MPPRC Finallllllll!!
MPPRC Finallllllll!!
MPPRC Finallllllll!!
Alberto
Fever
wks
g
-intermittent moderate to high grade fever -self medicated with Paracetamol (500mg/tablet, every 4 hours)
wk
-anorexia
ADMISSION
4
No significant weight loss (-) No loss of consciousness,no headache (-) No blurring of vision (-) No ear discharge, no tinitus (-) No cough, no difficulty of breathing (-) No chest pain, no palpitation (-) No diarrhea, no constipation, no melena, no hematochezia (-) No dysuria, no frequency, no urgeny, no pollakuria (-) No joint pains (-) No polyuria, no polydipsia, no polyphagia (-) No heat or cold intolerance (-)
5
No
No No
history of illicit drug use nor maintained on any medication history of tattoo piercing history of wading in flood waters
6
No No
Nulligravid
Menarche
- 13 yrs. Old
LMP
PMP
3-5
pads/day, no dysmenorrhea
7
Non
smoker, non passive smoker alcoholic beverage drinker of eating street food (+)
Non
Fond
No
No
No
No
No
Conscious, coherent, normosthenic, oriented as to time, place and person BP - 120/80 CR - 70 regular PR - 70 regular RR - 21 Temp - 39.5C (+)
10
- 1.5m Weight - 52.6kg BMI - 23 No skin rashes Pink palpebral conjuctivae, anicteric sclerae No nasal nor aural discharge No oral ulcers or sores, dry tongue (+), no dental caries Thyroid gland not enlarged, supple neck, no palpable cervical lymphadenopathy
Height
11
Symmetrical chest expansion, resonant, unimpaired transmission of vocal and tactile fremiti, clear breath sounds Adynamic precordium, apex beat at 5th LICS, MCL, at the apex, loud S1 followed by soft S2, at the base, soft S1 followed by loud S2, no heaves, no lifts, no thrills, no murmurs
12
Abdomen
flat; normoactive bowel sounds; tympanitic; non tender; Liver span 13cm (+) Liver edge 2cm below right subcostal margin (RSCM) sharp, smooth, non tender; Traubes space not obliterated calf tenderness, no edema 1-2+ on all extremeties
No
Pulse
13
Living
conditions
Urine
14
FEVER
15
Fever
is an elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point. a protective mechanism of the body
results
References: Guytons Textbook of Medical Physiology (11th Edition) Fever: From Symptom to Treatment (1978)
17
Mean
oral temperature
36.8 0.4 C or 98.2 0.7 F low levels at 6 A.M. and higher levels at 4 to 6 P .M.
Maximum
Normal
0.5 C or 0.9 F
Oral temperature Accurate and convenient usually quoted at 37C (98.6F) Place thermometer under tongue, then close both lips Mercury: 3-5 minutes ; Electric: 10 seconds
Axillary temperature Reads 1C lower than oral temperature Takes 5-10 minutess to register Lower accuracy Place the thermometer under the armpit and fold the arm across the chest to hold the thermometer in place.
Rectal temperature higher than oral temperatures by 0.4 to 0.5C patient lies on one side with the hip flexed Select a rectal thermometer with a stubby tip, use a lubricant, and insert it about 3-4 cm into the anal canal for about 3 minutes
Tympanic Membrane temperature measures core body temperature higher than the normal oral temperature by 0.8C measure radiant heat energy from the tympanic membrane and nearby ear canal Position the probe in the canal and wait 2 to 3 seconds
Range
C
<36 37 38.2-39 39 40 40 4 . >4 .
23
Continuous fever
Constantly elevated above the normal level
Remittent fever
Fluctuates daily from higher to lower levels, but is constantly above normal
Intermittent fever
Daily fluctuation at its lower level is below the normal 37C
Relapsing fever
One or more days of normal temperature alternate between days of fever
Reference: Fever: From Symptom to Treatment (1978)
24
Fever
FEVER Infection, microbial toxins, mediators of inflammation, immune reactions Microbial toxins Cyclic AMP Monocytes/macrophages, endothelial cells, others PGE Elevated thermoregulatory set point Heat conservation, heat production
Hypothalamic endothelium
Infection
Exogenous pyrogens: derived from outside an individual and may include LPS and toxins. Endogenous pyrogens: originating inside the body and may include pyrogenic cytokines,IL-1, IL-6, TNF.
