兒科-發燒-門診問診重要的臨床線索

尤其是不明原因發燒(fever of unknown origin, FUO)時，務必確認以下細節
節選自Uptodate：Fever of unknown origin in children: Evaluation

另外可以參考
Fever pattern
http://teachingcenter1.pixnet.net/blog/post/71192703
過年十大常見疾病-不明熱 Fever of Unknown Origin (FUO)
http://teachingcenter1.pixnet.net/blog/post/352657529 (1)
http://teachingcenter1.pixnet.net/blog/post/352684238 (2)
http://teachingcenter1.pixnet.net/blog/post/352712312 (3)
http://teachingcenter1.pixnet.net/blog/post/352714538 (4)
藥物造成的發燒
http://teachingcenter1.pixnet.net/blog/post/352697768

 

發燒史(fever history)

  1. 是怎麼燒的？發燒是怎麼表現的？
    What is the fever pattern?
  2. 發燒時是否呈現身體不適或其他症狀呢？例如全身無力？
    Is the fever associated with ill-appearance or symptoms (eg, malaise)?
    • 無任何不適的發燒，須思考詐病、假燒的可能
      Absence of malaise or other generalized symptoms with high fever may suggest factitious fever.
    • 但也需要小心長期的低溫燒，病人可能已經習慣這個狀態，沒有特別”額外”的不適感，應仔細記錄病人體溫和臨床表現
  3. 使用退燒藥可以退燒嗎？吃退燒藥有效嗎？
    Does the fever respond to antipyretic agents?
    • 如果對退燒藥物無反應，可能不是感染或風濕性疾病，須思考自律神經功能異常的可能
      Lack of response to anti-inflammatory antipyretics may suggest a cause other than infection or rheumatologic disease (eg, familial dysautonomia, ectodermal dysplasia).
    • 但這並不代表排除了感染和風濕性疾病，相關的詳細檢查不應該忽略，畢竟還是發燒甚至FUO的最常見原因
    • 另外劑量不足(體重對劑量算錯)或退燒效果較弱的藥物(acetaminophen的退燒效果一般比ibuprofen差一些)，也有可能是退燒藥無效的原因
  4. 退燒之後，全身性的症狀(如乏力、嗜睡)仍然持續嗎？
    Persistence of constitutional/general symptoms after fever abates?
    • 若持續，則會比較擔心是全身系統性的疾病，可能是嚴重感染、自體免疫等問題
      Persistence is worrisome for systemic disease.
  5. 發燒時會(大量)盜汗、冒冷汗嗎？
    Is there associated sweating with fever?
    • 若是有，甲狀腺機能亢進務必納入鑑別診斷中
      Yes: Hyperthyroidism
    • 若是完全不會發汗，須想到無汗外胚層發育不全(少見但不能忘掉)
      No: Anhidrotic ectodermal dysplasia
  6. 退燒時會發汗嗎？
    Is there associated sweating with defervescence?
    • 若退燒時完全不會發汗，假燒、詐病的可能性會提高些
      No: Factitious fever

 

伴隨的主訴(associated complaints)
(不一定是最常見，但不可忽略的鑑別診斷)

  1. 紅眼Red eyes
    • Kawasaki disease
    • Leptospirosis
    • Tuberculosis
    • Infectious mononucleosis
    • Tularemia
  2. 鼻腔(黃綠色)分泌物Nasal discharge
    • Rhinosinusitis
  3. 反覆的咽喉炎合併潰瘍Recurrent pharyngitis with ulcerations
    • PFAPA syndrome
  4. 腸胃道症狀Gastrointestinal complaints
    • Salmonellosis
    • Intra-abdominal abscess
    • Hepatic cat scratch disease
    • Inflammatory bowel disease
    • Leptospirosis
  5. 四肢或骨骼疼痛Limb or bone pain
    • Brucellosis
    • Leukemia
    • Lymphoma
    • Osteomyelitis
    • Infantile cortical hyperostosis
    • Kikuchi-Fujimoto disease

 

暴露、接觸史(exposures)

  1. 藥物，包含所有處方、非處方(包含中藥)、局部外用藥物等
    Medications (prescription or nonprescription, including topical agents)
  2. 手術史
    Surgery
    • Abdominal surgery: Intra-abdominal abscess
    • Tracheotomy or gastric tube, cochlear implant or other implantable devices: Expanded list of potential pathogens
  3. 疾病接觸史
    Ill-contacts
    • FUO is usually caused by unusual presentations of common illnesses
  4. 旅遊史
    Travel history, extending back to birth (including tick and insect exposure)
    • Endemic pathogens, for example: Histoplasmosis, Coccidioidomycosis, Blastomycosis, Leishmaniasis, Malaria, Tuberculosis, Typhoid fever,
  5. 動物接觸史
    Animals (household pets, domestic animals, or wild animals)
    • 須小心原蟲、寄生蟲感染
  6. 蚊蟲咬傷而常被遺忘的疾病
    • 蜱咬傷Ticks
      1. Rocky Mountain spotted fever
      2. Human ehrlichiosis or anaplasmosis
      3. Tularemia
      4. Tick-borne relapsing fever
      5. Lyme disease
    • Mosquitos
      1. Arboviruses (eg, West Nile virus)
      2. 日本腦炎
      3. 登革熱
    • 白蛉Sand flies
      1. Leishmaniasis
  7. 節食
    Diet
    • Game meat: Toxoplasmosis, tularemia
    • Raw/undercooked meat: Tularemia, brucellosis
    • Raw shellfish: Hepatitis
  8. 異食症(尤其是嗜食泥土的病人)
    Pica (specifically eating dirt)
    • Visceral larva migrans
    • Toxoplasmosis

 

種族或基因差異(ethnic or genetic background)

  1. Ulster Scot descent
    • Nephrogenic diabetes insipidus
  2. Turkish, Armenian, North African Jewish, Arab descent
    • Familial Mediterranean fever
  3. Ashkenazi Jewish descent
    • Familial dysautonomia

 

Clinical features worrisome for malignancy or granulomatous disease in children with peripheral lymphadenopathy

  1. Systemic symptoms (fever >1 week, night sweats, weight loss [>10% of body weight])
  2. Supraclavicular (lower cervical) nodes
  3. Generalized lymphadenopathy
  4. Fixed nontender nodes in the absence of other symptoms; matted nodes
  5. Lymph nodes >1 cm with onset in the neonatal period
  6. Lymph nodes ≥2 cm in diameter that increase in size from baseline or do not respond to two weeks of antibiotic therapy
  7. Abnormal chest radiograph (particularly mediastinal mass or hilar adenopathy)
  8. Abnormal complete blood count (eg, lymphoblasts, cytopenias in more than one cell line)
  9. Absence of symptoms in the ear, nose, and throat regions
  10. Persistently elevated ESR/CRP or rising ESR/CRP despite antibiotic therapy

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