DSA Fever

Question 1

What is a fever?

Answer 1

• A rise in body temperature in response to endogenous cytokines
• 37.4C (99.4F) to 38C (100.4F)

Question 2

What controls the normal, narrow range of temperature? what is that range?

Answer 2

• preoptic area of the hypothalamus

- 36.0° to 37.8°C (96.8°–100.0°F).

Question 3

What are chills? night sweats?

Answer 3

• subjective report of shaking/shivering due to rapid change in body temp; involuntary muscle contractions
• nocturnal sweating due to exaggeration of normal circadian temp rhythm

Question 4

How is a fever created?

Answer 4

EP –> hypothalamus –> fever due to release of PGE2, monoamines, cations, or cyclic AMP

*EP can be stimulated by LPS, lymphokines,

Question 5

What are the three endogenous pyrogens?

Answer 5

IL1, TNF, interferon alpha

Question 6

What is hyperthermia?

Answer 6

• elevation in body temp due to loss of homeostatic mechanisms and inability to increase heat loss in response to environmental heat
• levels to 41C (105.8F).

Question 7

Why are fever and hyperthermia considered the same?

Answer 7

they’re not –>

• hyperthermia is due to inability of body to dissipate heat
• fever is due to EPs

Question 8

Pt. presents with fever of 105.8F. What is top of your ddx?

Answer 8

hyperthermia

Question 9

Pt. presents with fever of 101F lasting approximately one month. All cultures are negative, CXR is clear, and CBC is upper limits of normal. What should you suspect?

Answer 9

Fever of unknown origin

*Fever that last 3 weeks or longer with temperatures exceeding 38.3C (100.9F) with no clear diagnosis despite 1 week of clinical investigation

Question 10

What is the most common cause of fever in older patients?

Answer 10

infection (bacterial)

3 common spots:

• Respiratory tract
• Urinary Tract
• Skin/soft tissue

Question 11

What malignancies are known to cause fever?

Answer 11

lymphoma, leukemia, renal cell carcinoma, primary or metastatic liver cancer

Question 12

pt. is prescribed new medication for heart health. Returns to your clinic with high fever. CXR is negative, cultures are negative, CBC is normal. How should you treat?

Answer 12

remove new drug - may have Drug Fever

Question 13

What is dangerous about chills?

Answer 13

the shaking increases risk of bacteremia

Question 14

What are the most common causes of nosocomial infections?

Answer 14

1. Bacterial
2. Non infectious etiologies
3. Unknown source
4. nonbacterial

Question 15

Pt. presents, and is dx with FUO. What malignancies should you be concerned of? What infections?

Answer 15

a. Hodgkin’s disease or non-Hodgkin’s lymphoma

b. TB and intra abdominal abscesses

Question 16

AA F presents with fever. you notice rash on face, and self reports of arthritis are given. Most likely dx?

Answer 16

SLE

*36% of SLE pts present with fever; and 52% develop one during dx evolution

Question 17

What three disease have fever on presentation often?

Answer 17

• SLE, Giant cell arteritis, IBD

Question 18

What are the alarm sx of a fever?

Answer 18

• high fever (>105.8F)
• rash
• change in mentation
• dizzy/light headed
• recent chemo tx
• SOB or chest pain

Question 19

If high fever is present, consider…

Answer 19

CNS infection, NMS, heat stroke

Question 20

If rash is present with fever, consider…

Answer 20

meningitis, bacteremia with septic shock, rickettsial disease, bacterial endocarditis

Question 21

If mentation change is present with fever, consider…

Answer 21

meningitis, encephalitis, NMS, heat stroke, bacterial infection with septic shock

Question 22

If dizzy/LH is present with fever, consider…

Answer 22

bacterial infection with septic shock, adrenal insufficiency, PE

Question 23

If recent chemo is present with fever, consider…

Answer 23

nosocomial infection with neutropenia

Question 24

If SOB/chest pain is present with fever, consider…

Answer 24

PE, pneumonia, empyema

Question 25

Pt. presents with fever, Janeway lesions, and Roth spots. They admit to using heroin, and had just gotten out of a rehab center in the hospital. You hear an opening snap on auscultation, and learn they suffered from an un treated strep infection as a child. What is the dx? what are the main risk factors this pt faced? How should you go about confirming your dx?

Answer 25

1. Infective endocarditis 2. health care contact and injection drug use are the primary risk factors. IE is associated, traditionally, with RHD 3. blood culture *Staph aureus if leading cause of IE

Question 26

What is the difference between HFrEF and HF with preserved EF? Main causes of each?

Answer 26

a. LV EF 40% or less - CAD--> LV dilation | b. LV EF 50% or more - HTN --> LV hypertrophy

Question 27

What specific signs are seen on PE of HF pt?

Answer 27

o Prominent jugular venous distention o Positive hepatojugular reflux o Laterally displaced apical impulse o Presence of S3 gallop with systolic HF; may have S4 gallop with diastolic HF

Question 28

Pt. presents one week post URI onset, and is now experiencing chest pain, dyspnea, and tachypnea. Echo finds cardiomegaly and contractile dysfunction. Pericardial friction rub is present. MI is ruled out due to normal coronary arteries. What is your dx? What prompted that?

Answer 28

a. Myocarditis b. HF sx, post URI, cardiomegaly, contractile dysfunction, pericardial friction rub, not an MI *primary myocarditis is caused by either an acute viral infection or a post-viral immune response. *secondary is result of inflammation caused by non-viral pathogens, medications, chemicals, physical agents, or inflammatory diseases (such as systemic lupus erythematosus).

Question 29

What may the ECG show in myocarditis?

Answer 29

- sinus tachycardia, other arrhythmias, nonspecific repolarization changes, and intraventricular conduction abnormalities, Q waves or left bundle branch block

Question 30

What may be in the initial, and only, finding in myocarditis?

Answer 30

ventricular ectopy

Question 31

What levels are elevated in myocarditis?

Answer 31

Troponin I or T levels are elevated in about one-third of patients, but CK-MB is elevated in only 10%. Other biomarkers, such as BNP and NT-proBNP, are usually elevated.

Question 32

40 y/o WM Pt. presents complaining of recurrent nose bleeds, a cough, visual disturbances, and skin lesions. What does he have?

Answer 32

Wegener's *Most commonly associated signs/symptoms: Upper and lower respiratory symptoms, renal insufficiency, skin lesions, visual disturbance

Question 33

65y/o WM presents with "bruises" and itchy red bumps. He also reports bowel bleeding and muscle pains. DX?

Answer 33

Microscopic Polyangitis - MPO ANCA * Most commonly associated signs/symptoms: Palpable purpura, macules, vesicles, bullae, urticaria * from Martin's slides: hemoptysis, hematuria, proteinuria, bowel pain or bleeding, muscle pain or weakness, palpable Purpura

Question 34

Pt. presents with track marks, fever, HTN (previous visit 1 year ago was 123/80, but now is 190/140), and myalgias. She admits to sharing needles with her bf. You confirm HBsAG-HBsAB complexes are present and dx her with Hep B. You're done, right?

Answer 34

nah she probs has polyarteritis nodosa too *Most commonly associated sx: fever, HTN, myalgias, abdominal pain, hematuria, CHF, GI bleeds, orchitis

Question 35

If a pt has at least one of what four sx would make you consider a PE?

Answer 35

syncope, dyspnea, chest pain, hemoptysis *but no single sx is reliably diagnostic of PE

Question 36

A high risk PE pt presents with what? Intermediate risk? low risk?

Answer 36

a. Severe dyspnea at rest, Hemodynamic instability that may present as syncope or cardiac arrest b/c. may be asymptomatic or minimally symptomatic

Question 37

What are the most common findings of a PE pt?

Answer 37

 Patient may appear anxious but otherwise comfortable or patient may appear to be very ill  Hypoxemia (with cyanosis in massive or sub-massive pulmonary embolism)  Tachypnea  Tachycardia  Rales  Decreased breath sounds

Question 38

What is the dx of FUO?

Answer 38

 Fever ≥38.3°C (≥101°F) on at least two occasions  Illness duration of ≥3 weeks  No known immunocompromised state  Diagnosis that remains uncertain after a thorough history-taking, physical examination, and the obligatory investigations (ex. ESR, CPR...) *often necessary to withhold ABs if source isn't apparent (unless pt is septic or toxic)

Question 39

Most common causes of FUO?

Answer 39

infection, noninfectious inflammatory diseases, and neoplasms

Question 40

Most common sites of infection for nosocomial infections?

Answer 40

bloodstream, lungs, urinary tract, surgical wounds

Question 41

During morning rounds, you check on your 75y/o F DM patient that has been in the hospital for months due to terminal cancer. On inspection, her catheter is secure. Her daughter, who is a nurse, is present. She reports her mother has declined her outdoor walk due to weakness. What are the risk factors for this pt developing a nosocomial infection?

Answer 41

- age, catheter, nurse (healthcare personnel exposure), lengthy stay, only indoor air exposure, DM ``` others include:  Prior antibiotic use  Iatrogenic  Conditions which require a high amount of interventional procedures (e.g., shock, major trauma, acute renal failure, coma)  Mechanical ventilation ```

Question 42

What causes Human Monocytotropic Ehrlichiosis (HME)?

Answer 42

- Ehrlichia chaffeensis | - transmitted via Lone Star Tick (white tailed deer are major reservoir)

Question 43

What sx are seen in HME?

Answer 43

- fever, HA, myalgia, malaise - leukopenia, thrombocytopenia, elevated aminotransferase levels are also common *complications include: toxic shock like syndrome, respiratory distress, cardiac failure, hepatitis, meningoencephalitis, fulminant infection, hemorrhage

Question 44

What causes ROCKY MOUNTAIN SPOTTED FEVER (RMSF)?

Answer 44

- R. rickettsii - tick transmission - the prevalence is highest in the south-central and southeastern states

Question 45

What are the sx of RMSF?

Answer 45

- rash (distal to proximal), fever - may develop hypovolemia, prerenal azotemia, hypotension, noncardiogenic pulmonary edema, renal failure, hepatic injury, and cardiac involvement with dysrhythmias - CNS involvement (ex. encephalitis)

Question 46

What is the cause of Lyme disease?

Answer 46

- Borrelia burgdorferi | - Ixodes tick (NE, MW), I. pacificus (W) transmission

Question 47

Pt. presents with a red macule that expands to form red outer border and central clearing. What stage of Lyme disease is this?

Answer 47

stage 1 *Central erythema, induration, necrosis, vesicular changes, or many red rings within an outer ring are also possible.

Question 48

Pt. presents with annular skin lesions, Neuro deficits, heart probs, severe HA, stiff neck, fever, chills, migratory arthralgia. What stage of Lyme disease is this?

Answer 48

stage 2

Question 49

Pt. presents with frank arthritis, chronic Neuro probs (memory, mood, sleep alterations), and Acrodermatitis chronica atrophicans. What stage of Lyme disease is this?

Answer 49

stage 3

Question 50

What is post lyme syndrome?

Answer 50

For months or years afterward, ~10% of pts have subjective pain, neurocognitive manifestations, or fatigue symptoms