logging in or signing up PYREXIA pravinboza2005 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 759 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: June 07, 2009 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... By: Marwani (7 month(s) ago) Hallo, I am a lecturer. Can I download your presentation? I think your poresentation is very interesting. Thanks. Marwani (brtsptr@yahoo.com) Saving..... Post Reply Close Saving..... Edit Comment Close By: 01011984 (18 month(s) ago) it is wonderful can i download it plz Saving..... Post Reply Close Saving..... Edit Comment Close By: pkgfdk (29 month(s) ago) Dear Doctor, Hello! We seek your kind permission to download the PUO presentation to teach our students Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript FEVER (Pyrexia) : FEVER (Pyrexia) BY DR PRAVIN B.OZA (M.D.) Ashirvad Hospital, Radhanpur. Slide 2: WEL COME TO ALL OF YOU “Fever” is HOT-But not like “These” : “Fever” is HOT-But not like “These” Slide 4: IT IS LIKE “THIS” FEVER (Pyrexia) : FEVER (Pyrexia) Definition :- Fever (known as pyrexia, from the Greek pyretos meaning fire, or a febrile response, from the Latin word febris, meaning fever, is a frequent medical sign that describes an increase in internal body temperature to levels above normal. -- temporary elevation in the body's thermoregulatory set-point, usually by about 1–2 °C (1.8-3.6 °F). Definition : Definition Fever refers to an elevation in body temperature. Technically, any body temperature above -the normal oral measurement of 98.6 F (37 C) or -the normal rectal temperature of 99 F (37.2 C) is considered to be elevated. However, these are averages, and your normal temperature may actually be 1 F (0.6 C) or more above or below the average of 98.6 F. Body temperature can also vary up to 1 F (0.6 C) throughout the day. Definition (Cont.) : Definition (Cont.) A feverish individual has a general feeling of cold despite an increased body temperature, and increases in heart rate, muscle tone and shivering, all of which are caused by the body's attempts to counteract the newly-perceived hypothermia and reach the new thermoregulatory set-point Definition ( Cont.) : Definition ( Cont.) Fever differs from hyperthermia in that hyperthermia is an increase in body temperature over the body's thermoregulatory set-point, due to excessive heat production or insufficient thermoregulation, or both. A fever is considered one of the body's immune mechanisms to attempt a neutralization of a perceived threat inside the body, be it bacterial or viral. A fever is not a disease, but the body's response to a disease. MECHANISM : MECHANISM Temperature is regulated in the hypothalamus. A trigger of the fever, called a pyrogenin, causes a release of prostaglandin E2 (PGE2). PGE2 then in turn acts on the hypothalamus, which generates a systemic response back to the rest of the body, causing heat-creating effects to match a new temperature level. MECHANISM : MECHANISM PYROGENS : PYROGENS Substance that induces fever. 1, External (exogenous) The bacterial substance lipopolysaccharide (LPS), present in the cell wall of bacteria, Pyrogenicity can vary, as in extreme examples some bacterial pyrogens known as superantigens can cause rapid and dangerous fevers. PYROGENS : PYROGENS 2, INTERNAL-(ENDOGENOUS) :- * Cytokines (especially interleukin 1) part of the innate immune system, -produced by phagocytic cells, -causes the increase in the thermoregulatory set-point in the hypothalamus. * Interleukin 6 (IL-6), * Tumor necrosis factor-alpha ACTION OF PYROGENS : ACTION OF PYROGENS These cytokine factors are released into general circulation where they migrate to the circumventricular organs of the brain due to easier absorption caused by the blood-brain barrier's reduced filtration action there. The cytokine factors then bind with endothelial receptors on vessel walls, or interact with local microglial cells. When these cytokine factors bind, the arachidonic acid pathway is then activated ACTION OF PYROGENS : ACTION OF PYROGENS One model for the mechanism of fever caused by exogenous pyrogens includes LPS, which is a cell wall component of gram-negative bacteria. An immunological protein called lipopolysaccharide-binding protein (LBP) binds to LPS. The LBP–LPS complex then binds to the CD14 receptor of a nearby macrophage. This binding results in the synthesis and release of various endogenous cytokine factors, such as interleukin 1 (IL-1), interleukin 6 (IL-6), and the tumor necrosis factor-alpha. In other words, exogenous factors cause release of endogenous factors, which, in turn, activate the arachidonic acid pathway. PGE2 Release : PGE2 Release PGE2 release comes from the arachidonic acid pathway. This pathway (as it relates to fever), is mediated by the enzymes phospholipase A2 (PLA2), cyclooxygenase-2 (COX-2), and prostaglandin E2 synthase. These enzymes ultimately mediate the synthesis and release of PGE2 ACTION OF PYROGENS : ACTION OF PYROGENS PGE2 is the ultimate mediator of the febrile response. The set-point temperature of the body will remain elevated until PGE2 is no longer present. PGE2 acts on neurons--- In the preoptic area (POA) through the prostaglandin E receptor 3 (EP3). EP3-expressing neurons in the POA innervate the dorsomedial hypothalamus (DMH),and the paraventricular nucleus (PVN) of the hypothalamus Fever signals sent to the DMH lead