Patient guide

Why does coming prepared matter?

With an infection, the doctor starts by asking about the story. Which medicine did you take, for how many days, and with what result? Where have you travelled? Have you been in contact with animals or raw dairy? The CDC Yellow Book treats a detailed account of travel and exposures as part of assessing a feverish patient after travel. MedlinePlus recommends writing down your symptoms, medicines and questions before the visit so nothing is forgotten in the room.

What should you bring?

• A description of your symptoms. MedlinePlus says to write down when each symptom started and what makes it better or worse. If you have a fever, the fever log does this for you.
• A list of all your medicines. MedlinePlus asks for the names of medicines, herbs, vitamins and supplements, and any allergies. A medicine box or a prescription helps. For an infection, also write the start and end dates of each antibiotic and how you responded. The CDC Yellow Book says every medicine taken, including antibiotics, should be recorded.
• Earlier test results. Culture and antibiogram reports, blood and urine tests, and any related scans or ultrasounds. MedlinePlus says a culture identifies the type of germ and an antibiogram shows which medicines work against it. If all you have is a number or a phone photo, bring that.
• Any treatment in a hospital or another country. The CDC and the Yellow Book both say that a hospital stay abroad, or antibiotics taken there, raise the chance of a resistant germ. Tell your doctor about it.
• Your questions. MedlinePlus says to write your questions down and to ask a friend or family member to come with you. They can take notes of what the doctor says.

What should you write down about travel and contacts?

The CDC Yellow Book has a full list of the questions a doctor asks after travel. If your visit is for a fever or illness after a trip, note these in advance:

• Dates of departure and return, and the cities and villages you visited, because diseases differ from one area to another.
• Where you stayed: was the room air-conditioned? Did the windows have screens? Did you have a bed net?
• Water and food: bottled or tap water, ice, raw vegetables, undercooked meat, unpasteurised dairy.
• Bites from mosquitoes, ticks and other insects, and any bite or scratch from an animal.
• Swimming or wading in fresh water.
• Any tattoo, piercing, injection or sexual contact. The doctor asks about these to find the cause, not to judge.
• Any treatment you received during the trip or after returning.
• Travel vaccines and malaria prevention tablets, if you took them.

If you are not sure whether to mention something, mention it. The Yellow Book says the time between each exposure and the start of symptoms helps the doctor, so write the dates as best you remember.

Write the timeline on one page

A simple timeline is enough: the day the fever started, the day each medicine started and ended, the day you had tests and what they showed. This order helps the doctor. It does not have to be elaborate.

At the visit itself

• Show all your documents from the start rather than holding some back midway.
• If you are given a prescription, ask there and then for how long, at what times, and what you should watch for.
• Ask when and how you will get your test results, and whom to contact if you get worse.
• Do not stop your regular medicines yourself. Give the doctor the list and let them decide.

When should you not wait for a visit?

If you have a warning sign, do not wait for a routine appointment. Read the list of urgent signs.

This guide is for preparation and does not replace an examination.

What is a fever?

The NHS usually defines a fever as a temperature of 38 degrees or higher. MedlinePlus stresses that a fever is not a disease in itself and is mostly a sign that the body is fighting an infection. Most fevers come from infection. Medicines, heat illness, cancer and autoimmune diseases are less common causes.

The NHS reminds us that you may have a fever even if the thermometer reads below 38. If you feel hot, shivery or have chills, note that down too.

How to take your temperature

The NHS describes these methods:

• Buy a digital thermometer. Wash the tip with cold water and soap before use, then rinse.
• Under the tongue: place the tip at the back of the mouth under the tongue, close your lips and wait for the beep or flash.
• Under the arm: hold your arm firmly against your body until you hear the beep.
• Ear thermometer: gently pull the ear up and back, then place the thermometer.
• Do not use a glass thermometer, because the NHS considers it dangerous. Forehead strips are not accurate either.

