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Chapter 15 • Fatigue 191
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PMI. An S3 and S4 can be heard on cardiac ausculta-
tion. Chest radiographs will disclose basilar consoli-
dation and increased heart size. An echocardiogram
shows a reduced ejection fraction.
Cancer
Lymphoma and leukemia may rst be detected by un-
explained fatigue that increases with activity and wors-
ens over time. A CBC with differential will show blood
dyscrasias. Gastrointestinal cancer may produce occult
blood loss that leads to anemia and fatigue.
Mononucleosis
Mononucleosis is often a disease of young adults that is
caused by Epstein-Barr virus in 90% of cases. History
discloses a gradual onset of low-grade fever, mild sore
throat, posterior cervical lymphadenopathy, and fatigue
and malaise. Splenomegaly occurs in 50% of cases, and
palatine petechiae are a less common sign. Diagnosis can
be conrmed with a positive Monospot test and a CBC
that shows greater than 50% lymphocytosis. Ten percent
of patients may also have concurrent ß-hemolytic strep-
tococcal pharyngitis.
Hepatitis
Generally associated with hepatitis B or C, patients
will report a history of malaise, fatigue, ulike symp-
toms, arthralgia, and an aversion to smoking. A health
history will reveal risky sexual behavior, exposure to
body secretions through blood transfusion or injectable
drug use, or exposure to contaminated food or water.
Physical ndings may include jaundice, fever, and an
enlarged and tender liver. Hepatitis serology for hepatitis A, B, and C will determine the causative agent.
Fibromyalgia
This condition occurs most often in women 20 to
50 years old. It is associated with chronic pain and
stiffness of the trunk and extremities, especially the
neck, shoulders, low back, and hips. Patients will report fatigue, headaches, sleep disturbance, and irritable bowel symptoms. To diagnose bromyalgia, 11 of
18 bilateral tender points must be conrmed by
physical examination.
Chronic Fatigue Syndrome
There is no single pathological mechanism to explain this condition that appears as an infectious or
autoimmune disorder that has neurological, affective, and cognitive symptoms. Chronic fatigue syndrome is severe fatigue lasting longer than 6 months
in association with (1) impaired memory or concentration, (2) sore throat, (3) tender cervical or axillary
lymph nodes, (4) muscle pain, (5) multiple joint
pain, (6) new-onset headaches, (7) nonrestorative
sleep, and (8) postexertional malaise.
DIFFERENTIAL DIAGNOSIS OF Common Causes of Fatigue
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Physiological Causes
Poor sleep and rest Adolescent and younger adult; history
Poor nutritional
status
Psychological Causes
Depression:
children
Depression: adults Loss of interest in usual activities
Anxiety Numerous somatic complaints,
of overwork, psychological stress,
disturbed sleep
Depression, decreased appetite, lack
of balanced nutrient intake, excessive
alcohol intake
Feeling sad, angry, irritable
Decrease in academic performance
Somatic complaints
Feelings of worthlessness
Sleep problems
breathlessness
Normal examination None
BMI reflecting
underweight or
overweight
None DSM-PC, DSM-IV
Depressed affect;
normal examination
Tachycardia,
palpitations,
diaphoresis
Hematocrit increased or
decreased, low serum
ferritin
Depression screening
instrument
None
Continued
192 Chapter 15 • Fatigue
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Fatigue—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Organic Causes: Acute Fatigue
Infection Sudden onset; history of exposure;
recent viral illness
Drugs and alcohol History of smoking, alcohol use;
antihistamines, analgesics,
antihypertensive medications
Anemia Breathlessness with exertion;
menstruating female; recent surgery,
delivery
Hypothyroidism
(myxedema)
Hyperthyroidism
(Graves disease)
Organic Causes: Chronic Fatigue
Sleep apnea Male, middle-age or older; partner
Medications History of allergies treated with
Heart failure Dyspnea, weight gain, fatigue, cough Anxiety, jugular
Cancer Fatigue, unexplained weight loss Observe, palpate, and
Mononucleosis
(Epstein-Barr
virus)
Hepatitis Jaundice, anorexia, fatigue; fever may
Fibromyalgia Female 20 to 50 yr; history of
Chronic fatigue
syndrome
ABGs, arterial blood gases; BMI, body mass index; CBC, complete blood count; DTR, deep tendon reflex; ECG, echocardiogram; PMI, point of
maximal impulse; T3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating hormone.
