Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 1. Identify significant signs and symptoms and correlate with fever. 2. Define and explain the etiology and pathophysiology of fever. 3. To identify the necessary ancillary procedures that can help in the diagnosis of a patient with fever 4. To formulate an effective pharmacologic and nonpharmacologic management for a patient with fever. 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 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 • 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 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 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 • • • • 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? Family History • No family history of hypertension, diabetes mellitus, cancer, pulmonary tuberculosis • Autoimmune disease, blood disorders? 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 Missing Data: 1. 2. 3. 4. 5. 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? 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? 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 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 Physical Examination • Pulse rhythm, amplitude, contour • Respiration regularity, rhythm, depth, breath sounds • Heart sounds • Abdominal tenderness • Inspection and palpation of lymph nodes • Pelvic examination 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. • Based on the Medical history and physical examination, the patient manifests with prolonged fever secondary to infection. 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 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 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 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 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. “ 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 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 Dissemination of the bacteria through the macrophages via the lymphatics and colonize reticuloendothelial tissue. Hepatosplenomegaly Use of antibiotic before seeking medical help Pulse Fever disproportion Prolonged fever Typhoid Fever Incubation period of the agent THE CAUSATIVE AGENT Salmonella is a genus in the family Enterobacteriaceae that has more than 2300 serotypes previously described in the Kauffman-White schema •Introduction to Diagnostic Microbiology by Danessa Delost •Clinical immunology and Serology by Dorresteyn Stevens S typhi has O and H antigens, an envelope (K) antigen, and a lipopolysaccharide macromolecular complex, called endotoxin, that forms the outer portion of the cell wall. Salmonellae are grouped based on the somatic O antigen and further divided into serotypes based on flagellar H and surface Vi (virulence) antigens •Introduction to Diagnostic Microbiology by Danessa Delost •Clinical immunology and Serology by Dorresteyn Stevens S typhi is similar to other salmonellae in that it is: • Gram-negative, • Flagellate, • Non-encapsulated, • Non-sporulating, • Facultative anaerobic bacillus, • Ferments glucose, • Reduces nitrate to nitrite, • Synthesizes peritrichous flagella when motile. •Introduction to Diagnostic Microbiology by Danessa Delost •Clinical immunology and Serology by Dorresteyn Stevens LABORATORY PROCEDURES Complete Blood Count (CBC) A complete blood count will normally include: Red cell count White cell count Hemoglobin Hematocrit Differential Count: Neutrophils: 55%–70% Band neutrophils:0%–3% Lymphocytes:20%–40% Monocytes: 2%–8% Eosinophils: 1%–4% Basophils: 0.5%–1% Complete Blood Count (CBC) • Neutropenia – May be present with some viral infections, drug reactions – Systemic Lupus Erythematosus – Typhoid – Brucellosis – Lymphoma – Tuberculosis Complete Blood Count (CBC) • Lymphocytosis – Typhoid – Brucellosis – Tuberculosis – Viral disease Complete Blood Count (CBC) • Monocytosis – Typhoid – Brucellosis – Tuberculosis – Lymphoma Complete Blood Count (CBC) • Monocytosis – Typhoid – Brucellosis – Tuberculosis – Lymphoma IDENTIFICATION / LABORATORY DIAGNOSIS • Gold Standard: Culture and Sensitivity • Widal Test • TyphiDot Test • PCR and Molecular Studies • • Introduction to Diagnostic Microbiology by Danessa Delost Clinical immunology and Serology by Dorresteyn Stevens CULTURE AND SENSITIVITY • The organism is non-fastidious • Can be cultured on Laboratory Culture Media – Hektoin Enteric Agar – Sheep Blood Agar – Salmonella-Shigella Agar – Mackonkey Agar – TSI, LIA, SSA, Motility Agar, Urea Broth and other Biochemical Test Agar Media Black Raised Colonies in HEA medinfo.ufl.edu/.../bms5300/images/d7047.jpg The presence of any black colored area indicates the deposition