1. Fever, PUO & SIRS
•History, examination, differential diagnoses,
investigations and management.
•Common terms and definitions.
•Antibiotics????
KHAIRUL AZHAR ABU BAKAR 3MB3 2011
3. CASE 1
A 15 year old girl presented to ED
through GP referral c/o two days history
of new onset fever, headache,
photophobia, rash and sore throat with
no previous background hx, medications,
or known allergies.
She denied any previous seizure, epilepsy,
loss of consciousness, agitation, chest pain,
palpitations, shortness of breath, cough,
abdominal pain, or GI bleeding.
4. CASE 2
A 51 years old lady was transferred from
LGH to MAU in UCHG c/o of one week
history of jaundice and two months
episodes of general malaise, fever, night
sweats, unintentional weight loss and
vague abdominal pain.
No previous gallstones or jaundice,
denied any illicit drug use, tattooing,
alcohol excess, recent travel or contact
with jaundiced people.
5. 8 Questions for you???
Did these two ladies have fever?
Did they both have SIRS?
Did they both have PUO?
What is the most likely aetiology?
What questions should you ask these patients?
What findings would you expect on
examinations?
What are the appropriate investigations and why?
How would you manage these patients? As
outpatients or inpatients?
What antibiotics would you prescribe?
7. Fever
A rise/?decrease in body temp (T>37.3°C or
<36.6°C) in response to endogenous cytokines.
Causes:
i. Infections – bacterial, viral, parasitic, fungal,
rickettsial.
ii. Malignancy – lymphoma, leukaemia, liver mets,
HCC, RCC, pancreatic ca.
iii. Inflammatory – SLE, RF, RA, IBD, sarcoidosis,
pancreatitis, gout.
iv. Vascular- PE, GCA,WG, PAN.
v. Endocrinology – adrenal insufficiency, DM I,
hyperthyroidism.
vi. Miscellaneous – drugs, factitious.
8. Pyrexia of unknown origin
First definition by Petersdorf & Beeson
(1961): fever of >38.3°C (101°F) on several
occasions persisting w/o Dx for ≥3/52
despite ≥1/12 investigations in hospital.
Types:
i. Classic ( as above or >2 visits or >3/7 inpt)
ii. Nosocomial (none O/A, posthosp >24 hrs)
iii. Immune deficient (>3/7, -ve C+S >48 hrs).
iv. HIV related
Causes:
all the above.
9. Hyperthermia
An elevation in body temp >41.6°C due to loss of
homeostatic mechanisms and inability to ↑ heat
loss in resp to env heat.
Causes:
i. Heat stroke – CNS dysf(x), Xs physical exertion
in warm env
ii. NMS – idiosyncratic reaction to antipsychotic
Mx e.g butyrophenones,phenothiazines,
thoxanthenes.
iii. Malignant hyperthermia – a rare genetic abn in
muscle membrane that predispose pts to
severe rhabdomyloysis and temp dysregulation.
i.e anaesthetics,hot ambient temp.
19. Management
IV/IM benzylpenicillin if suspected meningitis
ABC
O2 support, 2 large IV bores, IVF, IV
antibiotics, oral paracetamol.
If meningitis – manage according to
(i) septicaemic or (ii) meningitic.
If encephalitis – manage before cause known
1. start aciclovir within 30 min of pt arrival.
2. specific Rx for CMV and toxoplasmosis.
3. supportive – ↑ICP, IV dexamethasone.
Continue Ix and Rx for PUO.
20. Not really a good diagram: see OHCM for chapter on meningitis.
21. Our patients =)
PATIENT 1
On examination:
pharyngitis, strawberry
tongue, blanching itchy
rash seems to disappear.
GCS = 15/15, no nuchal
rigidity, negative Kernig’s
or Brudzinski’s
DDx? Scarlet fever
Management – discharge,
isolate,10 days full
course of amoxicillin PO,
follow up in 3 days.
PATIENT 2
On examination –
palpable gallbladder,
jaundice. ?painless
DDx? Pancreatic ca,
lymphoma,
cholangiocarcinoma,
TB hepatitis.
Management – liver
biopsy, refer to
hepatologist.
24. References
Oxford Handbook of Clinical Medicine 8E
Oxford Handbook of Infectious Diseases
Lange’sThe Patient History Evidence-
Based Approach
Talley et. al. Clinical Examination A
Systematic Guide to Physical Diagnosis 6E
UCHG Guidelines of Antibiotics
prescriptions 2011.