Poor appetite, fatigue, weight gain, cold
intolerance
Hyperactivity, heat intolerance, sleep
problems
reports periods of no breathing during
sleep, fatigue
antihistamines; medications for hypertension, heart disease, chronic pain
Young adult; slow onset of malaise,
low-grade fever, mild sore throat
be reported
depression, sleep disturbance, chronic
fatigue, general muscle and joint aches
Fatigue lasting longer than 6 mo;
sudden onset of flulike symptoms that
persist or recur
Fever; lymphadenopa-
thy, localized signs
of erythema, edema
Bilaterally enhanced
or depressed DTRs;
pupillary changes;
reduced attention
span, judgment
Increased pulse
rate; pale mucosa;
smooth red tongue
Decreased pulse rate;
dry skin, coarse dry
hair; thyroid possibly
enlarged, hoarseness
Lid lag, fine thinning
hair, tachycardia
Hypertension,
obesity, narrowed
upper airway
Nasal congestion,
cough, injected
conjunctiva
venous distention,
displaced PMI, rales
percuss all systems
for lumps, lesions,
or consolidation;
physical examination
may be normal
Palatine petechiae,
posterior cervical
lymphadenopathy,
splenomegaly
Jaundice, weight loss,
arthralgia, skin rash
Palpation of trigger
points will produce
pain; normal physical examination
Physical examina-
tion may be normal;
cervical and axillary
lymphadenopathy
CBC, ESR, Monospot
CAGE alcohol screening
CBC with indices,
serum iron, ferritin,
transferrin
T4 low, T3 low, TSH
elevated
T4 increased, T3
increased, TSH
depressed
Sleep studies
Evaluate medication
choices
ECG, chest radiograph,
ABGs
CBC to rule out anemia;
leukocyte count
Positive Monospot;
CBC with differential;
.50% leukocytes
Bilirubin increased;
hepatitis panel
None
CBC, ESR
Chapter 15 • Fatigue 193
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REFERENCES AND READINGS
American Diabetes Association (ADA): Clinical practice recom-
mendations, Diabetes Care 31:S1, 2008.
Cavanaugh R: Evaluating adolescents with fatigue: ever get tired of
it? Pediatr Rev 23:337, 2002.
Centers for Disease Control and Prevention: Chronic fatigue
syndrome, http://www.cdc.gov/cfs/general/symptoms/index.html.
Accessed October 7, 2010.
Craig T, Kakumanu S: Chronic fatigue syndrome: evaluation and
treatment, Am Fam Physician 65:1083, 2002.
Morrison RE: Fatigue in primary care, Obstet Gynecol Clin North
Am 28:225, 2001.
Pinching A: Chronic fatigue syndrome: believing in ME, Nurse
Prescribing 7:358, 2009.
Rodriguez T: The challenge of evaluating fatigue, J Am Acad Nurs
Pract 12:329, 2000.
Rosenthal TC, Majeroni BA, Pretorius R, Malik K: Fatigue: an
overview, Am Fam Physician 78:1173, 2008.
Sheperd C: The debate: myalgic encephalomyelitis and chronic
fatigue syndrome, Br J Nurs 15:662, 2006.
Solomon L, Reeves WC: Factors inuencing the diagnosis of
chronic fatigue syndrome, Arch Intern Med 164:2241, 2004.
U.S. Department of Agriculture: The dietary guidelines for Americans
2010, Washington, DC, 2010. Available online at www.cnpp.usda.
gov/dietaryguidelines.htm. Accessed January 17, 2011.
