Professional Documents
Culture Documents
August and
09, 2010
conservation
FEVER
- most common complaint; usually self-managed; not always due to
infection
- a state of elevated core temperature, which is often, but not
necessarily, part of the defensive responses of the multicellular
organism (host) to the invasion of the live microorganisms or inanimate
matter recognized as pathogenic or alien by the host (from the
International Union of Physiological Sciences Commission for Thermal
Physiology, 2001)
- elevation of the body temperature above the normal circadian range in
response to a new temperature set point that has been established in
the thermoregulatory center located in the hypothalamus
- inc. Hypothalamic set point activation of vasomotor center
vasoconstriction (shunting of blood from the periphery to the internal
organs) dec heat loss from skin person feels cold shivering
or non shivering heat production temp of blood surrounding
hypothalamus = new set point continuous febrile state dec. in
pyrogen conc. Or antipyretics downward reset of hypothalamic set
point
- hyperprexia
Heat stroke
o caused by thermoregulatory failure in association with a
warm environment
o can be terminal or can be secondary terminal
Exertional
o caused by exercise in higher-than-normal heat and/or
humidity
o can also be precipitated by dehydration or OTC
antihistamines with anticholinergic side effects
Nonexertional
o occurs in high heat or humidity in patients taking
anticholinergics (including antihistamines);
antiparkinsonian drugs; diuretics; phenothiazines
FEBRILE RESPONSE
- complex physiologic reaction to disease, involving not only cytokinemediated rise in core temperature but also the generation of acute
phase reactants, and the activation of numerous physiologic,
endocrinologic and immunologic systems (tachycardia, tachypnea,
hypotension, oliguria)
- Physiologic means that aside from a high temperature, you would
expect your patients to have competitor response= Heart rate,
respiratory rate, basal metabolic rate.
2.
Drug-induced
o caused by drugs such as MAO inhibitors, tricyclic
antidepressants, amphetamines, cocaine,
phencyclidine, LSD, sallicylates, lithium
o can increase heart rate, and basal metabolic rate
3.
4.
Malignant hyperthermia
o systemic response to halothane and other inhalational
anesthetics in patients with genetic abnormality (in
skeletal muscle sarcoplasmic reticulum)
o increased intracellular Calcium -> increased muscle
rigidity -> increased thrombogenesis
o also in post-operative patients
o patients prone to develop CV instability and acidosis
5.
Serotonin syndrome
o caused by selective serotonin reuptake inhibitors,
monoamine oxidase inhibitors, tricyclic antidepressants
o additional symptoms: diarrhea, tremor, myoclonus
prostaglandin E2
o in CNS: raises hypothalamic set point
o in peripheral tissues: causes myalgia, arthralgia
Fever results when exogenous pyrogens (bacteria, viruses, fungi, other
microorganisms, allergens, etc.) or pyrogenic factors (immune
complex, lymphokines from sensitized lymphocytes, etc.) encounter
circulating monocytes and monocyte-derived tissue macrophages, the
major sources of biologically defined endogenous pyrogens.
Endogenous pyrogens increase prostaglandin synthesis, which
stimulates the thermostat center, thereby elevating the set point.
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6.
7.
Endocrinopathy
o caused by thyrotoxicosis, pheochromocytoma
o increased basal metabolic rate
CNS Damage
o caused by cerebral hemorrhage,
epilepticus, hypothalamic injury
status
FEVER VS HYPERTHERMIA
status of patient
check responsiveness and coherence
if not coherent: severe infection
check vital signs (BP, HR, RR, temp)
ask when the last urination was. monitor urine
output.
check other signs that would suggest an
infection.
headache: CNS infection
cough (productive) then fever:
bacterial pneumonia
fever then cough: viral flu
dry cough: influenza
rashes: dengue
2.
3.
