DEMAM :

TIPE & PENDEKATANNYA

USMAN HADI

Divisi Penyakit Tropik Infeksi

Departemen - SMF Ilmu Penyakit Dalam
FK Unair RSU dr. Soetomo
SURABAYA

Body temperature:
The normal and the abnormal
Temperature

Centigrade

Fahrenheit

Normal

36.6 - 37.20 C

98 - 990 F

Pyrexia

>37.20 C

>990 F

Hyperpyrexia

>41.60 C

>1070 F

Subnormal

<36.60 C

<980 F

Hypothermia

<350 C

<950 F

CLINICAL THERMOMETRY
Observer Variability
Anatomic Variability
Physiologic Variables
Pathologic Variable

The Thermometer:

The body temperature is

lower in the morning and
rises by evening, with a
range of about half a
degree.

Day 1

Day 1

fever

390C

380C

A morning temperature of
>37.2C (>99.4F) or
evening temperature of
>37.7C (>99.9F) is
considered as 'fever'

370C

normal
360C

06.00

12.00

06.00

12.00

06.00

How to record the body temperature?

R>O>A

Body temperature is recorded with a

thermometer inserted under the
tongue.
In some cases, especially in children
and the infirm, the thermometer is
inserted under the arm pit (axilla) or
groin fold or into the rectum.
Generally the temperature is recorded
for 3 minutes.

The rectal temperature

represents the core temperature
and is about half degree higher
than the oral temperature.
The axillary temperature is about
half degree lower than the oral
temperature.

Fallacies in recording the body temperature:

1.

2.

3.

4.

Not keeping the thermometer

properly
Not keeping the thermometer
for required length of time
Recording the temperature
soon after a hot or cold drink
or food
Faulty thermometer

Infectious agents / Toxins / Mediators of inflammation

(Pyrogens)

Stimulate

Monocytes / Macrophages / Endothelial cells / Other cell types

release

Pyrogenic cytokines-IL - 1, TNF, IL - 6, IFN

stimulate

Anterior hypothalamus (Mediated by PGE2)

(Antipyretics/ NSAIDs act here)

results in

Elevated thermoregulatory set point

leads to

Increased Heat conservation

(Vasoconstriction/ behaviour changes)

Increased Heat production

(involuntary muscular contractions)

FEVER

result in

Infectious agents / Toxins / Mediators of

inflammation
(Pyrogens)

stimulate

Monocytes / Macrophages / Endothelial

cells / Other cell types

release

Pyrogenic cytokines-IL - 1, TNF, IL - 6,

IFNs

stimulate

Anterior hypothalamus (Mediated by PGE2)

(Antipyretics/ NSAIDs act here)

leads to

Increased Heat conservation

(Vasoconstriction/ behaviour changes)
Increased Heat production
(involuntary muscular contractions)
result in
FEVER

Thermoregulatory center

results in

Elevated thermoregulatory set point

Infeksi
- Virus
- Bakteri
- Parasit
- Jamur
Non Infeksi
- Autoimmune Disease
- Malignancy
- Vascular Accident
- Lain-lain

Obat
Parasetamol
Aspirin
NSAID
Steroid
Physical cooling

Patterns of Fever
Fever takes a characteristic course in
many diseases and the pattern of rise
and fall of temperature may itself be a
clue for diagnosis.

Sustained: Persistent elevation in

Intermittent: Circadian rhythm is

Remittent: Temperature variation

temperature with minimal diurnal

variation (<10C)

exaggerated, with wide variations;

when the variation is extremely large,
it is called hectic or septic.
is >20C, but does not touch normal.
e.g. Tuberculosis, viral fever, many
bacterial infections etc.

