Page 24 - Medicine and Surgery

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20 Chapter 1: Principles and practice of medicine and surgery

Table 1.6 Causes of pyrexia of unknown origin tenderness or rigidity and a neurological evaluation
including fundoscopy.
Cause % Examples
Infection 30–40 Bacterial infections – bacterial
endocarditis, abscess (e.g. Investigations
intra-abdominal), hepatobiliary 1 Initial investigations: close monitoring of tempera-
infection, urinary tract infection, ture;chestX-ray;urineforurinalysis,microscopy,cul-
osteomyelitis, typhoid fever, ture and sensitivity; full blood count and peripheral
tuberculosis, brucellosis, Lyme blood film; repeated blood cultures taken at times of
disease, syphilis
Viral infections – cytomegalovirus fever; culture of wounds, intravenous lines and other
infection, Epstein–Barr virus, HIV relevant sites, e.g. CSF; urea, creatinine, electrolytes
infection and blood sugar; creatine kinase and liver function
Fungal infections – Candida tests; C-reactive protein, ESR and immunoglobulins.
albicans, Cryptococcus
Protozoal infections – malaria, 2 Specific blood tests and microbiology may be required
toxoplasmosis for certain indications:
Neoplasia 20–30 Renal cell carcinoma, Malarial exposure: Repeated thick and thin blood
hepatocellular carcinoma, films, antigen testing.
disseminated carcinoma, Intravenous drug use or at risk: Hepatitis serology,
lymphomas, atrial myxoma
Rheumatological 10–20 Rheumatoid arthritis, SLE, vasculitis HIV testing.
Suspected thyrotoxicosis: Thyroid function testing.
Disorders (polymyalgia rheumatica,
temporal arteritis, polyarteritis Suspected rheumatological disorder: ANA, anti-
nodosum) DNA antibody, ANCA.
Miscellaneous 15–20 Drugs, thyrotoxicosis, Crohn’s Specific agent suspected: Serial titres for EBV, CMV,
disease, sarcoidosis, occult influenza, Toxoplasma, Lyme disease, chlamydia,
haematoma
No diagnosis 5–15 salmonella, Borrelia recurrentis,Q fever, leptospiro-
sis.
3 Other procedures that may also be considered are
Clinical features abdominal ultrasound for intra-hepatic, sub-
Acarefulhistory,includingsystematicreviewisessential. phrenic or paracolic abscesses.
Patternanddurationoffever(althoughthecorrelation
white cell scan for demonstration of an abscess,
between fever patterns and specific diseases is weak), empyema or osteomyelitis.
weight loss, night sweats, headaches, rashes and any bone scan for osteomyelitis or metastatic bone dis-
other symptoms. ease.
Previous illnesses including operations and psychi-
CT and MRI for lymphoma, tumours or abscesses.
atric illnesses. transoesophageal echocardiography for infective
Specific factors including family history, immunisa-
endocarditis or atrial myxoma.
tionstatus,occupationalhistory,travelhistory,history bone marrow biopsy for leukaemia or culture for
of consumption of unusual foods (e.g. unpasteurised miliary TB.
milk), drug history (including over-the-counter med- biopsy either endoscopically or percutaneously of
ications, homeopathic preparations, drugs of abuse), suspected area.
sexual history, infectious contacts and animal con-
tacts (including possible exposure to ticks and other Management
vectors). Blind treatment should be avoided unless the patient is
A full systematic examination is required including the septicaemic or deteriorating. In such cases a best guess
following: of the cause and hence the antibiotic cover has to be
Documentation of pattern and duration of fever.
made depending on the results of history, examination
Specific features include rashes, lymphadenopathy,
and investigations available. It is essential to continue
genitoperitoneal lesions, organomegaly, new or chan- regular reassessment for new symptoms or signs and to
ging cardiac murmurs, signs of arthritis, abdominal stop all other drugs wherever possible.