More Related Content Similar to Fever-DD&management (20) 2. Fever
• Since antiquity, Fever has been recognized as
cardinal manifestation of disease.
• Given importance over other symptoms and
demands high therapeutic expectation.
• Persistent and relapsing fevers are amongst
the most difficult diagnostic challenges in
medicine
3. Definition of Fever
• A state of elevated core temperature, which is
often, but not necessarily, part of defensive
response of body to invasion of live or
pathogenic matter.
• Pyrogen endogenous,or exogenous,iduced.
4. Definition of Hyperthermia
• Unregulated rise in body temp.
• Uncontrolled heat production, inadequate
heat dissipation, defective thermoregulation
• Not pyrogen related.
• No response to antipyratics.
5. Normal Temperature
• 37°C(98.6°F) is defined as normal
• There are various differences among workers
• Diurnal variation exist .
• Morning Temp.< Evening Temp.
• Female have higher Temp. ,and rises further
during menstruation
• Hyperpyrexia > 105°F
7. Antipyresis
• Physical: Tepid water sponging, Alcohol
sponging, ice packs, cooling blankets,
exposure to circulating fan
• Drugs: 1.Corticosteroids. 2.Aspirin & NSAID
3.Acetoaminophen (paracetamol)
• Benefits Vs Risk of lowering Temp.
8. Patterns of Fever
• Hi grade spike intermittent with /without rigor
• Low grade
• Continuous Hi grade
• Recurrent-intermittent
• Temperature-pulse dissociation: typhoid
fever, leptospirosis, brucellosis, and drug-
induced fever.
• Cyclical: hodgkin’s
9. Patterns of Fever
• Tertian, quartan: Malaria
• Travel related: H1N1 Swine Flu, Bird Flu
• Drug Fever
• Factitious Fever
• Fever in Immunocompromized
• PUO
10. Differential diagnosis of fever and
hyperthermia
• Fever—common causes
• Infections: bacterial, viral, rickettsial, fungal, parasitic
• Autoimmune diseases
• Malignant disease, especially renal cell carcinoma, primary or metastatic
• liver cancer, leukemia, and lymphoma
• Fever—less common causes
• Cardiovascular diseases, including myocardial infarction, thrombophlebitis,
• and pulmonary embolism
• Gastrointestinal diseases, including inflammatory bowel disease,
• alcoholic hepatitis, and granulomatous hepatitis
• Miscellaneous diseases, including drug fever, sarcoidosis, familial
• Mediterranean fever, tissue injury, hematoma, and factitious fever
• Hyperthermia
• Peripheral thermoregulatory disorders, including heat stroke, malignant
hyperthermia of anesthesia, and malignant neuroleptic
11. Common Febrile illness
Fever without Rash Fever with Rash
URTI,Sinusitis,Tonsillitis,Otitis,Pharyngitis
Viral :Infections:Dengue,Flu,Hunta virus,Viral Chickenpox,Measles,Dengue,Herpes,Mumps
Hepatitis, Measles,Mumps
Bacterial:Brucelosis,plague,Leptospirosis Typhus,Enteric
Fever,Sec.Syphilis,N.meningitis,gonorrhoea,L
eptospirosis,Staphylococcua
aures,Strepto(Scarlet Fever)
Respiratory:Pneumonia,Tuberculosis,Diptheri
a,Measles ,plague
GI: Enteric Fever,Bacillary
Desentry,Peritonitis,pancreatitis,Liver
Abscess,Hepatitis,Abscess,appendicitis,
cholecystitis
CNS:Meningitis,Brain Abscess
Urinary:Gonococci,UTI,Prostatitis
14. History
Fever
• O,D,P
• Nature of Fever:High grade,Low grade,
• Continuous /intermittent
• Diurnal variation
• Rigors: Present/Absent
• Past history of fever
15. Associated Symptoms
• Headache
• Vomiting
• Diarrhea
• Cough
• Jaundice
• Body ache/arthralgia/myalgia
• Abdominal pain
• Chest pain
• Localized pain
• Retro orbital pain
• Prostration/toxic
17. Associated Symptoms
• Urinary symptoms
• Breathlessness
• Joint pain
• Backache
• Eruptions
• Mouth ulcers/stomatitis
• Throat pain
• Swelling /Ulcers anywhere
• Recent travel
• Urticaria
18. Examination
general
Temprature
Pulse Tachycardia, relative bradicardia,irregular,low volume
Respiration Tachypnoea,shallow,
Sp o2 Optional
BP Hypotension, tourniquet test
Sclera,conjuctiva Jaundice,pallor,suffusion,haemorrhage
Tongue Coating,glossitis,candida,ulcers,cynosis
Throat,mouth Tonsills.pharyngs,diptheria,rash,dental
abscess,trysmus
Neck Lymph nodes-type,rigidiry,
Skin Rash,ulcers,abscess,nodules,perspiration
Axilla,groin Lymph nodes,abscess
19. Examination
general
Nails Pallor,clubbing,cynosis,infarcts,fungus
Higher function altered
20. Examination
Systemic
RS RR,Movments of chest,dull/tympanic node, Air entry, plural
rub, rales, rhnchi, bronchial breathing
AS Brathing,Distension,peristalsis,Tenderness-
quadrant,organomegaly,rigidity,gaurding,lump,dull-tympanic
node,
CVS Tachycardia,murmur,pericardial rub
CNS Higher function,Neck rigidity,Kernig’s sign,pupils,
Bones & joint Spine abnormality, tenderness,joint infammation
21. Investigations
basic
• Blood: CBC with ESR & Platelet count,PS.
