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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


bacterial
viral
rickettsial
fungal
parasitic
Pathlogeny and sort

2 Noninfective fever
aseptic necrosis mass absorption : tissue is
chemia and infarction,vascularitis, subarach
noid hemorrage
antigen-antibody reaction: acute rheumatic f
ever, still disease ,serum sickness, systemic
lupus erythematosus
familal fever: congenital familial mediterran
ean fever
endocrine disease: endocrine hyperthyroidism
tissue damage:myocardial infarction,
pullmonary infarction
drug reaction and gout
tumor: lymphomas,solid tumors
neuroleptic seizures
psychosocial factitious
Occurrence Mechanism
physiologic temperature elevated----fever
(elevation of hypothalamic set point)

Pathologic temperature elevated-- hyperthermia


( unregulated heat generation, impaired heat exch
ange)
Occurrence Mechanism--physiologic

set point (hypothalamus)


regulate

Internal temperature
maintain

cellular function
Deviation >4

cellular dysfunction
Occurrence Mechanism
increased heat production
decreased heat dissipation Set point change
failure of regulating system
Temperature deviation

fever
exogenous pyrogen (bacterial, viral)
activate
neutrophil, eosinophil, mononuclear macrophage
release
endogenous pyrogen(interleukin-1(IL-1),TNF, interfero
n

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

middle-grade fever:38.1-39
Grade
high-grade fever:39.1-41
(oral reading)
hyperthemia: 41
Clinical occurrence

effervescence heat production ,heat loss



(chill,rigor,vasoconstriction)
clinical features altithermal (reach new set point)
(warm,moist,flushed,tarchycardi
a)
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

temperature: 39-40 ,days or weeks;diurnal variati


on 0.5-1.0
disease: typhoid, acute pneumonia
Continuous fever
Remittent fever

temperature 38 , diurnal variation 2


no normal temeratrue
disease: sapraemia,acute rheumatic fever,
acute infectious endocarditis
Remittent fever
Intermittent fever

suddenly reach climax, continue several h


ours, suddenly fall to normal, intermission
1-several days
disease: malaria, acute pyelonephritis
Intermittent fever
Undulant fever

slowly reach 39 ,slowly return to nor


mal. (repeate the rhythm)
disease: brucellosis,tumor
Undulant fever
Relapsing fever

suddenly reach 39 , continue several day


s, suddenly drop to normal. bout every 5-7
days
disease: spirochetes infection
Relapsing fever
Episodic fever

last for days or longer, then without fever f


or at least 2 weeks
disease: familial periodic fever
Pel-Epstein fever

continuous or remittent fever bouts sever


al days
disease: Hodgkin disease
FUOfever of unknown origin

Diagnosis criteria:
the illness last at least 3 weeks;
38.3 repeatedly;
no diagnosis after 1 week hospitalization
Causes:
noninfectious inflammatory disease;
infections;
malignancies (hematologic);
50% unexplained
Edema
Pathophysiology
Clinicaloccurrence
Idiopathic edema
Tropical edema
angioedema
Pathophysiology hydrostatic and oncotic pressure

A fluid fluid V

filter resorption
interstitial tissues
out

Keep in balance
equilibrating factors

capillary hydrostatic pressure


filtration
interstitial fluid colloid osmotic pressure

serum colloid osmotic pressure


resorption
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 surfa
ce (anterior tibia, fibula,dorsum of foot, sacrum
to demonstrate the presence of edema. when th
thumb is withdrawn, an indention persist for a s
ort time.
Site of edema:

walking patient--feet, ankles gravity


supine patient--posterior calves, sacrum

both legs and symmetricin the pelvis or mor


e 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 tiss
ues disturbance or capillary permeability
disease: Inflammation infection

insufficiency of the venous valves


chemical or physical injuries
arteriovenous fistulas
site: above the diaphragm--superior ve
na cava obstruction
below the diaphragmjugular venou
s 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, dyspn


ea
Site: lower limbs
Disease right heart failure
renal edema

Symptoms hematuria proteinuria


Site: eyelid legs
Disease: nephrotic syndrome
hepatic edema

Symptoms: anorexia, vomitting,liver funct


ion 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 di


sorders and obesity may coexist
Mechanism :upright posture --capillary leakage
inappropriate chronic diuretic administration
activate
-----peripheral edema
hormones involved in s
alt and water retention
Tropical edema
Normal adults
condition:48h after traveled from temperate clim
ate 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 ren
al edema?