PEMBAHASAN SEMINAR BATCH IV SEPT-NOV 2013

Part I

ILMU PENYAKIT DALAM

1. Pharmacology
Antacids may affect a number of drugs by altering rates of dissolution & absorption, bioavailability, & renal elimination. The dissolution of erythromycin was found to be markedly retarded in the presence of all the antacids studied except sodium hydrogen carbonate. Al3+ & Mg2+ antacids have propensity to chelate other drugs in the GI tract forming insoluble complexes that pass through the GI tract without absorption. Most interactions can be avoided by taking antacids 2 hours before or after ingestion of other drugs.

2. Diabetes

16. Antidiabetic Drugs

3. Hypertension

1. 2.

ACE-I (kaptopril, lisinopril): Bradikinin & substansi P batuk ARB (valsartan, losartan): Tidak menyebabkan batuk

4. Heartburn
Effect of caffeine on GI tract:
Coffee promotes gastro-oesophageal reflux. Coffee stimulates gastrin release and gastric acid secretion. Coffee also prolongs the adaptive relaxation of the proximal stomach, suggesting that it might slow gastric emptying. However, other studies indicate that coffee does not affect gastric emptying or small bowel transit. Coffee induces cholecystokinin release and gallbladder contraction. Coffee increases rectosigmoid motor activity.

Although often mentioned as a cause of dyspeptic symptoms, no association between coffee and dyspepsia is found.
Boekema PJ, Samsom M, van Berge Henegouwen GP, Smout AJ. Coffee and gastrointestinal function: facts and fiction. A review. Scand J Gastroenterol Suppl. 1999;230:35-9.

5. Anaphylactic Shock

World Allergy Organization anaphylaxis guidelines: Summary

5. Anaphylactic Shock

World Allergy Organization anaphylaxis guidelines: Summary

6. Hipersensitivitas

7. Asthma: therapy
Asthma management has six interrelated parts:
1. Education 2. Assess & monitor severity 3. Avoid exposure to risk factors 4. individual medication plans 5. plans for managing exacerbations 6. regular followup

GINA 2005

7. Asthma: therapy

7. Asthma: therapy
Jika steroid jangka panjang terpaksa diberikan pada asma persisten sedang-berat karena tidak mampu, maka pertimbangkan:
Gunakan prednison, prednisolon, atau metilprednisolon karena efek mineralokortikoid minimal, waktu paruh pendek, & efek striae pada otot minimal Bentuk oral, bukan parenteral Penggunaan selang sehari atau 1x/hari pagi hari

8. Dyslipidemia
Estimation of LDL using Friedewald formula:
LDL = Total cholesterol HDL TG/5 TG/5 is a representative of VLDL This equation cant be used if the TG is >400 mg/dL.

LDL = 500 30 (350/5)

= 400 mg/dL

9. Hiperkortisolisme

10. Hipertensi dengan Bradikardia

11. E.S. OAT Mayor

MAYOR Gatal & kemerahan Tuli Ikterus Kemungkinan Penyebab Semua jenis OAT Streptomisin Sebagian besar OAT HENTIKAN OBAT Antihistamin & evaluasi ketat Stop streptomisin Stop streptomisin Hentikan semua OAT s.d. ikterik menghilang, hepatoprotektor Hentikan semua OAT & uji fungsi hati Stop etambutol Stop rifampisin

Vertigo & nistagmus (n.VIII) Streptomisin

Muntah & confusion Gangguan penglihatan Kelainan sistemik, syok & purpura

Sebagian besar OAT Etambutol Rifampisin

11. E.S. OAT Minor

Minor Kemungkinan Penyebab Tata Laksana

Tidak nafsu makan, mual, sakit perut

Nyeri sendi Kesemutan s.d. rasa terbakar di kaki Urine kemerahan

Rifampisin
Pyrazinamid INH Rifampisin

OAT diminum malam sebelum tidur

Aspirin/allopurinol Vit B6 1 x 100 mg/hari Beri penjelasan

12. Hiperkortisolisme

Elektrolit: hipokalemia, hipernatremia

13. Tiroid
In the presence of corticosteroids, which lower TBG levels, the total thyroid hormone (bound + free) in the blood will be low. Noted that free thyroid hormon is normal because of decrease TSH:
Low TBG increase free thyroid hormone decrease TSH normal free thyroid hormone.

B & D are correct.

14. Arrhytmia

SVT: young

AF: Elderly History of hypertension

15. Arrhytmia
Second degree AV block 3:1

16. Pharmacology
Rifampin potently induces CYP1A2, 2C9, 2C19, and 3A4 decreased half-life for a number of compounds, including:
HIV protease and non-nucleoside reverse transcriptase inhibitors, digitoxin, digoxin, quinidine, ketoconazole, propranolol, metoprolol, verapamil, clofibrate, methadone, corticosteroids, oral contraceptives oral anticoagulants, theophylline, barbiturates, fluconazole, sulfonylureas
Goodman & Gillman Pharmacology.

17. TB Paru Pada Gagal Ginjal

Jangan menggunakan streptomisin, kanamisin, & kapreomisin. Sebaiknya hindari penggunaan etambutol karena waktu paruhnya memanjang & terjadi akumulasi etambutol. Sedapat mungkin dosis disesuaikan dengan faal ginjal (CCT, ureum, kreatinin). Rujuk ke ahli paru.

18. Organophosphate Intoxication

Organophosphorus pesticides inhibit esterase enzymes, especially acetylcholinesterase in synapses and on red-cell membranes.

Acetylcholinesterase inhibition accumulation of acetylcholine & overstimulation of acetylcholine receptors in synapses of the autonomic nervous system, CNS, and neuromuscular junctions DUMBELS.
DUMBELS: diarrhea, urination, miosis, bradycardia/bronchorea/bronchospasm, emesis, lacrimation, salivation.
Review article: Allergic rhinitis management pocket reference 2008. Journal compilation 2008 Blackwell Munksgaard. Allergy 2008: 63: 990996.

18. Organophosphate Intoxication

19. Penyakit Paru

20. Suara Napas Tambahan

Ronki:
Suara berisik & terputus akibat airan udara yang melewati cairan. Ronki halus disebabkan oleh terbukanya saluran napas secara mendadak yang tadinya tertutup. Ronki kasar disebabkan oleh aliran udara yang melewati cairan.

Pneumonia:
Congestion: vascular engorgement, intra-alveolar fluid with few neutrophils, and often the presence of numerous bacteria. Hepatization: massive confluent exudation with neutrophils, red cells, and fibrin filling the alveolar spaces . Resolution: the consolidated exudate within the alveolar spaces undergoes progressive enzymatic digestion.

21. Regulasi Cairan Tubuh

Regulasi osmolaritas cairan ekstrasel diatur dengan vasopresin (ADH).

22. Beta Blocker

Nonselective beta blockers (such as propranolol) block all types of beta receptors throughout the body and are therefore more likely to cause side effects. At low doses, cardioselective beta blockers (such as atenolol and metoprolol) selectively block the beta receptors found in the heart and are less likely to cause side effects. However, at the high doses often needed to control angina, these medications lose their selectivity and may also block other types of beta receptors throughout the body, producing more side effects.

Some beta blockers (such as acebutolol and pindolol) are less likely to depress cardiac function or cause a slow resting heart rate and may be a better choice for people who have specific cardiac conditions or are more sensitive to the effects of beta blockers.
Some beta blockers (such as labetalol or carvedilol) also block alpha receptors, which are another type of receptor found in the blood vessels. These medications have the added benefit of dilating blood vessels.

