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| <div style="font-size: 90%;">
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| {{Familytree/start}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==SLE Presentation== <ref name="pmid11085805">{{cite journal |vauthors=Tench CM, McCurdie I, White PD, D'Cruz DP |title=The prevalence and associations of fatigue in systemic lupus erythematosus |journal=Rheumatology (Oxford) |volume=39 |issue=11 |pages=1249–54 |year=2000 |pmid=11085805 |doi= |url=}}</ref><ref name="pmid7779127">{{cite journal |vauthors=McKinley PS, Ouellette SC, Winkel GH |title=The contributions of disease activity, sleep patterns, and depression to fatigue in systemic lupus erythematosus. A proposed model |journal=Arthritis Rheum. |volume=38 |issue=6 |pages=826–34 |year=1995 |pmid=7779127 |doi= |url=}}</ref><ref name="pmid9598886">{{cite journal |vauthors=Wang B, Gladman DD, Urowitz MB |title=Fatigue in lupus is not correlated with disease activity |journal=J. Rheumatol. |volume=25 |issue=5 |pages=892–5 |year=1998 |pmid=9598886 |doi= |url=}}</ref>
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| *[[Fatigue]]
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| *[[Fever]]
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| *[[Myalgia]]
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| *Joint [[tenderness]]
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| *[[Muscle weakness]]
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| *[[Weight]] changes
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| </div>}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| |!| | | |}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Focused History==
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| * Verify the presence of fever and its pattern<ref>{{cite book | last = Isaac | first = Benedict | title = Unexplained fever : a guide to the diagnosis and management of febrile states in medicine, surgery, pediatrics, and subspecialties | publisher = CRC Press | location = Boca Raton | year = 1991 | isbn = 9780849345562 }}</ref><ref>{{Cite journal| issn = 0891-5520| volume = 10| issue = 1| pages = 33–44| last = Cunha| first = B. A.| title = The clinical significance of fever patterns| journal = Infectious Disease Clinics of North America| date = 1996-03| pmid = 8698993}}</ref>
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| :* Sustained fever (s/o [[brucellosis]], [[drug fever]], [[Gram-negative]] [[pneumonia]], [[tularemia]], [[typhoid]], [[typhus]])
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| :* Remittent fever (s/o [[tuberculosis]], [[mycoplasma pneumonia]], [[malaria]], [[legionellosis]])
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| :* Intermittent fever (s/o [[malaria]], [[Visceral leishmaniasis|kala-azar]], [[pyaemia]])
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| ::* Double quotidian fever (s/o [[Still's disease]], [[legionellosis]], [[miliary tuberculosis]], [[kala-azar]])
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| ::* Quotidian fever (s/o ''[[Plasmodium falciparum]]'' or ''[[Plasmodium knowlesi]]'' [[malaria]])
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| ::* Tertian fever (s/o ''[[Plasmodium vivax]]'' or ''[[Plasmodium ovale]]'' [[malaria]])
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| ::* Quartan fever (s/o ''[[Plasmodium malariae]]'' [[malaria]])
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| ::* Alternate-day fever (s/o response to [[antipyretic]] [[dosage|dosage schedule]])
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| :* Hyperpyrexia (s/o [[intracranial hemorrhage]], [[septicemia]], [[Kawasaki disease]], [[thyroid storm]], [[drug fever]])
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| :* Hectic or spiking pattern (s/o [[biliary tract|biliary]] or [[urinary tract infection]], [[endocarditis]])
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| :* Morning temperature spikes (s/o [[typhoid fever]], [[tuberculosis]], [[polyarteritis nodosa]])
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| :* Relapsing pattern (s/o ''[[relapsing fever|Borrelia recurrentis]]'', [[typhoid fever]], [[malaria]], [[brucellosis]], [[rat-bite fever]])
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| :* Irregular pattern (s/o [[fever|factitious fever]])
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| :* Pel-Ebstein pattern (s/o [[Hodgkin's lymphoma]])
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| :* Picket fence pattern (s/o [[mastoiditis|acute mastoiditis]] complicated by [[transverse sinus]] [[thrombosis]])
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| :* Saddleback (dromedary) pattern (s/o [[dengue fever]], [[leptospirosis]], [[poliomyelitis]], [[ehrlichiosis]])
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| :* Wunderlich curve pattern (s/o [[typhoid fever]])
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| * History of previous surgeries or procedures
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| * History of malignancy and related therapy
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| * History of previously treated infections
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| * History of sick or animal contacts
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| * History of psychiatric illness
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| * History of recent traveling
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| * History of comorbidities
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| * History of medications
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| * History of transfusions
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| * Social and family history
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| </div>}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| |!| | | |}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Physical Examination==
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| ===Vitals===
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| * A [[fever]] is often present. The [[Fever of unknown origin history and symptoms#Fever patterns|periodicity of fever]] may have clinical significance in selected contexts.
