Chief Complaint

Clinical Diagnosis
34 Symptoms
1. Fever 💢 12. Palpitation 25. Oliguria, Anuria &
2. Headache 13. Nausea & Vomiting Polyuria
3. Edema 14. Dysphagia 26. Urinary
4. Obesity 15. Dyspepsia Incontinence
5. Emaciation 16. Abdominal Pain 27. Dysuria
6. Anemia 17. Hematemesis 28. Low Back Pain
7. Mucocutaneous 18. Hematochezia 29. Arthralgia
Hemorrhage 19. Diarrhea 30. Vertigo
8. Cough and 20. Dyspnea 31. Syncope
Expectoration 21. Constipation 32. Tics and
9. Hemoptysis 22. Jaundice Convulsion
10. Chest Pain 23. Hematuria 33. Disturbance of
11. Cyanosis 24. Frequency, Urgency Consciousness
& Dysuria 34. Affective Disorder
Fever 发热
Rise of body temperature above normal 37.5 ℃
Table of contents

01 Definition 05 Accompanying Symptoms & Signs

02 Mechanism Fever 06 Treatment
03 Etiology 07 Key Points
04 Clinical Manifestation
01 Definition

Normal body temperature: 36-37.5 ℃

Daily fluctuation range < 1℃

Circadian of body temperature

Variation of body temperature by age

◆ 0-2 years
◆ 3-10 years
◆ 11-65 years Adult
◆ Over 65 years

Why is the body temperature stable?

01 Definition

Why is the body temperature stable?

Diencephalon
Which part of the
Diencephalon has a function
for temperature regulation?

H_ _ _ _H _ _ _ M _ _
12 Letters
01 Definition

HYPOTHALAMUS

The hypothalamus is a part of the diencephalon.

It lies in the floor and lateral wall of the third
ventricle (Anatomically). It has been designated
as the head ganglion of the autonomic nervous
systems because it take part in the control of
many visceral and metabolic activities of the body.
01 Definition

HYPOTHALAMUS

Temperature regulation

Homeostasis
HYPOTHALAMUS

Homeostasis
01 Definition

FEVER
Fever is “ a state of elevation an individual's core body temperature
above a 'set-point’ 37.5 ℃ which is often, but no necessarily, part of
the defensive response of multicellular organisms (hosts) to the
invasion of live (microorganisms) or inanimate matter recognized
as pathogenic or aline by the host.” That is normally regulated by
the body's thermoregulatory center in the hypothalamus.
Type of 0–2 years 3–10 years 11–65 years Over 65 years
reading

Oral 95.9–99.5°F 95.9–99.5°F 97.6–99.6°F 96.4–98.5°F

(35.5–37.5°C) (35.5–37.5°C) (36.4–37.6°C) (35.8–36.9°C)

Rectal 97.9–100.4°F 97.9–100.4°F 98.6–100.6°F 97.1–99.2°F

(36.6–38°C) (36.6–38°C) (37.0–38.1°C) (36.2–37.3°C)

Armpit 94.5–99.1°F 96.6–98.0°F 95.3–98.4°F 96.0–97.4°F

(34.7–37.3°C) (35.9–36.7°C) (35.2–36.9°C) (35.6–36.3°C)

Ear 97.5–100.4°F 97.0–100.0°F 96.6–99.7°F 96.4–99.5°F

(36.4–38°C) (36.1–37.8°C) (35.9–37.6°C) (35.8–37.5°C)
 Mechanism of fever

Elevation of body temperature

Physiological elevation Pathological elevation

 before/early stage of  Fever
menstruation (active, regulatory elevation
 strenuous exercise of core body temperature),
 Stress  Hyperthermia
(passive,
non-regulatory elevation of
core body temperature)
Mechanism of fever
 Pathogenesis of fever
Regulatory elevation of core body temperature

Fever (Febrile response) is a temporary resetting of the hypothalamic

thermostat to a higher level in response to exogenous or endogenous
pyrogen
◆ A pyrogen is a substance that induces fever in the body. Pyrogen can be
classified as:
◆ Exogenous(outside)pyrogen, EX-P (it can't cross the blood-brain barrier)
◆ Endogenous(inside)pyrogen, EN-P (it can cross the blood-brain barrier)
◆ Then secrete cytokines such as IL-1, IL-6, TNF, and IFN, which is promoting
synthesis and secretion of PGE2. PGE2 >> Thermostatic set point 💥
 Pathological Elevation
Regulatory elevation of core body temperature
 Pathological Elevation
Regulatory elevation of core body temperature
 Pathological Elevation

Non-regulatory elevation of core body temperature

◆ Direct damage to the thermoregulation center:

craniocerebral trauma、bleeding、 inflammation
◆ Pathologic hyperpyretic diseases: persistent epilepsy,
hyperthyroidism, etc
◆ Diseases with reduced heat dissipation: generalized skin
diseases, heart failure, massive blood loss or water loss,
etc
 Alterations Metabolic

Metabolic change during fever

Basal metabolic rate increases by 13% with 1℃

elevation in body temperature.

