Approach To A Patient With Fever?: 1 DR - Shamol /inter/fever

Approach to a patient with fever?
If patient comes with First exclude fever or pseudo fever (feverish sensation temp< 100)
fever Then look for any red flag sign present or not
Next –duration if less than 5 to 7days ---think it viral if not red
flag sign
If more than5 to 7days exclude enteric fever
If a patient comes with fever first you categorized in following

Duration less than 5 to 7 days
More than 7 day --
For months or more
Grade High grade Temp >104
Medium grade temp 02- 103
Low grade Temp < l02
Endemic Dhaka Dengue / chikungynya
zone Hilly tract and border area Malaria
Viral Headache / running nose malaise
prodome
Dr.Shamol /inter/fever 1
Red flag sign Unconsciousness / drowsy / irreverent talk cerebral malaria / encephalitis /
meningo-encephlitis
Bleeding manifestation Dengue / leukemia / aplastic anemia
(gum bleeding , bleeding from other site )
Neck rigidity encephalitis / meningo-encephlitis
Shock Sepsis
Oligouria
Immune suppressive patient –DM, CRF,CLD , COPD , on steroid or anti-cancer drug
Joint swell and tenderness Connective tissue / RA /SLE
Breathlessness Pneumonia /COPD
Jaundice
Wt loss and night sweat TB
chill and rigor malaria /cholangitis /UTI (pylonephritis)/ pneumonia / abscess
Rash Infective measles , rubella, chicken pox, dengue, chikungynya, enteric fever
Non infective Connective tissue –SLE/ Vasculitis / adult still disease /
Hematological disease – leukaemia /aplastic anaemia
drug
very sick person must take double eggs
1st day -> very --varicella (chicken pox )
second day  sick --scarntlet fever
third day  person -- pox (small pox)
fourth day  must --measles , rubella /german measles
fifth day  take --typhus
six day  double –dengue
seven day  eggs ---enteric feverDr.Shamol /inter/fever 2
Look for localizing symptoms present or not
Headache ,malaise ,running nose , dry cough Viral fever
Cough (dry /productive ) chest pain with or with Pneumonia
breathlessness
Urinary urgency , frequency ,dysuria , UTI
Fever cough with productive sputum with breathlessness COPD
Headache photophobia , vomiting ,neck rigidity ,kernig Meningitis
sign
Fever ,unconscious with /without convulsion Encephalitis /meningitis /
cerebral malaria
Fever with vomiting and diarrhea Gastroenteritis
Fever with joint pain and swelling Viral arthritis , rheumatological diseases
(RA/SLE)
FEVER with sore throat Tonsillitis / pharyngitis
Low grade fever evening rise TB
temperature ,weight loss, appetite
Fever with chill and rigor Pyelonephritis (uti),pneumonia , malaria , abscess
Fever with jaundice Viral hepatitis , malaria , cholangitis , liver abscess,
leptospira
Examination of a fever patient just one minute head to toe
Level of consciousness Unconscious /drowsy / delirium encephalitis /meningitis /cerebral
malaria
Eye Anaemia --- Short history Hematological causes—
leukaemia /aplastic anaemia
Long history --kala-azar / lymphoma
Cranial nerve palsy vi palsy ---- TBM (long HO low grade fever
)
Jaundice Liver abscess /viral hepatitis /malaria /
leptospirosis sepsis
Sub Conjunctival leukaemia /aplastic anaemia
haemorrhage Dengue
Coughing –may causes subconjuntival
hemorrhage
Conjuntival congestion Viral
Nose Running nose and blocked Viral fever /common cold
