This document discusses pyrexia of unknown origin (PUO). It defines PUO as a fever over 38°C lasting more than 3 weeks without an obvious cause despite evaluations. Common causes include infections (40%), malignancies (25%), and autoimmune diseases (15%). The document outlines the pathogenesis of fever and classifications of PUO. It describes the approach to evaluating a PUO patient through history, exam, and staged laboratory/imaging investigations. Empirical treatment trials are generally not recommended until a cause is found due to risks of misleading outcomes. The prognosis is determined by the underlying disease, with neoplasms having the worst outcomes.
Approach to a patient with fever of unknown origin sunil kumar daha
Please find the power point on Approach to a patient with fever of unknown origin . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Contains 17 clinical situations of prolonged fever and discussion of various differential diagnosis based on them. Also gives the key points in the diagnosis of a prototype diagnosis and the usefulness of a relevant investigation modality in identifying these conditions. This power point presentaion is based on the chapter in Harrison's Text Book on Internal Medicine chapter on Fever of Unknown Origin
Approach to a patient with fever of unknown origin sunil kumar daha
Please find the power point on Approach to a patient with fever of unknown origin . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Contains 17 clinical situations of prolonged fever and discussion of various differential diagnosis based on them. Also gives the key points in the diagnosis of a prototype diagnosis and the usefulness of a relevant investigation modality in identifying these conditions. This power point presentaion is based on the chapter in Harrison's Text Book on Internal Medicine chapter on Fever of Unknown Origin
is an upper respiratory tract bacterial infection associated with a characteristic rash, which is caused by an infection with pyrogenic exotoxin (erythrogenic toxin) -producing GAS in individuals who do not have antitoxin antibodies In the past.
scarlet fever was thought to reflect infection of an individual lacking toxin-specific immunity with a toxin-producing strain of GAS.
Subsequent studies have suggested that development of the scarlet fever rash may reflect a hypersensitivity reaction requiring prior exposure to the toxin.
a double-stranded DNA virus : human herpesvirus-3 subfamily Alphaherpersvirinae
only one serotype is known
humans are the only reservoir
VZV enters the host through the nasopharyngeal mucosa, and almost invariably produces clinical disease in susceptible individuals
Following varicella, the virus persists in sensory nerve ganglia, from where it may later be reactivated to cause herpes zoster (Shingles)
is an upper respiratory tract bacterial infection associated with a characteristic rash, which is caused by an infection with pyrogenic exotoxin (erythrogenic toxin) -producing GAS in individuals who do not have antitoxin antibodies In the past.
scarlet fever was thought to reflect infection of an individual lacking toxin-specific immunity with a toxin-producing strain of GAS.
Subsequent studies have suggested that development of the scarlet fever rash may reflect a hypersensitivity reaction requiring prior exposure to the toxin.
a double-stranded DNA virus : human herpesvirus-3 subfamily Alphaherpersvirinae
only one serotype is known
humans are the only reservoir
VZV enters the host through the nasopharyngeal mucosa, and almost invariably produces clinical disease in susceptible individuals
Following varicella, the virus persists in sensory nerve ganglia, from where it may later be reactivated to cause herpes zoster (Shingles)
Fever and Hyperthermia and Pyrexia of unknown origin by Dr Mohammad Hussien for Medical Student .
Ass.Lecturer of Hepatogastroentrology at Kafrelsheikh University.
This presentation focuses on the entity known as pyrexia of unknown origin / fever of unknown origin. It demonstrates both common and rare causes, and the epidemiological trend, its clinical presentation, management and prognosis.
The entire scope of febrile neutropaenia in paediatrics subpopulation undergoin cancer chemotherapy including guidelines for risk stratification and mangement.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. Introduction
Body teperature is normally maintained within
1-1.5°c in arange of 37-38° c ,normal body
temperature is generally cosidered to be 37°c
.
Low levels occur at 6 A.M and higher levels
at 4 - 6 P.M
3. • Normal body
temperature is
maintained by a complex
regulatory system in the
anteroir
hypothalamus,preoptic
area,temperature
sensitive area,thermal
set point .
4. Pathogenesis of fever
Pyrogens
Substances mediate the elevation of core body temperature.
Exogenous and endogenous pyrogens.
Exogenous pyrogens:
Derived from outside the host ,like Microorganisms, toxins and
microbial products,large molecule ,can not pass blood brain barrier
It induce release of endogenouse pyrogens from macrophages.
5. Endogenous pyrogens
derived from the
macrophages ,small
molecule ,can pass blood
brain barrier.
•Pyrogen cytokines trigger
hypothalamus to release
PGE2 resulting in resetting
of thermostatic
temperature,activation of
vasomotor center
,vasodilatation and heat
production.
6. Pyrexia of Unknown Origin
• Original Definition (by Petersdorf and Beeson, 1961)
• Temperatures ≥ 38.3ºC (101ºF) on several
occasions
• Fever ≥ 3 weeks
• Failure to reach a diagnosis despite 1 week of
inpatient investigations or 3 outpatient visits .
7. Pyrexxia of Unknown Origin
New definition;
temperature > 38 ° c,
lasting for more than 14 days
without an obvious cause despite a comlete
history, physical examination and routine
screening laboratory evaluation.”
8. Factors that may make it difficult to find a
cause include:
A common illness that does not have the usual
symptoms,sinusitis may be a symptomatic.
Illness, whose other symptoms appear later
Illnesses who may have a delayed positive
test
Person is unable to communicate about other
symptoms .
