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A woman with recurrent fever

HKCEM College Tutorial. A woman with recurrent fever. Author Dr. Eric Lam & Dr. CY Man Revised by Dr. Shek kam chuen Oct., 2013. Triage notes. F/45 on & off fever x 2/52 Reattendance Case BP/P 140/90, 110 RR 20/min Temp. 37.8℃. Triage category IV.

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A woman with recurrent fever

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  1. HKCEM College Tutorial A woman with recurrent fever Author Dr. Eric Lam & Dr. CY Man Revised by Dr. Shekkamchuen Oct., 2013

  2. Triage notes • F/45 • on & off fever x 2/52 • Reattendance Case • BP/P 140/90, 110 • RR 20/min • Temp. 37.8℃ Triage category IV

  3. What historical points are relevant?

  4. Review of other systems PH: ?immunocompromised, ?HIV Med e.g. GP drugs Allergies Recent Travel Animal contact Targeted History • Fever • duration • pattern • systemic upset • main systems involved • CNS • Resp (URI, LRTI) • GI, hepatobiliary • GU e.g. UTI? PID?

  5. History • on & off low grade fever x 2/52 • malaise, generalized joint with muscle ache, • lethargy, headache, • throat discomfort, gum pain • nausea & vomiting • attended AED x 2, treated as viral illness not responding to treatment • re-attended today because of persistent symptoms

  6. PMH / drug / travel / social history -unremarkable What is your focus in the physical exam?

  7. Neck rigidity LNs CVS/?Resp heart murmur crep, rhonchi Abdomen organomegaly tenderness: HBS, kidneys Musculo-skeletal joint swelling Focussed exam • Confirm fever • oral better than tympanic • Rash • distribution • characteristics • CNS • features for encephalitis & meningitis • HEENT • conjunctivitis • oral lesion

  8. Examination • unwell looking woman • pale • patches of bruises over limbs • no lymphadenopathy • gum hypertrophy • no hepatosplenomegaly • rest of the exam--non-contributory

  9. What do you need to rule in? This rash will not blanch on pressure.

  10. Meningococcemia! • This is a dire emergency that should not be missed. • Immediate antibiotics e.g. ceftriaxone 2 gm is needed.

  11. What is your differential diagnosis ?

  12. What is your differential diagnosis ? • infection • connective tissue disease • malignancy • drug • idiopathic

  13. What will you do nex ?t • Discharged with drugs • Observe in O ward pending Ix • Admit to medical ward

  14. What investigations would you request ? • CBC • R,LFT • Clotting profiles • blood culture • MSU, urine x microscopy

  15. CBC : • Hb 6 g / dL • WCC 40 x 109/L (predominantly blast cells) • Platelet 26 x 109/L INR: 5 APTT: 100 seconds

  16. What is your diagnosis? Acute leukaemia with possible DIC

  17. Acute leukaemia with possible DICWhich type is prone to DIC?

  18. Acute promyelocytic leukaemia(M3)

  19. What is your immediate treatment? • Stabilize ABC of patients • Identify and treat immediate problems (if any) e.g. severe anaemia, uncontrolled bleeding, severe septicaemia • Admit under the care of haematologist for bone marrow aspiration for confirmation

  20. Learning points • Patient with acute leukaemia may present with persistent or recurrent fever, flu or URI symptoms • Patient with persistent fever/Flu/URI symptoms lasting more than a week or so may need detailed history/examination/further investigations to identify or exclude important underlying causes, e.g. occult infection, leukaemia, connective tissue disease

  21. The end

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