Fever: Assessment and Associations

Fever

• Duration assessment helps determine if it is HIV-related (>1 month)
• Note the fever's grade (high or low)
• Determine the fever's pattern, whether continuous, remittent, or intermittent
• Check associations with chills and rigors
• Establish if fever is worse at certain times
• Check for associated convulsions, might indicate meningitis
• Note relieving factors like tepid sponging or antipyretics
• Check for associated headache, may indicate meningitis
• Check for associated vomiting, may indicate meningitis
• Determine if there's an associated cough
• Ascertain if body weakness is present
• HIV is associated with long duration, high grade, continuous fever that doesn't worsen at a specific time of day
• Tuberculosis is associated with long duration, low grade, continuous fever with drenching night sweats, a long-lasting cough, and bloody sputum production
• Meningitis is associated with short duration, high grade and continuous pattern fever including headache, and vomiting, that is relieved by antipyretics.
• Pneumonia is associated with short duration, high grade and continuous patterned fever including cough and chest pain
• Malaria has an intermittent, high-grade fever that worsens in the evening, is marked by chills, rigors, weakness, malaise, and body aches, and improves with antipyretics

Cough

• Note the duration of the cough
• Determine if sputum is produced
• Identify sputum color (blood-stained, whitish, yellowish)
• Consider sputum consistency, such as mucoid, thick, jelly-like, or frothy
• Note the odor: foul-smelling or odorless
• Determine the volume of sputum production (Copious or small- estimate it)
• Note if posture affects sputum production, which may indicate lung abscess or bronchiectasis
• Determine if the sputum is blood-stained
• Establish how long the blood has been present
• Blood appearance indicates if fresh or altered
• Frequency of blood in sputum helps estimate blood loss severity

Characteristics of Sputum

• Frothy sputum indicates LV failure
• Thick sputum indicates asthma
• Rusty brown sputum indicates pneumonia
• Copious mucoid sputum indicates chronic bronchitis
• Copious foul smelling sputum indicates bronchiectasis, lung abscess

Breathlessness (Fast Breathing)

• Determine when the breathlessness started and its duration
• Identify if breathlessness worsens at rest or during exertion, the latter suggests heart failure
• Assess how far the individual is able to walk before breathlessness happens
• For children, assess how well they suckle before tiring
• Determine if it has been progressive since its onset, may indicate heart failure
• Note if persistent or intermittent, suggesting asthma
• Determine the presence of aggravating or relieving factors
• Ascertain if breathlessness is worse at any time of day
• Examine if the patient can lie flat or needs pillows, the latter indicates orthopnea and potential heart failure
• Determine if the patient wakes up gasping, suggesting paroxysmal nocturnal dyspnea or PND
• Weight loss may be present due to energy expenditure from respiratory effort from asthma and emphysema

Symptoms Checklist

• Body swelling may indicate heart failure
• Squatting with exertion may indicate Tetralogy of Fallot (TOF)
• Wheezing may indicate asthma
• Bluish discoloration of lips, tongue, and palms may indicate TOF, asthma, or heart failure
• Restlessness from hunger and hypoxia indicates a Ventricular Septal Defect (VSD)
• Chest tightness may indicate asthma or emphysema
• Orthopnea, PND and body swelling indicates heart failure
• Aggravating factors - worse at night or early morning associated with wheezy breathing, chest tightness, and failure to thrive FTT indicates asthma

Vomiting

• Note if projectile
• Assess if the vomiting is with effort or effortless
• Check the content of the vomitus (recent food, bile, fresh or altered blood)
• Check for consistency (mucus)
• Check the odor (odourless or foul smelling)
• Determine how many times they vomited for the day
• Estimate volume lost in each episode
• Note aggravating or relieving factors
• Note associated weakness, may indicate dehydration
• Check for decreased bowel movements, may indicate constipation
• Noted if there is an associated fever, indicating infective process or gastroenteritis

Diarrhea

• Assess duration, if greater than a month may indicate HIV
• Determine bowel movement frequency per day
• Assess volume (copious or scanty)
• Assess the odour (odourless or offensive)
• Note the stool color is pale, putty-like, porridge-like or frothy, may indicate steatorrhea
• Check for blood, which may indicate an infective cause

