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2012School of Clinical Medicine              Clinical Skills            NRMSM UKZN           Dr RM Abraham
OVERVIEW Introduction Thermoregulation Pathophysiology of fever Aetiology /Differential diagnosis of fever Types of f...
INTRODUCTIONFEVER(Pyrexia) Is an elevation of body temperature above the normal  circadian range (daily variation) as a r...
THERMOREGULATION Body temperature is controlled in the hypothalamus, which is directly sensitive to changes in core tempe...
THERMOREGULATIONIn a hot environment sweating is the main mechanism for increasing heat  loss. This usually occurs when ...
PATHOPHYSIOLOGY OF FEVERThe initiation of fever begins: when exogenous or endogenous stimuli are presented  to specialize...
PATHOPHYSIOLOGY OF FEVERExogenous pyrogens: stimuli from outside the host  like : microorganism, their products, or toxins...
PATHOPHYSIOLOGY OF FEVEREndogenous pyrogens: polypeptides that are produced by the body ( by  monocytes and macrophages )...
PATHOPHYSIOLOGY OF FEVERPyrogens:  Substances that cause fever are called pyrogensCytokines : Cytokines are regulatory po...
PATHOPHYSIOLOGY OF FEVER   The most important cytokines are :   Interleukin 1 and 1 (The most pyrogenic)   Tumor necros...
PATHOPHYSIOLOGY OF FEVER Cytokine-receptor interactions in the pre-optic region of  the anterior hypothalamus activate ph...
FEVERnfection, microbial toxins,mediators of inflammation,           Microbial toxins    immune reactions                 ...
INFECTION                        Monocytes, macrophages                    Endogenous pyrogens (IL-1,TNF, IL-6)           ...
INFECTIONS        MALIGNANCIES AUTOIMMUNE               OTHERS•Typhoid Fever                  CONDITIONS-                 ...
TYPES OF FEVERThe pattern of temperature changes may occasionally hint at the diagnosis: Continuous fever: Temperature re...
TYPES OF FEVER Remittent fever: Temperature remains above normal throughout the day and fluctuates more than 1 °C in 24 h...
PYREXIA OF UNKNOWN ORIGIN (PUO) A common presenting problem. Defined as a consistently elevated body temperature of  mor...
Aetiology and Epidemiology ofPUO in developed countriesInfections (30%) Sepsis- Abscess at any site; Cholecystitis/ Chola...
Connective tissue disorders (15%)•Vasculitic disorders (including polyarteritis nodosaand rheumatoid disease with vasculit...
FACTITIOUS FEVER This is defined as fever engineered by the patient by  manipulating the thermometer and/or temperature  ...
FACTITIOUS FEVERCLUES TO THE DIAGNOSIS OF FACTITIOUS FEVER   A patient who looks well   Absence of temperature-related c...
HISTORY TAKING IN FEBRILEPATIENTS Using the Calgary Cambridge guide as a framework to    interviewing patients.   The mo...
Initiating the session                preparation                establishing initial rapport                identifying t...
The content of the medical interviewPatient’s problem list1.2.3.Exploration of patient’s problems:Biomedical perspectivese...
BIOMEDICAL PERSPECTIVEPresenting complaints of a patient with fever Feeling hot   A feeling of heat does not necessarily ...
BIOMEDICAL PERSPECTIVE Recurrent fever.   Source is often a focus of bacterial infection such as  cholecystitis or cholan...
BIOMEDICAL PERSPECTIVESymptom analysis for fever Verify presence of fever- True or factitious fever Duration- Acute or c...
BIOMEDICAL PERSPECTIVE Respiratory tract symptoms:1) Sore throat, nasal discharge, sneezing-URTI2) Sinus pain and headach...
BIOMEDICAL PERSPECTIVE Abdominal symptoms: diarrhea, with or without blood, weight loss and  abdominal pain -suggesting  ...
BIOMEDICAL PERSPECTIVE Joint symptoms: joint pain, swelling or limitation of movement is suggestive of active arthritis. ...
BIOMEDICAL PERSPECTIVEConstitutional symptoms: Weakness Fatigue Anorexia Change of weight Fever/chills Lumps Night ...