Step - ladder fever is the one

Relapsing: Febrile episodes are

where the temperature rises gradually

to a higher level with every spike.

separated by intervals of normal

temperature

Tertian fever - fever

occurs once in 3 days or
48 hours (P. malaria);
Quartan fever - fever
occurs once in four days
or 72 hours
(P. malariae);
Pel Ebstein: fever
occurs once in 7-20
days (Hodgkins and
other lymphomas)
Saddle Back: Patient
has fever for 1-2 days,
followed by remission
for 2-3 days and then
relapse of fever

H1

H2

H3

H4

Sustained

H1

H2

H3

H4

Intermittent

H1

H2

H3

H4

Remittent

H1

H2

H3

H4

Step - ladder fever

H1

H2

H3

H4

tertiana

H1

H2

H3

H4

pelana

H1

H2

H3

H4

sudden onset

H1

H2

H3

H4

Step - ladder fever

Evening rise in temperature or night sweats:

In some diseases, the rise in body

temperature s evident only in the
evening hours or the patient may
be woken up at night with
sweating.
This pattern is seen when the elevation
in the temperature is mild to moderate
and added to the diurnal rise in the
evening, the body temperature goes
beyond the normal level.
Common causes for evening rise of
temperature are tuberculosis,
leukemias, autoimmune disorders
etc

Approach to a
febrile patient

History of the
illness:
Like in any other
illness, a detailed
history plays a
vital role in making a
diagnosis. Attention
should be paid to
the following details:

Characteristic- Onset/ Sudden / insidious

/ unnoticed
Type - Sustained / intermittent / remittent /
relapsing
Duration

Associated complaints - head ache,

body ache, running nose, rashes, sore throat,

cough,
Chest pain, breathlessness, dysuria, frequency of
micturition, diarrhoea, vomiting, abdominal pain,
Pain / redness of limbs, swellings, joint pains etc.
Weight loss

Risk

Occupation, Contacts
Travel - Trekking / endemic areas
Stay (hotel, hostel, ashram, hospital)
Habits, Past history
Treatment history - Transfusions, injections,
allergies, medications, hospital interventions
Vaccination, Sexual practice

Approach to a febrile patient

Signs: Specifically look for lymph nodes,

jaundice, anemia, chest signs, abdominal
tenderness, organomegaly, free fluid, neck
stiffness etc.
Consider: Prolonged viral fever (infectious
mononucleosis, CMV, HIV, hepatitis); malaria;
enteric fever; tuberculosis; partially treated or
resistant infections
Investigations: Blood count, ESR, Urine
analysis, MP test, Widal, serological tests for
EBV, CMV, Leptospira, amebiasis, rickettsiae;
Chest X ray, Ultra sound abdomen

General Examination: Look for the following

Temperature

Oral preferred; record for 3 minutes

Pulse

For every 0 rise in temperature, pulse increases by 10.

Pulse - temperature dissociation is seen in typhoid,
brucellosis, leptospirosis, viral myocarditis, diphtheria,
rheumatic carditis, bacterial endocarditis etc

BP

Hypotension signifies septic shock

Tachypnoea

For every 0 rise in temp., respiratory rate rises by 4. Higher

respiratory rate signifies pneumonia, bronchitis,
pulmonary oedema

Breathlessness

Prostration

Bronchitis, pulmonary oedema, ARDS

Indicates severe infection

General Examination: Look for the following

Sensorium

Nails

Altered sensorium could be due to fever, metabolic

disturbances, CNS involvement
Look for anemia, jaundice, cyanosis, haemorrhages

Lymph nodes
Cervical, axillary, inguinal node enlargement
Oral cavity

Skin

Eyes

Thrush, palatal haemorrhages, dental sepsis, oral hygiene,

tonsils, pharynx, ulcers, pallor, jaundice
Rashes - haemorrhagic/ non haemorrhagic, purpura,
lymphangitis, cellulitis, pallor, jaundice
Injection of conjunctivae, jaundice, pallor, papilloedema

Fever - Systemic Examination

SYSTEM

WHAT TO LOOK FOR

POSSIBILITIES

Upper
Respiratory
Tract

Oral cavity for tonsils, pharynx,

dental sepsis; sinuses for
tenderness; ears for swollen
membrane, perforation,
discharge

Tonsillitis, pharyngitis,
sinusitis,

Respiratory
System

Tachypnoea, diminished breath

sounds, Bronchial breathing,
crackles, wheezes, rub, dullness

Pneumonia, bronchitis,
cavities, pleurisy,
effusion, empyema

Tenderness, organomegaly, free

fluid, mass

Hepatitis, splenomegaly
in various infections,
intra abdominal
abscesses, peritonitis

Cardio Vascular Heart rate, murmurs, pericardial

System
rub

Endo /peri / myocarditis

Abdomen

SYSTEM

WHAT TO LOOK FOR

Central Nervous Altered sensorium, neck

stiffness, ocular fundii, deficits
System

Musculo
Skeletal

Genitalia

Per Rectal
Pelvic
Examination

POSSIBILITIES
Meningitis, encephalitis,
abscess

Muscular tenderness in
shoulders, gluteals, calf; joint
pain, swelling, tenderness;
spine tenderness

Dengue, Leptospirosis;
arthritis, myositis etc.