What to write in the log

One column for each of these is enough:

1. Date and time.
2. The temperature and where you measured it (mouth, armpit, ear). Use the same method each time and write it down.
3. Chills, sweating, headache, body aches, cough, diarrhoea, burning when passing urine, swelling or redness anywhere on the body.
4. If you took something to bring the fever down, write its name and the time, so the doctor knows whether the reading was before or after the medicine.
5. How much water and other fluids you drank, and the colour of your urine.
6. Anything new that may be related: travel, contact with animals, a bite, a wound, contact with someone who is ill.

Write down fevers that come and go, too. The Yellow Book says a patient with malaria may have no fever at the time of examination. So “I have no fever right now” does not always mean the risk is ruled out.

What can you do at home?

The NHS says: rest as much as you can and drink fluids, preferably water. Drink enough that your urine is pale yellow and clear. Stay at home while you have a fever and avoid contact with others. This means do not go to work or mix with other people, not that you should put off seeing a doctor. Most fevers get better on their own.

If you take something for comfort, read the leaflet or ask a pharmacist. Do not start antibiotics on your own either. The NHS says antibiotics do not work on viral infections. Read taking antibiotics the right way.

When should you do more than keep a log?

• The NHS says that if a fever does not improve with home care, or gets worse, you should see a doctor the same day or contact the health service.
• If you have a fever and travelled to a malaria area in the past year, do not wait. The NHS says symptoms usually start 7 to 18 days after the bite, but can sometimes appear months after the trip. See the details in urgent signs.
• If your immunity is weak for any reason, do not just log a fever when it starts. Contact your doctor at once, and if you cannot reach them, go to a hospital emergency department. See the details in urgent signs.
• If the fever comes with confusion, severe chills, fast breathing, pale or mottled skin, a rash that does not fade under pressure, or very little urine, look at the signs of sepsis and call 115, Iran’s emergency number.

Bring your fever log to the visit. This guide does not replace an examination.

What are antibiotics for?

Antibiotics target bacteria. The NHS says they do not work on viral infections such as colds and flu, or on most coughs. The CDC also says antibiotics do not make someone with a virus feel better. Many mild bacterial infections also get better without antibiotics, and the doctor decides that.

That is why a doctor sometimes does not prescribe an antibiotic. This is not negligence. The CDC advises not to pressure your doctor to prescribe one.

Why does taking them properly matter?

The CDC says resistance means a germ has gained the ability to beat a medicine. This is a property of the germ and has nothing to do with your body. WHO considers unnecessary and inappropriate use of antibiotics one of the main drivers. The NHS also says that an antibiotic you take without a reason may not work for you later.

Before you start

• Your doctor chooses the medicine, not a guess and not the lab sheet. MedlinePlus says a culture identifies the type of bacteria and an antibiogram shows which medicine works against it. In some infections a doctor starts treatment before the result arrives. If the result shows no bacterial infection, do not stop a prescribed medicine yourself; show the result to your doctor soon. See also what an antibiogram is.
• Tell them about all your medicines and allergies. The NHS says some antibiotics do not mix well with other medicines and with alcohol. Ask your doctor or pharmacist.
• Do not take anyone else’s medicine. The NHS says to take antibiotics only when they were prescribed for you, and never to “borrow” them from a friend or family member. The CDC says the same and advises against sharing them.

While taking them

• Exactly as directed. The CDC says to take antibiotics exactly as prescribed. The NHS says to follow the instructions on the packet or leaflet, or what your doctor or pharmacist told you.
• The doctor decides how long the course is. If you think the medicine is not needed or is too much, do not stop it or change the amount without your doctor. If you have side effects or cannot tolerate the medicine, tell them the same day. If you get a rash, trouble breathing, or swelling of the face or throat, do not wait: call 115.
• If you miss a dose. The NHS says that in most cases you should take it when you remember and carry on with the course, unless it is nearly time for the next dose. Do not double up. If you are not sure, read the leaflet or ask a pharmacist.
• Do not keep leftovers. The CDC says not to save antibiotics for next time, because taking them for a different illness can delay proper treatment and cause serious side effects. If you have medicine left over, ask a pharmacist what to do with it. See also the article What to do with leftover antibiotics.