CONTEXTUAL HISTORYPast Medical /Surgical HistoryStart by asking the patient if they have any medical  problems IHD/DM/Ast...
CONTEXTUAL HISTORYDrug and allergy History dosage, timing &how long. Drug fever is uncommon and therefore easily missed-...
CONTEXTUAL HISTORYFamily History Any familial disease/running in families e.g. breast  cancer, IHD, DM, Asthma, Arthritis...
CONTEXTUAL HISTORYPersonal and Social History Smoking history - amount, duration & type- strong risk factor for IHD Alco...
CONTEXTUAL HISTORYTravel HistoryTravel to an area known to be endemic for certain disease:        Name of the area, durat...
PATIENTS PERSPECTIVEAlways ask the patient how he/she feels/thinks about  the illness by analysing Ideas Concerns Feeli...
SYSTEMS REVIEW General• Weakness• Fatigue• Anorexia• Change of weight• Fever/chills• Lumps• Night sweats
SYSTEMS REVIEWCardiovascular• Chest pain• Paroxysmal Nocturnal Dyspnoea• Orthopnoea• Short Of Breath(SOB)• Cough/sputum (p...
SYSTEMS REVIEWGastrointestinal• Appetite (anorexia/weight change)• Diet• Nausea/vomiting• Regurgitation/heart burn/flatule...
SYSTEMS REVIEWRespiratory System• Cough(productive/dry)• Sputum (colour, amount, smell)• Haemoptysis• Chest pain• SOB/Dysp...
SYSTEMS REVIEWUrinary System• Frequency• Dysuria• Urgency• Hesitancy• Terminal dribbling• Nocturia• Back/loin pain• Incont...
SYSTEMS REVIEWNervous System• Visual/Smell/Taste/Hearing/Speech problem• Head ache• Fits/Faints/Black outs/loss of conscio...
SYSTEMS REVIEWGenital system• Pain/ discomfort/ itching• Discharge• Unusual bleeding• Sexual history• Menstrual history – ...
SYSTEMS REVIEWMusculoskeletal System• Pain – muscle, bone, joint• Swelling• Weakness/movement• Deformities• Gait
THE END: REFERENCES Guytons Textbook of Medical Physiology Davidsons Principles & Practice of Medicine Hutchinsons Clin...
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Approach to history taking in a patient with fever

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Approach to history taking in a patient with fever

  1. 1. 2012School of Clinical Medicine Clinical Skills NRMSM UKZN Dr RM Abraham
  2. 2. OVERVIEW Introduction Thermoregulation Pathophysiology of fever Aetiology /Differential diagnosis of fever Types of fever Pyrexia of Unknown origin(PUO) Factitious fever History taking in a febrile patient
  3. 3. INTRODUCTIONFEVER(Pyrexia) Is an elevation of body temperature above the normal circadian range (daily variation) as a result of a change in the thermoregulatory center located in the anterior hypothalamus and pre-optic area (i.e. an increase in the hypothalamic set point of 37 C) due to infection, metabolic derangements or increased cell destruction.
  4. 4. THERMOREGULATION Body temperature is controlled in the hypothalamus, which is directly sensitive to changes in core temperature The normal set-point of core temperature is tightly regulated within 37 ± 0.5°C, as required to preserve normal function of many enzymes and other metabolic processes.
  5. 5. THERMOREGULATIONIn a hot environment sweating is the main mechanism for increasing heat loss. This usually occurs when the ambient temperature rises above 32.5°C or during exercise
  6. 6. PATHOPHYSIOLOGY OF FEVERThe initiation of fever begins: when exogenous or endogenous stimuli are presented to specialized host cells, principally monocytes and macrophages ,they will then stimulate the synthesis and release of various pyrogenic cytokines including : 1)interleukin-1, interleukin-6 2)TNF-α, and 3)IFN-γ.
