This is a new one for me...

[DrQuinn]

So (as a 6 shift old new attending), I call up Kaiser to discuss a patient...

me: "Hey! I got a x year old gentleman, came in with a fever, diaphoresis, tachycardia, looked like crap... no specific pains anywhere...."

them: "what was his temperature?"

me: "100.7 rectal"

them: "so, a low grade fever."

me: "..."

me: "one hundred POINT seven, I'm sorry if you heard me wrong."

them: "so, a low grade fever then."

me: "..."

them: "Was it 101.5?"

me: "nope, like I said, 100.7"

them: "then it wasn't a true fever..."

me: "so, anyways, he came in, we ordered..............."




weird weird weird. haven't heard that one before, uhm, ever.

Q

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[Apollyon]

I'm not gettin' ya, man- 38.0 (100.4) x 2 (4hrs apart, I think) or 38.3 (101) once qualify as fever.

 

[DrQuinn]

Everywhere I've trained, med school, rotations, residency, the definition of fever has been 100.4. I'm lucky I even got the rectal temp (i didn't settle for an oral). I know surgery doesn't really get too alarmed unless its even higher, and I'm sure the CDC or some crazy ass specialty group uses a higher number, but from every MD I've met, 100.4 is a fever.

99.1, sure, low grad.

99.9, yep.
100.3, yep, still low grade.
100.4, now yousa have a fever.

Q

 

[Apollyon]

Everywhere I've trained, med school, rotations, residency, the definition of fever has been 100.4. I'm lucky I even got the rectal temp (i didn't settle for an oral). I know surgery doesn't really get too alarmed unless its even higher, and I'm sure the CDC or some crazy ass specialty group uses a higher number, but from every MD I've met, 100.4 is a fever.

99.1, sure, low grad.

99.9, yep.
100.3, yep, still low grade.
100.4, now yousa have a fever.

Q

I agree - since we don't have the luxury of 4 hours, every and anytime I call anyone I have to give the temp to, I tell them "febrile to 38", even if it is only one reading.

To me, it's "yes" or "no" - 100.3, no fever. 100.4, yes. To me, 100.4 IS a low-grade fever, but it's febrile. I even tell the patients that say they have had a low-grade fever of "99.5" or whatever that they do NOT have a fever at all.

By the way, the rectal is a good thing to point out - whenever I have a temp that might tilt things one way or another (whether oral or tympanic), I push for the core temp.

 

[BKN]

I agree - since we don't have the luxury of 4 hours, every and anytime I call anyone I have to give the temp to, I tell them "febrile to 38", even if it is only one reading.

To me, it's "yes" or "no" - 100.3, no fever. 100.4, yes. To me, 100.4 IS a low-grade fever, but it's febrile. I even tell the patients that say they have had a low-grade fever of "99.5" or whatever that they do NOT have a fever at all.

By the way, the rectal is a good thing to point out - whenever I have a temp that might tilt things one way or another (whether oral or tympanic), I push for the core temp.

Every continuous measure gets a cut point in Medicine. For temp indicating infection though, the probability goes up linearly. So a cut point of 100.4 makes sense, so does a differentiation of low grade and high grade (set your definition). Probably easier to just state the temp.

 

[12R34Y]

fever equals 101.5 in the 3 hospitals I trained at prior to residency.

Plain and simple. If it wasn't 101.5 then it WAS NOT A fever and you'd have a conversation similar to what quinn just had.

I don't agree with that.

for instance. I called a surgery resident for a consult on a cholecystitis. Patient came in 99.1 (afebrile)..........after doing U/S and seeing stones and LFT's and alk phos waaaay up. Patient 3 hours later now has temperature of 101 and feels worse.

Now. I'm telling the resident the story and say "now she's got a fever".........he promptly interrupts me and says "that's not a fever".

I then said "well, when she came in she was 99.1 and now in the same temperature room in the same gown with probably cold iv fluids she is now 101 and feels worse....."

sounds like a fever to me.

I hate lack of common sense.

 

[southerndoc]

for instance. I called a surgery resident for a consult on a cholecystitis. Patient came in 99.1 (afebrile)..........after doing U/S and seeing stones and LFT's and alk phos waaaay up. Patient 3 hours later now has temperature of 101 and feels worse.

"I'll call you at 3 am when she hits 101.5. Enjoy a few more minutes of sleep."

 

[12R34Y]

"I'll call you at 3 am when she hits 101.5. Enjoy a few more minutes of sleep."

 

[Homunculus]

in peds we lean on the 100.4 heavily. not only in our own patients, but in the "chorio" workups we get from maternal fevers in the DR or OR.

the 101.5 thing is new to me.

