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{{SK}} febris continua e causa ignota; febris e causa ignota; febris E.C.I.; fever/pyrexia of obscured/undetermined/uncertain/unidentifiable/unknown focus/origin/source; fever/pyrexia without a focus/origin/source; FUO; PUO | {{SK}} febris continua e causa ignota; febris e causa ignota; febris E.C.I.; fever/pyrexia of obscured/undetermined/uncertain/unidentifiable/unknown focus/origin/source; fever/pyrexia without a focus/origin/source; FUO; PUO | ||
==Overview== | |||
Physical findings may be subtle and merit close scrutiny in the investigation of fever of unknown origin. | |||
==Physical Examination== | ==Physical Examination== | ||
Physical findings with diagnostic significance are as follows:<ref>{{Cite journal| doi = 10.1016/S0140-6736(97)07061-X| issn = 0140-6736| volume = 350| issue = 9077| pages = 575–580| last1 = Arnow| first1 = P. M.| last2 = Flaherty| first2 = J. P.| title = Fever of unknown origin| journal = Lancet| date = 1997-08-23| pmid = 9284789}}</ref><ref>{{Cite journal| doi = 10.1097/MAJ.0b013e31824ae504| issn = 1538-2990| volume = 344| issue = 4| pages = 307–316| last1 = Hayakawa| first1 = Kayoko| last2 = Ramasamy| first2 = Balaji| last3 = Chandrasekar| first3 = Pranatharthi H.| title = Fever of unknown origin: an evidence-based review| journal = The American Journal of the Medical Sciences| date = 2012-10| pmid = 22475734}}</ref><ref>{{Cite journal| doi = 10.1016/j.idc.2007.09.004| issn = 0891-5520| volume = 21| issue = 4| pages = 1137–1187, xi| last = Cunha| first = Burke A.| title = Fever of unknown origin: focused diagnostic approach based on clinical clues from the history, physical examination, and laboratory tests| journal = Infectious Disease Clinics of North America| date = 2007-12| pmid = 18061092}}</ref><ref>{{Cite journal| issn = 1058-4838| volume = 24| issue = 3| pages = 291–300; quiz 301-302| last = Hirschmann| first = J. V.| title = Fever of unknown origin in adults| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 1997-03| pmid = 9114175}}</ref> | |||
=== | |||
===Vitals=== | ===Vitals=== | ||
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====Pulse==== | ====Pulse==== | ||
* Weak or absent [[pulse]] may be present in [[Takayasu's arteritis]]. | |||
=====Rate===== | =====Rate===== | ||
* Physiologically, fever is accompanied by [[tachycardia]] | * Physiologically, fever is accompanied by [[tachycardia]]. | ||
* [[Faget's sign|Relative bradycardia (Faget's sign)]] may be present | * [[Faget's sign|Relative bradycardia (Faget's sign)]] may be present in [[legionellosis]], [[brucellosis]], [[psittacosis]], [[leptospirosis]], [[drug fever]], or [[fever|factitious fever]]. | ||
===Skin=== | ===Skin=== | ||
* [[Janeway lesion]]s may be present in [[infective endocarditis]]. | |||
* [[Petechiae]] may be present in [[Rocky Mountain spotted fever]]. | |||
* [[Rash|maculopapular, vesicular, or petechial rash]] may be present in [[typhus]]. | |||
* An [[eschar]] at the site of the tick bite may be present in [[tick-borne disease]]s. | |||
* [[Swollen lymph nodes]] may be present. [[Lymphadenopathy]] may represent reactive lymphoid hyperplasia (suggestive of [[inflammation]] or [[infection]]) or underlying malignant processes such as [[lymphoma]]. | |||
* [[Rose spots]] (blanching pink papules 2-3 mm in diameter) may be present on the trunk in [[salmonellosis]]. | |||
* [[Macules]], [[papules]], and [[nodules]] may be present on the trunk and extremities in [[meningococcemia]]. | |||
