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Fever A Case Presentation. Mona Jamtani 1006803266. Case Illustration. Identity Name: Ch. D A Age: 10 yo Address: Kelapa Gading Timur Religion: Moslem Medical Record: 1249xxx. Case Illustration. Chief Complaint Fever since 2 days prior to admission. Case Illustration. - PowerPoint PPT Presentation
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FEVERA CASE
PRESENTATIONMona Jamtani1006803266
CASE ILLUSTRATION Identity
Name: Ch. D AAge: 10 yoAddress: Kelapa Gading TimurReligion: MoslemMedical Record: 1249xxx
CASE ILLUSTRATION Chief Complaint
Fever since 2 days prior to admission
CASE ILLUSTRATION History of Present Illness
Two days prior to hospital admission, patient complained of a high fever that occurred suddenly and persisted. Temperature was not measured. Patient went to a clinic and was given medicine (antibiotics and fever medicine) but the fever remained.
Signs of acute systemic infection: Headache (+), muscle aches (+), loss of appetite(+)
Other symptoms: stomach ache (+), diarrhea (+) 1 x liquid with pulp, brown color, vomiting (-), cough (-), flu (+), pain in swallowing (-). Signs of bleeding; nosebleed (-), bleeding gums (-), petechiae (-). Pain on urination (-), pelvic pain (-)
CASE ILLUSTRATION
Previous History of IllnessPatient has never had a similar illness
Family History of IllnessThere is no similar illness in the familyThere is no history of TB in the family
CASE ILLUSTRATION Immunization History
Complete
Growth and Development HistoryWithin normal limits
CASE ILLUSTRATION Physical Examination
General condition: compos mentis, looks moderately ill
BP: 110/70 mmHgPulse: 120x/minuteRR: 40 x/ minuteTemp: 38.9CWeight: 24.5 kg
CASE ILLUSTRATION Physical ExaminationHead: normocephal, deformity (-)Eyes: anemic conjunctiva -/-, icteric sclera -/-ENT: nasal flare (-), secret (-), cerumen (-)Neck: suprasternal retraction (-)Lymph Nodes: No EnlargementChest: Symmetrical, static and dynamicHeart: S1-2 (N), murmur (-), gallop (-)Lungs: vesicular/vesicular, rhonki -/-, wheezing -/-Abdomen: supple, bowel sounds (+) normal, Pain
on palpation (+) epigastrium, good turgorNo enlargement of the liver spleen or kidneysExtremities: warm, CRT< 2”
CASE ILLUSTRATION Working Diagnosis
Fever ec Dengue Hemorrhagic Fever Differential Diagnosis
Urinary Tract Infection Work-up Plan:
Urinalysis, CBC/12 hoursTherapy Plan: IVFD RL 30 drops/minuteParacetamol ½ cth whenever there is feverRanitidin 3 x 1 amp
CASE ILLUSTRATION Laboratory Results Urinalyisis: ? CBC:
Hb 12.6 g/dL Ht 35%Leu 4700 /ulThrombo 73 000 / ul
CASE ILLUSTRATION Follow ups 24/9/10 S: fever (+) cough (-) stomach ache (+) vomit(-) O: compos mentis, looks moderately ill BP: 110/70 mmHg Pulse: 120 x /minute RR:
40x/ minute Temp: 38.9 C Hb: 16.4 g/dL Ht: 45% Leu: 6130/ uL
Thrombo: 49 000/uL A: DHF susp typhoid fever P: IVFD RL 30 drops/minute PCT 3 x 1 tab Ranitidine 3 x ½ amp
CASE ILLUSTRATION 25/9/10 S: Fever (+), flu (-), cough (-), stomach ache (+),
nosebleed (-), vomit (-) O: compos mentis, looks mildly ill BP: 110/80mmHg Pulse: 90 x/ minute RR:
32x/ minute Tem: 38C Hb: 13.6 g/dL Ht: 37% Leucocyte 6830/ uL
Thrombocyte: 45 000 /uL A: Dengue Fever susp Paratyyphoid P: RL 30 drops/minute Ranitidine 3 x ½ amp If fever spikes, consider cefixime administration
2 x 125 mg
CASE ILLUSTRATION 26/9/2010 S: Fever (D6) (-), cough (-), flu (-), stomach
ache (-), urineation (+) normal O: Compos Mentis BP: 100/70Pulse: 88x/minute RR: 40
x/minute Temp: 37 C Hb: 12.9 g/dL Ht: 36 % Leu: 67900/ uL
Thrombo: 57 000 / uL A: Demam Dengue + Susp Paratyphoid P: RL 30 drops/minute Ranitidine 3 x ½ amp If fever spikes, consider Cefixime 2 x 125 mg