23. E.S. OAT Mayor

MAYOR Gatal & kemerahan Tuli Ikterus Kemungkinan Penyebab Semua jenis OAT Streptomisin Sebagian besar OAT HENTIKAN OBAT Antihistamin & evaluasi ketat Stop streptomisin Stop streptomisin Hentikan semua OAT s.d. ikterik menghilang, hepatoprotektor Hentikan semua OAT & uji fungsi hati Stop etambutol Stop rifampisin

Vertigo & nistagmus (n.VIII) Streptomisin

Muntah & confusion Gangguan penglihatan Kelainan sistemik, syok & purpura

Sebagian besar OAT Etambutol Rifampisin

24. Hemolytic Anemia

Clinical & Lab signs are associated with:
Heme catabolism
Bilirubinemia icterus Dark/red urine (intravascular hemolysis)

Increased of erythropoiesis
Reticulocytosis (polychromation) Chronic severe bone marrow expansion cortical bone thinning Extramedullar hematopoiesis hepatosplenomegaly

Blood smear: normocytic normochrome or macrocytic because of reticulocytosis. If increased of erythropoiesis is not balanced by adequate Fe intake def Fe state microcytic hypochrome anemia
Clinical laboratory medicine

25.Intoksikasi Logam Berat

Symptoms related to mercury toxicity are typically neurologic, such as the following:
Visual disturbance - Eg, scotomata, visual field constriction Ataxia Paresthesias (early signs) Hearing loss Dysarthria Mental deterioration Muscle tremor Movement disorders Paralysis and death - With severe exposure

26. Pneumoniae in the Immunocompromised Host

Pulmonary infiltrate, with/without signs of infection (e.g., fever) one of the most common & serious complications in patients whose immune defenses are suppressed by:
disease, immunosuppressive therapy for organ transplants, chemotherapy for tumors, or irradiation.
Robbins & Cotran pathologic basis of diseases

26. Pneumoniae in the Immunocompromised Host

CMV infection:
Prominent intranuclear basophilic inclusions spanning half the nuclear diameter are usually set off from the nuclear membrane by a clear halo. In the lungs, the alveolar macrophages. epithelial and endothelial cells are affected; Affected cells are strikingly enlarged, often to a diameter of 40 m, and they show cellular & nuclear pleomorphism.

Robbins & Cotran pathologic basis of diseases

26. Pneumoniae in the Immunocompromised Host

Pneumocystis jiroveci/carini:
dyspnea, fever, nonproductive cough. tachypnea, tachycardia, and cyanosis, but lung auscultation reveals few abnormalities. CXR: bilateral diffuse infiltrates beginning in the perihilar regions. definitive diagnosis is made by histopathologic staining methenamine silver selectively stain the wall of Pneumocystis cysts.
Robbins & Cotran pathologic basis of diseases. Harrisons principles of internal medicine.

27. Pneumonia

27. Pneumonia
Faktor modifikasi pada terapi pneumonia: Pneumokokus resisten terhadap penisilin
Umur lebih dari 65 tahun Memakai obat-obat golongan P laktam selama tiga bulan terakhir Pecandu alkohol Penyakit gangguan kekebalan Penyakit penyerta yang multipel Penghuni rumah jompo Mempunyai penyakit dasar kelainan jantung paru Mempunyai kelainan penyakit yang multipel Riwayat pengobatan antibiotik Bronkiektasis Pengobatan kortikosteroid > 10 mg/hari Pengobatan antibiotik spektrum luas > 7 hari pada bulan terakhir Gizi kurang

Bakteri enterik Gram negatif

Pseudomonas aeruginosa

28. Anticoagulant Therapy

28. Anticoagulant Therapy

ISI: international sensitivity index

1 is the best

MNPT: mean normal PT laboratory

29. Rheumatoid Arthritis

29. Rheumatoid Arthritis

NSAIDs:
Are important for symptomatic relief but play only a minor role, if any, in altering the underlying disease process. Aspirin is the oldest drug of the non-steroidal class, but because of its high rate of GI toxicity, a narrow window between toxic and anti-inflammatory serum levels, and the inconvenience of multiple daily doses, aspirins use as the initial choice of drug therapy has largely been replaced by other NSAIDs

Glucocorticoid:
The paradigm ("bridge therapy") is to shut off inflammation rapidly with glucocorticoids, and then to taper these as the slower-acting DMARD begin to work.

30. ECG
Normal ventricular depolarization:
the QRS complex is narrow and the electrical axis lies between 0 and 90. All of this changes with bundle branch block.

Bundle branch block:

Changes of width and configuration of the QRS complexes.

30. ECG
Criteria for Right Bundle Branch Block
QRS complex greater than 0.12 s. RSR' in V1 & V2 (rabbit ears) with ST segment depression & T wave inversion Reciprocal changes in V5, V6, I, and AVL.

30. ECG
Criteria for Left Bundle Branch Block
QRS complex widened to greater than 0.12 seconds Broad or notched R wave with prolonged upstroke in leads V5, V6, I, and AVL, with ST segment depression and T wave inversion Reciprocal changes in V1 and V2 Left axis deviation may be present.

31. DM Complications
Diabetic neuropathy is distal symmetric polyneuropathy.
It most frequently presents with distal sensory loss, but up to 50% of patients do not have symptoms of neuropathy. Hyperesthesia, paresthesia, and dysesthesia also may occur. Symptoms may include a sensation of numbness, tingling, sharpness, or burning that begins in the feet and spreads proximally. Physical examination reveals sensory loss, loss of ankle reflexes, and abnormal position sense.

Peripheral artery disease:

The most common symptom is intermittent claudication, which is defined as a pain, ache, cramp, numbness, or a sense of fatigue in the muscles; it occurs during exercise and is relieved by rest.
Harrisons principles of internal medicine. 18th ed. McGraw-Hill; 2011.

32. Cardiomegaly
Left Atrium
The two popular radiologic signs of left atrial enlargementa double contour within the right cardiac border and elevation of the left main bronchusare accurate when present, but they are insensitive and seen in only about half the cases of mitral valve disease. when the right atrium also enlarges a continuous curve on the posterior cardiac border with the enlarged left atrium the double contour is not seen with mild left atrial enlargement or in severe cases of mitral valve disease.

32. Cardiomegaly
Left ventricle The shape of the dilated left ventricle depends to a large extent on the underlying cause.
When it is due to insufficiency of the aortic or mitral valve, the ventricle elongates and its apex is displaced downward, to the left, and posteriorly. When the dilation is due to coronary artery disease or primary myocardial disease, the ventricle tends to assume a more globular shape.

32. Cardiomegaly
Right Atrium
Dilation of the right atrium causes an accentuation and outward bowing of the curvature on the lower half of the right cardiac contour in the frontal view.

Right ventricle:
Even moderate right ventricular enlargement may produce no abnormality in this view other than some prominence of the main pulmonary artery. As right ventricular size increases, the transverse diameter of the heart enlarges to the left, and the cardiac apex becomes blunted and elevated. Enlargement of either or both ventricles displaces the apex of the heart to the left. It is not often possible to distinguish between biventricular enlargement and dilation of one or the other ventricle.

34. Nefropati Diabetik

Perkeni 2011.

34. Nefropati Diabetik

Tatalaksana:
Kendalikan glukosa darah Kendalikan tekanan darah Diet protein 0,8 gram/kgBB per hari. Jika terjadi penurunan fungsi ginjal yang bertambah berat, diet protein diberikan 0,6 0,8 gram/kg BB per hari. Terapi dengan obat penyekat reseptor angiotensin II, penghambat ACE, atau kombinasi keduanya Jika terdapat kontraindikasi terhadap penyekat ACE atau reseptor angiotensin, dapat diberikan antagonis kalsium non dihidropiridin. Apabila serum kreatinin >2,0 mg/dL sebaiknya ahli nefrologi ikut dilibatkan Idealnya bila klirens kreatinin <15 mL/menit sudah merupakan indikasi terapi pengganti (dialisis, transplantasi).