nose
Mouth Sore throat , Tonsillitis
Gumbleeding –leukaemia
Candidiasis –immune suppression
Ear -- Any discharge ---Otitis media
Neck Cervical lymph-adenopathy TB, Lymphoma , leukaemia ,
viral fever
Neck rigidity Dr.Shamol /inter/fever Meningitis 4
Thorax Boney tenderness Acute lukaemia
Lung auscultation Crep /ronchi COPD with CAP OR RTI
Anteroirly —apex , at level Incrasese –pneumonic consolidation
of nipple , lower part Decrease –effusion
Posterior –base
Tenderness on percussion pneumonia / lung abscess
if right sided lower part –liver abscess
Heart Changing murmur --- infective endocarditis
Abdomen Hepatomegaly Liver abscess
Splenomegaly Short history – enteric fever
/hepatosplenomegaly Long history Kalazar / TB/ Lymphoma
Ascites
Renal angle tender Pyelonephritis
Supra pubic tenderness Cystitis
Abdominal lymphadenopathy
Hand Pulse Relative bradycardia –enteric fever
BP Decrease –shock septic
Clubbing Lung abscess
Bronchiectasis
Infective endocarditis
Joint Joint pain full & swelling Connective tissues –RA?SLE?VIRAL
Axillary and inguinal lymphnode
Rash
Investigation in patient with fever
Depend on Duration of fever
Endemic zone
Red flag sign present or not
Day 1 to 5 No investigation is needed if red flag sign is absent –mostly are
Without red flag viral causes
NS1—antigen to detect dengue in endemic area and sign and
symptoms suggestive of dengue
CBC Leucopenia / normal –viral
Leucocytosis –bacterial
Pancytopenia –aplastic anaemia /leucopenia
Thrombocytopenia –dengue
Urine RME If pus cell more than 5 –UTI
RBS— If not done recently
S.Creatinine
Do blood culture If u suspect enteric fever
If fever CBC--- Leucopenia / normal –viral
duration is As part of Leucocytosis –bacterial
more than 5 routine Pancytopenia –aplastic anaemia
to 7days investigation /leucopenia
Thrombocytopenia –dengue
Urine RME If pus cell more than 5 –UTI
WBC cast pyelonephritis
RBS/Creatinine
Chest –x ray Consolidation /cap
Effusion
Lung abscess
RTI-bronchovascular prominence
USG Splenomegaly –,Hepatomegaly, liver
abscess
Pyelonephritis , lymphadenopathy ,
ascites , pelvic collection
ECG To exclude associated IHD if age > 35
ICT for malaria From endemic zone with typical chill &
rigor
From 6th day If patient endemic Anti-dengue IgM
to onward area Anti-chikungunya IgM
Triple antigen If u suspect ricketsia
If patient has red-flag Unconscious patient Do fundoscopy /CT-scan of brain
sign Followed by CSF & ICT for malaria if
from endemic zone
PBF IF patient have bleeding manifestation
Pancytopenia / thrombocytopenia
Leucocytosis more than 20000
If patient jaundice Hepatic function SGPT/ ALPO4/ PT
Fever more than If low grade & wt loss- Chest XRAY
months exclude TB Sputum for AFB
MT
ICT for KALA-AZAR If from endemic area
Blood & urine culture
Bone marrow
Lymphnode biopsy If present
Spleenic puncture If splenomegaly
RA/ANA/CRP Asssoicated with joint pain and
swelling
The following case you consider anti-biotic from the beginning
If patient is unconscious
Fever with purulent cough
Fever with shortness of breath /respiratory distress
Fever with urinary complaint urgency, frequency ,
dysuria
Fever with diarrhea vomiting –gastroenteritis
Fever with unconsciousness
Fever in immune-suppressive / cancer patient
