诊断学课件（英文）

CoughandexpectorationCoughingisanessentialdefensemechanismthatitpreventstheairwaysfromtheforeignsubstanceandcleartheexcretionofrespiratorytract. Coughingisareflex.permanentandfrequentcoughingindicatesanabnormality.MechanismExtrathoraciccoughreceptors(locatedinnoseoropharynxlarynxanduppertrachea)intrathoraciccoughreceptors(locatedinlowtracheaandlargecentralbronchi)Afferent(vague,trigeminal,superiorlaryngeal,glosso-pharyngealnerves)Efferentrecurrentlaryngealnerve---closureofglottiscorticospinaltractandperipheralnerves-------contractionofthoracicandabdominalmusculature.ThecoughreflexAdeepbreath---glotticclosure---relaxationofdiaphragm,contractionofexpiratorymuscle---positivethoracicpressure--suddenlyreleaseofglottisopen---thoracicpositivepressureairflowout---coughreflexEtiologyRespiratorypleuraldiseasecardiovasculardiseasecentralnervesystemfactorRespiratorydiseaseStimulator---extraandintrathoracic---fromnose,oropharynx---bronchi---coughreflex.suchas:1.inhalationofforeignmaterial2.inflammationofrespiratorytract3.bleedingofrespiratorytract4.tumorofrespiratorytractPleuralDiseaseSuchas: pleurisy,thoraciceffusion pleuralbiopsyorpleuracentisisCardiovascularDisease

Mitralstenosis---leftheartfailure---pulmonaryedema---trausudateorexudate---stimulatesintra-thoracic-coughreceptor---cough Embolismofpulmonarycancausepulmonaryvenouspressureelevate---pulmonaryedema---transudateorexudate---stimulatesintrathoraciccoughreceptor---coughCentralnervesystemInflammatoryofCNScancausecoughingsuchas:encephalitisandmeningitisExpectorationExpectorationisapathologicalphenomenonthathumanbeingremovethepathologicalsecretionfromrespiratorysystembymeansofcoughingExpectorationThedailyquantityofbronchialsecretionsproducedbyanormalpersonisunknown.Butitissufficientlysmalltoberemovedbymucocillaryactionalone. CoughandexpectorationarenotrequiredExpectorationExcessiveproductionAlteredphysicalpropertiesDeficientclearanceThesefactorscausethesecretionsaccumulateinthetracheobronchialsystemandcauseexpectoration.ExpectorationMechanical,chemical,physicalandallergicfactorscancauserespiratorymucosaedema,congestionandcausetransudateorexudatethencoughandexpectorationappearsExpectorationSuchas: 1)Inflammationincludevirus,bacteria,funguscancausecoughingandexpectoration. 2)Acuteleftheartfailurecancausepulmonaryedemaandpinkfoamysputum.ManifestationCharacterofcoughThedurationandpatternofcoughThetonequalityofcoughThecharacterandvolumeofsputumCharacterofcough

Coughwithoutsputum---unproductiveordrycoughmainlyinthepatientofacutepharyngitis,earlystageofbronchitis,pleurisyandTB. Coughwithsputumiscalledproductive.Itiscausedbypneumonia,chronicbronchitis,bronchiectasis,lungabscessandcavitiousTBThecharacterandvolumeofsputumclear,white,graysputum--chronicbronchitistenaciousstickymucoidsputum-----asthmatics(occasionallywithbronchialcast)foul-smellingpurulentsputum--bronchiectasissputumwithcalcificparticles-----broncholithoptysisThedurationandpatternofcough

Coughinitiatedsuddenly---acuteupperairwayinfectionChroniccough---chronicbronchitis,bronchialasthmaandTBParoxysmalcough---whoopingcough,bronchicompressedbytumorandTBThedurationandpatternofcough

Periodiccough---chronicbronchitisbronchiectasisrelatedtothechangeofbodyposition. Nocturnalcough---asthma,TB,chronicheartfailure--associatedwiththevagalexcitationatnight.Thetonequalityofcough

