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  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