Side effects

The NHS says common side effects are nausea, vomiting, bloating, indigestion and diarrhoea, and that serious side effects are rare. The CDC says that if you get side effects while taking an antibiotic, you should contact your doctor or health care provider. The CDC warns about a type of antibiotic-associated diarrhoea (C. diff) that can seriously damage the bowel. So tell your doctor the same day if you have severe or lasting diarrhoea while taking an antibiotic.

Allergy. The NHS says that if you get a rash, wheezing, tightness in the chest or throat, trouble breathing or talking, or swelling of the face, lips, tongue or throat while taking an antibiotic, call emergency services straight away (in Iran, 115).

What to show your doctor

• The names of all the antibiotics you have taken so far, and the dates.
• Earlier culture and antibiogram results.
• Any side effect or sensitivity you have had.

This guide does not replace your doctor’s instructions. If you have questions about a medicine you are taking, ask your doctor or pharmacist.

What is a culture, and why is one requested?

MedlinePlus says the laboratory places the sample in a dish so that bacteria can multiply and be identified. If bacteria grow, it usually means there is a bacterial infection. An antibiogram may then be requested to find out which medicine works against it. The result is usually reported as “sensitive”, “intermediate” or “resistant”.

The type of sample depends on where the infection is: blood, urine, sputum, stool, throat or a wound.

What should you tell your doctor and the lab before sampling?

• If you are taking or have taken antibiotics. For sputum cultures, MedlinePlus says antibiotics may change bacterial growth and the result. Tell them when you last took one.
• All your medicines. The same page says to tell your doctor about all your medicines and not to stop any without their instruction.
• If you need any special preparation. MedlinePlus says to ask your doctor whether you need to do anything to prepare. It differs for each sample.

Urine sample

MedlinePlus describes the “midstream” sample, which reduces contamination from the skin and genital area:

1. If possible, collect urine that has stayed in the bladder for 2 to 3 hours. Wash your hands well with warm water and soap.
2. Clean the area with the sterile wipe from the kit. Women wipe from front to back. Men clean the head of the penis, pulling back the foreskin first if uncircumcised.
3. Let a little urine go into the toilet, then stop the flow.
4. Hold the container close and fill it halfway. Pass the rest into the toilet.
5. Close the lid tightly and do not touch the inside of the container or the lid.

If you collected the sample at home, MedlinePlus says to put the container in a bag and keep it in the fridge until you hand it in. The lab’s instructions come first.

The NHS reminds us that a urine test does not always find an infection, especially if symptoms have lasted a long time. The doctor reads the result together with your symptoms.

Blood sample

MedlinePlus says a blood culture needs no special preparation. The skin where blood is taken is cleaned with an antiseptic so that skin germs do not contaminate the sample. Because bacteria sometimes show up in the blood only now and then, three or more samples may be taken. This is to raise the chance of finding the germ. A blood sample is usually requested when the doctor is concerned about a serious infection.

Sputum sample

MedlinePlus stresses that sputum is different from saliva. Sputum comes from the lungs and airways. You are asked to breathe deeply and cough deeply. The sample is often taken in the morning. Drinking more water the night before may help, and you may be asked to rinse your mouth with water before the sample. If coughing is difficult, tell your doctor.

Stool sample

MedlinePlus says to read the container instructions from the start. If you were given several containers, each may have separate instructions. Place the sample in the clean container provided, and do not mix urine, water or toilet paper with it. Get the sample to the lab as soon as possible.

Wound sample

A wound sample is usually taken by a health worker with a swab. MedlinePlus says that if the wound is deep, fluid may be drawn out with a syringe, or a biopsy may be taken.

When do the results come?