Itmeansthechangeofthesoundandmaysuggestthethelocationofpathology.“breaking”cough---epiglottaldisease“brassy”cough---trachealairways“hacking”or“cleaningofthroat”--postnasaldischarge“barking”or“croupy”--laryngealdisease.ThetonequalityofcoughHoarsenesswithcough---larynto-trachealbronchitisorimpairedthefunctionofrecurrentlaryngealnerve,asfromaneurysmoftheaorta,leftatrialenlargement,mediastinalmalignancy. Inspiratorystridor---upperairwayobstructionThetonequalityofcoughCoughwithhemoptysisalsoraisesthepossibilityofamalignantprocess,bronchiectasis,lungabscess,chronicbronchitis.Theassociatedclinicalfeaturescoughwithfever---acuterespiratoryinfectionincludingmeasles,pneumonia,influenza,lungabscess,TB,pleurisy.coughwithchestpain---pluralcavityinvolve,heartdisease,pneumonia,pleurisy,bronchogeniccarcinoma.Theassociatedclinicalfeaturescoughwithdyspnea--------edemaoflarynx,larynxtumor,chronicobstructivepulmonarydisease,severpneumonia,TB,massivepleuraleffusion,pulmonarycongestion,pneumothoraxandpulmonaryedema. coughwithquantitativepurulentsputum---bronchiectasis,lungabscess,bronchi-fistula.TheassociatedclinicalfeaturesCoughwithhemoptysis---bronchiectasis,TB,lungtumor,lungabscess,mitralstenosis. coughwithclubbedfingers---bronchiectasis,TB,lungabscess,carcinomaoflung,thoracicempyema.TheassociatedclinicalfeaturesCoughwithwheeze---bronchialasthma,cardiacasthma,foreignbodyintracheaandbronchi.Complicationofcoughpneumomediastinumposttussicemesistussicsyncoperibfracturespontaneouspneumothoraxbullousemphysemaabdominalhernias

Anychangeincharacterorpatternofachroniccoughwarrantsimmediatediagnosticevaluation,withspecialattentiondirectedtowardsthedetectionofbronchogeniccarcinoma.HemoptysisHemoptysisistheexpectorationofbloodfromairwayblowlarynx.Hemoptysispatientsshouldbeexaminedthenose,mouthandupperrespiratorytracttobefoundthehemorrhagicspot.Hemoptysisthequantityofbloodmayvaryfromstreaksandflecksinthesputumtomassivehemorrhage.minimalbleedingmaybeanearlyindicatorofthepresenceofseriousbronchopulmonarydisease.hemorrhagesofevenmoderatedegreemaylifethreatening.HemoptysisAbout50percentofthechestfilmsofthehemoptysispatientshownoabnormalitiesoronlyminimalnonspecificchange.Hemoptysismaybetheinitialorthesolesymptomofbronchopulmonarydisease.Thesefactorssometimescausethedignosticproblem.Etiology1.Bronchialdisease2.lungdisease3.cardiovasculardisease4.constitutionaldisease1.Bronchialdiseasehemoptysisoccurinbronchiectasis,chronicbronchitis,endobronchialtuberculosisandbronchogeniccarcinoma.Alsooccurinthebenignbronchogenictumor,bronchiectasis,foreignbody,bronchogenicnonspecificulceration.1.BronchialdiseaseTheinflammatoryprocessleadtotheincreasethepermeabilityofcapillaryandraptureofvesselsinbronchialmucosaandtheninducehemoptysis.blood-streakedsputumoccasionallyoccurinthecourseofacutebronchitis.2.LungdiseaseThesputumofpneumococcalpneumoniaisdescribedas“rusty”inappearance.PulmonaryTBisthecommoncauseofthehemoptysis.CavitiousTBmaycausetheexpectorationoffrankbloodfrompulmonarycavity.2.LungdiseaseLungabscessmayberelatedtoputridsmellingsputumandexpectorationofblood.hemoptysisoccurin25percentofthepatientofpulmonaryembolismandinfarction.pulmonaryfungiandparasiteinfectionmayalsoserveasthesourcesofhemoptysis.3.CardiovasculardiseasePinkfrothysputum---acutepulmonaryedemabloodstreakedsputum--acutepulmonarycongestionbloodcomesfrompulmonarycapillarieswhichrupturedunderhighintravascularpressure.3.CardiovasculardiseaseHemoptysisduetomitralstenosisisfrequentlyinducedbyphysicalexerciseorexcitement.Bloodcomesfromabreakinthepulmonaryveinswhichhaverupturedunderhighpressure.Thebleedingisduetoruptureofendobronchialvesselsthatfromcollateralchannelsbetweenthebronchialveinsandpulmonaryvenoussystem.Thebleedingtendtosubsideastheveinsadapttohighpressureandaspulmonaryarteriolardiseasedevelops.3.CardiovasculardiseaseManypulmonaryembolidonotleadtopulmonaryinfarction,whentheydo,frankhemoptysisoccursintheminorityofinstance.whenhemoptysisoccurinthepulmonaryinfarctionoftheheartfailurepatient,thebloodsputumusuallyappearswithinafewhourstoadayaftertheembolus,andthisisduetonecrosisandhemorrhagesintothealveoli.3.CardiovasculardiseaseHemoptysisisalsoassociatedwithcongenitalcardiacdiseaseandaorticaneurysms4.Constitutionaldisease

