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APPROACH TO A PATIENT WITH FEVER ASSOC. PROF. DR. ÖZLEMTANRIÖVER OBJECTIVES 1. Identify significant signs and symptoms and correlation with fever. 2. Define and explain the etiology and pathophysiology of fever. 3. To identify the patterns of fever. LET’S START WITH A CASE General Data A 56 year-old, female, patient Married with 2 children Market shopkeeper from Kadikoy, İstanbul CHIEF COMPLAINT : FEVER History of Present Illness: 3 weeks 2 weeks Day of consultation and admission • Fever • Persistence of fever • Self medication with Paracetamol, Ibuprofen, and Amoxicillin • Persistence of fever QUESTIONS TO ASK • How was the temperature taken? How often? • Impact on the patient’s lifestyle? • People the patient had contacted with who manifested the same signs and symptoms. • Associated symptoms 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 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? OBSTETRIC & GYNECOLOGIC HISTORY • 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? FAMILY HISTORY • No family history of hypertension, diabetes mellitus, cancer, pulmonary tuberculosis • Autoimmune disease, blood disorders? PERSONAL AND SOCIAL HISTORY •Market shopkeeper •Non smoker, non passive smoker •Non alcoholic beverage drinker •Likes eating street foods •No travel to endemic areas MISSING DATA: 1. What is the patient’s usual diet? Preferred foods? 2. Food preparation? 3. Source of drinking water? 4. How is the patient’s home condition? 5. Any household pets? INFECTIOUS • Systemic • Bacteremia, sepsis, meningitis, endocarditis • Respiratory • URI, sinusitis, otitis media, pharyngitis, pneumonia, bronchiolitis • Abdominal • Urinary tract infection, abscess (liver, kidney, pelvis) • Bone/joint infection INFLAMMATORY • • • • • Kawasaki disease Juvenile inflammatory arthritis Lupus Inflammatory bowel disease Henoch-Schonlein purpura OTHERS • CNS dysfunction • Drug fever REVIEW OF SYSTEMS (ROS) General • No sign of weight loss • Body malaise, fatique, 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, tinnitus • Otalgia? 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 ? 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 PHYSICAL EXAMINATION • Conscious, coherent, obese, oriented as to time, place and person • BP = 110/80 mmHg • PR = 80 beats per min (bpm) regular • RR = 22 per minute • Temperature = 39.5C • Height = 1.5m • Weight = 70kg • BMI = 31 • No skin rashes • Anicteric sclera • Hepatosplenomegaly PHYSICAL EXAMINATION • Pulse rhythm, amplitude, contour • Respiration regularity, rhythm, depth, breath sounds • Heart sounds • Abdominal tenderness • Inspection and palpation of lymph nodes • Pelvic examination SIGNIFICANT FEATURES Subjective Data • AÖ, 56 years old, female, married, market shopkeeper 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 • Anicteric sclera • Hepatosplenomegaly • Unremarkable head, neck, ear, nose, throat, eyes, chest and lungs, heart and blood vessels, breast and axilla, GI, GU, musculoskeletal. • Based on the Medical history and physical examination, the patient manifests with prolonged fever secondary to ……..? CHIEF COMPLAINT: 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 Fever classification Grade oC low grade 38–39 moderate 39–40 high-grade 40–42 hyperpyrexia >42 oF 100.4–102.2 102.2–104.0 104.0–107.6 >107.6 FEVER PATTERNS INTERMITTENT 40 39.5 39 38.5 38 37.5 37 36.5 36 35.5 D1 D2 D3 D4 Intermittent: marked by a daily temperature drop into the normal range and then a rise back to above normal REMITTENT 40.5 40 39.5 39 38.5 38 37.5 37 36.5 D1 D2 D3 D4 Remittent: A fever with diurnal variation of more than 1.1 0C but with no normal readings CONTINUOUS 39.6 39.5 39.4 39.3 39.2 39.1 39 38.9 38.8 38.7 38.6 D1 D2 D3 D4 Continuous: A fever with a diurnal variation of 0.5 to 10C RELAPSING 39.5 39 38.5 38 37.5 37 36.5 36 D1 D2 D3 D4 Relapsing: Febrile episodes are separated by intervals of normal temperature; bouts of fever occurring every five to seven days SEPTIC 40 39.5 39 38.5 38 37.5 37 36.5 36 35.5 D1 D2 D3 D4 Septic: An intermittent fever that fluctuates widely, typically producing chills and sweating FEVER - TYPES 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 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 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 PATHOPHYSIOLOGY OF FEVER • Cellular sources of pyrogenic cytokines include: monocytes, neutrophils, and lymphocytes Source: Harrison’s Principles of Internal Medicine (16th Edition), p. 106 PHYSIOLOGY OF FEVER • Exogenous pyrogen Activated leukocytes