Case instructions
Pager alert!
It’s your first night cross-covering for the internal medicine team. Things are pretty quiet so far, and you’re midway through a heated Mario Kart showdown in the residents’ lounge when your pager lights up like a red shell.
Click the pager icon to reveal the message.
A temperature of 39.5°C (103.1°F) could be serious, or it could be something fleeting. Your thumb hovers over the controller. Do you finish the race or forfeit your place to assess the patient?
What do you do next?
Make your choice, then click on the explanation bubble to reveal the answer.
- Forfeit the trophy and go see the patient.
- Have the nurse recheck the vitals and get back to you.
- Head out as soon as you finish your turn. You're just about to beat your biggest rival!
On the way to the patient
While you head over to evaluate the patient, you have a minute to collect your thoughts.
Question: What information is most crucial to know, and how will you find it?
Remember that trusty friend, your signout sheet? Quickly review it to think through the following information.
- Age
- Admission diagnosis
- Hospital course or recent procedures
- Allergies
- Recent laboratory results
At the nurses' station
You drift by the nurses' station on the way to the patient's room. The patient's nurse seems relieved to see you and thanks you for coming so quickly. You're still feeling a little grumpy about giving up your game, but the appreciation helps. You take a deep breath and, with the video game soundtrack echoing in your brain, shift your focus to the situation at hand.
Question: What information should you obtain from the nurse?
You'll want to get a quick report about the following:
- Vitals and trends
- Baseline
- Associated symptoms or findings
More information, please...
As you walk together to the patient's room, you learn the following information from the nurse:
- The patient is POD #2 following a planned hysterectomy for uterine prolapse.
- Recovery has been uneventful up to this point, and the patient was transferred to the medical service earlier today.
- It is the nurse’s first day caring for this patient.
- The patient's vital signs were stable throughout the day; this evening, she developed a fever of 39.5°C (103.1°F) and seemed more lethargic than earlier.
At the patient's door
You and the nurse arrive at the patient's room.
Question: Which of the following can you immediately assess from the doorway?
Make your choices, then click on the explanation bubbles for more information.
- Position of the patient
- Skin appearance
- Mental status
- Respiratory rate and pattern
- Lines and monitors
That's right—all of the above!
Your initial visual impression can guide urgency. Look for signs of distress: altered mental status, labored breathing, inability to speak full sentences, or mottled skin. These visual cues often indicate clinical deterioration before vital signs become overtly abnormal or trigger alarms, especially in sepsis or shock.
Pick your adventure
“Life is a highway...”
Question: Which clinical scenario would you like to explore?
Choose an option to continue the module.
Wrap-up
You kept your cool under pressure and steered your patient out of the danger zone.
You did a great job:
- Using visual assessment to quickly identify potential signs of critical illness in a patient with fever
- Calling for help early when signs of shock or sepsis were present (Option 1)
- Resuscitating a patient with septic shock while simultaneously initiating sepsis workup (Option 1)
- Identifying strategies for preventing postoperative complications (Option 2)
- Communicating effectively when requesting a consultation (Option 2)
Congratulations on completing this module. Hopefully you now feel more confident assessing a patient with fever!
Personal story from an AMBOSS clinician
A 56-year-old woman was admitted to the surgical ICU for stabilization while awaiting urgent return to the operating room. She had had an uneventful elective bowel resection for ulcerative colitis earlier in the day. She had been recovering well but then developed shaking rigors and a high fever of 40°C (104°F) over the last few hours. Her abdominal pain had become hard to control, and now her abdomen was rigid. The presumptive diagnosis was intra-abdominal infection, though the presentation so soon after the surgical procedure was unusual.
On examination, the patient was agitated, tachycardic (heart rate 124 beats/minute), hypertensive (blood pressure 178/105 mm Hg), and extremely diaphoretic. Her abdomen was rigid, but there was also a significant increase in muscle tone in her extremities. A quick neurological examination revealed mydriasis, hyperreflexia, and clonus at the ankle. Since the neurological findings were inconsistent with an intra-abdominal infection, we suspected a noninfectious cause of the fever.
Review of her medication list revealed she had received multiple doses of fentanyl in the last several hours for pain control and was on chronic duloxetine for a major depressive disorder. Suspecting serotonin syndrome caused by the interaction of fentanyl (which is weakly serotonergic) and an SNRI, we administered IV lorazepam for agitation and muscle rigidity and cyproheptadine via her NG tube to block serotonin receptors. Her symptoms rapidly improved, and she did not require a repeat laparotomy.
The lesson I learned: Though fever typically accompanies infection, the specificity is not absolute. Remember to keep other causes of hyperthermia (e.g., autonomic dysfunction) in your differential as you begin your workup for an elevated body temperature.