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An 86-year-old African American female with a history of hypertension, COPD, CHF with an ejection fraction (EF) of 40%, and coronary artery disease was admitted to the hospital 4 days ago with respiratory failure due to decompensation of her systolic heart failure. She was intubated in the ER and was transferred to the ICU for further management. In the ICU she required a central line due to poor IV access. A Foley catheter was placed for urine output monitoring. She was diuresed with Lasix successfully, and after 48 hours in the hospital she was extubated. She was maintaining her oxygen saturation of more than 90% on 4 L of O2. She was then transferred to a regular floor. Her current medications include Lasix 80 mg IV bid, lisinopril 40 mg daily, amlodipine 10 mg daily, metoprolol 50 mg bid, aspirin 325 mg bid, Spiriva inhaler qday, and enoxaparin 40 mg SQ daily. Now, 4 days after the admission, the patient is complaining of fever and chills since last night. She denies any cough, sputum production, postnasal drip, diarrhea, abdominal pain, suprapubic tenderness, or flank pain.

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Her vitals are temperature 39.2°C, BP 135/85 mm Hg, pulse 110/min, and respiratory rate 18/min. She is awake, alert, and oriented; central line in the internal jugular vein is without evidence of any discharge or surrounding erythema. There is 1+ pedal edema bilaterally. Cardiac examination shows a normal S1 and S2 without any gallops or murmur; respiratory examination shows vesicular breathing with bibasilar crackles (which have improved since admission 4 days ago). Abdomen is soft and nontender and bowel sounds are normal. Neurologic examination is nonfocal. Skin examination does not reveal any abnormalities. The patient still has a Foley catheter in place.

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1. What is your diagnosis?

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2. What is your next step in evaluation?

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Answers

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  1. The patient has a nosocomial fever at present, which by definition is a fever of at least 38.3°C occurring in a hospitalized patient at least 48 hours after admission in whom neither fever nor infection was present on admission.

  2. Once we have confirmed the fever, the next step is figuring out its source. The patient has had a thorough history and physical examination, which failed to reveal any etiology of fever, so we will start our evaluation with CBC, CMP, blood cultures × 2, urinalysis, and a chest x-ray.

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Fever is a sign of inflammation, not infection. It is not a specific response to infection, but rather is a response to any form of tissue injury that is sufficient enough to trigger an inflammatory response. This might explain why some hospitalized patients with fever have no apparent infection. The distinction between inflammation and infection is an important one, not only for the evaluation of fever but also for curtailing the use of antibiotics to treat a ...

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