This action might not be possible to undo. Are you sure you want to continue?
UKDI BATCH 2 (MEI) 2013 dr. Himawan, dr. Yusuf, dr. Cemara, dr. Dini, dr. Ratna, dr. Valenchia, dr. Rini, dr. Fatia
Ilmu Penyakit Dalam
1. Iron Therapy
Common adverse effects of oral iron therapy include nausea, epigastric
discomfort, abdominal cramps, constipation, & diarrhea.
These effects are usually dose-related & can often be overcome by lowering
the daily dose of iron or by taking the tablets immediately after or with meals.
Some patients have less severe gastrointestinal adverse effects with one iron
salt than another and benefit from changing preparations.
Cereals, cheese, coffee, eggs, milk, tea, whole grain breads, yogurt may
impair oral iron absorption.
Katzung BG. Basic & clinical pharmacology. 10th ed. New York: McGraw Hill.
2. Urinary Tract Infection
2. Urinary Tract Infection .
splenomegaly. meningoencephalitis. axillary. self-limited lymphoproliferative disorder. some people develop hepatitis. (lymphomas & nasopharyngeal carcinoma). Infectious mononucleosis is characterized by: fever. generalized lymphadenopathy (principally in the posterior cervical.3. atypical activated T lymphocytes (mononucleosis cells). sore throat. Harrison‘s principles of internal medicine . a benign. Lymphadenopathy EBV causes infectious mononucleosis. pneumonitis. Enlarged lymph nodes are frequently tender and symmetric but are not fixed in place. and groin regions). and is associated with the development of a number of neoplasms.
Four clinical types of HTLV-I-induced neoplasia: Acute Adult T-cell Leukemia (ATL) Lymphomatous ATL Chronic ATL Smoldering ATL Harrison‘s principles of internal medicine . through sexual activity. Lymphadenopathy HTLV-I is the cause of at least two important diseases: Acute T-cell leukemia (ATL) tropical spastic paraparesis or HTLV-I-associated myelopathy (HAM). especially via breast milk. uveitis. more commonly from men to women.3. HTLV-I infection is transmitted in at least three ways: from mother to child. and Sjögren's syndrome. HTLV-I may also play a role in infective dermatitis. and through the blood. arthritis.
hypercalcemia. except that circulating abnormal cells are rare & lymphadenopathy is evident. Harrison‘s principles of internal medicine . and lymphocytosis. The clinical picture is dominated by rapidly progressive skin lesions. Lymphomatous ATL: similar to the acute form in its natural history & clinical course. Lymphadenopathy Acute ATL: short clinical prodrome (2 weeks between the first symptoms and the diagnosis) & an aggressive natural history.3. pulmonary involvement.
and hepatosplenomegaly do not develop. bone. the malignant cells have monoclonal proviral integration. Smoldering ATL In this form. Harrison‘s principles of internal medicine . <5% of peripheral blood cells exhibit typical morphologic abnormalities.3. hypercalcemia. or gastrointestinal tract. and skin lesions and pulmonary lesions may be present. Lymphadenopathy Chronic ATL generally have normal serum levels of calcium and lactate dehydrogenase and no involvement of the CNS. the CNS. adenopathy. the bones. and the gastrointestinal tract are not involved.
Lymphadenopathy HTLV epidemiology Harrison‘s principles of internal medicine .3.
4. Hemolytic Anemia Clinical & Lab signs are associated with: Heme catabolism Bilirubinemia icterus Dark/red urine (intravascular hemolysis) Erythropoiesis Reticulocytosis (polychromation) Chronic severe bone marrow expansion cortical bone thinning Extramedullar hematopoiesis hepatosplenomegaly Clinical laboratory medicine .
