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2025.３.16時点のCOVIDとインフルエンザのまとめ
新米ID
1934704
6208
Approach to Fever (Basic)
順天堂大学医学部総合診療科学講座/マヒドン大学熱帯医学部・医学部
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概要
Approach to Fever (Basic)
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専攻医／専門医
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発熱へのアプローチと基本的な考え方
#1.
Approach to Fever (Basic) Juntendo University faculty of medicine, department of general medicine hirotake mori h.mori.oa@juntendo.ac.jp
#2.
Approach to Fever (Basic) – Main Points Fever – 5 causes Onset Symptoms ROS Treatment of bacterial infections – 3 principles Culture & gram stain Importance of anatomy Age and sex History and physical examination
#3.
Case 1: 25-year-old female Presenting complaint: fever & cough Current medical history The patient usually suffers from allergic rhinitis and receives antihistamine prescriptions from the ENT department. She presented to the emergency outpatient department after developing a fever of 39˚C. A cough has been present for 1 week. There is purulent rhinorrhea (nasal discharge) and nasal obstruction but only a small amount of sputum. She works as a daycare teacher and has an upcoming sports day event in 2 days. She appears distressed at the prospect of not being able to participate due to ill health. ROS negative for pharyngitis, abdominal pain, constipation, diarrhea, urinary symptoms, myalgia, and arthralgia. What do you think is causing the fever?
発熱の原因と症例1の詳細
#4.
Causes of fever ①Infection ②Autoimmune diseases and vasculitis ③Malignancy (malignant lymphoma, solid tumors) ④Drug-induced (including supplements and alcohol) ⑤Auto-inflammatory disease (Familial Mediterranean fever) ⑥Other (hyperthyroidism, pancreatitis, gout, venous thrombosis)
#5.
Case 1: 25-year-old female Presenting complaint: fever & cough Current medical history The patient usually suffers from allergic rhinitis and receives antihistamine prescriptions from the ENT department. She presented to the emergency outpatient department after developing a fever of 39˚C. A cough has been present for 1 week. There is purulent rhinorrhea (nasal discharge) and nasal obstruction but only a small amount of sputum. She works as a daycare teacher and has an upcoming sports day event in 2 days. She appears distressed at the prospect of not being able to participate due to ill health. ROS negative for pharyngitis, abdominal pain, constipation, diarrhea, urinary symptoms, myalgia, and arthralgia.
#6.
Case 1: 25-year-old female Presenting complaint: fever & cough Current medical history The patient usually suffers from allergic rhinitis and receives antihistamine prescriptions from the ENT department. She presented to the emergency outpatient department after developing a fever of 39˚C. A cough has been present for 1 week. There is purulent rhinorrhea (nasal discharge) and nasal obstruction but only a small amount of sputum. She works as a daycare teacher and has an upcoming sports day event in 2 days. She appears distressed at the prospect of not being able to participate due to ill health. ROS negative for pharyngitis, abdominal pain, constipation, diarrhea, urinary symptoms, myalgia, and arthralgia.
感染症の発症と診断の進め方
#7.
Onset Bacterial infection 1-month rule Acid-fast bacilli （TB, non-tuberculous mycobacterial infection） Chlamydia, infective endocarditis Abscess Viral infection 2 week rule Herpesviruses (HSV, VZV, EBV) HIV, HBV, HCV
#8.
Infection Microorganism (bacterial infection) = symptoms ROS Review of systems Pneumonia = cough, chest pain Cystitis = painful urination, dysuria, cloudy urine Enteritis = diarrhea, abdominal pain Meningitis = headache
#9.
Infection Bacteria vs Viruses Pneumococcal pneumonia vs influenza Streptococcus pyogenes vs influenza Bacterial infection are more focal ⇒Infective endocarditis being an exception
#10.
Case 1: 25-year-old female Diagnosis: bacterial pneumonia, bacterial sinusitis The next step… Presenting complaint: fever & cough Current medical history The patient usually suffers from allergic rhinitis and receives antihistamine prescriptions from the ENT department. She presented to the emergency outpatient department after developing a fever of 39˚C. A cough has been present for 1 week. There is purulent rhinorrhea (nasal discharge) and nasal obstruction but only a small amount of sputum. She works as a daycare teacher and has an upcoming sports day event in 2 days. She appears distressed at the prospect of not being able to participate due to ill health. ROS negative for pharyngitis, abdominal pain, constipation, diarrhea, urinary symptoms, myalgia, and arthralgia. Onset and symptom
細菌感染の診断と治療の原則
#11.
