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An Approach to a Patient with Fever

An Approach to a Patient with Fever. MPPRC- IIB Group 1. General Objective. Integrate and apply knowledge acquired in the subjects of Medicine I, Pathology, Pharmacology and Radiology in the management of a patient with fever. Specific Objectives.

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An Approach to a Patient with Fever

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  1. An Approach to a Patient with Fever MPPRC- IIB Group 1

  2. General Objective Integrate and apply knowledge acquired in the subjects of Medicine I, Pathology, Pharmacology and Radiology in the management of a patient with fever

  3. Specific Objectives Identify significant signs and symptoms and correlate with fever. Define and explain the etiology and pathophysiology of fever. To identify the necessary ancillary procedures that can help in the diagnosis of a patient with fever To formulate an effective pharmacologic and non-pharmacologic management for a patient with fever.

  4. General Data PP, 56 years old, female, married, market vendor from Sampaloc, Manila Missing Data: Date & time of interview Source & % reliability Interviewer & role Race Religion Birthday Place of birth

  5. Chief Complaint : Fever History of Present Illness:

  6. How was the temperature taken? How often? • Impact on the patient’s lifestyle? • Persons the patient had contact with who manifested the same signs and symptoms. • Associated symptoms

  7. Past Medical History No other medical or surgical illness requiring hospitalization No history of blood transfusion No history of illicit drug use No history of tattoo piercing No history of wading in flood waters

  8. Past Medical History • Childhood illness? • Measles? Mumps? Chickenpox? Scarlet fever? Acute rheumatic fever? • Major Adult illness? • Hepatitis? Myocardial infarction? Parasitic disease? Other infections? • Immunizations? • Influenza? Cholera? Typhus? Hepatitis B? BCG? Typhoid? • Past medications? • Allergies? • Recent health examination?

  9. Obstetric & Gynecologic History G5P5 (2005) Menarche- 13 years old Menopause- 50 years old Any complications in pregnancy or labor, postpartum or with the infant? Multiple sex partners? Date of most recent Pap smear and result? Hormone therapy? Dose and duration?

  10. Family History No family history of hypertension, diabetes mellitus, cancer, pulmonary tuberculosis Autoimmune disease, blood disorders?

  11. Personal and Social History Sampaloc, Manila Market vendor Non smoker, non passive smoker Non alcoholic beverage drinker Fond of eating street foods No travel to endemic areas

  12. Missing Data: What is the patient’s usual diet? Preferred foods? Food preparation? Source of drinking water? How is the patient’s home condition? Any household pets?

  13. Review of systems General No sign of weight loss Body malaise, fatigability, night sweats? Skin, hair, nails No rashes Bruising, lesions, dryness, pruritus? Head and Neck No headache Dizziness, syncope, trauma? Eyes No blurring of vision Discharge? Ears No ear discharge, tinitus Otalgia?

  14. Review of systems Nose No data given Nasal discharge? Breast No data given Lumps, nodules, pain? Chest and Lungs No cough, difficulty of breathing Dyspnea, sputum, hemoptysis? Cardiac No chest pain, palpitation Gastrointestinal No diarrhea, constipation, melena, hematochezia Dysphagia, hematemesis, flatulence ?

  15. Review of Systems Genitourinary No dysuria, frequency, urgency, pollakuria, polyuria Pain, hematuria, changes in urine? Lesions, discharges, pain? Lymph node No given data Enlargement, pain? Musculoskeletal No joint pains Joint stiffness, restriction of motion, swelling? Endocrine No heat or cold intolerance, polydipsia, polyphagia

  16. Physical Examination Conscious, coherent, obese, oriented as to time, place and person BP = 110/80 CR = 80 bpm regular PR = 80 bpm regular RR = 22 per minute Temperature = 39.5C Height = 1.5m Weight = 70kg BMI = 31 No skin rashes Pink palpebral conjunctiva Anicteric sclera Hepatospenomegaly

  17. Physical Examination Pulse rhythm, amplitude, contour Respiration regularity, rhythm, depth, breath sounds Heart sounds Abdominal tenderness Inspection and palpation of lymph nodes Pelvic examination

  18. Salient Features Subjective Data PP, 56 years old, female, married, market vendor from Sampaloc, Manila Prolonged intermittent, low to moderate fever lysed by ibuprofen and paracetamol Fond of eating street foods No travel to endemic areas Objective Data Pulse temperature disproportion (PR=80bpm;Temp=39.5C) RR= 22/ min No skin rashes Pink palpebral conjunctiva Anicteric sclera Hepatosplenomegaly Unremarkable head, neck, ear, nose, throat, eyes, chest and lungs, heart and blood vessels, breast and axilla, GI, GU, musculoskeletal.

