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Approach to patient with
infectious disease
By Dr. Murad Alariqi
Lecturer assistant of hepatology ang gastroenterology
11/10
Important points
1) Fever:
• ‘Feeling hot’ or sweaty does not necessarily signify fever.
• Fever is diagnosed only when a core body temperature of > 38°C is
recorded.
• Axillary and aural ‫ ﺳﻤﻌﻲ‬measurement is less accurate than oral or rectal.
• Outpatients may be trained to keep a temperature chart.
• °C: means Celsius which is a centigrade scale for measuring temperature in which water freezes at 0
degrees and boils at 100 degrees.
THE TEMPERATURE
• The temperature may be taken orally or rectally or axillary:

• Oral temperature:
- The clinical thermometer is placed after shaking under the tongue and is
held there with mouth closed for at least 1 minute - up to 3 minutes, in
doubtful cases.
Continue
• Fallacies: ‫ﻣﻐﺎﻟﻄﺎت‬
• False low readings may result from incomplete closure of the mouth, breathing
through the mouth, or leaving the thermometer for too a short time.
• False high readings may result from inadequate shaking down of the thermometer,
previous ingestion of warm substances, or recent strenuous activity.
Rectal temperature:
• A lubricated thermometer is inserted into the rectum for at least
2 minutes.
• This method is used in infants, mouth breathers, the extremely
irritable, extremely ill, and comatosed patients.
Continue
Axillary temperature:
• This method is inaccurate, and should be used only when it is impossible
to obtain oral or rectal temperature.
Normal Temperature:
- Varies at rest from 36.5°C to 37.2°C with the average is around 37°C
orally.
- lt is about half a degree higher in the rectum, and half a degree less in the
axilla.
- When the body temperature is above that which is normal for a given
person, fever is said to be present (in general > 38 °C (Davidson) )
Normal variations in body temperature occur normally, not only between persons,
but also in the same person.
➢ Rhythmic change occurs daily and may be of a magnitude of 1 °C:
❖The lowest temperature is reached during sleep, between 4 to 6 a.m.
❖The highest between 9- 11 p.m.
➢ Age: body temperature is somewhat lower in old persons.
➢ Ingestion of food: the temperature rises about half an hour after meals and
reaches its peak after about 1.5 hours.
➢Exercise: A rise is usual, and may reach high degrees after severe exercise.
➢Menstrual cycle: A slight rise (0.2-0 .5 °C) occurs at the time of ovulation till end
of cycle.
TYPES ( PATTERS) O F FEVE R
Continue
➢ CONTINUOUS FEVER:
- The temperature continues high for days or weeks, with slight change.
- The difference between morning and evening temperature is small, usually
0.5-1 ° C. This type is seen, e.g. in typhoid fever, pneumonia and meningitis
.
Continue
➢ INTERMITTENT (HECTIC) FEVER:
- The temperature falls to normal or subnormal level once or more during
the day. Seen classically in benign tertian malaria .
Continue
➢ REMITTENT FEVER:
- The temperature is always raised but shows considerable variation
between morning and evening temperatures. Seen typically in septic
conditions.
Continue
➢ DOUBLE QUOTIDIAN FEVER

Presence of 2 peaks in the daily temperature curve : seen in Kala- azar.
➢RELAPSING (CYCLIC) FEVER:

