PENATALAKSANAANDEMAMMELALUIPENDEKATAN

KEDOKTERANKELUARGA
Oleh:dr.ArlinaDewi,M.Kes
(Sumber:APrimeronFamilyMedicinePracticeby:GohLeeGan,AzrulAzwar,
SugitoWonodirekso.1stpublished.SingaporeInternationalFoundation:2004;176182)
Learningobjectivesyangharusdicapaimahasiswa:
1. Menjelaskanbatasansuhunormaldiberbagaitempatpengukuran
2. Menganalisiskemungkinankemungkinanetiologidemam
3. Menganalisisdiferensialdiagnosispenyebabdemammelaluianamnesa,
pemeriksaanfisikdanpenunjang
4. Memahamimanajemenkuratifdaridemam
5. Memahamimanajemenpencegahankomplikasidaridemam
6. Mengetahuiindikasirujukanpadakasusdemam

DEFINITIONOFFEVER
Theaveragenormaloralbodytemperatureis36.7C(range3637.4C),or98F
(range96.899.3F).Thenormalrectalorvaginaltemperatureis0.5C(1F)higherthan
the oral temperature, and the normal axillary temperature is correspondingly lower.
Rectal temperature is more reliable than oral temperature in patients who are mouth
breathersorwhoaretachypneic.
RELEVANCETOGENERALPRACTICE
Feverisasymptomthatismostreadilyrecognisedasasignofillnessandbrings
thepatientquicklytothedoctor.
Inthefebrilepatientwithashorthistoryandwhoisotherwisewell,symptomatic
treatmentbasedonapresumedviraletiologyisusual.Thedoctorusestimeasa
diagnostictool.Ifthefeverpersists,oriftheconditionofthepatientdeteriorates,
theanxietyofbothpatientanddoctoristhenquicklyarousedtofurtheraction.
CAUSES
Manyinfectious,inflammatory,neoplasticandhypersensitivityreactionsmayproduce
fever.Fevercanbebroadlydividedintoshortlivedfeverandprolongedfever.
SHORTLIVEDFEVER
Mostacutefeversencounteredintheambulatorycaresettingareofobviouscauseand
due to upper respiratory or urinary traction infection. Viral illness, drug allergy
(especiallytoantibiotics),andconnectivetissuediseaseareotherimportantcauses.

Symptomsaccompanyingthefever,ifpresent,helpinthediagnosis.Insuchcases,the
feverwouldhavesettledwithinafewdays.
PROLONGEDFEVER
Formostpatientswithafeverlastingoneortwoweeks,theunderlyingcauseis
soondiscoveredorthepatientrecoversspontaneously.Inthelattercase,aprotractedviral
illnessisusuallypresumedtobethesourceoffever.
Inasmallgroupofpatients,physicalexaminationandthebasictestsdonotrevealthe
causeoftheprotractedfever.Suchapatientisconsideredtohaveafeverofunknown
origin(PUO)iftherehasbeenadailyelevationinoraltemperatureto38Corhigherfor
threeweekswithoutanidentifiedcause.Fromstudiesutilisingthisdefinition,thevarious
causesandincidenceoflongstandingfeverscanbeassessed.TheseareshowninTable1.

Table1.
CausesofFeverofunknownOrigin
Infection (40%) Endocarditis; Abscesses; Zoonoses (Q fever, brucella, leptospira);
EpsteinBarrvirus,cytomegalovirus;
Neoplasia(20%);Hodgkinsdisease;Otherlymphomas;Hypernephroma;Leukemiaand
Hepatoma
Immunemediated(20%)Systemiclupuserythromatosus;Polymyalgiarheumatica;
Polyarteritisnodosa;StillsdiseaseandIdiopathicvasculitis
Miscellaneous(20%)Nodiagnosis;Drugfever(gold,phenytoin,penicillin)and
Granulomatousdisease(sarcoid,Crohns)
Source:WhitbyM.Thefebrilepatient.AustFamPhysician1993Oct;22:10:17531761
Thefollowingconditionsareparticularlyimportantcausesoffeveringeneralpractice,
eitherbecausetheyarerelativelycommon,orbecausetheyareeasilytreatedorbecause
theyhaveparticularlyunfortunateconsequencesifthediagnosisismissedordelayed.In
alltheseconditionstheessentialstepinthediagnosisistohavethoughtofthepossibility.