Anatomic variability:
Physiologic variability:
mean oral temp for healthy people
aged 18-40 y/o = 36.8 +/- 0.4 C
lowest at 6am = 37.2 C
dietary proclivities
household pets
sexual orientation and practices include
precautions taken/not taken
use of tobacco, marijuana, IV drugs, alcohol
drug allergies and hypersensitivities
season of the year
Physical Examination
-
general appearance
vital signs
signs of toxicity
focus of infection
skin lesions
presence and location of adenopathy
presence and morphology of genital, mucosal, or
conjunctival lesions
detection of hepatosplenomegaly (malaria)
presence of arthritis
signs of nuchal rigidity, meningismus or neurologic
dysfunction
rectal exam imperative
penis, prostate, scrotum, testes for males
pelvic exam part of complete PE of females
Laboratory Tests
2. chronology of symptoms
If fever comes first before dry cough along with
muscle pain, and joint pains, there is viral flu
If non productive cough occurred first then after 2
days becomes productive with chest pain then it is a
bacterial infection like pneumonia
3. antecedent events and precipitating factors
underlying medical illness (eg. valvular heat
disease, COPD, diabetes)
surgical and dental procedures
previous or recent hospitalizations
prescription drugs, supplements, herbs taken
without physicians supervision
factors affecting immunologic status (eg, cancer)
travel and residential history include locations
during military service; travel to Palawan:
consider malaria
occupational history exposure to animals; toxic
fumes; potential sinfectious agents; possible
antigens; febrile or infected individuals in the
home, workplace, school
immunizations flu shot: llocal soreness at
injection site + low-grade fever
STD exposure
family history and ethnicity
unusual hobbies
4. Neuromuscular blockers
1. Fever
oral aspirin, acetaminophen (preferred) , NSAIDs
glucocorticoids
2. Hyperthermia
physical cooling with the use of sponging, cooling
blankets, fans, ice baths
administration of IV fluids etc
gastric or peritoneal lavage w/ iced saline
for malignant cases: dantrolene, procainamide,
bromocriptine, levodopa, amantidine, nifedipine
for muscle paralysis: curare and pancuronium
HYPOTHERMIA
-
RISK FACTORS
A. Age extremes
Elderly and neonates are vulnerable to
hypothermia
1. Elderly
- diminished thermal perception
- more susceptible to immobility, malnutrition &
systemic illnesses that interfere with heat generation
or conservation
2. Neonates
- high rates of heat loss due to their increased surfaceto-mass ratio
- lack of effective shivering & adaptive behavioral
responses
B. Environmental exposure
- Occupational
- Sports related
- Inadequate clothing
- Immersion
C. Drugs and intoxication
1. Ethanol
causes vasodilation, which increases heat loss,
reduces thermogenesis & gluconeogenesis and
may impair judgement or lead to obtundation
2. Phenothiazines, barbiturates, benzodiazepines, cyclic
antidepressants
Reduce centrally mediated vasoconstriction
3. Anesthetics
Can block shivering responses
D. Endocrine related
1. Hypothyroidism
particularly when extreme (myxedema coma)
reduces metabolic rate & impairs thermogenesis
and behavioral responses
2. Adrenal insufficiency & hypopituitarism
Increase susceptibility to hypothermia
3. Hypoglycemia
Most commonly caused by insulin or other
hypoglycemics
Result of neuroglycopenic effects on
hypothalamic function
4. Uremia, diabetic ketoacidosis & lactic acidosis
Can lead to altered hypothalamic regulation
E. Neurologic-related
1. Trauma, cerebrovascular accident (ex. Stroke),
subarachnoid hemorrhage or hypothalamic lesions
increases susceptibility to hypothermia
2. Agenesis of corpus callosum, Shapiro syndrome
cause of episodic hypothermia
characterized by profuse perspiration followed by
rapid fall in temperature
3. Acute spinal cord injury
disrupts autonomic pathways that lead to
shivering
prevents cold-induced reflex vasoconstrictive
responses
4. Parkinsons disease
F. Multisystem
1. Malnutrition, Trauma
2. Sepsis
3. Shock
4. Hepatic or renal failure
Decreased glycogen stores & gluconeogenesis