C H A P T E R
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16
Fever
ever is an elevation of temperature above the
normal daily variation and is a symptom of
F
an underlying process. The major common
cause of fever is infection; however, noninfectious
processes may present with fever. Fever of unknown
origin (FUO) occurs in a small percentage of cases.
These fevers are usually caused by an infection that
has not yet been identied. A meticulous history
and physical examination supported by laboratory
investigation are necessary to nd the origin of the
fever.
There are three types of fevers, each caused by a
specic pathophysiological process. The rst involves
the raising of the hypothalamic set point. The receptors
in the area of the hypothalamus regulating body temperature are triggered to reset at a higher core body
temperature. This results in an elevation of the helper
T-cell production and an elevation in the effectiveness
of interferon. Infection, collagen disease, vascular disease, and malignancy are commonly responsible for
these fevers.
A second type of fever is a result of heat production
exceeding heat loss. Here the set point is normal, and
heat loss mechanisms are active. Fever occurs either
because the body raises its metabolic heat production
or because the environmental heat load exceeds normal
heat loss mechanisms. Aspirin overdose, malignant
hyperthermia, hyperthyroidism, or hypernatremia may
cause this type of fever.
A third type of fever is caused by a defective heat loss
mechanism that cannot cope with normal heat load. Heat
stroke, poisoning with anticholinergic drugs, ectodermal
dysplasia, and burns are causes of this kind of fever.
For the rst type of fever, antipyretics are given to
lower the hypothalamic set point. Antipyretics are ineffective for the second and third types of fever.
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Is this really a fever?
Key Questions
n How do you know you have a fever?
n Have you taken your temperature?
n How did you measure it?
Occurrence of Fever
Fever is a common presenting problem and a cardinal manifestation of disease. Patients often report
a subjective fever (i.e., clinical symptoms, such as
ushing, chills, shaking chills, headache, malaise, or
muscle aches) that is assumed by the patient to be a
fever although not validated with a thermometer.
Nevertheless, the absence of fever in a single patient
visit does not eliminate a febrile illness.
Measurement of Temperature
Many people use touch to determine whether a fever
is present. Although not a precise indication, touch
can signal a high fever. During the early stages of
fever, perfusion to the skin is decreased and skin
temperature falls. In later stages, when temperature
within the muscles has risen signicantly, increased
body temperature is reected by increased skin temperature. In children, hands and feet should not be
used to gauge a fever because they may be vasoconstricted and feel cold. Accurate temperature should
be measured using a thermometer. Because of the
diurnal variation in normal body temperature and the
effect of physiological factors and body rhythms,
frequent recordings throughout the day are needed to
monitor fever.
194
Chapter 16 • Fever 195
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Should sepsis or meningitis be of concern?
Key Questions
n Have you had any recent head trauma?
n Do you have recurrent ear infections?
n Have you had contact with anyone who has
been ill?
n Have you had a headache, lethargy, confusion, or a
stiff neck?
n If an infant: How old is the baby?
Head Trauma, Otitis Media, and Contact
Recent head trauma, especially at the base of the
skull, may provide an entrance for infectious organ-
isms. Children with recurrent or chronic otitis media
may have mastoiditis spreading to the meninges.
Contact with anyone with meningococcal disease
and/or Haemophilus inuenzae places the individual
at risk for contracting the disease.
Headache, Vomiting, Lethargy, or Stiff Neck
Meningitis is characterized by headache, fever, leth-
argy, confusion, vomiting, and stiff neck. However, the
presentation is highly variable. Any patient with even
minimal neurological signs and symptoms should be
evaluated for meningitis.
