Many of the fever encountered in general practice are viral self-limiting and require only symptomatic treatment. So let us first see what the symptomatic treatment of fever consist of.
Mild – Moderate fever :
If fever is mild to moderate say less than hundred degree Fahrenheit or less than 38 degree centigrade, then give tablet of Paracetamol 500 mg or 650 mg like Crocin or Dolo or Tylenol to be repeated as necessary.
High Grade fever :
If fever is higher, i.e. 100 to 103 degrees Fahrenheit then additionally give an injection of paracetamol 2 cc IM, other drugs used to reduce temperature are nimesulide and aspirin.
If fever is higher, in addition to the above measures give cold compresses or Ice packs over the forehead, neck, axilla and groins and sponge the skin with the damp cloth. Advice best rest at home and do not expose to sun and wind. Let the patient have liquid or semi solid diet and no cold water or cold drinks.
The viral fevers are invariably associated with body ache and headache, show the stronger analgesic like NSAID combination can be given, like combiflam.
Remember however your responsibilities doesn’t end here, you should always be aware of other common causes of fever, and warning signals that will tell you that this may not be simple viral fever. Especially when there is epidemic of malaria, typhoid, infective hepatitis or influenza. You should always rule out these conditions first, before labelling the fever as viral.
Fever with Chills :
Now let us consider the accompanying symptoms in detail. The first symptom to be considered is fever with chills, that is shivering of the body. Mild chills are always there but if body and limbs are shivering, that is very significant.
a) Malaria :
In case of severe chills Malaria is the most likely cause. Other causes being, urinary tract infections, cystitis or Pyelonephritis and abscess somewhere, and in endemic areas of filariasis like Bihar, filariasis is also to be considered.
When patient complains of fever with chills first ask whether the patient gets it everyday or on alternate days and is there an associated headache. A fever appearing typically on alternate days at the same time with chills high spikes and headache is diagnostic of malaria. But the malarial fever may not always be so typical so, even if the fever comes everyday and if there are severe chills, and if fever comes at the same time everyday, keep malaria in mind first.
b) UTI :
Second thing to ask if patient has fever with chills is urinary symptoms. Which are burning micturation, frequency of micturition or dysuria. If urinary symptoms are present, urinary infection should be treated first. Use urinary antibiotics like Norfloxacin 400 mg BD or levofloxacin 500 mg OD with syrup cital or syrup citralka and plenty of oral fluids.
c) Abscess :
If there is an abscess giving rise to fever with chills, the patient will primarily complain about painful swelling and then the fever. So abscess if present will have to be incised and drained by a surgeon. The problem only comes if the abscess is hidden somewhere in the chest or peritoneal cavity.
d) Filariasis :
If there is associated leg edema with painful inguinal lymph nodes then suspect Filariasis and test the blood for microfilaria. But think of it only if your area is endemic for filariasis.
So basically if fever is associated with marked chills then malaria and urinary tract infection are the commonest causes. Blood examination with all counts, peripheral smear study and a urine examination should be done for a perfect diagnosis.
Fever without Chills :
a) Simple viral fever :
Now we will come to fever without chills. If fever is associated with severe body ache, throat pain and coryza, that is watery nasal discharge, then viral infection like influenza is most likely. Viral fevers typically give a lot of body ache and coryza, they require only symptomatic treatment. Give tablet Paracetamol and Antihistaminics like cetirizine with anti cold formulations like Syrup Benadryl. For quick relief injection Paracetamol 2cc IM can be given. If body ache is severe then stronger analgesic like tramadol can be given. Viral fevers do not require the use of antibiotics, but in general practice one cannot take chances and later get blamed for not giving antibiotics. On day one you cannot be sure whether this is viral fever, typhoid or tuberculosis. So a common antibiotic like Amoxicillin or Cefixime or Azithromycin can be prescribed along with the symptomatic treatment.
b) Dengue fever :
Now a word of caution whenever you have a flu like fever, 99.9% of them will be simple viral fever but you should be aware of hemorrhagic viral fevers like dengue viral fever, especially in mosquito infested areas. This have similar symptoms of high fever, coryza, headache and body ache. In addition if there are petechial rashes and measles like rash on skin, or if there is bleeding from gums or the nose, or if the pulse is rapid, thready with low BP. or if the patient is restless with cold clammy skin, then it is a very severe situation of dengue hemorrhagic fever. Rapid infusions of IV fluid and fresh PCV will save the patient. The treatment has to be given in ICU. But it is very important for physician to suspect this condition which can be only suspected early by looking at a low platelet count. So always check platelet count in complete blood count report along with widal test and peripheral smear for malaria and if platelet count is on the lower side that is less than 1 lakh repeat it every alternate day and get dengue IgG IgM tests done
c) Meningitis :
If the patient with high fever complains of headache, always test for neck stiffness. It may be a simple headache, but never fail to detect neck stiffness of meningitis.
Protocol for examining a patient with fever.
- Look at the conjunctiva and tongue for pallor.
- Inspect the throat with a good torch for pharyngitis and tonsillitis.
- Inspect the sclera for Jaundice.
- Palpate the neck for lymph node and test for neck stiffness.
- Check the pulse for tachycardia and take blood pressure.
- Palpate the abdomen for liver and spleen.
- Auscultate the chest for rales, rhonchi, bronchial breath sounds or diminished breath sounds.
- Auscultate for tachycardia and murmurs over the heart.
- Inspect the legs for edema.
- Inspect the skin for petechiae and rashes.
In the next article, we will look at more causes of fever without chills and prolonged fever.