CASE ILLUSTRATION 27/9/10 S: fever (-), complains (-), urination (+) O: compos mentis, looks well BP: 110/70 mmHg Pulse: 80x/minute
RR: 32x/minute Temp: Afebrile Extremeties: petechiae (+)legs, phlebitis (+)
on hands, Rumpal Leed (+) Hb: 13.1 g/dL Ht: 36% Leu: 8560 / uL
Thrombo: 99 000 A: DF P: educate to drink lots of fluids Ranitidine 3 x 25 mg if stomach ache present
LITERATURE REVIEW
FEVER Controlled elevation of temperature >
37.5C , due to increase in temperature regulatory set point
Achieved & maintained the same way as normal body temperature: redirecting blood to or from cutaneous vascular
beds, increased or decreased sweating, behavioral responses such as seeking a warmer
or cooler environmental temperature. Hyperthermia: normal setpoint but
incapability to maintain temperature (heat stroke, drugs)
FEVER: PATHOGENESIS Regulated like body temperature, at a
higher set point Set point is reset by endogenous pyrogens
(IL-1, IL-6, TNF-a, TNF-b, and IFNg) Endogenous Pyrogens stimulate organum
vsculosum laminae terminalis (OVLT) surrounding the preoptic nucleus, anterior hypothalamus and septum palusolum
Triggered OVLT synthesis of PG (PGE2) preoptic nucleus fever
Sooo… endogenous pyrogens PG fever
FEVER: PATHOGENESIS Fever Active generation of heat &
retaining heat Blood temperature in brain must match
the set point Vasoconstriction reduces heat loss Shivering produce heat from muscle
movements When the fever stops hypothalamic
setting is set lower vasodilation, sweating
FEVER: IMMUNE RESPONSE Fever improves specific and non-specific
immune responses Non-specific; incr. phagocytic
recruitment, phagocytic capacity and elimination of pathogen (provides a bad condition for pathogens)
Specific; incr. T-cell proliferation, cytokine expression, cytotoxic function and antibody secretion
FEVER: IMMUNE RESPONSE Heat Shock Response:
Allows cells to remain thormotolerantProduces Heat Shock Proteins
HSP cell repair post-stress, regulates steroid receptors, reduces levels of cytokines in blood, reduces further stress
FEVER: MANIFESTATIONS Intermittent: exaggerated circadian
rhythm includes period of normal temperature. Wide fluctuations maybe termed septic or hectic fever
Sustained: persistent and does not vary by more than 0.5C/day
Remittent: persistent and varies by more than 0.5C/day
Relapsing: febrile periods separated by intervals of normal temperature
FEVER: MANIFESTATIONS Tertian fever: occurs on 1st and 3rd days
(P. vivax) Quartan fever: occurs on 1st and 4th days
(P. malariae) Biphasic: camelback pattern (same
illness, 2 distict periods; Poliomyelitis) Periodic: fever syndromes with regular
periodicity & recurrent fever not necessarily periodic
FEVER: TREATMENT Antipyretic; indicated in high-risk
patients (cardiopulmonary disease, metabolic disorders, neurologic disease with risk of febrile seizure)
Fever> 41C (hyperpyrexia) sever infection, hypothalamic disorders, CNS hemorrhage always given antipyretics
Acetaminophen, aspirin, ibuprofen inhibit hypothalamic cyclo-oxygenase no PGE2
FEVER OF UNCERTAIN SOURCE Acute febrile Illness, etiology unknown
after hhistory and physical examination Sick/toxic child suspect severe
bacterial infection Sometimes focal infections do not
explain severity of condition/fever laboratory diagnoses
DENGUE Dengue Fever is Sudden high fever
accompanied by:HeadacheRetroorbital painMusculoskeletal painSkin rashManifestations of bleedingLeukopeniaPositive IgG/IgM
DHF is accompanied by signs of plasma leakage, hemocentration, pleural effusion, ascites, hypoproteinemia
DENGUE: MANIFESTATIONS Febrile phase:
Dehydration, febrile seizures Critical Phase:
Shock, plasma leakage, severe hemorrhage, organ impairment
Recovery PhaseHypervolemia (too much IV fluids?)