Bloodspittingmayalsooccurinthepatientssufferingfromcertainblooddyscrasias,suchashemophilia,leukemiaandinfectiousdisease,connectivetissuedisease.

Clinicalmanifestation1.thepatient’sage.2.theamountofcoughingupblood.3.colorandcharacter.1.Thepatient’sageHemoptysisisoftenseeninpulmonaryTB,bronchiectasisandrheumaticheartdisease(mitralstenosis)formostyouth.Cancerisnowthediseasethatpatientsthinkofwhentheyexpectorateblood,justasitwasTB50yearsago.1.Thepatient’sageElderpatientwithbloodysputumorstreakedofbloodysputum,especiallyinthemaleswithlonghistoryofsmoking.cancershouldbetakenintoaccount.PatientsclosecontactwithTBsuffer,TBshouldbeconsidered.1.Thepatient’sageParagonimiasismaysuspectedinthepeoplewithhistoryofeatingraworimproperlycookedcrabsorcrayfish.Epidemichemorrhagicfever,leptospirosisalsocancausehemoptysis,theyareendemicdisease.2.TheamountofcoughingupbloodHemoptysiscanbeclassifiedintothreegroupsaccordingtotheamountofcoughingblood.Massive:expectoration>500ml/24hr.Moderate:500ml>expectoration>100ml/24hrminimal:expectoration<100ml/24hr

2.TheamountofcoughingupbloodmassivehemoptysisoftenoccursinpulmonaryTBcavity,chroniclungabscessandbronchiectasis.3.Colorandcharacter.

Toahemoptysispatient,itisnecessarytoascertaintheexactnatureofthesputum,thesputummustbeexaminedbothgrosslyandmicroscopically.3.ColorandcharacterItisusefultodeterminewhetherthematerialthatiscoughedupcontainslargeamountofliquidblood,whichisindicatesbriskbleeding,orwhetheritcontainssmallamountofdarkorclottedblood,whichwouldindicateslowbleedingfromlow-pressurevesselsorsubsidingbleeding.

