Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 1)

Harrisons Internal Medicine Chapter 115. Approach to the Acutely Ill Infected Febrile PatientApproach to the Acutely Ill Infected Febrile Patient: Introduction The physician treating the acutely ill febrile patient must be able to recognize infections that require emergent attention. If such infections are not adequately evaluated and treated at initial presentation, the opportunity to alter an adverse outcome may be lost. In this chapter, the clinical presentations of and approach to patients with relatively common infectious disease emergencies are discussed. These infectious processes and their treatments are discussed in detail in other chapters. Noninfectious causes of fever are...
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Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 1) Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 1) Harrisons Internal Medicine > Chapter 115. Approach to the Acutely IllInfected Febrile Patient Approach to the Acutely Ill Infected Febrile Patient: Introduction The physician treating the acutely ill febrile patient must be able torecognize infections that require emergent attention. If such infections are notadequately evaluated and treated at initial presentation, the opportunity to alter anadverse outcome may be lost. In this chapter, the clinical presentations of andapproach to patients with relatively common infectious disease emergencies arediscussed. These infectious processes and their treatments are discussed in detailin other chapters. Noninfectious causes of fever are not covered in this chapter;information on the approach to fever of unknown origin, including that eventuallyshown to be of noninfectious etiology, is presented in Chap. 19. Approach to the Patient: Acute Febrile Illness A physician must have a consistent approach to acutely ill patients. Evenbefore the history is elicited and a physical examination performed, an immediateassessment of the patients general appearance yields valuable information. Theperceptive physicians subjective sense that a patient is septic or toxic often provesaccurate. Visible agitation or anxiety in a febrile patient can be a harbinger ofcritical illness. History Presenting symptoms are frequently nonspecific. Detailed questions shouldbe asked about the onset and duration of symptoms and about changes in severityor rate of progression over time. Host factors and comorbid conditions may enhance the risk of infectionwith certain organisms or of a more fulminant course than is usually seen. Lack ofsplenic function, alcoholism with significant liver disease, intravenous drug use,HIV infection, diabetes, malignancy, and chemotherapy all predispose to specificinfections and frequently to increased severity. The patient should be questioned about factors that might help identify anidus for invasive infection, such as recent upper respiratory tract infections,influenza, or varicella; prior trauma; disruption of cutaneous barriers due tolacerations, burns, surgery, or decubiti; and the presence of foreign bodies, such asnasal packing after rhinoplasty, barrier contraceptives, tampons, arteriovenousfistulas, or prosthetic joints. Travel, contact with pets or other animals, or activities that might result intick exposure can lead to diagnoses that would not otherwise be considered.Recent dietary intake, medication use, social or occupational contact with illindividuals, vaccination history, recent sexual contacts, and menstrual history maybe relevant. A review of systems should focus on any neurologic signs or sensoriumalterations, rashes or skin lesions, and focal pain or tenderness and should alsoinclude a general review of respiratory, gastrointestinal, or genitourinarysymptoms. Physical Examination A complete physical examination should be performed, with specialattention to several areas that are sometimes given short shrift in routineexaminations. Assessment of the patients general appearance and vital signs, skinand soft tissue examination, and the neurologic evaluation are of particularimportance. The patient may appear either anxious and agitated or lethargic andapathetic. Fever is usually present, although elderly patients and compromisedhosts [e.g., patients who are uremic or cirrhotic and those who are takingglucocorticoids or nonsteroidal anti-inflammatory drugs (NSAIDs)] may beafebrile despite serious underlying infection. Measurement of blood pressure, heart rate, and respiratory rate helpsdetermine the degree of hemodynamic and metabolic compromise. The patientsairway must be evaluated to rule out the risk of obstruction from an invasiveoropharyngeal infection. The etiologic diagnosis may become evident in the context of a thoroughskin examination (Chap. 18). Petechial rashes are typically seen withmeningococcemia or Rocky Mountain spotted fever (RMSF); erythroderma isassociated with toxic shock syndrome (TSS) and drug fever. The soft tissue andmuscle examination is critical. Areas of erythema or duskiness, edema, and tenderness may indicateunderlying necrotizing fasciitis, myositis, or myonecrosis. The neurologicexamination must include a careful assessment of mental status for signs of earlyencephalopathy. Evidence of nuchal rigidity or focal neurologic findings should besought. Diagnostic Workup After a quick clinica ...