[NP-Clinical] Re: question for the list re: definition of "fever"

Sat Jan 13 18:12:07 PST 2007

Somehow I don't think we're going to resolve this issue for you, as there
are many opinions on this, and I've seen ID folks who might be concerned at
no temperature elevation or an elevation of 99.6 in an AIDS pt who appears
toxic, but not at all in an immunocompetent pt (or even in an HIV pt with
CD4>200) with a fever of 102 who doesn't look toxic. The way I see it, any
temperature reading must be viewed in the context of the individual pt and
what is going on at the time of the reading.

Case in point: if you have a pt who looks toxic, has chills and rigors, but
a "normal" temperature now or even a half hour ago, are you going to ignore
the fact they look ill and say "the temperature reading is/was normal", or
are you going to look at the patient and say "I don't care what the
thermometer said just now or even a half hour ago; this patient looks toxic
and is probably going to spike in the next 15-30 minutes"?

In other words, docs like the one you were speaking with make my skin crawl.
Providers who get caught up in specific readings, definitions, and rhetoric
box themselves in and then tend to miss the big picture. I personally
endorse your view that patient care is more about caring for the PATIENT and
NOT the patient's numbers alone.

In these situations, if you're not already, you can hedge a bit and use the
term "low-grade fever" and then present the other symptoms that concern you
with a list of differentials that then put this finding and your concerns
into context..

Diane Dito, NP

  _____  

From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net]
On Behalf Of Carla Anderson
Sent: Saturday, January 13, 2007 3:51 PM
To: np-clinical at nurse.net
Subject: [NP-Clinical] Re: question for the list re: definition of "fever"

Hi, I have a question about the definition of fever. In my opinion, a
patient may have a constellation of symptoms, and an elevated body
temperature is something to evaluate. I believe that one must look at the
individual patient, and not just categorize generally. However, a question
has come up with a physician who states that a fever is "over 101" per
Infectious Disease definition.  I have read several references, including a
couple dictionary definitions where the term "fever" refers to "elevation in
body temperature".  This is how I have also viewed it.  But I also found on
the website for American Academy of Family Physicians, the American Family
Physician  (http://www.aafp.org/aft/20031201/2223.html) that the definition
for "fever of unknown origin", which is not just "fever" is defined as
"temperature > 38.3 degrees Celsius, or 100.9 degrees F, and lasting > 3
weeks. (FUO).  I am just wishing to know your opinions/knowledge regarding
this, as a physican corrected me when I was stating that a patient had a
"fever" of 99.6F...he said it was not a fever according to "Infectious
Disease".. I admit, this must be taken into context, and the patient's
overall health needs are the priority, but I was just curious if any of you
had different views. Thank you, Carla Anderson FNP/Portland, OR

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Today's Topics:

1. Zithro for Sinus Infections... (Christine Smith)
2. Re: It's that time again (Kimberly Spering)
3. Re: It's that time again (Kimberly Spering)
4. MRSA UTI (Pat Camillo)
5. palpating spleens in suspected mono-reliable? (Lorraine Loretz)

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Message: 1
Date: Sat, 13 Jan 2007 05:44:02 -0800
From: "Christine Smith" 
Subject: [NP-Clinical] Zithro for Sinus Infections...
To: "NP Clinical" 
Message-ID: <021701c73718$e433eee0$6401a8c0 at ChristineNB>
Content-Type: text/plain; charset="iso-8859-1"

I have actually seen Zithro dosed twice for Acute Bacterial Sinusitis. The
ENT MD who is on call to our ER told me that true bacterial sinus infections
often take more than one abx course as they are hard to penetrate. He
suggested to me that exact regimen (since Zither is a 5 day abx but really
continues to work for 10 days - so 5 days on, hold 5 days and then repeat).
I since have rx'd standard Amox 500 TID x 10 days, then repeated if some
improvement but not resolved with good success. If Amox is not improving
them some by day 9 or 10 I switch to Bactrim DS for 10 days. I don't usually
ever do Augmentin because of the cost but if they have insurance I consider
it. I know there is alot of resistance to Amox but if a patient has not had
many abx in the past it seems to work well for many of my patients. I think
the assumption is that it is likely a chronic sinusitis and not acute. If
you do a literature search you should be able to find that a 20 day course
of abx is requ!
ired for those patients.

