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Clinical Medicine II > intro, fever, and FUO (quiz 1, exam 1) > Flashcards

intro, fever, and FUO (quiz 1, exam 1) Flashcards

1
Q

clinical decision making

__ + __ + __ = evidence based medicine

A
  • clinical expertise
  • best research evidence
  • patients’ values and wishes
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2
Q

clinical reasoning

1-5

A
  1. does this particular clinical picture seem to fit a disease pattern that i have seen before?
  2. is there 1 explanation for the clinical presentation?
  3. whta other things must be ruled out (DDx); what is imp. not to miss and how quicly does it need to be done?
  4. an uncommon presentaiton of a common illness is more likely than an uncommon illness (common things happen commonly)
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3
Q

clinical reasoning

5-8

A
  1. am i comfortable making the diagnosis based on the info that I have? or, what additional tests are needed (are the results going to affect my decision making)? (Dont get caught picking your nose in public)
  2. does the condition require specific treatment and can treatment wait while the definitive diagnosis is being sought? if not, does empirir treatment need to begin while diagnosis is being sought?
  3. does the pt require inpatient treatment or will out-pt treatmetn suffice?
  4. does the pt agree with the plan and understand the clinical rationale?
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4
Q

clinical reasoning

28yo otherwise healthy male presents with a 4 day history of productive cough w green sputum, fever, chills, and some SOB associated with R sided chest pain

exam is remarkable for temp of 102 F w otherwise normal VS

the pt appears to be in no apparent distress

lung exam is significan for few crackles in the R base

Dx and DDx?

A
  • bacterial pneumonia
  • DDx
  1. viral upper respiratory tract infeciton
  2. asthma exacerbation
  3. pulmonary embolism (PE)
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5
Q

clincical reasoning

definition of “declare oneself”

A

produce a recognizable disease; resolve, improve, worsen or stay the same; let the pt declare himself when diagnosis is unclear

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6
Q

infectious diseases

most curable and preventable diseases caused by

A

infectious agents

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7
Q

infectious diseases

gram negative bacteria’s cell walls contain __, a potent inducer of __ such at tumor necrosis factor, and are associated with fever and __ shock

A
  • lipopolysaccharide
  • cytokines
  • septic
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8
Q

host defeneses against infection

humoarl defenses

A
  • complement system
  • antibodies
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9
Q

host defeneses against infection

cellular defenses (dont forget anatomic defenses)

A
  • phagocytic cells
  • T lymphocytes
  • natural killer cells
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10
Q

host defenses against infection

cellular interactions

A

via cytokines and cytokine receptors

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11
Q

laboratory diagnosis of infectious diseases

  1. direct __
  2. microbial __ detection (latex agglutination, immunofluorescence, enzyme immunoassay)
  3. __ diagnostic techniques (PCR)
  4. __
A
  1. visualization
  2. antigen
  3. molecular
  4. culture
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12
Q

antimicrobial therapy

3 things to consider for antimicrobial therapy

A
  1. pathogen
  2. site of infection
  3. characteristics of the pathogen
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13
Q

what is fever?

an elevation of body temperature above normal limits induced by regulatory processos of __; it is greater than __ F

A
  • hypothalamus
  • 101F (38.3C)
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14
Q

what is fever?

normal is __ (normal range is __); __ is the least accurate; rectal temps usually __ higher than oral temp; otic temp convenient but more __; children have greater autonomic flexibility and can mount __ fevers with __ morbidity

A
  • 98.6F (36.8C)
    97. 6-99.6F (36.0-37.7C)
    0. 7F (0.4C)

variability

higher

less

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15
Q

pathogenesis of fever

cytokine receptors for __, __, and __ –>thermoregulatory center –> peripheral nerves –> __ –> core temperature rises

