Fever of unknown origin physical examination

Physical findings may be subtle and merit close scrutiny in the investigation of fever of unknown origin.

Physical findings with diagnostic significance are as follows:^[1][2][3][4]

• A fever is often present. The periodicity of fever may have clinical significance in selected contexts.

• Weak or absent pulse may be present in Takayasu’s arteritis.

• Physiologically, fever is accompanied by tachycardia.
• Relative bradycardia (Faget’s sign) may be present in legionellosis, brucellosis, psittacosis, leptospirosis, drug fever, or factitious fever.

• Janeway lesions may be present in infective endocarditis.
• Petechiae may be present in Rocky Mountain spotted fever.
• maculopapular, vesicular, or petechial rash may be present in typhus.
• An eschar at the site of the tick bite may be present in tick-borne diseases.
• Swollen lymph nodes may be present. Lymphadenopathy may represent reactive lymphoid hyperplasia (suggestive of inflammation or infection) or underlying malignant processes such as lymphoma.
• Rose spots (blanching pink papules 2-3 mm in diameter) may be present on the trunk in salmonellosis.
• Macules, papules, and nodules may be present on the trunk and extremities in meningococcemia.
• Macules or petechiae evolving into vesicles and pustules on a hemorrhagic base may be present in disseminated gonococcal infection.
• Diffuse hyperpigmentation may be present in Whipple’s disease.
• Papules and nodules evolving into crusted, verrucous growths may be present in blastomycosis.
• Warty nodules and subcutaneous abscesses may be present in coccidioidomycosis
• Erythematous papules, pustules, subcutaneous nodules, or cellulitis may be present in cryptococcosis.
• Sister Mary Joseph nodule (palpable nodule bulging into the umbilicus) may be present in metastasis of a malignant tumor in the pelvis or abdomen.
• Multiple purplish papules, nodules, and plaques may be present on the scalp, face, and neck in lymphoma.
• Multiple erythematous, painful plaques with small bumps, pustules, and vesicles may be present in Sweet’s syndrome.
• Palpable purpura may be present on the lower extremities and other areas of dependency in cutaneous vasculitis.

• Temporal artery tenderness with weak pulse may be present in temporal arteritis.
• Sinus tenderness may be present in sinusitis.

• Roth’s spots or conjunctival hemorrhage may be present in infective endocarditis.
• Photophobia or ocular pain on palpation suggestive of uveitis may be present in Wegener’s granulomatosis, Behcet syndrome, Vogt-Koyanagi-Harada syndrome, or infections.

• Oral thrush caused by candidiasis may be present in patients with HIV/AIDS.
• Oral ulcers may be present in systemic lupus erythematosis, disseminated histoplasmosis, and Behcet syndrome.
• Tenderness with a palpable abscess may be present in periodontal disease.
• Petechiae on the palate may be present in infective endocarditis.
• Parotid gland enlargement and tenderness may be present in infections (e.g., Staphylococcus aureus, tuberculosis, mumps, HIV), Sjogren’s syndrome, or sarcoidosis.

• Cervical lymph nodes may be present in inflammation, infection, lymphoma, or Kikuchi disease.
• Enlargement of the thyroid gland may be present in thyroiditis.

• Rales or rhonchi may be present in pneumonia.
• Fremitus with diminished breath sounds may be present in pneumonia.

• Heart murmurs may be present in endocarditis secondary to infections (infective endocarditis), systemic lupus erythematosus (Libman-Sacks endocarditis), or chronic diseases (marantic endocarditis)..

• Abdominal tenderness may be present in intra-abdominal infections.
• Rebound tenderness may be present in intra-abdominal infections.
• An acute abdomen may be present in intra-abdominal infections.
• Guarding may be present in intra-abdominal infections.
• Flank pain may be present in psoas muscle abscess, perinephric abscess, or pyelonephritis.
• An inguinal mass may be present in psoas muscle abscess.
• Splenomegaly may be present in infectious mononucleosis, splenic abscess, or hepatitis.

• Prostatic enlargement may be present in prostatic abscess.
• Epididymal nodule may be present in epididymitis.
• Testicular nodule may be present in polyarteritis nodosa.

• Osler’s nodes may be present in infective endocarditis.
• Swollen joints with effusion may be present in infectious arthritis or rheumatic diseases.
• Splinter hemorrhage in the nail beds may be present in infective endocarditis.
• Limb tenderness along deep veins may be present in deep vein thrombosis or thrombophlebitis.

• Altered mental status may be present.
• Cranial nerve deficits may be present in cerebral vasculitis associated with systemic lupus erythematosus.