3.ColorandcharacterBriskbleedingiscommonlyassociatedwithspecificfocalulcerationofthebronchus,suchasbronchogeniccarcinoma,aforeignbody,bronchiectasisorableedingaorticaneurysm.Slowbleedingstronglysuggestsvenousbleedingwhichismorelikelytobetheresultofincreasedinbloodflowthroughthebronchialvenoussystemsuchasmayoccurasaresultofmitralstenosisorbronchiectasis.AccompanyingsymptomHemoptysiswithfever:pulmonarytuberculosis,pneumonia,lungabscess,lopeospirosis,epidemichemorrhagicfever,bronchogeniccarcinoma.Hemoptysiswithchestpain:lobarpneumonia,pulmonaryinfarction,pulmonaryTB,lungcancer.AccompanyingsymptomHemoptysiswithputridsputum:lungabscesscavitiousTB,bronchiectasis.Hemoptysiswithirritatingcough:bronchogeniccarcinoma,mycoplasmapneumonia.AccompanyingsymptomHemoptysiswithskinandmucosableeding:hematologicaldisease,epidemichemorrhagicfever,rheumatism,leptospirosis.Hemoptysiswithjaundice:leptospirosis,lobarpneumonia,pulmonaryinfarction.ThedistinctionbetweenhemoptysisandhematemsisPhysicalexaminationofthechestSignificanceGeneralconditioncomprehensionConfirmhistoryinformationSpecificsigncollectionforthediagnosisofcertaindisease&inferscertainaccessoryexaminesGrosslyprecludesomecertaindisordersContributearelationbetweenthephysicianandthepatientMentionofConductionExposure/warmth/lighting/easyairInspection,palpation,percussion,auscultationAnterior-lateral-posteriorTop-baseComparison:toptobase/lefttorightBonelandmarksuprasternalnotch(胸骨上切跡)clavicle（鎖骨）Manubriumsterni(胸骨柄)Sternalangle(胸骨角)Louisanglesuprabdominalangle(腹上角)xiphoidprocess(劍突)Ribs&interspacesscapula(肩胛骨)spinousprocess(棘突)costolspinalangle(肋脊角)VerticallinesAnteriolmiddleline(前正中線）Mid-clavicularlines（鎖骨中線）Spinalline（後正中線）

axillarylines(anteriol,middle,posteriol)（腋前、中、後線）Scapularlines（肩胛線）Naturalfossa&anatomicregionAxillaryfossaSupraclavicularfossaSuprasternalfossaInfraclavicularfossaSuprascapularregionInfrascapularregionInterscapularregionTheboundaryoflung&pleuraLungapexUpperboundaryofthelungOuterboundaryInnerboundaryLowerboundary:Midclavicularline6thinterspaceMidaxillaryline8thinterspaceInferiorline10thinterspaceChestwallVein:BloodflowdirectionSubcutaneiusemphysema(皮下氣腫)TendernessInterspaceChestframworkNormalA-P/Tdiameter:1/1.5FlatchestBarrelchestRachiticchestRachiticrosary（肋骨串珠）

Funnelchest（漏斗胸）UnilateraldeformationLocalbulgeofchestwallThoracicdeformitycausedbydeformedspineInspectionBreathingmovement:DiaphragmaticvscostalrespirationRespiratoryrate:---Tachypnea---Bradypnea---ChangeofthebreathdepthsInspection(2)Rhythmofthebreath---Tidalbrathing---Ataxicbreathing---Inhibitorybreathing---SighingrespirationNormalBradypneaTachypneaKusmolsbreathSighingrespirationTidalbreathAtaxicbreathInhibitorybreathPalpationVocalfremitus(觸覺語顫)ThoracicexpansionPleuralfrictionfremitus(胸膜摩擦感)ConfirmetheinspectionPercussion

Method:mediatepercussion(Technics)

immediatepercussionplexemeter/plexorfingerPercussionnotesandtheircharacteristicsInfluencingfactorsforpercussionLungboundariesbeingpercussed

Kronigisthmusthemovementrangeofthe

lowerpulomonaryboundary

Midclavicularline6thinterspaceMidaxillaryline8thinterspaceInferiorline10thinterspaceAuscultationNormalbreathsound

vesicularbreathsoundbronchialbreathsoundbronchovescicularbreathsoundAbnormalbreathsoundDecreasedorabsentIncreasedalveolarbreathsoundJ:LowerbreathingJ:ExertyourbreathingAdventitioussoundsDiscontnuousContnuousfinecoarsewheezesrhonchusDry/rhonchiRale/crackesmoistrale(crackles)RhonchiVocalresonancepleuralrubbing:crepitusAdventitioussoundExtra-pulmonarysignCyanosis:Clubbingfingers:Paraneoplasticsyndrones:CentralperipheralLobepneumoniaCough,chestpain,dyspneaConsolidationsigns,pleuralfremitusWBC,lobelinfiltrationonchestfilmBronchialAsthma