Fever in ascites patient due to CLD
Fever in toxic patient
Fever that developed after admission in hospital
If CBC shows leucocytois with neutrophil
predominant
Neutropenia
Disease Choice of antimicrobial Dose and duration
UTI Generic or trade name
Tab.CEFUROXIME Furocef /kilbac/ cefotil 250 /500mg 1+0+1—7days
Cap.Cefixime Cef-3/ orcef 200mg 1+0+1—7days
400 mg 0+0+1—7days
Tab. Moxifloxacin Optimox / visomox 400 0+0+1—7days
Recurrent UTI Nitrofurantoin Ofuran SR /Nintoin SR 1+0+1—7 days
Pyelonephritis Inj.Cefuroxime Furocef /kilbac/ cefotil 750 mg 1 vial IV 8hrly 7days
Inj.ceftriaxone Ceftron /exephine 2g 1 vial IV daily 7day
RTI Tab. Azithromycine Zimax /zithrin/Azin 500mg 0+0+1-----7 days
Tab.CEFUROXIME Furocef /kilbac/ cefotil 250 /500mg 1+0+1—7days
Tab. Moxifloxacin Optimox / visomox 400 0+0+1—7days
Tab. Livofloxacin Evo/ trevox 500 0+0+1—7days
Enteric fever Inj.ceftriaxone Ceftron /exephine 2g 1 vial IV bd –7day
Meningitis
Pneumonia Tab. Co-amoxiclav Moxaclav/ Tyclav 625mg 1+1+1---7 t0 14
2 antibiotics Tab. Clarithromycin Clarin 500 mg 1+0+1---7 t0 14
Malaria Artemether & Coartem /Lumertam 4+0+4—3 days
Lumefantrine
Tab.Quine sulphate Jasoquine 300 mg 2 + 2 + 2—7days
Aspiration Inj.ceftriaxone Ceftron /exephine 2g 1 vial IV bd –7day
pneumonia Inj.metronidazole Amodis/filmet/metro 5oomg/ 1 bag 8hr for 7days
100ml
Viral encephalitis Inj. aciclovir Xovir 5oomg/1gm 10 mg/kg IV 3 times daily
for 2–3 wk
Average 1 bottle iv 8 hrly
Dr.Shamol /inter/fever 500mg 10
Ricketsia Cap .doxicycline Doxin 100 mg 1+0+1—7days
Still to be diagnosis If diagnosis is RTI
Bed rest Bed rest
Diet –normal Diet –normal
Tab . paracetamol500mg ( Napa extend/ NAPA) Antibiotic (any one of the following )
1 +1+1/ 1 tab if temp > 1000F Tab. Azithromycine 500mg(Zimax /zithrin/Azin)
Cap . omeprazole 20 mg (seclo /losectile ) 0+0+1-----7 days
1 + 0 + 1 hr before meal Tab.Cefuroxime 500mg (Furocef / cefotil )
Tab. Domperidone ( Omidone/domin ) 10 mg 1+0+1—7days
1 + 1 +1--- ½ hr before meal –if vomiting Tab. Moxifloxacin 400mg(Optimox / visomox )
0+0+1—7days
Tab . paracetamol 500mg ( Napa extend/ NAPA)
1 +1+1/ 1 tab if temp > 1000F
Cap . omeprazole 20 mg (seclo /losectile )
1 + 0 + 1 hr before meal
Anti histamine any one of the following
(e.g. fexofenadin 120(fexo /fenadin )
e.g. loratadin 10 mg (ordain )
e.g. citirizine 10 mg (alatrol )
0+0+1—7days
Fever with unconscious (cerebral malaria excluded ) Fever with unconscious (cerebral malaria suspected )
Diet : NG feeding Diet NG feeding
200 ml 2 hrly 200 ml 2 hrly
Inj. Normal saline 2000 ml Inj. Libot -25 100 ml
I v @ 20 drop /min ---------------------------
Inj.ceftriaxone 2 gm(ceftron / exephine /ceftizone ) I v @ 10 d/min
1 vial IV BD for 7 days . Inj . 5% DNS 500 ml
Inj. aciclovir 10 mg/kg (inj. Xovir 500 mg ) +
I vial/bottle IV 8hrly for 2-3 weeks Inj. Jasoquine 3 amp
( when the patient will become stable switch to -------------------------------------------
Tab .aciclovir (tab. Virux 400 mg )-- 2+2+2+2+2 Iv @ 30 d/min stat (over 4 hrs)
Inj. Pantoprazole 40 mg (pantonix )/ any PPI Then
I vial iv daily Inj . 5% DNS 500 ml
Inj. dexamethasone0.5mg(roxadex /d-cort) 0.15mg/kg) +
1 amp IV qds for 4 days Inj. Jasoquine 1 ½ amp
