Laoshealth.org



Fever of Unknown Source: Clues to a diagnosis based on history and physical examThere are 4 major groups of diseases that can cause fever in patients:InfectionsCancersAutoimmune diseasesMedicationsA. Infections1. Malaria Clues on history-Patient lives in or recently visited a rural area (Malaria is more common in rural regions)-Headache is present in nearly all patients with malaria-Cyclic symptoms of fever, sweats, chills, occurring every 48-72 hours-These cycles are not always present-Classically start with shivering and chills. 1-2h hours later, there is a high fever. The patient then has excessive sweating, and the body temperature drops back to normal or below normal-May have cerebral malaria (encephalopathy) : decreased level of consciousness, seizures, but no focal neurologic deficits-Note: changes to level of consciousness may also be from hypoglycemia, which is a common complication of malaria—so check blood glucose!-Otherwise symptoms are non specific and present as a flu-like illness with fatigue, muscle and joint aches, and general malaiseClues on physical exam-Evidence of anemia and pallor-Palpable splenomegaly and/or hepatomegaly-With complicated malaria, will have hemolysis and hemoglobulinuria leading to the physical exam findings of jaundice and very dark urine (also known as “blackwater fever”)2. Dengue FeverClues on history-Is it dengue season?-Presents with high fever that lasts up to 7 days.-Some patients have a second phase of fever, with the fever returning for 1-2 days -After the fever, there can be significant fatigue that lasts for days to week-Headache and eye pain -Severe bone and muscle pain (especially to arms, legs, and back), which is why dengue fever is also known as “breakbone fever”-Most patients have nausea and vomiting. Some present with respiratory symptoms like cough and sore throat. -Bleeding is common in dengue fever, but more severe in dengue hemorrhagic fever-Most often from the skin (petechiae, bruising, bleeding from venipuncture sites), and less commonly from the nose or gastrointestinal tractClues on physical exam-Positive tourniquet test:Inflate a blood pressure cuff in the middle between the systolic and diastolic pressure. Leave it at this pressure for 5 minutes. Examine the area of skin that was underneath the cuff. If there are >20 petechiae in an area of 2.5cm x 2.5cm, then the tourniquet test is positive.-Most patients have a maculopapular rash that can be itchy-Face, chest, and flexor surfaces-Starts on day 3 and lasts 2-3 days-Facial flushing-Redness of conjunctiva, redness of pharynx-Lymphadenopathy-HepatomegalyDengue hemorrhagic fever-With dengue hemorrhagic fever, after fever breaks, signs of bleeding and plasma leakage occur, such as pleural effusions and ascites. Examination for pleural effusion may reveal decreased breath sounds and dullness to percussion. When examining for ascites, a fluid wave and shifting dullness may be positive. Dengue shock syndrome-As dengue hemorrhagic fever progresses, can progress to shock-Hypotension-Narrow pulse pressure (Systolic – Diastolic pressure < 20)-Paradoxic bradycardia-Cold extremities-Hypothermia3. LeptospirosisClues on history-Good exposure history-Contact with soil and freshwater that has been contaminated by the urine of chronic animal carriers like rats, cows, pigs, dogs, and goats-Variable course: Can be self limited or can be severe and life threatening-Begins with high fevers and chills, sudden headache, nausea, vomiting, diarrhea, cough-Muscle pain, but mostly only to calves and lower back-After 7 days, the symptoms either resolve, or the patient gets much sicker. Leptospires can spread to all parts of the body, causing damage to blood vessels, leading to vasculitis and multiorgan failureClues on physical exam-*Conjunctival suffusion (redness to conjunctiva but with no inflammatory exudate)-Uveitis causing eye redness, pain, and blurry vision-Petechiae also present on the palate, purpura-Pain to palpation of liver-Hepatosplenomegaly-Lymphadenopathy-If the patient continues to get sicker, then there can be signs of:-Hypotension-Hemorrhage -Alveolar hemorrhage (presenting as hemoptysis)-Pulmonary edema -Decreased urine output4. Scrub TyphusClues on history-Mostly seen in patients from the countryside and villages -At the site of a bite from an infected mite, an ulcer forms, which then becomes necrotic (eschar). The eschar can form before the onset of any other symptoms.