➢ Glycogen degradation- blood sugar increases

➢ Glycolysis- Lactate increases
➢ Adipose tissue utilization- Ketone increase, weight loss
➢ Vitamin consumption increases
 Alterations Metabolic

Systemic change

Increases of heart rate, Headache

(18 bpm/1℃℃) Hallucination
Blood pressure change Twitch

Increase of respiratory rate Indigestion

Hyperventilation anorexia (no appetite)
(may cause acid-base imbalance) Abdominal distension
Constipation

Fever often increase the anti-infection capacity of the body

The anti-tumor activity is also augmented during fever
EP can induce the acute phase response
 Benefit of fever

Moderate fever helps the body respond to infectious processes

through several mechanism:
1. Kills many microorganisms and adversely affect their growth and
replication.
2. Decrease serum levels of iron, zinc, and cooper-minerals needed
for bacterial replication
3. Increased temperature cause lysosomal breakdown and
autodestruction of cells, preventing viral replication in infected
cells.
4. Increases lymphocytic transformation and motility of
polymorphonuclear neutrophils, facilitating the immune response
5. Phagocytosis is enhanced, and production of antiviral interferon is
augmented.
03 Etiology

Etiology

80% 20%

Infectious Non-infectious
Neoplasma, Non-infectious
Virus, Bacteria, Mycoplasma, inflammation, Metabolic and
Rickettsia, Spirochete, Fungi, endocrine disease, Tissue
Parasites, Other microorganisms Necrosis, Allergic Disease,
Central thermoregulatory
disorder, and Hyperthermia
04 Clinical Manifestation

Clinical Manifestations

Classification Grade of fever Febrile phases Fever patterns

of fever based 4 grades 3 Phrase 6 patterns
on the duration
3 Types
04 Clinical Manifestation

Classification of fever based on the duration

Type Duration Disorders

Acute <7 days › Malaria

› Viral (COVID-19)

Subacute Up to 2 weeks Typhoid fever

Chronic >2 weeks Tuberculosis

04 Clinical Manifestation

Grade of fever

Grade Celsius (℃) Fahrenheit (°F)

Low grade 37.5-38 ℃ 99.5-100.4 °F

Medium grade 38.1-39 ℃ 100.58-102.2 °F

High grade 39.1-41 ℃ 102.38-105.8 °F

Very high >41 ℃ >105.8 °F

04 Clinical Manifestation

Clinical process and febrile phase

 Clinical process and febrile phase

Effervescence period:
Release of endogenous pyrogens
elevates the hypothalamic
thermostatic set-point leading to
increased body temperature.
Onset: Rise Abruptly or Gradually

Within a few hours, rigors, convulsion

Rise Abruptly Malaria, Lobar pneumonia, Acute pyelonephritis, septicemia,
influenza, infusion reaction
Within for several day to peak, without rigors
Rise Gradually
Typhoid, tuberculosis or brucellosis

Shivering, Pale skin, cold limbs，high metabolic rate because

Clinical features
of cutaneous vasoconstriction
 Clinical process and febrile phase

Persistent febrile period:

When the new set-point is reached
with heat equipoise at a higher level

Onset: Fever may maintain for several

hours/days/weeks

Proses Varies of duration, production and dissipation of

characteristic heat keep equipoise.
Onset:
Several hours as in malaria
Several days as in lobar pneumonia or influenza
Several weeks as in typhoid
Clinical Features Feeling hot, dry skin, Skin flushing, sweating, high
metabolic rate (fast deep breathing)
 Clinical process and febrile phase

Defervescence period:
Return of the set-point to normal,
either temporarily or permanently.

