Hanson Infectious Diseases - Anamneza i Status

16INFECTIOUS DISEASE

Patricia A. Meier, MD, and Thomas S. Neuhauser, MD

I. CHIEF COMPLAINTA. Chief Complaint: Use the patient’s own words when possible.

Chronology is often included: Onset (acute, subacute or chronic),duration (minutes, hours, days, weeks, months or years), and frequency of symptom(s).

B. Identifying Data: Obtain patient’s name, age, race/ethnic background.

C. Fever: Fever is the most common symptom that leads patients and physicians to consider a diagnosis of infection. For this reason, the focus of this section is the work-up of the febrilepatient.1. Fever refers to a pyrogen-mediated elevation of body temper-

ature above the expected normal daily variation. In contrast,hyperthermia is an abnormality of thermoregulation that is notdriven by pyrogenic cytokines, and therefore, unlike fever, isnot ameliorated by antipyretic medications. For most patients,the temperature at which clinical evaluation of fever is indi-cated is 38.0°C (100.4°F).

2. Fever as a clinical symptom/sign of infection is neither sensi-tive nor specific. The absence of fever does not exclude infec-tion, particularly in an immunocompromised, debilitated, orelderly patient.

3. Conversely, the presence of fever does not equate to infectionbecause fever can be the initial manifestation of noninfectiousmaladies, including collagen vascular disease and malignancy.

4. A variety of terms are used to describe fever in terms of itspattern (e.g., intermittent versus remittent), duration (fever ofunknown origin), and unique host characteristics (neutropenicfever). The more commonly used terms are summarized inTable 16-1.

5. Although specific fever patterns are not pathognomonic, areview of the patient’s fever curve may provide diagnostic cluesabout the etiologic agent. Selected fever patterns and putativeetiologic agents are summarized in Table 16-2.

D. Appropriate Febrile Patient Triage: The goals of triage are toexpedite patient care while minimizing the unnecessary exposureof susceptible staff, patients, and family members.1. Decide if the patient requires an immediate intervention, such

as fluid resuscitation or empiric antibiotic therapy. For example,

273

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a patient with acute bacterial meningitis should have antibioticsstarted before further diagnostic testing is completed.

2. Determine if empiric isolation precautions are warranted. Theclinical syndromes for which empiric isolation precautions areadvised by the Centers for Disease Control and Prevention(CDC) are summarized in Table 16-3.

II. HISTORY OF PRESENT ILLNESSA. Infectious Diseases

1. The study of the relationship between a patient, an infectiousagent(s), and the environment.

2. Once you have completed your initial triage, you are ready toproceed with an orderly, systematic review of the patient’sunique susceptibilities and exposures.

274 Section II Specialty History and Physical Examination

Table 16-1. DEFINITION OF TERMS REGARDING FEVER.

TERM DEFINITION

Fever Fever is an elevation of temperatureabove the peak normal daily variation.The normal oral temperature range is36.0-37.8°C (96.8-100.0°F)

Continuous fever Persistent elevation of temperature withminimal fluctuations

Intermittent fever Daily fever spikes with return to normalbody temperature

Remittent fever Fever spikes without return to normalbody temperature between spikes

Relapsing fever Cyclical pattern of alternating fever andnormal temperature

Factitious fever Fever produced artificially by the patientFever of unknown Illness of more than three weeks’ duration.origin (FUO), Documented fevers above 101°F (38.3°C)classic definition on several occasions. Lack of specific

diagnosis after 1 week of inpatientinvestigation

Classic FUO, As above, but investigation now revised revised definition to three hospital days or three outpatient

visitsNeutropenic fever A single oral temperature of >38.3°C

(101.0°F) or >38.0°C (100.4°F) over atleast 1 hour, in patient with a neutrophilcount <500mm3 or <1000mm3 withpredicted decline to less than 500mm3

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Chapter 16 Infectious Disease 275

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Table 16-2. DIAGNOSTIC SIGNIFICANCE OF FEVER PATTERNS.

FEVER CAUSES

Single fever spike Manipulation of a colonized or infectedmucosal surface, transfusion of blood/blood products, infusion-related sepsis(contaminated infusate), temperatureerror, not a systemic infectious disease

Double quotidian Adult Still’s disease, visceral leishmaniasis,fevers (twice daily) miliary tuberculosis, mixed malarial

infections, right-sided gonococcalendocarditis

Tertian fevers Malaria (Plasmodium vivax)(every third day)Quartan fevers Malaria (Plasmodium malariae)(every fourth day)Intermittent fevers Gram-negative or gram-positive sepsis,

abscess (renal, abdominal, pelvic), acutebacterial endocarditis, Kawasaki disease,malaria, miliary tuberculosis, antipyretics,peritonitis, toxic shock syndrome

Remittent fevers Viral upper respiratory infections,Plasmodium falciparum malaria, acuterheumatic fever, Legionella/Mycoplasmainfection, tuberculosis, subacutebacterial endocarditis (SBE)

Continuous or Central fevers, roseola infantum (HHV6), sustained fevers brucellosis, Kawasaki disease,

psittacosis, rocky mountain spottedfever, scarlet fever, subacute bacterialendocarditis, typhoid fever, drug fever

Biphasic (camelback) Colorado tick fever, dengue fever, fever leptospirosis, brucellosis, lymphocytic

choriomeningitis, yellow fever, polio,smallpox, rat-bite-fever (Spirillumminus), Chikungunya fever, Africanhemorrhagic fevers (Marburg, Ebola,Lassa), Echovirus infection

Relapsing fever Relapsing fever (Borrelia recurrentis),yellow fever, smallpox, ascendingcholangitis, brucellosis, dengue, chronicmeningococcemia, malaria, rat-bite-fever

Table reproduced with permission from Cunha BA. Clinical approachto fever. In SL Gorbach, JG Bartlett, NR Blacklow (eds), InfectiousDiseases, ed 2. Philadelphia: WB Saunders, 1998;86.

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B. Symptoms1. May be localized or systemic.2. It is critical to be thorough in performing the entire history

and physical (H&P).C. Historical Clues That May “Break the Case”: These clues gen-

erally fall into two categories: (1) those that delineate potentialexposures to infectious agents, and (2) those that describe thepatient’s susceptibility to infection (Table 16-4).

D. Important Questions for a Febrile Patient1. What is the duration and magnitude of fever? This will allow

you to answer the important question, “Is this disease processacute or chronic?”

2. When did the fever begin? Quickly ascertain the onset of thefever because some disease processes dictate immediatetreatment (e.g., acute bacterial meningitis).

3. Is there a pattern to the fever? (See Tables 16-1 and 16-2.) Forsome diseases (e.g., malaria), the periodicity of the fever canbe a helpful clue. (Fever patterns also provide interesting material for questions during clinical rounds.)

4. Is there a specific part of your body that is botheringyou/painful (e.g., determine localized vs. systemic infection)?When examining the febrile patient, evaluate all localizingsymptoms so as not to overlook a potential infectious diseaseemergency, such as an invasive soft tissue infection.

5. Determine whether the patient is immunocompromised(Table 16-5). What is the specific immune defect? Certain hostdefects are associated with susceptibility to specific organismsor groups of organisms, some of which require immediatetherapy. When caring for immunocompromised patients, it isimportant to remember that infection with more than oneagent may occur simultaneously.

6. Has the patient traveled outside the United States recently?The febrile returning traveler should be evaluated expedientlyfor life-threatening infections, such as malaria. A careful travelhistory is critical in establishing a differential diagnosis thattakes into consideration details of travel itinerary, conditionsof travel, prior immunizations, antibiotic prophylaxis, andexposure history.