34. Nefropati Diabetik

Insulin pda DM tipe 2 diperlukan pada keadaan:
Penurunan berat badan yang cepat Hiperglikemia berat yang disertai ketosis Ketoasidosis diabetik Hiperglikemia hiperosmolar non ketotik Hiperglikemia dengan asidosis laktat Gagal dengan kombinasi OHO dosis optimal Stres berat (infeksi sistemik, operasi besar, IMA, stroke) Kehamilan dengan DM/diabetes melitus gestasional yang tidak terkendali dengan perencanaan makan Gangguan fungsi ginjal atau hati yang berat Kontraindikasi dan atau alergi terhadap OHO

35. Chronic Kidney Disease

Chronic kidney disease (CKD) encompasses a spectrum of different pathophysiologic processes associated with abnormal kidney function and a progressive decline in GFR. Etiology: DM, hypertension, glomerulonephritis, druginduced, myeloma.
Signs & Symptoms of Uremia General Neurologic Nausea, anorexia, malaise, fetor uremicus, pruritus Encephalopathy, seizures, neuropathy

Cardiovascular
Hematologic Metabolic

Pericarditis, accelerated atherosclerosis

Anemia due to erythropoietin deficiency, bleeding (due to platelet dysfunction) Hyperkalemia, hyperphosphatemia, hypocalcemia

35. Chronic Kidney Disease

Pathophysiology of disease.

36. Hipovitaminosis

37. Calorie Calculator

Kalori dari telur goreng: 90 kkal. Bersepeda 5 menit: 25 kkal. Bersepeda 10 menit: 50 kkal. Berlari kencang 5 menit: 50 kkal. Berlari kencang 10 menit sekitar 90 kkal. Berjalan 20 menit: 48 kkal.

38. DM Complications

39. Necrosis
Coagulative necrosis
a form of necrosis in which the architecture of dead tissues is preserved for a span of at least some days. The injury denatures not only structural proteins but also enzymes and so blocks the proteolysis of the dead cells. Ischemia caused by obstruction in a vessel may lead to coagulative necrosis of the supplied tissue in all organs except the brain

Robbins & Cotran Pathologic basis of disease. 2010.

39. Necrosis
Gangrenous necrosis
Not a specific pattern of cell death, but commonly used in clinical practice.
It is usually applied to a limb that has lost its blood supply & has undergone necrosis (typically coagulative necrosis). When bacterial infection is superimposed there is more liquefactive necrosis because of the actions of degradative enzymes in the bacteria & the attracted leukocytes (wet gangrene).
Robbins & Cotran Pathologic basis of disease. 2010.

39. Necrosis
Liquefactive necrosis
characterized by digestion of the dead cells, resulting in transformation of the tissue into a liquid viscous mass. It is seen in focal bacterial or, occasionally, fungal infections, because microbes stimulate the accumulation of leukocytes and the liberation of enzymes from these cells. The necrotic material is frequently creamy yellow because of the presence of dead leukocytes (pus)
Robbins & Cotran Pathologic basis of disease. 2010.

39. Necrosis
Caseous necrosis
encountered most often in foci of tuberculous infection. The term caseous (cheeselike) is derived from the friable white appearance of the area of necrosis the necrotic area appears as a collection of fragmented or lysed cells and amorphous granular debris enclosed within a distinctive inflammatory border (granuloma).
Robbins & Cotran Pathologic basis of disease. 2010.

39. Necrosis
Fat necrosis
focal areas of fat destruction, typically resulting from release of activated pancreatic lipases into the substance of the pancreas and the peritoneal cavity. In this disorder pancreatic enzymes leak out of acinar cells & liquefy the membranes of fat cells in the peritoneum. The released lipases split the triglyceride esters contained within fat cells. The fatty acids combine with calcium to produce grossly visible chalky-white areas (fat saponification).

Robbins & Cotran Pathologic basis of disease. 2010.

39. Necrosis
Fibrinoid necrosis
a special form of necrosis usually seen in immune reactions involving blood vessels. This pattern of necrosis typically occurs when complexes of antigens and antibodies are deposited in the walls of arteries. Deposits of these immune complexes, together with fibrin that has leaked out of vessels, result in a bright pink and amorphous appearance in H&E stains, called fibrinoid (fibrin-like) by pathologists.

Robbins & Cotran Pathologic basis of disease. 2010.

40. Cyanide Intoxication

Source:
the vasodilator drug nitroprusside, natural sources are found in cassava.

Mechanism of toxicity:
Cyanide binds to cellular cytochrome oxidase blocking the aerobic utilization of oxygen metabolic acidosis.

Symptoms
headache, nausea, dyspnea, & confusion. Syncope, seizures, coma, agonal respirations, & cardiovascular collapse ensue rapidly after heavy exposure.
Poisoning & drug overdose by the faculty, staff and associates of the California Poison Control System third edition

40. Cyanide Intoxication

Treatment: A. Emergency and supportive measures. Treat all cyanide exposures as potentially lethal. 1. Maintain an open airway and assist ventilation if necessary. 2. Treat coma, hypotension, & seizures if they occur. 3. Start an IV line and monitor the patients vital signs and ECG B. Specific drugs and antidotes 1. The cyanide antidote package consists of amyl & sodium nitrites, which produce cyanide-scavenging methemoglobinemia, & sodium thiosulfate, which accelerates the conversion of cyanide to thiocyanate. C. Prehospital. Immediately administer activated charcoal if available. Do not induce vomiting unless victim is more than 20 minutes from a medical facility and charcoal is not available.

41. Leukemia
CLL CML ALL AML

The bone marrow makes abnormal leukocyte dont die when they should crowd out normal leukocytes, erythrocytes, & platelets. This makes it hard for normal blood cells to do their work.
Prevalence Over 55 y.o. Mainly adults Common in children Adults & children

Symptoms & Grow slowly may asymptomatic, Signs the disease is found during a routine test.

Grow quickly feel sick & go to their doctor.

Fever, swollen lymph nodes, frequent infection, weak, bleeding/bruising easily, hepatomegaly/splenomegaly, weight loss, bone pain. Lab Mature lymphocyte, smudge cells Mature granulocyte, dominant myelocyte & segment Lymphoblas Myeloblast t >20% >20%, aeur rod may (+) Treated right away

Therapy

Can be delayed if asymptomatic

CDC.gov

41. Leukemia
Clinical Manifestation More common in AML
Leukostasis (when blas count >50.000/uL): occluded microcirculation headache, blurred vision, TIA, CVA, dyspnea, hypoxia DIC (promyelocitic subtype) Leukemic infiltration of skin, gingiva (monocytic subtype) Chloroma: extramedullary tumor, virtually any location.

More common in ALL

Bone pain, lymphadenopathy, hepatosplenomegaly (also seen in monocytic AML) CNS involvement: cranial neuropathies, nausea, vomiting, headache, anterior mediastinal mass (T-cell ALL) Tumor lysis syndrome

Pocket medicine.

42. Regulasi Cairan Tubuh

Regulasi osmolaritas cairan ekstrasel diatur dengan vasopresin (ADH). Olahraga berkeringat (cairan hipotonik) volume menurun & osmolaritas meningkat minum air volume meningkat & osmolaritas menurun.

43. NSAID

43. NSAID
PPI is chosen for prophylaxis because it produces maximal acid supression, better than H2 receptor inhibitor. Misoprostol has more side effects when acid supression dosage is used.

44. Clostridium Botulinum

Infeksi C. botulinum biasanya disebabkan oleh makanan yang terkontaminasi:
Daging yang tidak digoreng Ikan yang tidak matang Sayuran kaleng yang terbuka.

Infeksi juga dapat masuk melalui luka yang terkontaminasi.

44. Clostridium Botulinum

Botulinum toksin dari saluran cerna atau luka darah ujung saraf kolinergik di perifer, antara lain, ujung saraf postganglion parasimpatik, ganglia perifer, & terutama di neuromuscular junction. Toksin memecah protein yang berperan pada proses fusi vesikel-berisi asetilkolin ke membran presinaps asetilkolin tidak dapat disekresi paralisis flaksid (lumpuh layu).