MedlinePlus says it usually takes one to two days for enough bacteria to grow. Some bacteria need five days or more. A sputum culture result may take from a few days to a few weeks. This delay is normal. If you get worse in the meantime, do not wait for the result, and read the urgent signs.

The doctor interprets the result together with your symptoms. Do not choose a medicine yourself from the “sensitive” and “resistant” columns.

This guide does not replace the lab’s and your doctor’s instructions.

Vaccines in adulthood

Vaccines do not end with childhood. The CDC adult schedule has several groups: some vaccines are needed by all adults, such as a tetanus and diphtheria booster every ten years, and others only by certain groups depending on age, pregnancy or an underlying illness. The CDC says that if you are pregnant or have a condition that raises your risk of infection, you should talk to your doctor about which vaccines suit you.

For hepatitis B, the CDC in the United States includes all adults aged 19 to 59 and adults aged 60 and over with higher risk among those who should be vaccinated. The NHS says people with long-term (chronic) liver disease or kidney failure, close family members or sexual partners of someone with hepatitis B, and people who travel to high-risk areas should take the hepatitis B vaccine seriously. WHO says that once the vaccine course is complete, protection lasts at least 20 years and probably for life.

A practical point: keep your vaccination card or record of injections. The NHS says that if you do not know which vaccines you have had, ask your doctor or check your records. The Yellow Book also says that in a patient with jaundice, a documented hepatitis A and yellow fever vaccination makes those two diseases very unlikely. Which vaccines belong in your schedule is for your doctor to say.

How long before the trip?

The NHS recommends getting advice from a travel health professional about 4 to 6 weeks before you travel. The reason is that some vaccines need several doses and others need time to build protection. If you arrive late, you may be less protected during your trip.

Prepare these for the travel visit:

• Your exact destination, the cities and villages, and the season of travel. The Yellow Book says diseases differ from area to area and from season to season.
• How long you will stay and where: hotel, relatives’ home, guesthouse.
• Your vaccination card and a list of your regular medicines.
• Any underlying illness you have.

The Yellow Book says the pre-travel visit is also a chance for routine vaccines. The NHS also says all travellers, including children, should have standard vaccines such as measles up to date. For advice on each country, the NHS points to the TravelHealthPro website.

If you are travelling to visit family or friends. The Yellow Book says these travellers are at higher risk of malaria, typhoid, parasitic infections and tuberculosis.

Malaria

The CDC says that before travelling to an area with malaria, you should talk to your doctor about preventive medicines. The choice of medicine and when to take it is for your doctor, so do not decide on your own. The Yellow Book stresses that taking preventive medicine does not completely rule out malaria. So if you get a fever after travel, even with preventive medicine, you need to be tested.

Animals and rabies

If an animal bites you, scratches you or licks a wound while you travel, do not wait until you get home. WHO says to wash the wound straight away with soap and water for at least 15 minutes, and then see a doctor. The NHS says “do not wait until you return to your country” and that even if you have been vaccinated, you need medical help. See the details in urgent signs.

After you return

If you get a fever, chills or a new illness in the months after a trip, tell your doctor where you travelled. The NHS says that if you have symptoms up to 12 months after travelling to a malaria area, you should get advice the same day. The Yellow Book says malaria should be ruled out in every feverish patient returning from a malaria area. If you have a fever, keep a fever log and read the urgent signs.

This guide does not replace advice from a travel health professional and your doctor.

First of all

This list is for the day you are worried and cannot tell whether to wait. Most infections do not become serious. But a few situations do not wait for an appointment, and these are they.

In Iran, the emergency number is 115. If you feel very unwell, do not drive yourself. The NHS says this on several pages: call an ambulance or ask someone to take you, and take your medicines with you. If you are not sure, call and ask.

This list does not cover everything. If something worries you, trust that feeling.

