Fever in an adult
Fever is the commonest reason adults come to a health centre in malaria areas. Most have a treatable illness; a few are hours from collapse. This case is about telling them apart with your eyes, your hands and one rapid test.
- Setting: Rural health centre in a high malaria transmission area
- For clinical officers, nurses and doctors at first-level facilities
- Reviewed October 2026
The presentation
Amina, 28, is a farmer. She walked to the clinic with her sister. She has had fever, headache and aching all over for 3 days. She vomited once this morning and has eaten little, but she is drinking.
| Vital sign | Value |
|---|---|
| Temperature | 38.9 °C |
| Pulse | 104 per minute |
| Breathing rate | 20 per minute |
| Blood pressure | 112/70 mmHg |
| Conscious level (AVPU) | Alert |
| Weight | 58 kg |
Tests at hand: Malaria rapid diagnostic test (RDT) · Haemoglobin (Hb) · Blood glucose (finger-prick) · Urine pregnancy test · Urine dipstick · HIV rapid test
- Malaria Must not missStill possible
- Severe bacterial infection (sepsis) Must not missStill possible
- Meningitis Must not missStill possible
- PneumoniaStill possible
- Kidney or bladder infectionStill possible
- Typhoid (enteric fever)Still possible
- Viral fever (including dengue where it occurs)Still possible
- Illness related to undiagnosed HIVStill possible
Work through it
Read each question and decide your own answer first. Then open the model answer and see how the differential changes.
- Step 1 of 7 · Look
Before you take a history: is Amina an emergency? What do you check in the first minute, and what do her vital signs tell you?
Model answer
Start with the ABCDE and the triage criteria. Look for a red (emergency) sign: obstructed airway, respiratory distress, shock (cold hands, capillary refill over 3 seconds, weak fast pulse), reduced consciousness, convulsions, or very low glucose.
Then check the vital signs against the up-triage limits for adults: pulse under 60 or over 130, breathing under 10 or over 30 per minute, temperature under 36 or over 39 °C, SpO2 under 92%, or anything other than Alert on AVPU.
Amina is alert, talking in full sentences and walked in. Her pulse of 104 and temperature of 38.9 °C are raised but inside those limits. She is not an emergency; she can be assessed now, in order. Repeat the vital signs if she waits.
RememberA normal temperature does not rule out serious infection: very ill or immunosuppressed people may not mount a fever.Differential now- Malaria Must not missStill possible
- PneumoniaStill possible
- Kidney or bladder infectionStill possible
- Typhoid (enteric fever)Still possible
- Viral fever (including dengue where it occurs)Still possible
- Illness related to undiagnosed HIVStill possible
- Severe bacterial infection (sepsis) Must not missLess likely (moved down)
- Meningitis Must not missLess likely (moved down)
- Step 2 of 7 · Ask
What do you ask? Name the questions that change what you do next.
Model answer
- Danger symptoms: confusion, fits, fainting, vomiting everything, unable to drink, breathlessness, very little or dark urine, bleeding, yellow eyes.
- Where she lives and has travelled, and whether she sleeps under a net: malaria risk.
- Pointers to a source: cough or chest pain; burning urine or loin pain; abdominal pain or diarrhoea; severe headache with a stiff neck or light hurting the eyes; rash; joint pain.
- Her last menstrual period, and could she be pregnant? This changes which antimalarial is safe and raises the risk of severe malaria.
- Antimalarials or other medicines taken in the last 1 to 2 months.
- HIV status and when she was last tested.
- Anyone else at home or in the village ill with fever, bleeding or rash (an outbreak).
Amina lives where malaria is common and has not used a net since it tore. She has no cough, no urinary symptoms, no diarrhoea, no rash and no neck pain. Her period was 2 weeks ago. She has taken no medicines except a painkiller. Her HIV test a year ago was negative. No one else at home is ill.
Differential now- Malaria Must not missLeading (moved up)
- Typhoid (enteric fever)Still possible
- Viral fever (including dengue where it occurs)Still possible
- Illness related to undiagnosed HIVStill possible
- Severe bacterial infection (sepsis) Must not missLess likely
- Meningitis Must not missLess likely
- PneumoniaLess likely (moved down)
- Kidney or bladder infectionLess likely (moved down)
- Step 3 of 7 · Look
What do you look for on examination, and why each one?