starting with or just before the first dose of antibiotics ------------------------------------
If patient is restless then Iv @ 30 d/min (over 4 hrs) 8 hrly
. Inj .perol In between jasoquine drip
1 amp i.m. stat Inj. Hartman 1000 ml
Tab . paracetamol/PC 500mg ( Napa extend/ NAPA) -------------------------
1 +1+1/ 1 tab if temp > 1000F I v @ 10 d/min
Napa suppository 500mg If patient is restless then
I stick PR if temp is very high . Inj .perol
Tepid sponging 1 amp i.m. stat
Continuous catheterization Tab . paracetamol/PC 500mg (Napa extend/ NAPA)
1 +1+1/ 1 tab if temp > 1000F
Napa suppository 500mg
I stick PR if temp is very high
Tepid sponging
Continuous catheterization
Enteric fever Prolong fever diagnosed is clear cut / ricketsia is DD
Bed rest Bed rest
Inj.ceftriaxone 2 gm(ceftron / exephine /ceftizone ) Inj.ceftriaxone 2 gm(ceftron / exephine /ceftizone )
1 vial IV BD for 7 days 1 vial IV BD for 7 days
Tab . pa-------racetamol/PC 500mg ( Napa extend/ NAPA) Cap .doxicycline 100 mg(Doxin)
1 +1+1/ 1 tab if temp > 1000F 1+0+1—7days
Cap . omeprazole 20 mg (seclo /losectile ) Tab . Paracetamol/PC 500mg ( Napa extend/ NAPA)
1 + 0 + 1 hr before meal 1 +1+1/ 1 tab if temp > 1000F
Napa suppository 500mg Cap . omeprazole 20 mg (seclo /losectile )
I stick PR if temp is very high 1 + 0 + 1 hr before meal
Tepid sponging Napa suppository 500mg
Tepid sponging
Treat of fever due to pneumonia Fever due to Malaria
Bed rest Bed rest
Tab. Co-amoxiclav 625mg(Moxaclav/ Tyclav) Tab. Artemether & Lumefantrine (Coartem /Lumertam)
4+0+4—3 days
1+1+1---7 to 14 days Tab . pa-racetamol/PC 500mg ( Napa extend/ NAPA)
Tab. Clarithromycin 500 mg(Clarin) 1 +1+1/ 1 tab if temp > 1000F
1+0+1---7 t0 14 days Cap . omeprazole 20 mg (seclo /losectile )
Tab . pa-------racetamol/PC 500mg ( Napa extend/ NAPA) 1 + 0 + 1 hr before meal
1 +1+1/ 1 tab if temp > 1000F Napa suppository 500mg
Cap . omeprazole 20 mg (seclo /losectile ) I stick PR if temp is very high
1 + 0 + 1 hr before meal Tepid sponging
Tepid sponging
Aspiration pneumonia UTI
Bed rest Bed rest
Inj.ceftriaxone 2 gm(ceftron / exephine /ceftizone ) Antibiotic (any one of the following )
1 vial IV BD for 7 days Tab.Cefuroxime 500mg (Furocef / cefotil )
Inj. metronidazole 5oomg/ 100ml (filmet/metro) 1+0+1—7days
1 bag IV 8hr for 7days Tab. Moxifloxacin 400mg(Optimox / visomox )
Inj. dexamethasone0.5mg(roxadex /d-cort) 0+0+1—7days
1 amp IV qds for 4 days Tab . paracetamol/PC 500mg ( Napa extend/ NAPA)
Tab . paracetamol/PC 500mg ( Napa extend/ NAPA) 1 +1+1/ 1 tab if temp > 1000F
1 +1+1/ 1 tab if temp > 1000F Cap . omeprazole 20 mg (seclo /losectile )
Cap . omeprazole 20 mg (seclo /losectile ) 1 + 0 + 1 hr before meal
1 + 0 + 1 hr before meal
Tepid sponging
Dengue
If you are work in Dhaka can’t practice medicine without knowing dengue management
Dengue Classification Dengue fever
Dengue haemorrhagic fever
Dengue shock syndrome
Expanded dengue syndrome
Dengue fever Actual febrile Headache
illness with two Retro-orbital pain
or more of Myalgia
following Rash
Haemorrhagic manifestations
Leucopenia (wbc<_5000 cells mm3)
Thrombocytopenia(platelet count<150000 cells/mm3)
Rising haematocrit(5-10%)
And High index of suspicion based on period ,population &
place
And Absence of convincing evidence of any other febrile illness
.