Sepsis: the body’s dangerous reaction to an infection

The NHS says anyone can get sepsis, but babies under 12 months, people over 75, women who are pregnant or who have given birth or had a miscarriage or abortion in the past 6 weeks, people with weakened immunity, and people with a wound, a skin infection or a urinary catheter are at higher risk. In an older person the temperature may not be high.

In an adult or a child over 5, if you see any one of these, call 115, Iran’s emergency number:

• Confusion, or slurred or nonsensical speech.
• Very fast breathing, or shortness of breath.
• Severe chills.
• Skin, lips or tongue that is grey, blue, pale or mottled.
• A very high temperature or a very low body temperature, or feeling hot, cold and shivery.
• A rash on the skin that does not fade when pressed.

They do not all have to be present together. The NHS says that if you think it could be sepsis, get help immediately. The NHS also lists muscle pain and passing very little urine in the last 18 hours among the signs of sepsis.

In a child under 5, call 115 or go to an emergency department for: very fast breathing or grunting breaths, pale or blue skin and lips, being very sleepy or hard to wake, not feeding, a weak high-pitched cry, feeling cold and shivery, a seizure, no urine in the last 12 hours, or a temperature of 38 or above under 3 months, or 39 or above at 3 to 6 months.

Meningitis

The NHS says symptoms develop suddenly. Take these seriously:

• A very severe headache with fever.
• A stiff neck.
• Dislike of bright lights.
• Confusion or unusual drowsiness.
• A seizure, especially the first one.
• A skin rash that does not fade when pressed.

In babies and young children the NHS also lists: a bulging soft spot on the head, a high-pitched, unusual cry, a floppy or stiff body or being unresponsive, and not wanting to feed.

To check a rash, the NHS describes the “glass test”: press a clear glass firmly against the rash. If the rash is still visible through the glass, it is an emergency. On dark skin the rash is harder to see. Check the palms, soles, the inside of the mouth, the whites of the eyes and the inside of the eyelids.

Not all symptoms appear together, and not everyone gets a rash. The NHS says that if only a few symptoms are present but you are worried, get help straight away anyway. Call 115, and do not drive yourself.

Fever after travel to a malaria area

If you travelled in the past year to an area with malaria, for example south-eastern Iran, Afghanistan, Pakistan, India or Africa, and you have a fever, chills, sweats, a headache or you just feel unwell, go to a hospital emergency department or a health centre the same day and say that you need a malaria test.

• The NHS says symptoms usually start 7 to 18 days after the bite, but sometimes months later, and rarely years later.
• The CDC says malaria can be fatal if diagnosed late, and that early treatment prevents severe disease.
• The Yellow Book treats falciparum malaria as a medical emergency and says the test result should be available, preferably within a few hours.
• You may have no fever at the time of examination. Having no fever does not rule out malaria. Taking preventive medicine does not rule it out either.
• If you become confused or have a seizure, call 115. The CDC lists kidney failure, seizures and confusion among the signs of severe malaria.

Tell the doctor where you went and when you came back. If you are still travelling, the NHS says not to wait until you return. Your travelling companions should know too.

Fever in someone with weakened immunity

If your immunity is weak, do not leave a fever until next week’s appointment. The NHS lists chemotherapy, immunosuppressant and steroid medicines, HIV and sickle cell disease among the high-risk groups for sepsis. For people on chemotherapy, the NHS says to contact the treatment team straight away if they feel hot, cold and shivery, sweaty, or have a sore throat, a cough, diarrhoea or a burning feeling when passing urine, because these may need urgent treatment. If your immunity is weak for any reason, contact your doctor as soon as a fever starts, and do not wait until tomorrow. If you cannot reach them, go to a hospital emergency department straight away. Ask in advance how to reach them, and write it down.

If a fever comes with confusion, severe chills, fast breathing or paleness, look at the sepsis section on this page and call 115.

Severe dehydration

Severe dehydration can become dangerous. The NHS says to see a doctor the same day if you have these signs:

• Unusual tiredness or drowsiness.
• Dizziness when standing that does not go away.
• Dark or very little urine.
• Fast breathing or a fast heartbeat.