Diagnosis and Treatment of Bacterial Infection: 3 Principles Causative agent Host immunity Antibiotics Surgical treatment Infected Organ
#12.
Identification, Gram stain, and culture of the microorganism Consideration of incision and drainage Gram stain, acid-fast stain, culture Echo, X-ray, CT, MRI Past medical history, medication history Diabetes, steroids, immunosuppressants, renal failure, hepatic failure Culture is important Diagnosis and Treatment of Bacterial Infection: 3 Principles Causative agent Host immunity Antibiotics Surgical treatment Infected Organ
#13.
Case 1: 25-year-old female Diagnosis: bacterial pneumonia, bacterial sinusitis, H. influenzae Antibiotic therapy: Ceftriaxone（a third-generation cephalosporin antibiotic) Presenting complaint: fever & cough Current medical history The patient usually suffers from allergic rhinitis and receives antihistamine prescriptions from the ENT department. She presented to the emergency outpatient department after developing a fever of 39˚C. A cough has been present for 1 week. There is purulent rhinorrhea (nasal discharge) and nasal obstruction but only a small amount of sputum. She works as a daycare teacher and has an upcoming sports day event in 2 days. She appears distressed at the prospect of not being able to participate due to ill health. ROS negative for pharyngitis, abdominal pain, constipation, diarrhea, urinary symptoms, myalgia, and arthralgia.
症例2: 左側の頸部腫脹の評価
#14.
Case 2: 63-year-old female Presenting complaint: left-sided neck swelling Current medical history: Half a year ago, the patient noticed a small swelling on the left side of her neck but left it unattended. 2 months ago the swelling started to enlarge and her shoulder stiffness became worse. She was seen by a local doctor and referred for further examination of the neck swelling. 2 weeks ago a fever in the range of 37˚C developed and the left upper limb became swollen. ROS negative for pharyngitis, respiratory tract symptoms, gastrointestinal symptoms, urinary symptoms, and weight loss.
#15.
Case 2: 63-year-old female What is your differential diagnosis? What will you do next? Presenting complaint: left-sided neck swelling Current medical history: Half a year ago, the patient noticed a small swelling on the left side of her neck but left it unattended. 2 months ago the swelling started to enlarge and her shoulder stiffness became worse. She was seen by a local doctor and referred for further examination of the neck swelling. 2 weeks ago a fever of 37˚C developed and the left upper limb became swollen。. ROS negative for pharyngitis, respiratory tract symptoms, gastrointestinal symptoms, urinary symptoms, and weight loss.
#16.
Case 2: 63-year-old female Anatomy is important Lymph node(s), parotid gland, submandibular gland, muscle, thyroid, vasculature, bone. Presenting complaint: left-sided neck swelling Current medical history: Half a year ago, the patient noticed a small swelling on the left side of her neck but left it unattended. 2 months ago the swelling started to enlarge and her shoulder stiffness became worse. She was seen by a local doctor and referred for further examination of the neck swelling. 2 weeks ago a fever of 37˚C developed and the left upper limb became swollen。. ROS negative for pharyngitis, respiratory tract symptoms, gastrointestinal symptoms, urinary symptoms, and weight loss.
頸部リンパ節腫脹の鑑別診断
#17.
Cervical lymphadenopathy Rapid growth is accompanied by pain.
#18.
Case 2: 63-year-old female Differential diagnosis: Malignant lymphoma, tuberculous lymphadenopathy, solid tumour (rule out thyroid cancer) Presenting complaint: left-sided neck swelling Current medical history: Half a year ago, the patient noticed a small swelling on the left side of her neck but left it unattended. 2 months ago the swelling started to enlarge and her shoulder stiffness became worse. She was seen by a local doctor and referred for further examination of the neck swelling. 2 weeks ago a fever of 37˚C developed and the left upper limb became swollen。. ROS negative for pharyngitis, respiratory tract symptoms, gastrointestinal symptoms, urinary symptoms, and weight loss.
#19.