And Serology positive NS1 or anti-dengue IgM
Dengue hemorrhagic Acute onset of fever of 3 to 7days
fever Hemorrhagic manifestation Positive tourniquettest
any of the following Petechiae , ecchymosis , purpura
Bleeding from Mucous membrane
GIT
Injection site
Platelet count < 100000
Objective evidence of Clinical Pleural effusion
plasma leakage Ascites
Lab ↑hematocrit >20%
↓albumin or protein
Expanded dengue When patients with dengue illness develop unusual manifestations such as involvement of
syndrome / Isolated liver ,kidneys ,brain or heart with or without evidence of fluid leakage is called expanded
organopathy / dengue syndrome
unusual or atypical Neurolgical •Febrile seizures in young children •Encephalopathy
manifestation ) •Encephalitis/aseptic meningitis •Subdural
effusions•Mononeuropathies/
polyneuropathies/guilane-barre syndrome •Transverse myelities
Gastrointestinal/hepatic Hepatitis/fulminant hepatic failure /Acalculous cholecystitis Acute
pancreatitis ,Hyperplasia of peyer’s patches Acuteparotitis
Renal: Acute renal failure Hemolytic uremic syndrome
Cardiac: Conduction abnormalities ,myocarditis ,pericarditis
Respiratory Acute respiratory syndrome Pulmonary haemorrhage
Musculoskeletal Myositis with raised creative phosphokinase Rhabdomyolysis
Lymphoreticular/ ITP ,Spontaneous splenic rupture
bonemarrow
Eye Macular haemorrhage, Impaired visual acuity ,Optic neuritis
Others Post-infectious fatigue syndrome, depression, hallucinations,
psychosis, alopecia
Warning A- Afebrile No clinical improvement or worsening of the situation just
signs before or during the transition to afebrile phase
abdominal Severe abdominal pain
B Bleeding Bleeding : Epistaxis, black stool, haematemesis, excessive
menstrual bleeding , dark coloured urine (haemoglobinuria)or
haematuria
behavior sudden behavioral change or restlessness
vomiting Persistent vomiting
C Cold cold ,clammy and Pale hands and feet
D Dizziness Dizziness OR Giddiness
E Enlargement Liver enlargement >2cm
F Fluid Fluid accumulation / ascites /effusion
G General Generalized weakness or lethargy
H Haematocrit Haematocrit>20% increases
Less /no urine output for 4-6 hours
High-risk A Age Infant and elderly
patients B BMI Obesity
C Chronic DM, HTN,CRF,IHD, Asthama, Liver cirrhosis ,Hemolytic disease
diseases
D Drug on steroid or NSAID
3p Pregnant
PUD
Period WomenDr.Shamol /inter/fever
who have 17
menstruation or abnormal vaginal bleeding
STAGE CLINICAL FEATURE LAB finding
DHF I Features / History of Plus Positive Tourniquet Test Thrombocytopenia < 100,000 /mm3
features of DF · Hematocrit rise > 20%
DHF II DO Plus Spontaneous bleeding DO
DHF (DSS) III DO Plus Features of circulatory DO
failure
DHF (DSS) IV DO Plus Profound
Dr.Shamol shock
/inter/fever DO 18
Lab tests for diagnosis and monitoring
CBC Total Leucocyte Count,
Total Platelet Count and
Hct
Should done All febrile patients at the first visit
All patients with warning signs
All patients with fever >3 days
Leucopenia is common in both adult total white cell count
(<_5ooo cells /mm3)
neutrophils to lymphocyte (neutrophils< lymphocytes )