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| * Weak or absent [[pulse]] may be present in [[Takayasu's arteritis]].
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| * Physiologically, fever is accompanied by [[tachycardia]].
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| * [[Faget's sign|Relative bradycardia (Faget's sign)]] may be present in [[legionellosis]], [[brucellosis]], [[psittacosis]], [[leptospirosis]], [[drug fever]], or [[fever|factitious fever]].
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| ===Skin===
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| * [[Janeway lesion]]s may be present in [[infective endocarditis]].
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| * [[Petechiae]] may be present in [[Rocky Mountain spotted fever]].
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| * [[Rash|maculopapular, vesicular, or petechial rash]] may be present in [[typhus]].
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| * An [[eschar]] at the site of the tick bite may be present in [[tick-borne disease]]s.
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| * [[Swollen lymph nodes]] may be present. [[Lymphadenopathy]] may represent reactive lymphoid hyperplasia (suggestive of [[inflammation]] or [[infection]]) or underlying malignant processes such as [[lymphoma]].
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| * [[Rose spots]] (blanching pink papules 2–3 mm in diameter) may be present on the trunk in [[salmonellosis]].
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| * [[Macules]], [[papules]], and [[nodules]] may be present on the trunk and extremities in [[meningococcemia]].
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| * [[Macules]] or [[petechiae]] evolving into [[vesicles]] and [[pustules]] on a hemorrhagic base may be present in [[gonococcus|disseminated gonococcal infection]].
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| * Diffuse [[hyperpigmentation]] may be present in [[Whipple's disease]].
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| * [[Papules]] and [[nodules]] evolving into crusted, verrucous growths may be present in [[blastomycosis]].
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| * [[Wart]]y [[nodules]] and subcutaneous [[abscess]]es may be present in [[coccidioidomycosis]].
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| * [[Erythematous]] [[papules]], [[pustules]], subcutaneous [[nodules]], or [[cellulitis]] may be present in [[cryptococcosis]].
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| * [[Sister Mary Joseph nodule]] (palpable [[nodule]] bulging into the [[umbilicus]]) may be present in metastasis of a [[cancer|malignant tumor]] in the pelvis or abdomen.
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| * Multiple purplish [[papules]], [[nodules]], and [[plaques]] may be present on the scalp, face, and neck in [[lymphoma]].
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| * Multiple [[erythematous]], painful [[plaques]] with small bumps, [[pustules]], and [[vesicles]] may be present in [[Sweet's syndrome]].
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| * Palpable [[purpura]] may be present on the lower extremities and other areas of dependency in cutaneous [[vasculitis]].
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| ===Head===
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| * [[Temporal artery]] [[tenderness]] with weak [[pulse]] may be present in [[temporal arteritis]].
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| * Sinus [[tenderness]] may be present in [[sinusitis]].
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| ===Eyes===
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| * [[Roth's spot]]s or [[conjunctival hemorrhage]] may be present in [[infective endocarditis]].
