Common Symptoms---Fever and Edema

1. Common Symptoms---Fever and Edema The First Affiliated Hospital of Liaoning Medical College Nephropathy Deparment Zhou HongLi

2. Fever 1 Introduction 2 Pathlogeny and sort 3 Occurrence Mechanism 4 Clinical occurrence 5 Patterns of fever 6 FUO

3. Intruduction 1 normal rang: 36-37℃ 2 higher: late afternoon, evening maximum 8:00-10:00 pm lower: morning minimum 3:00-4:00 am 3measure pathway：rectum (higher 0.3-0.5) mouth axillia (lower 0.2-0.4)

4. Pathlogeny and sort 1 Infective fever-------most common cause ①bacterial ②viral ③rickettsial ④fungal ⑤parasitic

5. Pathlogeny and sort 2 Noninfective fever ①aseptic necrosis massabsorption : tissue ischemia and infarction,vascularitis, subarachnoid hemorrage ②antigen-antibodyreaction: acute rheumatic fever, still disease ,serum sickness, systemic lupus erythematosus ③familalfever: congenital familial mediterranean fever

6. ④endocrine disease: endocrine hyperthyroidism ⑤tissuedamage:myocardial infarction, pullmonary infarction ⑥drug reaction and gout ⑦tumor: lymphomas,solid tumors ⑧neuroleptic seizures ⑨psychosocial factitious

7. Occurrence Mechanism • physiologic temperature elevated----fever (elevation of hypothalamic set point) • Pathologic temperature elevated-- hyperthermia ( unregulated heat generation, impaired heat exchange)

8. Occurrence Mechanism--physiologic set point (hypothalamus) Internal temperature cellular function regulate maintain Deviation >4 ℃ cellular dysfunction

9. Occurrence Mechanism increased heat production decreased heat dissipation failure of regulating system Set point change Temperature deviation fever

10. exogenous pyrogen (bacterial, viral) activate neutrophil, eosinophil, mononuclear macrophage release endogenous pyrogen(interleukin-1(IL-1),TNF, interferon） hypothalamus Set point heat production heat dissipation fever

11. Occurrence Mechanism Specific patients: • elderly patients • renal failure patients • high doses of corticosteriods • immunocompromised hosts fever • HIV-infected fever • nosocomial fever unable to mount fever require special consideration

12. Clinical occurrence Grade (oral reading) low-grade fever:37.3-38℃ middle-grade fever:38.1-39℃ high-grade fever:39.1-41℃ hyperthemia:﹥41℃

13. Clinical occurrence clinical features effervescence（heat production ,heat loss ） (chill,rigor,vasoconstriction) altithermal (reach new set point) (warm,moist,flushed,tarchycardia) defervescence (heat production heat loss ) sweat

14. Patterns of fever • Continuous fever • Remittent fever • Intermittent fever • Undulant fever • Relapsing fever • Episodic fever • Pel-Epstein fever

15. Continuous fever ①temperature: 39-40 ℃,days or weeks;diurnal variation 0.5-1.0 ℃ ②disease: typhoid, acute pneumonia

16. Continuous fever

17. Remittent fever ①temperature ＞38 ℃, diurnal variation＞2 ℃（no normal temeratrue） ②disease: sapraemia,acute rheumatic fever, acute infectious endocarditis

18. Remittent fever

19. Intermittent fever ①suddenly reach climax, continue several hours, suddenly fall to normal, intermission 1-several days ②disease: malaria, acute pyelonephritis

20. Intermittent fever

21. Undulant fever ①slowly reach ＞39 ℃,slowly return to normal. (repeate the rhythm) ②disease: brucellosis,tumor

22. Undulant fever

23. Relapsing fever ①suddenly reach 39 ℃ , continue several days, suddenly drop to normal. bout every 5-7days ②disease: spirochetes infection

24. Relapsing fever

25. Episodic fever ①last for days or longer, then without fever for at least 2 weeks ②disease: familial periodic fever

26. Pel-Epstein fever ①continuous or remittent fever bouts several days ②disease: Hodgkin disease

27. FUO—fever of unknown origin Diagnosis criteria: ①the illness last at least 3 weeks; ②38.3 ℃ repeatedly; ③no diagnosis after 1 week hospitalization Causes: ①noninfectious inflammatory disease; ②infections; ③malignancies (hematologic); ④50% unexplained

28. Edema • Pathophysiology • Clinical occurrence • Idiopathic edema • Tropical edema • angioedema

29. Pathophysiology hydrostatic and oncotic pressure fluid fluid A V filter out resorption interstitial tissues Keep in balance

30. equilibrating factors capillary hydrostatic pressure interstitial fluid colloid osmotic pressure serum colloid osmotic pressure interstitial tissues pressure filtration resorption Filtration > resorption edema

31. Factors leading to edema • retention of sodium and water • capillary filtration pressure（right heart failure） • capillary permeability （acute nephritis） • serum colloid osmotic pressure (serum albumin ) • lymphatic return disturbance (filariasis)

32. pitting edema detectable:4.5kg fluid accumulate identifymethod : press thumb into the skin against a bony surface (anterior tibia, fibula,dorsum of foot, sacrum) to demonstrate the presence of edema. when the thumb is withdrawn, an indention persist for a short time.

35. Site of edema: • walking patient--feet, ankles • supine patient--posterior calves, sacrum • both legs and symmetric—in the pelvis or more proximally • arms and head---superior vena cava • limited one extremity-vascular channels, local inflammation gravity

36. Brawny edema: chronic edema of the legs leads to fibrosis of the subcutaneous tissues and skin, so they no longer pit on pressure.

37. Clinical occurrence Localized edema • cause: local vein or lymphatic return,soft tissues disturbance or capillary permeability • disease: Inflammation infection insufficiency of the venous valves chemical or physical injuries arteriovenous fistulas

38. site: above the diaphragm--superior vena cava obstruction below the diaphragm—jugular venous press ,portal vein hypertension, loss of venous tone drugs

39. Generalized edema: • cardiac edema • renal edema • hepatic edema • nutritional edema (protein losing conditions) • Drug (corticosteroid, NSAID) • Systemic inflammatory response syndrome(SIRS)

40. Cardic edema • Symptoms: chest distress, short breath, dyspnea • Site: lower limbs • Disease：rightheart failure

41. renal edema • Symptoms：hematuria，proteinuria • Site: eyelid，legs • Disease: nephrotic syndrome

42. hepatic edema • Symptoms: anorexia, vomitting,liver function test abnormal • Site: first lower limbs, then spread all over the body, ascites is most common • Disease：cirrhosis, chronic liver disease

43. Protein losing conditions • Enteropathy • Burns • fistulas

44. Idiopathic edema • women in 30-50years old without disease,affective disorders and obesity may coexist • Mechanism :upright posture --capillary leakage inappropriate chronic diuretic administration -----peripheral edema activate hormones involved in salt and water retention

45. Tropical edema • Normal adults • condition:48h after traveled from temperate climate to tropics or from cool and dry to warm and humid • resolve quickly in a few days of acclimatization

46. Angioedema • Site: face,lips,tongue, larynx----life-threatening Subcutaneous soft-tissue edema ;Erythema is not prominent. • Causes: hereditary absence of C1 esterase exposure to allergen angiotensin-converting enzyme inhibitors

47. 1Reasons of infective fever 2Grades of fever. 3Patterns of fever. 4cause of generaliz edema 5How to distinguish cardiac edema from renal edema?