  7. 7. PATHOPHYSIOLOGY OF FEVERExogenous pyrogens: stimuli from outside the host like : microorganism, their products, or toxins and it is called EndotoxinEndotoxin : lipopolysaccharide ( LPS) LPS: is found in the outer membrane of all gram negative organismsAction : 1) through stimulation of monocytes and macrophages 2) direct on endothelial cell of the brain to produce fever
  8. 8. PATHOPHYSIOLOGY OF FEVEREndogenous pyrogens: polypeptides that are produced by the body ( by monocytes and macrophages ) in response to stimuli that is usually triggered by infection or inflammation stimuli
  9. 9. PATHOPHYSIOLOGY OF FEVERPyrogens: Substances that cause fever are called pyrogensCytokines : Cytokines are regulatory polypeptides that are produced by 1) monocytes / macrophages 2) lymphocytes 3) endothelial and epithelial cell and hepatocytes
  10. 10. PATHOPHYSIOLOGY OF FEVER The most important cytokines are : Interleukin 1 and 1 (The most pyrogenic) Tumor necrosis factor Interferon gamma Interleukin 6 (The least pyrogenic) cytokines>fever develop within 1hr of infection
  11. 11. PATHOPHYSIOLOGY OF FEVER Cytokine-receptor interactions in the pre-optic region of the anterior hypothalamus activate phospholipase A. This enzyme liberates plasma membrane arachidonic acid as substrate for the cyclo-oxygenase pathway. The resulting mediator, prostaglandin E2, then modifies the responsiveness of thermosensitive neurons in the thermoregulatory centre. The PGE2 in the brain then stimulates the rapid release of cAMP from glial cells, this release then induces the release of neurotransmitters that raises the thermoregulatory set point in the hypothalamus. These events then lead to increased body heat content and fever.
  12. 12. FEVERnfection, microbial toxins,mediators of inflammation, Microbial toxins immune reactions Cyclic Heat conservation, AMP heat production nocytes/macrophages, dothelial cells, others PGE₂ Elevated thermoregulatory set point genic cytokines IL-1, IL- Hypothalamic 6, TNF, IFN endothelium Circulation 26
  13. 13. INFECTION Monocytes, macrophages Endogenous pyrogens (IL-1,TNF, IL-6) Hypothalamus: ↑ temperature setpoint Skeletal muscle Skin arterioles ↑ vasoconstriction shivering Curl up/add clothes↑ heat production ↓ heat loss Heat production > Heat loss Heat retention ↑ Body temperature Human Physiology 5th edition 1990
  14. 14. INFECTIONS MALIGNANCIES AUTOIMMUNE OTHERS•Typhoid Fever CONDITIONS- •Leukemia•Hepatitis A & B JOINT/CONNECT •Drug-induced •Lymphoma•Leptospirosis IVE TISSUE fever•Tuberculosis DISEASE•Malaria •Rheumatoid arthritis •Rheumatic fever •Systemic lupus erythematosus 14
  15. 15. TYPES OF FEVERThe pattern of temperature changes may occasionally hint at the diagnosis: Continuous fever: Temperature remains above normal throughout the day and does not fluctuate more than 1 °C in 24 hours, e.g. lobar pneumonia, typhoid fever, urinary tract infection, brucellosis Intermittent fever: The temperature elevation is present only for a certain period, later cycling back to normal(i.e. Normal temp. between fever episodes), e.g. malaria, pyaemia, or septicemia.Following are its types  Quotidian fever, with a periodicity of 24 hours, typical of Plasmodium falciparum malaria  Tertian fever (48 hour periodicity), typical of Plasmodium vivax or Plasmodium ovale malaria  Quartan fever (72 hour periodicity), typical of Plasmodium malariae malaria.
  16. 16. TYPES OF FEVER Remittent fever: Temperature remains above normal throughout the day and fluctuates more than 1 °C in 24 hours, e.g., infective endocarditis. Pel-Ebstein fever: A specific kind of fever associated with Hodgkins lymphoma, being high for one week and low for the next week and so on. However, there is some debate as to whether this pattern truly exists.
  17. 17. PYREXIA OF UNKNOWN ORIGIN (PUO) A common presenting problem. Defined as a consistently elevated body temperature of more than 37.5 C persisting for more than 2 weeks with no diagnosis despite one week of initial investigations. The commonest cause of PUO is a common disease presenting atypically. As the duration of fever increases the likelihood of an infectious cause decreases. Among children, infections are the most common causes.