shortofbreathOverinflationwheeze,dyspneaEOS

chestfilmandsputumchangesemphysemaIncreasingonsetofexertionaldyspneaBarrelchest,prolongedexpiration,decreasedordiminutionbreathsoundX-ray:overinflation,flattendiaphragm,driplikeheart.Respirationfunction:obstructiveabnormalitywithincreasedRV(>40%TLC)PleuralEffusion DullnessChestpainShortofbreathDullnessonpercussionDisappearedbreathingsoundChestfilmPneumothorax

AbruptchestpainafterinducingfactorshortofbreathTympaniorhyperresonanceonpercussionChestwallinflationAbsent/decreasedbreathingsoundChestfilmSubcutaneousemphysemaBarralchestwall,decreasedmovemnt,neckveindistensionHyperresonanceDecreasedbreathingsoundPhysicalexaminationofthechestSignificanceGeneralconditioncomprehensionConfirmhistoryinformationSpecificsigncollectionforthediagnosisofcertaindisease&inferscertainaccessoryexaminesGrosslyprecludesomecertaindisordersContributearelationbetweenthephysicianandthepatientMentionofConductionExposure/warmth/lighting/easyairInspection,palpation,percussion,auscultationAnterior-lateral-posteriorTop-baseComparison:toptobase/lefttorightBonelandmarksuprasternalnotch(胸骨上切跡)clavicle（鎖骨）Manubriumsterni(胸骨柄)Sternalangle(胸骨角)Louisanglesuprabdominalangle(腹上角)xiphoidprocess(劍突)Ribs&interspacesscapula(肩胛骨)spinousprocess(棘突)costolspinalangle(肋脊角)VerticallinesAnteriolmiddleline(前正中線）Mid-clavicularlines（鎖骨中線）Spinalline（後正中線）

axillarylines(anteriol,middle,posteriol)（腋前、中、後線）Scapularlines（肩胛線）Naturalfossa&anatomicregionAxillaryfossaSupraclavicularfossaSuprasternalfossaInfraclavicularfossaSuprascapularregionInfrascapularregionInterscapularregionTheboundaryoflung&pleuraLungapexUpperboundaryofthelungOuterboundaryInnerboundaryLowerboundary:Midclavicularline6thinterspaceMidaxillaryline8thinterspaceInferiorline10thinterspaceChestwallVein:BloodflowdirectionSubcutaneiusemphysema(皮下氣腫)TendernessInterspaceChestframworkNormalA-P/Tdiameter:1/1.5FlatchestBarrelchestRachiticchestRachiticrosary（肋骨串珠）

Funnelchest（漏斗胸）UnilateraldeformationLocalbulgeofchestwallThoracicdeformitycausedbydeformedspineInspectionBreathingmovement:DiaphragmaticvscostalrespirationRespiratoryrate:---Tachypnea---Bradypnea---ChangeofthebreathdepthsInspection(2)Rhythmofthebreath---Tidalbrathing---Ataxicbreathing---Inhibitorybreathing---SighingrespirationNormalBradypneaTachypneaKusmolsbreathSighingrespirationTidalbreathAtaxicbreathInhibitorybreathPalpationVocalfremitus(觸覺語顫)ThoracicexpansionPleuralfrictionfremitus(胸膜摩擦感)ConfirmetheinspectionPercussion

Method:mediatepercussion(Technics)

immediatepercussionplexemeter/plexorfingerPercussionnotesandtheircharacteristicsInfluencingfactorsforpercussionLungboundariesbeingpercussed

