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FEBRILNI PACIENT Temperatura 1. Acetalsalicilna kislina: NE pri otrocih (Reyev sindrom) Acetaminofen: NE pri pacientih z boleznimi jeter NSAID: NE pri pacientih z ishemicnimi boleznimi srca (Koronarna vazokonstrikcija) Body temperature is regulated by the hypothalamus,and prostaglandin E2 acts on this region to stimulate fever. Fever most commonly occurs in the evening as a consequence of the diurnal variation of body temperature. Fever may be protective and should be reduced only in patients with ischemic heart disease or pulmonary disease, in elderly patients, and in children who have a history of febrile seizures. Acetylsalicylic acid, nonsteroidal antiinflammatory drugs, and acetaminophen (agents that reduce prostaglandin E2 production), are the preferred method for reducing fever and need to be given on a regular schedule. 2. 3. 4. Kdaj naj damo antipiretike? -Pri pacientih z boleznimi srca (ishemija zaradi povecane frekvence srca + vecje zahteve po kisiku) -Pacienti z resnimi boleznimi pljuc (ne morejo zadostiti povecanim potrebam po kisiku) -Starejsi pacienti z omejeno mentalno kapaciteto (lahko pride do letargije in zmedenosti) -Otroci z zelo visoko temperaturo (lahko pride do temperaturnih krcev) TEMPERATURA NEZNANEGA IZVORA (FUO) Temperatura neznanega izvora (FUO) 1. 2. 3. Fever must persist for more than 3 weeks in order to exclude self-limiting viral illnesses. Temperature must be more than 38.3⁰C to exclude normal variations in core body temperature set point. No diagnosis reached after 3 days of testing. (1) Pregled 1. 2. 3. 4. 5. 6. Thoroughly examine skin for embolic lesions. Palpate all lymph nodes. (Limfom, infekcija) Perform a complete joint examination. (Artritis) Listen carefully for cardiac murmurs. (SBE) Abdominal exam should assess liver and spleen size and should palpate for masses and areas of tenderness. (Hepatom, infekcije žolčnega trakta) Palpacija ščitnice (Tiroiditis) Major Causes of Fever of Unknown Origin “Big 3” 1. Infection 2. Neoplasm 3. Autoimmune disease “Little 6” 1. Granulomatous disease 2. Regional enteritis 3. Familial Mediterranean fever 4. Drug fever 5. Pulmonary emboli 6. Factitious fever (2) Testi (Sutton’s law) “Go where the money is” -Krvna slika in diferencialna krvna slika -Krvni razmaz po Giemsi in Wrightu -Testi funkcije jeter -Antinuklearna protitelesa in revmatoidni faktor -Sedimentacija eritrocitov -Analiza urina -Hemokultura (vsaj 3 vzorci) -Urinokultura -Sputum, kostni mozeg, PCR (CMV, Epstein-Barr) -Titer protiteles v razmaku 3-4 tedne (če imamo v mislih že določenega patogena) -PPD test na koži -Tomografija prsnega koša in abdomna Key points 1. 2. INFEKCIJA 3. 4. 5. NEOPLASME 1. 2. 3. 4. 5. 6. AVTOIMUNE BOLEZNI 1. 2. 3. 4. Temperatura v intenzivni enoti DRUGI VZROKI 1. 2. 3. 4. 5. Infection is the most common cause of FUO in patients under 65 years of age. Epidemiology (animal exposure, insect bites, outdoor camping, travel, exposure to infected humans) is helpful. Physical exam may provide useful clues, particularly inspection of skin, nail beds, and fundi, and cardiac auscultation. Abdominal abscess, miliary tuberculosis, and disseminated fungal infections can be fatal. Prior antibiotic administration interferes with diagnosis. Lymphoma is the most common neoplasia causing FUO. Pel–Ebstein fever strongly suggests Hodgkin lymphoma. Preleukemia can present as FUO in the elderly. Primary hepatoma can be associated with FUO; however, metastatic liver disease usually does not cause fever. Renal cell carcinoma occasionally causes FUO. Atrial myxoma can mimic subacute bacterial endocarditis. 1. Sistemski lupus eritematozus 2. Stillova bolezen (lahko zamešaš z bakterijsko okužbo) 3. Hypersensitivity angiitis 4. Revmatična polimialgija s temporalnim artritisom 5. Poliarteritis nodoza 6. Mixed connective tissue disease 7. Subakutni tiroiditis (mehka ščitnica) Regional enteritis can present with fever in the absence of gastrointestinal symptoms. Pulmonary emboli can present with fever in the absence of respiratory symptoms. Discontinue all medications in the patient with FUO. Consider factitious fever in the female health care worker with a medical textbook at the bedside and recurrent polymicrobial bacteremia. No diagnosis is made in an increasing percentage of modern cases. Zdravila: Antihistamines, Isoniazid, Barbiturates, Nitrofurantoin, Chlorambucil, Penicillins, Dilantin, Procaine amide, Hydralazine, Quinidine, Ibuprofen, Salicyclates, Iodides. Thiouracil, Aldomet, Mercaptopurine Fever is extremely common in intensive care unit patients. A systematic approach to diagnosis is critical. Key sites of infection include these: a) Lungs (critical to differentiate colonization from infection) b) Intravenous and intra-arterial lines c) Urinary tract (at high risk secondary to prolonged bladder catheterization) d) Wounds (particularly in the early postoperative period) e) Sinuses (in patients with nasotracheal tubes) 4. Neinfekcijski vzroki: pulmonarna embolija, temperatura zaradi zdravil, stara krvavitev. Empiric antibiotics need to be streamlined based on culture results. Prolonged broad-spectrum antibiotic coverage predisposes to colonization with highly resistant bacteria, fungemia, Clostridium difficile colitis, and drug allergies. 6. 1. Absces 2. Osteomielitis (vretenca, mandibula, sinusi) 3. Subakutni bakterijski endokarditis (murmur usually present, beware of previous antibiotics, visoka SE) 4. Infekcije žolčnega trakta (may have no right upper quadrant tenderness) 5. Infekcije urinarnega trakta (in absence of related symptoms) 6. Tuberkuloza (especially miliary disease) 7. Spirohete (leptospirosis, Borrelia) 8. Bruceloza (animal exposure, unpasteurized cheese) 9. Rikecioza 10. Chlamydia 11. Epstein–Barr virus, cytomegalovirus 12. Glivična infekcija (Cryptococcus, histoplasmosis) 13. Paraziti (malaria, toxoplasmosis, trypanosomiasis) 1. Limfom (especially Hodgkin, Pel–Ebstein fever: en teden visoka vročina, naslednji teden brez vročine…) 2. Levkemija (aleukemic or preleukemic phase) 3. Hipernefrom (high sedimentation rate) 4. Hepatom (generally not metastatic liver disease) 5. Miksom atrijev Still’s disease is associated with high fevers, evanescent skin rash, leukocytosis, high serum ferritin, and elevated erythrocyte sedimentation rate (ESR). A diagnosis by exclusion. Polymyalgia rheumatica and temporal arteritis are found in elderly patients and cause proximal muscle weakness, visual symptoms, and a high ESR. Subacute thyroiditis should be considered if the thyroid is tender. Kikuchi’s disease often presents with fever and lymphadenopathy. 1. 2. 3. 5. Vzrok