fever

• defined: a.m.oral temperature of >37.2°C or p.m. temperature of >37.7°C  

Step 1: 注意vital sign( HR, RR mild↑為正常;if BP low[Symbol]小心septic shock) 

Step 2: review chart and drugs 

第一次燒? post-operative pt? chemo過後的病人? 

看是不是第一次燒，若當科已知道，做過blood culture，打過 anti，先查一 

下 blood culture 結果，看現在用的anti，是否 sensitive. 若有 sensitive，可給 

scanol  #1 TB 

Step 3: approach patient[Symbol] fever survey  

-90% related to infection! 症狀?重頭到腳問一遍,身上管路?wound? 

 Coughm rhinorrhea[Symbol] URI 

 Cough with sputums,dyspnea, breathing sound[Symbol] pneumonia 

 Dysuria,frequency and urgency, knocking pain,n/v[Symbol] UTI 

 Diarrhea and abdominal pain[Symbol] AGE 

 Joint pain[Symbol] septic arthritis or gout attack 

 Cons’ change, neck stiffness,headache[Symbol]meningitis 

身上管路? [Symbol]拔除送culture 

Wound[Symbol] cellulitis, necrotizing fascitis 

-tumor fever: 

-neutropenic fever: 

Order : 

CBC/DC, CRP,blood culture*3, sputum culture, CXR,ABG,UA,UC 

Catheter culture  

Lactate, procalcitonin(for sepsis) 

Treatment : 

-<39°C[Symbol]ice bag;> 39°C [Symbol]Scanol #1 ST 

-Dehydration： increase IV speed 

-gout attack: indomethacin 50mg Q6H or ketorolac IV +Colchicine#1 BID 

-if prominent infection source[Symbol]use anti 

• OP Wound infection:  

-<24hr(Suspect streptococcal or clostridial infection)：ampicillin 1g g6h IV 

-一般：Cephazolin 1g q8h IV 

• 常見感染： 

-skin/soft tissue infection：oxacillin 2g q6h-4h IV; (sa:深)[Symbol] penicillin 

-UTI：Cefazolin 1g q8h 

-pneumonia：Augmentin or Unasyn +/- macrolide or Levofloxacin #1 QD 

-intra-abdominal infection：cefmetazole 1g q8h or flomoxef 1g q8h 

-IE：Ampicillin-sulbactam 3g q6h IV  

-Dental problem caused: augmentin, unasyn 

-HAP, septic shock: tazocin, penam 

-Nosocomial anti-Pseudomonas : Ceftazidime 2g q8h. Pip/Tazo 4.5 q8h) 

-rickettisa or leptospirosis: doxycycline or minocycline 1# bid 

*G+,G-都有: unaysyn 

Salmonella: FQ(better pentetration), amoxicillin 

Gram negative;GI, GU: cepha!! 

Anaerobes: metronidazole 

穿透力強!: levofloxacine, ceftriaxone 

Nocardia: linezolid or baktar oramikacin or imipenam 

• Fever of unknown: 

 

Etiology: 

Infection	TB, intrabdominal abscess, endocarditis, osteomyelitis  Atypical infection: CMV, EBV, typhoid, fungus, leptospirosis
Autoimmune	Giant cell arteritis, AOSD,vasculitis, RA,SLE,reactive arthritis,sarcoidosis
Endocrine	Thyroid storm, adrenal insufficiency, pheochromocytoma
Neoplasm	Lymphoma, leukemia, RCC,GI tumor,sarcoma
Drugs
others	DVT,PE,familial Mediterranean fever

*AOSD: fever>38.3°C flare up with salmon trunk rash, LAN, cricoidcartilage pain, hepatosplenomegaly. lab:ferritin ↑↑,mild elevated of AST/ALT,leukocytosis, CRP.ERP↑ 

History: TOCC, fever curve  

PE: lymphadenopathy, skin rash, murmur,   

Work up: 

CBC/DC, ESR, CRP, ANA, RF,BC*3,ferritin, c3/c4 

T3/T4,cortisol,VMA 

d-dimer,PT,APTT,tumor marker 

CXR,CT with contrast, cardiosono, Doppler sono  

Treatment: empiric antibiotic use is not needed. 

-tumor fever: naproxen 250mg BID 

-treat etiology 

Neutropenic fever 

Suspect: post-chemotherapy  

Definition: oral temporal >38.3°C or >38.3°C for > 1 hr+ Neutropenia(ANC<500/µL) 

Pathogen: GNR,G+,fungus 

Risk :ANC>100/Ul,no symptom, no lab abnormal,normal CXR 

Tx:  

 I empiric antibiotics: vancomycin plus ceftazidime, cefepime, or carbapenem(+anti-fungus,if fever>5天) 持續到no fever 且ANC>500/uL 

 II GCSF or GM-CSF: 當懷疑neutropenic fever 發生機率>20% or previous neutropenic fever 

  

------ 

Fever : the mean oral temperature is 36.8° ± 0.4°C, The normal daily temperature variation is typically 0.5°C 

 肛溫和耳溫比口溫高0.6°C,腋溫較口溫低0.6°C 

-occurs in conjunction with an increase in the hypothalamic set point [e.g., from 37°C to 39°C 

- hyperpyrexia = fever >41.5°C. This extraordinarily high fever can develop in patients with severe infections but most commonly occurs in patients with central nervous system (CNS) hemorrhages. 

-hyperthermia=heat stroke:no increase in hypothalamic set point 

Hyperthermia is characterized by an uncontrolled increase in body temperature that exceeds the body's ability to lose heat. 

 Etiology:   

Exercise induced
Drugs	Amphetamine, cocaine, Li, serotonin syndrome ,NMS , malignant hyperthermia
Endocrine	Thyrotoxicosis, pheochromocytoma
CNS	Cerebral hemorrhage, status epilepticus, hypothalamic injury