45. Kolesistektomi
The consequence of removal of the gallbladder relates to the inability to form concentrated bile & to secrete it in a coordinated fashion when the meal enters the duodenum. Thus, patients who have undergone a cholecystectomy may find that they are less able to tolerate large fatty meals.

46. Leukemia
CLL CML ALL AML

The bone marrow makes abnormal leukocyte dont die when they should crowd out normal leukocytes, erythrocytes, & platelets. This makes it hard for normal blood cells to do their work.
Prevalence Over 55 y.o. Mainly adults Common in children Adults & children

Symptoms & Grow slowly may asymptomatic, Signs the disease is found during a routine test.

Grow quickly feel sick & go to their doctor.

Fever, swollen lymph nodes, frequent infection, weak, bleeding/bruising easily, hepatomegaly/splenomegaly, weight loss, bone pain. Lab Mature lymphocyte, smudge cells Mature granulocyte, dominant myelocyte & segment Lymphobla st >20% Myeloblast >20%, aeur rod may (+)

Therapy

Can be delayed if asymptomatic

CDC.gov

Treated right away

47. Hipertiroidisme

48. Pneumoconiosis
International Labour Organization (ILO) defines pneumoconiosis as "the accumulation of dust in the lungs and the tissue reactions to its presence." The main reaction to mineral dust in the lungs is fibrosis.

48. Pneumoconiosis
Coal workers' pneumoconiosis is a distinct pathologic entity resulting from the deposition of coal dust in the lungs. The tissue reactions to deposits of dust include the coal macule and the coal nodule and progressive massive fibrosis (PMF). CXR:
Macule: opacities < 1,5 mm Nodule: small rounded opacities PMF: parenchymal opacities >1 cm

49. Leukemia Granulositik Kronik

The marrow aspirate and biopsy are essential to the diagnosis of the myeloproliferative disorders.
The marrow aspirate provides information as to individual cell morphology and the distribution of cell types. It also provides essential information in diagnosis and management of patients with CML as they become increasingly dysplastic and evolve to acute leukemia. Chromosomal studies of peripheral blood and marrow are important, primarily to distinguish CML from the other myeloproliferative disorders

50. Asma

51. Asthma

51. Asthma
Posisi duduk agar mengurangi volume darah di vascular bed paru paru lebih terisi udara
Moderate Episode Severe Episode

52. Arthritis
Gout:
transient attacks of acute arthritis initiated by crystallization of urates within & about joints, leading eventually to chronic gouty arthritis & the appearance of tophi. Tophi: large aggregates of urate crystals & the surrounding inflammatory reaction.
Harrisons principles of internal medicine. 18th ed. McGraw-Hill; 2011. Robbins pathologic basis of disease. 2007.

52. Arthritis
The management of acute gout is to provide rapid & safe pain relief.
NSAID, Colchicine. Corticosteroid if NSAID is contraindicated.

Preventing further attacks by uric acid lowering agent:

Allopurinol Probenecid

Uric acid lowering agent shouldnt be given on acute attack, unless the patient has consumed it since 2 weeks before.

Current diagnosis & treatment in rheumatology. 2nd ed. McGraw-Hill; 2007.

52. Arthritis
NSAID:
Indomethacin is historically the NSAID of choice for acute gout, but other NSAIDs may be just as effective.

Colchicine:
is effective but less well tolerated than NSAIDs. Gastrointestinal side effects include gas, nausea, vomiting, diarrhea, and severe cramping abdominal pain.

53. Polyuria
If polyuria is shown to be dilute, pathophysiologic mechanisms include:
1. Hypothalamic or central diabetes insipidus with inability to synthesize and secrete vasopressin; 2. Nephrogenic diabetes insipidus with an inadequate renal response to vasopressin;

3. Transient diabetes insipidus of pregnancy produced by accelerated metabolism of vasopressin;

4. Primary polydipsia (psychogenic), in which the initiating event is ingestion of excess fluid and the subsequent hypotonic polyuria is an appropriate physiologic response.

53. Polyuria
During the dehydration or water deprivation test: primary polydipsia: concentrate his urine without becoming hyperosmolar diabetes insipidus: become hyperosmolar without concentrating the urine. After the patient is given desmopressin: Hypothalamic DI has minimal concentration of the urine & an additional in urine osmolality of at least 50%. partial hypothalamic DI concentrate their urine minimally with dehydration, but the maximum urinary concentration is not achieved, and there is an additional boost with administered desmopressin Nephrogenic DI do not concentrate their urine & no further increase in urine osmolality after the administration of desmopressin.

Harrisons principles of internal medicine. 18th ed. Greenspans clinical endocrinology.

ILMU BEDAH, ANESTESIOLOGI & RADIOLOGI

54. Forehand Fracture

Montegia Fracture Dislocation
It is a fracture of the proximal 1/3rd of the Ulna with dislocation of head of radius anteriorly. Posteriorly or laterally Head of Radius dislocates same direction as fracture It requires ORIF or it will redisplace

Lateral displacement

Galleazzi Fracture
It is a fracture of distal Radius and dislocation of inferior Radio- Ulnar joint Like Monteggia fracture if treated conservatively it will redisplace This fracture appeared in acceptable position after reduction and POP

Greenstick Fractures

Colles Fracture
Most common fracture in Osteoporotic bones Extra-Articular : 1 inch of distal Radius Results from a fall on dorsi flexed wrist Typical deformity : Dinner Fork Deformity is : Impaction, dorsal displacement and angulation, radial displacement and angulation and avulsion of ulnar styloid process

Colles Fracture

optimized by optima

# distal 1 Impaction ,Dorsal displacement and dorsal tilt

Smith Fracture
Almost the opposite of Colles fracture Much less common compared to colles Results from a fall on palmer flexed wrist Typical deformity : Garden Spade Management is conservative : MUA and Above Elbow POP

Smith Fracture

55. Femur Fractures

Common injury due to major violent trauma 1 femur fracture/ 10,000 people More common in people < 25 yo or >65 yo Femur fracture leads to reduced activity for 107 days, the average length of hospital stay is 25 days Motor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are most frequent causes

Symptoms in children
child has severe pain The thigh is noticeably swollen or deformed Expanding thigh hematoma unable to stand or walk, and/or There is a limited range of motion of the hip or knee allowed by the child because of pain Symptoms in children may be obscured related to fracture patterns (e.g. greenstick fractures)

56. Hernia
HERNIA HIATALHERNIA DIAFRAGMATIKA

/VENTRAL HERNIA

Additional: Spigellian hernia: very rare, a hernia through the spigelian fascia and in most cases, it has a small size Ventral hernia: hernia in the abdominal wall, for example: incisional, umbilical and paraumbilical hernia

Types of Hernia Reponible Irreponible Incarserated

Definition The sac can be inserted into the peritoneal cavity either manually or spontaneously The sac cannot be reinserted into the peritoneal cavity Passage obstruction of the small intestine in the hernia sac

Strangulated

Passage obstruction and vascular obstruction of the hernia sac

Indirect follows the tract through the inguinal canal Results from a persistent process vaginalis The processus vaginalis outpouching of peritoneum attached to the testicle that trails behind as it descends retroperitoneally into the scrotum.

Directusually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle

http://emedicine.medscape.com/article/

57. Phimosis
Phimosis Inability to retract the distal foreskin over the glans penis Physiologic in newborn Complications
Balanitis Postitis Balanopostitis

Paraphimosis Entrapment of a retracted foreskin behind the coronal sulcus Emergency

Superficial vein obstruction edema and pain penile glands necrosis

Treatment
Dexamethasone 0.1% (6 weeks) for spontaneous retraction

Treatment
Manual reposition Dorsum incision

http://radiologymasterclass.co.uk/tutorials/musculoskeletal/trauma/trauma_x-ray_page8.html

58. Complications of Fracture Healing

Delayed Union
Poor blood supply or infection.