  18. 18. Aetiology and Epidemiology ofPUO in developed countriesInfections (30%) Sepsis- Abscess at any site; Cholecystitis/ Cholangitis Urinary tract infection Dental and sinus infection Bone and joint infections Imported infections, e.g. Malaria, Dengue, Brucellosis Enteric or Typhoid fever Infective endocarditis Tuberculosis (particularly extrapulmonary) Viral infections (cytomegalovirus-CMV, Ebstein-Barr virus-EBV, human immunodeficiency virus-HIV), Hepatitis A and B and toxoplasmosis Fungal infectionsMalignancy (20%) Lymphoma and myeloma Leukaemia Solid tumours (renal, liver, colon, stomach, pancreas)
  19. 19. Connective tissue disorders (15%)•Vasculitic disorders (including polyarteritis nodosaand rheumatoid disease with vasculitis)•Systemic lupus erythematosis (SLE)•Rheumatoid arthritis•Rheumatoid fever•Temporal arteritis•PolymyositisMiscellaneous (20%)•Inflammatory bowel disease•Liver disease: Cirrhosis and granulomatous hepatitis•Sarcoidosis•Drug reactions•Thyrotoxicosis•Hypothalamic lesions•Familial meditaranean feverNo diagnosis or resolves spontaneously (15%)
  20. 20. FACTITIOUS FEVER This is defined as fever engineered by the patient by manipulating the thermometer and/or temperature chart apparently to obtain medical care. uncommon and typically presents in young women with a medical and nursing background. Examples include The dipping of thermometers into hot drinks to fake a fever. The factitious disorder is usually medical but may relate to a psychiatric illness with reports of depressive illness.
  21. 21. FACTITIOUS FEVERCLUES TO THE DIAGNOSIS OF FACTITIOUS FEVER A patient who looks well Absence of temperature-related changes in pulse rate Temperature > 41°C Absence of sweating during the period of fever Normal ESR and CRP despite high fever Useful methods for the detection of factitious fever include 1) Supervised (observed) temperature measurement 2) Measuring the temperature of freshly voided urine
  22. 22. HISTORY TAKING IN FEBRILEPATIENTS Using the Calgary Cambridge guide as a framework to interviewing patients. The most important step is taking a meticulous detailed history to explore the patients problems from three perspectives. Biomedical perspective- to understand the chronology of symptoms, analyse each symptom and review each system to localize the source of the fever. Contextual history- very important Patients perspective- to understand the patients interpretation of the illness. Systems review- This is a guide not to miss anything. Any significant finding should be moved to HPC or PMH depending upon where you think it belongs.
  23. 23. Initiating the session preparation establishing initial rapport identifying the reasons for the consultationProviding Gathering information Building thestructure exploration of the patient’s problems to discover the: relationship  biomedical perspective  the patient’s perspectivemakingorganisation  background information - context usingovert appropriate Physical examination non-verbalattending to behaviourflow Explanation and planning developing providing the correct type and amount of information rapport aiding accurate recall and understanding involving achieving a shared understanding: incorporating the the patient patient’s illness framework planning: shared decision making Closing the session ensuring appropriate point of closure forward planning a
  24. 24. The content of the medical interviewPatient’s problem list1.2.3.Exploration of patient’s problems:Biomedical perspectivesequence of events, symptom analysis, relevant systems reviewPatient’s perspectiveideas, concerns, expectations, effects on life, feelings ICEBackground information - contextPast medical historyFamily historyPersonal and social historyDrug and allergy historySystems review b
  25. 25. BIOMEDICAL PERSPECTIVEPresenting complaints of a patient with fever Feeling hot A feeling of heat does not necessarily imply fever Rigors. profound chills accompanied by chattering of the teeth and severe shivering, implies a rapid rise in body temperature. Can be produced by : 1) brucellosis and malaria 2) sepsis with abscess 3) lymphoma Excessive sweating. Night sweats are characteristic of tuberculosis, but sweating from any cause is usually worse at night.
