2) Demam by Dr. Musofa (Slide Prof. Usman)

DEMAM :TIPE & PENDEKATANNYA

USMAN HADIDivisi Penyakit Tropik Infeksi

Departemen - SMF Ilmu Penyakit DalamFK Unair – RSU dr. Soetomo

SURABAYA

Body temperature: The normal and the abnormal

Temperature 0 Centigrade 0 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.

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

370C

390C

360C

380C

06.00 12.00 06.00 06.0012.00

Day 1 Day 1

fever

normal

How to record the body temperature?

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.

R > O > A

Fallacies in recording the body temperature:

1. Not keeping the thermometer properly

2. Not keeping the thermometer for required length of time

3. Recording the temperature soon after a hot or cold drink or food

4. 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)

result in

F E V E R

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)

results in

Elevated thermoregulatory set point

leads to

Increased Heat conservation (Vasoconstriction/ behaviour changes)

Increased Heat production(involuntary muscular contractions)

result in

F E V E R

Infeksi

- Virus

- Bakteri

- Parasit

- Jamur

Non Infeksi

- Autoimmune Disease

- Malignancy

- Vascular Accident

- Lain-lain

Obat

Parasetamol

Aspirin

NSAID

Steroid

Physical cooling

Thermoregulatory center

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 temperature with minimal diurnal variation (<10C)

Intermittent: Circadian rhythm is exaggerated, with wide variations; when the variation is extremely large, it is called hectic or septic.

Remittent: Temperature variation is >20C, but does not touch normal. e.g. Tuberculosis, viral fever, many bacterial infections etc.

Step - ladder fever is the one where the temperature rises gradually to a higher level with every spike.

Relapsing: Febrile episodes are 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 (Hodgkin’s 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

H1 H2 H3 H4

H1 H2 H3 H4

H1 H2 H3 H4

Sustained

Intermittent

Remittent

Step - ladder fever

H1 H2 H3 H4

H1 H2 H3 H4

H1 H2 H3 H4

H1 H2 H3 H4

tertiana

pelana

sudden onset

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 disordersetc

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

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:

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

Approach to a febrile patient

General Examination: Look for the followingTemperature

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

BreathlessnessBronchitis, pulmonary oedema, ARDS

ProstrationIndicates severe infection

General Examination: Look for the followingSensorium

Altered sensorium could be due to fever, metabolic disturbances, CNS involvement

NailsLook for anemia, jaundice, cyanosis, haemorrhages

Lymph nodes

Cervical, axillary, inguinal node enlargement

Oral cavityThrush, palatal haemorrhages, dental sepsis, oral hygiene, tonsils, pharynx, ulcers, pallor, jaundice

SkinRashes - haemorrhagic/ non haemorrhagic, purpura, lymphangitis, cellulitis, pallor, jaundice

EyesInjection 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

Abdomen

Tenderness, organomegaly, free fluid, mass

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

Cardio Vascular System

Heart rate, murmurs, pericardial rub

Endo /peri / myocarditis

SYSTEM WHAT TO LOOK FOR POSSIBILITIES

Central Nervous System

Altered sensorium, neck stiffness, ocular fundii, deficits

Meningitis, encephalitis, abscess

Musculo Skeletal

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

Dengue, Leptospirosis; arthritis, myositis etc.

GenitaliaScrotum, testes, vagina, cervix Orchitis, pyocele,

balanoposthitis, STDs, abscess

Per RectalPerianal abscess, prostate & seminal vesicles

Perianal abscess, prostatitis, seminal vesiculitis

Pelvic Examination

PID

Duration What is to be donePossibiliti

es

<3 DaysIt is the beginning!

Viral feverMalariaURTILRTIUTIAny other

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

Duration What is to be donePossibilitie

s

3 days to 7 days

All aboveEnteric Fever

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

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<3 Days

Fever3 days to 7 days

Fever 7 days to 15 days

Viral fever, MalariaURTI, LRTI, UTI

Any other

Viral fever, MalariaURTI, LRTI, UTI

Any otherEnteric Fever

Symptom, sign,possibilities

FUO

CLASSICAL, NOSONEUTROPENIA, 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, aortitisSystemic: 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 - Hodgkin’s and Non Hodgkin’s lymphoma,

Immunoblastic lymphadenopathy, leukemia, renal cell carcinoma, hepatoma, sarcoma, pancreatic cancers.

Benign - Atrial myxoma, renal angiomyolipomaAuto immune syndromes: Rheumatoid arthritis, SLE,

PAN, etc.Granulomatous diseases: Crohn’s disease, Idiopathic

granulomatous hepatitis, SarcoidosisMiscellaneous: 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/laparoscopy 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.

.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

FUO - Empirical

Fever - Signs of severe illness and indications for admission

1. Prostration2. Sick & toxic3. Breathlessness4. Hypotension5. Severe head ache, severe body

ache6. Severe dehydration7. Persistent vomiting & diarrhoea8. Hyperpyrexia9. UTI with fever10. Haemoptysis11. Anemia &jaundice12. Convulsions, altered sensorium13. Immune compromised patients -

Extremes of age, diabetes, patients on steroids and immuno suppressants, patients with HIV

Indications To Treat Fever:

1. Hyperpyrexia (41.60 C or 1070

F) 2. Pregnancy 3. Children with

febrile seizures 4. Impaired

cardiac, pulmonary, cerebral functions

BAD1. 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.

GOOD1. 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.

When and How to Treat Fever?The GOOD and BAD of FEVER

Adverse effects of unnecessary treatment of fever:

Adverse effects of drugs Reye’s 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 α-Melanocyte-stimulating hormone

(α-MSH) Glucocorticoids and their inducers

(corticotropin-releasing hormone and corticotropin) inhibit the synthesis of pyrogenic cytokines such as IL-6 and TNF-α 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,[gastric-inhibitory 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 fever’s upper limit. There is, for instance, experimental evidence indicating that under certain conditions (e.g., with intracerebral injection of recombinant human TNF-α in Zucker rats), TNF-α 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

PEMERIKSAAN FISIK

PEMERIKSAAN TAMBAHAN

TANDA FOKAL TANDA UMUM

KHARAKTERISTIK DEMAM, LAMA DEMAM

GEJALA PENYERTA, REVIEW OF THE SYSTEM

PEMERIKSAAN DASAR PEMERIKSAAN LANJUT

EPIDEMIOLOGI

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 IHADemam dengue (D) dan demam berdarah D

Cytomegalovirus (CMV)Anti-CMV IgM Elisa

Anti CMV IgG ElisaInfeksi - cytomegalovirus

Epstein - Barr Paul Bunnel Mononukleosis Infeksiosa

Virus (EBV) Anti EBV

Hepatitis A s/d EVirus A s/d E, berbagai komponen antivirus A s/d E

Hepatitis akut

Coxiella burnetti IFA Demam Q

Human Immunodeficiency virus (HIV)

Anti HIV-Elisa

Anti HIV-Western Blot

Anti HIV-Agli PArtikel

Anti HIV DEI

Anti 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 Berhubungan dengan penyakit lama yang disertai diare dan

nyeri perut.

Elektrokardiografi Dapat melengkapi diagnosis pada pasien demam tifoid.

Biopsi 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 kecurigaan adanya emboli paru.

Scanning pada gallium sitrat dapat memperlihatkan titik fokus infeksi didaerah abdominalyang sulit ditemukan.

Computerized tomography (CT-Scan) dapat 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 3-5% 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