Scrotum, testes, vagina, cervix

Orchitis, pyocele,
balanoposthitis, STDs,
abscess

Perianal abscess, prostate &

seminal vesicles

Perianal abscess,
prostatitis, seminal
vesiculitis
PID

Duration

What is to be done

<3 Days
It is the be
ginning!

If in a malarious area - Do MP test in ALL cases,

and administer presumptive antimalarial
treatment to everybody

Fine rashes, runny nose, watering of eyes:

Consider viral exanthematous fever.
Rashes, severe body ache, pain on moving the
eye balls: Consider flaviviral fevers (dengue,
chikungunya), leptospirosis etc.

Consider acute urinary infection in women and

elderly men;
Consider respiratory infection in smokers,
alcoholics, elderly
Look for common sites of infections:
Pharynx/tonsils; sinuses; skin (cellulitis,
commonly of legs)
Symptoms & signs of severe illness - admit &
investigate
Investigations: Blood count; urine analysis,
particularly in a female; MP test

Possibiliti
es
Viral fever
Malaria
URTI
LRTI
UTI
Any other

Duration
3 days to 7
days

What is to be done
Case on follow-up: Look for new symptoms and
signs - Chest pain (pleurisy), localised pain (focal
infection), diarrhoea (enteric), head ache
(meningitis, sinusitis), lymph nodes etc.
New case: Examine in detail
Symptoms & signs of severe illness - admit &
investigate

Investigations: MP test (repeat), Blood count;

urine analysis, cultures, Widal test and other
serological tests; chest x ray

Possibilitie
s
All above
Enteric
Fever

Fever - 7 days to 15 days

Symptom

Possibilities

Head ache

Sinusitis, Otitis, dental sepsis, malaria, subacute meningitis

Cough

Tonsillitis, pneumonia, bronchitis, malaria, tuberculosis.

Chest pain

Pleural effusion / empyema, pericarditis, liver abscess,

root pain

Diarrhoea

Enteric fever, colitis, drug induced

Pain
abdomen

Hepatitis, liver abscess, appendicitis, PID, other intra

abdominal sepsis

Fever
Fever

Fever

<3 Days

3 days to 7 days

Viral fever, Malaria

URTI, LRTI, UTI
Any other

Viral fever, Malaria

URTI, LRTI, UTI
Any other
Enteric Fever

Fever

7 days to 15 days

Symptom, sign,
possibilities

FUO
CLASSICAL, NOSO
NEUTROPENIA,
HIV-RELATED

Fever of Unknown Origin

Definition of FUO:
Fever of >38.30 C (1010F) on several occasions
1.
Classic: Fever for >2 weeks OR in hospital
investigations for 3 days OR 3 out patient visits
2.
Nosocomial: Hospitalized for 3 days, no fever on
admission.
3.
Neutropenic: Neutrophil count <500/mm3, in hospital
investigations for 3 days
4.
HIV associated: Proven HIV infection, 3 days in hospital
or 4 weeks out patient

FUO - Common Causes:

Infections: Infections account for 40% of cases of
FUO.
Localised: Appendicitis, cholangitis, cholecystitis,
diverticulitis, dental sepsis, liver abscess, osteomyelitis
(with prosthesis), P.I.D., prostatic abscess, sinusitis,
intra-abdominal abscess, thrombophlebitis etc.
Intravascular: Endocarditis, aortitis

Systemic:
Bacterial - Tuberculosis, mainly extra pulmonary;