Stool Assessment

• Check presence and state of blood and it relation to passage of stool
• Check for mucus, or sliminess indicates infective diarrhea
• Check for pus indicates infective diarrhea
• Note abdominal pain characterizes it
• Weakness, abdominal distension, or tenesmus indicates amoebic dysentery
• Abdominal pain, fever, mucus, or blood in stool indicates infective diarrhea/gastroenteritis

Seizure Assessment

• Determine if the patient is a known epileptic
• If known epileptic, assess compliance with drugs
• Note patient’s actions when the seizure began
• Determine which body part was affected (whole body or generalized)
• Identify the seizure type (tonic, clonic, tonic-clonic, or atonic)
• Note if the patient experiences any signs before it occurs (aura)
• Establish the number of episodes and duration
• Inquire last episode details
• Later include questions on affect single body, loss of consciousness, sleepiness after, loss of sphincteric tone, foaming from mouth, associated cry or shout, rolling/blinking of eyes, breathing, fumbling of hands, biting tongue/lip, any falls or headache, time of day.

Rule out seizures with:

• Fever: to rule out cerebral malaria
• Trauma: RTA, fall from a height, fight
• Diabetes Mellitus DKA, Hypoglycemia
• Known hypertension to rule out hypertensive encephalopathy
• Headache preceding the onset can rule out increased Intracranial pressure-ICP
• Signs of liver failure
• Symptoms of renal chronic renal failure.
• Drugs can induce them
• Inquire on sleep

Edema (Body Swelling)

• Determine how it was noticed and by whom
• Determine where and rate of development
• Establish if localized or how it spread from onset
• Identify if bilateral or unilateral
• Identify it's constant or changes in the day
• Identify time of day its most severe
• Note if pitting or non-pitting
• Note factors to any changes and its characteristics
• Ask about infections, fever or malaria
• Any hx of soaps containing heavy metals
• Note associated flank pain and drug ingestion include analgesics, amino glycosides, NSAIDS
• Note anorexia, vomiting and weakness

Further History Taking for Edema

• Insect sting or bite
• Jaundice, anorexia and symptoms of complications of hepatic encephalopathy
• Cough, breathlessness, hypertensive heart dx
• Uremic encephalopathy – asterixis, altered consciousness and complications in established case of chronic renal failure CRF
• Gastritis
• Renal osteodystrophy
• Anaemia

Weight Loss Factors

• Note loose clothing, belt, bony prominences
• Note DM polyuria, polydypsia, polyphagia
• Note HIV infection persistent fever, chronic diarrhea, chronic cough
• Note feeding habits
• Note cardiac disease cough, breathlessness, PND, orthopnea
• Note malignancy cough, swelling in any part of the body, signs of metastasis
• Note malabsorption syndrome persistent diarrhea, steatorrhea, persistent vomiting
• Note respiratory disease cough, asthmatic, night sweats or hemoptysis
• Note thyrotoxicosis irritability, prominences of the eye, awareness of heart beat, heat intolerance

Pain Assessment

• Note location of pain by pointing and if it radiates

Characteristics of Note

• Interferes with daily activity, awakens at night
• Constant or intermittent
• When and how it has changed
• Note sensory nature
• Worsening or aggravation in any form
• Note what helps the pain

Mass/Swelling Assessment

• Determine when it was noticed and by to who
• Determine why they noticed it
• Determine of it is increasing since noticed and rate of growth
• Characterize of is is tender or painful
• Determine of its warm
• Identify consistency
• Determine if its mobile to tissues
• Any color changes in skin
• Any fever, weight changes, bone pain of swelling in other areas

Jaundice Assessment

• Inquire about past SCD, use of color changing drugs, change in urine color after previous blood transfusion
• Inquire about body itching, lack of appetite, stool color, abdominal pain and water source
• Inquire about family history of hepatitis A, drug injections, and sexual contact
• Inquire of neonatal jaundice and contact with virus for Hep A
• Inquire of hereditary cause with bone pain and contact

Cardiovascular Accidents - CVA

Ischemic CVA Types Considerations:

• First indication of neurological deficit noticed
• Sudden insidious onset
• Patient's actions
• Headache, seizures, loss of consciousness

Risk Factors for CVA

• Atherosclerosis
• Hypertension
• Diabetes -Smoking
• Heavy drinking
• SCD
• Cardiac disease
• Drug use
• Vomiting (ICH, SAH)
• Collapse (SAH)
• Rapid recovery of symptoms, TIA (Transient Ischemic Attack) or any past history
• Trauma (ICH)
• STDs

