FEVER
BY:
JANET LEIPHEIMER
Differential Diagnosis
Nursing 6917
October 11, 2021
INTRODUCTION TO COMPLAINT
Case: A 39-year-old Fever, also
African American referred to as
male presents with pyrexia, is defined
a chief complaint of as having a
fever for 10 days temperature above
and swelling to his
the normal range
right thigh and knee
due to an increase
for 1 week causing
him to have in the body's
difficulty temperature set
ambulating. point.
ETIOLOGIES
Most febrile episodes are mild and self-
limiting. However causes of a fever can be
minor to more serious such as:
Viral or bacterial infection
Malignancy
Adverse reaction to medication or blood
products
Connective tissue disease
SYMPTOMATOLOGY
Symptoms vary from person to person and across the life
span.
Fever is common in children and infants
Older adults are less likely to develop high fevers
Seniors may not be able to mount a febrile response at all.
Fatigue, weakness, lethargy
Tachycardia, SOB, Sweating
Chills and shivering
Headache
Muscle aches
Loss of appetite
Irritability
Dehydration
DIRECT QUESTIONS TO ASK
When did the fever and leg swelling begin?
Is the fever intermittent or continuous?
When did the pain begin?
Do you have any other complaints or symptoms
besides the fever and the leg swelling?
When did the redness start in your thigh?
Do you have any drainage from your incision?
Is there anything else you would like to tell
me about?
MEDICAL HISTORY
Surgical: R knee replacement 2 weeks ago
Medical: Diabetes; Sickle Cell; Vit D Deficiency,
Penicillin allergy
Family: Sickle Cell; Diabetes; Hypertension
Social: Non-smoker; no drugs, occasional alcohol
use.
Medications: Folic Acid 1 mg daily; multivitamin
1 daily; Vit D 400U daily; metformin 1000mg
twice daily; Percocet 10/325 mg every 4 hours
for pain as needed
Received influenza and pneumococcal vaccines.
TARGET PHYSICAL EXAM
VS: temp 101.90F; RR 22; HR 112; BP 147/86; SpO2 96% on RA.
General Appearance: normal male in moderate distress, restless, having severe pain.
HEENT: head symmetric, round; pupils PERRLA 3mm; eye, ears with no drainage
redness or trauma; TM visualized, intact and opaque; mucous membrane moist pink
and intact; no lesions or sores; nasopharynx reddened; visualized clear turbinates;
neck supple no adenopathy.
Cardiovascular: RRR; no murmurs, gallops or rubs; cap refill < 2 seconds; edema to
Right knee and thigh; pulses+ in right lower extremity.
Respiratory: Lungs CTA in all fields, no adventitious sounds; symmetrical; no cough.
Abdomen: soft, nontender, without mass or organomegaly; BS x4
Skin: intact with no rashes, lesions, or ulcerations; erythema to Right knee and Right
lower thigh.
Extremities: joint pain, swelling, tenderness, and redness to right lower knee and
lower thigh; no crepitus; swelling noted to lateral part of right lower thigh, diffuse
with ill-defined border; swelling soft in consistency, tender to touch, and warm;
the right thigh measures 3cm larger in circumference to that of the normal left
side; transillumination test was negative and no bruit heard; negative Homan’s
sign.
Musculoskeletal: gait antalgic with persistent right knee flexion; all movements of
hip were normal; unable to perform Trendelenburg’s test due to pain; movement 0-30
degrees right knee, 0-130 degrees left knee.
TOP 3 DIFFERENTIAL
DIAGNOSES
***Osteomyelitis: patient has history of
recent right knee replacement and diabetes.
The surgery may have caused direct
inoculation of a pathogen. The diabetes can
cause vascular insufficiency.
Cellulitis: patient presents with fever, joint
pain, redness, swelling and tenderness to
right knee
DVT: joint pain. This was ruled out quickly
due to absence of Homan’s sign.
LAB TESTING, IMAGING,
DIAGNOSTICS
CBC w/diff: evaluation of overall health, can detect
infection and anemia
Anterior and posterior x-ray of knee: may reveal
damage to the knee.
MRI: shows bones and soft tissue that surround them
Gram stain of synovial fluid: identifies bacteria
Blood culture: indentifies bacteria
ESR: indication of inflammation
C-reactive protein: correlates with clinical response to
therapy and can be used to monitor therapy
Bone biopsy: gold standard for diagnosing
osteomyelitis and can identify organism causing the
infection
REFERENCES
Buttaro, T., Trybulsiki, J., Bailey, P, Sandberg-Cook, J. (2017).
Primary care: A collaborative practice (5th Ed). St. Louis,
Elsevier.
Rhodes, J., Penick Julie C., (2015). Formulating a Differential
Diagnosis for the Advanced Practice Provider, second
edition, New York: Springer.