Onset: Decrease Suddenly or slowly

Decrease suddenly “crisis” Common seen in malaria, acute

pyelonephritis, lobar pneumonia of infusion
reaction
Decrease slowly “lysis” Typhoid fever or rheumatic fever

Clinical features Intensive sweating

04 Clinical Manifestation

Fever Pattern

CURRII
Continuous fever
Undulant fever
Remittent fever
Recurrent fever
Intermittent fever
Irregular fever
04 Clinical Manifestation

Fever Pattern

CURRII
Continuous fever
Undulant fever
Remittent fever
Recurrent fever
Intermittent fever
Irregular fever
04 Clinical Manifestation

Fever Pattern

Some points should be noted

◆The patient’s temperature are recorded at a regular interval
and temperature curve is generated by connecting each point
◆The patterns are USEFUL clue for Dx or DD
◆Take note that fever patterns can be influenced by drugs use
and individual response.
◆Typical or specific patterns could be changed to atypical or
irregular fever by the use of antibiotics, antipyretic drug or
glucocorticoids.
 Fever Patterns

Continuous Fever
◆The body temperature is maintained at a constant high level above
39 to 40 for days or weeks
◆The fluctuation range of body temperature within 24 hours shall not
exceed 1℃
◆It is commonly seen in lobar pneumonia, typhoid fever or typhus
 Fever Patterns

Undulant fever
◆The temperature gradually rises up to or above 39℃ for a few days and the
gradually decreases to normal for several days and then rise after few days
◆This pattern of repeated cycles “relapse fever”
◆It is commonly seen in brucellosis, connective tissue diseases or tumor
 Fever Patterns

Remittent Fever
⚫ The temperature is usually above 39
⚫ The fluctuation range is large, with the fluctuation range exceeding 2 within 24
hours, but all above the normal level
⚫ Common in septicemia, rheumatic fever ,severe pulmonary tuberculosis and
suppurative inflammation.
 Fever Patterns

Recurrent Fever
◆ The temperature abruptly rises up to or above 39℃ for a few days
◆ And sustains high fever for days，then decrease suddenly to normal with
sever days of afebrile period.
◆ borrelia recurrentis、Hodgkin's disease
 Fever Patterns

Intermittent fever
◆The temperature rises abruptly to peak sustained for several hours and
then decreases rapidly to normal followed by one or several days of
afebrile period (intermittent fever)
◆This pattern is repeated cycles of episodes of fever an afebrile period.
◆It is common in malaria ,acute pyelonephritis, biliary tract infections
 Fever Patterns

Irregular fever
◆The pattern of temperature curve is irregular
◆It is commonly seen in tuberculosis, rheumatic fever, bronchial
pneumonia or exudative pleurisy
 Accompanying symptoms and signs

Rigor, rash, mucocutaneous bleeding, arthralgia,

conjunctival congestion, herpes labialis,
lymphadenopathy, hepatomegaly, coma
Accompanying Symptoms & Signs

Rigor is a sudden feeling of cold with shivering

Commonly seen in
◆lobar pneumonia
◆Septicemia
◆acute cholecystitis
◆acute pyelonephritis
◆epidemic cerebrospinal meningitis
◆malaria
◆leptospirosis
◆drug fever
◆acute hemolysis or transfusion reaction.
 Accompanying Symptoms & Signs

Rash, rash is a noticeable change in the texture or color of skin.

The skin may become scaly, bumpy, itchy, or otherwise irritated.

Commonly seen in measles, scarlet fever, rubella, chicken

pox, typhus, rheumatic fever, connective tissue disease
(e.g. adult onset still’s disease, systemic lupus
erythematosus (SLE) ) or drug fever

rubella
Measles Scarlet
 Accompanying Symptoms & Signs

Chicken pox typhus

Rheumatic fever SLE

Accompanying Symptoms & Signs

Mucocutaneous bleeding, resulting from the

coagulopathies and hemostatic disorders, which
means that circulating blood infiltrating into the
skin or submucosal tissue from the capillaries

Hemorrhagic fever may present in

◆Severe infections
◆Acute infections diseases
◆Epidemic hemorrhagic fever
◆Viral hepatitis
◆Typhus
◆Septicemia
◆Hematological diseases
◆Acute leukemia, aplastic, anemia,
malignant histiocytosis
Accompanying Symptoms & Signs

Arthralgia is the pain in the area of joints

which is subjective symptoms of patient
with or without joint tenderness.

Commonly seen in
◆Acute gout arthritis
◆Infective arthritis
◆Septicemia
◆Scarlet fever
◆Brucellosis
◆Rheumatic fever
◆Connective tissue disease
Accompanying Symptoms & Signs

Conjunctival congestion, one of the common

clinical various type of conjunctivitis.

