DIFFERENTIAL DIAGNOSIS

DEMAM & SESAK

Disusun Oleh:
Rialta Hamda 130112120622

Preseptor:
Pandji Irani Fianza, dr., M.Sc., SpPD-KHOM

BAGIAN ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN UNIVERSITAS PADJADJARAN
RSUP DR. HASAN SADIKIN
BANDUNG
2013
 DEMAM

A. Definisi
1. Definisi demam: an elevation of body temperature that exceeds the normal daily
variation and occurs in conjunction with an increase in the hypothalamic set
point.
2. Definisi hyperthermia: an unchanged (normothermic) setting of the
thermoregulatory center in conjunction with an uncontrolled increase in body
temperature that exceeds the body’s ability to lose heat.

B. Demam kurang dari 7 hari

1. Demam kurang dari tujuh hari tanpa tanda local
Merupakan penyakit demam tanpa terlihat tanda yang jelas di salah satu sistem
tubuh. Penyebab terjadinya demam jenis ini adalah:
a. Infeksi virus dengue (demam dengue, demam berdarah dengue, sindrom syok
dengue)
Gejala Tanda
- Severe headache - Sudden onset of fever hingga
- Severe eye pain 410C, berakhir sekitar sampai
- Joint pain tujuh hari
- Muscle and/or bone pain - Rash
- Nausea and vomiting - Mild bleeding manifestation(e.g.,
nose or gum bleed, petechiae, or
easy bruising)
b. Malaria
Gejala Tanda
- Chills - Fever
- Joint pain
- Vomit
- Convulsion
- 3 stage of: cold, hot, and sweating
c. Demam pasca vaksinasi
Gejala Tanda
- Demam dengan riwayat vaksinasi - Bekas suntikan yang mungkin
- Artralgia diikuti oleh bengkak, abses
- Limfadenitis
- Reaksi alergi: urtikaria,
dermatitis, edema.
d. Sepsis
Gejala Tanda
- Riwayat penyakit terkait organ - Kesaran mungkin berkurang
penyebab sepsis - Tachycardia
- Mual dan muntah - Fever
- Diare - Pernapasan yang cepat
- Kencng berkurang
- Lemah badan
e. Demam yang berhubungan dengan HIV
Gejala Tanda
- Lemah badan - Fever
- Pegal otot - Berat badan menurun
- Nyeri sendi - Pembengkakan KGB
- Sakit tenggorokan - Ruam
- Sakit kepala - Tanda-tanda infeksi jamur
- Mual dan muntah - Herpres genital
- Diare
- Berkeringat malam hari
- Penurunan berat badan
- Kesemutan
- Haid tidak teratur
2. Demam kurang dari tujuh hari dengan tanda local.
Merupakan penyakit demam akut dengan fokus infeksi, yang dapat didiagnosis
setelah anamnesis dan pemeriksaan fisik
a. Infeksi pada saluran nafas bagian atas:
- VURTI (viral upper respiratory tract)
- Tonsilofaringitis
Gejala Tanda
- Nyeri tenggorokan - Granul pada faring
- Nyeri menelan - Kemerahan pada faring
- Sering berdeham - Kripta melebar pada tonsil
- Detritus pada tonsil
- Kemerahan pada tonsil
b. Sinusitis
Gejala Tanda
- Sering bersin, batuk, pilek - Fever
- Sering mampet - Allergic shiner
- Facial pain - Allergic salute
- Headache - Deni’s morgan lines (transverse
nasal crease)
- Hypertrophy conchae
c. OMA (otitis media akut)
Gejala Tanda
- Nyeri telinga - Fever
- Keluar cairan dari telinga - Tanda dari lima stadium OMA:
- Bindeng oklusi, hiperemis, suppurasi,
perforasi, resolusi.
d. Infeksi pada saluran nafas bagian bawah:
- Bronkhitis
Gejala Tanda
- Batuk berdahak - Fever
- Sesak napas - Bengkak di pergelangan kaki,
 - Sering menderita infeksi kaki, tungkai kaki kiri dan kanan.
pernapasan - Wajah, telapak tangan, atau
- Nafas berat mukosa yang tampak kemerahan.
- Mudah lelah
- Sakit kepala
- Gangguan penglihatan
- Pneumonia
Gejala Tanda
- Batuk berdahak - Fever
- Darah di dahak - Tachycardia
- Mudah lelah - Suara nafas yang kasar pada
- Keringat yang berlebihan auskultasi
- Nyeri otot
- Sesak napas
e. Infeksi saluran kemih
Gejala Tanda
- Nyeri saat kencing - Fever
- Sensasi terbakar saat kencing
- Frequent urge to urinate
- Passing only small amounts of
urine at a time despite the urge to
urinate
- Urine that is cloudy or bloody
with a strong, foul odor
- Chills
- Nausea and vomiting
- Have to urinate often, but not
much urine comes out.
f. Meningitis
Gejala Tanda
- Sakit kepala - Demam
 - Kaku kuduk
g. Gastroenteritis
Gejala Tanda
- Mual dan muntah - Fever
- Bloating - Efek dehidrasi: sunken eyes, dry
- Hilang nafsu makan mouth, tachycardia,
- Abdominal cramp
- Diarrhea
- Abdominal pain
- Bloody stools
- Terkadang pus di stool
- Lethargy and body aches