Genetic condition that causes periodic fevers.
9. common causes of PUO
Infection
(40%)
Malignancy
(25%)
Autoimmun
e Disease
(15%)
Others/
Miscellaneo
us (10%)
Undiagnose
d (10%)
10. Classification Durack and Street’s classification
Classical
Nosocomial
Neutropenic
PUO associated with HIV infection
11. Classic PUO
Temperature >38.3°C (100.9°F)
Duration of >3 weeks
Evaluation of at least 3 outpatient visits or 3 days in
hospital
Etiologies
I. Infections
II. Malignancies
III. Collagen Vascular Disease
Others/Miscellaneous which includes drug-induced fever.
12. 1. Infections
Bacterial: abscesses, TB,
complicated UTI,
endocarditis, osteomyelitis,
sinusitis, prostatitis,
cholecystitis, empyema,
biliary tract infection,
brucellosis, typhoid,,,, etc.
Viral: CMV, infectious
mononucleosis, HIV, etc.
Parasite: Malaria,
toxoplamosis,
leishmaniasis, etc.
Fungal: histoplasmosis, etc.
As duration of fever
increases, infectious etiology
decreases
Malignancy and factitious
fevers are more common in
patients with prolonged FUO.
13. 2 . Malignancies
Haematological
Lymphoma
Chronic leukemia
Non-haematological
Renal cell cancer
Pancreatic cancer
Colon cancer
Hepatoma
17. Fever pattern
Continuous fever: e.g. lobar
pneumonia, typhoid, urinary
tract infection,brucellosis.
Intermittent fever:
e.g. malaria, pyaemia,
or septicemia..
Remittent
fever: e.g, infective
endocarditis.
Pel-Ebstein fever
; Hodgkin's lymphoma
18. Nosocomial PUO
Temperature >38.3°C
Patient hospitalized ≥ 24 hours but no fever or incubating on admission
Evaluation of at least 3 days
More than 50% of patients with nosocomial PUO
are due to infection.
Focus on sites where occult infections may be
sequestered, such as:
- Sinusitis of patients with NG or oro-tracheal tubes.
- Prostatic abscess in a man with a urinary catheter.
25% of non-infectious cause includes:
- Acalculous cholecystitis,
- Deep vein thrombophlebitis
- Pulmonary embolism.
19. Immune deficient/ Neutropenic PUO
Temperature >38.3°C
Neutrophil count ≤ 500 per mm3
Evaluation of at least 3 days
Patients on chemotherapy or immune deficiencies are
susceptible to:
- Opportunistic bacterial infection
- Fungal infections such as candidiasis
- Infections involving catheters
- Perianal infections.
Examples of aetiological agent:
- aspergillus
- Candida
- CMV
- Herpes simplex
20. HIV-associated PUO
Temperature >38.3°C
Duration of >4 weeks for outpatients, >3 days for inpatients
HIV infection confirmed
HIV infection alone may be a cause of fever.
Common secondary causes include:
- Tuberculosis
- CMV infection
• Non-Hodgkin's lymphoma
- Drug-induced fever
26. Travel
Residental area
Occupation
Contact with domestic / wild animal / birds :
Diet history
Sexual orientation
Close contact with TB patients
36. STAGE 3 [CONT] ; Imaging
Studies
Chest radiograph
CT of abdomen or pelvis with
contrast agent
Gallium 67 scan
MRI of brain
PET scan
Transthoracic or transesophageal
echocardiography
Venous Doppler study
38. Pyrexia of Unknown Origin
The majority of disease remaining after an
initial NEGATIVE work-up are:
1. Neoplasm
2. Seronegative Collagen Vascular Disease
3. TB
4. Drug
5. Elderly with Endocarditis
6. HIV with or without infection or malignancy
7. Implanted prosthetic devices
8. Travel … New Exposure
38
39. Stage 4
Therapeutic trials:
Empirical treatment with corticosteroids or NSAIDS or
antimicrobials
Antimycobacterial agents in AIDS & neutropenic
Blind therapy;
40. Therapeutic Trials
Limitation and risk of empirical therapeutic
trials:
Rarely specific
Underlying disease may remit spontaneously false
impression of success.
Disease may respond partially and this may lead
to delay in specific dx
SE drugs can be misleading.
40
41. Therapy withheld until cause is found
Empirical corticosteroids or anti inflammatories in
temporal arteritis.
Vital sign instability & neutropenia –
Fluoroquinolones + piperacillin,
vancomycin + ceftazidime/cefepime/
carbapenem with or without aminoglycoside,
42. Therapeutic Trials
What is the best
therapy for PUO
patient?
To hold therapeutic
trials in the early
stage … demolish…
except in:
Patient who is very
sick to wait.
All tests have failed
to uncover the
etiology.
42
43. Prognosis
Prognosis is determined primarily by
the underlying disease.
Outcome is worst for neoplasms.
FUO patients who remain
undiagnosed after extensive
evaluation generally have a
favorable outcome and the fever
usually resolves after 4-5 weeks.
43
44. Summary
FUO is often a diagnostic
dilemma,quandary.
Infections comprise ~30% of cases
Bone marrow biopsies are of low
diagnostic yield
Diagnostic approach should occur in a
step-wise fashion based on the H&P
Patient’s that remain undiagnosed
generally have a good prognosis
44
45. References
NELSON ESSENSSIALS OF PEDIATRICS 6th
ED.
Harrison’s principles of internal medicine
18th edition.
Mandell, Bennet & Dolin’s, principle of infectious
disease 6th edition.