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| * [[Photophobia]] or ocular pain on palpation suggestive of [[uveitis]] may be present in [[Wegener's granulomatosis]], [[Behcet syndrome]], [[Vogt-Koyanagi-Harada syndrome]], or [[infection]]s.
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| ===Mouth===
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| * [[Oral thrush]] caused by [[candidiasis]] may be present in patients with [[HIV]]/[[AIDS]].
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| * [[Oral ulcer]]s may be present in [[systemic lupus erythematosis]], disseminated [[histoplasmosis]], and [[Behcet syndrome]].
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| * [[Tenderness]] with a palpable [[abscess]] may be present in [[periodontal disease]].
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| * [[Petechiae]] on the palate may be present in [[infective endocarditis]].
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| * [[Parotid gland]] enlargement and [[tenderness]] may be present in [[infection]]s (e.g., ''[[Staphylococcus aureus]]'', [[tuberculosis]], [[mumps]], [[HIV]]), [[Sjogren's syndrome]], or [[sarcoidosis]].
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|
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| ===Neck===
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| * Cervical [[lymph nodes]] may be present in [[inflammation]], [[infection]], [[lymphoma]], or [[Kikuchi disease]].
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| * Enlargement of the [[thyroid gland]] may be present in [[thyroiditis]].
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| ===Lungs===
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| * [[Rales]] or [[rhonchi]] may be present in [[pneumonia]].
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| * [[Fremitus]] with diminished [[breath sounds]] may be present in [[pneumonia]].
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| ===Heart===
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| * [[Heart murmurs]] may be present in [[endocarditis]] secondary to [[infection]]s ([[infective endocarditis]]), [[systemic lupus erythematosus]] ([[Libman-Sacks endocarditis]]), or chronic diseases ([[marantic endocarditis]]).
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| ===Abdomen===
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| * [[Abdominal tenderness]] may be present in [[intra-abdominal infection]]s.
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| * [[Rebound tenderness]] may be present in [[intra-abdominal infection]]s.
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| * An [[acute abdomen]] may be present in [[intra-abdominal infection]]s.
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| * Guarding may be present in [[intra-abdominal infection]]s.
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| * [[Flank pain]] may be present in psoas muscle [[abscess]], perinephric abscess, or [[pyelonephritis]].
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| * An inguinal mass may be present in psoas muscle [[abscess]].
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| * [[Splenomegaly]] may be present in [[infectious mononucleosis]], [[spleen|splenic]] [[abscess]], or [[hepatitis]].
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| ===Genitourinary===
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| * [[prostate|Prostatic]] enlargement may be present in [[prostate|prostatic]] [[abscess]].
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| * Epididymal [[nodule]] may be present in [[epididymitis]].
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| * [[testicle|Testicular]] [[nodule]] may be present in [[polyarteritis nodosa]].
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| ===Extremities===
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| * [[Osler's node]]s may be present in [[infective endocarditis]].
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| * Swollen joints with effusion may be present in infectious [[arthritis]] or [[rheumatic disease]]s.
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| * [[Splinter hemorrhage]] in the nail beds may be present in [[infective endocarditis]].
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| * Limb [[tenderness]] along deep veins may be present in [[deep vein thrombosis]] or [[thrombophlebitis]].
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| ===Neurologic===
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| * [[Altered mental status]] may be present.
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| * Cranial nerve deficits may be present in cerebral [[vasculitis]] associated with [[systemic lupus erythematosus]].