AST(SGOT) & ALT(SGPT) are frequently elevated
NS1 antigen positive on first day of illness
becomes negative from day 4-5 of illness
Anti dengue antibody test IgM --Uusually detected on day 6-10
Dengue lgM/lgG test Can be detected in low level up to 1-3 months after fever
primary dengue infection : IgM will be more than lg G
secondary dengue infection: elevation of anti- dengue specific lgG
antibodies and lower levels of lgM
Other to see RBS
commorbidity S.creatinine
ECG-middle age to elderly
Critical stages USG & CXR
Stable pulse, blood pressure and breathing rate
Signs of Recovery Normal temperature
No evidence of external or internal bleeding
Return of appetite
Good urinary output
Stable hematocrit`
Convalescent stable petechial rash
Criteria for Discharging Absence offever for at least 24 hours without the use of anti-fever therapy
Patients Return of appetite
Visible clinical improvement
Good urine output
Minimum three days after recovery from shock
No respiratory distress from pleural effusion and no ascitis
Platelet count of more than 50,000/mm3
Indication of Restlessness or lethargy frequent vomiting one or two days of febrile illness.
hospitalization Cold extremities or circumoral cyanosis
Bleeding in any form.
Rapid and weak pulse.
Capillary refill time > 3 seconds.
Narrowing of pulse pressure (<20 mm Hg) or Hypo tension.
Acute abdominal pain
Evidence of Plasma leakage. Eg. Pleural effusion /Ascities
Hematocrit of 40 or rising hematocrit.
Platelet count of < 1,00000/ mm3
in short All case of DHF Grades II, III & IV
DHF Grade I where nutrition and oral fluid electrolytes therapy, monitoring and observation
cannot be ensured, and or presence of concomitant illnes s or in special situations eg Diabetes,
IHD, Pregnancy, etc
Treatment
Adequate physical rest
Ensure adequate 2500 ml for 24 hours
oral fluid intake (if the body weight is less than 50kg give fluids as 50ml/kg for 24 hours).
oral rehydration fluid /coconut water / fruit juices/ soup rather than plain
water
Avoid red and brown drinks which cause confusion with haematemesis or
coffee ground vomitus
FEVER Tepid sponging
Paracetamol not exceeding 2 tablets six hourly
reduce dose for patients with lower body weights
Warn the patient that the fever may not fully settle with paracetamol and
advice not to take excess
AVOID Withhold Aspirin, Clopidogrel
Avoid all NSAIDS and steroids
Give anti-emetics and PPI if necessary
Advise to return to doctor if Inability to tolerate oral fluids
Severe abdominal pain
Bleeding tendency including inter-menstrual bleeding or
menorrhagia
Cold and clammy extremities
Clinical deterioration with settling of fever
Not passing urine for more than 6 hours
LethargyDr.Shamol
or irritability/restlessness
/inter/fever 21
DHF Grades I & II Therapy Chart
Initiate IV 5% DNS 6 ml/Kg/hr for 6 hours
therapy 5% ↓
DNS Monitor--- hematocrit / vital signs / urine output after 3 hours
↓
If improved If no improvement
↓ ↓
Reduce IV therapy to 3 increase IV therapy to 10 ml/kg/hour for 2 hour
ml/kg/hour for 3 hours
↓ ↓
If improved improvement now If no improvement of vital sign
↓ ↓ ↓
