Version November 2024
| History of present illness |
| Fever history and pattern, including duration |
| Associated symptoms (review of systems) |
| Past medical history, including past infections and surgeries |
| Medications, including prescription, over-the-counter, cannabis, herbal supplements, and others |
| Family history |
| Social history |
| Close contacts and their illnesses |
| Travel and residential history, including regions where patient has lived since childhood or exposures to prisons or congregate living facilities |
| Occupational history, hobbies, and sports |
| Outdoor exposures, including contaminated water and injuries |
| Animal exposures, including pets, livestock, and wild animals |
| Insect exposures, including mosquitoes, ticks, lice, fleas, and mites |
| Food and drink habits, including exposure to contaminated water/food or unpasteurized dairy products |
| Smoking and illicit drug use history, including injecting, smoking, inhaling, snorting, and skin popping |
| Sexual history, including recent and remote sexual activity, number of sexual contacts, gender, and type of sexual activity |
| Recent health care exposure, including dental and outpatient care and medical care in other countries |
| Physical examination |
| Temporal arteries |
| Ophthalmologic examination (conjunctivae, fundoscopy) |
| Oral cavity (palate, teeth, gums) |
| Thyroid |
| Lymph nodes (neck, supraclavicular, axillae, groin) |
| Lungs |
| Heart |
| Abdomen, including liver and spleen size and rectal and prostate exam |
| Genitalia, including testes and epididymis in men, and gynecologic pelvic exam in women |
| Neurologic examination, including cranial nerves and cognition |
| Joints and spine |
| Skin and nails, including wounds under dressings and casts |
| Laboratory tests (if not already performed) |
| Complete blood count (CBC) with differential and peripheral smear |
| Complete metabolic panel, including calcium |
| Liver biochemical tests (eg, aminotransferases, alkaline phosphatase, bilirubin) |
| Blood cultures (two sets) obtained from two separate venous sites prior to administration of antibiotics (ask microbiology laboratory to incubate cultures for at least five days.) |
| Urinalysis with reflex to urine culture |
| HIV antigen/antibody testing with reflex confirmatory testing (add viral load if acute HIV syndrome is suspected) |
| Antinuclear antibodies |
| Rheumatoid factor |
| Heterophile antibody test (eg, Monospot test) or Epstein-Barr virus (EBV) antibody tests in young adults |
| Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) |
| Ferritin |
| Thick and thin blood smears for malaria, in areas where malaria is endemic |
| Imaging tests |
| CT of the chest, abdomen, and pelvis with contrast |
| Transthoracic echocardiogram, in patients with risk factors or signs suggestive of endocarditis |
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