EM Quick Hits 71 EMC²: Fever Without a Source, Coaching the EM Mind Part 1, Traumatic Pneumothorax Part 2, PECARN C-spine Rule, Medetomidine Withdrawal, EMS Handover

A 59-year-old man with hypertension presented with 10 days of fever, anorexia, and mild right-upper-quadrant discomfort yet no localizing symptoms, negative imaging, and normal labs including LFTs and lactate. The discussion moved quickly from that case into practical decision points across several areas of emergency care.

Fever without an obvious source
The initial approach focused on rapid risk-factor screening before the full history: travel, immigration, sexual contacts, camping or outdoor exposure, sick contacts, and any immunocompromising conditions. When those were unrevealing, attention turned to a short list of treatable, high-stakes diagnoses that can hide on exam and basic imaging. Endocarditis, meningitis without meningismus, spinal epidural abscess with only modest back pain, giant-cell arteritis presenting mainly as fever and malaise, leukemias visible only on careful review of the CBC differential, adrenal crisis, thyroid storm, serotonin syndrome, and neuroleptic malignant syndrome were highlighted. In the case itself, extensive negative testing eventually yielded positive West Nile virus serology; the patient had simply walked in an urban area where mosquitoes were present. The segment closed by noting that roughly half of patients who meet formal fever-of-unknown-origin criteria never receive a diagnosis and generally do well once serious causes are exc