Approach to PUO (Pyrexia of Unknown Origin)👇
A patient has been febrile for weeks. Multiple antibiotics have failed. Cultures are negative. What next?
The biggest mistake is ordering random investigations without a diagnostic framework.
Think of PUO in 5 major categories:
1. Infections
Still the most common cause in many developing countries.
Never miss:
Tuberculosis (pulmonary or extrapulmonary)
Infective endocarditis
Deep-seated abscess
Brucellosis
HIV-related infections
Osteomyelitis
Clues:
✔ Weight loss
✔ Night sweats
✔ Travel history
✔ Animal exposure
✔ Prosthetic valves or cardiac murmurs
2. Malignancy
Especially when fever is associated with constitutional symptoms.
Think:
Lymphoma
Leukemia
Renal cell carcinoma
Metastatic cancers
Clues:
✔ Lymphadenopathy
✔ Splenomegaly
✔ Unexplained anemia
✔ Elevated LDH
✔ Significant weight loss
3. Autoimmune / Inflammatory Diseases
Important differentials:
SLE
Vasculitis
Adult-onset Still disease
Rheumatoid arthritis
Giant cell arteritis
Clues:
✔ Rash
✔ Arthritis
✔ Oral ulcers
✔ Very high ESR/CRP
✔ Multisystem involvement
4. Drug Fever
Always review medications before ordering expensive tests.
Common offenders:
Beta-lactam antibiotics
Sulfonamides
Anticonvulsants
Allopurinol
Clue:
Patient looks surprisingly well despite persistent fever.
5. Miscellaneous Causes
Don’t forget:
Pulmonary embolism
Sarcoidosis
Thyroiditis
Inflammatory bowel disease
Factitious fever👇
Approach to Hypertension for House Officers, Interns & Residents 👇
1. First Confirm It Is Actually Hypertension
One high reading ≠ diagnosis.
Correct BP Technique
Patient rested for 5 min
Back supported
Feet on floor
Correct cuff size
No caffeine/smoking 30 min before
Measure in both arms initially
Take 2 readings
➡️ Classification
Normal: <120/80
Elevated: 120–129 / <80
Stage 1 HTN: 130–139 or 80–89
Stage 2 HTN: ≥140 or ≥90
Hypertensive crisis: ≥180 and/or ≥120
2. Ask the MOST Important Question
“Is this emergency, urgency, or stable hypertension?”
This single step changes everything.
3. Rule Out Hypertensive Emergency
Severe BP + END ORGAN DAMAGE
➡️ Symptoms you MUST ask
Chest pain
Dyspnea
Neuro deficit
Confusion
Visual loss/blurring
Seizures
Decreased urine output
Severe headache
Pregnancy symptoms
➡️ Examine for
Pulmonary edema
Stroke signs
Papilledema
Heart failure
Aortic dissection findings
➡️ Investigations
ECG
Troponin
CXR
Creatinine
Urine protein
Fundoscopy
CT brain if neuro symptoms
4. Differentiate Emergency vs Urgency
➡️ Hypertensive Emergency
BP usually >180/120 + organ damage
➡️ Management
Admit
IV antihypertensives
Reduce MAP gradually
Avoid rapid overcorrection
➡️ Common IV Drugs
Labetalol
Nicardipine
Nitroglycerin
Nitroprusside (selected cases)
➡️ Hypertensive Urgency
Very high BP WITHOUT organ damage
➡️ Management
Oral drugs
Slow reduction over 24–48 hrs
No aggressive IV treatment
Restart missed meds if noncompliant
➡️ Common Oral Drugs
Amlodipine
Captopril
Labetalol
5. If Stable HTN → Take Proper History
Important History
➡️ Duration
Newly diagnosed or chronic?
➡️ Drug history
NSAIDs
Steroids
OCPs
Decongestants
Cocaine/amphetamines
➡️ Comorbidities
Diabetes
CKD
CAD
Stroke
OSA
➡️ Symptoms suggesting secondary HTN
Episodic headache/sweating → pheochromocytoma
Muscle weakness → hyperaldosteronism
Snoring/daytime sleepiness → OSA
Renal disease symptoms
Young patient with severe HTN
6. Examine Properly
Don’t just write “CVS normal”
Look specifically for:
BMI/obesity
Fundoscopy
Radio-radial delay
Renal bruit
Edema
Signs of Cushing syndrome
Thyroid signs
Heart failure signs
7. Baseline Investigations Every Resident Should Order
➡️ Basic Workup
CBC
Creatinine/eGFR
Electrolytes
Urine R/E
Urine ACR if possible
HbA1c
Lipid profile
ECG
➡️ Optional
Echo
Renal ultrasound
TSH
Aldosterone/renin ratio
8. Think About Secondary Hypertension
Especially if:
Young age
Resistant HTN
Sudden onset
Severe HTN
Hypokalemia
Renal dysfunction
➡️ Common Causes
CKD
Renal artery stenosis
Primary hyperaldosteronism
OSA
Thyroid disease
Pheochromocytoma
Cushing syndrome
9. Choosing Antihypertensives (VERY Important)
➡️ First-Line Drugs
ACE inhibitors
ARBs
Calcium channel blockers
Thiazide diuretics
10. Drug Selection Based on Patient
➡️ Diabetes/CKD with proteinuria
→ ACEi/ARB
➡️ CAD/Post MI
→ Beta blocker + ACEi
➡️ Heart failure
→ ACEi/ARB + beta blocker + diuretics
➡️ Elderly isolated systolic HTN
→ CCB/thiazide
➡️ Pregnancy
→ Labetalol, nifedipine, methyldopa
➡️ Avoid in pregnancy:
ACEi
ARBs
APPROACH TO HYPERNATREMIA FOR HOs & RESIDENTS 👇
When you see Na⁺ >145, don’t panic. Think in 4 steps:
1) FIRST ASK: IS THE PATIENT DRY OR WET?
Most hypernatremia patients are volume depleted.
Look for:
- Hypotension
- Tachycardia
- Dry mucosa
- Low urine output
Some time ago, I begged someone to consent to a cesarean section. There was a clear fetal indication for CS. She declined. She ultimately gave birth normally, but the baby didn’t score well.
She even celebrated that she had been coerced into a CS but ultimately gave birth normally, that is what she told fellow mothers in labour.
A year later, I met her, the child hasn’t even sat without support. I felt sad. I couldn’t even talk with her. Some things drain you emotionally.
Abacha time is more better than Tinubu time
Big love to Mr sani Abacha
They said Abacha embezzled Trillions, but people are living fine and happily no single inflation until 1998, but they said Tinubu is working but we are facing x14 hardship of that Muhammad Buhari time
Big shout out to Sani Abacha, rest well ❤️
(I will never keep shut because I can afford my daily needs, I'm down for any betterment idea, God created Life without no Government policy or law or system, so it means better days can still show for we Nigerian citizens ❤️
@elonmusk