C. DEMAM LEBIH DARI 7 HARI

1. Infeksi
a. Demam tifoid

- Diare - Demam, step wise, puncak pada

- Konstipasi malan hari, turun di pagi hari.
- Abdominal pain - Rose spot sign.
- Mual muntah - Typhoid tongue.
- Nafsu makan menurun - Splenomegaly.
- Batuk kering - Bradycardia relative.
- Frontal headache
- Delirium, malaise.
b. Tuberkulosis (TB)
Gejala Tanda
Sistemik: - Fever
- Penurunan berat badan
- Keringat malam hari.
- Penurunan nafsu makan
 Pulmonik:
- Batuk lebih dari 2 minggu.
c. Leptospirosis
Gejala Tanda
- Calf pain - Non pruritic rash
- Headache - Jaundice
- Nausea
- Vomit
- Diare
- Batuk
- Nyeri tenggorokan
d. Hepatitis virus
Gejala Tanda
- Fase 1: asymptomatic - Fase 1: -
- Fase 2 (prodromal phase) – - Fase 2: urticarial, pruritus.
Patients experience anorexia, - Fase 3: icteric, hepatomegaly.
nausea, vomiting, alterations in - Fase 4: -
taste, arthralgias, malaise, fatigue,
and some develop an aversion to
cigarette smoke; when seen by a
health care provider during this
phase, patients are often
diagnosed as having
gastroenteritis or a viral syndrome
- Fase 3 (icteric phase) – Patients
may note dark urine, followed by
pale-colored stools; in addition to
the predominant gastrointestinal
(GI) symptoms and malaise,
patients may develop right upper
quadrant pain with.
 - Fase 4 (convalescent phase) –
symptoms and icterus resolve, and
liver enzymes return to normal.
2. Neoplasma
a. Limfoma Hodgkin
Gejala
- Asymptomatic lymphadenopathy
may be present (above the
diaphragm in 80% of patients)
- Constitutional symptoms (eg,
unexplained weight loss, fever,
night sweats) are present in 40%
of patients. Collectively, these are
known as "B symptoms."
- Intermittent fever is observed in
approximately 35% of cases;
infrequently, the classic Pel-
Ebstein fever is observed (high
fever for 1-2 wk followed by an
afebrile period of 1-2 wk)
- Chest pain, cough, shortness of
breath, or a combination of these
things may be present due to a
large mediastinal mass or lung
involvement; rarely, hemoptysis
occurs
- Patients may present with
pruritus
- Pain at sites of nodal disease,
precipitated by drinking alcohol,
occurs in less than 10% of
Tanda
- Palpable, painless
lymphadenopathy can be seen in
the cervical area (neck, 60-80%),
axilla (armpit, 6-20%), and, less
commonly, in the inguinal area
(groin, 6-20%); it is described as
rubbery adenopathy
- Involvement of the Waldeyer ring
(back of the throat, including the
tonsils) or occipital (lower rear of
the head) or epitrochlear (inside
the upper arm near the elbow)
areas is infrequently observed
- Splenomegaly and/or
hepatomegaly may be present
- Superior vena cava syndrome may
develop in patients with massive
mediastinal lymphadenopathy
- Central nervous system (CNS)
symptoms or signs may be due to
paraneoplastic syndromes,
including cerebellar degeneration,
neuropathy, Guillain-Barre
syndrome, or multifocal
leukoencephalopathy.
 patients but is specific for
Hodgkin lymphoma
- Back or bone pain may rarely
occur
b. Leukemia
Gejala
- In most patients, a diagnosis of
leukemia has been made before
presenting to an ophthalmologist.
However, in some patients,
ocular symptoms and
examination lead to a diagnosis
of leukemia.
- Most patients do not develop
symptoms as a result of
intraocular involvement.
Tanda
Posterior segment manifestations
 The posterior segment
manifestations are protean in
nature and may be secondary to
direct invasion of the leukemic
cells.
 They result from systemic
hematological abnormalities, such
as anemia, thrombocytopenia, and
hyperviscosity or opportunistic
infections secondary to the
immune dysfunction.
 Direct infiltration
o Retinal grayish white nodules
that may be surrounded by
hemorrhage manifest direct
infiltration.
o Perivascular sheathing may be
another manifestation of a
leukemic infiltrate.
o Roth spots, white-centered
retinal hemorrhages, may
represent a cluster of leukemic
cells. On the other hand, septic
emboli or platelet-fibrin