Model answer
- Can she sit, stand and walk without help? Prostration is a sign of severe malaria.
- Neck stiffness and level of consciousness (meningitis, cerebral malaria).
- Pallor of the inner eyelids and palms (anaemia), jaundice, bleeding from gums or puncture sites.
- Breathing: rate and depth (deep breathing suggests acidosis), chest crackles.
- Abdomen: tenderness, an enlarged spleen or liver; loin tenderness.
- Skin: rash, wounds, abscesses; mouth for thrush (a clue to HIV).
Amina walks unaided and is fully alert. No neck stiffness. Mild pallor, no jaundice, no bleeding. Chest clear, breathing normal depth. Slight tenderness under the left ribs; no loin tenderness. No rash, mouth normal.
Differential now- Malaria Must not missLeading
- Typhoid (enteric fever)Still possible
- Viral fever (including dengue where it occurs)Still possible
- Severe bacterial infection (sepsis) Must not missLess likely
- Meningitis Must not missLess likely
- Kidney or bladder infectionLess likely
- Illness related to undiagnosed HIVLess likely (moved down)
- PneumoniaSet aside for now (moved down)
- Step 4 of 7 · Test
You have a malaria RDT, haemoglobin, glucose, a urine dipstick and a pregnancy test. Which do you use, in what order, and why?
Model answer
- Malaria RDT first. Every suspected case should have a parasitological test (RDT or microscopy) before treatment; treat on a positive result.
- Pregnancy test. She is of childbearing age: the result decides which antimalarial is safe.
- Haemoglobin, because she is pale. Severe anaemia is a sign of severe malaria in adults.
- Glucose, because she has vomited and eaten little; low glucose is a danger sign.
- A urine dipstick is not needed today: she has no urinary symptoms or loin pain. Use it if a urinary source is possible.
Results: RDT positive for P. falciparum. Pregnancy test negative. Hb 10.8 g/dL. Glucose 5.6 mmol/L.
Differential now- Malaria Must not missLeading
- Severe bacterial infection (sepsis) Must not missLess likely
- Meningitis Must not missLess likely
- Kidney or bladder infectionLess likely
- Typhoid (enteric fever)Less likely (moved down)
- Viral fever (including dengue where it occurs)Less likely (moved down)
- Illness related to undiagnosed HIVLess likely
- PneumoniaSet aside for now
- Step 5 of 7 · Do
The test is positive. Is this uncomplicated or severe malaria? What would make it severe?
Model answer
Severe malaria needs only one of: impaired consciousness, prostration, more than two convulsions in 24 hours, deep or laboured breathing, shock, jaundice with other signs, abnormal bleeding, very little or dark urine, inability to drink or keep tablets down, haemoglobin below 7 g/dL in an adult, or glucose below 2.2 mmol/L.
Amina has none. She can swallow and keep tablets down. This is uncomplicated falciparum malaria.
A positive RDT does not exclude a second illness. If she does not improve as expected, look again for another cause.Differential now- Malaria Must not missLeading
- Kidney or bladder infectionLess likely
- Typhoid (enteric fever)Less likely
- Viral fever (including dengue where it occurs)Less likely
- Illness related to undiagnosed HIVLess likely
- Severe bacterial infection (sepsis) Must not missSet aside for now (moved down)
- Meningitis Must not missSet aside for now (moved down)
- PneumoniaSet aside for now
- Step 6 of 7 · Do
How do you treat her, and what do you do before she leaves?
Model answer
- Give the national first-line artemisinin-based combination therapy (ACT) for 3 days. With artemether-lumefantrine (20 mg/120 mg tablets), a person of 35 kg or more takes 4 tablets per dose, twice a day for 3 days: six doses. The first two doses are about 8 hours apart. Take with food or a milky drink.
- Give the first dose in the clinic and watch for 1 hour. If she vomits it within an hour, repeat the dose; if she keeps vomiting, treat as severe.
- Paracetamol for fever and aches (dose per your national formulary); plenty of fluids.
- Write the time of the first dose and the times of the next ones on the packet.