Brucellosis, Leptospirosis, Salmonellosis, atypical

mycobacteria, nocardia, actinomycosis
Rickettsial, mycoplasma
Fungal - Aspergillosis, candidiasis, cryptococcosis,

P.carinii
Viral - Hepatitis A, B, C, D, E.; EBV, CMV, HIV
Parasitic - Malaria, Leishmania, Amebiasis

Other causes:
Neoplasms:

Malignant - Hodgkins and Non Hodgkins lymphoma,

Immunoblastic lymphadenopathy, leukemia, renal cell
carcinoma, hepatoma, sarcoma, pancreatic cancers.
Benign - Atrial myxoma, renal angiomyolipoma
Auto immune syndromes: Rheumatoid arthritis, SLE,
PAN, etc.
Granulomatous diseases: Crohns disease, Idiopathic
granulomatous hepatitis, Sarcoidosis
Miscellaneous: Drug fever, sub-acute thyroiditis,
hematomas, gout, post MI, tissue infarction/ necrosis,
cyclic neutropenia, adrenal insufficiency, brain tumor,
hyperthyroidism, phaeochromocytoma, factitious fevers,
habitual hyperthermia

FUO of more than > 6 months is less likely to be

due to an infection

FUO - Investigations:
FUO may require a wide array of investigations to locate
the cause of the fever.
History, clinical findings and findings of routine
investigations should guide the selection of these
special investigations.
Hematological: Blood count, ESR, PS study, Malarial
Parasite, Microfilaria, Leishmania
Biochemical: LFT, CSF study, analysis of pleural /
peritoneal fluids
Serological: Widal, Brucellosis, Weil - Felix, Amebiasis,
Hepatitis, HIV, EBV, CMV, Leptospira, Tuberculosis etc.,
Anti nuclear antibody, RA factor

Microbiological: Cultures of blood, body fluids,

secretions; staining and examination of secretions
Pathological: Bone marrow aspiration, FNAC,
examination of fluids and secretions, histopathology Biopsy of liver, lymph nodes
Skin tests: Tuberculosis
Radiological: X - Ray of chest (PA, lateral, apical,
under penetrated AP), sinuses, bones, joints, Barium
Series etc.; Ultra sound studies, echocardiography (for
vegetations) CT scan / MRI Scan
Invasive: Biopsy of lymph nodes, liver, bone marrow;
exploratory laparotomy; Ultra sound/CT guided
aspiration/biopsy Aspiration of fluids - pleural
/peritoneal/Lumbar Puncture
Endoscopy:
Gastroscopy/colonoscopy/cystoscopy/arthroscopy/laparo
scopy etc.

FUO - Empirical Therapy:Empirical therapy should be

avoided as far as possible. However, on certain demanding
situations, one may have to resort to empirical treatment.
Some examples are given below

Presumptive therapy for malaria:

For ALL cases of fever in an malarious
area or in a visitor to malarious area.
Only the first full dose of chloroquine
should be used for presumptive
treatment and second line drugs should
be avoided.
In areas with known resistance to
chloroquine, pyrimethamine/sulfadoxine
can be added.

FUO - Empirical
.Empirical antimicrobial therapy:
Severe sepsis, shock, severe
neutrophilic leukocytosis,
immunocompromised patients are
indications to start empirical broad
spectrum antibacterial therapy (to
cover Gram positive, Gram negative
and anaerobes).
Examples include 3rd generation
cephalosporins + Aminoglycosides +
Metronidazole OR Pseudomonas
specific penicillins / cephalosporins +
Metronidazole

FUO - Empirical

Empirical antitubercular therapy: This can be used

when all investigations are negative and there is
reasonable doubt about tuberculosis, particularly in
areas where tuberculosis is common. Only INH and
Ethambutol should be used in this therapeutic trial
(other antitubercular drugs like rifampicin and
streptomycin are effective against other bacterial
infections as well). A fair trial for up to 8 weeks should
be given and if the disease is indeed tuberculosis, the
patient will show signs of recovery and may become
apyrexial.
Empirical steroids: It can be tried only when all
infections are ruled out and reasonable doubt of
autoimmune syndromes exists

Fever - Signs of severe illness

and indications for admission
1.
2.