3. Penyakit jaringan ikat dan vascular
a. Demam Rematik Akut (DRA)
Gejala
 Diagnosis is challenging for
several reasons, as follows:
o Approximately 70% of older
children and young adults
recollect pharyngitis. However,
only approximately 20% of
young children recollect
pharyngitis. Therefore, younger
children who present with signs
or symptoms consistent with
acute rheumatic fever (ARF)
merit a higher index of
suspicion.
o The rate of isolation of group A
streptococci from the
oropharynx is extremely low in
all populations.
 Usually, a latent period of
approximately 18 days occurs
between the onset of streptococcal
pharyngitis and ARF. This latent
material gives a similar
funduscopic finding.
o Rarely, pale gray swelling of
the optic nerve head may
indicate optic nerve
infiltration.
Tanda
Physical findings can be
nonspecific and misleading;
therefore, a high index of suspicion is
required for diagnosis.
Suspicious signs for carditis
include new or changing valvular
murmurs, cardiomegaly, congestive
heart failure, and/or pericarditis.
Nearly 60% of patients with
carditis develop isolated mitral valve
involvement, followed in prevalence
by combined mitral and aortic valve
involvement.
When present, Sydenham chorea
is seldom evident at the time of
initial presentation.
Erythema marginatum and
subcutaneous nodules are rare (<
10% of patients).
Arthritis, which occurs in 80% of
patients, usually involves multiple
 period is rarely shorter than 1
week or longer than 5 weeks.
o Typically, the first
manifestation is a very painful
migratory polyarthritis. Often,
associated fever and
constitutional toxicity develop.
o Acute attacks usually resolve
within 12 weeks.
 Guidelines for diagnosis published
more than 50 years ago by T.
Duckett Jones[3] have been slightly
revised by the American Heart
Association (AHA).[4] Prior
history of a preceding group A
streptococcal infection is helpful
but not required. In addition, 2
major manifestations or 1 major
and 2 minor manifestations must
be present.
o Major manifestations include
carditis, polyarthritis, chorea,
erythema marginatum, and
subcutaneous nodules.
o Minor manifestations include
arthralgias and fever.
Laboratory findings include
elevated levels of acute-phase
reactants (erythrocyte
sedimentation rate [ESR] and
C-reactive protein) and a
large joints, particularly the knees,
ankles, elbows, and wrists.
 Hips and smaller joints of
hands and feet are less
commonly involved.
 Migratory polyarthritis is
usually associated with a
febrile illness. It involves a
series of painful joints,
followed by another series of
painful joints.
 This form of arthritis rarely
causes permanent joint
deformity.
Unusual presentations, such as
indolent carditis and isolated chorea,
may also occur. Even rarer
manifestations include epistaxis and
abdominal pain due to serositis.
 prolonged PR interval. A
prolonged PR interval is not
specific and has not been
associated with later cardiac
sequelae. The utility of
echocardiography is also
controversial.
 The Jones criteria[4] should be
viewed as a guide to determine
who is at high risk but cannot be
used to define diagnosis with
absolute certainty.
o An exception includes chorea,
which can present as the sole
manifestation of ARF, in spite
of negative laboratory results.
o Another possible exception is
indolent carditis.
 A throat culture with results
positive for Streptococcus is found
in approximately 25% of patients
at the time of presentation.
 SESAK (DYSPNEA)