7. Has the patient been hospitalized recently?8. Has the patient taken any medications that may alter the

fever?9. Does the patient have occupational exposures or hobbies that

make him or her susceptible to infection?10. Has the patient been exposed to animals, raising the possi-

bility of a zoonotic infection (Table 16-6)?


Text continued on p. 283.

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Table 16-4. HOST FACTORS THAT INFLUENCE EXPOSURE, INFECTION, AND DISEASE.

FACTORS THAT INFLUENCEINFECTION AND THE OCCURRENCE

FACTORS THAT INFLUENCE AND SEVERITY OF DISEASE FOREXPOSURE TO INFECTIOUS AGENTS THE PATIENT

Animal exposure, including pets Age at the time of infectionBehavioral factors related to age, Alcoholism

drug usage, and alcohol Anatomic defectconsumption Antibiotic resistance (agent)

Blood or blood product recipient Antibiotic use (host)Child day care attendance Coexisting noninfectious Closed living quarters: military diseases, especially chronic

barracks, dormitories, Coexisting infectionshomeless shelters, facilities Dosage: amount and virulence for the elderly and mentally of the organism to whichhandicapped, prisons the host is exposed

Food and water consumption Duration of exposure to theFamilial exposures organismGender Entry portal of organisms and Hospitalization or outpatient presence of trauma at the site

medical care of implantationHygienic practices GenderOccupation Genetic makeupRecreational activities, including Immune state at the time of

sports and recreational infection, includinginjecting drug use immunization status

Sexual activity: heterosexual Immunodeficiency (specific or and homosexual, type and nonspecific): natural, drug number of persons induced, or viral (HIV)

School attendance Mechanism of disease Socioeconomic status production: inflammatory,Travel, especially to developing immunopathologic, or toxic

countries Nutritional statusVector exposure Receptors for organism on

cells needed for attachmentor entry of the organism

Table reproduced with permission from Osterholm MT, Hedberg,CW, Moore KA. In Mandell GL, Bennett JE, Dolin R (eds), Principlesand Practice of Infectious Diseases, ed 5. Philadelphia: Churchill Livingstone, 2000;163.

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Table 16-5. CONDITIONS RESULTING FROM IMMUNEDEFECTS AND ASSOCIATED INFECTING ORGANISMS.

ASSOCIATED INFECTINGDEFECTS CONDITIONS ORGANISMS

Neutropenia Leukemia, cytotoxic Escherichia colichemotherapy, AIDS, Klebsiella pneumoniaesystemic lupus Pseudomonaserythematosis (SLE), aeruginosa Felty syndrome, drugs Staphylococcus aureus

StaphylococcusepidermidisStreptococci speciesYeastsAspergillus and other fungi

Defective Diabetes, alcoholism, Staphylococci, chemotaxis renal failure, SLE, streptococci, and yeasts

Hodgkin’s disease, trauma, lazy leukocyte syndrome

Defective Chronic granulomatous Catalase-positive neutrophil disease, Down syndrome bacteria (e.g., S. aureus,killing myeloperoxidase E. coli, Candida spp.).

deficiency B-lymphocyte Congenital and acquired Encapsulated defects agammaglobulinemia, organisms (e.g.,

burns, enteropathies, Streptococcusmyeloma, lymphocytic pneumoniae,leukemia Haemophilus

influenzae, Neisseria spp.; also Salmonella and Campylobacter spp.)

T-lymphocyte Congenital Intracellular infectionsdefects immunodeficiencies, with bacteria,

AIDS, lymphoma, mycobacteria, viruses, sarcoidosis, Epstein-Barr parasites, fungivirus (EBV) infection, SLE, cytomegalovirus infection (CMV)

Complement Congenital absence Miscellaneous components bacterial infections

Reproduced with permission from Zinner SH. Treatment and pre-vention of infections in immunocompromised hosts. In Gorbach SL,Bartlett JG, Blacklow NR (eds), Infectious Diseases, ed 2. Philadel-phia: WB Saunders, 1998;1252.

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ID

Tabl

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Tabl

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III. PAST MEDICAL AND SURGICAL HISTORYA. Past Medical History

1. What diseases have you had? How were they treated? Certaindisease processes and treatments may alter immune function.

2. Do you have any deficiencies? Determine whether they arenatural, induced (chemotherapy), or viral (human immunode-ficiency virus [HIV]).

3. Have you had a chronic disease process or paralysis?4. Have you recently been hospitalized or received inpatient

medical care? Consider recent outbreaks of hospital-acquired(nosocomial) infections.a. Have you had an infection? Involving the urinary tract,

lungs, surgical wound, blood? The most common sites ofnosocomial infections are the urinary tract, lung (pneumo-nia), surgical wound, and bloodstream (sepsis).

b. Eliciting a history of recent hospitalization is helpful for bothplanning the diagnostic evaluation and for selecting empirictherapy.

c. Hospital-acquired pathogens are often more drug resistantthan community-acquired pathogens (e.g., vancomycin-resistant enterococcus, methicillin-resistant Staphylococcusspecies), and may require a modification of the usualempiric therapy for a given infection.

B. Past Surgical History1. Have you had any surgical procedures that involved implanting

foreign bodies (e.g., mesh, joints, screws/hardware, toothimplants, heart valves, pacemaker, breast implants)?

2. Did you undergo surgery to repair an anatomic defect (naturalor acquired)?

3. Have you had a splenectomy?C. Emergency and Trauma History

1. Have you ever been treated for trauma? Any damage to skin ormucous membranes?

2. Have you had a blood transfusion? The risk of a transfusion-transmitted infection has decreased considerably but has notbeen eliminated.

D. Childhood History1. Development.2. Illnesses (e.g., otitis media, respiratory infections, urinary tract

infections [UTIs], seizures, and hospitalizations).3. Child day care attendance.

E. Occupational History1. What, if any, organisms or toxins are you exposed to at work?2. Do you work in close proximity to co-workers (e.g., assess risk

of exposure to co-workers)?F. Travel History

1. Have you traveled within the United States? To foreign coun-tries? Include geographic locations and dates.


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2. Did you have a fever during or after your trip? Fever in thereturning traveler requires an expedient evaluation to promptlyrecognize and treat potentially fatal diseases, such as malaria.

3. When taking a travel history, it is important to ask:a. Where did you go? For what duration? When did you return?b. What were the travel conditions (e.g., city versus remote)?c. Did you drink the local water?d. What exposures did you have to insects and animals?e. What types of food and drink did you consume?f. Did you have any sexual contacts? Was protection used?g. Obtain immunization and medication history, including

those taken as prophylaxis.4. Identify diseases that are capable of being transmitted to

others, and for which isolation precautions are advised.G. Animal and Insects Exposure History (See Table 16-6 for detailed

list.)1. What animals and insects have you recently been exposed to

(including pets)? Have you been exposed to cats (toxoplasmo-sis, cat scratch disease) or pigeons (Chlamydia psittacosis)?

2. Have you had any reactions to bites or stings (envenomations)?IV. MEDICATIONS

1. Are you taking any medications? Which ones? Note medicationsthat may alter fever (e.g., nonsteroidal anti-inflammatory drugs[NSAIDs], medications containing NSAIDS, acetominophen).

2. Have you recently used antibiotics? For what reason? Antibiotics may alter disease manifestation and ability toculture etiologic agent.

3. Have you had any allergic or adverse reactions? Some patientsmay experience anaphylactic reactions to certain medications(penicillin and derivatives). Note specific agent and type ofreaction. For some infections, desensitization may be required.

V. HEALTH MAINTENANCEA. Prevention

1. What immunizations have you had?a. Childhood immunizations by type and/or age: Diphtheria,

pertussis, tetanus, polio, measles, mumps, rubella, varicella,influenza, Hemophilus influenza type b, hepatitis B,meningococcus.

b. Adult immunizations by type and/or age: Varicella,influenza, pneumococcus, tetanus-diphtheria toxoid, hepa-titis A, hepatitis B, rabies, meningococcus, anthrax, yellowfever, cholera.