to stimulation of the sympathetic output system, which evokes non-shivering thermogenesis to produce body heat and skin vasoconstriction to decrease heat loss from the body surface. ACTION OF PYROGENS : ACTION OF PYROGENS The brain ultimately starts heat effector mechanisms via the autonomic nervous system. These may be: Increased heat production by increased muscle tone, shivering and hormones like epinephrine. Prevention of heat loss, such as vasoconstriction. The autonomic nervous system may also activate brown adipose tissue to produce heat (non-exercise-associated thermogenesis, also known as non-shivering thermogenesis), Classification : Classification Fever classificationGrade *Low grade : 38–39°C, 100.4–102.2 °F *Moderate : 39–40°C, 102.2–104.0 °F *High-grade: 40–41.1°C, 104.0–106.0 °F *Hyperpyrexia : >41.1°C, >106.0 °F The last is a medical emergency because it approaches the upper limit compatible with human life. If the temperature is taken by another route (mouth, ear, armpit), then the reading needs to be converted to the equivalent core body temperature. Variations in normal body Temp. : Variations in normal body Temp. These variations in normal body temperature, are to be considered when measuring for fever. The values given are for an otherwise non-fasting adult, dressed comfortably, indoors, in a room that is kept at a normal room temperature (27 C), during the morning, but not shortly after arising from sleep. Furthermore, for oral temperatures, the subject must not have eaten, drunk, or smoked anything in at least the previous fifteen to twenty minutes. Variations : Variations Body temperature normally fluctuates over the day, with the lowest levels around 4 a.m. and the highest around 6 p.m.. Therefore, an oral temperature of 37.2 °C (99.0 °F) would strictly be a fever in the morning, but not in the afternoon. An oral body temperature reading up to 37.5 °C (99.5 °F) in the early/late afternoon or early/late evening also wouldn't be a fever. Variations : Variations Normal body temperature may differ as much as 1 °F (0.6 °C) between individuals or from day to day. In women, temperature differs at various points in the menstrual cycle. Temperature is increased after eating, and psychological factors also influence body temperature How should I take a temperature for fever? : How should I take a temperature for fever? Digital thermometers can be used to measure rectal, oral, or axillary (under the armpit) temperatures. The American Academy of Pediatrics does not recommend use of mercury thermometers (glass), and they encourage parents to remove mercury thermometers from their households to prevent accidental exposure to this toxin. Routine Analouge Mercury Thermometer : Routine Analouge Mercury Thermometer Digital Thermometer : Digital Thermometer * Axillary : Axillary Measuring an axillary (under the armpit) temperature for fever: Axillary temperatures are not as accurate as rectal or oral measurements, and these generally measure one degree lower than a simultaneously obtained oral temperature. Place the tip of the digital thermometer in armpit. Leave in place about one minute or until you hear a beep to check a digital reading. Measuring fever by eardrum temperature : Measuring fever by eardrum temperature Tympanic (ear) thermometers must be placed correctly in your external ear to be accurate. Too much earwax can cause the reading to be incorrect. Eardrum temperature measurements are not accurate in small children and should not be used in children under 3 years (36 months) of age. This is especially true in infants below 3 months of age when obtaining an accurate temperature is very important. Oral Measurement : Oral Measurement Children of age more then 4 to 5 years and adults can have their temperature taken with a digital thermometer under the tongue with their mouth closed. Clean the thermometer with soapy water or rubbing alcohol and rinse. Turn the thermometer on and place the tip of the thermometer as far back under the tongue as possible. The thermometer should remain in place for about one minute or until you hear the beep. Check the digital reading. Avoid hot or cold drinks within 15 minutes of oral temperature measurement to ensure correct readings. Measuring Rectal Temp : Measuring Rectal Temp This method is recommended in children under 3 years, as this gives the most accurate reading of core temperature. Clean the thermometer with soapy water or rubbing alcohol and rinse with cool water. Use a small amount of lubricant, such as petroleum jelly, on the end. Place the child prone (belly-side down) on a firm surface, or place your child face up and bend his legs to his chest. After separating the buttocks, insert the thermometer approximately ½ to 1 inch into the rectum. Do not inset it too far. Hold the thermometer in place, loosely keeping your hand cupped around your child's bottom, and keep your fingers on the thermometer to avoid it accidently sliding further into the rectum. Keep it there for about one minute, until you hear the beep. Remove the thermometer, and check the digital reading. Label the rectal thermometer so it's not accidentally used in the mouth. A rectal temperature will read approximately one degree higher than a simultaneously obtained oral temperature. Patterns of Fever : Patterns of Fever Intermittent fever: Elevated temperature is present only for