History And Physical Examination

The history should include determination of the underlying cancer, the type and date of most recent chemotherapy, concomitant immunosuppressive medications, and exposures. Symptoms relating to the sinuses, eyes, ears, respiratory and gastrointestinal systems, skin, and catheter sites are of particular importance. The magnitude of the fever and the presence of rigors are also indicators of the severity of illness.

On physical examination, attention should be given to the sinuses, oropharynx, lung and heart exams, catheter site, abdomen, external perianal exam, and skin. Classic signs of inflammation may be absent in the setting of neutropenia. For example, pneumonia is not usually accompanied by lobar consolidation or sputum. Fever, dry cough, and dyspnea might be the only signs of pneumonitis. Peritoneal signs are often absent, and nonspecific abdominal pain might reflect appendicitis, typhlitis, or even perforated viscus. Any proptosis, chemosis, limitation of extraocular motion, or dark nasal or oropharyngeal lesions should prompt emergent surgical consultation for possible invasive fungal infection. Lethargy or focal neurologic signs should prompt emergent imaging of the central nervous system (CNS).

External perianal inspection should be performed, but internal rectal examination should be avoided.

Skin lesions may be the only clues to the etiology of a fever, and biopsy and culture of these lesions can be crucial for diagnosis (see below).

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