Diminished shivering responses
5. Acute myocardial infarction
low cardiac output
G. Burns, psoriasis, erythrodermas, & exfoliative dermatologic
disorders
increased peripheral blood flow
excessive heat loss
H. Immobility or debilitation
THERMOREGULATION
Preoptic anterior hypothalamus
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handles thermoregulation
B. Active
- for moderate (28-32C)
- necessary under the following conditions:
cardiovascular instability, age extremes, CNS
dysfunction, endocrine insufficiency, or any suspicion
of secondary hypothermia
1. External
Best accomplished with forced-air heating
blankets
Prevent use of electric blankets
Radiant heat sources / hot packs
2. Core
- Airway rewarming with heated humidified
oxygen (40C - 45C) via mask or endotracheal
tube
C. Intensive
- For intense (<28C)
- Use extracorporeal blood rewarming techniques
TREATMENT
A. CV stabilization
Achieving a mean arterial pressure of at least
60mmHg should be an early objective
Perfusion of vasoconstricted CV system with low
dose IV nitroglycerin
Monitoring of atrial arrythmias
B. Endocrine balance
Look for clues of hypothyroidism
If myxedema is the cause, Achilles tendon reflex is
prolonged more than the contraction phase
C. Empiric antimicrobial therapy
If infection is identified as the cause
D. Preventive measures
Layered clothing
Adequate shelter
Increased caloric intake
Avoidance of ethanol
Immediate diagnosis
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Physical Examination
Salient features:
1. Type of rash
Macule flat, raised, erythematous, <5mm
Papule raised, <5mm
Plaque plateau-like, raised, irregular borders, >5mm
Nodule - round
Wheal-erythematous
Vesicle- round, w/ fluid inside
Bulla- larger than vesicle, w/ fluid inside
Pustule w/ pus
Purpura: Palpable vs Non-palpable
Ulcer w/ concavity
Eschar necrotic center; in bed sores
2. Configuration
3. Arrangement diffuse or localized
4. Distribution
IMPORTANT CAVEATS
- The presence of rash may indicate a life-threatening or a
highly contagious disease.
- Different types of rashes may co-exist in one clinical
condition.
EXAMPLES
1. Centrally distributed maculopapular eruptions
most common type of eruption
primarily truncal
examples
rashes due to measles vs German measles
* Both have maculopapular rashes but the
rashes do not coalesce in German
measles
erythema infectiosum
caused
by
Human
Parvovirus B19
slapped cheeks appearance
with perioral pallor
Exanthem subitum
Caused
by
Human
herpesvirus 6
Rose-pink macules and
papules that rarely coalesce
drug-induced eruptions
2. Peripheral eruptions
prominent peripherally or begin in peripheral or
acral areas
examples
Meningococcemia, disseminated gonococcal
infection
Rocky Mountain Spotted Fever prominent in
wrist, hand, dorsum
Secondary syphilis- on palms, soles
Hand, Foot, and Mouth Disease (HFMD)
Erythema multiforme, usually drug-induced
hyperpigmentd on center
3. Confluent desquamative erythemas
diffuse erythema followed by desquamation
examples
Toxin-mediated syndromes
Staphylococcus aureus
Group A Streptococcus
Toxic Epidermal Necrolysis (TEN), StevensJohnson Syndrome (SJS)
4. Vesicobullous eruptions
could suggest a highly contagious condition
examples
Varicella
Prominent on the trunk
Pseudomonas (pruritic appearance)
Prominent
on
regions
occluded by bathing suits
Variola (small pox)
Prominent on the face and
extremities
Herpes Simplex Virus
HSV1: oral
HSV2: genital
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Dengue fever
5. Urticarial Eruptions
typically look like hives
usually due to a hypersensitivity reaction to a drug
without associated fever
lasts up to 5 days
examples
Drug-induced urticaria
Urticarial vasulitis
6. Nodular eruptions
suggestive of widespread infection in
immunocompromised hosts
examples
Erythema nodosum (septal panniculitis)
Sweets syndrome with concomitant
vesiculobulbar eruptions
Disseminated infection
7. Purpuric eruptions
occurs prominently in the distal areas or
extremities
examples
Meningococcemia
SUMMARY
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