MPPRC CONFERENCE Group 1 2-A Abajon, Abriol-Santos, Acedera, Acero, Adducul, Agcaoili, Agravante, Aguda, Agulto Ajari, Alba,

Alberto

Fever

wks
g

-intermittent moderate to high grade fever -self medicated with Paracetamol (500mg/tablet, every 4 hours)

wk

-anorexia

ADMISSION
4

No significant weight loss (-) No loss of consciousness,no headache (-) No blurring of vision (-) No ear discharge, no tinitus (-) No cough, no difficulty of breathing (-) No chest pain, no palpitation (-) No diarrhea, no constipation, no melena, no hematochezia (-) No dysuria, no frequency, no urgeny, no pollakuria (-) No joint pains (-) No polyuria, no polydipsia, no polyphagia (-) No heat or cold intolerance (-)
5

 No

other medical or surgical illness requiring hospitalization history of blood transfusion

No No

history of illicit drug use nor maintained on any medication history of tattoo piercing history of wading in flood waters
6

No No

 Nulligravid

Menarche

- 13 yrs. Old

LMP

- May 20-24, 2009 - June 19-23, 2009

PMP

3-5

pads/day, no dysmenorrhea
7

 Non

smoker, non passive smoker alcoholic beverage drinker of eating street food (+)

Non

Fond

No

travel to endemic areas

 No

hypertension diabetes mellitus cancer pulmonary tuberculosis

No

No

No

Conscious, coherent, normosthenic, oriented as to time, place and person BP - 120/80 CR - 70 regular PR - 70 regular RR - 21 Temp - 39.5C (+)
10

- 1.5m Weight - 52.6kg BMI - 23 No skin rashes Pink palpebral conjuctivae, anicteric sclerae No nasal nor aural discharge No oral ulcers or sores, dry tongue (+), no dental caries Thyroid gland not enlarged, supple neck, no palpable cervical lymphadenopathy
Height

11

Symmetrical chest expansion, resonant, unimpaired transmission of vocal and tactile fremiti, clear breath sounds Adynamic precordium, apex beat at 5th LICS, MCL, at the apex, loud S1 followed by soft S2, at the base, soft S1 followed by loud S2, no heaves, no lifts, no thrills, no murmurs

12

 Abdomen

flat; normoactive bowel sounds; tympanitic; non tender; Liver span 13cm (+) Liver edge 2cm below right subcostal margin (RSCM) sharp, smooth, non tender; Traubes space not obliterated calf tenderness, no edema 1-2+ on all extremeties

No

Pulse

13

 Living

conditions

If in squatters area If living near a body of water Source of water

Urine

color Stool color Sexual History

14

FEVER

15

 Fever

is an elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point. a protective mechanism of the body

Reference: Harrisons Principles of Internal Medicine, 16th ed. 16

 results

from a resetting of the set-point for temperature control

could be a result of protein breakdown products or bacterial toxins called pyrogens. Due to infection, metabolic derangements or increased cell destruction

A.M. temperature of >37.2C P .M. temperature of 37.7C

References: Guytons Textbook of Medical Physiology (11th Edition) Fever: From Symptom to Treatment (1978)
17

 Mean

oral temperature

36.8 0.4 C or 98.2 0.7 F low levels at 6 A.M. and higher levels at 4 to 6 P .M.

Maximum

normal oral temperature

37.2 C or 98.9 F at 6 A.M. 37.7 C or 99.9 F at 4 P .M.

Normal

daily temperature variation

0.5 C or 0.9 F

Reference: Harrisons Principles of Internal Medicine, 16th ed.

18

Oral temperature  Accurate and convenient  usually quoted at 37C (98.6F)  Place thermometer under tongue, then close both lips  Mercury: 3-5 minutes ; Electric: 10 seconds

Reference: Bates Guide to Physical Examination and History Taking 19

Axillary temperature  Reads 1C lower than oral temperature  Takes 5-10 minutess to register  Lower accuracy  Place the thermometer under the armpit and fold the arm across the chest to hold the thermometer in place.

