# Fever and new confusion in a 45-year-old: an emergency case to work up

> An emergency case for medical students: a 45-year-old with two days of high fever, shivering and right-sided pain who has stopped making sense. What to ask, red flags, first tests and the differential.

- Emergency Medicine · Intermediate · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/45-year-old-woman-with-fever-who-has-become-confused
- Work up this patient: https://www.medikarya.in/case-studies/45-year-old-woman-with-fever-who-has-become-confused

## How the patient presents

Her husband brings her in after two days of high fever with shivering and pain in her right side. Since last night she has been vomiting, and this afternoon she stopped making sense.

## Why fever with confusion matters

Fever with new confusion is sepsis or a brain infection until proven otherwise. Start treatment quickly while you look for the source, because the outcome depends on how soon the right antibiotics and fluids arrive.

## What to ask in the history

- How long the fever has lasted, shivering
- Where the pain is
- Urinary symptoms
- Vomiting, diarrhoea
- Headache, neck stiffness, rash, seizures
- Diabetes, other illness, medicines that lower immunity
- Recent travel, mosquitoes, water or animal exposure
- Medicines, alcohol
- Could she be pregnant

## Red flags

- Low blood pressure, fast breathing, confusion
- Little urine
- Low glucose
- Neck stiffness or a rash
- Jaundice

## What to examine

- Airway, breathing, circulation; conscious level; glucose
- Full observations
- Skin: rash, perfusion
- Neck stiffness
- Chest
- Abdomen, including the flanks and liver
- Focal neurological signs

## First investigations

- Blood cultures before antibiotics, without delaying them
- Lactate and blood gas
- Full blood count, CRP, kidney and liver function, glucose, clotting
- Urine test and culture
- Malaria test
- Chest X-ray
- Ultrasound of the abdomen
- CT head and lumbar puncture if meningitis or encephalitis is suspected

## Differential diagnosis of fever with confusion

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

### Brain

- Meningitis
- Encephalitis
- Cerebral malaria

### Tropical infections

- Malaria
- Leptospirosis
- Scrub typhus
- Dengue
- Typhoid

### Sources of sepsis

- Kidney infection
- Infection of the bile ducts or a liver abscess
- Pneumonia

### Metabolic

- Low glucose
- Low sodium
- Diabetic ketoacidosis

## Common mistakes

- Holding antibiotics until every test is back.
- Blaming the confusion on the fever alone.
- Forgetting the malaria test.

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