--your friendly neighborhood saturday night fever caveman

 

[BKN]

in peds we lean on the 100.4 heavily. not only in our own patients, but in the "chorio" workups we get from maternal fevers in the DR or OR.

the 101.5 thing is new to me.

--your friendly neighborhood saturday night fever caveman

Like any other cut point as you raise sensitivity (that is drop the temp you consider positive) you lose specificity. Given that many septics have hypothermia, you could drop it to 98.6 and not get all the infections. Conversely if you want to take 101.5 you're gonna miss a bunch of infections.

Just report the temp and use the rest of the workup to determine whether there's an infection. Tempurature varies minute to minute and is only a screen anyway.

 

[roja]

BKN raises a good point (I have always heard the 100.4 as well). Fever is only one part of the whole picture. As I have told many a surgical resident... No pt doesnt have a fever or an elevated WBC, but does have an appy... here is your CT scan to prove it. Many many processes keep people from having a fever despite infection. Its a poor prognosticator for many diseases.

(just intubated an AMS guy whose rectal temp was 100.1 and he grew out gram pos diplococci)

Its great if its there, but in a sick patient it means nothing if its not....


Weird that you were calling Kaiser...

 

[dlung]

I just had a patient with a temp of 97-something and WBC 4-5 with gas gangrene. a local infection, but still weird.

 

[The White Coat Investor]

I've always used this:

Peds: 37.9 or less, no fever. 38.0, fever

Adults: 37.9, no fever. 38.0-38.4 low grade fever, 38.5 fever.

How can 99.1 be low grade fever if 98.1 isn't mild hypothermia?

 

[Apollyon]

How can 99.1 be low grade fever if 98.1 isn't mild hypothermia?

See, that gets to the meat of the issue. Where did the 98.6 being "body temperature" come from? From measurements of hundreds of thousands of people. You can't calculate it.

As the erstwhile BKN stated, you need a cutoff.

 

[Annette]

I hate when the patient, usually with malignant terminal fibromyalgia, says 99.9 is a fever for them because "my usual temperature is 96.3."

 

[BKN]

I hate when the patient, usually with malignant terminal fibromyalgia, says 99.9 is a fever for them because "my usual temperature is 96.3."

Oh yeah. And they clearly understand it when you give them a discussion of diurnal and natural variability.

 

[ERMudPhud]

I hate when the patient, usually with malignant terminal fibromyalgia, says 99.9 is a fever for them because "my usual temperature is 96.3."

Everytime I hear that I want to send them home with a digital rectal thermometer in place and ask them to chart their temps hourly for the next 3 days

 

[Homunculus]

Like any other cut point as you raise sensitivity (that is drop the temp you consider positive) you lose specificity. Given that many septics have hypothermia, you could drop it to 98.6 and not get all the infections. Conversely if you want to take 101.5 you're gonna miss a bunch of infections.

Just report the temp and use the rest of the workup to determine whether there's an infection. Tempurature varies minute to minute and is only a screen anyway.

yup. and some scuttlebutt around the ID folks is that after they crunch more numbers in the new post HiB and pneumococcal vaccination era that our management of the cutoffs may change.

it's spooky to hear about the HiB meningitis cases our attendings dealth with. frank pus from a tap? good god

--your friendly neighborhood culturin' caveman

 

[roja]

We have one or two of those every 6 months or so.

 

[waterski232002]

I have always used 100.4 (38.0) as the cut-off for fever in peds, and 101.0(38.3) as the cut-off in adults. This is also what all hospitals I have worked at have used. It is also what is considered a fever by most textbooks I have studied in medical school and residency.... Emergency Medicine Secrets, Tintinalli, Harriet Lane to name a few.

If a patient is painting a picture of an infection, and has a temp between 38.0 - 38.3 then I will consider it a "low grade fever". However, I recognize that when speaking to any off service, it is not a "true fever" by academic standards, but like others have pointed out, a single temp is a slice in time. Just withhold any antipyretics (despite nurses urging you to "make the patient comfortable"... just tell them to recheck the temp) and you will have your "true fever" soon enough.

 

[edinOH]

Like any other cut point as you raise sensitivity (that is drop the temp you consider positive) you lose specificity. Given that many septics have hypothermia, you could drop it to 98.6 and not get all the infections. Conversely if you want to take 101.5 you're gonna miss a bunch of infections.

Just report the temp and use the rest of the workup to determine whether there's an infection. Tempurature varies minute to minute and is only a screen anyway.

I had a lady yesterday who was one month out from a total knee. Her wound was open with a bunch of bloody puss oozing from the site. Her temp was normal. Not obviously septic but obviously infected. Thankfully the ortho intern knew enough not to get hung up on her temp.