SGPT, RBS, S.CREATININE,RDT(pf)
• Urine
• X-ray chest
• USG: Abdomen,chest
22. Investigations
specific & advanced
• Serology:Widal,NS1antigen,IgM,IgG for
Lepto,Hunta,TB,Virus,HIV
• Sputum:AFB,Gram st.,C&S,Cytology
• Culturs:Blood,urine,pus,aspirates,stool
• CT Scan: Abdoman,Brain,Chest+HRCT,Sinus
• MRI:Spine.Joints,Brain
• Acute phase reactant: CRP,ProCalcitonin
23. CBC
• Hb: down,up,
• RBC:down,Sickle,MP,Fragments
• WBC:N,H,D
• Platelet:N,H,D,ask for manual count,look for
other cause
• ESR:non specific
• PS: MP,Parasites,Leucamia,TTP,ITP,RBC
morphology,Platelet,Thin and Thick(3) smear
• Auto Cell counter
24. Urine
• Proteins:Infection,renal,pregnancy
• Acetone:DM,dehydration,poor nutrition
• Sugar:DM,IV fluid,renal
• Pus cells:infection,renal
• Organism:bacteria,fungus
25. X-Ray
• Chest:PA,Portable
• Spine:
• Sinus:
• Abdoman:Supine,Standing
26. USG
• Look for areas studied.Discuss with sonologist
• Always ask for Whole abdoman+Chest
• In doubt confirm with CT
27. Investigations
increase platelet
Condition Adults, >500,000/μL >1,000,000/μL
Infection 22% 31%
Rebound thrombocytosis 19% 3%
Tissue damage (surgery) 18% 14%
Chronic inflammation 13% 9%
Malignancy 6% 14%
Renal disorders 5% <1%
Hemolytic anemia 4% <1%
Post-splenectomy status 2% 19%
Blood loss NS 6%
Primary thrombocythemia 3% 14%
28. Investigation
Decrease platelet
Immune destruction Autoantibodies: ITP, disease-associated IT (collagen
disease, lymphoproliferative disorders)
Alloantibodies: post-transfusion purpura, neonatal
purpura
Drug-induced IT: quinidine, quinine, sulfonamides,
gold, etc.
Acute ITP
Infection HIV, hepatitis, cytomegalovirus, Epstein-Barr virus
Nonimmune destruction Infection (bacterial, viral, malarial)
or platelet removal Thrombotic thrombocytopenic purpura/hemolytic-
uremic syndrome
D.I.C. ,Hemangiomas,Platelet loss (massive bleeding)
Platelet redistribution (enlarged spleen)
Congestive splenomegaly
Other (non-Hodgkin's
lymphoma, Gaucher's
disease, etc.)
29. Investigation
Decrease platelet
DECREASED PLATELET PRODUCTION Myeloproliferative disorders (acute or chronic
leukemias, multiple myeloma, myelofibrosis
Lymphoproliferative disorders (non-Hodgkin's
lymphoma, CLL)
Aplasia or hypoplasia (idiopathic, drug induced,
radiation)
Ineffective hematopoiesis (myelodysplasia,
vitamin B12 or folate deficiency)
Myelophthisis (prostate, lung, breast,
gastrointestinal cancers)
Drugs (chemotherapy, thiazides, alcohol, etc.)