2. Hygiene practice: How often do you bathe? Do you brush yourteeth daily? How often? How often and when do you wash yourhands? How do you control menses (e.g., pads vs. tampons)?If you use tampons, how often do you change them? If a child,inquire about toilet training.


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3. Prophylaxis: Do you take antibiotics on a daily basis or for spe-cific procedures (e.g., before dental care in patients)? Ask aboutprophylactic antibiotic use if patient is immunocompromised(e.g., asplenic patients, HIV-infected patients) or has hadsurgery involving foreign body placement (e.g., cardiac valvereplacement, hip replacement).

4. Do you use an insect repellent or take other precautions (e.g.,covering head/face, tent)?

B. Diet: What food and water have you been exposed to recently?What is your usual diet? Evaluate nutritional status.

C. Exercise/Recreational Activities: In particular, note environ-mental exposures and zoonotic risks.

D. Sleep Patterns1. Have there been any changes in your sleep pattern?2. Have changes been caused by night sweats?

E. Social Habits1. Do you use alcohol? How much and how often?2. Do you use tobacco? What type? How much and for how long?3. Do you use illicit or recreational drugs?

VI. FAMILY HISTORYA. First-Degree Relatives’ Medical History and Three-Generation

Genogram: Look for a history of disease process(es) alteringimmune function (e.g., severe combined immune deficiency syndrome [SCIDS]).

B. Familial Exposure: Inquire about recent, potentially communica-ble, illnesses in family members.

VII. PSYCHOSOCIAL HISTORYA. Personal and Social History

1. Where were you born (country and city)?2. What is your religious affiliation?3. What is your ethnic background?4. Socioeconomic status: Describe your current residence. Whom

do you live with? What is the physical layout? Note especiallyclose-quarters facilities, such as military barracks, dormitories,homeless shelters, facilities for the elderly and mentally handicapped, and prisons.

5. Are you currently attending school?6. Are you involved in a social club?

B. Current Illness Effects on Patient1. Does the patient understand the illness?2. Is counseling necessary (e.g., risk of transmission to others, any

special precautions)?3. Will the patient be able to continue current occupation?

C. Interpersonal and Sexual History1. Are you sexually active? More than one partner? Do you use

protection? Possible exposure to sexually transmitted disease(STD).


ID

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2. Do you now have, or have you had, an STD? Consider the needto report to appropriate authority(ies). Contact partners.

D. Family Support1. Are family members available to provide any necessary

assistance?2. Consider whether it is necessary to counsel family members.3. Does the patient require any special needs or arrangements

(e.g., wheelchair, supplies for wound care, home health care)?E. Occupation Aspects of the Illness

1. How will the rehabilitation requirements affect your employ-ment (i.e., tertiary prevention)?

2. Will you be able to take necessary precautions (to protect selfand co-workers)?

VIII. REVIEW OF SYSTEMS (Tables 16-7, 16-8, and 16-9)


Table 16-7. GENERAL INFECTIOUS DISEASE SYMPTOMSBY SYSTEM.

SYSTEM SYMPTOMS

General Weight loss, fatigue/weakness, chills(frequency, how long do they last?), nightsweats, fever, and anorexia/loss of appetite

HEENT Sinus pain, headache, conjunctivitis, icterus,eyes/ears/nose pain, bleeding or discharge,photophobia, sore throat, difficultyswallowing, drainage in back of throat,dentition

Neck Any masses, pain on movement, stiffnessCardiac Angina, dyspnea, murmurRespiratory Cough (productive or nonproductive),

hemoptysis, pleurisy, chest pain with orwithout radiation, shortness of breath

Gastrointestinal Abdominal pain (location, quality, radiation),change in bowel habits/diarrhea, jaundice

Genitourinary Flank pain, pain or burning on urination,discharge, hematuria

Obstetrics / Pelvic pain, dyspareunia vaginal discharge, gynecologic last menstrual period (LMP), contraceptivesHematopoietic Anemia, easy bruising, bleedingSkin Color change (jaundice), easy bruising, rashNeurologic Loss of consciousness, change in mentationLymphatic Neck, axillary, groin masses, drainageMusculoskeletal Trauma, pain, stiffness, swelling, backache,

tumors/lesions

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IX. PHYSICAL EXAMINATION (Table 16-10)The physical examination of a patient with a febrile illness is no dif-ferent from that of any other patient, with one exception: the needfor empiric isolation precautions (Table 16-9). Because some infec-tions are contagious, precautions may be needed to protect those whomust interact with the patient.

A question that needs to be answered early in the triage of thefebrile or infected patient is: “Does this patient have a disease that is


ID

Table 16-8. NONSPECIFIC SYMPTOMS AND THEIRINFECTIOUS DISEASE CORRELATES.

SYMPTOM DISEASE

Abdominal pain Appendicitis, abscess (peritoneal, (localized) subphrenic, of solid organs)Abdominal pain (diffuse) Peritonitis, gastroenteritisChange in mentation Meningitis (bacterial, fungal, viral,

parasitic), anoxia (many etiologies)Cough Sinusitis, pharyngitis, bronchitis,

pneumoniaIcterus Many etiologies including hemolysis,

liver/ biliary disease, malariaJoint pain Septic arthritisNeck stiffness Meningitis, osteomyelitis, soft tissue

abscessPelvic pain STD, PIDPhotophobia MeningitisPleurisy Pleural effusion, irritation of

diaphragm (abscess), pneumonia

Table 16-9. COMMON INFECTIOUS DISEASE SYNDROMES AND THEIR SYMPTOMS.

SYNDROME SYMPTOMS

Sinusitis Nasal discharge, cough, sinus pain, feverMeningitis Headache, photophobia, neck pain/stiffness,

lethargy, fever, nausea, vomitingPneumonia Fever, chills, rigors, headache, malaise, cough

(may or may not be productive), hemoptysis,pleuritic chest pain, possible diarrhea,chest/back pain

Gastroenteritis Fever, nausea, vomiting, variable abdominalpain (localized, diffuse, intermittent, colicky)


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Tabl

e 16

-10.

FIN

DIN

GS

OF

EXA

MIN

ATIO

N A

ND

PO

SSIB

LE D

IAG

NO

SES.

SYST

EMPH

YSI

CA

LEX

AM

INAT

ION

FIN

DIN

GPO

SSIB

LED

IAG

NO

SES

Gen

eral

Chi

llsSe

ptic

sho

ck (

Gra

m-n

egat

ive

bact

eria

), lo

caliz

ed

infe

ctio

n, p

aras

item

iaW

eigh

t lo

ss/e

mac

iatio

nU

ndia

gnos

ed a

bsce

ss (

e.g.

, su

bphr

enic

, pe

rire

nal,

othe

r de

ep s

eate

d),

chro

nic

infe

ctio

n (H

IV,

para

site

)

Vit

al s

ign

s

Puls

eTa

chyc

ardi

aM

ay b

e ea

rly

sign

of

impe

ndin

g se

psis

Blo

od p

ress

ure

Hyp

oten

sion

Sept

ic s

hock

Res

pira

tory

rat

eTa

chyp

nea

Pneu

mon

ia

HEE

NT

Eyes

Phot

opho

bia

Men

ingi

tis (

e.g.

, vi

ral,

bact

eria

l, fu

ngal

), sy

phili

sIc

teru

sM

any

etio

logi

es,

incl

udin

g liv

er/b

iliar

y di

seas

e,

hem

olys

is (

mal

aria

)Pe

rior

bita

l ede

ma/

redn

ess

Peri

orbi

tal c

ellu

litis

Inje

cted

con

junc

tivae

Con

junc

tiviti

sFa

ilure

to

acco

mm

odat

e/re

act

to li

ght,

wea

kex

trao

cula

r m

uscl

es,

ptos

isB

otul

ism

Cor

neal

ulc

erat

ion/

lesi

ons

Bac

teri

al,

vira

l, pa

rasi

te (

e.g.