DENGUE: LABORATORY CHANGES Dengue fever;
pancytopenia may occur after the 3–4 days of illness. Neutropenia may persist or reappear during the latter stage of the disease and may continue into convalescence with white blood cell counts of <2,000/mm3.
Platelets rarely fall below 100,000/mm3. Venous clotting, bleeding and prothrombin times, and
plasma fibrinogen values are within normal ranges. The tourniquet test result may be positive. Mild acidosis, hemoconcentration, increased
transaminase values, and hypoproteinemia may occur during some primary dengue virus infections.
The electrocardiogram may show sinus bradycardia, ectopic ventricular foci, flattened T waves, and prolongation of the P-R interval.
DENGUE: LABORATORY CHANGES DHF & DSS Hemoconcentration: increase >20% in
hematocrit Thrombocytopenia Prolonged bleeding time Moderate incr tansaminase levels,
consumption of complements, hypoalbuminemia
Pleural effusions
DENGUE: TREATMENT Group A – patients who may be sent home adequateoral fluids, urinate/6 hours, no warning
signs, must be reviewed daily for disease progression (decreasing white blood cell count, defervescence and warning signs) until they are out of the critical period. Oral intake of ORS, juices, etc [Caution: fluids containing
sugar/glucose may exacerbate hyperglycaemia of physiological stress from dengue and diabetes mellitus.
Paracetamol for high fever if the patient is uncomfortable.
Hospitalize if: no clinical improvement, severe abdominal pain, persistent vomiting, cold and clammy extremities, lethargy or irritability/restlessness, bleeding , not passing urine for more than 4–6 hours.
DENGUE: TREATMENT Group B – patients who should be
referred for in-hospital management critical phase; patients with warning
signs, with co-existing conditions complicating management Serial CBC Give only isotonic solutions such as 0.9%
saline, Ringer’s lactate, or Hartmann’s solution. Start with 5–7 ml/ kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response
DENGUE: TREATMENT Group B
Reassess the clinical status and repeat the haematocrit. If the haematocrit remains the same or rises only minimally, 2–3 ml/kg/hr) for another 2–4 hours.
If the vital signs are worsening and haematocrit is rising rapidly, 5–10 ml/kg/hour for 1–2 hours.
Minimum IV fluid to maintain good perfusion and urine output of about 0.5 ml/kg/hr.
Encourgae oral fluids
DENGUE: TREATMENT Group C – patients who require
emergency treatment and urgent referral when they have severe dengue
There should be continued replacement of further plasma losses to maintain effective circulation for 24–48 hours. Blood transfusion should be given only in cases with suspected/severe bleeding.
If resuscitation needed 10-20ml/kg for limited period under close observation
Goal: Improve central and peripheral circulation, achieve stable consciousness
DENGUE: TREATMENT Discharge Criteria
No fever for 48 hours Improvement in clinical stats (general well
being, good appetite, stable haemodynamic, urine output, no respiratory distress)
Increasing trend of platelet countStable hematocrit w/o IV fluids
COMPLICATIONS & PROGNOSIS DF; self-limiting and benign (usually) Febrile convulsions, epistaxis, GI
bleeding
Death occurs in 40-50% pts with shock Survival related to early and proper care
THANK YOU