some hours of the day and becomes normal for remaining hours, e.g. malaria, kala-azar, pyaemia, or septicemia. In malaria, there may be a fever with a periodicity of 24 hours (quotidian), 48 hours (tertian fever), or 72 hours (quartan fever, indicating Plasmodium malariae). Patterns of Fever : Patterns of Fever Continuous fever: Temperature remains above normal throughout the day and does not fluctuate more than 1 °C in 24 hours, e.g. lobar pneumonia, typhoid, urinary tract infection, brucellosis, or typhus. Typhoid fever may show a specific fever pattern, with a slow stepwise increase and a high plateau. (Step ladder pattern) Patterns of Fever : Patterns of Fever Remittent fever: Temperature remains above normal throughout the day and fluctuates more than 1 °C in 24 hours, e.g. infective endocarditis. * Pel-Ebstein fever: A specific kind of fever associated with Hodgkin's lymphoma, being high for one week and low for the next week and so on. CAUSES-Infections : CAUSES-Infections A) SPECIFIC : Bacterial:-Tubercolosis,Typhoid-Para typhoid, Pneumonia,E.coli,Brucellosis,Septisemia-Pyemias,Bacterial endocarditis. Viral :- Influenza,Viral encephelitis, Inf.Mononeucleosis ,Psittacosis. Fungal:- Actinomycosis,Histoplasmosis. CAUSES-Infections : CAUSES-Infections Protozoal:- Amoebiasis,malaria,Kala-azar, Toxoplasma,Schistosomiasis,Trypanosomiasis. Spirochetal:-Syphilis,Rat bite fever B) Local septic Infections with pus formation: Sinusitis,mastoiditis,tonsillar /dental abscesses,suppurating glands,mammary abscess,parotid abscess,pyo salpinx,and parametritis,hepatic abscess,cholecystitis, pyonephrosis,lung abscess,bronchiectasis, appendicular abscess. CAUSES-Infections : CAUSES-Infections C) Local Infection without pus formation: Cystitis,Phlebitis,Inflammed piles, ulcerative colitis,regional enteritis, diverticulitis. CAUSES-NonInfectious : CAUSES-NonInfectious 1) Neoplasms:- Hodgekins and other lymphomas,hypernephromas,hepatoma,atrial myxomas. 2) Blood diseases:- Leukemias, agranulocytosis, hemolytic episodes. 3) Collagen disease:-Rheumatic fever, Rheumatoid arthritis,polyarteritis nodosa,erythema nodosum , SLE. CAUSES : CAUSES Infectious disease, e.g. influenza, common cold, HIV, malaria,thyphoids, infectious mononucleosis, or gastroenteritis Various skin inflammations, e.g. boils, pimples, acne, or abscess Immunological diseases, e.g. lupus erythematosus, sarcoidosis, inflammatory bowel diseases Tissue destruction, which can occur in hemolysis, surgery, infarction, crush syndrome, rhabdomyolysis, cerebral hemorrhage, etc. CAUSES : CAUSES Drug fever directly caused by the drug, e.g.sulphonamides,atropines,salicylates ,phenytoine methyl dopa,INH,Iodine, progesterone, or chemotherapeutics causing tumor necrosis as an adverse reaction to drugs, e.g. antibiotics or sulfa drugs. after drug discontinuation, e.g. heroin ,morphin or fentanyl withdrawal Reaction to incompatible blood products Cancers, most commonly renal cancer and leukemia and lymphomas CAUSES : CAUSES Metabolic disorders, e.g. gout or porphyria Thrombo-embolic processes, e.g. pulmonary embolism or deep venous thrombosis Persistent fever which cannot be explained after repeated routine clinical inquiries, is called fever of unknown origin How will you Investigate ? : How will you Investigate ? By History-Symptoms By Clinical Examination By Investigations. By History : By History Onset:- * Sudden- in Influenza, malaria ,pneumonia and Pyelitis . * Gradual- inTyphoid,Tuberculosis,SBE, & Brucellosis. Rigors:- Malaria,filariasis,empyema, pyelitis ,cholangitis,liver abscess and appendicular abscess, septisemia. * : * 3) Headache : Meningitis.Typhoid at onset encephelitis, 4) Bodyache : Influenza,dengue,small pox secondary syphilis,brucellosis and rat bite fever. 5) Sweating : Malaria,Pul. Or Milliary TB, Influenza,Rh.Fever,brucellosis amoebic hepatitis /abscess * : * 6) Convulsion : Cerebral malaria,encephilitis, Meningitis,Apical Pneumonia. 7) Delirium : Typhoid,Pneumonia,Meningitis, Septisemia,Plague. * : * 8) Loss of weight : TB,Chronic suppurative disease like empyema or lung abscess. 9) Diarrhoea : Algid malaria,Typhoid,paratyphoid,Thyro- toxicosis,regional ileitis,ulcerative colitis, TB enterocolitis and chronic dysentery. * : * 10) Vomiting : Malaria,meningitis,appendicitis, pyelonephritis. 11) Sore throat : Diptheria,Sec.Syphilis, leukemia, agranulocytosis. 12) Frequency of micturition : Pyelonephritis,cystitis,Koch’s urogenitals PAST HISTORY : PAST HISTORY Of Rh.fever,or valvular disease, TB lymphadenitis,or pleural effusion, Rat bite,syphilis or filariasis. PERSONAL HISTORY : PERSONAL HISTORY Residence of endemic area in Kala azar,Malaria,Amoebiasis. Mediterranean fever and trypanosomiasis. Occupational History In Weil’s disease, H/O Infection in other family members. Contacts with domestic or wild animals Or birds * : * Contacts with domestic or wild animals Or birds such infections can be --Brucellosos ( Cattle), --Psittacosis(birds) --Leptospirosis (rats,dogs and pigs) --Salmonellosis(ducks,rats,tortoises) Contacts with persons with TB * : * H/O Administration of drugs or serum. H/O Prior surgery or trauma. General Examination : General Examination Pattern of Fever-As discussed earlier. Pulse rate: Relative bradycardia in Typhoid,Meningitis,Influenza,dengue Respiration: Increased much much rate in Respiratory disease—Pneumonia, broncho-pneumonia,Pul.Koch’s,Pl.Eff., empyema,Milliary TB,Pul.Infacrtion. General Examination. : General Examination. 