Non-Union
Bone loss or wound contamination.

Malunion
Bone healed in a nonanatomic position Can be angulated, rotated, or shortened
Affect function? Likely to affect function? Consequences with or without treatment

Fibrous Union
Improper immobilization

Avascular necrosis (AVN)

the death of bone cells through lack of blood supply its internal blood supply is compromised

59. Avascular Necrosis

Definition
Loss of blood flow to the bone leading to death of the cellular components of bone.

Femoral head most common by far Shoulder humeral head Odontoid (Neck) Scaphoid (Wrist) Lunate (Wrist) Talus (Ankle)

Etiologies
Trauma Alcohol Steroids Diving (Caissons Disease) Sickle Cell Idiopathic (up to 30% of cases) Risk Factor Alcoholism Pancreatitis Diabetes Gout Elderly

60. Acute Achilles Tendon Rupture

Adults 40-50 y.o. primarily affected (M>F) Athletic activities, usually with sudden starting or stopping Snap in heel with pain, which may subside quickly

Diagnosis
Weakness in plantarflexion Gap in tendon Palpable swelling Positive Thompson test

Imaging of Achilles tendon

Ultrasound
Inexpensive, fast, reproducable, dynamic examination possible Operator dependent Best to measure thickness and gap Good screening test for complete rupture

Imaging
MRI
Expensive, not dynamic Better at detecting partial ruptures and staging degenerative changes, (monitor healing)

61&62. Gallbladder Disorder

Mosby's Medical Dictionary, 8th edition. 2009, Elsevier.

Gallbladder stone
Clinical symptoms Acute: fever,right upper quadrant(RUQ) pain,murphys sign +, may be icteric Chronic:no fever,recurrent RUQ pain,no icteric,USG:may be calculus/not,cyst wall thickening Recurrent RUQ pain,recurrent dyspepsia,no fever,no icteric,pain after fatty meal,Ro:radioopaque RUQ Symptoms depend on stone location, only use this terms if the stone location is not established Colicky pain(biliary colic),icteric,may be with cholangitis signs(charcoats triads) Pain on right lower quadrant,migratory pain,nausea,vomiting,specific signs(rovcing,McBurney,etc)

Term Cholecystitis

Definition Inflammation of the gallbladder

Cholecystolitiasis

the presence of gallstones in the gallbladder. The presence or formation of gallstones in the gallbladder or bile ducts the presence of gallstones in the common bile duct Inflammation of the vermiform appendix.

Cholelitihiasis

Choledocholithiasis

Appendicitis

62. Cholelitiasis laboratorium Findings

No sign of obstruction
Normal Liver function test, Bilirubin,Urobilinogen

Sign of obstructionCholedocholithiasis
Increase LFT Increase Bilirubin Increase alkaline phosphatase

63. Sertoli Cell Only-syndrome

Sertoli cells respond FSH Epidemiology:
men between age 20-40 years

Sign&Symptoms:
infertility without sexual abnormality normal- or small-sized testes Azoospermic

Diagnosis
Testicular biopsy absence of spermatozoa and only Sertoli cells line the seminiferous tubules

http://emedicine.medscape.com/article/437884-overview#a0104

Pathophysiology
testosterone and LH levels are normal, but due to lack of inhibin, FSH levels are increased

64. Apendicitis TB
Tuberculosis of the appendix presenting with the signs and symptoms of acute appendicitis it is not possible to make the correct diagnosis because the clinical picture is that of acute appendicitis, the diagnosis of appendicular tuberculosis is usually made on histopathological examination of the appendectomy specimen

 the presence of caseating granulomas, epitheloid cells and Langhans giant cells, characteristic of tuberculous inflammation. important because of the risk of post-operative fistula On diagnosis, these patients must be started on anti-tubercular treatment

65. Tamponade Jantung

 Tamponade suspected
Echocardiography Pericardiocentesis
done immediately for diagnosis and treatmenta brief delay might be life threatening.

Needle pericardiocentesis is often best when the etiology is known or the presence of tamponade is in question

http://en.wikipedia.org/wiki/Burn

66. Burn Injury

prick test (+)

 Berat luka bakar: Ringan: derajat 1 luas < 15% a/ derajat II < 2% Sedang: derajat II 1015% a/ derajat III 510% Berat: derajat II > 20% atau derajat III > 10% atau mengenai wajah, tangan-kaki, kelamin, persendian, pernapasan

To estimate scattered burns: patient's palm surface = 1% total body surface area

Total Body Surface Area

Parkland formula = baxter formula

http://www.traumaburn.org/referring/fluid.shtml

67. Le Fort Fracture

68. Prostatic malignancy

PSAProstate Cancer
PSA >4.0 ng/mL mandatory biopsy 50% of all the cancers detected because of an elevated PSA level are localized these patients are candidates for potentially curative therapy

Manifestations of Metastatic Prostate Cancer

Anemia Dispnoe Bone marrow suppression Weight loss Pathologic fractures Spinal cord compression
LMN Paralisis Paresthesia Sensory deficit

Hematuria Ureteral and/or bladder outlet obstruction Urinary retention Chronic renal failure Urinary incontinence Symptoms related to bony or soft-tissue metastases

Pain

69. Management of Trauma Patient

70. Syok Anafilaktik

www.resus.org.uk/pages/reaction.pdf 2012.

71. Abdominal Injuries

abdominal injuries can be either open or closed open injuries are caused by sharp or high velocity objects that create an opening between the peritoneal cavity and the outside of the body closed injuries are caused by compression trauma associated with deceleration forces and include: contusions ruptures lacerations shear injuries

Hollow and Solid Organs

The type of injury will depend on whether the organ injured is solid or hollow. hollow organs include: stomach intestines gallbladder bladder

solid organs include: liver spleen kidneys

Abdominal Injuries
Hollow Organ Injuries when hollow organs rupture, their highly irritating and infectious contents spill into the peritoneal cavity, producing a painful inflammatory reaction called peritonitis Solid Organ Injuries damage to solid organs such as the liver can cause severe internal bleeding blood in the peritoneal cavity causes peritonitis when patients injure solid organs, the symptoms of shock may overshadow those from peritonitis

Blunt Abdominal Trauma

Signs of intraperitoneal injury
Abdominal tenderness, peritoneal irritation Distention pneumoperitoneum, gastric dilation, or ileus Ecchymosis of flanks (grayturner sign) or umbilicus (cullen's sign) retroperitoneal hemorrhage Abdominal contusions seat belts sign Bowel sounds suggests intraperitoneal injuries DRE: blood or subcutaneous emphysema
http://regionstraumapro.com/post/663723636

 Dullness in Traube's space

Kehr's sign

above the left midaxillary costal margin suggests an enlarged spleen, and can occur on inspiration the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated Kehr's sign in the left shoulder is considered a classical symptom of a ruptured spleen

Cullens sign: purple-blue discoloration around umbilicus (peritoneal hemorrhage)

Grey Turners sign:flank discoloration (retroperitoneal hemorrhage)

http://www.sharinginhealth.ca/clinical_assessment/abdominal_exam.html

 Upper left quadrant Rich blood supply Slightly protected by organs surrounding it and by lower rib cage Most commonly injured organ from blunt trauma Associated intraabdominal injuries common Suspect splenic injury in: Motor vehicle crashes Falls or sports injuries involving was an impact to the lower left chest, flank, or Management : upper left abdomen Kehrs sign Resuscitation. Left upper quadrant pain radiates to left Laparotomy (repair, shoulder partial excision or Common complaint with splenic injury splenectomy)

Spleen

Observation in hospital for patients with subcapsular haematoma

Stomach/duodenum
Not commonly injured by blunt trauma Protected location in abdomen Penetrating trauma may cause gastric transection or laceration
Signs of peritonitis from leakage of gastric contents