Symptoms for each CVA:

• Embolic: sudden, headaches, seizures, loss of consciousness, rapid recovery
• SAH: dramatic, activity-driven, thunderclap headaches (occipital or temporal), collapse post-activity, no neurological signs, neck stiffness, loss of consciousness, vomiting, raised BP
• ICH: sudden, headache, vomiting, loss of consciousness, no neck stiffness, stress-related
• Thrombotic: slow, no headaches, at rest/relaxing, no loss of consciousness/seizures, atherosclerosis risks

Characteristics of Headaches

Tension

• Associated with stress/worries
• Pressing, radiates from the back of the head
• Analgesia provides poor relief
• Less during the day, worse during evening
• Not aggravated by coughing, bending, or straining

Vascular

• Throbbing
• Associated with infections
• Typically confined to one side of the head

Increased ICP symptoms

• Increases respiration
• Mostly during evenings
• Progressive, continuous increase
• Aggravated by coughing, straining, bending, position changes
• Analgesia relieves
• Vomiting occurs during mornings

Inflammation Meningitis

• Patient may be drowsy
• Generalized aches are worsened by movement, coughing

Referred

• Located over the eyes, sinuses, maxillary area
• Increases reading
• Tooth or ear related

Migraine

• Malaise and irritability
• Neurological
• Light sensitive, prefer dark room, sleep

Diabetes Mellitus Assessment:

• Polydypsia, polyuria, weakness, boils
• Determine if known diabetic
• Note past surgeries
• Changes in weight rate of eating
• Changes in urination
• Double vision
• Ankle swelling
• Nerve sensation/Pain
• Ulcers or skin changes
• Changes in BMs and erectile dysfunction

Congestive Cardiac Failure - CCF

• PC presents dyspnoea, fatigue, orthopnoea, cough, hemoptysis and edema
• Inquire for Palpitations
• Ask if known hypertensive
• Chest pain angina with any smoking and alcohol intake.
• Note and past infections

Summary to rule out heart failure:

• Hypertension
• Angina pectoris
• Myocardial infarction
• Pericarditis
• Anaemia
• Rheumatic heart disease
• Alcoholic heart disease
• Atherosclerosis
• Thyrotoxicosis

Pulmonary Tuberculosis

• PCs include Fever, cough, weight loss and haemoptysis over greater 1 month
• Rule out asthma and lung issues above.

Further Rule Outs for Pulmonary Issues

• Infections
• Malignancy
• Issues in nutrition
• Primary TB infection and pruritus in HIV/lymphoma
• Paragonimiasis or contact
• Body itching and neck selling

Parkinsonism Assessment

• PCs include tremors, rigidity, hypokinesia, pains and tiredness
• Check movement and swinging of arm and drooling effects if speech is impacted
• Evaluate history on infections, if hypertensive, use of poisons and mental wellnes

Rule outs for conditions such as

• STD
• Thyrotoxicosis

Check Following Signs of Parkinsonism:

• Expressionless face
• Stell wag’s sign
• Glabella tap (meryeson’s sign)
• Festinant gait
• Kaysor-fleisschers
• Corneal arcus

Assessing HIV

• PCs include fever, cough, and weight loss requiring counselling
• Counsell fear and stigma and ensure dietary intake, vaccine usage and drug adherence
• Promote a life of exercise without smoking, drug intake and ensure protection and awareness.
• Ensure to follow up with support
• Also assess how the start of the ulcer was noticed
• Check for site, shape

Assessment for Chronic Leg Ulcers

• Pain or movement
• Any itching or discharge
• Assess if a hx of fever, cough or sweats
• Assess any hx of trauma, weight loss hx and if the patient is diabetic

Leg Ulcer Differentials

• Rule out trauma, DM, Tb and more

Examination Steps

General

• Musculoskeletal examinations of the ulcer
• Respiratory cardiovascular and digestive checks
• Further testings must be run with sample collections for wounds, drugs, lipid or genetic testing with HIV screening

To assess Nephrotic Syndrome

• PCs include edema, anuria, uremic signs and swelling, any kidney failure known
• Note any drug intake and assess all of the history for trauma, pain and skin assessment