29/10/2024
Diagnosis of a febrile patient in a resource constraint setup:
(Extract from my book "Managing Acute Medical Emergencies".
The problem with patients presenting with fever in third world countries is self-medication or inappropriate and inadequate treatment dispensed by unqualified practitioners and over the counter availability of almost any drug including antibiotics. Under these circumstances, most of the times, the treatment already received is either inadequate in the form of inappropriate doses and duration of antibiotics or absolutely un-indicated. These factors have played a vital role in rapidly emerging bacterial resistance against the antibiotics in third world countries. Secondly, most of the patients belonging to poor socioeconomic background either refuse or can’t afford lab investigations or quality of lab results is quite poor. Under these circumstances, physicians’ clinical acumen (using careful history and clinical examination) is the only tool to make a diagnosis and manage accordingly.
As long as the importance of clinical history is concerned, it is very important to determine the duration of fever and then carefully look for any FOI. Common cold and uncomplicated URTI tend to settle with or without treatment within 7-10 days any way. However, if the fever is of 10-14 days duration with no FOI; it may either be malaria, enteric fever or some viral infection. If the patient has cough, headache, bowel disturbances with coated tongue and abdominal tenderness it is most likely Typhoid. Fever, anemia, jaundice with small firm spleen in the absence of cough and abdominal tenderness may clinch the diagnosis of Malaria or Acute hepatitis. Fever, flu–like symptoms and rash may be a viral exanthem, dengue fever or drug rash (Amoxicillin in IMN or sulfonamides with Fixed Drug Eruptions [FDEs] in suspected malaria). In the presence of any FOI (pharyngitis, Sinusitis, bronchitis, pneumonia, pleural effusion [TB], RHC tenderness [liver abscess, cholecystitis], SSTIs, arthritis and SOMI [meningitis]), making a clinical diagnosis should not be a difficult task. Similarly it should not be difficult to make a diagnosis of adult Still’s disease when a patient presents with a combination of rash, arthritis, high grade swinging fever with neutrophilic leukocytosis and very high S. ferritin levels. Don’t forget connective tissue diseases (CTDs), malignancies (especially Hepatocellular carcinoma) and HIV infection as a cause of fever and investigate and manage accordingly. Clinical examination for lymphadenopathy, hepatosplenomegaly, ascites, arthritis and rash may narrow down the diagnostic possibilities as well. Sometimes a therapeutic trial of anti TB treatment (cryptic TB) or of steroids (suspected poly myalgia rheumatica or PMR) needs to be given in highly suspected cases presenting with fever and unexplained weight loss in appropriate clinical settings.
Professor Dr Intekhab Alam