Brain
lesions
Compression of the hypothalamus by a brain tumor. Operations in the region of the hypothalamus
INFECTION Monocytes, macrophages Endogenous pyrogens (IL-1,TNF, IL-6) Hypothalamus: temperature setpoint
heat production
heat loss
Heat production > Heat loss Heat retention Body temperature Human Physiology 5th edition 1990
29
TEMPERATURE-DECREASING MECHANISMS Vasodilatation Sweating Decrease in heat production TEMPERATURE-INCREASING MECHANISMS Skin vasoconstriction throughout the body Piloerection Increase in heat production
Textbook of Medical Physiology 10th edition 2000
Feeling of cold despite an increase in body temperature Vasoconstriction in hands and feet Shivering Increase in heart rate & muscle tone (increases about 18 beats per minute for each degree Celsius increase in temp.) Behavioral adjustments
WHEN HYPOTHALAMIC SET POINT IS AGAIN RESET DOWNWARD Intense sweating Hot skin (vasodilatation)
26 y/o female Continuous Moderate to high grade fever (Temp - 39.5C (+) Pulse-temperature disproportion Hepatomegaly (liver span: 13cm) Anorexia Fond of eating streetfoods Dry tongue
33
INFECTIONS
Typhoid Fever Hepatitis A & B Leptospirosis Tuberculosis Malaria
OTHERS
Drug-induced fever
34
INFECTIONS Typhoid Fever Possible Enteric (Typhoid) Fever because of fondness of eating street food Fond of eating street foods, but, no jaundice no jaundice, no history of illicit drug use, no history of tattoo and piercing No history of chronic cough, weight loss, no difficulty of breathing No wading in flooding water, no calf tenderness No recurrent fever (2-3 days interval) , no history of blood transfusion, no travel to endemic areas
35
Typhoi f v r is syst i is s haract riz y fever and abdominal pain caused by dissemination of S. typhi or S. paratyphi. > 75% of cases present to 40% abdominal pain of ith fever ith
cases
most prominent symptom: prolonged fever (38.8 to 40.5 C) nonspecific symptoms: chills, headache, anorexia, cough, weakness, sore throat, dizziness, and muscle pains early physical findings : ~30% of patients with rash (rose spots), hepatosplenomegaly, epistaxis, and relative bradycardia.
Reference: Harrisons Principles of Internal Medicine 16th ed.
The
diagnostic gold standard is a culture positive for S. t i or S. r t i. The yield of blood cultures is variable:
It can be as high as 90% during the first week of infection. It can decrease to 50% by the third week.
http://bioinfo.bact.wisc.edu/themicrobialworld/S.typhi
40
To
To
41
ANTIPYRETICS
drugs that reduce fever drugs that cause a lowering of the elevated hypothalamic set point The antipyretic potency of various drugs is directly correlated with the inhibition of brain cyclooxygenase.
Harrisons Principles of Internal Medicine, 17th ed. Pharmacology Examination and Board Review by Katzung43
Corticosteroids NSAIDs
Endoperoxides
Hydroperoxides
Leukotrienes
P I P E, P E
TXA
44
poor cyclooxygenase inhibitor in peripheral tissue and is without noteworthy antiinflammatory activity by the p450 cytochrome system, and the oxidized form inhibits cyclooxygenase activity inhibition of another enzyme, COX-3
oxidized
the
Physical cooling
use of cooling blankets, tepid water sponge bath or ice baths may also be done to facilitate the reduction of the body temperature
Adequate hydration
Hydration maintenance is important in order to balance the fluid lost due to fever.
46
Use
47
agents
used to destroy or inhibit the growth of other microorganisms used to inactivate microbial cells toxicity to the host and maximize chemotherapeutic activity affecting invading microbes only.
limit
Polymyxins
Rifampin Metronidazole
Harrisons Principles of Internal Medicine, 17th ed. Medical Microbiology by Jawetz, 24th ed 49
50
Widespread
Changes
Masking
Direct
Development
Proper waste disposal Proper food handling Avoid high-risk food like shellfish, raw food or semicooked food. Wash hands properly with soap and water before eating or handling food, and after toilet or changing diapers. Cook food thoroughly.
52
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