My vote for the etiology of the hives goes to the PCN portion of the
Augmentin. There is nothing to make me think Mono - Sinusitis would not
present like a strep throat infection. I doubt this is cold induced
urticaria. It began right after she finished her Augmentin - not uncommon
for PCN allergies to occur this way. 

As for Zrytec - love the drug for Seasonal allergies, better than Claritin
or Allegra in my highly allergic daughter but I personally have never
thought it was near as good for Urticaria as good old Benedryl even though
it is approved. I would never give a Zyrtec as an emergent treatment for
Urticaria, but I give Benedryl all the time as it works so quickly. Too
pricey and not covered on lots of plans too. That said, I sure wish I could
get some samples for my kid.

Kathleen - abdominal exam to check for splenomegaly seen with Mono. Your
daughter is classic age for mono but assuming she has a good PCP, he must
have not seen anything to make him consider Mono. 

Christine Smith, NP

----- Original Message ----- 
From: Kathleen 
To: NP Clinical 
Sent: Friday, January 12, 2007 7:39 AM
Subject: Re: [NP-Clinical] Help with Hives......Just some thoughts.....

No mono testing done and why an abdominal exam? Her doc seems to think that
her sinus infection is not resolved and that's why the Zith paks. The doc is
calling me back this PM and I will ask about the mono test. Thanks.
Kathleen

mmhelgert46 at comcast.net wrote:
I wonder if.......this 15 year old didn't actually have Mono and the "hives"
weren't actually an Amoxicillin rash secondary to Augmentin 875?
I know psych folks don't treat alot of medical problems...but...was a mono
spot done? or an abdominal exam?
just my thoughts.......

Adolescent 15 yo female on Amoxicillin 875 bid for sinus infection for ten 
days. On 11th day with no antibiotic given developed hives, benadryl gave
some 
relief but not entirely, still breaking out. No wheezing or SOB. Off
antibiotic 
for four days, put on azythromycin for 10 days yesterday (5 days on and wait
5 
days, then do the next pack for five days), and Alavert (loratadine 10mg
qd), 
still hives but not as much. What next? Continue with same treatment? (This
is 
my daughter, by the way). Thoughts?

Kathleen Allen, Psych. NP 

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Message: 2
Date: Sat, 13 Jan 2007 08:55:33 -0500
From: "Kimberly Spering" 
Subject: Re: [NP-Clinical] It's that time again
To: "NP Clinical" 
Message-ID: <004201c7371a$7ee47fd0$2e01a8c0 at Kim2>
Content-Type: text/plain; charset="iso-8859-1"

Julie~

My thoughts and prayers have continued for you along this journey...now
there is more "light at the end of the tunnel." So, extra hugs sent your way
for the 17th~

Kim Spering
OB-GYN
----- Original Message ----- 
From: Julie Orfirer 
To: np-clinical at nurse.net 
Sent: Thursday, January 11, 2007 3:17 PM
Subject: [NP-Clinical] It's that time again

Hey all. I can't believe it but I'm getting ready for surgery again! At
least this time it has nothing to do with nodes and margins and treatment
decisions. Just replacing the tissue expander with an implant. Hopefully
this'll be an easy recovery - no drain!, small incision even tho it is into
the muscle..... 

So, I'm asking again for good thoughts, energies, prayers as I wait in the
holding area preparing to go into the OR. It's scheduled for 10:30 eastern
time on the 17th (next Wednesday). You guys did me good in the past. I hope
this is the last time I have to ask!

Thanks for your love and support!

Julie
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Message: 3
Date: Sat, 13 Jan 2007 08:58:30 -0500
From: "Kimberly Spering" 
Subject: Re: [NP-Clinical] It's that time again
To: , "NP Clinical"

Message-ID: <004701c7371a$e84805a0$2e01a8c0 at Kim2>
Content-Type: text/plain; format=flowed; charset=iso-8859-1;
reply-type=original

Priscilla~

Gee, waiting is the hardest part for many of us--myself included. You and 
your hubby are in my thoughts and prayers this week, too. Take care~

Kim Spering
OB-GYN

----- Original Message ----- 
From: 
To: 
Sent: Thursday, January 11, 2007 3:35 PM
Subject: RE: [NP-Clinical] It's that time again