Endogenous pyrogen (IL1,TNF,…) Acute Phase Response • Preoptic area of anterior hypothalamus (PGE2) increase of set point => • Brain cortex • Vasoconstriction heat conservation • Muscle contraction heat production FEVER INDUCTION OF FEVER Infection, microbial toxins, mediators of Inflammation, immune reactions Microbial toxins Cyclic AMP Monocytes / macrophages, endothelial cells, others Pyrogenic cytokines IL-1, IL-6, TNF, IFN, ciliary neurotrophic factors PGE2 Hypothalamic endothelium Fever Heat conservation, heat production Elevated thermoregulatory set point Circulation Harrison’s Principle of Internal Medicine 17 th edition DISCOMFORT DUE TO FEVER • For each 1 °C elevation of body temperature: • Metabolic rate increase 10-15% • Insensible water loss increase 300-500ml/m2/day • O2 consumption increase 13% • Heart rate increase 10-15/min PATHOPHYSIOLOGY OF FEVER • Tachycardia usually accompanies fever PULSE RATE is PROPORTIONAL to TEMPERATURE Source: DeGowin’s Diagnostic Examination (8th Edition), p. 61-62 Pathophysiology of Fever “For every 10C rise in temperature, pulse increases by 10 bpm. Pulse temperature dissociation typhoid, brucellosis, leptospirosis, viral myocarditis, diphtheria, rheumatic carditis, bacterial endocarditis“ WWW.RATIONALMEDICINE.COM -allergic reactions -stimulation of the body's immune response -autoimmune diseases - cancer - drug reactions - hormonal disorder - hypothalamic tumors -too much exposure to the sun autoimmune diseases allergic reactions cancer drug reactions hormonal disorder hypothalamic tumors Non - infectious No joint pains No skin rashes autoimmune diseases allergic reactions cancer drug reactions hormonal disorder hypothalamic tumors Non - infectious No difficulty breathing No skin rashes allergic reaction cancer drug reactions hormonal disorder hypothalamic tumors Non - infectious No significant weight loss No family history of cancer cancer drug reactions hormonal disorder hypothalamic tumors Non - infectious drug reactions No illicit drug use No skin rashes hormonal disorder hypothalamic tumors Non - infectious No heat or cold intolerance No significant weight loss hormonal disorder hypothalamic tumors Non - infectious No heat or cold intolerance No significant weight loss hypothalamic tumors Non - infectious Non - infectious Prolonged fever with hepatosplenomegaly Infectious origin Tuberculosis Brucellosis Typhoid Fever Pulse fever disproportion Prolonged fever with hepatosplenomegaly Infectious origin Tuberculosis Brucellosis Typhoid Fever Dissemination of the bacteria through the macrophages via the lymphatics and colonize reticuloendothelial tissue. Hepatospleno megaly Use of antibiotic before seeking medical help Pulse Fever disproportion Prolonged fever Incubation period of the agent TYPHOID FEVER PHARMACOTHERAPY Problem Goal Solutions • Decrease fever •Antipyretics • Find cause of fever and eliminate Typhoid Infection •Eliminate infective •antibiotics agent with broader range Persistent fever despite of medication SUMMARY OF THE LECTURE APPROACH TO FEVER • Personal History: • • • • Age Occupation Place of origin,Travel History Habits • • • • Sexual Practices Injection Drug Abuse Excessive Alcohol Use Consumption of Unpasteurized Dairy Products APPROACH TO FEVER • Underlying Diseases: • • • • Splenectomy Surgical Implantation of Prosthesis Immunodeficiency Chronic Diseases: • Cirrhosis • Chronic Heart Diseases • Chronic Lung Diseases APPROACH TO FEVER • Drug History: • Antipyretics • Immunosuppressants • Antibiotics • Family History: • TB in the Family • Recent Infection in the Family APPROACH TO FEVER • Associated Symptoms: • Shaking chills • Ear pain,Ear drainage,Hearing loss • Visual and Eye Symptoms • Sore Throat • Chest and Pulmonary Symptoms • Abdominal Symptoms • Back pain, Joint or Skeletal pain APPROACH TO FEVER • Physical Examination: • Vital Signs • Neurological Exam. • Skin Lesions,Mucous Membrane • Eyes • ENT • Lymphadenopathy • Lungs and Heart • Abdominal Region (Hepatomegaly,Splenomegaly) • Musculoskeletal LABORATORY STUDY IN PATIENT WITH FEBRILE ILLNESS • Assess the extent and severity of the inflammatory response to infection • Determine the site(s) and complications of organ involvement by the process • Determine the etiology of the infectious disease INDICATIONS OF HOSPITALISATION IN PATIENT WITH FEBRILE ILLNESS • People who are clinically unstable or are at risk for rapid deterioration • Major alterations of immunity • Need for IV Antimicrobials or other fluids • Advanced age QUESTIONS? • Assoc. Prof. Dr. Özlem TANRIÖVER Tel: (216)5783742 E-mail: [email protected]