Kronigisthmusthemovementrangeofthe

lowerpulomonaryboundary

Midclavicularline6thinterspaceMidaxillaryline8thinterspaceInferiorline10thinterspaceAuscultationNormalbreathsound

vesicularbreathsoundbronchialbreathsoundbronchovescicularbreathsoundAbnormalbreathsoundDecreasedorabsentIncreasedalveolarbreathsoundJ:LowerbreathingJ:ExertyourbreathingAdventitioussoundsDiscontnuousContnuousfinecoarsewheezesrhonchusDry/rhonchiRale/crackesmoistrale(crackles)RhonchiVocalresonancepleuralrubbing:crepitusAdventitioussoundExtra-pulmonarysignCyanosis:Clubbingfingers:Paraneoplasticsyndrones:CentralperipheralLobepneumoniaCough,chestpain,dyspneaConsolidationsigns,pleuralfremitusWBC,lobelinfiltrationonchestfilmBronchialAsthma

shortofbreathOverinflationwheeze,dyspneaEOS

chestfilmandsputumchangesemphysemaIncreasingonsetofexertionaldyspneaBarrelchest,prolongedexpiration,decreasedordiminutionbreathsoundX-ray:overinflation,flattendiaphragm,driplikeheart.Respirationfunction:obstructiveabnormalitywithincreasedRV(>40%TLC)PleuralEffusion DullnessChestpainShortofbreathDullnessonpercussionDisappearedbreathingsoundChestfilmPneumothorax

AbruptchestpainafterinducingfactorshortofbreathTympaniorhyperresonanceonpercussionChestwallinflationAbsent/decreasedbreathingsoundChestfilmSubcutaneousemphysemaBarralchestwall,decreasedmovemnt,neckveindistensionHyperresonanceDecreasedbreathingsoundFeverFeverNormalbodytemperature:37oC,Circadianvariation<1oCDefinitionoffever:AnelevationofcorebodytemperatureabovethenormalrangerectalT0.5oC>oralT0.5oC>axillaryT（腋溫）FeverHyperthermia(體溫過高）feverduetoadisturbanceofthermalregulatorycontrolexcessiveheatproductiondecreaseddissipationlossofregulationPathophysiologyBodytemperatureisdeterminedbytwoopposingprocesses

heatproductionheatlossTheyareregulatedbythecentralnervoussystemEnergyintheformofheatisgeneratedbylivingtissues(thermogenesis)EnergymaybepassivelyabsorbedfromtheenvironmentandtransfertheenergytothesurroundingmediumPathophysiologyThebodytemperatureisundercontrolofthepreopticareaoftheanteriorhypothalamus（下丘腦）

Thermostat

（恒溫器）ItreceivesinputfrombothcentralreceptorsandperipheralreceptorsHeatproductionandheatlossBasalmetabolicrateiscontrolledbyhypothalamus,byvaryingthelevelofcirculatingthyroxine（腎上腺素）Increasedmusclesensitivity(shivering)Byvaryingthevolumeofbloodflowingtoskin’ssurface(>100fold)Byvaporization(exocrinesweating)Setpoint370C390CHeatProductionHeatLossHeatProductionHeatLossPathophysiologyElevationofbodyTemperatureshiveringthermogenesisanddermalvasoconstriction

sympatheticoutflowCoolingmechanismsweatinganddermalvasodilationmixtureofsympatheticandparasympatheticpathwaysPathophysiologyHypothalamicthermostatSetpoint:37oClowest:4a.m;peak:6~10p.mFeverfollowthispatternFactorsaffectbodyTemperatureexercisemenstrualcycleenvironmental

temperaturePyrogensNeuroimmunoendocrineSubstancesthatcancausefeverEitherexogenousorendogenousExogenousPyrogensFromoutsidethehost(somemaybetheendogenousproducts)Majorityaremicroorganism,theirproductsortoxinsG-:endotoxin(內毒素）

(lipopolysaccaride,LPS)（脂多糖）G+:lipoteichoicacid（脂磷壁酸）

peptidoglycan（肽聚糖）

variessuperantigensandenterotoxinsExogenousPyrogensOthers(endogenousproducts)complementproductssteroidhormonemetablitesantigen-antibodycomplexwithcomplementMostofthemarewithhighmoleculeweightCouldnotpenetrateblood-brainbarrier

