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					PGY 歐軒甫
Durack and Street, 1991
      APPROACH TO THE PATIENT
                           HISTORY
   Combined symptoms              Unusual hobbies
   Fever pattern                  Dietary proclivities
   Medication                     Household pets
   Surgical or dental             Sexual exposure
    procedure
   Any prosthetic                 IV drug abuse, alcoholism
    materials or implanted         Trauma
    devices                        Animal or insect bite
   Occupation ( animal;           Blood transfusion
    fume; infectious agent
    or infected individuals )      immunization
   Travel history                 Family history
    APPROACH TO THE PATIENT
          PHYSICAL EXAMINATION

   Head to toe
   Finger to hole
   Special attention to skin, lymph nodes, eyes, nail
    bed, CV system, chest , abdomen,
    musculoskeletal system, and nerve system.
   Rectal examination is imperative
   Penis, scrotum, testes , foreskin and pelvic
    examination in women should be examined
    APPROACH TO THE PATIENT
               LABORATARY TESTS

   Clinical Pathology
       CBC+DC+PLT, blood smear, UA, ESR, abnormal
        fluid accumulation and CSF examination, bone
        mallow aspiration, stool routine
   Chemistry
       Electrolyte, BUN, creatinine, LFTs, amylase, CPK
        and serology…
   Microbiology
       Gram’s stain and culture
   Imaging
       Plain film, sonography, CT, MRI and Gallium scan
FUO
    MALIGNANCY ASSOCIATED

   Hodgkin’s lymphoma
   Non-Hodgkin lymphoma
   Leukemia
   Renal cell carcinoma
   Hematoma
   Colon carcinoma
FUO
    AUTOIMMUNE ASSOCIATED

   SLE
   RA
   Adult Still’s disease
   Temporal arteritis
   Mixed connective tissue disease
    FUO
      INFECTION ASSOCIATED

   Intra-abdominal or pelvic abscess
     Abscess 1/3 infection origin of FUO, most intra-
       abdominal or pelvic
     Vague localized abdominal pain

     Surgical complication or leakage of visceral
       contents
     Liver abscess:
          elevated ALK-p
          K. pneumoniae bacteremia in DM, alcoholism, Liver
           cirrhosis
          Liver echo may be negative, so abdominal CT is
           important for diagnosis
    FUO
        INFECTION ASSOCIATED

   Osteomyelitis and septic hip
       Tenderness over infected site, but some patients
        only with fever
       Associated sign: L-spine OM with root
        compression sign, vertebral OM with psoas
        muscle abscess or CV surgery with sternal OM
       Septic hip: 16% of septic arthritis, most with OA
        or destructive joint, so that with prolonged and
        insidious onset
       Diagnostic tool: Bone scan or Gallium scan CT
        or MRI
    FUO
        INFECTION ASSOCIATED

   Infectious endocarditis
       Clue of DX: continuous bacteremia, new
        murmurs, vascular phenomenon, vegetation on
        cardiac echo, and unexplained fever
       Culture negative endocarditis
           Recently received antibiotics
           HACEK group organisms. Haemophilus parainfluenaze/
            aphrophilus, Actinobacillus actinomycetemcomitans,
            Cardiobacterium hominis, Eikenella corrodens, and Kingella
            kingae
           Fungus, Rickettsia and Chlamydia
       TTE(60%) and TEE(95%)
FUO
    INFECTION ASSOCIATED

   Granulomatous infection
       TB( extrapulmonary TB or miliary TB) is the
        most common cause in Taiwan
       TB may involve liver, spleen, bone, kidneys,
        pericardium or meninges and in miliary TB
        of lung CXR may be negative initial
       Bone marrow study may diagnose
       Nontuberculous mycobacterial infections and
        deep-seated fungal infection
    FUO
      INFECTION ASSOCIATED

   Dengue fever
   Infectious mononucleosis
   Scrub typhus
   Typhoid fever
   HIV
   Malaria
   Amebiasis
   NG related sinusitis
Yamaguchi Criteria