, ac

anth

amoe

ba)

Subr

etin

al h

emor

rhag

eTr

ichi

nosi

s

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ID

Ears

Inje

cted

, im

mob

ile t

ympa

nic

mem

bran

esO

titis

med

iaIn

flam

ed c

anal

Otit

is e

xter

naD

isch

arge

Bac

teri

al,

fung

al,

vira

l inf

ectio

nN

ose

Peri

phar

ynge

al/p

erito

nsill

ar m

ass

Ret

roph

aryn

geal

/per

itons

illar

abs

cess

Mou

thTo

nsill

ar e

xuda

tePh

aryn

gitis

(e.

g.,

stre

p th

roat

)W

hitis

h co

lora

tion

Thru

shIn

dura

tion/

edem

a flo

or o

f m

outh

Infe

ctio

n of

sub

lingu

al/s

ubm

andi

bula

r sp

ace

Pete

chia

e, e

ryth

ema

soft

pal

ate

Scar

let

feve

rK

oplik

’s s

pots

Mea

sles

Bee

fy r

ed t

ongu

eSc

arle

t fe

ver

Mem

bran

eD

ipht

heri

aG

ingi

val e

dem

a/bl

eedi

ngG

ingi

vitis

(e.

g.,

bact

eria

l)Si

t fo

rwar

d w

ith p

rotr

usio

n of

man

dibl

eEp

iglo

ttiti

sFl

uid

in s

inus

(tr

ansi

llum

inat

ion)

Sinu

sitis

Face

Uni

late

ral p

ain/

swel

ling

with

ove

rlyi

ng r

edne

ssSu

ppur

ativ

e pa

rotit

isB

ilate

ral s

wel

ling/

pain

Vir

al (

e.g.

, m

umps

)Pa

in/s

tiffn

ess

in ja

w (

risu

s sa

rdon

icus

)Te

tanu

sD

isfig

urem

ent

Han

sen’

s di

seas

e, L

eish

man

iasi

sN

eck

Stiff

ness

(e.

g.,

Ker

nig’

s si

gn,

Bru

dzin

ski’s

sig

n)M

enin

gitis

, su

bmas

toid

(B

ezol

d’s)

abs

cess

Gen

eral

Poin

t te

nder

ness

/mas

sD

eep

infe

ctio

n, o

steo

mye

litis

Thro

mbo

phle

bitis

jugu

lar

vein

Ass

ocia

ted

with

Bez

old’

s ab

sces

sLu

ngs

Ral

es/r

honc

hiPu

lmon

ary

edem

a (s

eptic

sho

ck),

bron

chiti

s, p

neum

onia

Dul

lnes

s to

per

cuss

ion

Effu

sion

, co

nsol

idat

ion

(e.g

., pn

eum

onia

)R

espi

rato

ry o

bstr

uctio

nM

edia

stin

al a

bsce

ss

Cont

inue

d

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Tabl

e 16

-10.

FIN

DIN

GS

OF

EXA

MIN

ATIO

N A

ND

PO

SSIB

LE D

IAG

NO

SES—

cont

’d

SYST

EMPH

YSI

CA

LEX

AM

INAT

ION

FIN

DIN

GPO

SSIB

LED

IAG

NO

SES

Bro

ncho

phon

y, p

ecto

rilo

quy,

tra

chea

l dev

iatio

nPn

eum

onia

Left

ple

ural

eff

usio

nSp

leni

c/pa

ncre

atic

/sub

phre

nic

absc

ess,

pne

umon

ia,

empy

ema

Rig

ht p

leur

al e

ffus

ion

Live

r/su

bphr

enic

abs

cess

, pn

eum

onia

, em

pyem

a,

ameb

iasi

sPa

inPn

eum

onia

, em

pyem

a, b

ronc

hitis

Ch

est

Fric

tion

rub

Peri

card

itis

Car

diov

ascu

lar

New

ons

et m

urm

urEn

doca

rditi

sD

ecre

ased

hea

rt s

ound

sTa

mpo

nade

(pe

rica

rditi

s)A

bdom

enFl

uid

wav

ePe

rito

nitis

(e.

g.,

spon

tane

ous

bact

eria

l per

itoni

tis [

SBP]

)Pa

in,

righ

t lo

wer

qua

dran

t (M

cBur

ney’

s po

int)

App

endi

citis

, ab

sces

s, P

IDD

ulln

ess

to p

ercu

ssio

nA

scite

s/pe

rito

nitis

Mas

s, r

ight

upp

er q

uadr

ant

Live

r ab

sces

s (e

.g.,

amoe

bic,

bac

teri

al),

echi

noco

ccal

cy

st,

PID

Rig

idity

Peri

toni

tisH

epat

omeg

aly

Abs

cess

Vagu

e, v

aria

ble,

non

loca

lized

dis

com

fort

Bac

teri

al i

nfec

tion,

“fo

od p

oiso

ning

” (e

.g.,

ente

roto

xin)

, pr

otoz

oal (

e.g.

, G

iard

ia)

Sple

nom

egal

yA

bsce

ss,

para

site

mia

(e.

g.,

mal

aria

, sc

hist

osom

iasi

s)Lo

wer

abd

omin

al p

ain

App

endi

citis

, PI

D

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ID

Dis

tens

ion

Org

anom

egal

y (e

.g.,

absc

ess)

som

e pn

eum

onia

s,

peri

tone

al e

ffus

ion

Reb

ound

Peri

toni

tis,

appe

ndic

itis,

gas

troe

nter

itis

Flan

kPa

inR

etro

peri

tone

al a

bsce

ss,

pyel

onep

hriti

s, g

astr

oent

eriti

sG

enit

ouri

nar

yPe

rine

al p

ain,

ten

der

pros

tate

Pros

tatit

isM

ale

Ure

thra

l pai

n, m

eata

l ery

them

aST

DTe

stic

ular

pai

nEp

idid

ymiti

s, S

TDU

lcer

atio

n(s)

STD

Scro

tal e

dem

aPa

rasi

tem

ia (

e.g.

, fil

aria

sis)

Fem

ale

Vagi

nal “

fulln

ess”

/ten

dern

ess

Ret

rofa

scia

l abs

cess

Pelv

ic p

ain

duri

ng e

xam

inat

ion/

cerv

ical

PID

mov

emen

tAd

nexa

l mas

s/fu

llnes

sTu

boov

aria

n ab

sces

s (T

OA

)Vu

lvar

/vag

inal

/intr

oitu

s er

ythe

ma

with

or

Fung

al (

e.g.

, C

andi

da)

with

out

whi

te d

isco

lora

tion

Vagi

nal d

isch

arge

Bac

teri

al/f

unga

l dis

ease

, ST

D,

PID

Ulc

erat

ion(

s)ST

D,

fung

al,

vira

lC

yano

sis

Sept

ic s

hock

, pn

eum

onia

Skin

Jaun

dice

Hem

olys

is (

e.g.

, se

ptic

sho

ck),

bilia

ry d

isea

se

(cho

lang

itis)

, liv

er d

isea

se (

e.g.

, ab

sces

s, c

yst:

am

oebi

c,ec

hino

cocc

al,

vira

l)R

edne

ss,

tend

erne

ss,

swel

ling,

hea

tD

erm

al/s

ubcu

tane

ous

infe

ctio

nR

eddi

sh s

trea

ks w

ith ly

mph

aden

opat

hyLy

mph

angi

tisW

arts

, pa

pule

sV

iral

(e.

g.,

HPV

)

Cont

inue

d

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Tabl

e 16

-10.