INFECTIONS
Meningitis. This has to be considered in acute fevers if there is neck stiffness,
photophobicorvomiting.Lumbarpunctureisnecessaryforconfirmation.Theprognosis
ismadeworseifbacterialmeningitisisnotpromptlydiagnosed.
Urinarytractinfection.Atanyagethisisacommonandeasilymissedcauseoffever.

Perhapsitisparticularlyinyoungchildrenthatthisconditioncommonlypresentsasa
PUO,oftenwithvomitingandirritability,butwithoutanyobviousurinarysymptoms.
The microscopicexaminationof theurineisanessentialdiagnosticprocedureinthe
investigationofaPUOandtheearlieritisdonethebetter.Thepresenceofpuscellsina
freshspunspecimenestablishesthediagnosiswhichcanbeconfirmedbyculture.Its
diagnosisisoftenmademoredifficultbyantibiotictherapygivenintheabsenceofa
diagnosis.
Hiddenpus.ThisisoftenacauseofPUO.Thethreemostlikelysitesareunderthe
diaphragm,inthepelvis,orroundthekidney.
Subacutebacterialendocarditis.ThisisanothercauseofPUO.Itmaynotbeacommon
diseasebutmustbethoughtof.Increasinglyittendstooccurinanolderagegroup,to
attackvalvesdamagedbyarterioscleroticdegenerationaswellasrheumaticfever,andto
beacomplicationofabdominalorpelvicsurgeryorinstrumentationoftheurinarytract,
aswellasdentalwork.
Septicaemia.Thisisapossibilitythatshouldalwaysbeinthedoctor'smind;ifitis
suspected,abloodcultureisobligatory.
Pneumonia.Segmentalpneumoniacancausefeverwithfewsymptomsorcleardiagnostic
signs.Intheelderly,particularlywhentheyareillandarelyinginbed,pneumoniamay
behardtodiagnoseandthephysicalsignsinthechestdifficulttointerpret.
Entericfever(typhoidandparatyphoid).
Intheearlystagesofthedisease,thereisfeverwithoutlocalisingsignsorsymptoms.
Thediagnosisisbestmadeonabloodculture.
Gallbladderinfection.Cholecystitis,empyemaofthegallbladderandascending
cholangitiscanpresentasfeverwithoutanyconvincinglocalsymptomsorsigns.The
patientmaybeveryill.Bloodculturesmaybepositive.
Diverticulitis.Thisiscommonintheelderlyandmaycausefeverwithoutanyclear
localizingsigns.Abscesses,eitherparacolicorpelvic,mayoccur.
Infectiousdiseasesassociatedwithtravel.Theeaseofmoderntravelhasmade
certaindiseasesarealdiagnosticpossibilityinanycaseofPUO.Specificenquirymustbe
madeaboutrecenttravelandtonamethecountriestravelledto.Onehastobeawareof
conditionsendemictospecificcountries.
Malaria.Themostdangerousconditiontoleaveuntreatedinatravellerismalariaand
everydoctorshouldbepreparedtotakeathickbloodfilmforexaminationbythe
laboratoryinpatientspresentingwithhighfeverinwhichmalariaisapossibility.Enteric
feversandhepatitishavealsotobeconsidered.

Viraldiseases.Thereisagroupofviraldiseases,ordiseasesofpossibleviraletiology
whichmaypresentasanobscurefever.
Infectivehepatitis.Thiscanpresentwithafeverwhichmaylastforfourorfivedays
before jaundice becomes clinically evident. Anorexia and nausea are likely to be
prominent symptoms. Enlargement of the liver may be noticed before the jaundice
appears.Urobilinogenintheurineprecedestheappearanceofjaundiceandofbileinthe
urine.
Infectiousmononucleosis(glandularfever).Thiscanpresentwithprolongedfever.

Noninfectiousdiseases
Feverdoesnot,ofcourse,alwaysmeaninfectionandtherearesomerelatively
commoncausesoffeverfromnoninfectiousdiseasesthatshouldbeinthedoctor'smind.
Asageneralprinciple,thelongerthefeverpersists,thelesslikelyadiagnosisofinfection
becomes.Themorecommoncausesofsuchfeverare:
Malignant disease, including leukaemia and Hodgkin's disease. These can present as
feverofunknownoriginforseveralweeks.
Autoimmunedisorders.Autoimmunedisorderssuchassystemiclupuserythematosus,
arerarebutpossiblecausesofprolongedfever.Rheumatoidarthritiscausesfeverbutthe
localjointsignsarelikelytomakethediagnosisclear.

