Transcript Fever
Common Symptoms---Fever and Edema The First Affiliated Hospital of Liaoning Medical College Nephropathy Deparment Zhou HongLi Fever 1 Introduction 2 Pathlogeny and sort 3 Occurrence Mechanism 4 Clinical occurrence 5 Patterns of fever 6 FUO Intruduction 1 normal rang: 36-37℃ 2 higher: late afternoon, evening maximum 8:00-10:00 pm lower: morning minimum 3:00-4:00 am 3measure pathway：rectum (higher 0.3-0.5) mouth axillia (lower 0.2-0.4) Pathlogeny and sort 1 Infective fever-------most common cause ①bacterial ②viral ③rickettsial ④fungal ⑤parasitic Pathlogeny and sort 2 Noninfective fever ①aseptic necrosis mass absorption : tissue ischemia and infarction,vascularitis, subarachnoid hemorrage ②antigen-antibody reaction: acute rheumatic fever, still disease ,serum sickness, systemic lupus erythematosus ③familal fever: congenital familial mediterranean fever ④endocrine disease: endocrine hyperthyroidism ⑤tissue damage:myocardial infarction, pullmonary infarction ⑥drug reaction and gout ⑦tumor: lymphomas,solid tumors ⑧neuroleptic seizures ⑨psychosocial factitious Occurrence Mechanism physiologic temperature elevated----fever (elevation of hypothalamic set point) Pathologic temperature elevated-- hyperthermia ( unregulated heat generation, impaired heat exchange) Occurrence Mechanism--physiologic set point (hypothalamus) regulate Internal temperature maintain cellular function Deviation >4 ℃ cellular dysfunction Occurrence Mechanism increased heat production decreased heat dissipation failure of regulating system Set point change Temperature deviation fever exogenous pyrogen (bacterial, viral) activate neutrophil, eosinophil, mononuclear macrophage release endogenous pyrogen(interleukin-1(IL-1),TNF, interferon） hypothalamus Set point heat production heat dissipation fever Occurrence Mechanism Specific patients: elderly patients renal failure patients high doses of corticosteriods unable to mount fever immunocompromised hosts fever HIV-infected fever nosocomial fever require special consideration Clinical occurrence low-grade fever:37.3-38℃ Grade (oral reading) middle-grade fever:38.1-39℃ high-grade fever:39.1-41℃ hyperthemia:﹥41℃ Clinical occurrence effervescence（heat production ,heat loss ） (chill,rigor,vasoconstriction) clinical features altithermal (reach new set point) (warm,moist,flushed,tarchycardia) defervescence (heat production heat loss ) sweat Patterns of fever Continuous fever Remittent fever Intermittent fever Undulant fever Relapsing fever Episodic fever Pel-Epstein fever Continuous fever ①temperature: 39-40 ℃,days or weeks;diurnal variation 0.5-1.0 ℃ ②disease: typhoid, acute pneumonia Continuous fever Remittent fever ①temperature ＞38 ℃, diurnal variation＞2 ℃ （no normal temeratrue） ②disease: sapraemia,acute rheumatic fever, acute infectious endocarditis Remittent fever Intermittent fever ① suddenly reach climax, continue several hours, suddenly fall to normal, intermission 1-several days ②disease: malaria, acute pyelonephritis Intermittent fever Undulant fever ①slowly reach ＞ 39 ℃,slowly return to normal. (repeate the rhythm) ②disease: brucellosis,tumor Undulant fever Relapsing fever ①suddenly reach 39 ℃ , continue several days, suddenly drop to normal. bout every 5-7days ②disease: spirochetes infection Relapsing fever Episodic fever ①last for days or longer, then without fever for at least 2 weeks ②disease: familial periodic fever Pel-Epstein fever ①continuous or remittent fever bouts several days ②disease: Hodgkin disease FUO—fever of unknown origin Diagnosis criteria: ①the illness last at least 3 weeks; ②38.3 ℃ repeatedly; ③no diagnosis after 1 week hospitalization Causes: ①noninfectious inflammatory disease; ②infections; ③malignancies (hematologic); ④50% unexplained Edema Pathophysiology Clinical occurrence Idiopathic edema Tropical edema angioedema Pathophysiology hydrostatic and oncotic pressure A fluid fluid filter out interstitial tissues Keep in balance V resorption equilibrating factors filtration resorption capillary hydrostatic pressure interstitial fluid colloid osmotic pressure serum colloid osmotic pressure interstitial tissues pressure Filtration > resorption edema Factors leading to edema retention of sodium and water capillary filtration pressure（right heart failure） capillary permeability （acute nephritis） serum colloid osmotic pressure (serum albumin ) lymphatic return disturbance (filariasis) pitting edema detectable:4.5kg fluid accumulate identify method : press thumb into the skin against a bony surface (anterior tibia, fibula,dorsum of foot, sacrum) to demonstrate the presence of edema when the thumb is withdrawn, an indention persist for a short time. Site of edema: walking patient--feet, ankles gravity supine patient--posterior calves, sacrum both legs and symmetric—in the pelvis or more proximally arms and head---superior vena cava limited one extremity-vascular channels, local inflammation Brawny edema: chronic edema of the legs leads to fibrosis of the subcutaneous tissues and skin, so they no longer pit on pressure. Clinical occurrence Localized edema cause: local vein or lymphatic return,soft tissues disturbance or capillary permeability disease: Inflammation infection insufficiency of the venous valves chemical or physical injuries arteriovenous fistulas site: above the diaphragm--superior vena cava obstruction below the diaphragm—jugular venous press ,portal vein hypertension, loss of venous tone drugs Generalized edema: cardiac edema renal edema hepatic edema nutritional edema (protein losing conditions) Drug (corticosteroid, NSAID) Systemic inflammatory response syndrome(SIRS) Cardic edema Symptoms: chest distress, short breath, dyspnea Site: lower limbs Disease： right heart failure renal edema Symptoms：hematuria，proteinuria Site: eyelid，legs Disease: nephrotic syndrome hepatic edema Symptoms: anorexia, vomitting,liver function test abnormal Site: first lower limbs, then spread all over the body, ascites is most common Disease：cirrhosis, chronic liver disease Protein losing conditions Enteropathy Burns fistulas Idiopathic edema women in 30-50years old without disease,affective disorders and obesity may coexist Mechanism :upright posture --capillary leakage inappropriate chronic diuretic administration activate -----peripheral edema hormones involved in salt and water retention Tropical edema Normal adults condition:48h after traveled from temperate climate to tropics or from cool and dry to warm and humid resolve quickly in a few days of acclimatization Angioedema Site: face,lips,tongue, larynx----life-threatening Subcutaneous soft-tissue edema ;Erythema is not prominent. Causes: hereditary absence of C1 esterase exposure to allergen angiotensin-converting enzyme inhibitors 1Reasons of infective fever 2Grades of fever. 3Patterns of fever. 4cause of generaliz edema 5How to distinguish cardiac edema from renal edema?