B12 Defisiensi Folat Defisiensi Folat & vit. B12 Obat-obatan & Toksin mengganggu sintesis DNA Metotreksat 6-merkaptopurin Siklofosfamid Trimetoprim Kontrasepsi oral Arsen Anemia pernisiosa Operasi gaster Overgrowth bakteri intestin Reseksi ileum Enteritis regional Kurang faktor instrinsik Defisiensi zat makanan Defisiensi zat makanan Kehamilan Bayi Anemia hemolitik kronik Alkoholisme Malabsorbsi folat kongenital Imbas obat Tropical sprue Gluten sensitiveenteropathy . Megaloblastic Macrocytic Anemia Defisiensi vit.5.
anemia pascaperdarahan Alkoholisme Anemia hemolitik Anemia pascaperdarahan Penyakit hepar Sindrom myelodisplasia Anemia aplastik Anemia sideroblastik didapat Hipotiroidisme Retikulositosis .5. Nonmegaloblastic Macrocytic Anemia Penyebab anemia makrositik nonmegaloblastik Eritropoiesis yang dipercepat: Anemia hemolitik.
Typhoid Fever .6.
ECG Abnormalities of the plasma level of K. & Mg affect the ECG. The only ECG book you‘ll ever need. Ca. though changes in the plasma sodium level do not. .7.
The only ECG book you‘ll ever need. . ECG Three changes in hypokalemia (occurring in no particular order): ST segment depression Flattening of the T wave Appearance of a U wave.7.
7. Classic sine wave pattern. The widened QRS complexes & peaked T waves are almost indistinguishable The only ECG book you‘ll ever need. The T waves are even more peaked. Peaked T waves P waves are no longer visible. . ECG Hyperkalemia produces a progressive evolution of changes in the EKG that can culminate in ventricular fibrillation.
Demam 4.500 .8. Perubahan karakter dahak/purulen 3. ronkhi 5. Batuk progresif 2. Lung Disease Diagnosis pneumonia: Infiltrat baru/infiltrat progresif + ≥2 gejala: 1. Fisis: tanda konsolidasi. Lab: Leukositosis ≥10. napas bronkial.000/leukopenia ≤4. Suhu aksila ≥38 C/riw.
Nephrotic Syndrome Signs & Symptoms: Proteinuria >3.9.5 g/day Hypoalbuminemia Edema Hypercholesterolemia Treatment: Protein supplement Diuretics for edema Treat hyperlipidemia Na restriction (<2 g/day) .
10. . Pathophysiology of heart disease. Acute Coronary Syndrome Henry‘s clinical diagnosis & management by laboratory method.
10. Acute Coronary Syndrome CK-MB or troponin I/T are a marker for infark miocard & used as a diagnostic tool. cardiac troponins are the preferred serum biomarkers to detect myocardial necrosis. Given their high sensitivity & specificity. .
favoring proton pump inhibitor therapy over placebo. Dyspepsia Meta-analysis of eight controlled trials calculated a risk ratio of 0. .86.78–0.95. The benefits of less potent acid reducing therapies such as H2 antagonists are unproven. with a 95% confidence interval of 0.11.
respiratory function may worsen during the second week of illness and progress to frank adult respiratory distress syndrome accompanied by multiorgan dysfunction. Harrison‘s principles of internal medicine . including patchy areas of consolidation —most frequently in peripheral and lower lung fields—or interstitial infiltrates. Approximately 25% of patients have diarrhea. which can progress to diffuse involvement. and myalgias is followed in 1–2 days by a nonproductive cough and dyspnea.12. Chest x-rays: infiltrates. In severe cases. headache. SARS Etiologi: coronavirus Course: incubation period 2–7 days begins as a systemic illness marked by of fever accompanied by malaise.
hipoalbuminemia. pyuria. hiperkolesterolemia. Jika kreatinin serum meningkat cepat dalam beberapa hari. nefritik akut: proteinuria 1-2 g/24 jam. pyuria. 5th ed. . hipertensi. proteinuria. Pathophysiology of disease: an introduction to clinical medicine. & hematuria mikroskopik. Penyakit Ginjal Sind. Harrison‘s principles of internal medicine. nefrotik: proteinuria berat (>3.0 g/24 jam). hematuria dengan silinder eritrosit. retensi cairan. Sind. edema/anasarka. Glomerular Disease: hematuria. 13.. peningkatan kreatinin serum. hipertensi. kadang nefritis akut disebut rapidly progressive glomerulonephritis (RPGN).