Infant
Fever in children less than 2 months of age is
uncommon but must be viewed as serious. Generally
neonates and young infants are less able to mount a
febrile response; when they do, it is a signicant nd-
ing. Fever can be viral or bacterial in nature. Fevers
in the neonate may also be an indication of an under-
lying anatomical defect. Urinary tract infection and
bacteremia are often the rst indications of a struc-
tural abnormality of the urinary tract. Also, infants
with galactosemia may present in the rst weeks to
1 month of life with gram-negative sepsis. Occasion-
ally, infants present with sepsis associated with deliv-
ery (prolonged rupture of membranes); acquired from
instrumentation used during delivery, such as scalp
electrodes; or from a procedure performed in a neona-
tal intensive care unit.
All infants younger than 2 months with fever are
considered to have sepsis or meningitis until proven
otherwise.
What does the pattern of fever tell me?
Key Questions
n How long have you had the fever?
n What has been the highest temperature reading?
When did this occur?
Duration of Fever
In adults, fevers from an acute process usually resolve in
1 to 2 weeks. Fevers that last 3 weeks or longer, that
exceed temperatures of 38.4° C (101.1° F), and that
remain undiagnosed after 1 week of intensive diagnostic
study are classied as FUOs.
Fevers in children can be grouped into three categories: short-term fever, fever without localizing signs,
and fever of unknown origin. Short-term fever is
dened as a fever of short duration, readily diagnosed,
that resolves within 1 week. Fever without localizing
signs is a fever with no localizing sign and of brief
duration (usually ,10 days) that is not explained by
ndings on history or physical examination. FUO is a
fever usually greater than 38.5° C (101.2° F) that lasts
longer than 2 weeks on more than four occasions.
Height of Fever
Dehydration and febrile seizures are related to the
height of the fever. Generally, body temperatures
greater than 41.1° C (106° F) are seen in heat illness,
central nervous system disease, or either of these in
combination with infection. The higher the fever, the
greater is the likelihood of bacteremia.
Is the fever caused by a localized infection?
Key Questions
n Do you have frequency, burning, or urgency with
urination?
n Are you having unusual vaginal/penile discharge?
n Do you have face or sinus pain?
n Do you have nasal discharge? If so, what color is
the discharge?
n Do you have a cough? Is it productive? What color
is the sputum?
n Do you have ear pain?
n Is your throat sore?
n Do you have any sores (aphthous ulcers) in your
mouth?
196 Chapter 16 • Fever
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n Are you having any nausea/vomiting or diarrhea?
n Do any of your joints hurt?
Location of Symptoms
Localizing symptoms will point to the site of the
infection. These diagnostic clues include headache
or sinus pain, purulent nasal discharge, ear pain,
toothache, sore throat, breast tenderness, chest pain,
cough, dyspnea, abdominal pain, ank pain, dysuria,
vaginal discharge, pelvic pain, rectal pain, testicle
pain, calf pain, neck stiffness, joint stiffness, pain or
heat, or focal neurological decits (see appropriate
chapters).
Genitourinary Tract
Upper urinary tract infection (UTI) in adults commonly produces systemic symptoms with ank pain
and fever (see Chapters 17, 31, and 32). Fever with
cystitis is uncommon in adults, but children with
UTIs present with systemic rather than localized
signs and symptoms. UTI is the most common infection in girls younger than 2 years who present with a
high fever and in all infants younger than 90 days
with fever. Pelvic inammatory disease in women
may cause fever as well as an increased amount of
vaginal discharge and bleeding after intercourse.
Men who have an acute UTI often present with
chills, high fever, urinary frequency and urgency,
perineal pain, and low back pain. They may also
have penile discharge.
Joint Pain
Joint pain may indicate connective tissue disorders in
adults and in children more than 6 years of age (see
Chapter 20). Osteomyelitis or septic arthritis may also
produce fever.
Can I narrow the diagnostic possibilities
or eliminate a cause?
Key Questions
n Have you noticed a rash?
n Do you ache all over?
