with urinary tract symptoms you may omit to send urine examination unless the patient is pregnant another important aspect is UTI in elderly where you won't find the classical symptoms therefore an elderly patient presenting to you with fever with no evident localization or has severe disease you should always send urine routine and culture biochemistry which include liver function test renal function test should only be performed in severely ill patient or patients with possible organ involvement hepatorenal involvement is common with tropical infections left scrub and leptospirosis a history of pre-ictric fever with elevated liver enzymes could indicate a viral hepatitis a common disease in our country coming to imaging performing a chest X-ray in all severe patients or patients having tachypnea, tisnea, cough or other features of pluripalmin to involvement should be thought in chest X-ray look for non-homogeneous opacities plural effusion and medecine lymphadenopathy an ultrasound of the abdomen is to be ordered for a patient who has jaundice abdominal pain or maybe a patient who has present to you in shock here you look for hepatic abscess, plenic abscesses, cholecystitis, features of pancreatitis you can look for lymphadenopathy features of cholangitis, acitis, presence of pleural effusion etc. It's important to remember that biochemical and radiological investigation should not be a norm in your assessment of patient with fever and should only be case based. An additional point pertaining to a patient who gave you history of high risk behavior IV drug abuse, commercial sex workers, unsafe tattooing, generalized lymphadenopathy on examination go ahead and ask for an HIV test in such patients. After all this it's time to treat the patient and when you have a patient of fever your treatment should mainly focus on supportive measures and treating the underlying cause and supportive treatment should focus on relieving the patient of the distressing symptoms. For this you should prescribe tepid sponging antipyretics and speaking of antipyretics ideally you should be prescribing it on an SOS basis because if patient is on specific treatment like for example antibiotic for a bacterial infection. It is important that you give SOS basis antipyretics because the presence of fever, the frequency of fever that the patient has everything helps us in knowing if the patient is responding to a treatment or not. And again if you suspect a bacterial infection in a patient before you start antibiotics should always send cultures of appropriate samples before you start antibiotics empirically and then maybe change over to culture specific antibiotics once you get the culture reports. The antibiotics may have to be stopped or maybe change subsequently if no bacterial infection could be proved and the patient has improved and patient or it has to be changed to a better antibiotic with better coverage if the patient has shown no improvement with the empirical drugs that you have given. Having said that it is important to remember that antibiotics should never be a norm and treating a patient with fever. By now you have done your job the possible outcomes in your patient can be either your patient have recovered spontaneously which might suggest a possible etiology of viral illness that your patient might have had then you might have actually found the diagnosis of the patient and started the patient on definitive management. And third possibility is that the patient has not improved and the fever and the disease persists is then and if the disease has lasted for more than three weeks now you can label your patient as a case of piracy of unknown origin or fever of unknown origin and feel free to refer the patient to higher centers if you haven't already referred the patient for a severe disease or the patient had specific diagnosis for which you needed an expert advice. This part is for the undergraduates and medical officers for the medicine residents. This is where our job should start unless you have already treated the patient or started the treatment for maybe a severe disease. Before I close this session I would like to give a few do's and do's or maybe take away a point from this session one is that antibiotics should never be prescribed during strong suspicion of viral fever and it is important to draw two sets of blood cultures before the start of empiric antibiotic therapy. Start antibiotics for a presumed bacterial infection promptly but adjust the dosage and duration switch or end antibiotic therapy when result do not support or justify the need to continue. Check the situation within 48 hours based on test results and patient status. Supportive therapy with paracetamol is advisable along with rapid sponging and adequate hydration of the patient. If orally tolerating ask the patient to drink plenty of oral fluids and if not consider giving intravenous or parenteral fluid high fluids to the patient. It is very important to avoid indiscriminate use of antibiotic agents, non-stored, anti-interpremented drugs or maybe seen in practice patients are also exposed to steroids when no diagnosis is reached. So these are the things that you should keep in your mind when you are approaching a patient of fever. And I would like to conclude the session by once again thanking Brigade J. Muthukishan for this opportunity and from all the listeners I am looking forward for your valuable feedbacks and will be extremely happy to hear back from you all. Thank you. Thank you Hari. I think that was a very simplified and extremely practical approach to fever that you have discussed today and I am sure the students will benefit a great deal and more than the students who are right now in college I feel it is those students who have recently passed out and are now working as interns or medical officers in various hospitals who will benefit a great deal because I am sure while they are doing their duties in the hospital they are frequently seeing such patients who are coming to them with fever and to approach this very common problem properly can ensure that we can deliver at the very effective healthcare that is required in practice and often diagnose conditions which we if we delay may be detrimental to our patients. So thank you very much for sparing your time and I am glad that we have started this new concept of bringing young teachers and role models into our podcast. Thank you.