MiscellaneousCauses
Dehydration.Dehydrationcancausefever.Itisparticularlyimportanttothinkofthis
possibilityintheelderlyandintheinfant.
Drugs.Drugsmustalwaysbesuspectedasapossiblecauseoffever.Evendrugstakenfor
longperiodswithoutanyilleffectcanstillcausefeverunexpectedly,e.g.,sulphonamides.
Selfprescribeddrugsaswellasthosegivenbydoctorsmaybethecause
offever.Carefulenquirymustbemadeaboutallformsofmedication.
Venousthrombosis.Venousthrombosismaycausefeverwithoutanydramaticlocal
symptoms.Examinationofthecalvesshouldbearoutineinthephysicalexaminationof
patientswithfever,butitshouldberememberedthatthrombosismayaffectveinsnot
accessibletoexternalphysicalexamination.
WORKUP
The acutely febrile patient presents a common but demanding problem in
differential diagnosis. In most cases, a careful history and physical examination will
revealthediagnosticclues,sothatlaboratorystudiescanbeusedselectively.

Theevaluationofpersistentfevercanbemoredemanding.Theinitialofficeevaluation
shouldhelpdeterminetheproperpaceofdiagnostictestingandtheneedfortherapeutic
intervention.Ifthepatientisacompromisedhost,orifheisacutelyillandtoxic,several
immediate diagnostic studies are needed such as blood counts and blood cultures to
confirmaninfectivecauseandtreatmentmayevenberequiredsuchasantibioticsgiven
empiricallybeforealltheresultsareavailable.Hospitalisationisusuallynecessaryin
suchcases.
Ifthepatientisnottoxicandclinicallystable,theworkupcanbelessrushed.The
diagnosticuseoftimeisanessentialproblemsolvingmethodforthegeneralpractitioner.
Certainsafeguards,however,arerequired.
The patient must understand that the doctor needs to know if the illness
changes in a significant way or if his general condition deteriorates
unexpectedly.Patientsdosometimesconcludethatbecausenotreatmenthas
been given the doctor considers the illness insignificant. Developments of
importance either for diagnosis or management may then not be
communicatedtothedoctor.Thepatientshouldunderstandwhatishappening,
whenthedoctorisgoingtoseehimagain,andunderwhatcircumstanceshe
shouldseekadvicebeforethattime.
Thedoctormustbeavailablesothatitispossibleforhispatienttofindhimin
caseofunexpectedorworryingdevelopments,or,ifthisisimpossible,the
patientmusthaveclearinstructionsaboutwhomtocontact.
Inthemodernorganizationofgeneralpracticeitoftenhappensthatthepatient
who calls unexpectedly has to be seen by another doctor. This makes it
important that the clinical record should make clear the diagnostic and
managementplansoftheoriginaldoctorsothatanyotherpersonwhohasto
takeoverresponsibilityforthepatientcanunderstandthem,andintegratehis
ownactionsinlinewiththem.Forinstance,ifthepresenceoffeveranda
heartmurmurinanelderlypatientmakestheoriginaldoctorthinkthathe
shouldexcludethepossibilityofbacterialendocarditis,thisshouldbeclearly
statedinthenotes.Ifnot,aseconddoctorcalledinunexpectedlyisquitelikely
toprescribeanantibioticwithoutperhapsconsideringthatabloodculture
mightberequired.

History

Durationandprogressionoffever,accompanyingsymptoms,chillsandrigorsif
any,recenttravel,similarcasesathome,drugstakensofar,andthenumberofother
doctorsconsultedshouldbeasked.

PhysicalExamination

Wherethesiteofinfectionisobviouse.g.,aURTIorUTI,aselectiveexamination
maysuffice.
Fortherest,amoreextensiveexaminationofthechest,abdomen,CNSandneck
stiffnesswillbeneedednotinginparticular,ifanyskinrashispresent.