Skin Rash
The prodromal period of a rash is an important
historical clue to diagnosis (see Chapter 25). Fever
and rash usually appear together 1-5 days after infection. Common eruption periods are as follows:
n Varicella, rubella, erythema infectiosum—1 day
n Scarlet fever—2 days
n Rocky Mountain spotted fever—3 days
n Measles—4 days
n Roseola infantum—5 days
Ache
Fevers localized to a site without general body
manifestations are often bacterial in nature. Fevers
accompanied by muscle aches (myalgias), malaise,
and/or respiratory symptoms are often viral in
nature.
Ear, Nose, and Throat Symptoms
Viral infections of the upper respiratory tract are common and usually produce fever (see Chapters 14, 22,
and 29). Otitis media is common in children. Fever
may accompany both viral and bacterial pharyngitis.
Pharyngitis is frequently manifested only by fever,
with the infection localizing 1 or 2 days later. Acute
sinusitis can produce a fever. Aphthous ulcers with
pharyngitis and cervical lymphadenopathy are seen in
children with periodic fevers.
Respiratory or Gastrointestinal Symptoms
Most febrile illnesses are caused by viral upper respiratory infection (URI), lower respiratory infection (LRI)
(see Chapters 10 and 13), or gastrointestinal (GI) tract
infection (see Chapter 2). Localized symptoms can
help pinpoint the cause of the fever. Vomiting occasionally signals pneumonia.
Does the patient have an increased risk
for complications?
Key Questions
n Do you have any chronic health problems?
n Have you had recent surgery?
n Have you been diagnosed with an infectious disease
recently?
n Are you sexually active? If so, how many partners
do you have?
n Are your immunizations up to date?
n Does anyone in the family have tuberculosis (TB)
or hepatitis?
Chronic Disease
Chronic conditions and systemic disorders (such as
diabetes mellitus, human immunodeciency virus
[HIV], malignancies, neutropenia, and sickle cell
anemia) compromise host resistance and increase
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susceptibility to infection. Prosthetic devices, such
as heart valves or joint prostheses, also increase susceptibility to infection.
Health Problems, Surgery, and Recent
Infection
Current health problems, recurrent infection, or incomplete treatment of infection may be the cause of
fever. Such risk factors as diabetes mellitus, neutropenia, and sickle cell anemia heighten the likelihood
of bacterial infection. Patients with a past history of
infection (such as URI or streptococcal pharyngitis)
may be prone to relapse or recurrence. Recent surgical procedures can provide a locus for occult infection; however, a surgical procedure can also induce
an inammatory response, which causes a fever
without infection.
Sexual Activity
High-risk sexual activity may raise the index of suspicion for HIV infection and additionally for pelvic
inammatory disease (PID) in women.
Chapter 16 • Fever 197
Could the fever be caused by something
acquired while traveling?
Key Questions
n Have you been out of the country recently?
n Have you spent time in the woods or been camping
recently?
Travel
Patients can be exposed to an emerging infectious disease based on their travel activities. A history of travel
out of the country presents the possibility of infection
with amebiasis, malaria, schistosomiasis, typhoid fever,
or hepatitis A and B. Dengue is the most common
vector-borne disease worldwide and is a differential
diagnosis for acute febrile illnesses in patients who live
or have recently traveled to the tropics or subtropical
areas of the United States. Epidemiological surveillance
data continually provide updates on patterns of occurrence of infections such as severe acute respiratory
syndrome (SARS), avian inuenza or “bird u,” and
West Nile virus (see Box 16-1).
Immunizations
Children and adults who have not been properly immunized are at greater risk for infectious diseases.
Tuberculosis or Hepatitis Exposure
Exposure to populations with a high incidence of TB or
viral hepatitis increases the risk of infection. Inquire
further about constitutional symptoms, such as cough
or night sweats (TB) or malaise and abdominal discomfort (hepatitis).
Does the parent report a behavior change
in the child?
Key Questions
n Is the child sleepier than normal?
n Is the child more irritable?
n How is the child’s behavior?