continue IV therapy at 6 ml/kg/hour 6 hours See Hematocrit
3 ml/kg/hour for 6-12 hours If improved ↓
then discontinue IV therapy ↓ If raised If fall
Reduce IV therapy to ↓ ↓
3 ml/kg/hour for 3 hours
↓ Colloidal fluid Dextran Fresh whole blood
10 ml/kg/hr for 1 hr 10 ml/kg as a bolus
For 1 hr
If improved ↓ ↓
↓ If improved
continue IV therapy at 3 10ml/kg/hour to 6 ml/kg/hour and further to 3
ml/kg/hour for 6-12 hours ml/kg/hour accordingly discontinued
then discontinue IV therapy 24 to 48 hr
Improvement: Hematocrit falls,
pulse rate & blood pressure stable,
urine output rises
No improvement Hematocrit
pulse rate rise &pulse pressure
Dr.Shamol < 20 mm of Hg
/inter/fever 22
urine output falls
DHF Grades III & IV 5% DNS therapy to 10 ml/kg/hour for 2 hour
IV: ↓
Monitor--- hematocrit / vital signs / urine output after 3 hours
↓
improvement now If no improvement of vital sign
↓ ↓
6 ml/kg/hour 6 hours See Hematocrit
If improved ↓
↓ If raised If fall
Reduce IV therapy to 3 ↓ ↓
ml/kg/hour for 3 hours
↓ Colloidal fluid Dextran Fresh whole blood 10
10 ml/kg/hour for 1 hr ml/kg as a bolus For 1 hr
If improved ↓ ↓
↓ If improved
continue IV therapy at 3 10ml/kg/hour to6 ml/kg/hour and further to 3
ml/kg/hour for 6-12 hours then ml/kg/hour accordingly discontinued
discontinue IV therapy 24 to 48 hr
Give platelet rich plasma transfusionexceptionally when platelet
counts are below 5,000-10,000/mm
What advice will you give the patient in afbrile state ?
the patient should be observed for at least 2-3 days after the fall in temperature, for rashes on the skin,
bleeding from nose or gums,blue spots on the skin or tarry stools. If any of these signs are observed, the
patients should be brought to the hospital without delay.
Tourniquet Test Inflate blood pressure cuff to a point midway between systolic and diastolic
pressure for 5 minutes
Positive test: 20 or more petechiae per 1 inch² (6.25 cm²)
Chikungunya----the clinical feature
The incubation period time from infection to illness can be 2-12 days, but is usually 3-7 days.
Fever from low grade to high grade
lasting usually for 24 to 48
rises abruptly in some, reaching 39-400C
Started with chills and rigor
No diurnal variation & subsides with use of antipyretics.
Joint manifestation arthralgia or arthritis ,Migratory polyarthritis with effusions
symmetric small joints of the hand, wrists and ankles
knee and shoulder joints and spine were also involved
Pain tends to be worse in the morning, relieved by mild exercise and
exacerbated by aggressive movements
pain may be relieved for 2-3 days & then reappear in a saddle back pattern
due to involvement of the lower limb and back forced the patient to stoop
down and bend forward
MucoCutaneous Transient maculopapular rash
manifestation Stomatitis and oral ulcers
Most skin lesions recovered completely
Neurological meningo-encephalitis,
manifestation encephalitis,
acute encephalopathy
Guillain-Barré syndrome and myelitis
Ocular manifestation granulomatous and nongranulomatous anterior uveitis,
optic neuritis,
retrobulbar neuritis, and
dendritic lesions.
Majority of the patients recover with good vision.