FIN

DIN

GS

OF

EXA

MIN

ATIO

N A

ND

PO

SSIB

LE D

IAG

NO

SES—

cont

’d

SYST

EMPH

YSI

CA

LEX

AM

INAT

ION

FIN

DIN

GPO

SSIB

LED

IAG

NO

SES

Eryt

hem

atou

s le

sion

sIm

petig

o, p

yode

rma,

cel

lulit

isU

lcer

atio

nV

iral

(e.

g.,

HSV

), ba

cter

ial (

e.g.

, se

ptic

thr

ombi

)Pe

tech

iae

Endo

card

itis

Red

ras

hSc

arle

t fe

ver

Red

ras

h, e

xfol

iativ

e de

rmat

itis

Scal

ded

skin

syn

drom

e, t

oxic

sho

cksy

ndro

me

Eryt

hem

atou

s pa

pule

—es

char

Ant

hrax

Mar

blin

g/br

onzi

ng o

f sk

inC

lost

ridi

umPe

tech

iae,

hem

orrh

ages

Wat

erho

use-

Frid

eric

hsen

syn

drom

e, D

IC a

ssoc

iate

d w

ith s

epsi

sA

nnul

ar le

sion

sLy

me

dise

ase

Targ

etoi

d ra

sh o

n pa

lms/

sole

sSy

phili

s (s

econ

dary

)M

acul

opap

ular

ras

hV

iral

exa

nthe

ms,

tri

chin

osis

Vesi

cles

(di

ffus

e, d

erm

atom

e di

stri

butio

n)H

SV,

VZV

Larg

e sk

in f

olds

Onc

hoce

rcia

sis

Lym

phad

enop

athy

Infe

ctio

n of

dra

inin

g ar

ea,

lym

phan

gitis

, pa

rasi

tem

iaLy

mph

atic

sSu

ppur

ativ

e ly

mph

aden

itis

in g

roin

Lym

phog

ranu

lom

a ve

nere

um (

LGV

)M

ass

Abs

cess

Extr

emit

ies

Join

t pa

in,

swel

ling,

red

ness

Sept

ic a

rthr

itis

Cre

pitu

sIn

fect

ion

with

gas

-pro

duci

ng o

rgan

ism

(em

erge

ncy)

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ID

Paro

nych

iaIn

fect

ion

arou

nd n

ail

Bon

e pa

inO

steo

mye

litis

Exqu

isite

ten

dern

ess

in d

istr

ibut

ion

of t

endo

nSu

ppur

ativ

e te

nosy

novi

tissh

eath

/com

part

men

t w

ith fl

exio

nH

ip/t

high

pai

n, p

ares

thes

ias

Ret

rops

oas

absc

ess

Ingu

inal

/ilia

c cr

est

pain

, pa

in w

ith m

ovem

ent

Ret

rofa

scia

l abs

cess

of h

ipH

yper

refle

xia

Teta

nus

Prog

ress

ive

wea

knes

s—pa

raly

sis

Bot

ulis

m,

vira

l (e.

g.,

polio

)R

educ

ed r

eflex

esB

otul

ism

Mas

sive

ede

ma

Para

site

mia

(e.

g.,

filar

iasi

s)Se

vere

pai

n, e

dem

a (c

ompa

rtm

ent

synd

rom

e)G

as g

angr

ene

(e.g

., C

lost

ridi

a)Sp

linte

r he

mor

rhag

es (

nail)

Endo

card

itis,

tri

chin

osis

Men

tal s

tatu

s ch

ange

sM

enin

gitis

, se

ptic

sho

ck,

para

site

mia

(e.

g.,

Cha

gas’

di

seas

e, t

rypa

noso

mia

sis)

, ru

ptur

ed a

bsce

ssN

euro

logi

cR

adic

ulop

athy

, cr

ania

l neu

ritis

Lym

e di

seas

eC

hore

aLy

me

dise

ase

Peri

rect

al m

ass/

pain

, fis

tula

(s)

Peri

rect

al a

bsce

ssR

ectu

mFu

llnes

s/te

nder

ness

Ret

rofa

scia

l abs

cess

Vagu

e to

sev

ere

pelv

ic p

ain,

rel

ieve

d w

ithSu

pral

evat

or (

isch

iore

ctal

) ab

sces

sde

feca

tion,

ana

l/coc

cyge

al p

ain

Eryt

hem

a, e

xuda

tes,

ulc

erat

ion,

muc

osal

Pr

octit

is (

e.g.

, ST

D:

bact

eria

l, vi

ral)

blee

ding

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potentially transmissible, and thus should isolation precautions be initiated?”X. LABORATORY STUDIES AND DIAGNOSTIC EVALUATIONSA. Diagnostic Studies: Microbiologic cultures, in particular, are an

integral part of the work-up of a patient with a suspected infection.1. It is important to be familiar with the unique capabilities of your

hospital laboratory and to communicate directly with labora-tory personnel about your differential diagnosis.a. Some infections require unique methods of detection, and

you must convey your suspicions to the laboratory person-nel. For example, if you suspect a skin infection is causedby Mycobacterium marinum, the specimen should be cul-tured at 30°C to optimize growth.

b. You should also alert lab personnel if you suspect the patient’s infection is caused by an etiologic agent that may pose a danger to lab personnel if cultured (e.g.,coccidioidomycosis).

2. The diagnosis of an infection is typically made by the follow-ing method:a. Direct examination of a clinical specimen.b. Isolation of the microorganism(s).c. Measurement of the host’s immune response to the

organism.3. The proper collection, transport, and handling of specimens

are critical to obtaining useful information (Table 16-11). The goal of proper specimen collection and handling is to minimize extrinsic contamination while facilitating growth ofthe pathogen.

B. Radiologic Studies: These may be critical for arriving at a correctdiagnosis (chest x-ray for pneumonia, abdominal CT for abscess).

C. Routine Tests: In hospitalized patients with community-acquiredpneumonia.1. Chest radiograph.2. Arterial blood gas (ABG) analysis.3. Complete blood count (CBC).4. Chemistry profile, including kidney and liver function tests

(LFTs) and electrolyte levels.5. HIV serology (age 15 to 54 years).6. Blood culture.7. Sputum Gram stain and culture +/- acid-fast stain and culture,

Legionella test (culture, direct fluorescent antibody stain, orurinary antigen assay), Mycoplasma immunoglobulin M.

8. Pleural fluid analysis (if present): White blood cell (WBC) countand differential, lactate dehydrogenase (LDH), pH, protein,glucose, Gram stain, acid-fast stain; and culture for bacteria(aerobes and anaerobes), fungi, and mycobacteria.



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ID

Tabl

e 16

-11.

SPEC

IMEN

CO

LLEC

TIO

N A

ND

TRA

NSP

ORT

FO

R BA

CTE

RIO

LOG

Y.

SPEC

IMEN

CO

LLEC

TIO

NA

ND

TRA

NSP

OR

TC

OM

MEN

T

BLO

OD

Adul

ts1.

10m

L in

to e

ach

of t

wo

100-

mL

vacu

um b

ottle

s or

2.5

mL

into

eac

h of

tw

o 50

-mL

vacu

um b

ottle

s an

d 10

mL

into

iso

lato

r, or

3.

10m

L in

to o

ne 1

00-m

L va

cuum

bot

tle a

nd 1

0m

L in

to i

sola

tor

4.10

mL

into

eac

h of

tw

o BA

CTEC

hig

h-vo

lum

e re

sin

resi

n bo

ttle

sIn

fant

s1.

1-3

mL

into

eac

h of

tw

o 50

- or

100

-mL

vacu

um

A m

inim

um o

f tw

o an

d a

max

imum

of

four

bott

les,

or

cultu

res

per

sept

ic e

piso

de a

re r

ecom

men

ded

2.0.