INVESTIGATIONS
Ifthehistoryandphysicalexaminationprovidestrongindicationsofaninfectious
process, laboratory studies can be used selectively to confirm or refute the clinical
diagnosis.
Initial investigations may not be necessary if the cause is obvious e.g., a URTI.
However,ifpneumoniaisapossibilitythenachestXrayandcompletebloodcount
wouldbenecessary.
UrineFEME,bloodfilmformalariaparasitemaybeindicatedbasedonthehistory.
Inotherpatients,moreextensivetestsareneededtoestablishthediagnosiswhenthe
causeoffeverremainsunknown.Althoughsuchstudiesmustbeindividualised,the
approachtodiagnosiswouldincludethefollowing:
completebloodcount,differentialtotalwhiteandsedimentationrate.
urinalysis.Isolatedhematuriamaybeacluetounderlyingglomerulardisease
orurinarytractmalignancy.
chestXraymaydetectinfiltrates,effusionsormassesevenintheabsenceof
abnormalitiesonphysicalexamination;aKUBanduprightabdominalfilms
candiscloseairfluidlevelsinthebowel;ultrasoundorCATstudymaybe
neededifthereisasuspicionofamasslesion,suchasanabscessoratumour.
bloodchemistry:liverfunctiontestsareusefulinhelpingtodefineobscure
sourcesoffever.Forexample,transaminaseelevationsuggestshepatitis,and
isolatedrisesinalkalinephosphatasepointtoinfiltrationoftheliver.
bloodcultures:ifthepatienthasaheartmurmuroraprostheticheartvalveor
appearsseriouslyill.
serological tests: Widal and Weil Felix tests may help to confirm typhoid
fever.
MANAGEMENT
InitialRoutineManagement
symptomaticreliefoffever.
antibioticsifbacterialinfectionisthoughtlikely.
adviceonfluidintake.
advisefurtheractiontoreportbackiffeverdoesnotsettleinadayortwoor
therearenewdevelopmentse.g.,rash,patientbecomesmoreill.
illpatientsarereferredforadmission.
PreventionofComplications
Thecomplicationsoffeverlikelytobeseeningeneralpracticearedehydration
andfebrileconvulsionsinchildhood,andconfusionalstatesintheelderly.Oldpeople
alsobecomeeasilydehydratedwhenfebrileandill.
Dehydrationinchildrenoccursmorequicklythaninadultsandchildrenmayfail
todrinkwhenill.Theirparentsneedclearinstructionsaboutmaintaininganadequate

fluidintake.
In the elderly, fever, dehydration and confusion are interrelated problems.
Confusionresultsinfailuretodrinkanddehydrationincreasestheconfusion.Itisjustnot
enoughtoleaveajugofwaterbesidethebed.Atleast11/2litresofurineshouldbe
passeddailyandthisrequiresafluidintakeof2to3litres.Ifdoubtexistsaregular
routinefluidintakeshouldbeorganisedandtheintakerecorded.
Febrileconvulsionsdeserveaspecialword.Theyoccurchieflybetweentheages
of1and3years.Thereisoftenafamilyhistory.Themostimportantprincipleinthe
managementoffebrileconvulsionsiscontrolofthetemperature.Theparentsmustbe
taughttodothiswithconfidence.
For the patient having the first febrile fit, admission for observation and
investigationwillbeneeded.Inapatientwithaknownhistoryoffebrilefits,asingle
febrileconvulsionisnotareasonforadmissiontohospitalbut,ifthefitscontinueor
recur,orifthereisanyclinicalsuspicionofmeningitis,thechildmustbeinhospital,
sincealumbarpunctureistheonlycertainwaytoexcludemeningitis.
SubsequentManagement
Theinitialwaitandseediagnosticperiodwherethepresumptivediagnosisisa
viralinfectioncommonlylastsfromtwotofivedays.Duringthattimeitisusefultohave
inmindtheexpectedtimesfortheappearanceoftherashesofspecificfevers.
Chickenpoxappearsonthefirstday,rubellaonthesecondorthird,andmeasles
onthefourth.Ifbytheendofthefifthdaynorashhasappeared,measlescanusuallybe
excluded.Mostviralillnesseswillhaveruntheircoursebythattime.
Beyondthisperiod,bothdoctorsandpatientsbegintofeelthatsomethingmore
mustbedone.Itisoftennotuntilthenthatthedoctorfeelsobligedtotreatthesituation
moreseriouslyandthediagnosticlabeltendstochangefromapresumedviralillnessto
pyrexiaofuncertainorigin.Thisisnotinfactacommonsituationingeneralpracticebut
itisaworryingoneforthegeneralpractitioner,andanimportantoneforthepatient.
INDICATIONSFORREFERRAL
Theillpatient.
Clinicallydiagnosedseriousconditions:meningitis,pneumonia,cholecystitis,to
nameafew.
Thepatientwhosefeverpersistsbeyondaweekandthecauseisstilluncertain.
References
1.WhitbyM.Thefebrilepatient.AustFamPhysician1993Oct;22:10:17531761.
2. Simon HB. Evaluation of fever. in: Goroll et al. Primary Care Medicine. 3rd ed.
Philadelphia:Lippincott;1995;4853.