Examination: Causes of Pyrexia

Possible OSCE scenario: You are the doctor covering the medical wards and have been asked to review a patient on the ward with a fever of 38.5 degrees. Please examine the patient and explain to the examiner what you would do next.

• Introduce yourself
• Wash your hands
• Explain to the patient that you have been asked to review them due to a high temperature
• Ask for the patients observations – if any signs that patient is unwell/septic advise you would asses using ABCD technique, otherwise continue as below

• Look at the patient from the end of the bed:
• Look for any obvious signs of infection or abnormality– e.g. tachypnoea,

• Review the hands:
• Peripheral stigmata of infective endocarditis
• Feel the temperature
• Capillary refill

• Feel the pulse:
• Feel for rate and rhythm, and pulse volume

• Look at both arms:
• Look for any areas of erythema or rashes
• Look at any peripheral access points (cannula’s, PICC lines) – check dates on them and check surrounding skin areas

• Feel the neck
• Feel for any enlarged lymph nodes – if any are enlarged note if they are unilateral or bilateral and state what they feel like (rubbery, firm, mobile)
• Check for neck stiffness

• Look in the mouth
• Check for enlarged tonsils
• Check for any oral infections – e.g. candida, ulcerations
• Check mucosal membranes
• Look for any abnormalities in the lips and tongue (Kawasaki disease)

• Look in the eyes
• Offer to check the retinae with a fundoscope

• Look at the rest of the body for a full skin examination (ensure undress patient fully to check all areas)
• Erythema
• Scars, wound infections
• Rashes

• Explain at this point you would do a full cardiac, respiratory, neurological and abdominal examination but will concentrate on the main points now.
• Respiratory:
• Listen to the chest for any signs of infection – crepitations, bronchial breathing
• Cardiac:
• Feel the apex beat
• Listen to the heart sounds for any murmurs
• Examine the abdomen:
• Feel for any tenderness
• Feel for any enlarged organs (spleen)
• Listen for bowel sounds
• Neurology examination if indicated:
• Kernigs sign
• Any cranial nerve deficits or peripheral neurology

• Thank the patient
• Summarise what you have found
• Explain to the examiner what you would do next:
• Take a full history
• Explain you would like to do a full septic screen:
• Full set of bloods including FBC and CRP
• Blood cultures
• Urine dip +/- MC&S
• Chest X-ray
• Specific investigations if anything picked up on examination e.g, sputum sample, wound swab
• Explain you would like to give the patient paracetamol to bring their fever down (check allergies and whether has already had)
• If the patient had any signs of sepsis or SIRS explain you would resuscitate the patient e.g. IV fluids and treat appropriately e.g. antibiotics
• Explain you would like to read through the patients notes and drug chart to check if any history of infection or risk factors

• Pyrexia = temperature above the normal range
• Usually considered > 37.5 degrees
• Pyrexia of unknown origin = fever of over 38.3 degrees or greater for at least 3 weeks with no identified cause after 3 days of hospital evaluation or three outpatient visits

• Most common infections:
• Bacterial:
• Chest infection
• Urinary infection
• Cellulitis
• GI – gastroenteritis, cholangitis
• Viral infections
• Influenza
• Rare infections but important to rule out:
• Infective Endocarditis
• Meningitis
• Encephalitis
• HIV (seroconversion)
• Non-infective causes:
• Inflammatory: Inflammatory bowel disease, Kawasaki disease, Juvenile RA
• Neoplastic: ALL, lymphoma
• Drugs/toxins

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