She keeps the first dose down.
- Step 7 of 7 · Ask
What do you tell her, and when must she come back?
Model answer
- Finish all six doses, even when she feels better.
- Come back at once, day or night, if she becomes drowsy or confused, has a fit, cannot drink or keeps vomiting the tablets, breathes fast, passes dark or very little urine, or bleeds.
- Come back if the fever is still there after 3 days. At review, reassess fully and do not repeat an HRP2-based RDT: it can stay positive for weeks after cure. Use microscopy if available.
- Fever returning within 28 days of a full course suggests treatment failure: second-line treatment or referral.
- Get a new insecticide-treated net and sleep under it every night.
The test shows malaria. These tablets will cure it if you take all of them: four tablets twice a day for three days, with food. Come back straight away if you become very weak or drowsy, keep vomiting, or breathe fast.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Severe malaria | Any one sign of severity: impaired consciousness, prostration, convulsions, deep breathing, shock, jaundice, bleeding, dark or little urine, vomiting everything, Hb below 7 g/dL, glucose below 2.2 mmol/L. | Do not wait for a test. Give pre-referral artesunate (IM, or IM artemether or quinine if unavailable), treat low glucose, and refer urgently. |
| Sepsis or septic shock | Fever (or low temperature) with fast pulse, fast breathing, low BP, cold hands, slow capillary refill, confusion; a skin, chest, urine or abdominal source. | ABCDE; IV fluids if signs of poor perfusion (watch for fluid overload); first dose of antibiotic as early as possible; refer urgently. |
| Bacterial meningitis | Fever with severe headache, stiff neck, confusion, fits or a purple rash. | First dose of antibiotic (and antimalarial in a malaria area) now; refer urgently. |
| Viral haemorrhagic fever or another outbreak disease | Fever with unexplained bleeding, contact with a similar case, or a declared outbreak. | Isolate, use protective equipment, follow your outbreak screening protocol and report. |
Decision at first-level care
Amina has uncomplicated falciparum malaria: positive RDT, no sign of severity, not pregnant, keeps tablets down. She can be treated at the health centre with a 3-day ACT, the first dose observed, clear return advice and review if the fever persists after 3 days.
Source: WHO guidelines for malaria (2026 version); WHO and ICRC Basic emergency care (2018).
- Positive malaria test with no sign of severity.
- Can drink and keep the first dose of ACT down.
- Not pregnant, or pregnant with a safe ACT available for the trimester and no complication.
- Vomited the first dose: repeat and observe for an hour.
- Negative test, well, no danger sign and no source found: symptomatic care, review in 2 to 3 days or sooner if worse.
- Living far away with no transport back: consider keeping for observation before sending home.
- Any danger sign or sign of severe malaria (after pre-referral artesunate).
- Signs of sepsis, meningitis or shock.
- Vomiting every dose of ACT.
- Fever every day for more than 7 days with no cause found, or failure after a full course.
Key learning points
- Triage first: danger signs and vital signs before history.
- Test every suspected malaria case before treating, and treat a positive test with a full 3-day ACT by weight.
- One sign of severity makes malaria severe: pre-referral artesunate and urgent referral.
- Ask every woman of childbearing age about pregnancy before choosing the antimalarial.
- A positive RDT does not rule out a second cause; an HRP2 RDT stays positive for weeks, so do not repeat it to judge cure.
Sources
- World Health Organization. WHO guidelines for malaria (10 September 2026 version). 2026. Parasitological diagnosis before treatment, ACT duration and artemether-lumefantrine weight bands, first trimester, signs of severe malaria, pre-referral treatment, follow-up.
- World Health Organization and International Committee of the Red Cross. Basic emergency care: approach to the acutely ill and injured. Participant workbook. 2018 (ISBN 9789241513081). ABCDE approach; special considerations for fever (absence of fever does not rule out infection); severe infection and its management.
- World Health Organization, International Committee of the Red Cross and Médecins Sans Frontières. Interagency Integrated Triage Tool (age 12 and over). 2023. Red criteria and high-risk vital signs for up-triage.
- World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring. 2021. Offering HIV testing to people with symptoms that may be related to HIV.