Criteria for the Identification of Chikungunya Infection
Clinical criteria acute onset of fever >38.5°C
severe arthralgia/arthritis not explained by other medical conditions
Epidemiological Residing or having visited epidemic areas
criteria having reported transmission within 15 days prior to the onset of symptoms
Laboratory Criteria: at Virus isolation by Cell Culture
least one of the Within 5 days of onset of Illness Presence of viral RNA by real Time RT-PCR (
following tests in the within 5 to 28 days of onset Fever Presence of viral specific IgM antibody in single
acute phase: serum sample collected
severity of clinical presentation
Mild Moderate Severe
Low grade fever Low to high grade persistent fever Persistent high grade fever
Mild artharlgia Moderate arthralgia /arthritis Severe arthralgia/Arthritis
Mild focal myalgia Generalized myalgia Persistent vomiting / Diarrhoea
General weakness Retro-orbital pain Altered sensorium
Skin rash/itching Mild bleeding Bleeding
(GI bleeding due to use of drugs e.g. analgesics)
Hypotension & Oliguria Shock due to persistent vomiting and diarrhoea
chikungunya virus infections compared with dengue virus infections
Chikungunya Dengue
Fever (>39°C) +++ ++
Arthralgia +++ +/-
Arthritis + -
Headache ++ ++
Rash ++ +
Myalgia + ++
Hemorrhage +/ - ++
Shock - +
Lymphopenia +++ ++
Neutropenia + +
Thrombocytopenia + +++
Hemoconcentration - ++
more likely to cause high fever, severe more likely to cause neutropenia,
polyarthralgia, arthritis, rash, and thrombocytopenia,
lymphopenia hemorrhage, shock, and death
patients with suspected chikungunya should be managed as dengue until dengue has been ruled out
Routine Laboratory Investigations
CBC Leucopenia (Decreased WBC)
Thrombocytopenia: rare
ESR: Usually Elevated
C-Reactive Protein Increased during the Acute Phase and may remain elevated for a week
SGPT : Elevated
Confirm DX Within 5 days of onset of Illness viral RNA by real Time RT-PCR
within 5 to 28 days of onset Fever Anti chikungunya antibody IgM
Virus isolation Dr.Shamol /inter/fever by Cell Culture 26
Treatment
Water intake Consume plenty of water with electrolytes (approximately 2 litres of home available
fluids with salt in 24 hours).
Rest Adequate rest in a warm environment
For fever Take paracetamol tablets during periods of fever (up to 1000 mg tablets four times
daily), in persons with no preexisting liver or kidney disease
Children may be given 50-60 mg per kg body weight per day in divided dose
Joint pain Cold compresses may help in reducing joint damage.
Heat may increase/worsen joint pain and is therefore best to avoid during acute stage
Avoid self medication with aspirin or NSAIDs
Aspirin or NSAIDs should be avoided during first 10 days. NSAIDs can be used in
Chikungunya only when Dengue fever is adequately excluded
Refrain from exertion
Antihistamine For itching
Steroid has no role in acute stage.
Admission criteria If the person is hemo-dynamically unstable (frequent syncopal attacks, hypotension
with a systolic BP less than 90 mmHg or a pulse pressure less than 30 mmHg),
oliguria (urine output less than 500 ml in 24 hours),
altered sensorium
bleeding manifestations
persons not responding or having persistent joint pain or disabling arthritis even
after three days of symptomatic treatment
persons above sixty years
infants (below one year of age)
Pregnancy
High risk Group
Treatment of serious complications
Bleeding disorders platelet transfusions in case of bleeding with platelet counts < 50,000 cells p
Fresh frozen plasma, or Vitamin K injections if prothrombin time INR is more
Hypotension with fluids/ inotropics
acute renal failure with dialysis
contractures & deformities with physiotherapy/surgery
myo-pericarditis or require intensive care with regular monitoring, inotropic support, ventilation
meningoencephalitis
neuropathies. Anti-neuralgic drugs (Amitryptyline, Carbamazepine, Gabapentin, and
Pregabalin)
refractory arthralgia hydroxychloroquine 200 mg orally once daily or chloroquin phosphate 300 mg
orally per day for a period of four weeks in cases where other drug not worked
Hyperpigmentation and may be managed with Zinc oxide cream and/or Calamine lotion
papular eruptions
High Risk group a) Co-morbid condition Hypertension,
Diabetic,
CAD/CVD,
Geriatric age,
Pregnancy,
COPD,
b) Co-infection Dengue,
Tuberculosis,
Enteric fever,
Pneumonia,
HIV,
Malaria

Approach To A Patient With Fever?: 1 DR - Shamol /inter/fever

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Approach To A Patient With Fever?: 1 DR - Shamol /inter/fever

Uploaded by

Copyright:

Available Formats

Approach to a patient with fever?

If a patient comes with fever first you categorized in following

You might also like