May present in infectious disease such as

◆ Measles
◆ Epidemic hemorrhagic fever
◆ Typhus
◆ Leptospirosis
 Accompanying Symptoms & Signs
Herpes labialis, also called cold sore. Tiny fluid-filled
blisters on and around your lips. These blisters are often
grouped together in patches.

commonly seen in acute febrile illness

◆Lobar pneumonia
◆Meningococcal meningitis
◆Tertian malaria
◆influenza
Accompanying Symptoms & Signs

Lymphadenopathy refers to the

swelling of lymph nodes

Commonly seen in
◆Tuberculosis
◆Focal suppurative infection
◆Metastatic cancer
◆Infectious mononucleosis
◆Rubella
◆Brucellosis
◆Leptospirosis
◆Filariasis
◆Leishmaniasis
◆Leukemia
◆Lymphoma
◆Connective tissue disease
Accompanying Symptoms & Signs

Lymphadenopathy

Commonly seen in
◆Tuberculosis
◆Focal suppurative infection
◆Metastatic cancer
◆Infectious mononucleosis
◆Rubella
◆Brucellosis
◆Leptospirosis
◆Filariasis
◆Leishamaniasis
◆Leukemia
◆Lymphoma
◆Connective tissue disease
Accompanying Symptoms & Signs

Hepatosplenomegaly (HPM) is a
disorder where both the liver and
spleen swell beyond their normal size,
due to one of a number of causes

May occur in
◆Liver and biliary tract infections
◆Acute schistosomiasis
◆Infectious mononucleosis
◆Viral hepatitis
◆Brucellosis
◆Malaria
◆Leishmaniasis
◆Connective tissue disease
◆Leukemia
◆lymphoma
 Accompanying Symptoms & Signs

Coma
if fever is prior to coma, it may reveal
◆encephalitis
◆typhus
◆epidemic cerebrospinal meningitis
◆toxic bacillary dysentery or heat stroke.
If coma is prior to fever, it is seen in
◆cerebral hemorrhage or barbiturate poisoning
Treatment

Principle of fever treatment:

Care
Suitable medication when necessary
 Treatment

Care, try a number of things to make more comfortable during a fever:

➢ Drink plenty of fluids. Fever can cause fluid loss and dehydration.
➢ Rest. You need rest to recover, and activity can raise your body
temperature.
➢ Stay cool. Dress in light clothing, keep the room temperature cool and
sleep with only a sheet or light blanket.
 Treatment

Medicine

Q: When should we take medicine?

A: When the fever in the high grade >39 ℃ or
in low grade causing discomfort.
Because in fever more than 40 ℃ can cause
confusion, seizure, and brain damage

Review benefit of fever

 Treatment

Medicine

Antipyretic
➢ Aspirin (NSAIDs)
➢ Ibuprofen (NSAIDs)
➢ Acetaminophen (paracetamol)
 Treatment

How the medicine works?

Acetaminophen, aspirin, ibuprofen and the other NSAIDs all

seem to block conversion of arachidonic acid to PGE2 by
inhibiting COX. So the production of PGE2 will decreased
which is causing the temperature decreased as well.

Review pathogenesis
 Treatment
Acetaminophen, Ibuprofen, Aspirin?
Which one should we take?

Drug Dosage usage and usage considerations

acetylsalicylic acid 325-650 mg, q.i.d. Adult, do not give to children (reye syndrome)
(Aspirin) reduce pain, fever, and inflammation.
Efek samping: tidak enak pada lambung, tinnitus,
vertigo, tuli (reversible), bertambahnya perdarahan.
Ibuprofen 3-4 x 200-400 mg/day Adult & Children
(5-10 mg/kgBB) reduce fever and treat pain or inflammation
Ind: pegal dan nyeri otot yang ringan sampai
sedang. Menimbulkan tidak enak pada lambung,
tetapi lebih ringan daripada aspirin. Harus dipakai
d.c. atau dengan banyak cairan.
Acetaminophen 3-4 x 500 mg/day Adult & Children
(Paracetamol) (10-15 mg/kgBB) Pain reliever and a fever reducer.
Don’t use if the patient has: liver disease, or
alcoholic.
Side effect: Proper dose or long-term use, high
doses can cause liver hepatotoxicity.
 Key point in history taking

1. The onset of fever(slowly or abruptly), its grade and duration,the

pattern of temperature fluctuation, frequency (intermittent or
persistent), predisposition factors and season.
2. Whether it occurs with chills, rigors, sweating or night sweats.
3. Review of systemic symptoms, such as cough, sputum, hemoptysis,
chest pain; abdominal pain, vomiting and diarrhea; urinary
frequency, urgency, dysuria; rash, bleeding, headache, muscle pain
and arthralgia.
4. General status including mental status,appetite, any change of
weight, sleep, urination and defecation.
5. Detail information about previous treatment, especially medication
and their dosage,efficacy including antibiotics, antipyretics,
corticosteroids and anti-tuberculosis therapy.
6. History of exposure o infectious diseases and contaminated
water,surgical history,history of miscarriage or childbirth.
““By learning you will teach,
by teaching you will learn”
 Agung Tri Laksono
Medical Student of Shanxi Medical University, China

Email: [email protected]