* [[Macules]] or [[petechiae]] evolving into [[vesicles]] and [[pustules]] on a hemorrhagic base may be present in [[gonococcus|disseminated gonococcal infection]]. | |||
* Diffuse [[hyperpigmentation]] may be present in [[Whipple's disease]]. | |||
* [[Papules]] and [[nodules]] evolving into crusted, verrucous growths may be present in [[blastomycosis]]. | |||
* [[Wart]]y [[nodules]] and subcutaneous [[abscess]]es may be present in [[coccidioidomycosis]] | |||
* [[Erythematous]] [[papules]], [[pustules]], subcutaneous [[nodules]], or [[cellulitis]] may be present in [[cryptococcosis]]. | |||
* [[Sister Mary Joseph nodule]] (palpable [[nodule]] bulging into the [[umbilicus]]) may be present in metastasis of a [[cancer|malignant tumor]] in the pelvis or abdomen. | |||
* Multiple purplish [[papules]], [[nodules]], and [[plaques]] may be present on the scalp, face, and neck in [[lymphoma]]. | |||
* Multiple [[erythematous]], painful [[plaques]] with small bumps, [[pustules]], and [[vesicles]] may be present in [[Sweet's syndrome]]. | |||
* Palpable [[purpura]] may be present on the lower extremities and other areas of dependency in cutaneous [[vasculitis]]. | |||
===Head=== | ===Head=== | ||
* | * [[Temporal artery]] [[tenderness]] with weak [[pulse]] may be present in [[temporal arteritis]]. | ||
* Sinus [[tenderness]] may be present in [[sinusitis]]. | |||
===Eyes=== | ===Eyes=== | ||
* [[Roth's spot]]s or [[conjunctival hemorrhage]] may be present in [[infective endocarditis]]. | |||
* [[Photophobia]] or ocular pain on palpation suggestive of [[uveitis]] may be present in [[Wegener's granulomatosis]], [[Behcet syndrome]], [[Vogt-Koyanagi-Harada syndrome]], or [[infection]]s. | |||
===Mouth=== | |||
* [[Oral thrush]] caused by [[candidiasis]] may be present in patients with [[HIV]]/[[AIDS]]. | |||
=== | * [[Oral ulcer]]s may be present in [[systemic lupus erythematosis]], disseminated [[histoplasmosis]], and [[Behcet syndrome]]. | ||
* [[Tenderness]] with a palpable [[abscess]] may be present in [[periodontal disease]]. | |||
* [[Petechiae]] on the palate may be present in [[infective endocarditis]]. | |||
* [[Parotid gland]] enlargement and [[tenderness]] may be present in [[infection]]s (e.g., ''[[Staphylococcus aureus]]'', [[tuberculosis]], [[mumps]], [[HIV]]), [[Sjogren's syndrome]], or [[sarcoidosis]]. | |||
===Neck=== | ===Neck=== | ||
* [[ | * Cervical [[lymph nodes]] may be present in [[inflammation]], [[infection]], [[lymphoma]], or [[Kikuchi disease]]. | ||
* Enlargement of the [[thyroid gland]] may be present in [[thyroiditis]]. | |||
* [[ | |||
===Lungs=== | ===Lungs=== | ||
* [[ | * [[Rales]] or [[rhonchi]] may be present in [[pneumonia]]. | ||
* [[ | * [[Fremitus]] with diminished [[breath sounds]] may be present in [[pneumonia]]. | ||
===Heart=== | ===Heart=== | ||
* | * [[Heart murmurs]] may be present in [[endocarditis]] secondary to [[infection]]s ([[infective endocarditis]]), [[systemic lupus erythematosus]] ([[Libman-Sacks endocarditis]]), or chronic diseases ([[marantic endocarditis]]).. | ||
=== | ===Abdomen=== | ||
* [[ | * [[Abdominal tenderness]] may be present in [[intra-abdominal infection]]s. | ||
* [[ | * [[Rebound tenderness]] may be present in [[intra-abdominal infection]]s. | ||
* [[ | * An [[acute abdomen]] may be present in [[intra-abdominal infection]]s. | ||
* Guarding may be present in [[intra-abdominal infection]]s. | |||
* [[ | * [[Flank pain]] may be present in psoas muscle [[abscess]], perinephric abscess, or [[pyelonephritis]]. | ||
* | * An inguinal mass may be present in psoas muscle [[abscess]]. | ||
