Septicemia

Encephalitis

Serotonin syndrome

Thyroid storm

Neuroleptic malignant syndrome.

Aseptic Fever

Malignancies

Acute myocardial infarction

Sarcoidosis

Chronic renal failure

Collagen vascular diseases

Drug fever

Radiation sickness

Postsurgical patients.

Drug Fever

It is a prolonged fever with relative bradycardia and hypotension. It persists 2–3 days even after drug is

withdrawn and is associated with rash and eosinophilia. For example, penicillin, procainamide,

propylthiouracil, sulfonamides, anticonvulsant, etc.

Note: All drugs except digitalis can cause drug induced fever.

Nature of Defervescence

The nature of fever defervescence may also provide some diagnostic clues.

Defervescence by crisis (Fig. 2B.33) Defervescence by lysis (Fig. 2B.34)

Within hours Gradually over days

Example: Effective antimalarial therapy leads to fever

defervescence by crisis

Example: Typhoid fevers resolution occurs by lysis following

effective antibiotics

Disorders of increased body temperature

Hyperpyrexia The body’s temperature regulation mechanism sets the body temperature above the normal temperature, then

generates heat to achieve this temperature

Hyperthermia Unchanged (normothermic) setting of the thermoregulatory center in conjunction with an uncontrolled increase

in body temperature that exceeds the body’s ability to lose heat

Heat stroke Acute condition of hyperthermia that is caused by prolonged exposure to excessive heat/± humidity. The heatregulating mechanisms of the body eventually become overwhelmed and unable to effectively deal with the

heat, causing the body temperature to climb uncontrollably

Malignant

hyperthermia

Occurs in individuals with an inherited abnormality of skeletal-muscle sarcoplasmic reticulum that causes a

rapid increase in intracellular calcium levels in response to halothane and other inhalational anesthetics or to

succinylcholine

Neuroleptic malignant

syndrome

(NMS)

Seen with neuroleptic use (antipsychotic phenothiazines, haloperidol, prochlorperazine, and metoclopramide)

or the withdrawal of dopaminergic drugs. Characterized by “lead-pipe” muscle rigidity, extrapyramidal side

effects, autonomic dysregulation, and hyperthermia

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Fig. 2B.33: Defervescence by crisis.

Fig. 2B.34: Defervescence by lysis in typhoid fever.

Hypothermia

Hypothermia is defined as a core temperature below 35°C (95°F).

Mild hypothermia Core temperature 32– 35°C (90–95°F)

Moderate hypothermia Core temperature 28–32°C (82–90°F)

Severe hypothermia Core temperature below 28°C (82°F)

Profound hypothermia Core temperature <24°C (75°F) or <20°C (68°F)

Causes of Hypothermia

Decreased heat production

Hypopituitarism

Hypoadrenalism

Hypothyroidism

Increased heat loss

Burns

Cold immersion injuries

Vasodilatation from pharmacologic or toxicologic agents

Cold infusions

Overenthusiastic treatment of heatstroke

Impaired thermoregulation

Central nervous system (CNS) trauma

Strokes

Toxicologic and metabolic derangements

Intracranial bleeding

Parkinson disease

CNS tumors

Miscellaneous causes

Sepsis

Multiple trauma

Pancreatitis

Prolonged cardiac arrest

Uremia

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Wernicke disease

Multiple sclerosis

Named fevers Disease/organism

Glandular fever Infectious mononucleosis (EBV)

Pappataci, 3 days, sandfly fever Phlebotomus fever

Goal fever Rickettsia prowazekii

Malta, undulating fever Brucellosis

Relapsing fever Borrelia recurrentis (louse)

B. duttoni (Tick)

Rat bite fever Spirillum minus

Streptobacillus moniliformis

Trench or 5 day fever Bartonella quintana

Oroya fever Bartonella bacilliformis

Q fever Coxiella burnetti

7 day fever Leptospira hebdomadis

Pretibial fever L. atumnale

Haverhill fever Streptobacillus moniliformis

Pontiac fever Legionella

Monkey fever Kyasanur forest disease

Biphasic fever Dengue

Kala-azar

Chikungunya

Polio

Valley fever Coccidioidomycosis

Dumdum/burdwan fever Kala-azar

Brazilian purpuric fever H. aegyptius

PAIN: THE FIFTH VITAL SIGN

Pain is recognized as the fifth vital sign.