4) Anaemia: Malaria,Liver abscess,SBE, chronic sepsis. 5) Lymphadenopathy: Generalised: in TB, Sec.Syphilis, Hodgkins, leukemia, Localised : in plague,rat bite fever, glandar fever, lymphogranuloma inguinale. 6)Jaundice: in infective hepatitis,malaria, liver - abscess,cholecystitis,cholangitis. General Examination. : General Examination. 7) Skin: Rash-meningococcal meningitis, dengue, viral fevers, 8) Clubbing: Bronchiectasis,lung abscess, chronic empyema,SBE, liver- abscess. 9) Arthritis: Rh.fever,SBE,brucellosis,gout, leukemia,SLE, Poliarteritis – nodosa. General Examination. : General Examination. 10) Herpes labialis: in pneumococcal, meningococcal or streptococcal infection, Malaria. 11) Nodules: in Rh fever, Rheumatoid artritis,polyarteritis nodosa, cystecercosis. 12) Neck rigidity : Meningitis,Meningism. Systemic Examination : Systemic Examination 1) ENT : for focal sepsis in tonsils,teeths, quincy,sepsis in naso pharynx. 2) Abdomen: Spleenomegaly-Malaria,Hodgkins,typhoid, SBE, Hepatomegaly-Liver abscess,Cholecystitis, malaria,leukemia,Mets in liver. . : . Ascitis-TB peritonitis. Localising signs-Appendicular abscess, Cholecystitis,colitis, diverticulitis,perinephric sub phrenic abscess, salpingitis, Testicles: Epididimo orchitis,,TB,Teratoma . : . 3) Heart : Pericarditis,SBE, 4) Lungs : Pneumonia,Lung abscess, Pl eff.,TB,bronchiectasis, Actinomycosis. 5) Head & Neck :Sinusitis,OM, mastoidtis diptheria,tonsills,meningitis, brain abscess and Encephilitis. . : . 6) Limbs : Phlebitis ,Osteomyelitis,cellulitis, elephentiasis,polyneuritis, 7) Rectum: for missed appendicular abscess 8) External genitals: for sepsis/neoplasm 9) Fundus(Eye): for choroidal TB. LAB Invetigations : LAB Invetigations * Haemogram: Normochromic normocytic anaemia S/O Chronic sepsis, Neutrophilia-S/O bacterial Infection, Parasites.in Blood smear s/o Malaria. Exam.shold be in thick & thin smear Neutropenia,decreased platelets : May s/o Viral-Dengue. * Urine Exam : Pus cells & RBC S/O Pyelonephritis,Cystitis,Renal TB. . : . Stool Exam : for cysts of E.Histolytica, organisms of Typhoid and B.dysentery. Chest X-Ray : For TB,Pneumonia,Bronchiectasis, Fungal ball Actinomycosis,Pl.Eff. Lymphadenopathy in hilums. . : . Agglutination tests : For Typhoid: S. Widal- O, H, Para typhi A, Para –typhi B, How to Interprit-False positive, Better is tube test. For Brucellosis & Cold agglutination test for Viral pneumonia, Viral Hepatitis, Montoux test with PPD 10 TU.: negative Reaction excludes TB except in pt of Immuno compromised status. . : . * Serological test for Syphilis, * LE cell phenomena for SLE * Sputum Exam : For pus and culture for bacteria and fungus. * CSF exam for Meningitis-TB / Pyogenic . - Encephalitis. * Auto antibody test : RA factor for RA. * Antinuclear antibody : for Auto immune disease. . : . * Blood Culture:Typhoid,Paratyphoid, Septisemia,SBE,Brucellosis Leptosiposis,Histoplasmosis * ESR : Normal ESR excludesactive pul TB, Rh fever,Suppurative disease. Normal ESR with low grade long lasting fever may be Psychogenic fever. . : . USG Scanning : For any anomaly seen in abdominal visceras—Liver abscess, Hepatospleenomegaly, sub diaphragmatic abscess, Ascitis, mass- mets in any organ, retroperitoneal lesions,pelvic abscess. *CT/MRI/Isotop scanning: If anomaly seen in USG scanning. : * Bx of the lesion : Lymphnode,Liver,Kidney. Fluid exam. Of Eff.,Acsitis, All Bx material should sent : for HPE and Culture for Organism. . : . * Laparoscopy : for direct visual diagnosis & Bx. By frozen section Bx ,if arrived at Diagnosis at time of Laperoscopy –Curative Rx can be initiated at the same sitting. Treatment-Supportive : Treatment-Supportive Supportive Rx : Hydration : Oral/IV Dehydration produced by a mild fever can be more dangerous than the fever itself. Orally Water is generally used for this purpose because it is a universal solvent, but there is always a small risk of hyponatremia if the patient drinks too much water. For this reason, some patients drink sports drinks or electrolyte-replacing products designed specifically for this purpose. . : . Supportive Rx can be done by Two ways A) By lowering the hypothalamic set point: By- Antipyretics-Ibuprofen,PCM,Aspirin and acetaminophen. B) By Heat removal: by Cold sponging with wet cloth or pads, applied to the forehead,Over abdomen or through bathing the body in tepid water. Treatment-Specific : Treatment-Specific According to Organism/Parasites isolated Specific Treatment should be instituted as early as possible. EVEN AFTER GIVING OPTIMAL CUORSE Of Rx, If Pt is not responding- Think- PUO. WHEN TO REFER PT ? : WHEN TO REFER PT ? * FEVER WITH alterd VITAL DATAS & HYPOTENSION , * FEVER WITH OTHER PRE EXISTING - DISEASE LIKE HT,DM,IHD,Valvular Disease. * ALTERED SENSORIUM, HYPER PYREXIA. * NECK RIGIDITY,BREATHLESSNESS, WHEN TO REFER PT ? : WHEN TO REFER PT ? * BLEEDING GUMS/COAGULOPATHY, * SEPTISEMIA-Count <4000.>11000/Cmm. * CONVULSIONS,SEVERE ANAEMIA, * COMPLCATIONS WHICH NEEDS SURGICAL INTERVENTION. * PTs HAVING SPO2 less than 94 mm should reach to secondary center as early as possible. WHEN TO REFER PT ? : WHEN TO REFER PT ? * EVERY REGISTERED MEDICAL PRACTITIONER MUST HAVE Digital THERMOMETER & PULSE OXYMETER in THEIR O.P.D. Slide 71: HAVE A GOOD NIGHT!!! THANK YOU You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
PYREXIA pravinboza2005 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 759 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: June 07, 2009 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... By: Marwani (7 month(s) ago) Hallo, I am a lecturer. Can I download your presentation? I think your poresentation is very interesting. Thanks. Marwani (brtsptr@yahoo.com) Saving..... Post Reply Close Saving..... Edit Comment Close By: 01011984 (18 month(s) ago) it is wonderful can i download it plz Saving..... Post Reply Close Saving..... Edit Comment Close By: pkgfdk (29 month(s) ago) Dear Doctor, Hello! We seek your kind permission to download the PUO presentation to teach our students Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript FEVER (Pyrexia) : FEVER (Pyrexia) BY DR PRAVIN B.OZA (M.D.) Ashirvad Hospital, Radhanpur. Slide 2: WEL COME TO ALL OF YOU “Fever” is HOT-But not like “These” : “Fever” is HOT-But not like “These” Slide 4: IT IS LIKE “THIS” FEVER (Pyrexia) : FEVER (Pyrexia) Definition :- Fever (known as pyrexia, from the Greek pyretos meaning fire, or a febrile response, from the Latin word febris, meaning fever, is a frequent medical sign that describes an increase in internal body temperature to levels above normal. -- temporary elevation in the body's thermoregulatory set-point, usually by about 1–2 °C (1.8-3.6 °F). Definition : Definition Fever refers to an elevation in body temperature. Technically, any body temperature above -the normal oral measurement of 98.6 F (37 C) or -the normal rectal temperature of 99 F (37.2 C) is considered to be elevated. However, these are averages, and your normal temperature may actually be 1 F (0.6 C) or more above or below the average of 98.6 F. Body temperature can also vary up to 1 F (0.6 C) throughout the day. Definition (Cont.) : Definition (Cont.) A feverish individual has a general feeling of cold despite an increased body temperature, and increases in heart rate, muscle tone and shivering, all of which are caused by the body's attempts to counteract the newly-perceived hypothermia and reach the new thermoregulatory set-point Definition ( Cont.) : Definition ( Cont.) Fever differs from hyperthermia in that hyperthermia is an increase in body temperature over the body's thermoregulatory set-point, due to excessive heat production or insufficient thermoregulation, or both. A fever is considered one of the body's immune mechanisms to attempt a neutralization of a perceived threat inside the body, be it bacterial or viral. A fever is not a disease, but the body's response to a disease. MECHANISM : MECHANISM Temperature is regulated in the hypothalamus. A trigger of the fever, called a pyrogenin, causes a release of prostaglandin E2 (PGE2). PGE2 then in turn acts on the hypothalamus, which generates a systemic response back to the rest of the body, causing heat-creating effects to match a new temperature level. MECHANISM : MECHANISM PYROGENS : PYROGENS Substance that induces fever. 1, External (exogenous) The bacterial substance lipopolysaccharide (LPS), present in the cell wall of bacteria, Pyrogenicity can vary, as in extreme examples some bacterial pyrogens known as superantigens can cause rapid and dangerous fevers. PYROGENS : PYROGENS 2, INTERNAL-(ENDOGENOUS) :- * Cytokines (especially interleukin 1) part of the innate immune system, -produced by phagocytic cells, -causes the increase in the thermoregulatory set-point in the hypothalamus. * Interleukin 6 (IL-6), * Tumor necrosis factor-alpha ACTION OF PYROGENS : ACTION OF PYROGENS These cytokine factors are released into general circulation where they migrate to the circumventricular organs of the brain due to easier absorption caused by the blood-brain barrier's reduced filtration action there. The cytokine factors then bind with endothelial receptors on vessel walls, or interact with local microglial cells. When these cytokine factors bind, the arachidonic acid pathway is then activated ACTION OF PYROGENS : ACTION OF PYROGENS One model for the mechanism of fever caused by exogenous pyrogens includes LPS, which is a cell wall component of gram-negative bacteria. An immunological protein called lipopolysaccharide-binding protein (LBP) binds to LPS. The LBP–LPS complex then binds to the CD14 receptor of a nearby macrophage. This binding results in the synthesis and release of various endogenous cytokine factors, such as interleukin 1 (IL-1), interleukin 6 (IL-6), and the tumor necrosis factor-alpha. In other words, exogenous factors cause release of endogenous factors, which, in turn, activate the arachidonic acid pathway. PGE2 Release : PGE2 Release PGE2 release comes from the arachidonic acid pathway. This pathway (as it relates to fever), is mediated by the enzymes phospholipase A2 (PLA2), cyclooxygenase-2 (COX-2), and prostaglandin E2 synthase. These enzymes ultimately mediate the synthesis and release of PGE2 ACTION OF PYROGENS : ACTION OF PYROGENS PGE2 is the ultimate mediator of the febrile response. The set-point temperature of the body will remain elevated until PGE2 is no longer present. PGE2 acts on neurons--- In the preoptic area (POA) through the prostaglandin E receptor 3 (EP3). EP3-expressing neurons in the POA innervate the dorsomedial hypothalamus (DMH),and the paraventricular nucleus (PVN) of the hypothalamus Fever signals sent to the DMH lead to stimulation of the sympathetic output system, which evokes non-shivering thermogenesis to produce body heat and skin vasoconstriction to decrease heat loss from the body surface. ACTION OF PYROGENS : ACTION OF PYROGENS The brain ultimately starts heat effector mechanisms via the autonomic nervous system. These may be: Increased heat production by increased muscle tone, shivering and hormones like epinephrine. Prevention of heat loss, such as vasoconstriction. The autonomic nervous system may also activate brown adipose tissue to produce heat (non-exercise-associated thermogenesis, also known as non-shivering thermogenesis), Classification : Classification Fever classificationGrade *Low grade : 38–39°C, 100.4–102.2 °F *Moderate : 39–40°C, 102.2–104.0 °F *High-grade: 40–41.1°C, 104.0–106.0 °F *Hyperpyrexia : >41.1°C, >106.0 °F The last is a medical emergency because it approaches the upper limit compatible with human life. If the temperature is taken by another route (mouth, ear, armpit), then the reading needs to be converted to the equivalent core body temperature. Variations in normal body Temp. : Variations in normal body Temp. These variations in normal body temperature, are to be considered when measuring for fever. The values given are for an otherwise non-fasting adult, dressed comfortably, indoors, in a room that is kept at a normal room temperature (27 C), during the morning, but not shortly after arising from sleep. Furthermore, for oral temperatures, the subject must not have eaten, drunk, or smoked anything in at least the previous fifteen to twenty minutes. Variations : Variations Body temperature normally fluctuates over the day, with the lowest levels around 4 a.m. and the highest around 6 p.m.. Therefore, an oral temperature of 37.2 °C (99.0 °F) would strictly be a fever in the morning, but not in the afternoon. An oral body temperature reading up to 37.5 °C (99.5 °F) in the early/late afternoon or early/late evening also wouldn't be a fever. Variations : Variations Normal body temperature may differ as much as 1 °F (0.6 °C) between individuals or from day to day. In women, temperature differs at various points in the menstrual cycle. Temperature is increased after eating, and psychological factors also influence body temperature How should I take a temperature for fever? : How should I take a temperature for fever? Digital thermometers can be used to measure rectal, oral, or axillary (under the armpit) temperatures. The American Academy of Pediatrics does not recommend use of mercury thermometers (glass), and they encourage parents to remove mercury thermometers from their households to prevent accidental exposure to this toxin. Routine Analouge Mercury Thermometer : Routine Analouge Mercury Thermometer Digital Thermometer : Digital Thermometer * Axillary : Axillary Measuring an axillary (under the armpit) temperature for fever: Axillary temperatures are not as accurate as rectal or oral measurements, and these generally measure one degree lower than a simultaneously obtained oral temperature. Place the tip of the digital thermometer in armpit. Leave in place about one minute or until you hear a beep to check a digital reading. Measuring fever by eardrum temperature : Measuring fever by eardrum temperature Tympanic (ear) thermometers must be placed correctly in your external ear to be accurate. Too much earwax can cause the reading to be incorrect. Eardrum temperature measurements are not accurate in small children and should not be used in children under 3 years (36 months) of age. This is especially true in infants below 3 months of age when obtaining an accurate temperature is very important. Oral Measurement : Oral Measurement Children of age more then 4 to 5 years and adults can have their temperature taken with a digital thermometer under the tongue with their mouth closed. Clean the thermometer with soapy water or rubbing alcohol and rinse. Turn the thermometer on and place the tip of the thermometer as far back under the tongue as possible. The thermometer should remain in place for about one minute or until you hear the beep. Check the digital reading. Avoid hot or cold drinks within 15 minutes of oral temperature measurement to ensure correct readings. Measuring Rectal Temp : Measuring Rectal Temp This method is recommended in children under 3 years, as this gives the most accurate reading of core temperature. Clean the thermometer with soapy water or rubbing alcohol and rinse with cool water. Use a small amount of lubricant, such as petroleum jelly, on the end. Place the child prone (belly-side down) on a firm surface, or place your child face up and bend his legs to his chest. After separating the buttocks, insert the thermometer approximately ½ to 1 inch into the rectum. Do not inset it too far. Hold the thermometer in place, loosely keeping your hand cupped around your child's bottom, and keep your fingers on the thermometer to avoid it accidently sliding further into the rectum. Keep it there for about one minute, until you hear the beep. Remove the thermometer, and check the digital reading. Label the rectal thermometer so it's not accidentally used in the mouth. A rectal temperature will read approximately one degree higher than a simultaneously obtained oral temperature. Patterns of Fever : Patterns of Fever Intermittent fever: Elevated temperature is