In infants and children, behavior changes may be
the only indication that the child is ill. Mildly ill infants
may act alert, be active, smile, and feed well. Moderately ill infants may be fussy or irritable but continue
to feed, be consolable, and may smile. Severely ill infants appear listless, cannot be consoled, and feed
poorly or not at all.
Camping
Camping or exposure to wooded areas may indicate
exposure to ticks, Q fever, tularemia, Rocky Mountain
spotted fever, Giardia, or Lyme disease.
Could the fever be medication-related
or caused by poisoning?
Key Questions
n What medications have you taken recently?
n Can you tell me what foods you have eaten in the
past 3 days?
n Could the child have eaten a poisonous plant?
Medications
Medications may hide an occult infection. Many drugs
(e.g., penicillin, atropine, sulfonamides, streptomycin,
and diphenylhydantoin) can induce fever in predisposed individuals. The fever starts about 7 days after
the drug is taken for the rst time or soon after the rst
dose in a patient previously sensitized. Any patient
who is taking immunosuppressive agents is at a higher
risk for infection. Some medications interfere with
thirst recognition (e.g., sedatives, haloperidol) or
sweating (e.g., anticholinergics, phenothiazines).
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Box 16-1
Emerging Infectious Diseases
Associated with Fever
Avian Influenza (“Bird Flu”)
A highly pathogenic strain of avian influenza A virus,
H5N1, infects birds and mutates rapidly to acquire
genes from viruses infecting other animal species. “Bird
flu” is transmitted to humans usually through the slaughtering and processing of infected birds. Symptoms of
infection can range from flulike symptoms (e.g., fever,
cough, sore throat, muscle aches) to pneumonia and severe respiratory distress. Outbreaks that began in Asia
in 2003 have spread to parts of Europe. Suspect infection in persons showing flulike symptoms, such as high
fever and cough, who have confirmed contact with birds
in an area where confirmed outbreaks have occurred.
Clinical deterioration is rapid over 4 to 13 days. Laboratory findings include leukopenia, thrombocytopenia, and
elevated levels of aminotransferases. Although avian
influenza is a rare disease, more than half of reported
cases have been fatal and there is great potential for this
virus to evolve into a world pandemic.
SARS (Severe Acute Respiratory Syndrome)
SARS is a febrile severe lower respiratory tract illness
that is caused by infection with SARS-associated coronavirus (SARS-CoV). From 2002 through 2003, the
World Health Organization received reports of more than
8000 cases and nearly 800 deaths. No specific laboratory test distinguishes SARS-CoV from other febrile
respiratory illness. Lymphopenia and elevated levels of
hepatic transaminases, creatinine, and C-reactive protein have been seen in some patients. Diagnosis is
based on clinical features (e.g., fever, difficulty breathing, pneumonia) and epidemiologic history of exposure
either to a SARS patient or to a setting in which the
SARS-CoV transmission is occurring.
West Nile Virus (WNV)
WNV is a potentially serious illness most often caused
by the bite of an infected mosquito. It occurs most often
in summer and fall in North America. Symptoms develop
3 to 14 days after being bitten. Approximately 80% of
people who are infected with WNV will not show symptoms; however, up to 20% have symptoms called West
Nile fever, characterized by fever, headache, fatigue,
truncal rash, lymphadenopathy, and eye pain lasting
from days to several weeks. People more than 50 years
of age are more likely to develop serious symptoms.
A positive IgM antibody test of serum or cerebral spinal fluid is needed to confirm the disease. The test is
positive in most patients within 8 days of onset of
symptoms.
NOTE: The most current information on these diseases can be found
online at the Centers for Disease Control and Prevention, http://cdc.
gov, and The World Health Organization, http://who.int.
Aspirin overdose can also cause fever. Earliest signs
are vertigo and tinnitus, but fever can occur shortly
thereafter and may be the only symptom that patients
recognize.
Food Poisoning
Food poisoning fevers may occur up to 72 hours after
ingestion of contaminated food.
Plants
Plants containing alkaloid atropine (deadly nightshade,
jessamine, and thornapple) cause dilated pupils, ushed
skin, and fever because they interfere with the normal
heat loss mechanism.
