upc check digit calculator excel formula D Immunologic Status in Objective-C

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D Immunologic Status
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In the neutropenic patient, fungal infections and occult bacterial infection are important causes of FUO In the patient taking immunosuppressive medications (particularly organ transplant patients), cytomegalovirus (CMV) infections are a frequent cause of fever, as are fungal infections, nocardiosis, Pneumocystis jiroveci (formerly Pneumocystis carinii) pneumonia, and mycobacterial infections
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Because the evaluation of a patient with FUO is costly and time-consuming, it is imperative to first document the presence of fever This is done by observing the patient while the temperature is being taken to ascertain that fever is not factitious (self-induced) Associated findings that accompany fever include tachycardia, chills, and piloerection A thorough history including family, occupational, social (sexual practices, use of injection drugs), dietary (unpasteurized products, raw meat), exposures (animals, chemicals), and travel may give clues to the diagnosis Repeated physical examination may reveal subtle, evanescent clinical findings essential to diagnosis
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E Classification of Causes of FUO
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Most patients with FUO will fit into one of five categories 1 Infection Both systemic and localized infections can cause FUO Tuberculosis and endocarditis are the most common systemic infections, but mycoses, viral diseases (particularly infection with Epstein-Barr virus and CMV), toxoplasmosis, brucellosis, Q fever, cat-scratch disease, salmonellosis, malaria, and many other less common infections have been implicated Primary infection with HIV or opportunistic infections associated with AIDS particularly mycobacterial infections can also present as FUO The most common form of localized infection causing FUO is an occult abscess Liver, spleen, kidney, brain, and bone are organs in which abscess may be difficult to find A collection of pus may form in the peritoneal cavity or in the subdiaphragmatic, subhepatic, paracolic, or other areas Cholangitis, osteomyelitis, urinary tract infection, dental abscess, or paranasal sinusitis may cause prolonged fever 2 Neoplasms Many cancers can present as FUO The most common are lymphoma (both Hodgkin s and nonHodgkin s) and leukemia Other diseases of lymph nodes, such as angioimmunoblastic lymphoma and Castleman s disease, can also cause FUO Primary and metastatic tumors of the liver are frequently associated with fever, as are renal cell carcinomas Atrial myxoma is an often forgotten neoplasm that can result in fever Chronic lymphocytic leukemia and multiple myeloma are rarely associated with fever, and the presence of fever in patients with these diseases should prompt a search for infection 3 Autoimmune disorders Still s disease, systemic lupus erythematosus, cryoglobulinemia, and polyarteritis nodosa are the most common autoimmune causes of FUO Giant cell arteritis and polymyalgia rheumatica are seen almost exclusively in patients over 50 years of age and are nearly always associated with an elevated erythrocyte sedimentation rate (> 40 mm/h)
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In addition to routine laboratory studies, blood cultures should always be obtained, preferably when the patient has not taken antibiotics for several days, and should be held by the laboratory for 2 weeks to detect slow-growing organisms Cultures on special media are requested if Legionella, Bartonella, or nutritionally deficient streptococci are considered possible pathogens Screening tests with immunologic or microbiologic serologies ( febrile agglutinins ) are of low yield and should not be done Specific serologic tests are helpful if the history or physical examination suggests a specific diagnosis A single elevated titer rarely allows one to make a diagnosis of infection; instead, one must demonstrate a fourfold rise or fall in titer to confirm a specific infectious cause Because infection is the most common cause of FUO, other body fluids are usually cultured, ie, urine, sputum, stool, cerebrospinal fluid, and morning gastric aspirates (if one suspects tuberculosis) Direct examination of blood smears may establish a diagnosis of malaria or relapsing fever (Borrelia)
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All patients with FUO should have a chest radiograph Studies such as sinus films, upper gastrointestinal series with small bowel follow-through, barium enema, proctosigmoidoscopy, and evaluation of gallbladder function are reserved for patients who have symptoms, signs, or a history that suggest disease in these body regions CT scan of the abdomen and pelvis is also frequently performed and is particularly useful for looking at the liver, spleen, and retroperitoneum When the CT scan is abnormal, the findings often lead to a specific
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