  26. 26. BIOMEDICAL PERSPECTIVE Recurrent fever. Source is often a focus of bacterial infection such as cholecystitis or cholangitis or urinary tract infection especially associated with an obstruction or calculi. Headache. Fever from any cause may provoke headache. Severe headache and photophobia, may suggests meningitis. Delirium. Mental confusion during fever is well described and relatively more common in young children and in old age. Muscle pain. Myalgia is characteristic of viral infections such as influenza, Malaria and brucellosis.
  27. 27. BIOMEDICAL PERSPECTIVESymptom analysis for fever Verify presence of fever- True or factitious fever Duration- Acute or chronic Mode of onset- Abrupt or gradual Progression- Continuous or intermittent. If intermittent ask about frequency to determine the pattern. Severity- how it affects daily work/physical activities. Relieving and aggravating factors Treatment received or/and outcome Associated symptoms- Localizing symptoms may indicate the source of fever.
  28. 28. BIOMEDICAL PERSPECTIVE Respiratory tract symptoms:1) Sore throat, nasal discharge, sneezing-URTI2) Sinus pain and headache-suggests sinusitis3) cough, sputum, wheeze or breathlessness-suggests a LRTI Genitourinary symptoms:1) Frequency of micturition, dysuria, loin pain, and vaginal or urethral discharge-suggesting a) Urinary tract infection, b) Pelvic inflammatory disease and c) Sexually transmitted infection (STI)
  29. 29. BIOMEDICAL PERSPECTIVE Abdominal symptoms: diarrhea, with or without blood, weight loss and abdominal pain -suggesting a) Gastroenteritis, b) Intra-abdominal sepsis, c) Inflammatory bowel disease, d) Malignancy Skin rash: enquire about appearance and distribution as it may provide clues to the diagnosis-1) Macular- Measles,Rubella,toxoplasmosis2) Haemorrhagic- Meningococcal infections, viral haemorrhagic fever.3) Vesicular- Chickenpox, Shingles, herpes simplex4) Nodular- Erythema nodosum( TB and Leprosy)5) Erythematous- Drug rashes, Dengue fever
  30. 30. BIOMEDICAL PERSPECTIVE Joint symptoms: joint pain, swelling or limitation of movement is suggestive of active arthritis. A) distribution : mono , oligo or poly arthritis B) appearance : fleeting 1) infective arthritis- oligoarthritis 2) collagen vascular disease-fleeting 3) reactive arthritis
  31. 31. BIOMEDICAL PERSPECTIVEConstitutional symptoms: Weakness Fatigue Anorexia Change of weight Fever/chills Lumps Night sweats
  32. 32. CONTEXTUAL HISTORYPast Medical /Surgical HistoryStart by asking the patient if they have any medical problems IHD/DM/Asthma/HT/RHD, TB/Jaundice/Fits e.g. if diabetic- mention time of diagnosis/current medication/clinic check upPast surgical/operation history E.g. time/place/ what type of operation. Note any blood transfusion / blood grouping. H/O dental extractions/circumcision & any excessive bleeding during these procedures. Patient known to have rheumatic heart disease is at risk to develop infective endocarditis if not given prophylaxis Any minor operations or procedures including endoscopies, dental interventions, biopsies.History of trauma/accidents E.g. time/place/ and what type of accident History of tattoo piercing
  33. 33. CONTEXTUAL HISTORYDrug and allergy History dosage, timing &how long. Drug fever is uncommon and therefore easily missed-The culprits include : penicillin and cephalosporin sulphonamide anti tuberculous agents anticonvulsants particularly phenytoin OCT/Vitamins/Traditional /Herbal medicine & alternative medicine such as acupuncture. Blood transfusion. Immunization against Hepatitis A &B, Typhoid fever. Malaria prophylaxis
  34. 34. CONTEXTUAL HISTORYFamily History Any familial disease/running in families e.g. breast cancer, IHD, DM, Asthma, Arthritis Infections running in families as TB, Leprosy. Cholera, typhoid in case of epidemics.