A
  • COX 2/3, PGE2, cAMP
  • vasoconstriction
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16
Q

approach to pt with a fever

3 groups of febrile pts

A
  1. fever without localixing signs and symptoms
  2. fever and rash (usually viral)
  3. fever and lymphadenopathy (generalized, regional)
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17
Q

approach to febrile pts

epidemiological factors (5)

A
  1. seasonal patterns
  2. travel (malaria, dengue, TB)
  3. occupation (livestock- brucella, coxiella)
  4. food pathogens
  5. exposure
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18
Q

approach te febrile pts

host factors (4)

A
  1. age
    a. children: cetain infecitons most common in childhood and appear later in life only in immunocompromised children (exanthems, EBV, parvovirus, enterovirus, H. influenza)
    b. elderly: decreased immunodefenses/dampened febrile response- can present w/ serious less specific sxs
  2. immunity
  3. chronic disease
  4. ethnicity
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19
Q

history and physical for fever

HPI includes these 9 symptoms

A
  1. headache
  2. eye sxs
  3. ear pain
  4. sore thorat
  5. chest/pulmonary sxs (cough, dyspnea)
  6. rhinorrhea
  7. abdominal sxs
  8. back pain
  9. joint/skeletal pain
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20
Q

history and physical for fever

PMH (6)

A
  1. immunocompromised
  2. chronic lung disease
  3. recent meds
  4. prosthetic/implanted materials
  5. surgery/dental work
  6. habits: drug, cigarrates, alcohol
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21
Q

history and physical for fever

family history (1)

A

TB

22
Q

history and physical for fever

PE (8)

A
  1. vitals: temp
  2. HEENT: skin (rash; nail beds); oropharyngeal erythema, ulcers, exudates (throat); TM clear (ears); schlera (eyes); lymphadenopathy supply (neck)
  3. chest/lungs: decreased breath sounds, rales, rackles, rhonchi, wheezes
  4. cardiac heart: murmers
  5. abdomen: liver/spleen size
  6. GU/pelvic/rectal
  7. musculoskeletal
  8. neurologic: r/o meningitis
23
Q

most common causes of fever

5

A
  1. URIs
  2. UTIs
  3. Cellulitis
  4. Superficial abscesses
  5. pneumonia
24
Q

3 categories of lab tests in fever/infection

A

inflammatory: response to infeciton
location: site of infection
etiology: cause of infection

25
Q

FUO criteria (3)

A
  1. significant fever (>101F) documented by healthcare professional on several occasians
  2. lasts more than 3 weeks
  3. failure to reach a diagnosis despite thorough history, physical and lab tests
26
Q

causes of FUO in adults in the US (from most to greatest)

A
  • infection (34%)
  • neoplasms (25%)
  • miscellaneous (20%)
  • connecetive tissue diseases (13%)
  • undiagnosed (8%)
27
Q

etiology of FUO

infectoin: 6 most common types

A
  1. tuberculosis
  2. cytomegaolovirus
  3. endocarditis
  4. intra-abdominal
  5. mycosis
  6. occult abcesses
28
Q

etiology of FUO

neoplasms: 4 most common

A
  1. lymphoma (hodgkins and nonhodgkins lymphoma most common malignancies)
  2. leukemia

3 carcinoma

  1. atrial myxoma
29
Q

etiology of FUO

connective tissue disease (5)

A
  1. still’s disease (juvenile RA)
  2. polyarteritis nodosa
  3. rheumatoid arthritis
  4. SLE
  5. temporal arteritis
30
Q

etiology of FUO

miscellaneous (6)

A
  1. drug induced fever: antimicrobials most common (1/3); also beta lactams anad sulfonamides; also anticonvulsants
  2. granulomatous hepatitis
  3. inflammatory bowel disease
  4. pancreatitis
  5. pulmonary embolism
  6. factitiuos illness
31
Q

etiology of FUO

undiagnosed: pts who remain without dx had __ prognosis; 5 year mortality was __%

