01 patient with fever
TRANSCRIPT
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The patient with fever
Assoc. Prof. Simona Dragan
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Definition Elevation of body temperature
above normal daily variation
Normal and adaptive response toagression
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Measure temperature
Oral probe Normal: 98.2o 98.8o F
Low grade fever: 99 100.5o F
Fever: > 100.5o F
Rectal probe Normal 99.2 99.8o F
Low grade fever: 100 101.5o F
Fever: > 101.5o F
> 37,0 oC (axilar)> 37,8 oC (oral)
> 38,2 oC (rectal)
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Study fever curve
Procedure Take and record the patients temperature every 6 to 8 hours
Study the patterns
Patterns: Continuous (variation < 1o)
Remittent (variation > 2o over 1 day)
Intermittent (afebrile periods mixed with fever spikes)
Quotidian (remittent with daily fever spikes) ex: Plasmodium
Relapsing (intermittent and cyclic, fever returns every 5-7
days ex: Borrelia sp)
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Diagnostic approach to fever
History of fever/pattern Date of onset
Periodicity
Accompanying symptoms
Chills
Sweating
Arthralgias
Myalgias
Information on travel/exposure to agents or animals
History personal or family: Blood transfusions
Immunizations
Thromboembolic disease, valvular disease, tuberculosis
Cancer Repeated physical examinations:
Skin
Eyes
Nail beds
Heart
Abdomen
Lymph nodes
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Laboratory evaluation
Elevated ESR, neutrophilia
Elevated CPR
Elevated liver functional tests
Creatinine, bloodglucose, calcemia
LDH, coagulation
Proteinuria, urinary sediment
Blood cultures
Serology: Salmonella, Brucella, Yersinia
Increased immunoglobulins: nuclear antibodies,rheumatoid factor, cryoglobulin
TSH
Tumor markers
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Approach algorrhythm
Clinical examinationLaboratory evaluation
Abdominal ultrasound
Chest X-Ray
known origin unknown origin
targeted investigations well toleratedworsening of clinical
condition/ anemia/
inflammatory
false track
dg.
further investigation follow up
FUO
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Common causes of intermittent fever
Infections
Connective tissue disorders
Neoplasia ( leukemia, lymphoma)
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Intermittent fever of infectious origin
Situations:
1. channel fever: gram-negative or gram positive
bacteremia of urinary, biliary or intestinal origin
2. Infection of implants orthopedic, vascular,prosthesis, pace-maker
3. Infectious endocarditis
4. Tuberculosis
5. Persistent infection with Yersinia enterocolitica
6. Malaria
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Fever of urinary origin
1. UTI
- Plain X-ray of abdomen
- Intravenous urography
- Cystogram- Ultrasonography
- Computed tomography
2. Acute nephritic syndrome
- Red blood cell casts- Antibody titer:ASLO
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UTI localizing urinary tract infection
Method Comments
Clinical Distinct features of pyelonephritis, perinephric abcess,
cystitis, prostatitis, urethritis
Urinalysis Bacterial cast pathognomonic of pyelonephritis: WBC castsuggests nonspecific tubulointerstitial inflammation; tissue
may indicate papillary necrosis
Differential culture Controlled voidings plus prostatic secretions or semen;
bladder washout methods or ureteral catheterization todistinguish upper from lower tract infection
Antibody-coated bacteria Indicate bacterial invasions of tissues (kidney, prostate)
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Fever of biliary origin
Symptoms / signs Laboratory Dg
- Abdominal pain (colicky)
- Jaundice
- Dark urines
- Murphys sign
- Cholestasis,
hyperbilirubinemia
- Elevation of transaminases
- Blood cultures
- Endoscopic retrograde
cholangiopancreatography
-Ultrasound endoscopy of
ducks
-Ultrasonography
-Procedure of choice to
differentiate extra hepatic /
intrahepatic jaundice (dilated
ducts = extra hepatic
obstruction)
- Gallstones
Acute cholecystitis
Acute viral hepatitis
Differential diagnosis Hepatocellular carcinoma
Pancreatic carcinoma
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Fever of intestinal origin
- Most frequent: sigmoiditis