of hydrogen sulfide, (H2S) under alkaline conditions in SSA medinfo.ufl.edu/.../bms5300/images/d7047.jpg Salmonella typhi in BSA medinfo.ufl.edu/.../bms5300/images/d7047.jpg THE WIDAL TEST Accurate Serological Study SEROLOGICAL STUDIES • Employs the Widal Test (pronounced VIDAL TEST) • This test involves the agglutination of reagent typhoid bacilli parts when mixed with serum containing typhoid antibodies from an individual having typhoid fever. • This test differentiates typhoid fever and paratyphoid fever. • • Introduction to Diagnostic Microbiology by Danessa Delost Clinical immunology and Serology by Dorresteyn Stevens THE WIDAL TEST • This test is Specific for the detection of typhoid fever. • It measures the pressence of anti-”O” and anti-”H” antibodies • Uses bacterial suspension of killed S. typhi and S. paratyphi. (Salmonella “O” antigens of groups A,B,C,D and Salmonella “H” antigens groups a,b,c,d • Antibodies formed against the “O” antigen are generally of the IgM type and the Anti-H antibodies are generally IgG type. • • Introduction to Diagnostic Microbiology by Danessa Delost Clinical immunology and Serology by Dorresteyn Stevens TYPHI DOT TEST • Employs Immunochrom Procedure • Uses prepared antigen and patient’s serum with antibody • Sensitive and fast • Expensive • • Introduction to Diagnostic Microbiology by Danessa Delost Clinical immunology and Serology by Dorresteyn Stevens RADIOLOGY • Chest X-ray • Abdominal X-ray • Ultrasound Imaging CHEST X-RAY • Not a reliable procedure to diagnose • To rule out the possibility of tuberculosis Abnormal Chest X-ray • Fluffy infiltrate with patchy areas of consolidation involving the upper and lower parts of the right lower and right upper lobes respectively Plain Films • Determination of hepatomegaly on plain films is generally unreliable and can be made with certainty only when the liver is massively enlarged. • May show liver calcifications and air within the biliary tree or abscesses • Don’t show soft-tissue abnormalities such as fluid-filled cysts, liver tumors, and dilated bile ducts. ULTRASOUND IMAGING • To evaluate size, shape, and position of the liver. • To evaluate problems of the liver, including liver masses, cirrhosis, fat deposits • To determine the size of the enlarged spleen and look for damage or disease. • To determine whether a mass in any of the abdominal organs (such as the liver) is a solid tumor or a simple fluid-filled cyst. Pharmacotherapy 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 How to decrease Fever? Antipyretics • drugs that reduce body temperature • cause the hypothalamus to override an interleukin-induced increase in temperature – Aspirin and paracetamol Antipyretics Aspirin • Anti-inflammatory, antipyretic, analgesic, anticlotting drug • suppressed the production of prostaglandins and thromboxanes – irreversible inactivation of the cyclooxygenase (COX) enzyme • acts as an acetylating agent where an acetyl group is covalently attached to a serine residue in the active site of the COX enzyme Antipyretics Paracetamol • widely-used analgesic and antipyretic • reduces the production of prostaglandins – inhibit the cyclooxygenase (COX) family of enzymes • has no direct effect at the site of inflammation but instead acts in the CNS to reduce temperature Antipyretics Febrifuges – herbal remedies with a fever-reducing effect • catnip • chamomile • sage • wormwood • yarrow How to decrease Fever? • • • • Non pharmacologic approach maintenance of adequate hydration Maintenance of adequate fluid intake External cooling – use of cooling blankets – alcohol sponges How to eliminate Food-borne infection? Drug of choice: Ciprofloxacin • oral tablets (250, 500, 750, and 1000 mg) • ready-made infusion bottles (200 and 400 mg) • BID How to eliminate Food-borne infection ? • Alternative choices: 3rd generation antibiotics Ceftriaxone • starting dose is 1 gram IV daily • Doses range from 1–2 grams IV or IM every 12–24 hours, depending on the type and severity or the infection, up to 4 grams daily How to eliminate Food-borne infection Alternative choices: 4th generation antibiotics Cefepime Mild to moderate: 500 mg to 1 gram IV q12h. Moderate to severe: 1-2 grams IV q12h. http://www.globalrph.com/cefepime_renal.htm How to eliminate Food-borne infection ? Alternative choices: Antibiotic combinations Co-amoxiclav Standard adult dosage: co-amoxiclav 250/125 (one tablet Augmentin 250) taken every 8 hours How to eliminate Food-borne infection ? Lt Gen SP Kalra AVSM Bar*, Lt Col N Naithani+, Col SR Mehta VSM#, Sqn Ldr AJ Swamy**. Current Trends in the Management of Typhoid Fever http://medind.nic.in/maa/t03/i2/maat03i2p130.pdf Thank you!!!