MICA · FIRST-LINE LEARNING NOTES
Understand, prioritise and organise follow-up
Prolonged fever requires a reliable timeline, repeated examination and a search for diagnostic clues. Duration never reduces the priority of acute organ dysfunction.
Confirm fever and reconstruct its course
Record measured temperatures, method, timing, treatments and associated symptoms. Review travel, TB contacts, animal exposure, recent procedures, implanted material and medicines started before fever. Examine skin, mucosa, joints, nodal regions, heart and abdomen. Immunosuppression or a prosthetic valve changes risk and diagnostic possibilities; a normal temperature during consultation does not refute documented episodes.
[1][2]Sample according to diagnostic hypotheses
Blood counts, inflammatory markers, kidney and liver tests and urinalysis contribute to the initial assessment, supplemented by findings. Suspected endocarditis requires appropriate blood cultures and cardiac assessment; obtain cultures before antibiotics when possible without delaying urgent treatment. TB testing requires specimens appropriate to the suspected site. Serology and advanced imaging should answer a clinical question rather than follow an indiscriminate catalogue.
[1][2]Reconstruct measured temperature, symptoms, treatments and samples on a timeline. Consider valve disease, intracardiac devices, recent care and embolic features when endocarditis is plausible. For tuberculosis, include exposure, epidemiology and extrapulmonary manifestations. Consider drug fever without indiscriminately stopping essential medicines.
[1][3]Distinguish outpatient investigation from emergency care
Confusion, respiratory distress, poor perfusion, reduced urine output or rapid deterioration require urgent assessment, including consideration of sepsis. In a stable patient, consider infection, malignancy, inflammatory disease and drug-related fever according to clues. Fever, rash and arthralgia may suggest Still’s disease, but high ferritin does not remove the need to assess alternatives. Cytopenias with hyperinflammation warrant prompt specialist review.
[4][5]- When clinically safe, obtain useful microbiological samples before further antibiotics without delaying care for severe infection.
- Fever with a new murmur, embolic features or cardiac devices needs prompt specialist discussion.
- Communicate negative as well as positive results, dates and previous antibiotic exposure.
Re-examine rather than repeat unchanged testing
Share one timeline of findings and treatments with the specialist. Identify pending samples and check their final results. If the person remains stable, successive visits should seek new signs and reconsider hypotheses. Explain specific reasons for emergency reassessment and maintain clinical follow-up while investigations are pending.
[4][2]A learning situation
FICTIONAL CASE · SELF-REFLECTION WITHOUT A SCORE
A 67-year-old man with a prosthetic valve describes intermittent fever and fatigue for several weeks. He has received several short treatments without microbiological documentation. He is currently alert, well perfused and not breathless at rest.
Which history element should structure the investigation?
Read the reasoning
The prosthetic valve raises concern for endocarditis and warrants an organised specialist assessment with appropriate blood cultures and cardiac imaging. An inconclusive initial echocardiogram may not exclude it. Any clinical deterioration would require emergency care rather than waiting for scheduled tests.
References and scope
- WHO consolidated guidelines on tuberculosis: module 3: diagnosis ↗
- Guía ESC 2023 sobre el diagnóstico y el tratamiento de la endocarditis — traduction officielle SEC, corrigenda 2025 ↗
- 2023 ESC Guidelines for the management of endocarditis — official guideline portal ↗
- Suspected sepsis in people aged 16 or over (NG253): face-to-face assessment ↗
- EULAR/PReS recommendations for the diagnosis and management of Still’s disease, comprising systemic juvenile idiopathic arthritis and adult-onset Still’s disease ↗
Original educational synthesis for adult first-line practice. International references must be interpreted with the clinical setting and local care pathways. Independent human scientific review remains to be confirmed.