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IM4.1-20 | Fever and Febrile Syndromes — Assignment

CLINICAL SCENARIO

You will present a structured clinical case report of a real or composite patient with an acute febrile illness or fever of unknown origin encountered during your general medicine posting. The report covers the full clinical cycle from structured history and examination to differential diagnosis, targeted investigation, empiric treatment, and patient communication. The goal is to demonstrate that you can reason systematically about fever — moving from clinical features to a probability-ranked differential, building a step-wise investigation strategy, and constructing a safe and justified empiric treatment plan. The report should reflect the approach of a confident final-year MBBS student who understands both the common causes of fever in India and the structured approach to prolonged fever (FUO).

Instructions

Submit a structured written report in the sections below. Use professional clinical language throughout. For all drug treatments, specify dose, route, and duration. Do not copy SDL content verbatim — integrate the clinical reasoning in your own words. All factual claims (drug doses, investigation thresholds, diagnostic criteria) must be accurate. Word limit: 1,200-1,600 words.

Length: 1,200-1,600 words across all sections

What to Submit

Section 1: Structured History of the Febrile Patient

Guidance: Using the six-domain structured fever history framework (fever characterisation, associated symptoms, immune status and comorbidities, exposure and epidemiology, travel and occupation, medications and prior treatments), present your patient's history. For each domain, state the finding AND explain its diagnostic significance. Describe the fever pattern (continuous, remittent, intermittent, relapsing, quotidian) and state what diagnoses each pattern suggests or refutes. Approximately 300 words.

Section 2: Physical Examination and Differential Diagnosis

Guidance: Document the key findings from a systematic examination covering general appearance, skin and mucous membranes, lymph nodes, chest, and abdomen (including liver and spleen size). For each abnormal finding, state the diagnostic significance. Then construct a prioritised differential diagnosis list with at least three conditions spanning at least two categories (infectious, inflammatory/autoimmune, malignant, or rheumatological). For each diagnosis, state the clinical and epidemiological features that support it and one feature that argues against it. Approximately 300 words.

Section 3: Investigation Plan and Interpretation

Guidance: Build a step-wise investigation plan (first tier, second tier, third tier) linked explicitly to your differential diagnosis. State what specific question each investigation is intended to answer. For at least two investigations that you have results for, provide an interpretation with actual or likely values and their clinical significance. If Mantoux testing was ordered, describe the technique (intradermal, forearm, 0.1 mL), the correct reading method (induration not erythema, at 48-72 hours), and state the threshold applicable to your patient. Approximately 300 words.

Section 4: Empiric Treatment Plan

Guidance: For the most probable diagnosis (or top two if closely matched), construct an empiric treatment plan: name the drug(s), dose, route, and duration. State why you chose this regimen over alternatives. Define the exit strategy: what response in 48-72 hours would confirm the diagnosis, and what would prompt you to broaden or change the regimen. If the differential includes any possibility of TB or visceral leishmaniasis, explicitly state that corticosteroids must NOT be initiated until both are excluded. Approximately 200 words.

Section 5: Patient and Family Communication

Guidance: Write a brief structured script or summary of how you would communicate the following to the patient and family: (1) the current working diagnosis or state of diagnostic uncertainty, (2) the purpose of the investigations being ordered, (3) the proposed treatment and expected timeline for response, and (4) at least two specific red flag symptoms that should prompt immediate return to hospital. Use plain language accessible to a patient with no medical background. Approximately 150 words.

Section 6: Reflective Practice

Guidance: Identify one specific moment in this case where you were uncertain — about the diagnosis, investigation choice, or treatment decision — and reflect on what clinical reasoning principle that uncertainty highlighted for you. What would you do differently in the next similar case? Approximately 100 words.

Grading Rubric — Fever Workup and Management Plan Rubric

Criterion	Points	Full-marks descriptor
History and Clinical Assessment (Section 1): Presents a structured, complete history using all six fever history domains; identifies the fever pattern and links it to the differential; documents immune status, epidemiological context, and relevant comorbidities.	20 pts	All six history domains present and linked to the differential; fever pattern correctly characterised and interpreted; epidemiological exposure and immune status clearly documented with diagnostic significance explained.
Examination and Differential Diagnosis (Section 2): Documents the key physical examination findings relevant to febrile diagnosis; generates a prioritised differential across infectious, inflammatory, malignant, and rheumatological categories with justification.	20 pts	Systematic examination findings documented for skin/mucosa/lymph nodes/chest/abdomen; at least one finding from each major category; prioritised differential with minimum three diagnoses, each with explicit supporting and refuting features.
Investigation Plan and Interpretation (Section 3): Constructs a prioritised, step-wise investigation plan aligned to the differential; correctly interprets at least two key results including the Mantoux test if applicable.	25 pts	Investigation plan explicitly linked to each differential diagnosis; step-wise (not shotgun) ordering; correctly states Mantoux reading technique (induration not erythema) and cutoff; correctly interprets at least two other investigations with specific values and their clinical significance.
Empiric Treatment Plan (Section 4): Develops a syndrome-specific empiric treatment plan with explicit justification, identifies the exit strategy, and avoids high-risk empiric treatments (steroids before TB/kala-azar exclusion).	20 pts	Empiric regimen precisely specified (drug, dose, route, duration) for the most probable diagnosis; rationale explicit; exit strategy defined (when to narrow/broaden/stop); explicitly states that corticosteroids must not be started before TB and kala-azar exclusion.
Patient and Family Communication (Section 5): Presents a structured communication plan for the patient and family that explains the diagnosis (or diagnostic uncertainty), investigation purpose, and treatment plan in accessible language.	10 pts	Communication is structured (opening, explanation, treatment, red flags, follow-up); uses lay terms appropriately; acknowledges uncertainty honestly without causing excessive anxiety; includes at least two specific red flag symptoms for the family to monitor.
Reflective Practice (Section 6): Reflects on a specific moment of diagnostic uncertainty encountered in the case and what clinical reasoning principle it reinforced.	5 pts	Reflection is specific to a genuine diagnostic uncertainty in the case; identifies a concrete clinical reasoning principle learned; goes beyond restating the clinical outcome.

PEER REVIEW

Review your peer's fever case report using the rubric provided. For each section, assign a score and write one specific comment explaining your assessment. For Section 3 (Investigations): check whether the Mantoux reading method is correctly described (induration, not erythema; 48-72 hours; correct cutoff for the patient's immune status). For Section 4 (Treatment): verify that drug doses and durations are specific and accurate; check whether the steroid warning is present if TB or kala-azar was on the differential. For Section 5 (Communication): identify whether the red flag symptoms provided are specific enough to be actionable by a non-medical family member (e.g., 'bleeding from gums' is specific; 'feels worse' is not). Complete your review within 72 hours.