Week 2 - Severe fatigue and fever

Question 1

D.Y. is a 53-year-old male who presents with a 5 day Hx of severe fatigue and high temperatures. He lives in Cairns (returned from PNG 3 days back).

Take a history of this patient.

HPC:
• Cough (dry) and sore throat.
• Headache.
• Fever and night sweats.
• Extreme fatigue (run over by truck).
• Muscle and joint pains.
• Returned from PNG 3 days (symptoms 
present for 5 days).
• Temp 39.5˚C little relief with paracetamol.
• Has not taken malaria prophylaxis.
• Had flu shot in April.

Answer 1

HPC:
• How long have you had high temperatures?
• Alleviating factors?
• Exacerbating factors?
• Constant or intermittent? How long does it last?
• Severity? i.e. maximum temperature.
• Associated symptoms? i.e. cough/sputum, sore throat, myalgia, arthralgia, headache, rash.
• Effect on lifestyle?

• Fatigue - onset? Alleviating or exacerbating factors? Timing and severity?

• Recent travel or illness?
• Contact with sick people?
• Recent operations or medical procedures?
• Antimalarial prophylaxis and recommended travel vaccines?
• Overseas - duration, activities?
• Have you had shivers and shakes (rigors)?
• Weight loss, night sweats, haemoptysis?

PMHx:
• Past history of arboviral/tropical disease?
• Any medical conditions?

PSHx:
• Any recent surgeries or medical procedures?
• Past surgeries?

Medications:
• Any regular medications?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?

FHx:
• Family history of any medical questions?

SHx:
• Background?
• Occupation?
• Education?
• Religion?
• Living arrangements?
• Smoking?
• Nutrition?
• Alcohol/recreational drugs?
• Physical activity?

Systems Review:
• General - weight change, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum?
• GI - vomiting, diarrhoea, abdominal pain?
• UG - dysuria, urine output?
• CNS - headaches, nausea?
• MSK - painful or stiff joints, muscle aches or rash?
• ENDO
• HAEM

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands.
2. General inspection: consciousness/orientation, distressed, anxious, malaise, dyspnoeic, cough, cyanosis.

3. Vital signs:
• HR - may be tachycardic.
• RR - may be tachypnoeic.
• BP
• Temp - may be febrile.

4. Hands:
   • Warm/cool, dry/sweaty.
   • Pallor, peripheral cyanosis.
   • CRT.
5. Face:
   • Eyes - conjunctival pallor, conjunctivitis.
   • Nose - discharge/deformity.
   • Mouth - peripheral/central cyanosis.
6. Neck:
   • Cervical/axillary lymph nodes.
7. Chest:
   • Inspection - shape/symmetry, scarring/deformity, chest expansion.
   • Palpation - chest expansion, vocal fremitus, chest wall tenderness.
   • Percussion
   • Auscultation - bronchial breath sounds, reduced intensity, crackles. Vocal resonance.
8. Legs:
   • Temperature.
   • CRT.
   • Peripheral pulses.
9. CVS/GI:
   • Auscultation.
   • Hepatosplenomegaly.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: Influenza with a chest infection.
• DDx:
- Malaria.
- Dengue.
- RRV.
- TB.
- Typhoid.
- Atypical pneumonia.

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC (anaemia, thrombocytopenia), U+Es (renal failure).
• Serology.
• Culture (nasopharyngeal swab).
• PCR.
• Thick and thin blood film.
• Rapid antigen test.
• CXR, Mantoux test, Ziehl-Neelsen stain (acid fast bacilli).

Question 5

What treatment does this patient require?

Answer 5

• Rest.
• Fluids.
• Analgesia e.g. paracetamol.
• Anti-virals e.g. Oseltamivir, zanamivir.