Reference: Bates Guide to Physical Examination and History Taking 20

Rectal temperature higher than oral temperatures by 0.4 to 0.5C patient lies on one side with the hip flexed Select a rectal thermometer with a stubby tip, use a lubricant, and insert it about 3-4 cm into the anal canal for about 3 minutes

Reference: Bates Guide to Physical Examination and History Taking 21

Tympanic Membrane temperature measures core body temperature higher than the normal oral temperature by 0.8C measure radiant heat energy from the tympanic membrane and nearby ear canal Position the probe in the canal and wait 2 to 3 seconds

Reference: Bates Guide to Physical Examination and History Taking 22

Range

C
<36 37 38.2-39 39 40 40 4 . >4 .

Hypothermia Normal Low Grade or Mild Moderate or Average High-Grade Severe

Reference: Fever: From Symptom to Treatment (1978)

23

Continuous fever
Constantly elevated above the normal level

Remittent fever
Fluctuates daily from higher to lower levels, but is constantly above normal

Intermittent fever
Daily fluctuation at its lower level is below the normal 37C

Relapsing fever
One or more days of normal temperature alternate between days of fever
Reference: Fever: From Symptom to Treatment (1978)
24

Fever

Immune Nervous Digestive Respiratory Urinary

Reference: Harrisons Principles of Internal Medicine, 16th ed. 25

FEVER Infection, microbial toxins, mediators of inflammation, immune reactions Microbial toxins Cyclic AMP Monocytes/macrophages, endothelial cells, others PGE Elevated thermoregulatory set point Heat conservation, heat production

Pyrogenic cytokines IL-1, IL6, TNF, IFN

Hypothalamic endothelium

Circulation Harrisons Principles of Internal Medicine, 16th Edition 26

 Infection

Exogenous pyrogens: derived from outside an individual and may include LPS and toxins. Endogenous pyrogens: originating inside the body and may include pyrogenic cytokines,IL-1, IL-6, TNF.

Brain

lesions

Compression of the hypothalamus by a brain tumor. Operations in the region of the hypothalamus

Essential Medical Physiology 3rd edition 2003

INFECTION Monocytes, macrophages Endogenous pyrogens (IL-1,TNF, IL-6) Hypothalamus: temperature setpoint

Skeletal muscle shivering Curl up/add clothes

Skin arterioles vasoconstriction

heat production

heat loss

Heat production > Heat loss Heat retention Body temperature Human Physiology 5th edition 1990

29

TEMPERATURE-DECREASING MECHANISMS Vasodilatation Sweating Decrease in heat production TEMPERATURE-INCREASING MECHANISMS Skin vasoconstriction throughout the body Piloerection Increase in heat production
Textbook of Medical Physiology 10th edition 2000

INCREASE IN HYPOTHALAMIC SETPOINT

Feeling of cold despite an increase in body temperature Vasoconstriction in hands and feet Shivering Increase in heart rate & muscle tone (increases about 18 beats per minute for each degree Celsius increase in temp.) Behavioral adjustments

Textbook of Medical Physiology 10th edition 2000

31

WHEN HYPOTHALAMIC SET POINT IS AGAIN RESET DOWNWARD Intense sweating Hot skin (vasodilatation)

Textbook of Medical Physiology 10th edition 2000

32

26 y/o female  Continuous Moderate to high grade fever (Temp - 39.5C (+)  Pulse-temperature disproportion  Hepatomegaly (liver span: 13cm) Anorexia Fond of eating streetfoods  Dry tongue

33

INFECTIONS
Typhoid Fever Hepatitis A & B Leptospirosis Tuberculosis Malaria

MALIGNANCIES AUTOIMMUNE CONDITIONS

Leukemia Lymphoma Rheumatoid arthritis Rheumatic fever Systemic lupus erythematosus Vasculitides

OTHERS
Drug-induced fever

34

INFECTIONS Typhoid Fever Possible Enteric (Typhoid) Fever because of fondness of eating street food Fond of eating street foods, but, no jaundice no jaundice, no history of illicit drug use, no history of tattoo and piercing No history of chronic cough, weight loss, no difficulty of breathing No wading in flooding water, no calf tenderness No recurrent fever (2-3 days interval) , no history of blood transfusion, no travel to endemic areas