  35. 35. CONTEXTUAL HISTORYPersonal and Social History Smoking history - amount, duration & type- strong risk factor for IHD Alcohol history - amount, duration & type-Unhealthy alcohol use is associated with cardiomyopathy, CVA, liver cirrhosis, alcoholic hepatitis, hepatocellular carcinoma. Occupation, social & education background, family social support& financial situation, Social class. Home conditions-Water supply, Sanitation status in his home & surrounding, Geographic area of living, fresh-water swimming. Animals / birds in his/her house- exposure to birds (psittacosis) or animals (toxoplasmosis, brucellosis, leptospirosis) Consumption of unpasteurized milk or milk products (tuberculosis, brucellosis and Q fever). Sexual History- Unprotected exposure to sexual partner with STI, HIV Illicit drug usage- injections and sharing of needles (HIV, hepatitis B &C, infective endocarditis), site of injection (e.g Femoral vein-septic arthritis, ilio-psoas abscess)
  36. 36. CONTEXTUAL HISTORYTravel HistoryTravel to an area known to be endemic for certain disease:  Name of the area, duration of stay  Onset of illness- (incubation period) 1 –10 Days- Malaria, Dengue, Salmonella 10 –21Days-Malaria,Typhoid,Brucella,HepatitisA Weeks-Months- Amoebiasis, HIV, HepatitisVital questions-(Always ask about foreign travel). a) Where have you been? …Endemic area or not ? b) What have you done? C) How long were you there? d) Did you have insect bites or contact with animals? e) Did you take precautions/prophylaxis against malaria?If the patient has been in an endemic area The most common diagnoses :Malaria, Typhoid fever, Viral hepatitis, Dengue fever Malaria must be excluded whatever the presenting symptoms
  37. 37. PATIENTS PERSPECTIVEAlways ask the patient how he/she feels/thinks about the illness by analysing Ideas Concerns Feelings Expectations Effects on daily living
  38. 38. SYSTEMS REVIEW General• Weakness• Fatigue• Anorexia• Change of weight• Fever/chills• Lumps• Night sweats
  39. 39. SYSTEMS REVIEWCardiovascular• Chest pain• Paroxysmal Nocturnal Dyspnoea• Orthopnoea• Short Of Breath(SOB)• Cough/sputum (pinkish/frank blood)• Swelling of ankle(SOA)• Palpitations• Cyanosis
  40. 40. SYSTEMS REVIEWGastrointestinal• Appetite (anorexia/weight change)• Diet• Nausea/vomiting• Regurgitation/heart burn/flatulence• Difficulty in swallowing• Abdominal pain/distension• Change of bowel habit• Haematemesis, melaena• Jaundice
  41. 41. SYSTEMS REVIEWRespiratory System• Cough(productive/dry)• Sputum (colour, amount, smell)• Haemoptysis• Chest pain• SOB/Dyspnoea• Tachypnoea• Hoarseness• Wheezing
  42. 42. SYSTEMS REVIEWUrinary System• Frequency• Dysuria• Urgency• Hesitancy• Terminal dribbling• Nocturia• Back/loin pain• Incontinence• Character of urine: color/ amount (polyuria) & timing• Fever
  43. 43. SYSTEMS REVIEWNervous System• Visual/Smell/Taste/Hearing/Speech problem• Head ache• Fits/Faints/Black outs/loss of consciousness(LOC)• Muscle weakness/numbness/paralysis• Abnormal sensation• Tremor• Change of behaviour or psyche.• Paresis.
  44. 44. SYSTEMS REVIEWGenital system• Pain/ discomfort/ itching• Discharge• Unusual bleeding• Sexual history• Menstrual history – menarche/ LMP/ duration & amount of cycle/ Contraception• Obstetric history – Para/ gravida/abortion
  45. 45. SYSTEMS REVIEWMusculoskeletal System• Pain – muscle, bone, joint• Swelling• Weakness/movement• Deformities• Gait
  46. 46. THE END: REFERENCES Guytons Textbook of Medical Physiology Davidsons Principles & Practice of Medicine Hutchinsons Clinical Methods Harrison’s Principles of Internal Medicine Google images

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