5 g). Rapidly progressive glomerulonephritis Chronic glomerulonephritis Nephrotic syndrome Pathophysiology of disease: an introduction to clinical medicine. hyperlipidemia. manifested as marked proteinuria. Worsening renal function results in irreversible and complete renal failure over weeks to months. and fat bodies in the urine. hypoalbuminemia.13. . renal impairment after acute glomerulonephritis progresses slowly over a period of years & eventually results in chronic renal failure. particularly albuminuria (defined as 24-h urine protein excretion > 3. recovery from the acute disorder does not occur. 5th ed. followed by full recovery of renal function. Renal Disorder Diagnosis Acute glomerulonephritis Characteristic an abrupt onset of hematuria & proteinuria with reduced GFR & renal salt and water retention. edema.
bmj. owing to mucus plugging Fewer generations of bronchi than normal Parallel tram-track lines are seen on CXR or CT scan CT cross-section views reveal 'signet ring' appearance of the dilated bronchus and its accompanying vessel.com/best-practice/monograph/1007/basics/classification.14. http://bestpractice. forming a cluster of round air-filled or fluid-filled cysts Only 25% of the normal number of bronchial subdivisions Degree of bronchial dilation increases proximal to distal Bronchial tree ends in blind sacs. with alternating dilation and constriction Bronchographic pattern resembles varicose veins. Saccular or cystic bronchiectasis: Most severe form Commonly found in cystic fibrosis patients Bronchi are dilated. Varicose bronchiectasis: Irregular bronchi.html . Reid‘s Classification Bronchiectasis Cylindrical bronchiectasis: Bronchi enlarged and cylindrical in shape Normal tapering of airway as it traverses to the periphery is not present Distal airways end abruptly.
Antihypertensive Drugs .15.
15. bisoprolol). acebutolol..g. metoprolol. Antihypertensive Drugs Some -sympatholytics possess higher affinity for cardiac 1-receptors than for 2-receptors and thus display cardioselectivity (e. None of these blockers is sufficiently selective to permit its use in asthma or DM .
Komplikasi Tuberculosis Komplikasi tb: Batuk darah Pneumotoraks Luluh paru Gagal napas Gagal jantung Efusi pleura .16.
Dengue Hemorrhagic Fever .17.
19. Asthma .
19. Asthma Moderate Episode Severe Episode .
20. Liver Disease .
malaise. photophobia. but in some patients mild weight loss (2.20. the constitutional prodromal symptoms usually diminish. cough. Constitutional symptoms of anorexia. With the onset of clinical jaundice. Liver Disease Acute viral hepatitis occurs after an incubation period that varies according to the responsible agent. headache. The prodromal symptoms of acute viral hepatitis are systemic and quite variable. arthralgias. The liver becomes enlarged and tender and may be associated with right upper quadrant pain and discomfort. myalgias. pharyngitis. fatigue. Dark urine and clay-colored stools may be noticed by the patient from 1–5 days before the onset of clinical jaundice. .5–5 kg) is common and may continue during the entire icteric phase. nausea and vomiting. and coryza may precede the onset of jaundice by 1–2 weeks.
Pathophysiology of heart disease. STEMI Lilly LS. 5th ed. Lipincott Williams & Wilkins. .21. 2011.
22. DM Complications .
the mainstay of treatment involves altering loading across the painful joint and improving the function of joint protectors. Degenerative Disease Since OA is a mechanically driven disease. . 2. improving the strength and conditioning of muscles that bridge the joint. as evidenced by their causing pain. so as to optimize their function. avoiding activities that overload the joint. either by redistributing load within the joint with a brace or a splint or by unloading the joint during weight bearing with a cane or a crutch. and 3. unloading the joint. so they can better distribute load across the joint. Ways of lessening focal load across the joint include 1.23.
