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CARDINAL PRESENTATIONS
CHAPTER 12
119
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120 PART I ◆ Fundamental Clinical Concepts / Section Two • Cardinal Presentations
Critical Diagnoses
Acute myocardial infarction
Pulmonary embolism or infarction
Unstable
Intracranial hemorrhage Stable
Cerebrovascular accident • Altered mental status
• Respiratory distress
Neuroleptic-malignant syndrome
• Hemodynamic instability
Thyroid storm
Acute adrenal insufficiency
Transfusion reaction Complete
Pulmonary edema history and Rapid resuscitation as appropriate
physical • Airway management/oxygen
Emergent Diagnoses
• Cardiac monitoring
Congestive heart failure • IV fluids
Dehydration
Recent seizure
Sickle cell disease See
Transplant rejection Consider rapid cooling, broad-
Figure 12-2 spectrum antibiotics, antivirals,
Pancreatitis
Deep vein thrombosis antifungals
Nonemergent Diagnoses
Drug fever
Complete history
Malignancy
and physical
Gout
Sarcoidosis
Crohn’s disease
Postmyocardiotomy syndrome See
Figure 12-2
Differential Considerations
instability, may require rapid, vigorous treatment. Prompt airway
The complete differential diagnosis for the patient in the ED management and initiation of monitoring, intravenous access,
with fever is extensive. The major infectious and noninfectious fluid resuscitation, supplemental oxygen, and respiratory support
causes are summarized in Table 12-1 and Box 12-1, respectively. are often necessary despite incomplete information concerning
The vast majority of serious causes are infectious in origin. the cause of the fever. Sustained temperatures above 41.0° C are
Immediate threats to life are from decompensated shock (usually rare but can be damaging to neural tissue and require rapid
septic), respiratory failure (related to shock or pneumonia), or cooling (e.g., misting, fans, cooling blankets).
central nervous system infection (meningitis). Some critical non- In the younger, otherwise healthy patient with fever, immediate
infectious causes of fever also exist (see Box 12-1), but these are threats to life such as toxic or septic shock, meningitis, meningo-
relatively rare and frequently do not occur with fever as the coccemia, and peritonitis should be considered and treated empir-
primary symptom. ically. In older, chronically ill patients with fever, most of the
A primary medical decision in acute febrile illness is based serious illnesses originate from infections in the respiratory tract,
on assessment of patient stability (Fig. 12-1). Patients with the genitourinary tract, and the skin and soft tissues.2 Meningitis,
life-threatening signs and symptoms, including significant altera- although less common, can also be a significant cause of morbidity
tions in mental status, respiratory distress, and cardiovascular and mortality in this group.
Complete history
and
physical
examination Consider IVF
rehydration,
antipyretics,
antiemetics,
analgesics
Positive
findings
Yes No
Yes Positive
results?
No
Reassess
clinical status
Consider
Resuscitate
Miscellaneous Malignancy Autoimmune Infectious
Empirical
treatment
with broad-
spectrum
Consider ANA, coverage,
See Table Work up as See antibiotics,
RF, ESR;
12-1; work up indicated Table 12-1 antivirals,
other workup
as indicated antifungals
as indicated
Figure 12-2. Approach to the stable adult with an acute febrile illness. ANA, antinuclear antibody; CBC, complete blood count; CT, computed
tomography; CXR, chest x-ray; ESR, erythrocyte sedimentation rate; IVF, intravenous fluids; PPD, purified protein derivative; RF, rheumatoid factor;
UA, urinalysis. (Adapted from Holder BM, Ledbetter C: Fever of unknown origin: An evidence-based approach. Nurse Pract 36:46-52, 2011.)
Pivotal Findings
shown in Figure 12-2. In younger and otherwise healthy adults,
Although the differential diagnosis of fever is broad, most of the self-limited, localized bacterial infections or benign systemic viral
treatable causes are of infectious origin. Most of these causes of infections are usually the cause of fever. The challenge with
fever may be diagnosed by careful history and physical examina- this group is to identify the rare life-threatening illness, such as
tion alone.6 Age and the presence of underlying medical condi- meningococcemia, meningitis, or systemic methicillin-resistant
tions can substantially influence the evaluation and subsequent Staphylococcus aureus (MRSA) infection.
decision-making regarding management. In the older or chronically ill population, fever is frequently a
An approach to diagnosis and management of the healthy, sign of severe illness. Usually the cause is infectious. In addition
otherwise well, stable adult patient with acute febrile illness is to the most common infectious causes of illness (respiratory,
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