Cachexia or other signs of chronic illness

Perform a brief mental status examination. In

the elderly, AMS may be the only sign of an

occult infection.

Examine the tympanic membranes and pharynx

for evidence of otitis media or exudative pharyngitis. Assess the neck for thyroid enlargement, lymphadenopathy, and meningismus.

Auscultate for evidence of pneumonia (eg, rales

or rhonchi), new murmurs suggesting endocarditis, or the rub of pericarditis.

Palpate for signs of focal or generalized peritonitis. Check for costovertebral angle tenderness. Perform a genitourinary examination in

males and a pelvic examination in females

with abdominal pain.

Disrobe the patient and examine for rashes

(petechiae of meningococcemia) or focal

infection Uoint inflammation, cellul itis,

infected ulcers, or abscess).

taken in infants, children, and adults with significant

tachypnea, tachycardia, or altered mental status (AMS).

Heart rate (HR) and respiratory rate (RR) increase as fever

rises. An increase in temperature of 1 °C results in an

increase in HR by approximately 10 bpm. The RR may also

increase 2-4 breaths/minute per degree Celsius. The elderly

and immunosuppressed patients may not mount a febrile

response despite serious infection.

In most patients, the examination is directed by the

patient's symptoms (Table 33- 1). Patients with significant

alterations in mental status, respiratory distress, and car ­

diovascular instability require rapid assessment and stabi ­

lization. Once the patient has been stabilized, assess for

infectious causes that may be a threat to life ( eg, toxic

shock, septic shock, meningitis, peritonitis).

DIAGNOSTIC STUDIES

..... Laboratory

In children and the elderly, the highest yield laboratory test

will be the urinalysis. It is highly accurate for urinary tract

infection. In most cases, a complete blood count (CBC)

will be sent to look for an elevated white blood cell (WBC)

count, but this test lacks specificity and sensitivity. The

WBC count can be normal in cases of severe infection or

falsely elevated when no infection is present. The most

helpful component of the CBC is the neutrophil count, as

it can provide a measure of response to infection or determine whether a patient is neutropenic and unable to

mount a response to infection ( eg, immunocompromised

chemotherapy patient). Gram stains, blood, urine, and

FEVER

wound cultures can be obtained in the ED. Although not

helpful in the ED management of the patient, these studies

direct targeted antibiotic therapy in the future.

..... Imaging

The chest x-ray is helpful in patients with s uspected pneumonia, but may be difficult to interpret in the dehydrated patient

or those with underlying pulmonary or cardiovascular disorders. For patients with abdominal pain, a computed tomography ( CT) scan of the abdomen can be performed to

evaluate for appendicitis, diverticulitis, cholecystitis, and

intra-abdominal abscess. A head CT should be performed for

patients with focal neurologic findings, seizures, AMS, human

immunodeficiency virus (HIV)/acquired immune deficiency

syndrome or signs of increased intracranial pressure. The

administration of antibiotics should not be delayed in

patients with suspected meningitis awaiting CT scan results.