Perforation Presentation :
abdominal pain rigidity peritonism, shock Air under diaphragm on Xray

Diagnosis confirmed during surgery

Unless nasogastric drainage returns blood

Treatment
Antibiotics resuscitate repair

72. Cara Kerja Lidokain

http://emedicine.medscape.com/article/2047916

73. Chest Trauma

Disorders Etiology Clinical

Hemothorax

lacerated blood vessel in thorax

Anxiety/Restlessness,Tachypnea,Signs of Shock,Tachycardia Frothy, Bloody Sputum Diminished Breath Sounds on Affected Side,Flat Neck Veins, Dullness to percussion Opening in lung tissue that leaks air into chest cavity, Chest Pain,Dyspnea,Tachypnea Decreased Breath Sounds on Affected Side,hipersonor Opening in chest cavity that allows air to enter pleural cavity, Dyspnea,Sudden sharp pain,Subcutaneous Emphysema Decreased lung sounds on affected side Red Bubbles on Exhalation from wound (Sucking chest wound)

Simple/Closed Pneumothorax

Blunt trauma spontaneous

Open Pneumothorx

Penetrating chest wound

Disorders Tension Penumothorax

Etiology

Clinical Anxiety/Restlessness, Severe ,Poor Color Dyspnea,Tachypnea,Tachycardia Absent Breath sounds on affected side, Accessory Muscle Use, JV Distention Narrowing Pulse Pressures,Hypotension Tracheal Deviation, hypersonor

Flail Chest

Trauma

a segment of the rib cage breaks becomes detached from the rest of the chest wall, 3 ribs broken in 2 or more places,painful when breathing,Paradoxical breathing Dyspnea, cough, chest pain, which results from pleural irritation, Dullness to percussion, decreased tactile fremitus, and asymmetrical chest expansion, with diminished or delayed expansion on the side of the effusion, decreased tactile fremitus, and asymmetrical chest expansion, diminished or delayed expansion on the side of the effusion Fever,dysnea,cough,rales in ausultation

Pleural Efusion

congestive heart failure, pneumonia, malignancy, or pulmonary embolism infection

Pneumonia

Infection, inflammation

Pemeriksaan Penunjang
Trauma dada dapat ditentukan dengan pemeriksaan X-Ray dada, untuk menentukan jenis trauma yang timbul

74. Forehand Fracture

Montegia Fracture Dislocation
It is a fracture of the proximal 1/3rd of the Ulna with dislocation of head of radius anteriorly. Posteriorly or laterally Head of Radius dislocates same direction as fracture It requires ORIF or it will redisplace

Lateral displacement

Galleazzi Fracture
It is a fracture of distal Radius and dislocation of inferior Radio- Ulnar joint Like Monteggia fracture if treated conservatively it will redisplace This fracture appeared in acceptable position after reduction and POP

75. Treatment of Poison ingestion

Gastric lavage
Flexible tube is inserted through the nose into the stomach Stomach contents are then suctioned via the tube A solution of saline is injected into the tube Recommended for up to 2 hrs in trichloro acetate & up to 4hrs in Salicylate OD

Activated charcoal
In conscious patients Adsorbs toxic substances or irritants, thus inhibiting GI absorption Addition of sorbitol laxative effect Oral: 25-100 g as a single dose repetitive doses useful to enhance the elimination of certain drugs (eg, theophylline, phenobarbital, carbamazepine, aspirin, sustainedrelease products) not effective for cyanide, mineral acids, caustic alkalis, organic solvents, iron, ethanol, methanol poisoning, lithium

Induced Vomiting
Ipecac - Not routinely recommended Risk of aspiration

Renal elimination

Medication to stimulate urination or defecation may be given to try to flush the excess drug out of the body faster.

Hemodialysis or haemoperfusion:

Forced alkaline diuresis

Infusion of large amount of NS+NAHCO3 Used to eliminate acidic drug that mainly excreted by the kidney eg salicylates Serious fluid and electrolytes disturbance may occur Need expert monitoring

Reserved for severe poisoning Drug should be dialyzable i.e. protein bound with low volume of distribution may also be used temporarily or as long term if the kidneys are damaged due to the overdose.

76. Hemorrhoid

External Hemorrhoids Outside anal canal, around sphincter Symptoms due to thrombosis

Internal Hemorrhoids Inside anal canal Symtomps due to bleeding and/or irritation of mucosa

Can not be inserted to anal canal

Can be inserted to anal canal up to grade III

 Internal Hemorrhoids Internal hemorrhoidal plexus

V. Rectus Inferior V. Rectus Media

External Hemorrhoids external hemrroidal plexus

V. Rectus Inferior

Histological Feature
Hemorrhoids vascular structures in the anal canal Histological Feature
simple columnar epithelium and stratified squamous epithelium with distention of veins in the lamina propria and submucosa of the anal canal

77. Bladder Stone

Bladder calculi are usually associated with urinary stasis Urinary infections increase the risk of stone formation Foreign bodies (e.g. suture material) can also act as a nidus for stone formation They can however form in a normal bladder There is no recognized association with ureteric calculi
Bladder calculi can be asymptomatic Common symptoms include
Suprapubic pain Dysuria Haematuria

Abdominal examination may be normal can be identified on

Plain abdominal x-ray Bladder ultrasound CT scan Cystoscopy

Uric acid stones are radiolucent but may have an opaque calcified layer

78. Hirschsprungs disease

Clinical symptoms
The disease can considered to be incomplete intestinal obstruction The lenght of the aganglionic segment is variable The symptoms are variable too The symptoms appears in different ages

Symptoms in newborn age

Fail to pass meconium (in 24 hours of life) Abdominal distension, but the abdomen is palpable Vomiting The rectal tube cant be put easily After irrigation the signs and symptoms return again in a few days

Symptoms in newborn age(enterocolitis)

Life-threatening condition Diarrhea: it can be an early sign Toxic megacolon Abdominal distension Bile-stained vomiting Fiver and signs of dehydration Rectal tube:explosive expulsion of gas and foulsmelling stools

Symptoms in infants
Constipation Meteorism Palpable faecaloma Sometimes putrescent diarrhea Ulceration, bleeding Hypoproteinaemia, anaemia Electrolyt disorders

Symptoms in childhood Gracile limbs Dilated drumlike belly Long history of constipation Defecation in 7-10 days Multiple fecal masses The stimulus of defecation is missing Rectum is empty and narrow

 Darm kontur: visible shape of intestines on the abdomen Darm Steifung: visible peristaltic movement on the abdomen
Rontgen : Plain abdominal radiography
Dilated bowel Air-fluid levels. Empty rectum

Contrast enema
Transition zone Abnormal, irregular contractions of aganglionic segment Delayed evacuation of barium

Biopsy :
absence of ganglion cells hypertrophy and hyperplasia of nerve fibers,

79. Humerus Fractures

Proximal Humerus Fractures Clinical Evaluation
Patients typically present with arm held close to chest by contralateral hand. Pain and crepitus detected on palpation Careful NV exam is essential, particularly with regards to the axillary nerve. Test sensation over the deltoid. Deltoid atony does not necessarily confirm an axillary nerve injury

Humeral Shaft Fractures

Clinical evaluation
Thorough history and physical Patients typically present with pain, swelling, and deformity of the upper arm Careful NV exam important as the radial nerve is in close proximity to the humerus and can be injured

Humeral Shaft Fractures

Holstein-Lewis Fractures
Distal 1/3 fractures May entrap or lacerate radial nerve as the fracture passes through the intermuscular septum

80. Urine Incontinence

81. Testicular torsion

Signs and symptoms of testicular torsion include: Sudden or severe pain in the scrotum the loose bag of skin under your penis that contains the testicles Swelling of the scrotum Abdominal pain Nausea and vomiting A testicle that's positioned higher than normal or at an unusual angle

Treatment
Manual detorsion
If it is successful (ie, confirmed by color Doppler sonogram in a patient with complete resolution of symptomsdefinitive surgical fixation of the testes before leaving the hospital

Surgical detorsion definitive treatment Orchiectomyif the testis is necrotic

82. Pathophysiology of Foot Ulceration

Neuropathic

Ischemic Neuro -ischemic

83. Clavus
A clavus is a thickening of the skin due to intermittent pressure and frictional forces. These forces result in hyperkeratosis Conditions associated with clavus formation Advanced patient age Amputation (ie, stump callosities)] Doxorubicin toxicity[20] Keratoderma palmaris et plantaris Obesity Minor trauma

 Relief of symptoms may be achieved by thinning and cushioning of the involved lesion Surgical Care Surgical options should be used when conservative measures fail. Chronic foot pain despite conservative therapy is the number one indication for surgery.