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| </div>}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| |!| | | |}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Laboratory Workup==
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| * [[Complete blood count|CBC with DC]]
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| * [[Basic metabolic panel|SMA-7]]
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| * [[AST]], [[ALT]], [[LDH]], [[bilirubin]], and [[ALP]]
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| * [[Creatine kinase]]
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| * [[Blood cultures]], at least 2 sets
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| * [[Urinalysis]] with [[Urinalysis#Microscopic examination|microscopic examination]]
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| * [[Urine culture]]s
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| * [[Erythrocyte sedimentation rate]]
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| * [[C-reactive protein]]
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| * [[Gamma-glutamyl transferase]]
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| * [[Coombs test]]
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| * [[Cold agglutinins]]
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| * [[Ferritin]]
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| * [[Angiotensin-converting enzyme]]
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| * [[Thyroid peroxidase]] and [[ATG|anti-thyroglobulin antibodies]]
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| * [[Antinuclear antibodies]]
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| * [[Rheumatoid factor]]
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| * [[Cryoglobulins]]
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| * [[CMV]] [[serology]] and [[heterophile antibody test]] if ⊕ [[Reactive lymphocyte|atypical lymphocytes]]
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| * [[Q fever]] [[serology]] if ⊕ exposure to livestocks
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| * [[HIV]] [[serology]]
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| * [[Serum protein electrophoresis]]
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| * [[Tuberculin skin test]]
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| * [[Fecal occult blood test]]
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| </div>}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| |!| | | |}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Imaging Study==
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| ===Chest Radiograph===
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| * Chest radiograph should be considered as a part of the initial diagnostic workup.
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| ===Echocardiography===
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| * Echocardiography should be considered when suspecting [[endocarditis]].
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| ===Abdominal Ultrasonography===
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| * Abdominal ultrasonography should be considered when suspecting hepatobiliary pathology.
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| ===Chest CT Scan===
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| * Chest CT scan may detect nodular lesions (s/o [[malignancy]] or [[fungal]]/[[mycobacterial]]/[[nocardial]] [[infection]]) or [[mediastinal]] [[adenopathy]] (s/o [[lymphoma]], [[histoplasmosis]], or [[sarcoidosis]]).
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| ===Abdominal CT Scan===
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| * Abdominal CT scan should be considered when suspecting [[intra-abdominal abscess]] or [[malignancy]].
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| ===Positron Emission Tomography===
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| * PET may be useful in localizing the nidus of fever of unknown origin.
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| </div>}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| |!| | | |}}
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| {{Familytree|boxstyle=width: 700px; text-align: left; font-size: 100%; padding: 0px;| A01 | | |A01=<div style="padding: 10px;">
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| ==Other Investigation==
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| ===Lymph Node Biopsy===
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| * Lymph node biopsy may be useful when suspecting [[lymphoma]], [[lymphogranuloma venereum]], [[toxoplasmosis]], and [[Kikuchi disease]].
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| * Granuloma may indicate disorders associated with granulomatous [[inflammation]] (eg, [[tuberculosis]], [[sarcoidosis]]) or [[lymphoma]].
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| ===Bone Marrow Biopsy===
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| * Bone marrow biopsy may be considered when suspecting intracellular infectious pathogens or hematologic malignancies.
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| ===Discontinuation of Nonessential Medications===
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| * Nonessential medications should be discontinued.
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| * Defervescence in less than 72 hours after discontinuing the culprit medication suggests [[drug fever]].
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| * Rechallenge with the offending agent usually results in recurrence of [[drug fever]].
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| ===Trial of Empiric Antibiotics===
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| * Therapeutic trials of antimicrobial agents may be considered if other techniques fail to disclose the etiology.
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| * An infectious etiology is likely if abatement of fever occurs after the administration of empiric antibiotics.
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| ===Naproxen Test===
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| * Naproxen test (375 mg twice daily) can be used to distinguish [[neoplastic]] [[fever]] from other etiologies.
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| * Naproxen test is considered positive when there is a rapid or sustained abatement of fever during the 3 days of the trial period.
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| * Defervescence within 12 hours occurs in almost all patients with [[neoplastic]] [[fever]].
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| * Fever recurs after discontinuation of naproxen in patients with [[neoplasms]].
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| * Naproxen demonstrated no antipyretic activity against fever in patients with occult infection.
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| </div>}}
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| {{Familytree/end}}
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| </div>
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