-High fever 8-10 days after the bite-Intense headache-Diffuse muscle pain-Half of patients get a non-itchy macular rash that starts on the abdomen then spreads to the arms and legs. The face is often involved as well.-In the 2nd week after symptom onset, can present with neurologic symptoms like slurred speech, deafness, neck stiffness from meningitis -CoughClues on physical exam-Relative bradycardia (an increase of HR <10 beats per min per 1 degree Celsius increase in body temperature) -Enlarged lymph nodes-Splenomegaly4. MelioidosisClues on history-Occurs usually in the rainy or wet season-History of direct contact with contaminated soil and water either through an abrasion or laceration in the skin, or through the mucous membranes, or from inhaling or ingestion of the contaminated soil.-Those with severe disease and at risk for dying from melioidosis usually have one of the following risk factors: diabetes, alcoholism, renal failure, immunosuppresion, and thalassemia-Non specific symptoms like fevers, muscle aches, joint pain, headache-Can involve any organ of the body-Pneumonia is the most common presentation: may present with cough, sputum production, and shortness of breath-Skin ulcers-Swelling and pain to the parotid salivary glands-Can have abdominal pain from liver and spleen abscesses -If the genitourinary tract affected, can present with suprapubic pain, pain with urination, or inability to pass urine-May have septic arthritis (pain, swelling, warmth of the affected joint) or osteomyelitisClues on physical exam-Cervical lymphadnopathy-Hepatosplenomegaly-Tender abdomen from liver and spleen abscesses-Skin rashes including urticaria (hives), papules, and pustules-If there is meningitis or brain abscesses, the patient will have an abnormal neurologic exam such as neck stiffness, unilateral limb weakness, cranial nerve palsies, nystagmus, or imbalance.-Can lead to hypotension, shock, and death5. TuberculosisClues on history-Fever, lasting on average of 2-3 weeks but up to 3 months-Symptoms are “subacute”, or begin slowly and are present for weeks to months-Night sweats and weight loss-The lungs are the major site for tuberculosis infection-Chest pain, especially pleuritic (pain with deep breath in)-Shortness of breath-Cough: In he beginning, the cough is usually not productive and occurs mostly in the morning. It then progresses to a continuous cough productive of yellow green sputum.-Hemoptysis is a late symptom-Ulcers in mouth or tongue from frequent coughing of very infectious secretions-May involve other organs, most commonly:-Bones and joints: can cause pain, mostly in the back (thoracic and lumbar spines). In children, this vertebral tuberculosis can cause scoliosis and limping.-Gastrointestinal (GI) tract: abdominal pain (especially to the right upper quadrant when the liver is involved), nausea, vomiting, diarrhea.-Central nervous system (CNS): Headache, focal neurologic deficits-Genitourinary tract (GU): Blood in urine, flank pain-In women, menstrual abnormalities-In men, scrotal pain, swellingClues on physical exam-Lung exam-Crackles-Bronchial breath sounds from consolidation-Distant hollow breath sounds (sounds like blowing across the mouth of a jar) if there is a cavitary lesion -Dullness, decreased tactile fremitus, and dullness to percussion if a pleural effusion is present-Clubbing-If lymphatic system involved: Cervical lymph node enlargement-If GI tract involved:-Pain to palpation to right upper quadrant from liver involvement-Jaundice-Ascites (from tuberculous peritonitis): Look for fluid wave, bulging flanks, shifting dullness of the abdomen, and leg edema.-If CNS involved, will find focal neurologic deficits on exam (such as one sided weakness or sensory deficity)-If GU tract involved:-Costovertebral angle tenderness-Prostate tenderness on digital rectal exam-Scrotal pain and swelling6. EndocarditisClues on history-Any risk factors:-History of any structural heart disease (for example, valvular abnormalities or rheumatic heart disease)-Intravenous drug use-Prosthetic heart valve-Invasive procedures, or any indwelling lines and catheters in hospital-History of endocarditis-Ask about complications of endocarditis-Cardiac complications: - Heart failure- presenting with shortness of breath, orthopneaAbscesses – Patients present continue to have persistent fever even when given appropriate antibiotic treatmentHeart block – presenting as syncope and fatigue-Complication from embolization of vegetations:-Stroke -Blindness-Painful ischemic extremities-Pain (such as from splenic of renal infarction)-Pulmonary emboli leading to hypoxia-Acute myocardial infarction presenting with chest pain-Septic arthritis, especially in the joints of the axial skeleton (pubic, sacroiliac joints, manubriosternal joints, spine)Clues on physical exam-Skin: petechiae, splinter hemorrhages on the nail, Janeway lesions (nonpainful erythematous lesions on palms and soles), and Osler’s nodes (painful violaceous nodules on the pad of the fingers and toes)-Gangrene and ischemia of the fingers and toes (from emboli)-Ophthalmologic exam: Roth’s spots on fundoscopy (exudative, edematous, hemorrhagic lesions on the retina)-Neurologic exam: Focal neurologic deficits from embolization-Heart: new regurgitant murmur, evidence of heart failure (high jugular venous pressure [JVP], S3 on auscultation, crackles on lung exam)-Lungs: Pleural rub from pulmonary infarct (from embolization), crackles from heart failure-Abdominal exam: Pain on palpation from abscesses -Joints: Pain, decreased range of movement, warmth, and redness to joints from septic arthritisB. CancersThe most common cancers that can cause fever are:-Lymphoma-Leukemia-Renal cell carcinoma-Hepatocellular carcinoma, or metatstases to the liver-Brief characteristics of each disease on history and physical exam:i) Lymphoma: History: -Previous exposure to chemotherapies, radiation therapy, pesticides-Constitutional symptoms such as weight loss, night sweats, fever-Masses that the patient has noticed (such as in the axilla, neck)-Fatigue-Cough and chest pain from mediastinal lymphadenopathy-Abdominal discomfort from splenomegaly-Pallor, shortness of breath from anemia-Gum bleeding, nose bleeds from thrombocytopeniaPhysical:-Lymphadenopathy-Enlargement of tonsils, base of the tongue-Hepatosplenomegalyii) LeukemiaHistory:-Symptoms usually related to anemia, thrombocytopenia, or Neutropenia:-Anemia: fatigue, shortness of breath, dizziness-Thrombocytopenia: bruising, gum bleeding, nose bleeds, heavy menstrual periods-Neutropenia: Repeated infections-Bony pain-Low energy levelsPhysical: -Skin: Pallor, petechiae, bruising, gum hypertrophy-Uncommon to have enlarged lymph nodes -Can have (though uncommon) hepatomegaly or splenomegalyiii) Renal cell carcinomaHistory:-Most are asymptomatic-Can have fever, night sweats, weight loss, and fatigue-Classic symptoms are flank pain, hematuria, and palpable renal mass-Leg swelling and increased abdominal size from tumor obstructing the inferior vena cava Physical:-Cachexia (Wasting)-Renal mass palpated on exam. It is firm, not painful, and may move with breathing in-Swelling of the scrotum (because of obstruction of the gonadal vein by the renal tumor)-Ascites and leg swelling from the tumor involving the inferior vena cava causing obstruction of blood flow back to the heartClues from labs: -Anemia or less commonly erythrocytosis-Liver dysfunction-Hypercalcemiaiv) Hepatocellular carcinoma (HCC)History:-History of chronic liver disease or cirrhosis, such as chronic hepatitis B or C, or alcohol related-Upper abdominal pain-Early satiety-Bone pain from metastasisPhysical: -Decompensated cirrhosis, with ascites, gastrointestinal bleeding, encephalopathy (confusion)-Jaundice-Palpable mass in the abdomen-Bruit auscultated over liver -SplenomegalyClues from labs: -Hypoglycemia -Erythrocytosis -Hypercalcemia C. Autoimmune diseasei) Giant Cell ArteritisClues on history: -Age over 50-New headache, sudden visual loss-Jaw claudication-Symptoms of polymyalgia rheumatica morning stiffness and pain in shoulders and hipsClues on physical:-Tender and thickened temporal arteries-Absent temporal artery pulse-Signs of polymyalgic rheumatic Painful range of movement of shoulders, neck, and hips. Also tenderness to palpation of these joints.-Bruits over large arteries such as carotids, over supraclavicular, axillary, brachial, and femoral areasD. Medications (“Drug Fever”)-Occurs more often in patients who are hospitalized rather than outpatients-Classically see a rash and eosinophilia-Diagnosis of exclusion (rule out other common causes of fever first, especially infections)-Mostly caused by antibiotics Sulfonamides, penicillins, antimalaria drugs-Usually fever presents soon after starting the medication-Diagnose a drug fever by stopping the suspected drug: Fever will resolve within 72 hours of stopping the drug. Can try “rechallenging” the drug, or restarting it and seeing if the fever returns. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download