Congenital/hereditary disorders
31. Plt. & atypical Lymphocytes
• Platelet :↓ + Atypical Lymphocytes
Day 1-2 – Malaria
• Platelet : N Day 1-2 + Atypical Lymphocytes
↓ Day 2-3-4+ Atypical
Lymphocytes - Dengue
32. Indirect evidence of Malaria
• Platelet:↓ Day 1-2
• Hb:↓ Day 1-2
• Atypical Lymphocytes day 1-2
• SGPT:↑
• Bilirubin:↑
• Band cells & Monocytes:↑
• Polychromasia
• Cholesterol:↓
33. Rash
• Morbilliform
• Macular
• Papular
• Nodular
• Vesicular or bullous
• Pustular
• Plaques
• Purpura, petechiae, ecchymosis
• Erythematous
42. Petechial and purpuric illnesses
• Purpura fulminans
• Viral hemorrhagic fevers
• Thrombocytopenia
• Vasculitis
47. Treatment
• General • Specific
• Antipyresis • Antibiotics
• Hydration • Antimalarial
• Nutrition • Vaccines
• Antiemetics • Antibodies serun
• Antacids • Steroids?
• Reassurance
• Prevent panic in
epidemics
• Family care
48. Dengue
• Self limited
• Symptomatic in majority cases
• Close observation
• IV fluids
51. Dengue-What not to do
• Do not give Aspirin or Brufen for treatment of fever.
• Avoid giving intravenous therapy before there is evidence of
haemorrhage and bleeding.
• Avoid giving blood transfusion unless indicated, reduction in
haematocrit or severe bleeding.
• Avoid giving steroids. They do not show any benefit.
• Do not use antibiotics
• Do not change the speed of fluid rapidly, i.e. avoid rapidly
increasing or rapidly slowing the speed of fluids.
• Insertion of nasogastric tube to determine concealed
bleeding or to stop bleeding (by cold lavage) is not recommended
since it is hazardous
53. P.F.Malaria
• Uncomplicated:treat
• Complicated:Reference
• Tratment:ACT(Artemisinin derivative combined with
long acting antimalarial)(Amodiaquinine,Lumefantrine,
Mafloquine,Sulfadixine-pyrimethamine)
• Artemisinin alone? No
• Pregnancy:ACT in 2nd & 3rd trimester,Quinine in 1st
• Mixed Infection: treat like pf
• Clinical Malaria: RDT,PS negative but strong clinical
presentation
• Vaccine
54. Complicated PF
• If not detected early and treated ,in severe pF
malaria,sevre meifestations can develop in
12-24 hr,and lead to death
• Platelet factor responsible for immunity storm
• P.Knowelsi : Thailand , in Monkey
55. Complicated PF
Severe manifestations
• Impaired conciousness/coma
• Convulsions
• Renal failure
• Jaundice
• Anaemia:rapid lowerin of Hb <5 g/dl
• ARDS
• Hypoglycemia
• Metabolic Acidosis(clinical?)
• Shock
• DIC /bleeding
• Haemoglobinuria
• Hypothermia
• Heavy parasitemia
• Pregnancy
58. UTI
• Antibiotics:
• Quinolons
• Aminoglycosides
• Septran
• Cephalosporins
• C&S
• USG
62. PRACTICAL PROBLEMS
• DIFFERENTIAL DIAGNOSIS :any fever in
endemic area demands for quick identification
• QUICK DETECTION & TRETMENT : Late
diagnosis &treatment & inadequate treatment
in PF,LEPTO,Dengue,PNEUMONIA
,Enteric,Meningitis.
Proves expensive and lethal
• Variable presentation
64. Antibiotics case1
• Oral quinolon,IV
• 3rd cephalosporin
• Cefaparozone+sulbactum+new quinolon
• Anti viral
• Carbapenum + quinolon
• Aminoglycoside+carba+new quinolon
• 8 in 48 hr
65. Antibiotics case 2
• 80/male
• Circumsion
• Aminoglycoside single dose
• ARF
• Bleeding p/r
• Hemicolectomy
• Ventilated/VAP/recovered
• Rebleed
• ARDS
• 3 weeks
66. DHF case 3
• 45/m
• Platelet :2000
• Ascites,Pl.effusion
• Iv Fluid
• Platelet count low <15000 for 6 days
