html5-img
1 / 35

Fever A Case Presentation

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.

dino
Download Presentation

Fever A Case Presentation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. FeverA Case Presentation Mona Jamtani 1006803266

  2. Case Illustration • Identity • Name: Ch. D A • Age: 10 yo • Address: KelapaGadingTimur • Religion: Moslem • Medical Record: 1249xxx

  3. Case Illustration • Chief Complaint • Fever since 2 days prior to admission

  4. 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 (-)

  5. Case Illustration • Previous History of Illness • Patient has never had a similar illness • Family History of Illness • There is no similar illness in the family • There is no history of TB in the family

  6. Case Illustration • Immunization History • Complete • Growth and Development History • Within normal limits

  7. Case Illustration • Physical Examination • General condition: compos mentis, looks moderately ill • BP: 110/70 mmHg • Pulse: 120x/minute • RR: 40 x/ minute • Temp: 38.9C • Weight: 24.5 kg

  8. Case Illustration • Physical Examination • Head: normocephal, deformity (-) • Eyes: anemic conjunctiva -/-, icteric sclera -/- • ENT: nasal flare (-), secret (-), cerumen (-) • Neck: suprasternal retraction (-) • Lymph Nodes: No Enlargement • Chest: Symmetrical, static and dynamic • Heart: S1-2 (N), murmur (-), gallop (-) • Lungs: vesicular/vesicular, rhonki -/-, wheezing -/- • Abdomen: supple, bowel sounds (+) normal, Pain on palpation (+) epigastrium, good turgor • No enlargement of the liver spleen or kidneys • Extremities: warm, CRT< 2”

  9. Case Illustration • Working Diagnosis • Fever ec Dengue Hemorrhagic Fever • Differential Diagnosis • Urinary Tract Infection • Work-up Plan: • Urinalysis, CBC/12 hours • Therapy Plan: • IVFD RL 30 drops/minute • Paracetamol ½ cth whenever there is fever • Ranitidin 3 x 1 amp

  10. Case Illustration • Laboratory Results • Urinalyisis: ? • CBC: • Hb 12.6 g/dL • Ht 35% • Leu 4700 /ul • Thrombo 73 000 / ul

  11. 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/ uLThrombo: 49 000/uL • A: DHF susp typhoid fever • P: IVFD RL 30 drops/minute • PCT 3 x 1 tab • Ranitidine 3 x ½ amp

  12. 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/ uLThrombocyte: 45 000 /uL • A: Dengue Fever suspParatyyphoid • P: RL 30 drops/minute • Ranitidine 3 x ½ amp • If fever spikes, consider cefixime administration 2 x 125 mg

  13. Case Illustration • 26/9/2010 • S: Fever (D6) (-), cough (-), flu (-), stomach ache (-), urineation (+) normal • O: Compos Mentis • BP: 100/70 Pulse: 88x/minute RR: 40 x/minute Temp: 37 C • Hb: 12.9 g/dL Ht: 36 % Leu: 67900/ uLThrombo: 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

  14. 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, RumpalLeed (+) • Hb: 13.1 g/dL Ht: 36% Leu: 8560 / uLThrombo: 99 000 • A: DF • P: educate to drink lots of fluids • Ranitidine 3 x 25 mg if stomach ache present

  15. Literature Review

  16. 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)

  17. 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 organumvsculosumlaminaeterminalis (OVLT) surrounding the preoptic nucleus, anterior hypothalamus and septum palusolum • Triggered OVLT  synthesis of PG (PGE2)  preoptic nucleus  fever • Sooo… endogenous pyrogens  PG  fever

  18. 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

  19. 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

  20. Fever: Immune Response • Heat Shock Response: • Allows cells to remain thormotolerant • Produces Heat Shock Proteins • HSP  cell repair post-stress, regulates steroid receptors, reduces levels of cytokines in blood, reduces further stress

  21. 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

  22. 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

  23. 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

  24. 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

  25. Dengue • Dengue Fever is Sudden high fever accompanied by: • Headache • Retroorbital pain • Musculoskeletal pain • Skin rash • Manifestations of bleeding • Leukopenia • Positive IgG/IgM • DHF is accompanied by signs of plasma leakage, hemocentration, pleural effusion, ascites, hypoproteinemia

  26. Dengue: Manifestations • Febrile phase: • Dehydration, febrile seizures • Critical Phase: • Shock, plasma leakage, severe hemorrhage, organ impairment • Recovery Phase • Hypervolemia (too much IV fluids?)

  27. Dengue: Laboratory changes • Dengue fever; • pancytopeniamay occur after the 3–4 days of illness. Neutropeniamay 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.

  28. Dengue: Laboratory changes • DHF & DSS • Hemoconcentration: increase >20% in hematocrit • Thrombocytopenia • Prolonged bleeding time • Moderate incrtansaminase levels, consumption of complements, hypoalbuminemia • Pleural effusions

  29. 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. • Paracetamolfor 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.

  30. 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

  31. 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

  32. 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

  33. 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 count • Stable hematocrit w/o IV fluids

  34. 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

  35. THANK YOU

More Related