3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Prostration
Sick & toxic
Breathlessness
Hypotension
Severe head ache, severe body
ache
Severe dehydration
Persistent vomiting & diarrhoea
Hyperpyrexia
UTI with fever
Haemoptysis
Anemia &jaundice
Convulsions, altered sensorium
Immune compromised patients Extremes of age, diabetes,
patients on steroids and immuno
suppressants, patients with HIV

Indications
To Treat Fever:
1.

2.
3.
4.

Hyperpyrexia
(41.60 C or 1070
F)
Pregnancy
Children with
febrile seizures
Impaired
cardiac,
pulmonary,
cerebral
functions

When and How to Treat Fever?

The GOOD and BAD of FEVER
GOOD
1.
Elevation of body
temperature increases
survival.
2.
Growth and virulence of
bacteria are impaired at
high temperature.
3.
Inhibiting fever is
known to increase
mortality in rabbits.
4.
Temperature increases
phagocytic and
bactericidal activity of
neutrophils and the
cytotoxic effects of
lymphocytes.

BAD
1. With 100C elevation in
temperature, O2 consumption
increases by 13%
2. Fluid and caloric requirements
are increased
3. Stress of increased metabolic
activity can be fatal to the
growing fetus and for patients
with end stage organ failure
4. Increase in IL - 1 and TNF
accelerates muscle catabolism,
resulting in weight loss and
negative nitrogen balance
5. Fever reduces mental acquity,
can cause delirium and stupor
and can trigger convulsions
6. Single episode of fever doubles
the risk of neural tube defects in
the fetus.

Adverse effects of unnecessary treatment of

fever:
Adverse effects of drugs
Reyes syndrome with aspirin; gastritis
etc.
All NSAIDs inhibit inflammatory
response - mask the localised infection,
prevent its detection, and may even aid
its spread
NSAIDs have anti platelet and anti
phagocytic activity, a. coronaria
constriction

How To Treat Fever:

Primary infection
Resetting
hypothalamic set
point: Any antipyretic
or NSAID can be used
as antipyretic agent.
Paracetamol, Aspirin,
Ibuprofen or
Mefenamic acid can
be used.
Paracetamol is the
safest with least side
effects.

Physical cooling:
Uncovering the body,
tepid sponging, cooling
blankets can be tried.
Cold sponging may
cause peripheral
vasoconstriction and
may result in the
increase of core
temperature and
should therefore be
avoided.

ENDOGENOUS CRYOGEN

arginine vasopressin
-Melanocyte-stimulating hormone
(-MSH)
Glucocorticoids and their inducers
(corticotropin-releasing hormone and
corticotropin) inhibit the synthesis
of pyrogenic cytokines such as IL-6
and TNF- inhibitory feedback on
LPS-induced fever
Lipocortin-1.
corticotropin-releasing hormone
(CRH) Thyrotropin-releasing
hormone,[gastric-inhibitory peptide,
neuropeptide Y,nitric oxide,carbon
monoxide,and bombesin

Thyrotropin-releasing hormone,[gastricinhibitory peptide, neuropeptide Y,nitric

oxide,carbon monoxide,and bombesin likewise
exhibit cryogenic properties under certain
conditions.
Of these, bombesin has exhibited the highest
potency, in that it consistently produces hypothermia
associated with changes in heat dissipation and heat
production when injected into the preoptic area or
anterior hypothalamus of conscious goats and
rabbits. Bombesin is believed to exert its
hypothermic effect by decreasing the sensitivity of
warm-sensitive neurons
Pyrogenic cytokines, the mediators of the febrile
response, might themselves have a role in
determining fevers upper limit. There is, for
instance, experimental evidence indicating that
under certain conditions (e.g., with intracerebral
injection of recombinant human TNF- in Zucker
rats), TNF- acts to lower, rather than to raise, body
temperature, although only in the presence of LPS.
Thus, it is possible that at certain concentrations
or in the appropriate physiologic milieu,
pyrogenic cytokines function paradoxically as
endogenous cryogens.

