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Approach to fever:Management

Approach to fever:Management

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Published by drbhaskar
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Approach to short fever- Management
Management [investigations and treatment]of a patient with short fever depends on a good history taking and clinical examination to identify features of localization. In this document I have discussed the approach to management of a patient with short fever with no localizing signs. Approach to history and clinical examination in a patient with short fever has been discussed in the previous document. It is preferable to read that first since certain explana
1

Approach to short fever- Management
Management [investigations and treatment]of a patient with short fever depends on a good history taking and clinical examination to identify features of localization. In this document I have discussed the approach to management of a patient with short fever with no localizing signs. Approach to history and clinical examination in a patient with short fever has been discussed in the previous document. It is preferable to read that first since certain explana

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Published by: drbhaskar on May 09, 2010
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06/09/2013

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Approach to short fever- Management
Management [investigations and treatment]of a patient with shortfever depends on a good history taking and clinical examination to identify features of localization.
In this
 
document I have discussed the approach to management of apatient with short fever with no localizing signs.
Approach to history and clinicalexamination in a patient with short fever has been discussed in the previous document. Itis preferable to read that first since certain explanations in this document are continuouswith the previous one.When a clinician faces a patient suffering from a short fever with nolocalizing signs many questions will arise in his mind.1. What could be the possible cause for this patients fever?2. Should I do any investigations in him.3. Should empirical therapy be started pending investigations.4. What should be the empirical drugs5. Should I admit the patient.……..and so on.I would like to explain the approach in two settings. First , in asetting where reasonable investigations are available. Second , in a resource poor setting. 
 
 
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In a patient with short fever with no localization, investigation inany form is not required in the first 3-4 days of illness in the absence of significant co-morbid conditions like diabetes, cardiac illness, renal disease , liver disease, old age ,etc.If the illness does not resolve within 4 days then the basic investigations will bea. Hb%, PCV, Total count, platelet count. b. Urine routinec. RBSd. creatininee. CPK-Totalf. Smear for malarial parasiteg. Blood cultureh. AST and ALTOther investigations like ultrasound of abdomen, complete liver function tests , QBC rather than conventional smear for malaria are optional.Routine CXR in the absence of clinical findings or comorbidillness is not required. Similarly tests like Widal , Ig M ELISA for Dengue , IgM ELISAfor Leptospirosis, other antibody based test are not indicated due to doubts in the validityof these tests .
The following are the findings in the initial investigations which may point towardsa particular etiology.
 
Dengue
- Increased Hb% and PCV , thrombocytopenia and polyserositis[ pleuraleffusion, ascites] are diagnostic for dengue .Deranged liver functions can also occur butare not specific for dengue. Often IgM ELISA for dengue is requested by clinicians as aroutine in any patient with fever. I will discourage this practice since the tests identifiesantibodies to dengue in the patients serum and does not identify the viral antigen. In a patient who has all the above mentioned clinical/ lab features, a negative IgM does not
 
 
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negate the diagnosis. On the other hand if none of the clinical/ lab features of dengue are present in a patient but IgM for dengue is positive it does not indicate a diagnosis of dengue. The reason is very simple . These tests were standardized using patients whohave high clinical probability of dengue and the false positivity of these tests in other febrile or non-febrile illness is not known.
Malaria
Anemia, thrombocytopenia, elevated creatinine and deranged liver functions[ hemolytic, hepatitic and cholestatic pattern can occur] may suggest malaria. However, parasite identification is the definitive indicator of malarial infection. QBC has a better yield than smear in identifying the parasite especially among less experienced lab personnel.Tests identifying plasmodium lactate dehydrogenase [ OPTIMAL] can also beused to identify malarial infection. This latter test is probably of more value in centreswhere lab personnel are not experienced to identify the parasites in peripheral blood.Further, parasite may escape detection in patients with complicated malaria due to a phenomenon called visceral pooling. This occurs due to sequestration of malarial parasites [ often falciparum species] in viscera like liver, spleen, renal and cerebral bloodvessels. Hence patients have all lab features of complicated malaria except the parasite in blood .
Leptospirosis
- Increased CPK-Total, elevated creatinine and deranged LFT may suugestleptospirosis. Clinicians should have high suspicion for leptospirosis during monsoons.However all these investigations can be normal in anicteric leptospirosis. IgM for leptospirosis is also not advisable for the same reason as explained for dengue. In other words these IgM ELISA tests results should be interpreted taking the pre-test probabilityof the disease into consideration.

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