5-1.

0m

L in

to p

edia

tric

iso

lato

r an

d an

yre

mai

ning

blo

od i

nto

50-

or 1

00-m

L va

cuum

bot

tleIn

trav

ascu

lar

Rem

ove

cath

eter

ase

ptic

ally

, cl

ip o

ne (

from

2-

to

Cat

hete

r se

gmen

ts s

houl

d be

cul

ture

d se

mi-

cath

eter

3-in

ch c

athe

ter)

or

two

(fro

m 8

- to

24-

inch

cat

hete

r)

quan

titat

ivel

y2-

inch

seg

men

ts,

and

tran

sfer

int

o sw

ab t

rans

port

de

vice

(C

ultu

rett

e)Ex

uda

te (

tran

suda

te,

Swab

or

ster

ile,

scre

w-c

appe

d tu

beSu

ch s

peci

men

s ar

e ra

rely

sui

tabl

e fo

rdr

ain

age,

ulc

er)

anae

robi

c cu

lture

Fece

sFr

eshl

y pa

ssed

spe

cim

en i

n se

aled

con

tain

er o

r Tr

ansp

ort

med

ium

is

reco

mm

ende

d if

dela

y is

rect

al s

wab

antic

ipat

ed

Cont

inue

d

W8712-016.qxd 7/7/03 3:00 PM Page 295

www.belimantil.info

296 Section II Specialty History and Physical ExaminationTa

ble

16-1

1.SP

ECIM

EN C

OLL

ECTI

ON

AN

D T

RAN

SPO

RT F

OR

BAC

TERI

OLO

GY—

cont

’d

SPEC

IMEN

CO

LLEC

TIO

NA

ND

TRA

NSP

OR

TC

OM

MEN

T

FLU

IDS

Cer

ebro

spin

al fl

uid

Ster

ile,

scre

w-c

appe

d tu

be t

o be

del

iver

ed t

o th

e R

efri

gera

tion

may

be

harm

ful t

o N

eiss

eria

or

(CSF

)la

bora

tory

im

med

iate

lyH

aem

ophi

lus

Peri

ton

eal

(in

clu

din

gIn

ocul

ate

10m

L in

to b

lood

cul

ture

bot

tles

Dir

ect

inoc

ulat

ion

of b

lood

cul

ture

sys

tem

sdi

alys

ate)

has

incr

ease

d yi

eld

of b

acte

ria

from

pat

ient

sw

ith s

pont

aneo

us p

erito

nitis

and

con

tinuo

us

ambu

lato

ry p

erito

neal

dia

lysi

s-as

soci

ated

pe

rito

nitis

Pleu

ral

Inoc

ulat

e a

port

ion

of t

he s

peci

men

int

o an

Pleu

ral o

r em

pyem

a flu

id i

s a

maj

or s

ourc

e of

anae

robi

c tr

ansp

ort

syst

eman

aero

bic

bact

eria

cau

sing

ple

urop

ulm

onar

y in

fect

ion

GE

NIT

OU

RIN

AR

YSY

STE

M

For

Nei

sser

iaSe

nd s

wab

moi

sten

ed w

ith S

tuar

t or

Am

ies

Wom

engo

nor

rhoe

aetr

ansp

ort

med

ium

dir

ectly

to

labo

rato

ry (

4-ho

ur

Cer

vix:

Moi

sten

spe

culu

m w

ith w

ater

bef

ore

max

imum

tra

nspo

rt t

ime)

or

dire

ctly

ino

cula

te

inse

rtin

g in

to v

agin

a; i

nser

t sw

ab i

nto

cerv

ical

m

odifi

ed T

haye

r M

artin

med

ium

int

o Tr

ansg

row

or

cana

lJE

MB

EC d

evic

eA

nal

sw

ab:

Inse

rt s

wab

app

roxi

mat

ely

2cm

and

mov

e fr

om s

ide

to s

ide

to s

ampl

e cr

ypts

Men

Ure

thra

:Sw

ab m

ay b

e us

ed w

hen

a di

scha

rge

is p

rese

nt;

othe

rwis

e, a

ste

rile

bac

teri

olog

ic

loop

is

inse

rted

to

obta

in s

crap

ings

for

sm

ear

and

cultu

reA

nal

sw

ab:

Sam

e pr

oced

ure

as f

or w

omen

W8712-016.qxd 7/7/03 3:00 PM Page 296

www.belimantil.info


ID

Cer

vix,

vag

ina,

for

Swab

Spec

imen

s fr

om t

hese

site

s ar

e no

t su

itabl

eot

her

bac

teri

afo

r an

aero

bic

cultu

reU

RIN

E

Mid

stre

am c

ath

eter

Col

lect

in

ster

ile,

scre

w-c

appe

d co

ntai

ner,

whi

ch

mus

t be

tra

nspo

rted

to

the

labo

rato

ry w

ithin

2 h

ours

unle

ss r

efri

gera

ted

Supr

apu

bic

aspi

rate

Inje

ct p

ortio

n of

asp

irat

e in

to a

n an

aero

bic

tran

spor

tTh

is i

s th

e on

ly t

ype

of u

rine

spe

cim

en t

hat

istu

be o

r vi

alac

cept

able

for

ana

erob

ic c

ultu

reA

bsce

ss,

trau

mat

icA

spir

ate

pus

with

syr

inge

and

nee

dle

and

tran

spor

t A

sw

ab p

rovi

des

too

little

mat

eria

l for

Gra

m-

or p

osto

pera

tive

to la

bora

tory

by

inje

ctin

g as

pira

te i

nto

an a

naer

obic

st

aine

d sm

ear

or a

erob

ic a

nd a

naer

obic

w

oun

dtr

ansp

ort

vial

or

taki

ng s

yrin

ge d

irec

tly t

o th

e cu

lture

s. I

f th

e am

ount

of

pus

is li

mite

d, o

nela

bora

tory

may

inj

ect

the

area

with

0.5

to

1.0

mL

bact

erio

stat

-fre

e la

ctat

ed R

inge

r’s,

and

asp

irat

em

ater

ial

RE

SPIR

ATO

RY

TRA

CT

For

Bor

dete

lla

Use

flex

ible

-wir

e, c

alci

um-t

ippe

d sw

ab o

r so

ft r

ubbe

rC

ough

pla

te i

s no

t re

com

men

ded

pert

uss

isca

thet

er t

o ob

tain

nas

opha

ryng

eal s

peci

men

Thro

atSw

ab p

oste

rior

pha

rynx

, to

nsils

, an

y ar

eas

ofAv

oid

cont

amin

atio

n w

ith o

ral s

ecre

tions

.pu

rule

nce

or u

lcer

atio

n; d

ry s

wab

acc

epta

ble

ifO

rdin

arily

, te

stin

g fo

r gr

oup

A s

trep

toco

cci

iscu

lture

d w

ithin

2 h

ours

; ot

herw

ise,

moi

sten

sw

ab

suffi

cien

t. T

he la

bora

tory

mus

t be

not

ified

in

with

Stu

art

or A

mie

s tr

ansp

ort

med

ium

case

of

susp

ecte

d di

phth

eria

, pe

rtus

sis,

or

gono

cocc

al i

nfec

tion

Cont

inue

d

W8712-016.qxd 7/7/03 3:00 PM Page 297

www.belimantil.info


Tabl

e 16

-11.