DEMAM

ANAMNESIS
GEJALA PENYERTA,
REVIEW OF THE SYSTEM

KHARAKTERISTIK DEMAM,
LAMA DEMAM
EPIDEMIOLOGI

PEMERIKSAAN FISIK

TANDA FOKAL

TANDA UMUM

PEMERIKSAAN TAMBAHAN

PEMERIKSAAN DASAR

PEMERIKSAAN LANJUT

Fever - Rational Approach

It can be the simplest to most difficult and challenging

Patient has only one consideration - fever, but the treating
doctor has to consider hundreds of causes
Sometimes it may be difficult to convince the patient and
relatives
Both patient and doctor should have ample patience
Better to avoid empirical therapy in the initial stages to
avoid confusion later
It is important to know the natural history of common
febrile illnesses to rationalize diagnosis and treatment
Review and second opinion are very useful. In cases of FUO,
one has to retake the history, redo the examination and go
through the available reports once again, as if in a new
case. Such a review may itself provide a diagnosis.

SERO-IMUNOLOGI

Pemeriksaan serologis sebenarnya sangat bermanfaat

pada seorang pasien demam belum terdiagnosis.
Diperlukan speciman darah untuk pemeriksaan ini, untuk
memudahkan interpretasi titer serologik yg ditemukan.
Kenaikan titer sebesar 4 kali atau lebih mempunyai arti
besar untuk menentukan kemungkinan penyakit.
Pemeriksaan jenis lain yang dapat membantu adalah :
faktor artritis reumatoid, imunoglobulin, antibodi
antinuklear, antigen otot polos serta auto antibodi
lainnya dan imuno-elektroforesis.

MIKROBIOLOGI

Isolasi kuman penyebab infeksi merupakan diagnosis utama

pada pasien yang tersangka deman karena menderita infeksi.
Pengambilan darah untuk kultur mikroorganisme dilakukan
aseptik dan diambil sekitar 10ml yg kemudian dilarutkan dlm
media untuk menumbukan kuman aerob dan kuman anaerob.
Selain kultur darah, mikroorganisme dlm darah jg penting
karenanya pengambilan sampel hrs representatif.
Isolasi virus diambil dari sekret hidung, usap tenggorok atau
sekresi bronkial.
Untuk TBC pemeriksaan sputum minimal 3 hari.
Untuk infeksi saluran cerna pemeriksaan mikroorganisme dari
feses diperlukan untuk memantau spektrum kuman
penyebab.

HEMATO-KIMIA KLINIS

Meluasnya spektrum panyakit virus dewasa kini karena

pengaruh urbanisasi, globalisasi maupun lingkungan yg
kurang memadai.
Diperlukan patokan yg dpt membedakan pasien
terjangkit virus atau bakteri yg pelaksanaanya berbeda
total.
Pengukuran awal yg dpt dilaksanakan adl pemeriksaan
hematologis yg pada infeksi bakteri akut dpt
menunjukkan pergeseran hitung jenis ke kiri atau tanpa
lekositosis.

Bila keadaan ini tdk di jumpai, dpt dilakukan

pemeriksaan C-reaktif protein (CRP)

DAFTAR UJI VIROLOGIS

Virus penyebab

Jenis Uji

Penyakit

Dengue

IHA

Demam dengue (D) dan

demam berdarah D

Cytomegalovirus (CMV)

Anti-CMV IgM Elisa

Anti CMV IgG Elisa

Infeksi - cytomegalovirus

Epstein - Barr

Paul Bunnel

Mononukleosis Infeksiosa

Virus (EBV)

Anti EBV

Hepatitis A s/d E

Virus A s/d E, berbagai

komponen antivirus A s/d E

Hepatitis akut

Coxiella burnetti

IFA

Demam Q

Human Immunodeficiency
virus (HIV)