Could exposure to animals explain the fever?
Key Questions
n Has a cat scratched you recently?
n Have you been around any animals?
Cat-Scratch Disease
Cat-scratch disease, or toxoplasmosis, is a bacterial
infection transmitted by cats. The etiological agent is a
gram-negative bacillus. Single-node or regional adenopathy is the dominant clinical feature. A low-grade
fever is also present.
Animal Exposure
Also possible are brucellosis and leptospirosis from
dogs; tularemia from rabbits; ornithosis, histoplasmosis, or psittacosis from birds; and lymphocytic choriomeningitis from hamsters or cats. Exposure to infected
animals can produce infection and fever in humans.
Occupational exposure to pathogens, such as brucellosis, should be investigated in patients who work with
animals or animal products.
Could this be the result of a recent
immunization?
Key Question
n What immunizations have you had recently?
Immunization Reactions
Adverse effects of immunization are rare but do occur.
History of recent immunization followed by 4 hours of
high temperature (39.5° C, 103° F) may indicate such
an adverse reaction. Measles/mumps/rubella (MMR)
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immunization may cause elevation of temperature 10
to 14 days after the inoculation.
Could the fever be caused by heat exposure?
Key Questions
n Were you overdressed? If an infant: Is the infant
overbundled?
n Do you have air conditioning or windows that open?
n How warm is (are) the room(s) in which you live/sleep?
Overdressing
Classic heatstroke occurs when the person is unable to
dissipate the environmental heat burden. Mothers may
inadvertently overdress children or cover them in blankets; the elderly may not be able to get out of bed when
hot. Obese persons have extra adipose tissue that insulates
the body, preventing loss of heat. Some cultures treat illnesses with bundling, which can cause high fevers.
Air Conditioning and Room Temperature
During heat waves, persons may become overheated in
homes without air conditioning or with windows that will
not open or are not opened because of safety concerns.
The high ambient temperatures in those homes produce
elevations in core body temperature that cannot be compensated for, leading to hyperthermia. The elderly and
persons with impaired mobility are most at risk.
Box 16-2
Common Causes of Fever
in Children
Acute Fever
• Upper respiratory tract disorders
• Viral respiratory tract diseases
• Otitis media
• Sinusitis
• Lower respiratory tract disorders
• Bronchiolitis
• Pneumonia
• Gastrointestinal disorders
• Bacterial gastroenteritis
• Viral gastroenteritis
• Musculoskeletal infections
• Septic arthritis
• Osteomyelitis
• Cellulitis
• Urinary tract infections
• Bacteremia
• Meningitis
Fever of Unknown Origin
• Infectious diseases (localized and systemic)
• Collagen/inflammatory diseases
• Neoplastic diseases
• Miscellaneous disorders
• Drug fever
• Factitious fever
• Kawasaki disease
• Inflammatory bowel disease
• Immunodeficiency
• Central nervous system dysfunction
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Most fevers have an obvious cause, so look initially for
localizing symptoms or clusters of symptoms that
point to the cause. Remember that in both children and
adults, bacterial and viral URIs, LRIs, and GI tract infections are the most common causes of fevers. Look
for and rule out the common causes before investigating more unlikely causes. Boxes 16-2 and 16-3 list the
common causes of fever in children and adults.
Fever in a Child Less Than 2 Months Old
The younger the child, the greater is the cause for concern in the presence of fever. Neonates and young infants are less able to mount a febrile response and
therefore are more vulnerable to meningitis and other
hematogenous complications. The infrequency of high
fever in this age-group relates to innate differences in
the ability to mount a febrile response. The data suggest that fever in the rst 2 to 3 months of life is rela-
tively uncommon but that when it does occur, it is
usually signicant and often ominous.
Observe the Patient
General appearance is a most important aspect of
physical examination. Note how the patient looks—
does he or she appear acutely ill, look dehydrated,
seem lethargic, respond appropriately?
