3-32
relapsing fever, rheumatic fever
Chronic (>30 days): Tuberculosis, leishmaniasis, visceral amebic liver abscess, trypanosomiasis, brucellosis,
bartonellosis, deep fungal infections, filariasis, Q fever
Specific symptoms (combined with high-grade fever) that differentiate between febrile illnesses include hemor-
rhage, hypotension, rash, diarrhea, lymphadenopathy, altered mental status or other central nervous system
symptoms.
Focused History: Fever: How high is your temperature? (expect to document a temperature >100°F) Is
the fever constant, or does it come and go, or only come at night? (nocturnal fever pattern with some malaria,
TB; recurrent fever with some malaria, relapsing fever, leptospirosis) Duration: How long have you felt sick?
(differential diagnosis of causes of fever based on chronicity) Other Sx: Have you noticed [select: rash,
headache, diarrhea, swollen lymph nodes, localized pain, stiff neck, cough]? (identify affected systems). Do
you know other persons with similar symptoms? (suggests contagious illness or point source outbreak) Are
you pregnant? (changes medications that can be used) Are you taking any medications? (Antimalarials may
decrease your ability to diagnose malaria. Fever may be sign of an allergic reaction to medication.)
NOTE: Micromedex software includes Martindale’s “The Extra Pharmacopoeia,” which is a good reference
for drugs worldwide.
Objective: Signs
Using Basic Tools:
Vital signs: Temperature > 101°F (also look for relapsing pattern or pulse-temperature dissociation as hints
to specific types of infection), respiratory rate over 14/minute, heart rate over 100 beats/minute, systolic blood
pressure <100 mm
Inspection: Evaluate for pallor, diaphoresis, rigors, mental status changes, rash (especially any petechiae or
purpura), jaundice, unwillingness to move body parts (stiff neck, limb, back etc); evaluate for pharyngitis
Palpation: Feel for inflammatory changes (warmth, tenderness) in areas of symptoms; test range of motion
in areas where patient voluntarily restricts movement to see if tenderness is elicited; check for enlarged
lymph nodes and assess if fluctuant, tender or draining; evaluate abdomen for hepatosplenomegaly, peritoneal
signs, tenderness.
Auscultation: Listen for rales in lungs (egophony or dullness suggest pneumonia; rales that clear after cough
have traditionally been associated with tuberculosis); listen for heart murmurs, S3 that could suggest carditis
(such as rheumatic fever), or endocarditis; evaluate for abnormal bowel sounds (hyperactive in gastroenteritis,
hypoactive in ileus/intra-abdominal abscess)
Using Advanced Tools:
Lab: Thick and thin blood smears (malaria, filaria, babesia and other parasites); WBC with differential;
urinalysis; Gram’s stain of any pus or sputum; stool for fecal leukocytes and O&P if diarrhea; pregnancy test for
females of childbearing age (less likely if breastfeeding)
CXR if available (PA and Lateral)
Assessment:
Clinical Questions - Complete attached algorithm and follow indicated protocol as appropriate for mission
situation.
- Does patient need outpatient treatment or evacuation/hospitalization for intravenous therapy, resuscitation,
possible end organ support (ventilator, dialysis) if available? - Does patient need isolation to prevent contagion (such as meningitis, hemorrhagic fever viruses, plague,
pulmonary tuberculosis)? - Should the patient receive empiric treatment for several conditions simultaneously (e.g., bacterial infection)
or should he be treated more specifically? (e.g., for malaria). - Is the patient at increased risk: elderly, young child, immunocompromised, wounded, concurrent or chronic
illness (e.g., sickle cell disease, HIV, diabetes, cancer, malnourished)? If so, he will require evacuation
and/or more resources. - Does the patient have signs of sepsis syndrome present (fever or hypothermia, heart rate >90/minute,