Symptoms / signs Laboratory Dg
- Elderly
- Known diverticulosis
- Lower abdominal pain
- Blood cultures positive
- Gram negatives
- Anaerobes
- Abdominal CT
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Infection of implants orthopedic, vascular
Symptoms / signs Laboratory Dg
- Local pain -Leucocytosis-CPR elevated
-Blood cultures positive
(white Staphylococcus)
-Scintigraphy with Galliummarked leucocytes
-Cultures from implant
material
-Surgery ablation
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Endocarditis of valvular prosthesis, or
known valvular disease
Symptoms / signs Laboratory Dg
-Change of murmur
-Extracardiac sign: emboli,
arthralgias, purpura
-Blood cultures
-TEE
-Bacteriology + histology of
biopsy from valve
Endocarditis or pace-makerSymptoms / signs Laboratory Dg
-Pain thoracic
-Tricuspid regurge
-Dyspnea
-Blood cultures
(Staphylococus)
-Pulmonary scintigraphy
-TEE
-Bacteriology from pace-
maker
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Tuberculosis
Symptoms / signs Laboratory Dg
-Elderly-Malnourished
-Immune deficit
-IDR to PPD intenselypositive
-Absence ofleucocytosis
-Microbiology of urinary andrespiratory prelevations
-Culture in special medium
-CT
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Common causes of intermittent fever
Infections
Connective tissue disorders
Neoplasia (leukemia, lymphoma)
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Connective tissue disorders
Systemic lupus eritematosus
Rheumatoid arthritis
Polymiositis
Arthritis associated to spondylitis: ankylosis spondylitis
Juvenile arthritis
Symptoms / signs Laboratory Dg
Joint motions
-Swelling, stiffness
-Crepitus
-Monarthritis / symmetric
arthritis /polyarticular onset
-Major joints
-Shoulder
-Ankle
-Knee
-Hip
-Vertebral column
-Small joints
-Hand, foot
-Specify type
-Elevated ESR
-Elevated CPR
-Latex fixation test for
rheumatoid factor
-Antinuclear factor
-Anti double stranded DNA
level
-X-Ray
-Joint space narrowing
- Synovial fluid
measurements
-Microscopic synovial fluidexamination
-CT, MRI
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Common causes of intermittent fever
Infections
Connective tissue disorders
Neoplasia (leukemia, lymphoma)
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Fever in neoplasic disease
T > 37.8 C at least once daily
Duration of fever > 2 weeks
Absence of infection
ClinicalBiological
Imagistic
Absence of allergy (to drugs, transfusion,
radio/chemotherapy) Absence of response to antibiotic therapy done for at
least 7 days
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Neoplasia and hemopathies with
intermittent fever
Neoplasia Colorectal cancer
Cancer of pancreas
Grawitz kidney tumor
Cancer of the ovary
Metastasis
Hemopathies
Hodgkin Non-Hodgkin malignant lymphomas
Acute leukemias
myelodysplasia
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Clinical case
HT
Dyslipidemia
3 months ago - progressive weakness
- progressive weightloss (10kg)
- non-productive cough (dry)
- retro-sternal chest pain, more severe with
inspiration
On admission:
- no fever (36.8o C )
- dullness at percussion, abolished breath sounds in left lower
pulmonary lobe
J.I. , 71 Years [M]
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Chest X-ray: Dense consolidation ofleft lowerlobe
Multiple non-homogeneous infiltrates in medium and lower
right lobes
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Laboratory test
Hg (g%) 13,9
Ht (%) 42,4
L (mmc) 10.800
Gr = 77%, Lf = 18%
ESR (mm/1h) 83
Fibrinogen (g/l) 6,8
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Diagnosis
RETICULAR PULMONARY FIBROSIS. BILATERAL BRONCHIECTASISCOMPLICATED WITH LEFT LOWER LOBE PNEUMONIA
Evolution: complicated
THERAPY: Cephalosporin gen III +
Aminoglicozide +
Metronidazol Continous fever
Acute respiratory failure
37
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Zile de spitalizare
Temperatura(gra
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Reconsider diagnosis
Hemoculture: negative
CT scan thorax:
Bilateral reticular fibrosis of the 2lower/3rds of
pulmonary parenchima, bronchiectasis.Extensive consolidation of right lower lobe andof external 1/3 of middle and lower right lobes
Minimal mediastinal and bilateral tracheo-bronchial
adenopathy Bronchofibroscopy/Biopsy:
Broncho-pulmonary oat cellcarcinoma