* [[Splenomegaly]] may be present in [[infectious mononucleosis]], [[spleen|splenic]] [[abscess]], or [[hepatitis]]. | |||
* | |||
=== | ===Genitourinary=== | ||
* [[ | * [[prostate|Prostatic]] enlargement may be present in [[prostate|prostatic]] [[abscess]]. | ||
* [[ | * Epididymal [[nodule]] may be present in [[epididymitis]]. | ||
* [[testicle|Testicular]] [[nodule]] may be present in [[polyarteritis nodosa]]. | |||
* | |||
===Extremities=== | ===Extremities=== | ||
* [[ | * [[Osler's node]]s may be present in [[infective endocarditis]]. | ||
* [[ | * Swollen joints with effusion may be present in infectious [[arthritis]] or [[rheumatic disease]]s. | ||
* [[ | * [[Splinter hemorrhage]] in the nail beds may be present in [[infective endocarditis]]. | ||
* Limb [[tenderness]] along deep veins may be present in [[deep vein thrombosis]] or [[thrombophlebitis]]. | |||
===Neurologic=== | ===Neurologic=== | ||
* | * [[Altered mental status]] may be present. | ||
* Cranial nerve deficits may be present in cerebral [[vasculitis]] associated with [[systemic lupus erythematosus]]. | |||
* | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Ailments of unknown etiology]] | [[Category:Ailments of unknown etiology]] | ||
Latest revision as of 17:44, 18 September 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: febris continua e causa ignota; febris e causa ignota; febris E.C.I.; fever/pyrexia of obscured/undetermined/uncertain/unidentifiable/unknown focus/origin/source; fever/pyrexia without a focus/origin/source; FUO; PUO
Overview
Physical findings may be subtle and merit close scrutiny in the investigation of fever of unknown origin.
Physical Examination
Physical findings with diagnostic significance are as follows:[1][2][3][4]
Vitals
Temperature
- A fever is often present. The periodicity of fever may have clinical significance in selected contexts.
Pulse
- Weak or absent pulse may be present in Takayasu's arteritis.
Rate
- Physiologically, fever is accompanied by tachycardia.
- Relative bradycardia (Faget's sign) may be present in legionellosis, brucellosis, psittacosis, leptospirosis, drug fever, or factitious fever.
Skin
- Janeway lesions may be present in infective endocarditis.
- Petechiae may be present in Rocky Mountain spotted fever.
- maculopapular, vesicular, or petechial rash may be present in typhus.
- An eschar at the site of the tick bite may be present in tick-borne diseases.
- Swollen lymph nodes may be present. Lymphadenopathy may represent reactive lymphoid hyperplasia (suggestive of inflammation or infection) or underlying malignant processes such as lymphoma.
- Rose spots (blanching pink papules 2-3 mm in diameter) may be present on the trunk in salmonellosis.
- Macules, papules, and nodules may be present on the trunk and extremities in meningococcemia.
- Macules or petechiae evolving into vesicles and pustules on a hemorrhagic base may be present in disseminated gonococcal infection.
- Diffuse hyperpigmentation may be present in Whipple's disease.
- Papules and nodules evolving into crusted, verrucous growths may be present in blastomycosis.
- Warty nodules and subcutaneous abscesses may be present in coccidioidomycosis
- Erythematous papules, pustules, subcutaneous nodules, or cellulitis may be present in cryptococcosis.
- Sister Mary Joseph nodule (palpable nodule bulging into the umbilicus) may be present in metastasis of a malignant tumor in the pelvis or abdomen.
- Multiple purplish papules, nodules, and plaques may be present on the scalp, face, and neck in lymphoma.