SPEC

IMEN

CO

LLEC

TIO

N A

ND

TRA

NSP

ORT

FO

R BA

CTE

RIO

LOG

Y—co

nt’d

SPEC

IMEN

CO

LLEC

TIO

NA

ND

TRA

NSP

OR

TC

OM

MEN

T

RE

SPIR

ATO

RY

TRA

CT

Spu

tum

Obt

ain

spec

imen

by

expe

ctor

atin

g a

deep

cou

gh i

nto

Spec

imen

s sh

ould

be

scre

ened

cyt

olog

ical

lya

ster

ile,

scre

w-c

appe

d ja

ran

d an

othe

r sp

ecim

en r

eque

sted

whe

n >2

5 sq

uam

ous

epith

elia

l cel

ls a

re o

bser

ved

per

low

-pow

er fi

eld

Tran

stra

chea

lC

olle

ct a

spir

ate

in a

Luk

ens

trap

or

inje

ct i

nto

an

Such

spe

cim

ens

are

suita

ble

for

anae

robi

cas

pira

tean

aero

bic

tran

spor

t vi

alcu

lture

Prot

ecte

d br

ush

The

brus

h is

sev

ered

fro

m t

he i

nner

can

nula

and

Q

uant

itativ

e cu

lture

of

the

vort

exed

lact

ated

tran

spor

ted

to t

he la

bora

tory

in

1m

L of

bac

teri

osta

t-R

inge

r’s

solu

tion

help

s di

ffer

entia

te u

pper

fr

ee la

ctat

ed R

inge

r’s

solu

tion

from

low

er r

espi

rato

ry t

ract

bac

teri

al o

rigi

nB

ron

choa

lveo

lar

Obt

ain

at le

ast

40m

L fo

r co

mpl

ete

mic

robi

olog

ic

Cyt

ocen

trifu

ge s

mea

rs s

houl

d be

mad

e fo

rla

vage

(BA

L)ex

amin

atio

nG

ram

and

oth

er a

ppro

pria

te s

tain

s.Q

uant

itativ

e cu

lture

will

hel

p di

ffer

entia

teup

per

from

low

er r

espi

rato

ry t

ract

bac

teri

alor

igin

Tiss

ue

Ster

ile,

scre

w-c

appe

d co

ntai

ner

A s

uffic

ient

am

ount

of

tissu

e m

ust

beob

tain

ed f

or b

oth

hist

opat

holo

gic

and

mic

robi

olog

ic e

xam

inat

ions

*Rep

rodu

ced

with

per

mis

sion

fro

m I

senb

erg

HD

. C

linic

al m

icro

biol

ogy.

In

Gor

bach

SL,

Bar

tlett

JG

, B

lack

low

NR

(ed

s),

Infe

ctio

usD

isea

ses,

ed

2. P

hila

delp

hia:

WB

Sau

nder

s, 1

998;

125.

W8712-016.qxd 7/7/03 3:00 PM Page 298

www.belimantil.info


ID

XI.

EPO

NY

MS,

AC

RO

NY

MS,

AN

D A

BB

REV

IATI

ON

S (T

able

s 16

-12

and

16-1

3)

Tabl

e 16

-12.

SELE

CTE

D I

NFE

CTI

OU

S D

ISEA

SE–F

OC

USE

D E

PON

YMS.

EPO

NY

MD

ESC

RIP

TIO

NA

SSO

CIA

TIO

N(S

)

Bez

old’

s ab

sces

sA

bsce

ss a

ssoc

iate

d w

ith m

asto

id d

isea

seM

asto

iditi

sB

iede

rman

’s s

ign

Dar

k re

d co

lora

tion

of t

he a

nter

ior

pilla

rs o

f th

e th

roat

Seen

in

som

e pa

tient

s w

ith s

yphi

lisB

orsi

eri’s

sig

n (li

ne)

Whe

n fin

gern

ail d

raw

n al

ong

skin

, a

whi

te li

ne i

s le

ft,

whi

ch

Ass

ocia

ted

with

ear

ly s

tage

s of

quic

kly

turn

s re

d.Sc

arle

t fe

ver

Bru

dzin

ski’s

sig

nFl

exio

n of

the

nec

k re

sults

in

flexi

on o

f th

e hi

p an

d kn

eeA

ssoc

iate

d w

ith m

enin

gitis

Bru

nati’

s si

gnO

paci

ties

in t

he c

orne

aA

ppea

ranc

e in

the

cou

rse

of p

neum

onia

or t

ypho

id f

ever

Cla

vicu

lar

sign

Tum

efac

tion

of t

he i

nner

thi

rd o

f th

e ri

ght

clav

icle

Ass

ocia

ted

with

con

geni

tal s

yphi

lisFi

lopo

vitc

h’s

Yello

w d

isco

lora

tion

of t

he p

rom

inen

t pa

rts

of t

he p

alm

s/so

les

Seen

with

typ

hoid

fev

er(p

alm

opla

ntar

) si

gnG

uilla

nd’s

sig

nB

risk

flex

ion

of t

he h

ip w

hen

cont

rala

tera

l qua

dric

eps

are

Ass

ocia

ted

with

men

inge

al i

rrita

tion

pinc

hed

Hat

chco

ck’s

sig

nTe

nder

ness

on

runn

ing

finge

r to

war

d an

gle

of t

he ja

wA

ssoc

iate

d w

ith m

umps

Jack

son’

s si

gnPr

olon

gatio

n of

exp

irat

ory

soun

d ov

er a

ffec

ted

area

Pulm

onar

y tu

berc

ulos

isH

orn’

s si

gnPa

in p

rodu

ced

on t

ract

ion

of r

ight

spe

rmat

ic c

ord

Ass

ocia

ted

with

app

endi

citis

Ker

nig’

s si

gnW

hen

lyin

g w

ith k

nee

on a

bdom

en o

r w

hen

sitt

ing,

the

leg

Ass

ocia

ted

with

men

ingi

tisca

nnot

be

com

plet

ely

exte

nded

Kop

lik’s

spo

tsB

righ

t re

d sp

ots

on b

ucca

l/lin

gual

muc

osa

Mea

sles

Lenh

off’s

sig

nFu

rrow

app

eari

ng o

n de

ep i

nspi

ratio

n be

low

the

low

est

rib

Echi

noco

ccal

cys

t of

live

ran

d ab

ove

cyst

in

liver

Cont

inue

d

W8712-016.qxd 7/7/03 3:00 PM Page 299

www.belimantil.info


Tabl

e 16

-12.

SELE

CTE

D I

NFE

CTI

OU

S D

ISEA

SE–F

OC

USE

D E

PON

YMS—

cont

‘d

EPO

NY

MD

ESC

RIP

TIO

NA

SSO

CIA

TIO

N(S

)

McB

urne

y’s

sign

Tend

erne

ss a

t a

poin

t tw

o th

irds

of

the

dist

ance

fro

m t

he

Ass

ocia

ted

with

app

endi

citis

umbi

licus

to

the

ante

rior

sup

erio

r sp

ine

of t

he i

lium

Mur

at’s

sig

nV

ibra

tion

of t

he a

ffec

ted

side

of

the

ches

t w

ith a

fee

ling

of

Ass

ocia

ted

with

tub

ercu

losi

sdi

scom

fort

whe

n sp

eaki

ngO

btur

ator

sig

nH

ypog

astr

ic/a

dduc

tor

pain

by

pass

ive

inte

rnal

rot

atio

n of

the

Ass

ocia

ted

with

app

endi

citis

flexe

d th

igh

Osl

er’s

sig

nPa

infu

l, sm

all e

ryth

emat

ous

swel

lings

in

the

skin

of

the

hand

s A

ssoc

iate

d w

ith e

ndoc

ardi

tisan

d fe

etPa

rrot

’s s

ign

Dila

tion

of t

he p

upils

whe

n sk

in o

n th

e ba

ck o

f th

e ne

ck i

s Se

en w

ith m

enin

gitis

pinc

hed

Rom

berg

’s s

ign

Sway

ing

of t

he b

ody

or f

allin

g w

hen

stan

ding

with

fee

t cl

ose

Seen

with

tab

es d

orsa

listo

geth

er a

nd e

yes

clos

edSk

oda’

s si

gnTy

mpa

nic

soun

d he

ard

on p

ercu

ssin

g ch

est

abov

e la

rge

Pneu

mon

iapl

eura

l eff

usio

n or

lung

con

solid

atio

nSq

uire

’s s

ign

Alte

rnat

e di

latio

n an

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., m

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ntile

pne

umon

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ide

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ID

Tabl

e 16

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SELE

CTE

D I

NFE

CTI

OU

S D

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le t

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rem

ic s

yndr

ome

UTI

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nary

tra

ct i

nfec

tion

HAV

, H

BV,

HC

VH

epat

itis

A,

B,

and

C v

irus

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EVa

ncom

ycin

-res

ista

nt e

nter

ococ

cus

VZV

Vari

cella

Zos

ter

viru

s

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Table 16-14. INFECTIOUS DISEASE–FOCUSED DEFINITIONS.