Anti
Anti
Anti
Anti
Anti

HIV-Elisa
HIV-Western Blot
HIV-Agli PArtikel
HIV DEI
HIV Line Imun As

AIDS
AIDS
AIDS
AIDS
AIDS

DAFTAR UJI BAKTERIO-PARASITOLOGIS

Virus penyebab

Jenis Uji

Penyakit

Salmonella typhi

Widal Thypidot PCR

Demam tifoid

S. Paratyphi A/B/C

Widal

Demam paratifoid

Streptokokkus

ASTO

Demam reumatik

Mikobakteria

Myco Dot TB PAP

Anti TB

TBC pulmonal dan TBC

Ekstrapulmonal

Leptospira spp

MAT

Leptospirosis

Brucella spp

Aglutinasi

Brusellosis

Rickettsia spp

Well felix

Ricketsiosis

Mycoplasma pneum

IF

Mycoplasmosis

Legionella

IF

Legionellosis

Toxoplasma gondii

Elisa IgG/IgM

Tokoplasmosis

Entamoeba histolitica

IDT

Amubiasis

Filaria spp

IFAT

Filariasis

Candida spp

IHA atau IFAT

Candidiasis

Histoplasma capsulatum

IDT

Histoplasmosis

SINAR TEMBUS

Foto rongent merupakan pemeriksaan penunjang medis

dalam membantu diagnosis kelainan paru dan ginjal.
Sumsum tulang belakang dan persendian juga bagian
ideal untuk di periksa sinar tembus.
Angiografi dapat membantu menegakkan diagnosis
emboli paru-paru.
Limfangiografi untuk mendeteksi suatu limfoma
abdominal retroperitonial.

Lanjutan

Endoskopi

Elektrokardiografi

Dapat melengkapi diagnosis pada pasien demam tifoid.

Biopsi

Berhubungan dengan penyakit lama yang disertai diare dan

nyeri perut.

Berguna untuk menetapkan penyakit seperti : limfoma,

metastasis keganasan, tuberkulosis atau infeksi jamur, dll

Ultrasonografi (USG)

Berguna untuk kelainan seperti miksoma di atrium atau vegetasi

di katub2 jantung.
Pada abdomen dideteksi kelianan seperti : ginjal,
retroperitoneal, juga gangguan pelvis.

PENCITRAAN

Banyak membantu untuk pemeriksaan khusus terhadap

hati.

Scanning paru-paru dapat membantu diagnosis pada

Scanning pada gallium sitrat dapat memperlihatkan titik

Computerized tomography (CT-Scan) dapat

kecurigaan adanya emboli paru.

fokus infeksi didaerah abdominalyang sulit ditemukan.

menunjukkan kelainan badan melalui pemotongan

lintang anatomis organ tubuh.

Lanjutan

Laparatomi

Memegang peranan penting dimana fasilitas kesehatan masih

memiliki peralatan sederhana.
Dibenarkan bila ada suatu petunjuk keras bahwa penyebab
demam adalah suatu kelainan keras di abdomen.
tindakan peritoneoskopi dapat membantu mencapai diagnosis :
infeksi peritonitis tuberkulosa, karsinomatosis peritneal,
kolesistisis dan infeksi rongga pelvis.

Terapi ad Juvantibus

Dilakukan apabila tidak lagi dapat ditempuh jalan lain untuk

memperoleh suatu kepastian diagnosis.
Pemakaian kombinasi antibiotika berspektrum luas tidak
dibenarkan mengingat penyebabnya demam belum terdiagnosis
bukan krn infeksi bakterial.

DEMAM OBAT (DRUG FEVER)

Efek samping pengobatan berupa demam obat terjadi 35% dari reaksi obat yang dilaporkan.
Obat yang dapat mengakibatkan demam dapat
digolongkan sbg:
Obat yang sering mengakibatkan demam
Obat yang kadang2 dapat mengakibatkan demam
Oabta yang secara insidentil sekali dapat
mengakibatkan demam

Salah satu ciri obat demam adl akan timbul tidak lama
setelah pasien mulai pengobatan.

Tipe obat demam dapat berupa : remitan, intermiten,

hektik atau kontinyu

DEMAM DIBUAT-BUAT

Pasien dgn berbagai cara berusaha menaikkan suhu

badan dari suhu badan yang sesungguhnya.

Keadaan suhu badan yang sengaja dibuat lebih tinggi ini

dikenal dgn sbg demam faktisius (factitious fever).

Maka harus dilakukan pengawasan yang ketat dlm

pengukuran suhu badan bila seseorang berpura2 sakit
demam (malinger).

Karena akan sia-sia saja dicari penyebab demamnya.

Pasien seperti ini mungkin memerlukan bantuan dokter

ahli jiwa