- Multiple erythematous, painful plaques with small bumps, pustules, and vesicles may be present in Sweet's syndrome.
- Palpable purpura may be present on the lower extremities and other areas of dependency in cutaneous vasculitis.
Head
- Temporal artery tenderness with weak pulse may be present in temporal arteritis.
- Sinus tenderness may be present in sinusitis.
Eyes
- Roth's spots or conjunctival hemorrhage may be present in infective endocarditis.
- Photophobia or ocular pain on palpation suggestive of uveitis may be present in Wegener's granulomatosis, Behcet syndrome, Vogt-Koyanagi-Harada syndrome, or infections.
Mouth
- Oral thrush caused by candidiasis may be present in patients with HIV/AIDS.
- Oral ulcers may be present in systemic lupus erythematosis, disseminated histoplasmosis, and Behcet syndrome.
- Tenderness with a palpable abscess may be present in periodontal disease.
- Petechiae on the palate may be present in infective endocarditis.
- Parotid gland enlargement and tenderness may be present in infections (e.g., Staphylococcus aureus, tuberculosis, mumps, HIV), Sjogren's syndrome, or sarcoidosis.
Neck
- Cervical lymph nodes may be present in inflammation, infection, lymphoma, or Kikuchi disease.
- Enlargement of the thyroid gland may be present in thyroiditis.
Lungs
- Rales or rhonchi may be present in pneumonia.
- Fremitus with diminished breath sounds may be present in pneumonia.
Heart
- Heart murmurs may be present in endocarditis secondary to infections (infective endocarditis), systemic lupus erythematosus (Libman-Sacks endocarditis), or chronic diseases (marantic endocarditis)..
Abdomen
- Abdominal tenderness may be present in intra-abdominal infections.
- Rebound tenderness may be present in intra-abdominal infections.
- An acute abdomen may be present in intra-abdominal infections.
- Guarding may be present in intra-abdominal infections.
- Flank pain may be present in psoas muscle abscess, perinephric abscess, or pyelonephritis.
- An inguinal mass may be present in psoas muscle abscess.
- Splenomegaly may be present in infectious mononucleosis, splenic abscess, or hepatitis.
Genitourinary
- Prostatic enlargement may be present in prostatic abscess.
- Epididymal nodule may be present in epididymitis.
- Testicular nodule may be present in polyarteritis nodosa.
Extremities
- Osler's nodes may be present in infective endocarditis.
- Swollen joints with effusion may be present in infectious arthritis or rheumatic diseases.
- Splinter hemorrhage in the nail beds may be present in infective endocarditis.
- Limb tenderness along deep veins may be present in deep vein thrombosis or thrombophlebitis.
Neurologic
- Altered mental status may be present.
- Cranial nerve deficits may be present in cerebral vasculitis associated with systemic lupus erythematosus.
References
- ↑ Arnow, P. M.; Flaherty, J. P. (1997-08-23). "Fever of unknown origin". Lancet. 350 (9077): 575–580. doi:10.1016/S0140-6736(97)07061-X. ISSN 0140-6736. PMID 9284789.
- ↑ Hayakawa, Kayoko; Ramasamy, Balaji; Chandrasekar, Pranatharthi H. (2012-10). "Fever of unknown origin: an evidence-based review". The American Journal of the Medical Sciences. 344 (4): 307–316. doi:10.1097/MAJ.0b013e31824ae504. ISSN 1538-2990. PMID 22475734. Check date values in:
|date=(help) - ↑ Cunha, Burke A. (2007-12). "Fever of unknown origin: focused diagnostic approach based on clinical clues from the history, physical examination, and laboratory tests". Infectious Disease Clinics of North America. 21 (4): 1137–1187, xi. doi:10.1016/j.idc.2007.09.004. ISSN 0891-5520. PMID 18061092. Check date values in:
|date=(help) - ↑ Hirschmann, J. V. (1997-03). "Fever of unknown origin in adults". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 24 (3): 291–300, quiz 301-302. ISSN 1058-4838. PMID 9114175. Check date values in:
|date=(help)