present only for some hours of the day and becomes normal for remaining hours, e.g. malaria, kala-azar, pyaemia, or septicemia. In malaria, there may be a fever with a periodicity of 24 hours (quotidian), 48 hours (tertian fever), or 72 hours (quartan fever, indicating Plasmodium malariae). Patterns of Fever : Patterns of Fever Continuous fever: Temperature remains above normal throughout the day and does not fluctuate more than 1 °C in 24 hours, e.g. lobar pneumonia, typhoid, urinary tract infection, brucellosis, or typhus. Typhoid fever may show a specific fever pattern, with a slow stepwise increase and a high plateau. (Step ladder pattern) Patterns of Fever : Patterns of Fever Remittent fever: Temperature remains above normal throughout the day and fluctuates more than 1 °C in 24 hours, e.g. infective endocarditis. * Pel-Ebstein fever: A specific kind of fever associated with Hodgkin's lymphoma, being high for one week and low for the next week and so on. CAUSES-Infections : CAUSES-Infections A) SPECIFIC : Bacterial:-Tubercolosis,Typhoid-Para typhoid, Pneumonia,E.coli,Brucellosis,Septisemia-Pyemias,Bacterial endocarditis. Viral :- Influenza,Viral encephelitis, Inf.Mononeucleosis ,Psittacosis. Fungal:- Actinomycosis,Histoplasmosis. CAUSES-Infections : CAUSES-Infections Protozoal:- Amoebiasis,malaria,Kala-azar, Toxoplasma,Schistosomiasis,Trypanosomiasis. Spirochetal:-Syphilis,Rat bite fever B) Local septic Infections with pus formation: Sinusitis,mastoiditis,tonsillar /dental abscesses,suppurating glands,mammary abscess,parotid abscess,pyo salpinx,and parametritis,hepatic abscess,cholecystitis, pyonephrosis,lung abscess,bronchiectasis, appendicular abscess. CAUSES-Infections : CAUSES-Infections C) Local Infection without pus formation: Cystitis,Phlebitis,Inflammed piles, ulcerative colitis,regional enteritis, diverticulitis. CAUSES-NonInfectious : CAUSES-NonInfectious 1) Neoplasms:- Hodgekins and other lymphomas,hypernephromas,hepatoma,atrial myxomas. 2) Blood diseases:- Leukemias, agranulocytosis, hemolytic episodes. 3) Collagen disease:-Rheumatic fever, Rheumatoid arthritis,polyarteritis nodosa,erythema nodosum , SLE. CAUSES : CAUSES Infectious disease, e.g. influenza, common cold, HIV, malaria,thyphoids, infectious mononucleosis, or gastroenteritis Various skin inflammations, e.g. boils, pimples, acne, or abscess Immunological diseases, e.g. lupus erythematosus, sarcoidosis, inflammatory bowel diseases Tissue destruction, which can occur in hemolysis, surgery, infarction, crush syndrome, rhabdomyolysis, cerebral hemorrhage, etc. CAUSES : CAUSES Drug fever directly caused by the drug, e.g.sulphonamides,atropines,salicylates ,phenytoine methyl dopa,INH,Iodine, progesterone, or chemotherapeutics causing tumor necrosis as an adverse reaction to drugs, e.g. antibiotics or sulfa drugs. after drug discontinuation, e.g. heroin ,morphin or fentanyl withdrawal Reaction to incompatible blood products Cancers, most commonly renal cancer and leukemia and lymphomas CAUSES : CAUSES Metabolic disorders, e.g. gout or porphyria Thrombo-embolic processes, e.g. pulmonary embolism or deep venous thrombosis Persistent fever which cannot be explained after repeated routine clinical inquiries, is called fever of unknown origin How will you Investigate ? : How will you Investigate ? By History-Symptoms By Clinical Examination By Investigations. By History : By History Onset:- * Sudden- in Influenza, malaria ,pneumonia and Pyelitis . * Gradual- inTyphoid,Tuberculosis,SBE, & Brucellosis. Rigors:- Malaria,filariasis,empyema, pyelitis ,cholangitis,liver abscess and appendicular abscess, septisemia. * : * 3) Headache : Meningitis.Typhoid at onset encephelitis, 4) Bodyache : Influenza,dengue,small pox secondary syphilis,brucellosis and rat bite fever. 5) Sweating : Malaria,Pul. Or Milliary TB, Influenza,Rh.Fever,brucellosis amoebic hepatitis /abscess * : * 6) Convulsion : Cerebral malaria,encephilitis, Meningitis,Apical Pneumonia. 7) Delirium : Typhoid,Pneumonia,Meningitis, Septisemia,Plague. * : * 8) Loss of weight : TB,Chronic suppurative disease like empyema or lung abscess. 9) Diarrhoea : Algid malaria,Typhoid,paratyphoid,Thyro- toxicosis,regional ileitis,ulcerative colitis, TB enterocolitis and chronic dysentery. * : * 10) Vomiting : Malaria,meningitis,appendicitis, pyelonephritis. 11) Sore throat : Diptheria,Sec.Syphilis, leukemia, agranulocytosis. 12) Frequency of micturition : Pyelonephritis,cystitis,Koch’s urogenitals PAST HISTORY : PAST HISTORY Of Rh.fever,or valvular disease, TB lymphadenitis,or pleural effusion, Rat bite,syphilis or filariasis. PERSONAL HISTORY : PERSONAL HISTORY Residence of endemic area in Kala azar,Malaria,Amoebiasis. Mediterranean fever and trypanosomiasis. Occupational History In Weil’s disease, H/O Infection in other family members. Contacts with domestic or wild animals Or birds * : * Contacts with domestic or wild animals Or birds such infections can be --Brucellosos ( Cattle), --Psittacosis(birds) --Leptospirosis (rats,dogs and pigs) --Salmonellosis(ducks,rats,tortoises) Contacts with persons with TB * : * H/O Administration of drugs or serum. H/O Prior surgery or trauma. General Examination : General Examination Pattern of Fever-As discussed earlier. Pulse rate: Relative bradycardia in Typhoid,Meningitis,Influenza,dengue Respiration: Increased much much rate in Respiratory disease—Pneumonia, broncho-pneumonia,Pul.Koch’s,Pl.Eff., empyema,Milliary TB,Pul.Infacrtion. General Examination. : General Examination. 