Monday, 12 November 2007

Absence of Fever

The elderly are a unique subset of the patient population. When the elderly get sick, it is time to throw the book out of the window for adult medicine because there are not firm & fast rules.

When I say this I mean for example about sepsis. In sepsis, elderly patients do not always have a fever, they do not always mount a white count or even a rise in C-reactive protein.

Patients do not always get headache, Kernigs or Brudzinski sign in meningitis and alot of elderly patients have a stiff neck just from age related osteoarthritis rather than from meningism.

Hence, relying on the patient not having a fever, a normal WCC and CRP does not exclude sepsis.

Patients can present with confusion and low blood pressure and a tachycardia. The observations of the patient and looking at the patient from the bedside can sometimes be more revealing than the blood results.

Therefore, don't be mislead by seemingly normal blood results. Remember to always take cultures of blood, sputum and urine, and if warranted, CSF to check for meningitis / encephalitis or even stool culture / toxins.

A good example was of a recent case from another hospital of a male patient with a 3 week history of worsening cough. The patient had otherwise been remarkably well despite having severe aortic stenosis. However, the patient lost his appetite and the cough worsened precipitating a hospital admission. All the observations were normal. No fever, normal blood pressure and pulse and SpO2 was 96% on room air.

Even the white cell count was normal. CRP was only slightly raised at just above 1.

Examination was most revealing as the patient appeared weak and tired and slightly confused. Chest examination revealed dullness to percussion and crackles with the addition of increased tactile vocal fremitus. JVP was not raised but peripheral edema was evident.

The concern was of rather than just a straight forward pneumonia, it was considered that there could be heart failure plus pneumonia.

The patient's sputum examination revealed gram positive diplococci consistent with streptococcus pneumoniae.

Echocardiogram and BNP exams were also ordered.

In this case, the patient had a pneumonia plus suspected heart failure from severe AS. Despite these problems he only manifested loss of appetite, weakness and mild confusion. No obvious problem with his vital signs and no fever.

Please remember that patients do not write the textbooks---doctors do. A typical case is a typical case, but patients sometimes do not fit the mould and do not obey by the rules of illness as defined by doctors.

Hence, when it comes to the elderly don't just label them as demented when they turn up to your hospitals with confusion, it could be due to overwhelming sepsis!

Please consider.... :)

No comments: