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HKCEM College Tutorial
A woman with
recurrent fever
AUTHOR
DR. ERIC LAM & DR. CY MAN
REVISED BY
DR. SHEK KAM CHUEN
OCT., 2013
Triage notes
▪ F/45
▪ on & off fever x 2/52
▪ Reattendance Case
▪ BP/P 140/90, 110
▪ RR 20/min
▪ Temp. 37.8℃
Triage category IV
What historical points are
relevant?
Targeted History
▪ Fever
▪ duration
▪ pattern
▪ systemic upset
▪ main systems involved
▪
▪
▪
▪
CNS
Resp (URI, LRTI)
GI, hepatobiliary
GU e.g. UTI? PID?
▪ Review of other systems
▪ PH:
▪ ?immunocompromised,
▪ ?HIV
▪ Med e.g. GP drugs
▪ Allergies
▪ Recent Travel
▪ Animal contact
History
on & off low grade fever x 2/52
malaise, generalized joint with muscle ache,
lethargy, headache,
throat discomfort, gum pain
nausea & vomiting
attended AED x 2, treated as viral illness not responding to
treatment
re-attended today because of persistent symptoms
PMH / drug / travel / social history
-unremarkable
What is your focus in the physical exam?
Focussed exam
▪ Confirm fever
▪ oral better than tympanic
▪ Rash
▪ distribution
▪ characteristics
▪ CNS
▪ features for encephalitis & meningitis
▪ HEENT
▪ conjunctivitis
▪ oral lesion
▪ Neck
▪ rigidity
▪ LNs
▪ CVS/?Resp
▪ heart murmur
▪ crep, rhonchi
▪ Abdomen
▪ organomegaly
▪ tenderness: HBS, kidneys
▪ Musculo-skeletal
▪ joint swelling
Examination
▪ unwell looking woman
▪ pale
▪ patches of bruises over limbs
▪ no lymphadenopathy
▪ gum hypertrophy
▪ no hepatosplenomegaly
▪ rest of the exam--non-contributory
What do you
need to rule in?
This rash will not blanch on pressure.
Meningococcemia!
▪ This is a dire emergency that should not be missed.
▪ Immediate antibiotics e.g. ceftriaxone 2 gm is needed.
What is your
differential diagnosis ?
What is your differential diagnosis ?
▪ infection
▪ connective tissue disease
▪ malignancy
▪ drug
▪ idiopathic
What will you do nex ?t
▪ Discharged with drugs
▪ Observe in O ward pending Ix
▪ Admit to medical ward
What investigations would you request ?
CBC
R,LFT
Clotting profiles
blood culture
MSU, urine x microscopy
CBC :
▪ Hb
6 g / dL
▪ WCC
40 x 109/L
(predominantly blast cells)
▪ Platelet
INR: 5
APTT: 100 seconds
26 x 109/L
What is your diagnosis?
Acute leukaemia with possible DIC
Acute leukaemia with possible DIC
Which type is prone to DIC?
Acute promyelocytic leukaemia(M3)
What is your immediate treatment?
•
•
•
Stabilize ABC of patients
Identify and treat immediate problems (if any) e.g. severe
anaemia, uncontrolled bleeding, severe septicaemia
Admit under the care of haematologist for bone marrow
aspiration for confirmation
Learning points
▪ Patient with acute leukaemia may present with persistent or
recurrent fever, flu or URI symptoms
▪ Patient with persistent fever/Flu/URI symptoms lasting more
than a week or so may need detailed
history/examination/further investigations to identify or
exclude important underlying causes, e.g. occult infection,
leukaemia, connective tissue disease
The end