A
  • favorable
  • 3.2%
32
Q

factitious fever happens in what populations

A
  1. young adults within health profession
  2. psychiatic problems
  3. history of multiple hospitalizaitons in different institutions
33
Q

look for these 4 signs for factitious fever

A
  1. rapid change in body temp without chills or sweating
  2. large discrepancy in rectal and oral temperature
  3. discrepancy between fever and pulse or general appearance
  4. atypically localized abscesses or polymicrobial infections
34
Q

age consideration in FUO

children: look for __; elderly look for __ and __; for FUO greater than 1 year, look for __

A
  • infections
  • neoplasms
  • connective tissue diseases
  • granulomatous disease
35
Q

to diagnose for FUO, you need to do these 7 things

A
  1. comprehensive history
  2. verification that the pt actually has a fever
  3. repeated physical exams
  4. lab tests: CBC, CMP, U/A w/ micro, ESR, ANA, RF, CMV, EBV, HIV, TB skn test, blood cultures 3+ sites
  5. radiologic and diagnostic tests: CT (abdomen, pelvis), MRI, venous duplex of lower extremetieis
  6. referral to an infectious disease specialist or rheumatologist
36
Q

most FUOs resolve __

A

spontaneously

37
Q

potential causes of fever and rash include __(6)

A
  1. viral
  2. bacterial
  3. spirochetes
  4. rickettsiae
  5. medications
  6. rheumatological
38
Q

fever and rash: are the skin lesions consistent with __ disease which requires immediate Abx?

A

meningococcal

39
Q

epidemiological and host factors for fever and rash (12)

A
  1. specific travel history
  2. occupational exposure
  3. woodland exposure
  4. animal exposure; history of arthropod or animal bites
  5. time of year
  6. contact with ill persons
  7. medications taken within the previous month
  8. psat illnesses, including drug allergies
  9. immune status
  10. immunization status
  11. sexually transmitted disease exposure
  12. cardiac abnormalities
40
Q

fever and rash: thorough physical to include close examination of the rash with a precise defintion of its features (4)

also look for these symptoms

A
  1. the primary type(s) of skin lesions present
  2. the distribution of the eruption
  3. the pattern of pregression of the rash
  4. the timing of the onset of the rash relative to the onset of fever and otehr signs of systemic illness
    - adenopathy, hepatosplenomegaly, arthritis, meningismus, nuchal rigidity
41
Q

define exanthem

A

acute generalized skin eruption

42
Q

rashes are classified on teh basis of their morphology, and the two most common presentations are __ and __

A
  1. morbilliform: erythematous macules and papules
  2. scarlatiniform: confluent blanching erythema
43
Q
A

morbilliform eruption: erythematous macules and papules

44
Q
A

scarlatiniform eruption: confluent blanchign erythema; GABHS pharyngitis

45
Q
A

macule: flat lestion of any size with circumscribed area of change in normal skin color

blanchable erythema

46
Q
A

papule: solic, raised lesion up to 0.5cm in greatest diameter

47
Q
A

maculopapular rash

48
Q
A

vesicle: circumscribed, elevated, fluid containing lesion less than 0.5 cm in greatest diameter

49
Q

define petechiae and purpura

A

both seen when there is extravasation of blood cells into the dermis; lesion DO NOT blanch with pressure

  • petechiae are < 3 mm and purpura are _>_3 mm
  • divided into two major categogries: palpable and nonpalpable
50
Q
A

purpura and petechiae (non blanching)

51
Q

palpable purpura are usually __ in outline and can be caused by infectious __

A
  • irregular
  • emboli: Osler nodes are painful infectious emboli and are often related to Infective Endocarditis
52
Q

palpable purpura can be caused by these 2 things

A
  1. gram negatie cocci infections: MEningococcus (meningococcemia -80% progress to meningitis): common in mid winter months
  2. rickettsial infeciton (rocky mountain spotted fever): tick bite, highest in April - September

Clinical Medicine II (11 decks)

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