Module 12: Fever Flashcards
definition of fever of unknown origin
-fever higher than 38.3 C on several occasions -duration of fever for at least 3 weeks -uncertain diagnosis after 1 week of study in the hospital -elders could be a 1.1 rise or > 37.2
categories of FUO
infection, malignancies, connective tissue diseases
you must do the following prior to assigning a diagnosis of FUO
-history -physical exam -cbc w/ diff -blood cultures w/o antibiotics given -CMP, bilirubin -hepatitis A, B C serologies if liver test abnormal -urinalysis micro & urine CX -CXR
pathophysiology
hypothalamus set point altered by pyrogens endogenous -injury, inflammation, infection, antigenic challenge -IL, TNF, interferons, prostaglandins exogenous -endotoxin ( gram negative) -enterotoxins (Gram positive)
how to approach patient
careful history: chills, night sweats, malaise, myalgia, weight loss, painful swollen nodes -elders: new confusion, falling, incontinence, anorexia or decreased oral intake
what should you collect in patient history
-ethnicity -occupational exposures -living situation: group vs. community -travel outside US (Africa & Asia) -dietary choices -sexual practices -animals -bites -ivda -etoh
healthcare data
-procedures -transufions -prosthtic devices -immunizations IMMUNODEFICIENT -transplant -cancer (chemo & RT) -chronic steroids (asthma) -splenectomy (need to get all vaccinations after splenectomy) -advanced age -chronic illnesses (HIV, DM, renal, hepatic)
ROS?
general: night sweats, jaundice, erythema, rash - macular, vesicular, petechial, swelling, tenderness HEENT: herpes discharge in ear from lesions, pain, CNS: AH, photophobia, nuchal rigidity, change is MS RESP: cough, sputum, hemoptysis, sob, pleuritic pain CV: chest pain GI: gerd, nausea, vomiting, diarrhea, abd pain GU: frequency, urgency, hesitation, dysuria, hematuria, foul odor, discharge, pruritus, lesions
what to look for on physical exam?
VS-tachycardia, hypotension, tachypnea general: toxic appearance, rash, jaundice, lymphadenopathy, asymmetrical swelling HEENT: butterfly rash, TM, nasal congestion, sinus tenderness, oral lesions, swollen erythematous exudate covered tonsils, pharyngeal membrane CNS: change in MS, focal abnormality, nuchal rigidity RESP: adventitious sounds, dullness, increased tactile fremitus, egophony, pectoriloquy, pleural rub CV: new murmur, muffling, rub GI: distention, tenderness, guarding, rebound, ascites, organomegaly GU: enlarged kidney, CVA tenderness, suprapubic tenderness, genital lesions/discharge, Cervical motion tenderness, peri-rectal tenderness, prostate tenderness
musculoskeletal physical exam
spinal tenderness, red/warm/tender/deformed joints, right skin with calcinosis (calcium deposits), raynauds, janeway lesions (endocarditis), osler nodes, sublingual splinter hemorrhages, wounds or ulcers
diagnostic testing
- ESR or CRP
- serum LDH
- TB skin test
- interferon gamma release assays for diagnosis of latent TB infection
- HIV antibiody assay and HIV viral load
- 3 routine blood cx dranwn prior to administering abx
- rheumatoid factor
- creatinine phosphokinase
- heterophile antibody comes from h/o strep infection seen in children and young adults
- serum ferritin: malignancies & SLE flare
- ANA
- CBC
- CMP
- serologies: cmv, ebv, hiv, toxoplasmosis
- serum protein electrophoresis
- ct scan of abdomen/chest
- pulmonary angiogram
- chest x ray
- pet scan
- echocardiography
- biopsy - liver, lymph node, temporal artery, pleural, bone marrow
causes of FUO
- pneumonia
- meningitis
- intra abdominal abscess
- peritonitis/diverticulitis
- osteomyelitis/septic joint
- uti/pyelo/prosttatis
- cellulitis
- rheumatic fever
- endocarditis
- sinusitis/bsi/vap
- wound/c diff
- cancers: hodgkin’s non-hodgkin’s lymphona, leukemia, renal cell, hepatoma, metastatic
most common causes of FUO in elderly
- PNA
- diverticulitis
- UTI
- endocarditis
- c diff
- lymphoma
- leukemia
common hiv opportunistic infections
cmv
maic (Mycobacterium avium-intracellulare complex)
pcp
coccidioidomycosis
non infectious causes of FUO
- CNS: bleed, seizures
- cardiac: MI, pericarditis/dresslers-non acute form of pericarditis, myocarditis
- pulmonary: atelectasis, infarction, pe
- metabolic: withdrawal, hyperthyroid, adrenal insufficiency, heat stroke
- hematologic: bleeding, dvt, sickle cell
- GI: pancreatitis, cholecystitis, hepatitis, IBD, colitis
- MISC: iatrogenic, rejection, gout, sarcoid, burns, factious