Epidermal Cyst
A raised nodule on the skin of the face or neck May be noted intraorally on occasion Histologic
Lined by keratinizing epithelium the resembles the epithelium of the skin The lumen is usually filled with keratin scales

Treatment
Surgical excision

Dermoid Cyst and Benign Cystic Teratoma

A developmental cyst often present at birth or noted in young children Histologic

It is usually found on the floor of the mouth when it is located in the oral cavity. May have a doughy consistency when palpated Lined by orthokeratinized, stratified squamous epithelium surrounded by a connective tissue wall The lumen is usually filled with keratin Hair follicles, sebaceous glands, and sweat glands may be seen in the cyst wall Benign cystic teratoma
Resembles a dermoid cyst

Treatment

Surgical excision

Diagnosis Lipoma Atherom cyst

Histologic Soft mass, pseudofluctuant with a slippery edge Occur when a pilosebaceous unit or a sebaceous gland becomes blocked. Skin Color is usually normal, and there is a punctum (comedo, blackhead) on the dome

84. Resusitasi Monitoring

Fluid resuscitation target:
Euvolemia Improve perfusion
Urine Output

Improve oxygen delivery

British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients 2011

85. Hernia Skrotalis

86. Head Injury

87. Trauma Olahraga

88.Undescended Testis

A, 5th week Testis begins its primary descent; kidney ascends. B, 8th-9th weeks. Kidney reaches adult position. C, 7th month, Testis at internal inguinal ring; gubernaculum (in inguinal fold) thickens and shortens. D, Postnatal life.

189

A, Ectopic testes. Perineal ectopia not shown.

B, Undescended testes. Percentages of testes arrested at different stages of normal descent

190

Management Hormone therapy Orchidopexy Orchidectomy Laparoscopic surgery

Surgery should be done by the age of 5 years but it is unnecessary to do this operation before completion of second birthday of the child

89. Acute Achilles Tendon Rupture

Adults 40-50 y.o. primarily affected (M>F) Athletic activities, usually with sudden starting or stopping Snap in heel with pain, which may subside quickly

Diagnosis
Weakness in plantarflexion Gap in tendon Palpable swelling Positive Thompson test

90. Basic Life Support

Indication for CPR
No response Not breathing No pulse

http://circ.ahajournals.org/content/11 2/24_suppl/IV-156/F2.expansion.html

91. Humeral Shaft Fractures

Holstein-Lewis Fractures
Distal 1/3 fractures May entrap or lacerate radial nerve as the fracture passes through the intermuscular septum

92. Obstruction
Accounts for 5% of all acute surgical admissions Patients are often extremely ill requiring prompt assessment, resuscitation and intensive monitoring Obstruction A mechanical blockage arising from a structural abnormality that presents a physical barrier to the progression of gut contents. Ileus is a paralytic or functional variety of obstruction

Obstruction is:

Partial or complete Simple or strangulated

Causes- Small Bowel

Luminal F. Body Bezoars Gall stone Food Particles
A. lumbricoides

Mural Neoplasims lipoma polyps leiyomayoma hematoma lymphoma carcimoid carinoma secondary Tumors Crohns TB Stricture Intussusception Congenital

Extraluminal Postoperative adhesions Congenital adhesions Hernia Volvulus

1. History
The Universal Features
Colicky abdominal pain, vomiting, constipation (absolute), abdominal distension. Complete HX ( PMH, PSH, ROS, Medication, FH, SH)

High
Pain is rapid

Distal small bowel

Colonic Preexisting change in

bowel habit Colicky in the lower abdomin Vomiting is late Distension prominent Cecum ? distended

Pain: central and colicky Vomitus is feculunt Vomiting copious and Distension is severe contains bile jejunal content Visible peristalsis May continue to pass Abdominal distension is flatus and feacus before limited or localized absolute constipation
Rapid dehydration

Persistent pain may be a sign of strangulation Relative and absolute constipation

2. Examination
General
Vital signs: P, BP, RR, T, Sat dehydration Anaemia, jaundice, LN Assessment of vomitus if possible Full lung and heart examination

Abdominal
Abdominal distension and its pattern Hernial orifices Visible peristalsis Cecal distension Tenderness, guarding and rebound Organomegaly Bowel sounds
High pitched (metallic sound) Absent

Others
Systemic examination If deemed necessary. CNS Vascular Gynaecological muscuoloskeltal

Rectal examination

Darm kontur: visible shape of intestines on the abdomen Darm Steifung: visible peristaltic movement on the abdomen

Radiological Evaluation
Normal Scout Always request: Supine, Erect and CXR Gas pattern:
1. 2. 3. 4. Gastric, Colonic and 1-2 small bowel Gastric 1-2 small bowel Caecal Hepatobiliary Free gas under diaphragm Rectum

Fluid Levels:

Check gasses in 4 areas:

Look for calcification Look for soft tissue masses, psoas shadow Look for fecal pattern

The Difference between small and large bowel obstruction

Large bowel Small Bowel

Peripheral ( diameter 8 cm max) Presence of haustration

Central ( diameter 5 cm max) Vulvulae coniventae Ileum: may appear tubeless

Radiology: Flat and upright (or decubitus) abdominal X-Ray A. Sensitivity: 60% (up to 90%) B. Typical findings of Bowel Obstruction
1. 2. 3. 4. Bowel distention proximal to obstruction Bowel collapsed distal to obstruction Upright or decubitus view: Air-fluid levels Supine view findings a. Sharply angulated distended bowel loops b. Step-ladder arrangement or parallel bowel loops

Initial Management in the ER

Resuscitate:
Air way (O2 60-100%) Insert 2 lines if necessary at IVF : Crytloids least 120 ml/h. (determined by estimated fluid loss and cardiac function). Add K+ at 1mmmol/kg

Draw blood for lab investigations Inform a senior member in the team. NPO. Decompress with Naso-gastric tube and secure in position Insert a urinary catheter (hourly urinary measurements) and start a fluid input / output chart Intravenous antibiotics (no clear evidence) If concerns exist about fluid overloading a central line should be inserted Follow-up lab results and correction of electrolyte imbalance The patient should be nursed in intermediate care Rectal tubes should only be used in Sigmoid volvulus.