A. Definisi: an abnormally uncomfortable awareness of breathing.

B. Differential diagnosis
1. Obstructive disease of airways
a. Asthma
Gejala Tanda
- Batuk - Wheezing
- Gejala alergi - Vocal fremitus menurun
- Sesak - Vocal resonance menurun
b. PPOK / COPD
Gejala Tanda
- Batuk - Pursed lip breathing
- Sesak - Wheezing
- Acute chest illness - Barrel chest
- Vocal fremitus menurun
- Vocal resonance menurun
- Hyperresonance on percussion
- Prolonged expiration
2. Acutre Respiratory Distress Syndrome (ADRS
3. Pneumotoraks
Gejala Tanda
Simple
- Sesak, tapi terkadang ada pasien - Hyperresonance
yang tidak begitu merasa sesak.
Tension
- Sesak - Deviasi trakea
- Chest pain - Hypotension
- Anxiety - Hyperresonance of thorax
- Ftigue - Jugular venous distention
- Acute epigastric pain (rare find) - Tachycardia

4. Pulmonary embolism
Gejala Tanda
- Seizure - Fever
- Syncope - Wheezing
- Abdominal pain - Decreasing level of consciousness
- Productive cough - Hemoptysis
- - Flank pain
- Delirium (in elder patient)
5. Hypoventilation Syndrome

6. Heart disease
a. Gagal jantung (heart failure)
Gejala Tanda
- Sesak - Hypertension
- Sleep disorder breathing - Dyslipidemia
- Exertional dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Chest pain
- Palpitasi
- Fatigue, weaknsess
- Nocturia, oliguria
b. Penyakit arteri coroner (coronary artery disease)
Gejala Tanda
- Chest pain - Hypertension
- Sesak - Dyslipidemia
c. Kardiomiopati
Gejala Tanda
- Sesak, Orthopnea - S1 normal. S2 normal,
- Syncope terkadang paradoxical split. S3
- Presyncope gallop. S4 frequently heard.
- Angina - Systolic ejection murmur.
- Palpitasi - Holosystolic murmur.
- PND (paroxysmal nocturnal
dyspnea)
- Dizziness
d. Disfungsi katup (ex: mitral valce prolapse)
Gejala Tanda
- Sesak - Arrythmia
- Fatigue
- Exercise intolerance
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Anxiety
- Panic attacks
- Palpitasi
e. Hipertrofi ventrikel kiri
Gejala Tanda
- Shortness of breath - Tachycardia
- Chest pain
- Palpitasi
- Dizziness or fainting