# Eight days of fever after cutting grass, a 42-year-old: a case to work up

> An infectious disease case for medical students: a farm worker from the hills with eight days of high fever, headache and body aches after the monsoon. What to ask, examination, first tests and the differential.

- Infectious Disease · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/42-year-old-woman-with-eight-days-of-fever-after-cutting-grass
- Work up this patient: https://www.medikarya.in/case-studies/42-year-old-woman-with-eight-days-of-fever-after-cutting-grass

## How the patient presents

A farm worker from the hills has had high fever, a pounding headache and aching all over for eight days, through the end of the monsoon. Paracetamol brings the fever down for a few hours only.

## Why a prolonged fever in a farm worker matters

A fever lasting more than a week in rural India has a short list of common, treatable causes. Her work, the season and her exposures, together with a careful head-to-toe examination, narrow it quickly.

## What to ask in the history

- Fever pattern, shivering
- Headache, body aches, cough, breathlessness
- Rash
- Yellow eyes, dark urine
- Bleeding
- Work in fields, grass or water; animals; mosquitoes
- Travel, anyone else ill
- Every medicine taken so far

## Red flags

- Breathlessness, low oxygen saturation
- Low blood pressure, little urine
- Confusion or seizures
- Jaundice
- Bleeding
- A falling platelet count

## What to examine

- Observations
- A full skin examination for rashes, bites and lesions
- Lymph nodes
- Jaundice
- Chest
- Liver and spleen
- Neck stiffness

## First investigations

- Full blood count with platelets, liver and kidney function
- Malaria test
- Dengue tests
- Antibody tests for rickettsial infection and leptospirosis
- Blood culture for typhoid
- Chest X-ray
- Urine test

## Differential diagnosis of a prolonged fever in a farm worker

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

### Parasitic and viral

- Malaria
- Dengue
- Chikungunya

### Bacterial

- Typhoid
- Leptospirosis
- Brucellosis

### Rickettsial

- Scrub typhus
- Spotted fever

### Other

- Tuberculosis
- An abscess
- Autoimmune disease

## Common mistakes

- Relying on the Widal test.
- Not examining the whole skin.
- Holding treatment while waiting for tests when she is very unwell.

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