Indications for Surgery

Immediate intervention: Evidence of strangulation (hernia.etc) Signs of peritonitis resulting from perforation or ischemia

93. Hemorrhaegic Shock

94. Osteoporosis
A systemic skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue lead to bone fragility and susceptibility to fracture

Prevalence of osteoporosis
Osteopenia
Female Age > 50 year 37-50%

Osteoporosis
13-18%

Male Age > 50 year

28-47%

3-6%

Incidence of osteoporotic Fx
Forearm Fracture

Vertebral Fracture

Hip Fracture

Osteoporosis Tipe 1 (POSTMENOPAUSAL)

affects primarily trabecular bone 5 years after menopause weight-bearing bones fractures vertebrae, ankle, and distal radius

optimized by optima

Osteoporosis

(A) Normal right hip with trabecular pattern well demonstrated. (B) (B) Osteoporotic right hip with poorly defined trabeculae (arrows)

http://www.msdlatinamerica.com/ebooks/Mu sculoskeletalImagingCompanion/sid250409.ht ml

95. Peritonitis
Peritonitis
an inflammation of the peritoneum, the thin membrane that lines the abdominal wall and covers the organs inside caused by a bacterial or fungal infection of this membrane

Types of peritonitis
Primary peritonitis
caused by the spread of an infection from the blood and lymph nodes to the peritoneumliver disease Fluid builds up in the abdomen, creating an environment for bacteria to grow rare less than 1% of all cases of peritonitis

Secondary peritonitis
More common Happens when the infection comes into the peritoneum from the gastrointestinal or biliary tract
http://www.umm.edu/altmed/articles/peritonitis-000127.htm#ixzz28YAqqYSG

 Secondary peritonitis
caused by other conditions that allow bacteria, enzymes, or bile into the peritoneum from a hole or tear in the gastrointestinal or biliary tracts. Such tears can be caused by
Pancreatitis a ruptured appendix stomach ulcer Crohn's disease Diverticulitis Typhoid complication

Signs & Symptoms

Swelling & tenderness in the abdomen Fever & Chills Loss of Appetite Nausea & Vomiting Increased breathing & Heart Rates Shallow Breaths Low BP Limited Urine Production Inability to pass gas or feces Exam : The usual sounds made by the active intestine and heard during examination with a stethoscope will be absent, because the intestine usually stops functioning. The abdomen may be rigid and boardlike Accumulations of fluid will be notable in primary due to ascites.

96. Triage
D. Triage Priorities 1. Red- highest priority patients need immediate care (usually circulatory or respiratory) 2. Yellow- second highest priority able to wait longer before transport (45 minutes) 3. Green- walking able to wait several hours for transport 4. Black- dead will die during emergency care (have lethal injuries)

*** mark triage priorities (tape, tag)

Triage Category: Red

Red (Highest) Priority: Patients who need immediate care and transport as soon as possible
Airway and breathing difficulties Uncontrolled or severe bleeding Decreased level of consciousness Severe medical problems Shock (hypoperfusion) Severe burns

Yellow
Yellow (Second) Priority: Patients whose treatment and transportation can be temporarily delayed Burns without airway problems Major or multiple bone or joint injuries Back injuries with or without spinal cord damage

Green
Minor fractures Minor soft-tissue injuries Green (Low) Priority: Patients whose treatment and transportation can be delayed until last

97. Choking

Child choking

Abdominal thrust = Heimlich manouvre

www.resus.org.uk/pages/pchkalgo.pdf

To estimate scattered burns: patient's palm surface = 1% total body surface area

98. Total Body Surface Area

Parkland formula = baxter formula

http://www.traumaburn.org/referring/fluid.shtml

99. Osteomyelitis
Inflammation of the bone and bone marrow caused by an infecting organism. Although bone is normally resistant to bacterial colonization, events such as trauma, surgery, presence of foreign bodies, or prostheses may disrupt bony integrity and lead to the onset of bone infection

Pathogenesis
Waldvogel, 1971

1. Hematogenous 2. Contiguous focus of infection 3. Direct inoculation

Symptoms
Osteomyelitis is often diagnosed clinically with nonspecific symptoms fever, chills, fatigue, lethargy, irritability. The classic signs of inflammation, including local pain, swelling, or redness, may also occur and normally disappear within 5-7 days
http://emedicine.medscape.com/article/1348767-overview#a0112

 S aureus is the most common pathogenic organism recovered from bone, followed by Pseudomonas and Enterobacteriaceae. Less-common organisms involved include anaerobe gram-negative bacilli. Intravenous drug users may acquire pseudomonal infections

 Acute hematogenous osteomyelitis has a predilection for the long bones of the body. The ends of the bone near the growth plate (the metaphysis) is made of a maze like bone called cancellous bone. It is here in the rapidly growing metaphysis that osteomyelitis often develops
http://www.hawaii.edu/medicine/pediatrics/pedtext/s19c04.html

100. Radiologic Findings Of OA

In knee (genu) x-ray Narrowing of joint space (due to loss of cartilage) Osteophytes Subchondral (paraarticular) sclerosis Bone cysts

101. BPH-associated Acute Urinary Retention

AUR:Acute urinary retention PUC:Perurethral catheter SPC:Suprapubic catheter TWOC:Trial without catheter -Blocker relaxing smooth muscle fibers located in the prostate and its capsule, bladder neck and prostatic urethra TWOC when a catheter is removed from the bladder for a trial period to determine whether the patient are able to pass urine spontaneously.
http://www.indianjurol.com/article.asp?issn =0970-1591;year=2007

Treatment Urinary Retention

PUC:Perurethral catheter

SPC:Suprapubic catheter

http://en.wikipedia.org/wiki/Urinary_retention

102. Volume Perdarahan Fraktur Femur

Femur bone anatomy
Near major blood vessel (femoral artery)

Femur Fracture blood loss up to 1,500 ml per femur

Fluid Resuscitation
Crystalloids
Are as effective as albumin in post-operative patients Are the initial resuscitation fluid of choice for: Hemorrhagic shock / traumatic injury Septic shock Hepatic resection Thermal injury Cardiac surgery Dialysis induced hypotension

Non-protein colloids
Should be used as second-line agents in patients who do not respond to crystalloid May be used in the presence of capillary leak with pulmonary or peripheral edema Are favored over albumin due to their lower cost

Resuscitation
Crystalloid solution rapidly equilibrates between the intravascular and interstitial compartments Adequate restoration of hemostatic stability may require large volumes of ringer's lactate. It has been empirically observed that approximately 300 cc of crystalloid is required to compensate for each 100 cc of blood loss. (3:1 rule)

 Fluid resuscitation target:

Euvolemia Improve perfusion Improve oxygen delivery

British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients 2011

http://emedicine.medscape.com/article/

http://en.wikipedia.org/wiki/

103. Male Genital Disorders

Disorders Testicular torsion Etiology Intra/extra-vaginal torsion Congenital anomaly, blood blockage in the spermatic cord Inflammation or injury Vein insufficiency persistent patency of the processus vaginalis Clinical Sudden onset of severe testicular pain followed by inguinal and/or scrotal swelling. Gastrointestinal upset with nausea and vomiting. accumulation of fluids around a testicle, swollen testicle,Transillumination +

Hidrocele

Varicocele Hernia skrotalis

Scrotal pain or heaviness, swelling. Varicocele is often described as feeling like a bag of worms Mass in scrotum when coughing or crying. Bowel sound on scrotum. Strangulated nausea, vomiting, fever, edematous, erythematous, discolored retention cyst of a tubule of the rete testis or the head of the epididymis distended with barely watery fluid that contains spermatozoa

Spermatokel

diverticulum from the tubules found in the head of the epididymis, possibly trauma

104. Muscle Atrophy

Weakening and shrinking of a muscle May be caused
Immobilization
Due to trauma Reluctant to move limbs because of pain Unable to move secondary to neurologic process

Loss of neural stimulation

Lower motor neuron paralysis

105. Orchitis
Orchitis is an inflammation of the testes. Etiology
Mumps

Testicular congestion Viral Parasitic Trauma

Signs & Symptoms

Pain Swollen

Treatment Rest - bed Elevate scrotum Ice pack Antibiotics Analgesics Anti-inflammatory

106. Orbital Wall Anatomy

The 4 Walls of orbit are:
Roof frontal bone Floor maxillary and zygomatic Lateral sphenoid and zygomatic Medial ethmoid, lacrimal, maxilla, and lesser wing of the sphenoid

 Left zygoma Maxillary process of zygomaone of the components of lateral orbital floor