Assessment should include:

Location

Intensity

Character/quality

Frequency

Duration

Pattern.

Location—determine as precisely as possible where the pain is felt. Indicate if the pain radiates or

moves.

Intensity—a grade of how severe the pain is, using a pain assessment tool the resident finds easy to

use, e.g. a numerical, verbal descriptor, faces, or behavioral.

Frequency:

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The occurrence of the pain.

How often the pain occurs?

Is it breakthrough pain?

Quality—aching, annoying, cramping, exhausting, nauseating, pounding, sharp, throbbing, stabbing,

agonizing, blowing, dull, fearful, nagging, penetrating, quivering, shooting, suffocating, numbness,

tingling, weakness, spasm, burning, gnawing, pressure, squeezing, radiating, tingling, touch sensitive,

etc.

Pain behaviors—facial (wrinkled forehead, tightly closed eyes, grimacing, and frowning), nonverbal

behavior (bracing, rubbing, and guarding), and vocalizations (crying, yelling, groaning, and moaning).

Nonverbal indicators of discomfort—aggressive, crying, fearful, noisy respirations, pacing, repetitive,

restless, rocking, confusion, irritability, increased activity, withdrawal, tense, calling out, grunting, knees

pulled up, other change in usual activities, or behavior patterns/routine.

Duration:

How long does the pain last (minutes or hours)?

Sudden or gradual onset.

Is it consistent or persistent?

Does it change over time or come and go (intermittent)? If intermittent—frequency, duration, and

circumstances in which it occurs.

Pattern:

How does the pain start?

What was being done when it started?

What makes it better?

What makes it worse?

Types of Pain

Somatic pain (bone and muscle) is:

Relatively well localized, worse on movement

Tender to pressure over the area

Often accompanied by a dull background aching pain.

Visceral pain is:

Often poorly localized, deep, and aching

Usually constant

Often referred (e.g. diaphragmatic irritation may be referred to the right shoulder; pelvic visceral

pain is often referred to the sacral or perineal area).

Fig. 2B.35: Pain assessment model.

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Neuropathic pain is:

A constant, superficial burning sensation, or a deeply aching quality that may be accompanied by

some sudden, sharp, shooting, and lancinating (stabbing) pain.

In a relatively constant area of the body surface (dermatome), if caused by actual damage to a

specific peripheral nerve, plexus, root, or spinal cord.

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C. PHYSICAL EXAMINATION

PALLOR

Definition

Paleness of skin and mucous membranes.

Sites of Examination

Conjunctiva (Fig. 2C.1)

Tongue

Oral mucosa

Palmar crease (Fig. 2C.2)

Nail bed (Hb <8 g/dL).

Fig. 2C.1: Method of demonstration of pallor over conjunctiva.

Grading of Pallor

Mild Moderate Severe

Cannot be detected clinically Clinically visible Clinically visible plus one of the following features

Palmar crease disappearance

Cervical venous hum (suggestive of chronic compensation)

Method of Elicitation of Cervical Venous Hum (Fig. 2C.3)

Auscultate the root of the neck on the right side with bell of stethoscope, with patient in standing or

sitting position.

A continuous murmur will be heard.

The cervical venous hum was first described by Pontain and hence called Pontain’s murmur.

The presence of a cervical venous hum indicates chronic compensated severe anemia.

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Fig. 2C.2: Demonstration of pallor in hands.

Fig. 2C.3: Demonstration of cervical venous hum.

Conditions Causing Pallor without Anemia

Hypopituitarism

Hypothyroidism

Hypogonadism

Shock

Left heart failure.

Definition of Anemia

Anemia is defined as decrease in circulating red blood cell (RBC) mass. It is characterized by decrease

of hemoglobin concentration (Hb)/RBC count/hematocrit [packed-cell volume (PCV)] below normal for

the patient’s age, sex, and altitude of residence.

Normal adult hemoglobin level is in the range of 13–17 g/dL in males and 12–15 g/dL in females.

Clues for Etiology of Anemia

Iron deficiency anemia

Specific symptoms Pica, dysphagia, restless leg syndrome, and melena

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