TERM DEFINITION

Bacteremia Bacteria present in blood, as confirmed byculture; may be transient

Hypotension A systolic blood pressure of <90mmHg or areduction of >40mmHg from baseline in theabsence of another known cause forhypotension

Infection Presence of an organism in a normally sterilesite that is usually, but not necessarily,accompanied by an inflammatory hostresponse

Refractory septic Septic shock that lasts for more than 1 hour shock and does not respond to fluid administration

or pharmacologic interventionSepsis Describes the inflammatory response to

infection. See clinical evidence of infectionand evidence of systemic response, manifestedby two or more of the following conditions:

Temperature >38°C (100.4°F) or <36°C(96.8°F)Heart rate >90 beats per minuteRespiratory rate >20 breaths/minute orarterial carbon dioxide tension of <32mmWhite blood cell (WBC) count: >12,000cells/mm3, <4000 cells/mm3, or >10%immature band forms

These changes should represent an acutealteration from baseline in the absence ofanother known cause for the abnormalities

Sepsis syndrome Sepsis plus evidence of altered organ perfusion,with at least one of the following: Hypoxemia,elevated lactate, oliguria, altered mentation

Septicemia Same as bacteremia, but implies greater severitySeptic shock Sepsis with hypotension despite adequate

fluid resuscitation, with the presence ofperfusion abnormalities that may include, butare not limited to, lactic acidosis, oliguria, oran acute alteration in mental status. Patientswho are receiving inotropic or vasopressoragents may not be hypotensive at the timethat perfusion abnormalities are measured

XII. DEFINITIONS (Table 16-14)

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ID

Table 16-14—cont’d

TERM DEFINITION

Severe sepsis Sepsis associated with organ dysfunction,hypoperfusion, or hypotension.Hypoperfusion and perfusion abnormalitiesmay include, but are not limited to, lacticacidosis, oliguria, or altered mental status

Systemic Response to a wide variety of clinical insults, inflammatory which can be infectious, as in sepsis, but response can be noninfectious in etiology (e.g., burns, syndrome pancreatitis)

Table adapted with permission from Young LS. Sepsis syndrome. InMandell GL, Bennett JE, Dolin R (eds), Principles and Practice ofInfectious Diseases, ed 5. Philadelphia: Churchill Livingstone, 2000;690.

XIII. SAMPLE H&P WRITE-UPCC: “I’ve got the worst headache of my life.”HPI: J.R. is an 18-year-old white male college student who pres-

ents with an acute onset of the worst headache of his life. He was inhis usual state of excellent health until 12 hours before admission,when he developed fever, headache, and stiff neck.

PMHx: The patient denies any chronic medical problems. Hestates that two other students in his dormitory have similar symptomsand are being evaluated in the emergency room.

PSHx: History of an automobile accident at age 16, during whichhe suffered a ruptured spleen and required a splenectomy. No otherhospitalizations or surgeries.

Emergency and Trauma History: No history of head trauma. Noprior transfusions.

Childhood History: Varicella at age 7. He denies any other child-hood illnesses.

Occupational History: Freshman in college; works at a local fast-food restaurant as a cook.

Travel History: No recent or remote history of travel.Sexual History: Reports monogamous relationship with healthy

female student.MEDICATIONS: Ibuprofen during the past day for headache and

fever. He has not taken any other medications. The patient denies anyknown allergies.

HEALTH MAINTENANCEPrevention: The patient received all of the usual childhood immu-

nizations. He does not recall receiving any additional immunizationsfollowing his splenectomy.

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Diet: Regular diet with no restrictions. Eats meals in college cafe-teria and at fast-food restaurant where employed. No ingestion of rawmeats.

Exercise: The patient is on the college track team.Sleep Patterns: Wakes at most once each night to void. Denies

recent changes.Social Habits: The patient denies tobacco use or illicit drug use.

Drinks approximately one six-pack of beer per weekend.FAMILY HISTORYFirst-Degree Relatives’ Medical History: The patient’s father

has hypertension and adult-onset diabetes mellitus. The patient’smother has a history of intermittent migraine headaches that respondwell to medication. The patient’s two siblings have no medical problems.

PSYCHOSOCIAL HISTORYPersonal and Social History: The patient is a white college student

who lives in the freshman dormitory.REVIEW OF SYSTEMSGeneral: Fever, chills, rigors, and severe headache over past 12

hours.HEENT/Neck: Positive for headache, photophobia. No discharge,

difficulty swallowing, or drainage in back of throat.Respiratory: Denies cough or dyspnea.Cardiovascular: No chest pain, dyspnea, or history of murmur.Gastrointestinal: Mild abdominal pain “all over” without radiation.

Reports several episodes of emesis after headache began. No diarrhea.

Genitourinary: No dysuria, urinary urgency, hematuria, or discharge.

Hematopoietic/Lymphatic: No bleeding or adenopathy.Neurologic: No loss of consciousness (LOC) or change in

mentation.Skin: New onset of rash on legs and lower abdomen.Musculoskeletal: Recent neck stiffness.PHYSICAL EXAMINATIONVitals: T (oral) 102°F P 99 BP 90/60 RR 22 Weight 170 lbs.General: Agitated, well-developed, well-nourished Caucasian male

who appears his stated age. Patient is oriented to person, place, time,and circumstances, but appears in moderate distress secondary toheadache.

HEENT: Head is normocephalic without palpable defects. Mildsinus tenderness on percussion. Lids/sclera normal. Conjunctivaeslightly injected. Pupils measure 3mm bilaterally and react sym-metrically to light. Photophobia present. Tympanic membranes areclear and mobile. Nares are patent with slight mucosal erythema and clear nasal discharge. Neck stiff with limited range of motion. Pos-itive Kernig’s and Brudzinski’s signs. Trachea normal position. No JVD.


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Tonsils slightly injected but otherwise within normal limits. Noadenopathy appreciated.

Lungs: Clear to auscultation bilaterally.Cardiovascular: Normal S1 and S2. Regular rate and rhythm. No

JVD, murmur.Abdomen: Well-healed surgical scar in the left upper quadrant.

Soft with diffuse mild tenderness and no localizing signs. Noorganomegaly, flank pain (CVAT), or suprapubic tenderness.

Genitalia: Normal circumcised male. No penile lesions/discharge,testicular pain, or masses.

Rectum/Prostate: Normal external appearance. Guaiac negative.Prostate normal size with no tenderness on palpation.

Extremities: Normal range of motion. No weakness or muscle tenderness.

Skin: Multiple purpuric lesions noted on both lower extremitiesand lower abdomen.

Lymphadenopathy: “Fullness” noted bilateral neck (anterior cervical), but otherwise no adenopathy.

Neurologic: Normal mental status examination and gait.


ID

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