Short periods of fever intercepted ‫ ﻣﻌﺘﺮﺿﺔ‬by short periods of normal temperature
every one or tow weeks .
Examples include: '
• brucellosis
• spirochaetal relapsing fever,
• Mediterranean fever
• Pel- Ebstein fever of Hodgkin’s disease.
• Charcot's intermittent fever in cases of cholangitis.
HYPERPYREXIA==for your benefit
• Temperature more than 41.5 °C may result from:
❖ Heat stroke
❖Encephalitis
❖Pontine hemorrhage.
❖Status epilepticus
❖Thyrotoxic crisis:
❖Trauma or surgical operations in the region of the hypothalamus.
❖Malignant Hyperthermia: rapid rise of temperature accompanied by muscular
rigidity following anaesthesia with halothane or ether, is seen very rarely in
individual with a genetic metabolic defect probably involving cellular calcium.
Important points
2) Rigors:
Shivering (followed by excessive sweating) occurs with a rapid rise
in body temperature from any cause.
3) Night sweats:
Associated with particular infections (e.g. TB, infective
endocarditis); sweating from any cause is worse at night.
4) Excessive sweating without temperature elevation:
Alcohol, anxiety, thyrotoxicosis, diabetes mellitus, acromegaly, and
excessive environmental heat.
Important points
5) Recurrent fever:
There are various causes, e.g. Borrelia recurrentis, bacterial abscess.
6) Accompanying features:
• Severe headache and photophobia, although characteristic of meningitis,
may accompany other infections.
• Delirium during fever is more common in young children or the elderly.
• Myalgia may occur with viral infections, such as influenza, and with sepsis
including meningococcal sepsis.
• Shock may accompany severe infections and sepsis.
History-taking in suspected infectious
disease
➢Presenting complaint:
We should ask the duration of fever, pattern of fever, associated
symptoms, for example :
• Fever lasting 2 days associated with cough, simply it indicate an acute
respiratory tract infection but if fever and cough, last 2 months and
associated with drenching night sweating it may suggest TB.
➢Review of systems:
Must be comprehensive.
Continue
➢Past medical history:
• Define the ‘host’ and likelihood of infection(s)
• Include surgical and dental procedures involving prosthetic materials ( ‫)أﻋﻀﺎء‬
‫ﺻﻨﺎﻋﻴﻪ او ﺑﺪﻳﻠﻪ‬
• Document previous infections.
➢Medication history: ‫ﻛﻞ اﻷدوﻳﺔ اﻟﻤﺴﺘﺨﺪﻣﺔ ﺿﺪ اﻟﺤﻤﻲ ﻗﺒﻞ اﻟﻮﺻﻮل اﻟﻲ اﻟﻄﺒﻴﺐ او ﺑﺼﻮره ﻣﺰﻣﻨﻪ‬
• Include non-prescription drugs,
• use of antimicrobials
• Use of immunosuppressants.
• Identify medicines that interact with antimicrobials or that may cause fever.
Continue
➢Allergy history:
• Especially to antimicrobials, noting allergic manifestation (e.g. rash versus
anaphylaxis).
➢Family and contact history:
• Note similar infections and their duration in the family.
• explore exposure to infections, e.g. TB and HIV.
➢Travel history:
• Include countries visited and where previously resident.
➢Occupation:
•e.g. Anthrax in leather tannery workers (‫اﻟﺠﻠﻮد‬ ‫)ﻋﻤﺎل دﺑﺎﻏﻪ‬
➢Recreational pursuits: ‫اﻟﻤﺴﺎﻋﻲ اﻟﺘﺮﻓﻴﻬﻴﺔ‬
• e.g. Leptospirosis in canoeists ‫ زوارق اﻟﻜﺎﻧﻮ‬and windsurfers ‫اﻟﻤﺘﺰﻟﺠﻮن‬
Continue
➢Animal exposures:
• Include pets, e.g. dogs/hydatid disease.
➢Dietary history:
• Consider under-cooked meats, shellfish, unpasteurised dairy products or
well water.
• Establish who else was exposed, e.g. to food-borne pathogens.
➢History of intravenous drug injection or receipt of blood products:
• Risks for blood-borne viruses, e.g. HBV, HCV and HIV-1.
Continue
➢Sexual history:
• Explore in private; remember that the most common mode of HIV-1
transmission is heterosexual.
➢Vaccination history and use of prophylactic medicines:
• Consider occupation-or age-related vaccines: MMR, BCG, HBV, others.
• In a traveller or infection-predisposed patient, establish adherence to
prophylaxis.
Clinical examination of patients with
infectious disease
systemic approach
Tropical area
• What is the meaning of tropical area or zone?
• It is the part of the earth's surface between the tropic of cancer ( ‫ﺑﺮج‬
‫ )اﻟﺴﺮﻃﺎن‬and the tropic of Capricorn (‫ )ﺑﺮج اﻟﺠﺪي‬that characterized by a
hot and humid climate in which the average monthly temperature is always
18 c or higher and the year consists of 2 seasons: the wet/rainy season
and the humid/ hot season.
• Example: Africa.
Subtropical area
• It belong to parts of the word that are immediately south or north of the
tropics= the hottest areas.
Thank u

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Approach to patient with

• The temperature may be taken orally or rectally or axillary:

➢ DOUBLE QUOTIDIAN FEVER

➢RELAPSING (CYCLIC) FEVER:

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