> So, on a similar note, my hubby and I go for his neck mass biopsy results
> today. I was expecting the worse, hoping for the best, but not in my
> wildest dreams expecting NO news! So no results after one week. We are 
> to
> call tomorrow around 1 pm. I must admit to being a bit more nervous since
> he said, if all was well, we'd know in a couple of days and if suspicious,
> it goes through a longer process. The endoscopy was clear and he just saw
> "a bunch of matted nodes with one large one adherent to the
> sternocleidomastoid." He said he truly didn't know what it was so that
> gives me some hope. Since he knows I'm a NP, I think he would've come out
> and said it WAS lymphoma/cancer. Whatever will be, I know we'll be OK but
> the waiting is the toughest. I will keep you updated since you're a great
> source of support.
>
> Priscilla Merrill FNP 

------------------------------

Message: 4
Date: Sat, 13 Jan 2007 09:53:34 -0500
From: "Pat Camillo" 
Subject: [NP-Clinical] MRSA UTI
To: "NP Clinical" 
Message-ID: <005301c73722$9a72a990$40864b0c at IBME6A21918636>
Content-Type: text/plain; charset="iso-8859-1"

Recently saw a woman who had been having 2-3 UTI's a year, ran a culture -
came back MRSA.......tx with cipro which was found to be sensitive.......she
also complains of vulvar burning .....tx with terazole thinking it was yeast
following multiple antibiotic therapies......some relief but not gone. I'm
beginning to wonder if perhaps the vulvar complaint might be related to the
MRSA.....

Any thoughts would be appreciated :)

Pat

Pat Camillo PhD,RN,APN,C
Certified Nurse Practitioner in Women's Health,
Gerontology and Menopause
Carmenta Health
1 Kalisa Way Suite 103
Paramus, New Jersey 07652
(201) 265-9042
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Message: 5
Date: Sat, 13 Jan 2007 17:22:33 GMT
From: "Lorraine Loretz" 
Subject: [NP-Clinical] palpating spleens in suspected mono-reliable?
To: np-clinical at nurse.net
Message-ID: <20070113.092245.3483.1909600 at webmail12.lax.untd.com>
Content-Type: text/plain; charset="us-ascii"

Following the thread on sinusitis with the mention of r/o mono:

<<-- "Christine Smith" wrote:

Kathleen - abdominal exam to check for splenomegaly seen with Mono. Your
daughter is classic age for mono but assuming she has a good PCP, he must
have not seen anything to make him consider Mono. Christine Smith, NP>> 
I'll always try to palpate the spleen, but based on my reading I'm not very
secure in trusting the exam. Splenomegaly trivia from one of my sports med
lectures:

Spleen size is not a reliable guide to splenic function, and palpable
spleens are not always abnormal. 
Patients with COPD and low diaphragms commonly have palpable spleens. In one
study, 3% of college freshmen had palpable spleens; an additional study
showed that 5% of hospitalized patients with normal spleens based on scan
results were thought to have palpable spleens by their physicians.
Experienced MD's had 27-58% accuracy in detecting an enlarged spleen in one
study.
Although most patients do not have a palpable spleen on physical
examination, a study of 29 patients who were hospitalized with infectious
mononucleosis (and who therefore may have had more severe disease) found
that all patients had splenomegaly on ultrasound examination and that one
half of them had hepatomegaly. Only 17 percent of the enlarged spleens and 8
percent of the enlarged livers were palpable on physical examination, a
finding that is consistent with other studies. (Ebell, 2004)
Examination should include palpation with the patient in the supine and
right lateral decubitus position, with knees up and hips flexed. Apply light
fingertip pressure as the patient slowly inspires. The use of the reverse
Trendelenburg position may aid in bringing the spleen into contact with the
examiner's fingers. This is especially helpful in patients with morbid
obesity. 
American Academy of Pediatrics, American Academy of Family Physicians,
American Academy of Pediatrics, American Medical Society for Sports
Medicine, American Orthopedic Society for Sports Medicine, American
Osteopathic Society for Sports Medicine. 2005. Preparticipation physical
evaluation, ed 3. Minneapolis, MN: McGraw Hill, 98pp.
Ebell, MH. 2004. Epstein-Barr virus infectious mononucleosis. AFP
70(7):1289-90.
Lorraine Loretz, DPM, NP (and bucking for Queen of Trivia award)
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