Fever

CME to hospital staff

1. Approach To Fever Dr. Sachin Nepali MBBS

2. Normal Body Temperature Normal: 98 ° F – 99 ° F Diurnal variatiation of 0.5 °F - 1 °F; temp being lowest in the morning and highest in evening Subnormal < 98 °F Pyrexia > 99 °F Hypothermia < 95 °F Hyperpyrexia > 106.7 °F

3. Normal body temperature Mean oral temperature is 36.8° ± 0.4°C (98.2° ± 0.7°F), with low levels at 6 a.m. and higher levels at 4–6 p.m Maximum normal oral temperature is 37.2°C (98.9°F) at 6 a.m. and 37.7°C (99.9°F) at 4 p.m An a.m. temperature of >37.2°C (>98.9°F) or A p.m. temperature of >37.7°C (>99.9°F) defines a fever

4. Rectal temperatures are generally 0.4°C (0.7°F) higher than oral readings Increase in the hypothalamic set point [e.g., from 37°C to 39°C (98.6°F to 102.2°F)] A fever of >41.5°C (>106.7°F) is called hyperpyrexia

5. Pathogenesis

6. FEVER INFECTIONS MALIGNANCIES CONNECTIVE TISSUE DISEASE OTHERS Sinusitis URTI LRTI Tuberculosis Typhoid Fever Malaria Kala- azar Dengue Typhus Leptospirosis Meningitis Hepatitis A & B Leukemia Lymphoma Rheumatoid arthritis Rheumatic fever SLE Vasculitis Drug-induced 7 Aetiology/Differential diagnosis

7. History MODE OF ONSET Fever due to acute infections is acute in onset e.g in malaria or pneumonia Fever due to chronic diseases is gradual in onset. RIGORS & CHILLS Indicate a sudden rise in body temperature due to acute infection e.g Malaria

8. Grading of fever No precise definition of grade of fever. Temperature Grade < 101 ̊F Low grade fever > 102 ̊F High grade fever < 95 ̊F Hypothermia > 106.7 ̊F Hyperpyrexia

9. Pattern of fever Continuous fever Remittent fever Relapsing fever Intermittent fever Tertian fever Quotidian fever Quartan fever

10. ASSOCIATED SYMPTOMS Headache Vomiting Night sweats Sore throat Ear discharge Cough(chest infection) Diarrhea with blood and mucus (dysentery) Rash Pain abdomen Pain in flank ( pyelonephritis ) Dysuria , burning micturation (UTI)

11. Personal History Occupation Travel history Sexual history if suspected sexually transmitted disease

12. Family History Recent infection in family TB in family (contact history)

13. Drug History Antibiotics Immunosuppressants

14. Others Recent immunization Infant

15. Physical Examination: Vital Signs Lymphadenopathy Skin Lesions, Mucous Membrane Eyes ENT examination Respiratory Examination CVS Abdominal Examination ( Hepatomegaly,Splenomegaly ) Neurological Examination Musculoskeletal

16. Investigation Hb TC DC ESR, CRP MP antigen USG Urine Examination Sputum AFB CXR Blood culture

17. Treatment IV fluids/Oral rehydration O2 Paracetamol Aspirin Ibuprofen Tepid sponge bath / Cold sponging Treat the cause

18. N S A I Ds

19. Class Drugs Nonselective COX inhibitors Salicylates Aspirin Propionic acid derivative Ibuprofen, Naproxen, Ketoprofen , Flurbiorofen Anthranilic acid derivative Mephenamic acid Aryl acetic acid derivative Diclofenac , Aceclofenac Oxicam derivative Piroxicam , Tenoxicam Pyrrolo-pyrrole derivative Ketorolac Indole derivative Indomethacin Pyrazolone derivatives Phenylbutazon , Oxyphenbutazone Preferential COX-2 inhibitors Nimesulide , Meloxicam , Nabumeetone Selective COX-2 inhibitors Celecoxib , Etoricoxib , Parecoxib

20. Analgesics-antipyretics with poor antinflammatory action Paraaminophenol derivative Paracetamol (Acetaminophen) Pyrazolone derivatives Metamizolone , Propiphenazone Benzoxazocine derivatives Nefopam

21. Dose of common antipyretics Paracetamol : 10-15 mg/kg/dose Adult: 500mg – 1gm 4-6 hrly (maximum 4gm/24 hrs) Nimesulide : 5mg/kg/day q 8-12 hr Adult dose: 100mg BD

22. Ibuprofen: 10-15mg/kg/dose q 4-6 hr Adult dose: 400mg q 8 hr Diclofenac sodium: 1-3 mg/kg/day q hr oral/IM Adult dose: 50-150 mg/day q 8 hr

23. Pathways of biosynthesis of Eicosanoids

24. Thank You