MISC - Pt with fever Flashcards
Key questions in assessing patients with fever - History
- Duration, and rate of evolution of symptoms
- Localising symptoms – detail is essential
- Immunosuppression
- Diabetes, (and recent poor control)
- Recent hospitalisation
- Recent family illness
- Any foreign body or prosthesis
- Occupation, recreation, hobbies (animal contact)
- Medication, especially new
- Recent travel (detail is essential: geographical history, setting (rural or urban, type of accommodation), time of onset and duration of symptoms, activities undertaken, food history, sexual activity, prior vaccinations, malaria prophylaxis fresh or salt water exposure
- Injecting drug use
- Sexual history
What (5) are the Warning bells in the history in patients with fever?
- Patient presents within first 24 hours of illness
- Patient presents for a second time within a short period
- Severe muscle pain
- Severe localised pain
- Repeated vomiting but no diarrhoea
Note: The elderly often have non-localising symptoms despite serious bacterial infection
What are the Key findings in assessing patients with fever - Examination?
•Abnormal “vital” signs
(Note: not all patients with significant infection have a fever)
- Signs related to local symptoms
- Areas commonly missed in cursory examinations:
- entire skin (petechiae, rashes),
- nails (splinter haemorrhages),
- conjunctivae (petechiae),
- soft heart murmurs,
- retinae (haemmorages and exudates),
- tenderness in any of the following: loins, spine, temporal arteries (also palpable) thyroid, teeth (also caries), prostate
•Repeated examinations are often necessary if the source of fever is unclear
Non-specific Ix of a pt with fever
- FBE
- Electrolytes, creatinine,
- Liver enzymes
- Glucose
- Blood gases (if shocked, possible acidosis or respiratory failure)
- CRP
More specific Ix of a pt with fever
- MSU for microscopy and culture (urinalysis / “full ward test should be considered part of the routine physical examination)
- CXR
- Blood cultures – minimum of 2 sets (not all patients with fever warrant blood cultures)
- If relevant, appropriate tests related to travel, eg malaria ICT, thick and thin films, stool culture, serology eg hepatitis, amoebic, arbovirus, other
- CT abdomen / pelvis / chest
- Biopsy of relevant tissue (eg lymph gland, temporal artery) for histology and appropriate culture
- Serology eg. Hepatitis A, B, C (may need hep C PCR in early infection), EBV, CMV, HIV, other
- Haemolytic screen
- LDH
What are the common Dx mistakes made in Mx of fever pts?
•Failing to collect 2 sets of blood cultures before commencing antibiotics in patients in whom a source of infection is not clearly apparent
•Treating adults with spontaneous septic arthritis without first collecting blood cultures
•Making a diagnosis of “viral meningitis” before CSF PCR is available or the patient has recovered. Viruses are only one cause for an aseptic meningitis syndrome
•Not considering meningitis unless the patient has photophobia and neck stiffness
•Failure to look for staph aureus septicaemia in a patient in whom staph aureus has grown from a urine culture
(i.e. the septicaemia came first)
- Failure to consider TB in patients who have lived in TB endemic areas
- Failure to consider acute HIV infection
- Diagnosing a “viral illness” in the elderly with hidden bacterial sepsis
- Failure to consider non-infective causes of fever
- Treating fever simply because it’s present
- A common mistake is to assume that a patient without a fever does not have a serious infection. This especially applies to patients who are elderly, neonates, with end- stage renal failure, severe debility, hypothyroidism, or who are taking anti-inflammatory drugs
Reasons (3) for & (3) against treating fever
For treating:
•Potential for aggravating heart failure, or precipitating premature labour if high fever is untreated
•Fever greater than 40 degrees (risk of CNS and other injury
•Patient discomfort
Against treating:
•Fever is part of the host defence against infection
•Treatment may obscure the response to antibiotics
•Treatment with antipyretics (paracetamol, NSAIDs, aspirin) can have side effects
What can you see in the blood film in a malaria pt?
Ring form of Plasmodium falciparum
Mx of malaria
IV (and subsequently oral) artesunate ( part of the artemisinin group of drugs that treat malaria)
% of red blood cells parasitised should improve -> corresponding with an improvements in level of alertness, thrombocytopaenia, and acute renal failure
Mx of Staph aureus endocardititis complicated by an epidural abscess with cord compression
high dose flucloxacillin and vancomycin
urgent laminectomies and debridement to decompress the spinal cord.
6 weeks of IV flucloxacillin, followed by several months orally
Discuss symptoms & importance of meningococcaemia
- Meningococcaemia alone, although less common than meningococcal meningitis, progresses more rapidly, and has a much higher fatality rate. Diagnosis is commonly missed or delayed.
- Unfortunately, the early symptoms and signs are often non-specific, and can easily be diagnosed as influenza (which it often cannot be differentiated from clinically)
- Furthermore, symptoms sometimes transiently improve after 4-6 hours of onset, possibly leading to a false sense of reassurance
- Within 6-12 hours after onset of initial symptoms, marked symptoms of severe sepsis (weakness, severe myalgias or arthralgias, cold limbs, vomiting) and a rash often appears. Contributing to possible misdiagnosis, the latter may initially have a diffuse blanchable macular appearance resembling a viral rash. Not all patients develop a rash
- The rash may subsequently resolve totally, but often changes to a classical petechial (which initially may be sparse and easily missed) or grossly haemorrhagic rash, possibly accompanied by signs of meningitis
