Fever

 

1. Fever Differential is broad: 
- Infection (lung, heart, brain, urine, sinuses, prostate, abdomen, skin, joints, lines, etc) 
- Infammation (Collagen vascular disorder, neoplastic disorder) 
- Mucositis
- Atelectasis
- Blood product reaction
- Drug fever (beta lactam antibiotics and amphotericin common causes)
- PE vs DVT 

2. Is it a true temperature? 
-  Is it greater than >100.4 F?
- Quickly chart check and determine if patient is stable vs unstable.unstable (look at vitals, etc).  If unstable go to bedside immediately! 

3.  If unstable:
- First:  Brief yet thorough chart check
- Go assess bedside. Get as much hx as you can - senddrug allergies, recent infections, blood transfusions, etc. Targeted exam (skin, lungs, extremities, etc). If patient is not responsive or sudden change in mentation, address those first.  
- If you have an idea where the infection is coming from, start targeted antibiotics.   
- If no idea where infection is coming from,  repeat blood culture if > 48 hours since last blood culture. If blood culture performed less than 48 hours ago, usually no need to ICU.repeat ifblood stableculture.
-Consider pan culture - UA, Urine Clx, line clx, CXR, and EKG on top of repeat blood cultures. 
- Labs to order (based on presentation/suspicion): CBC, CMP, Lactate, Trop, BNP, D-dimer, PT/PTT, etc.
- Also start broad-spectrum antibiotics (Vancomycin/Zosyn) (unless antibiotic allergies)
- ICU consult, Stat. 

4. If stable:
- Assess where the nurse took temperature?temperature, is it in the correct location?
- Have the nurseRN recheck the temperature in 30 minutesmins and dochalo/ call you. You do not have to act on one temperature, first confirm it. (Exceptions might be if the patient is neutropenic, then consider neutropenic fever). 
- Do a thorough chart check while you back.wait Infor thea meantime,call lookback: at
  hx       - why admitted, any infections, whatWhy was the WBC,patient whatadmitted?
         - What was the WBC?
         - What was the urine output,output? any
         - Any recent medications,meds/blood etc.transfusions/surguries?
- If after 30 minutes temperature is confirmed, go assess patient bedside. 
- Get a detailed history from patient. 
- Do a thorough PE, looking for skin infections (including decubitus ulcers), and looking at all lines. 
- If worried about an infectious cause, start appropriate antibiotics. 

2.5. OnceSpecial fever established DDx Broad:considerations: 

3. Workup: pan culture if needed (CXR, uine, stat blood cultures x 2 (if lines, line clx), EKG 

4. If no source but concerned, start broad spectrum antibiotics.