Call 115 if dehydration comes with:

• Blue, grey, pale or mottled skin, lips or tongue.
• Cold skin.
• Difficulty breathing, or quick, repeated breaths.
• Confusion.
• Being very sleepy or slow to wake.

The NHS considers these signs of shock. WHO says that if there is blood in the stool, or diarrhoea lasts 14 days or more, you should definitely consult a health worker. Take a child who cannot drink or has sunken eyes to an emergency department at once (WHO). In a baby, the NHS also lists a sunken soft spot on the head and few or no tears when crying as signs of dehydration, and advises seeing a doctor the same day for them.

Possible rabies exposure

If an animal bites you, scratches you, or licks a wound or your eyes, mouth or nose, wash the wound first, then go to a medical facility straight away.

• WHO says to wash the wound straight away with soap and water for at least 15 minutes.
• WHO and the CDC both say that post-exposure treatment is an emergency treatment and should start as soon as possible.
• The NHS says that even if you have been vaccinated, you need medical help.
• WHO says dogs cause up to 99% of human rabies cases.
• Ask your doctor about a tetanus vaccine too.

WHO says that if preventive treatment is started in time, death from rabies is preventable. The reason for the hurry is that once symptoms start, WHO, the CDC and the NHS all say the disease is almost always fatal. The NHS says symptoms usually start 3 to 12 weeks after exposure. So having no symptoms does not mean there is no risk. Do not wait for symptoms.

Sudden fever after a tick bite or slaughtering livestock

Crimean-Congo haemorrhagic fever also occurs in Iran. WHO says it spreads through tick bites and contact with infected animal blood or tissue during and just after slaughter, and that it starts suddenly with fever. If you get a fever after such contact, go to a hospital emergency department the same day and mention the contact. If you also have bleeding or blood spots on the skin, call 115.

A diabetic foot ulcer with a warning sign

In diabetes, nerve damage can mean you do not feel a sore or a blister. The CDC says a sore can become infected and not heal, and that early treatment greatly reduces the risk of amputation. So look at your feet every day, and use a mirror or ask for help if you cannot see the soles.

MedlinePlus lists these as signs of infection. If you see any of them, tell your doctor or foot specialist the same day and do not wait for the next appointment. If you cannot reach them, go to a health centre or hospital emergency department the same day:

• Redness, warmth or swelling around the sore.
• More drainage, pus or a bad smell.
• More pain.
• Firmness around the sore.
• A sore that has turned very pale, blue or black.

The CDC also lists a change in the colour or temperature of the foot, burning or pain in the foot, and calf pain when walking as reasons to call your doctor.

If a foot sore comes with fever, severe chills, confusion, fast breathing or paleness, this may be sepsis, the body’s dangerous reaction to an infection. The NHS counts wounds and skin infections among the risk factors for sepsis. Call 115.

Urinary infection with confusion

The NHS says that if you become confused, drowsy or have trouble speaking with a urinary infection, call 115. In an older or frail person, and in someone with a catheter, take a change in behaviour, restlessness or sudden confusion seriously too, and let the doctor know the same day.

If a urinary infection comes with fever, chills or pain in your back just under the ribs, it may have reached the kidney. The NHS says a kidney infection can be serious. See a doctor the same day.

An allergic reaction to an antibiotic

If you get a rash, wheezing, tightness in the chest or throat, trouble breathing or talking, or swelling of the face, lips, tongue or throat while taking an antibiotic, call 115 (NHS). Show the medicine you took to the health workers.

If you are going to the emergency department

• Do not drive yourself. Call 115 or ask someone to take you.
• Take your medicines with you. Earlier test results and a list of the antibiotics you have taken help too.
• Say when the symptoms started, whether you have travelled or had contact with animals, and what medicines you take.

This page does not replace an examination and your doctor’s instructions.