Case 3: 23-year-old female Presenting complaint: left-sided neck pain Current medical history: Three months ago the patient developed a fever of 37˚C and has been left with a sense of malaise since. Two months ago she had a blood test at a local outpatient department and a raised WBC (9900) and CRP (5) were identified. She was seen by a local ENT doctor two months ago as she developed pain in the left side of her neck which increased in severity. However, a cause was not identified. A repeat blood test revealed an elevated WBC (13,000) and CRP (5). When having her blood taken at the ENT department, she started to feel unsteady and nauseated. A vasovagal response was suspected. She was referred for further assessment of a 3 month inflammatory response, malaise, and unsteadiness.
症例3: 左側の頸部痛の詳細と鑑別診断
#20.
Case 3: 23-year-old female What is the differential diagnosis? Lymph nodes, parotid glands, and tonsils are not enlarged Presenting complaint: left-sided neck pain Current medical history: Three months ago the patient developed a fever of 37˚C and has been left with a sense of malaise since. Two months ago she had a blood test at a local outpatient department and a raised WBC (9900) and CRP (5) were identified. She was seen by a local ENT doctor two months ago as she developed pain in the left side of her neck which increased in severity. However, a cause was not identified. A repeat blood test revealed an elevated WBC (13,000) and CRP (5). When having her blood taken at the ENT department, she started to feel unsteady and nauseated. A vasovagal response was suspected. She was referred for further assessment of a 3 month inflammatory response, left-sided neck pain, malaise, and unsteadiness. Anatomy is important Lymph node(s), parotid gland, submandibular gland, muscle, thyroid, va
#21.
Age
#22.
Age, Sex Red: frequent occurrence in females. Blue: frequent occurrence in males.
#23.
Case 3: 23-year-old female What is the differential diagnosis? Lymph nodes, parotid glands, and tonsils are not enlarged Presenting complaint: left-sided neck pain Current medical history: Three months ago the patient developed a fever of 37˚C and has been left with a sense of malaise since. Two months ago she had a blood test at a local outpatient department and a raised WBC (9900) and CRP (5) were identified. She was seen by a local ENT doctor two months ago as she developed pain in the left side of her neck which increased in severity. However, a cause was not identified. A repeat blood test revealed an elevated WBC (13,000) and CRP (5). When having her blood taken at the ENT department, she started to feel unsteady and nauseated. A vasovagal response was suspected. She was referred for further assessment of a 3 month inflammatory response, left-sided neck pain, malaise, and unsteadiness. Anatomy is important Lymph node(s), parotid gland, submandibular gland, muscle, thyroid, va
#24.
Case 3: 23-year-old female What is the differential diagnosis? Vasculature, bone, TB, autoimmune disease or malignancy. Presenting complaint: left-sided neck pain Current medical history: Three months ago the patient developed a fever of 37˚C and has been left with a sense of malaise since. Two months ago she had a blood test at a local outpatient department and a raised WBC (9900) and CRP (5) were identified. She was seen by a local ENT doctor two months ago as she developed pain in the left side of her neck which increased in severity. However, a cause was not identified. A repeat blood test revealed an elevated WBC (13,000) and CRP (5). When having her blood taken at the ENT department, she started to feel unsteady and nauseated. A vasovagal response was suspected. She was referred for further assessment of a 3 month inflammatory response, left-sided neck pain, malaise, and unsteadiness.
不明熱の定義と考慮すべき疾患
#25.
Contrast CT of the neck and thorax Aortitis syndrome (Takayasu’s arteritis)
#26.
Fever of Unknown Origin According to Petersdorf et.al, the definition of a classical fever of unknown origin is a fever of >38.3˚C occurring on separate occasions over a period of at least 3 weeks with no cause being identified after 1 week of hospital investigation. Infection Bacteria abscess, infective endocarditis, TB, non-tuberculous mycobacterial infection, chlamydia Viruses HIV, herpesviruses Autoimmune diseases, vasculitis Malignancy Drug-induced
#27.
不明熱 According to Petersdorf et.al, the definition of a classical fever of unknown origin is a fever of >38.3˚C occurring on separate occasions over a period of at least 3 weeks with no cause being identified after 1 week of hospital investigation. Infection Bacteria abscess, infective endocarditis, TB, non-tuberculous mycobacterial infection, chlamydia Viruses HIV, herpesviruses Autoimmune diseases, vasculitis Malignancy Drug-induced Always make sure a blood culture is taken!
発熱へのアプローチのまとめ
#28.