4) Anaemia: Malaria,Liver abscess,SBE, chronic sepsis. 5) Lymphadenopathy: Generalised: in TB, Sec.Syphilis, Hodgkins, leukemia, Localised : in plague,rat bite fever, glandar fever, lymphogranuloma inguinale. 6)Jaundice: in infective hepatitis,malaria, liver - abscess,cholecystitis,cholangitis. General Examination. : General Examination. 7) Skin: Rash-meningococcal meningitis, dengue, viral fevers, 8) Clubbing: Bronchiectasis,lung abscess, chronic empyema,SBE, liver- abscess. 9) Arthritis: Rh.fever,SBE,brucellosis,gout, leukemia,SLE, Poliarteritis – nodosa. General Examination. : General Examination. 10) Herpes labialis: in pneumococcal, meningococcal or streptococcal infection, Malaria. 11) Nodules: in Rh fever, Rheumatoid artritis,polyarteritis nodosa, cystecercosis. 12) Neck rigidity : Meningitis,Meningism. Systemic Examination : Systemic Examination 1) ENT : for focal sepsis in tonsils,teeths, quincy,sepsis in naso pharynx. 2) Abdomen: Spleenomegaly-Malaria,Hodgkins,typhoid, SBE, Hepatomegaly-Liver abscess,Cholecystitis, malaria,leukemia,Mets in liver. . : . Ascitis-TB peritonitis. Localising signs-Appendicular abscess, Cholecystitis,colitis, diverticulitis,perinephric sub phrenic abscess, salpingitis, Testicles: Epididimo orchitis,,TB,Teratoma . : . 3) Heart : Pericarditis,SBE, 4) Lungs : Pneumonia,Lung abscess, Pl eff.,TB,bronchiectasis, Actinomycosis. 5) Head & Neck :Sinusitis,OM, mastoidtis diptheria,tonsills,meningitis, brain abscess and Encephilitis. . : . 6) Limbs : Phlebitis ,Osteomyelitis,cellulitis, elephentiasis,polyneuritis, 7) Rectum: for missed appendicular abscess 8) External genitals: for sepsis/neoplasm 9) Fundus(Eye): for choroidal TB. LAB Invetigations : LAB Invetigations * Haemogram: Normochromic normocytic anaemia S/O Chronic sepsis, Neutrophilia-S/O bacterial Infection, Parasites.in Blood smear s/o Malaria. Exam.shold be in thick & thin smear Neutropenia,decreased platelets : May s/o Viral-Dengue. * Urine Exam : Pus cells & RBC S/O Pyelonephritis,Cystitis,Renal TB. . : . Stool Exam : for cysts of E.Histolytica, organisms of Typhoid and B.dysentery. Chest X-Ray : For TB,Pneumonia,Bronchiectasis, Fungal ball Actinomycosis,Pl.Eff. Lymphadenopathy in hilums. . : . Agglutination tests : For Typhoid: S. Widal- O, H, Para typhi A, Para –typhi B, How to Interprit-False positive, Better is tube test. For Brucellosis & Cold agglutination test for Viral pneumonia, Viral Hepatitis, Montoux test with PPD 10 TU.: negative Reaction excludes TB except in pt of Immuno compromised status. . : . * Serological test for Syphilis, * LE cell phenomena for SLE * Sputum Exam : For pus and culture for bacteria and fungus. * CSF exam for Meningitis-TB / Pyogenic . - Encephalitis. * Auto antibody test : RA factor for RA. * Antinuclear antibody : for Auto immune disease. . : . * Blood Culture:Typhoid,Paratyphoid, Septisemia,SBE,Brucellosis Leptosiposis,Histoplasmosis * ESR : Normal ESR excludesactive pul TB, Rh fever,Suppurative disease. Normal ESR with low grade long lasting fever may be Psychogenic fever. . : . USG Scanning : For any anomaly seen in abdominal visceras—Liver abscess, Hepatospleenomegaly, sub diaphragmatic abscess, Ascitis, mass- mets in any organ, retroperitoneal lesions,pelvic abscess. *CT/MRI/Isotop scanning: If anomaly seen in USG scanning. : * Bx of the lesion : Lymphnode,Liver,Kidney. Fluid exam. Of Eff.,Acsitis, All Bx material should sent : for HPE and Culture for Organism. . : . * Laparoscopy : for direct visual diagnosis & Bx. By frozen section Bx ,if arrived at Diagnosis at time of Laperoscopy –Curative Rx can be initiated at the same sitting. Treatment-Supportive : Treatment-Supportive Supportive Rx : Hydration : Oral/IV Dehydration produced by a mild fever can be more dangerous than the fever itself. Orally Water is generally used for this purpose because it is a universal solvent, but there is always a small risk of hyponatremia if the patient drinks too much water. For this reason, some patients drink sports drinks or electrolyte-replacing products designed specifically for this purpose. . : . Supportive Rx can be done by Two ways A) By lowering the hypothalamic set point: By- Antipyretics-Ibuprofen,PCM,Aspirin and acetaminophen. B) By Heat removal: by Cold sponging with wet cloth or pads, applied to the forehead,Over abdomen or through bathing the body in tepid water. Treatment-Specific : Treatment-Specific According to Organism/Parasites isolated Specific Treatment should be instituted as early as possible. EVEN AFTER GIVING OPTIMAL CUORSE Of Rx, If Pt is not responding- Think- PUO. WHEN TO REFER PT ? : WHEN TO REFER PT ? * FEVER WITH alterd VITAL DATAS & HYPOTENSION , * FEVER WITH OTHER PRE EXISTING - DISEASE LIKE HT,DM,IHD,Valvular Disease. * ALTERED SENSORIUM, HYPER PYREXIA. * NECK RIGIDITY,BREATHLESSNESS, WHEN TO REFER PT ? : WHEN TO REFER PT ? * BLEEDING GUMS/COAGULOPATHY, * SEPTISEMIA-Count <4000.>11000/Cmm. * CONVULSIONS,SEVERE ANAEMIA, * COMPLCATIONS WHICH NEEDS SURGICAL INTERVENTION. * PTs HAVING SPO2 less than 94 mm should reach to secondary center as early as possible. WHEN TO REFER PT ? : WHEN TO REFER PT ? * EVERY REGISTERED MEDICAL PRACTITIONER MUST HAVE Digital THERMOMETER & PULSE OXYMETER in THEIR O.P.D. Slide 71: HAVE A GOOD NIGHT!!! THANK YOU