Hepatitis A Hepatitis B Tuberculosis Leptospirosis Malaria

35

 Typhoi f v r is syst i is s haract riz y fever and abdominal pain caused by dissemination of S. typhi or S. paratyphi. > 75% of cases present to 40% abdominal pain of ith fever ith

cases

incubation period: 3 to 21 days

Reference: Harrisons Principles of Internal Medicine 16th ed.

 most prominent symptom: prolonged fever (38.8 to 40.5 C) nonspecific symptoms: chills, headache, anorexia, cough, weakness, sore throat, dizziness, and muscle pains early physical findings : ~30% of patients with rash (rose spots), hepatosplenomegaly, epistaxis, and relative bradycardia.
Reference: Harrisons Principles of Internal Medicine 16th ed.

 The

diagnostic gold standard is a culture positive for S. t i or S. r t i. The yield of blood cultures is variable:

It can be as high as 90% during the first week of infection. It can decrease to 50% by the third week.

Harrison Principles of Internal Medicine, 17th ed.

http://bioinfo.bact.wisc.edu/themicrobialworld/S.typhi

The Pharmacologic and Non-Pharmacologic Approach to Treatment

40

 To

lower the body temperature completely eradicate the pathogen

To

41

Objectives of treating fever

 

reduce the elevated hypothalamic set point facilitate heat loss

Harrisons Principles of Internal Medicine, 17th ed.

42

ANTIPYRETICS

drugs that reduce fever drugs that cause a lowering of the elevated hypothalamic set point The antipyretic potency of various drugs is directly correlated with the inhibition of brain cyclooxygenase.

Harrisons Principles of Internal Medicine, 17th ed. Pharmacology Examination and Board Review by Katzung43

Membrane Lipid Phospholipase A2

Corticosteroids NSAIDs

Arachidonic Acid Lipoxygenase Cyclooxygenase

Endoperoxides

Hydroperoxides

Leukotrienes

P I P E, P E

TXA

Pharmacology Examination and Board Review by Katzung

44

poor cyclooxygenase inhibitor in peripheral tissue and is without noteworthy antiinflammatory activity by the p450 cytochrome system, and the oxidized form inhibits cyclooxygenase activity inhibition of another enzyme, COX-3

oxidized

the

Harrisons Principles of Internal Medicine, 17th ed.

45

Physical cooling


use of cooling blankets, tepid water sponge bath or ice baths may also be done to facilitate the reduction of the body temperature

Adequate hydration


Hydration maintenance is important in order to balance the fluid lost due to fever.

46

 Use

of antimicrobial therapy directed against the pathogen

47

 agents

used to destroy or inhibit the growth of other microorganisms used to inactivate microbial cells toxicity to the host and maximize chemotherapeutic activity affecting invading microbes only.

limit

Blacks Medical Dictionary, 41st ed. Medical Microbiology by Jawetz, 24th ed

48

Selective toxicity Inhibition of cell wall synthesis

-lactams (Penicillin and Cephalosporin) Vancomycin

Inhibition of cell membrane function

Polymyxins

Inhibition of protein synthesis

Macrolides Chloramphenicol Tetracycline Aminoglycosides

Inhibition of nucleic acid synthesis

Rifampin Metronidazole

Harrisons Principles of Internal Medicine, 17th ed. Medical Microbiology by Jawetz, 24th ed 49

Chloramphenicol Amoxicillin Cotrimoxazole

50

 Widespread

sensitization of the population

Changes

in the normal flora of the body serious infection without eradicating it

Masking

Direct

drug toxicity of drug resistance

Development

Medical Microbiology by Jawetz, 24th ed

51

Proper waste disposal Proper food handling Avoid high-risk food like shellfish, raw food or semicooked food. Wash hands properly with soap and water before eating or handling food, and after toilet or changing diapers. Cook food thoroughly.
52

53