  19. Based on the Medical history and physical examination, the patient manifests with prolonged fever secondary to infection.

  20. Chief complaint: FEVER

  21. fever “Is an elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point.” Harrison’s Principles of Internal Medicine, 17th edition

  22. Fever classification

  23. FEVER PATTERNS

  24. Intermittent Intermittent:marked by a daily temperature drop into the normal range and then a rise back to above normal

  25. Remittent Remittent:A fever with diurnal variation of more than 1.10C but with no normal readings

  26. Continuous Continuous: A fever with a diurnal variation of 0.5 to 10C

  27. Relapsing Relapsing:Febrile episodes are separated by intervals of normal temperature; bouts of fever occurring every five to seven days

  28. Septic Septic: An intermittent fever that fluctuates widely, typically producing chills and sweating

  29. Pathophysiology of Fever Pyrogen the term is used to describe any substance that causes fever Source: Harrison’s Principles of Internal Medicine (16th Edition), p. 106

  30. Pathophysiology of Fever Cytokines small proteins (molecular mass,10,000 to 20,000 Da) that regulate immune, inflammatory, and hematopoietic processes Pyrogenic cytokines: IL-1, IL-6, tumor necrosis factor (TNF), ciliary neurotropic factor (CNTF), and interferon (IFN) . Source: Harrison’s Principles of Internal Medicine (16th Edition), p. 106

  31. Pathophysiology of Fever The synthesis and release of endogenous pyrogenic cytokines are induced by a wide spectrum of exogenous pyrogens (bacterial, fungal or viral sources) Source: Harrison’s Principles of Internal Medicine (16th Edition), p. 106

  32. Pathophysiology of Fever Cellular sources of pyrogenic cytokines include: monocytes, neutrophils, and lymphocytes Source: Harrison’s Principles of Internal Medicine (16th Edition), p. 106

  33. INDUCTION OF FEVER Infection, microbial toxins, mediators of Inflammation, immune reactions Microbial toxins Fever Cyclic AMP Heat conservation, heat production Monocytes / macrophages, endothelial cells, others PGE2 Elevated thermoregulatory set point Hypothalamic endothelium Pyrogenic cytokines IL-1, IL-6, TNF, IFN, ciliary neurotrophic factors Circulation Harrison’s Principle of Internal Medicine 17th edition

  34. Pathophysiology of Fever Tachycardia usually accompanies fever PULSE RATE is PROPORTIONAL to TEMPERATURE Source: DeGowin’s Diagnostic Examination (8th Edition), p. 61-62

  35. www.rationalmedicine.com Pathophysiology of Fever “For every 0 rise in temperature, pulse increases by 10. Pulse temperature dissociation is seen in typhoid, brucellosis, leptospirosis, viral myocarditis, diphtheria, rheumatic carditis, bacterial endocarditis, etc. “

  36. fever non-infectious infectious

  37. fever non-infectious infectious • -allergic reactions • autoimmune diseases • cancer • drug reactions • hormonal disorder • hypothalamic tumors • too much exposure to the sun • stimulation of the body's immune response

  38. Non - infectious

  39. No joint pains No skin rashes Non - infectious

  40. No difficulty breathing No skin rashes Non - infectious

  41. No significant weight loss No family history of cancer Non - infectious

  42. No illicit drug use No skin rashes Non - infectious

  43. No heat or cold intolerance No significant weight loss Non - infectious

  44. No heat or cold intolerance No significant weight loss Non - infectious

  45. Non - infectious

  46. Prolonged fever with hepatosplenomegaly Pulse fever disproportion Infectious origin Tuberculosis Brucellosis Typhoid Fever

  47. Enteric (Typhoid) Fever Is a systemic disease characterized by fever and abdominal pain and caused by dissemination of S. Typhi or S. Paratyphi. Harrison’s Principles of Internal Medicine, 17th edition

  48. Typhoid Fever Dissemination of the bacteria through the macrophages via the lymphatics and colonize reticuloendothelial tissue. Use of antibiotic before seeking medical help Incubation period of the agent

  49. THE CAUSATIVE AGENT • Introduction to Diagnostic Microbiology by Danessa Delost • Clinical immunology and Serology by Dorresteyn Stevens Salmonella is a genus in the family Enterobacteriaceae that has more than 2300 serotypes previously described in the Kauffman-White schema

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