Responsiveness in children older than 2 months of
age has been used by pediatricians to identify febrile
children with serious illness. The Yale Observation
Scale for severity of illness in children is commonly
used to quantify observations (Table 16-1). The scale
has six general areas related to the child’s appearance
and behavior. Two thirds of children with acute illness
have scores of less than 10 and, of these, only 3% were
found to have serious illness. Scores greater than 10
predicted serious illness, and a score of 16 was associated with serious illness 92% of the time.
200 Chapter 16 • Fever
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Box 16-3
Common Causes of Fever
in Adults
Acute Fever
• Upper respiratory tract infections
• Tonsillitis
• Sinusitis
• Pneumonia
• Gastrointestinal disorders
• Bacterial gastroenteritis
• Viral gastroenteritis
• Acute abdomen
• Urinary tract infection
• Pelvic inflammatory disease
• Prostatitis
• Drug reactions
• Alcohol withdrawal
Fever of Unknown Origin
• Infectious disease
• Neoplasm
• Collagen/vascular; other multisystem disease
• Drug fever
• Factitious fever
Take Vital Signs and Note Temperature
The incidence of bacteremia, as well as specic infections, increases with the magnitude of fever. A temperature greater than 40° C (104° F) seems to be the
marker for occult bacteria. However, many patients
with high fever do not have major diseases. In adults,
take an oral temperature; in infants and children, a
rectal temperature is more reliable.
Most infectious diseases produce temperatures
between 37.2° C and 41° C (99° F and 106° F,
respectively). However, some patients with infectious diseases remain afebrile; these include neonates, immunocompromised hosts, patients with
chronic renal insufciency, and the elderly. Extreme
pyrexia (i.e., temperatures exceeding 41.5° C ) rarely
occurs with an infectious disease. Conditions in
which extreme pyrexia is seen include drug fevers,
central nervous system injury, malignant hyperthermia, stroke, and HIV.
Hypothermia is always an unfavorable prognostic
sign in the presence of infectious disease. This condition is seen with overwhelming sepsis (most commonly
in the elderly and neonates), uremia, cold exposure, and
hypothyroidism.
Observe Skin and Mucous Membranes
A macular/papular rash may indicate a viral exanthema, infectious disease, or a drug sensitivity reaction (see Chapter 25). Vesicular rashes occur with
viral infection. A petechial skin rash indicates meningococcemia or Rocky Mountain spotted fever. Petechial eruptions on the hard and soft palate may indicate mononucleosis. Splinter hemorrhages found in
Table 16-1
Yale Observation Scale Predictive Model:
Six Observation Items and Their Scales
OBSERVATION ITEM 1 NORMAL 3 MODERATE IMPAIRMENT 5 SEVERE IMPAIRMENT
Quality of cry Strong with normal tone or
Reaction to parent
stimulation
State variation If awake, stays awake or if
Color Pink Pale extremities or
Hydration Skin normal, eyes normal,
Response (talk, smile)
to social overtures
From McCarthy PL, Sharpe MR, Spiesel SZ, Dolan TF, Forsyth BW, DeWitt TG, et al: Observation scales to identify serious illness in febrile children,
Pediatrics 70:806, 1982.
Whimpering or sobbing Weak or moaning or
content and not crying
Cries briefly and then stops
or content and not crying
asleep and stimulated,
wakes up quickly
and mucous membranes
moist
Smiles or alerts (,2 mo) Brief smile or alerts (,2 mo) No smile, face anxious,
Cries on and off Continual cry or hardly
Eyes close briefly, not awake
or awakes with prolonged
stimulation
acrocyanosis
Skin and eyes normal and
mouth slightly dry
high-pitched
responds
Falls to sleep or will not
rouse
Pale or cyanotic or
mottled or ashen
Skin doughy or tented and
dry mucous membranes
and/or sunken eyes
dull, expressionless or
no alerting (,2 mo)
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