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01/02/2017

DIAGNOSTIC INFECTION DISEASES

RIYANI SUSAN BT. HASAN, dr, MKT


Medical Faculty Prima Indonesia
Thursday, 2 February 2017 PDPI FEB'17 (SS) 1 PDPI FEB'17 (SS) 2

CLINICAL APPROACH HISTORY

• A comprehensive history is key to determining


HISTORY aetiology of fever
• Include:
• When did the fever begin ?
• Where and what exposures may have taken place?
EXAMINATIONS • A sexual history is also vital.
• Incubation periods of infection.
• Exposure to risk factors, such as : insect bites or
INITIAL other contacts. For example :
• Water and soil contact  Leptospirosis,
INVESTIGATION • Contact with rivers & freshwater lakes in Africa 
Schistosomiasis (Katayama fever).
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HISTORY HISTORY

• Important symptoms are headache, • The pattern of fever is rarely helpful in making a
photophobia, cough, sputum, pleurisy, localized diagnosis in practice.
pain, diarrhoea (especially if bloody) and urinary • Older children will give a history in the same way
symptoms. as adults.
• Coryza and upper respiratory symptoms generally • For infants and babies, enquiry should be made
suggest a viral illness. about feeding, weight gain, general activity and
• Prior treatment with antibiotics may make the health of the parents.
diagnosis difficult.
• Recent travel (within 3 weeks) to high-risk
countries should always raise the possibility of
viral haemorrhagic fever.
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EXAMINATION EXAMINATION

• A temperature >38.0°C is clinically significant. • A full clinical examination should be undertaken.


• Spontaneous haemorrhage suggests a viral
• A pulse rate >100 or <60 or systolic blood pressure haemorrhagic fever.
<100 mmHg in an adult  Seriously ill and • The eyes should be inspected for anaemia, icteric,
conjunctival injection (measles and leptospirosis).
needs urgent physiological support and empirical • Psychosis may be a manifestation of typhoid.
treatment.
• The mouth should be examined for candidiasis (HIV
• Conscious level, orientation and neck infection), Koplik’s spots (measles) and pharyngitis.
stiffness need to be assessed. • The tympanic membranes of all young children
should be inspected, but only in adults if there are
relevant symptoms.

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EXAMINATION EXAMINATION

• Cervical and axillary lymphadenopathy should be • The chest and heart require examination for signs of
sought (pharyngitis, HIV, cytomegalovirus [CMV], Epstein–Barr consolidation (pneumonia often fails to give respiratory
virus [EBV], tuberculosis, lymphoma, toxoplasmosis, syphilis)
symptoms), pleural or pericardial effusion
and also occipital lymphadenopathy (rubella and
(tuberculosis, HIV, empyema) and heart murmurs
trypanosomiasis).
(bacterial endocarditis, rheumatic heart disease).
• The skin should be carefully inspected for rash (viral
• In infants and babies a raised respiratory rate may be
exanthems, non-blanching meningococcal petechiae), an
the only evidence of pneumonia.
eschar (tick-borne rickettsial infection) or anaesthetic
patches with pigmentary change (leprosy). • Abdominal tenderness and peritonism should be
sought (appendicitis, peritonitis, pelvic inflammatory disease).
• Severe skin and soft tissue infections (usually
• Localized right lower intercostal tenderness suggests
streptococcal or staphylococcal) are common causes of fever.
amoebic liver abscess.
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EXAMINATION INITIAL INVESTIGATION

• Hepatomegaly (Important Sign)  Malaria, • Where facilities are available, measurement of


tuberculosis, hepatitis, schistosomiasis, hepatoma, urea and electrolytes (renal failure in sepsis
amoebic liver abscess syndromes, shock, severe malaria, leptospirosis,
haemolytic uraemic syndrome; hyponatraemia in
• Splenomegaly (Important Sign)  Malaria, typhoid, tuberculosis), liver function tests (viral hepatitis)
leishmaniasis, HIV, infectious mononucleosis, lymphoma and C-reactive protein (CRP) are helpful.
and leukaemia, portal hypertension, brucellosis, • Lumbar puncture is necessary if symptoms and
disseminated tuberculosis signs suggest meningitis.
• Ascites and Tapping pain  Important sign • CT scan is only indicated if there are :
• Recent onset seizures,
• Focal neurology,
• Significantly depressed Glasgow Coma Score (<8),
• Papilloedema,
• immunosuppression status (e.g. by HIV)

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INITIAL INVESTIGATION INITIAL INVESTIGATION

• Genital swabs for microscopy and culture should be taken


if sexually transmitted infection is suspected;
• Syphilis serology is also relevant, especially with a rash
extending to the palms and soles.

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(Flu Singapura)

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