EndogenousPyrogenInresponsetoinvasivestimuli:exogenouspyrogenchemicalagents(amphotericinandotherdrug)

Producedbythehost,cellsofimmunesystemDesignated‘monokines’and‘lymphokins’cytokines（細胞因數）EndogenousPyrogenCytokinesIL-1IL-1TNFTNFIFNIL-6Phagocytesandlymphocytes:majorsourceofpyrogeniccytokinesItmayalsoreleasedthroughautonomousproductionandsecretionPathogenesisoffeverPyrogeniccytokinesbindreceptorspresentonvascularendothelialcellsthatliewithinthehypothalamusResettingthehypothalamicthermoregulatorycenterbyincreasedprostaglandinandcAMPPathogenesisoffeverBacteriaprovokereleaseofIL-1ViralproteinsstimulateIFNCombinedproductionofseveralcytokinescausefeverProductionofendogenouspyrogensEtiologyandclassificationInfectivefeverNon-infectivefeverInfectivefeverMetabolitesfromorganismcausefeverMostcommoncausesoffever(50%~60%)Bacteriapyrogens:commoncauseofinfectivefever(43%)Viralpyrogens:(6%)Non-infectivefeverAbsorptionofnecroticsubstances:

injuryischemicnecrosiscellnecrosisAllergyAntibioticsEndocrineandmetabolicdisturbances:hyperthyroidismdehydrationDecreasedeliminationofheatfromskin:

heatfailureNon-infectivefeverDysfunctionofcentralheatregulationphysical:heatstrokechemical:barbituratepoisoningmechanical:cerebralhemorrhageDysfunctionofvegetativenervoussystemsympatheticoveractivityClinicalmanifestationThegradeoffeverLowgradefever:37.3~38oCModeratefever:38~39oCHighfever:39.1~41oCHyperthermiafever:>41oCClinicalmanifestationClinicalcourseoffeverOnset:Suddenonsetwithinfewhours

pneumoniaGradualonsetgraduallyforfewdays

typhoid

Persistence:variespatternSubsidence:bycrisisorlysisCharacteroffeverContinuousT:keptat39oC~40oCconstantlyCircadianvariation:<1oC

pneumoniatyphoidfeverRemittentT:>39oCcircadianvariation>2oCrheumaticfevertuberculosissepticaemiasepticinflammationCharacteroffeverIntermittentT:suddenrising(fewhours)andsuddendecreasingmalariaacutepyelonephritisRecurrentT:abruptlyrisingtothepeak,lastingforseveralday,suddendecreasetothenormalrepeatedlyHodgkindiseaseCharacteroffeverUndulantT:risinggraduallytothepeak(>39oC)decreasinggraduallytothenormalrepeatedlyforseveraltimesBrucellosisIrregulartuberculosisrheumaticfeverbrochopneumoniaFeverpatternasdiagnosticcluesFeverPatternCauseAlternate-dayfeverPlasmodiumvivax,P.OvaleFevereverythirddayP.MalariaeRelapsingfeverdailyfor3~6daysBorreliasp,ratbitefeverfever-freeinterval(Streptobacillusmoniliformis;forabout1weekSpirillumminus)supervenesContinuous“undulating”Brucellosis,typhoidPeriodicpyrexiaHodgkin’sdisease(Pel-EbsteinPhenomenon)withvariablecyclesFeverofunknownorigin(FUO)FUOdefinedbyPetersdorfandBeeson(1961)

Fevershigherthan38.3oConseveraloccasionsAdurationofmorethan3weeksFailuretoreachadiagnosisafter1weekofinpatientinvestigation70%~90%ofthecasescanbediagnosedModification

ThreeoutpatientvisitsorthreedaysinthehospitalTwoweeksoffeverSummaryFever:elevationofsetpointHeatproduction/conservation

shiveringdermalvasoconstriction

Heatloss

sweatingdermalvasodilationPyrogen:exogenousorendogenous

endotoxin(LPS)pyrogeniccytokines

PGEs