# Feverish and unwell for nine days, a 19-year-old hostel student: a case to work up

> An infectious disease case for medical students: a 19-year-old hostel student with a fever rising for nine days, headache, belly ache and no appetite, no better after tablets from the chemist. What to ask, first tests and the differential.

- Infectious Disease · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/19-year-old-hostel-student-who-has-felt-hot-and-unwell-for-nine-days
- Work up this patient: https://www.medikarya.in/case-studies/19-year-old-hostel-student-who-has-felt-hot-and-unwell-for-nine-days

## How the patient presents

An engineering student's temperature has climbed a little higher each day for nine days, with a headache, a dull ache in the belly and no appetite. A course of tablets from the chemist did nothing.

## Why a fever lasting more than a week matters

A fever that has lasted more than a week has outlasted most viral illnesses. In India the common treatable causes include malaria, dengue, typhoid and other bacterial infections, urinary infection and tuberculosis; where he eats and drinks, how the fever has behaved and a few tests narrow them. Tablets from the chemist, often antibiotics, can blunt the fever and make cultures harder to grow.

## What to ask in the history

- How the fever started and how it has changed day by day
- Headache, abdominal pain, constipation or diarrhoea, vomiting
- Cough, sore throat, rash, joint pains
- Urinary symptoms; yellow eyes
- Where he eats and drinks: hostel mess, street food, water source; others ill in the hostel
- Travel home or elsewhere, mosquitoes
- Exactly what the chemist gave, and for how long
- Vaccinations; contact with tuberculosis; sexual history

## Red flags

- Confusion or drowsiness
- Severe or worsening abdominal pain, a swollen or rigid abdomen
- Blood in the stool or black stools
- Jaundice
- Low blood pressure
- Bleeding or a falling platelet count
- Breathlessness

## What to examine

- Temperature with the pulse
- Hydration
- Rash, lymph nodes, throat, tongue
- Abdomen: tenderness, liver, spleen
- Chest
- Neck stiffness, jaundice

## First investigations

- Blood cultures, before any further antibiotic
- Full blood count, liver and kidney function, CRP
- Malaria test
- Dengue tests chosen by the day of illness
- Urine routine and culture
- Stool culture
- Chest X-ray
- Further tests, including for tuberculosis, if the fever goes on

## Differential diagnosis of a fever lasting more than a week

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Parasitic and viral

- Malaria
- Dengue
- Viral hepatitis
- Infectious mononucleosis
- Acute HIV infection

### Bacterial

- Enteric fever (typhoid or paratyphoid)
- Urinary infection
- Leptospirosis
- Rickettsial infection
- Brucellosis

### Other

- Tuberculosis
- Liver abscess
- Autoimmune disease or drug fever

## Common mistakes

- Relying on the Widal test.
- Starting another antibiotic before blood cultures are taken.
- Missing a surgical abdomen in a patient who has had a long fever.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.