. Drug Therapy for PEA/Asystole A vasopressor can be given as soon as feasible with the primary goal of increasing myocardial and cerebral blood flow during CPR and achieving ROSC Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit. PEA PEA encompasses a heterogeneous group of organized electric rhythms that are associated with either absence of mechanical ventricular activity or mechanical ventricular activity that is insufficient to generate a clinically detectable pulse.24.
cyclosporine. and 3A4). some anticonvulsants. 2D6. and thrombocytopenia and sometimes is associated with acute tubular necrosis. Rifampin strongly induces most cytochrome P450 isoforms (CYPs 1A2. chills. It may cause cholestatic jaundice and occasionally hepatitis. If administered less often than twice weekly. and contact lenses (soft lenses may be permanently stained). protease inhibitors. Rifampin commonly causes light-chain proteinuria. 2C9. 2C19. sweat. thrombocytopenia. anticoagulants. contraceptives. some nonnucleoside reverse transcriptase inhibitors. anemia. Rifampin Adverse Reactions Rifampin imparts a harmless orange color to urine. . tears. rifampin causes a flu-like syndrome characterized by fever. which increases the elimination of methadone. Occasional adverse effects include rashes.26. and nephritis. myalgias. and a host of others.
Harrison‘s principles of internal medicine. the administration of 0. casual contacts (office. IG is effective in preventing clinically apparent hepatitis A.27. 18th eds. it may be effective even when administered as late as 2 weeks after exposure. or those known to have anti-HAV in their serum. For postexposure prophylaxis of intimate contacts (household. or hospital). institutional) of persons with hepatitis A. most elderly persons. factory. . sexual. who are very likely to be immune.02 mL/kg is recommended as early after exposure as possible. Hepatitis A Prophylaxis When administered before exposure or during the early incubation period. school. Prophylaxis is not necessary for: those who have already received hepatitis A vaccine.
injection drug users. 1. inmates of long-term correctional facilities. and 6 months for pre-exposure prophylaxis against hepatitis B in settings of frequent exposure: health workers exposed to blood. unvaccinated children under the age of 18. Harrison‘s principles of internal medicine. . high-volume therapy with blood derivatives. persons living in or traveling extensively in endemic areas. hemodialysis patients and staff. Hepatitis B Prophylaxis • Three IM injections of hepatitis B vaccine are recommended at 0. persons with multiple sexual partners. persons such as hemophiliacs who require long-term. residents and staff of custodial institutions for the developmentally handicapped. 18th eds.27. household and sexual contacts of HBsAg carriers.
28. Infective Endocarditis .
anorexia. Pathophysiology of heart disease. conduction abnormality Septic emboli Immune complex phenomena: arthritis. Infective Endocarditis Clinical Manifestations: Persistent bacteremia: fever. Lipincott Williams & Wilkins.28. CHF. night sweat. 5th ed. weight loss. ESR Lilly LS. . 2011. fatigue Valvular/perivalvular infection: murmur. glomerulonephritis.
29. Instead of three large meals. UpToDate. eat five or six small meals Avoiding food that make feel worse. Dyspepsia Advice for patient with dyspepsia: Avoiding fatty foods (which can slow the emptying of the stomach) Eating small. frequent meals.com .
tubular or peritubular capillary basement membranes. The principal mechanism of injury is immune complex deposition in the glomeruli.30. or larger blood vessels. Lupus Nephritis Lupus nephritis affects up to 50% of SLE patients. .
30. Lupus Nephritis .
31. Acute Coronary Syndrome .
Dyspepsia Lokasi Nyeri Nyeri epigastrik Kembung Anamnesis Membaik dgn makan (ulkus duodenum). Hepatomegali Pankreatitis Resusitasi cairan Nutrisi enteral Analgesik Transaminase. Mual. TIDAK Demam Nyeri epigastrik/ Mual/muntah. Demam Penyebab: alkohol (30%). Memburuk dgn makan (ulkus gastrikum) Pemeriksaan Fisis Tidak spesifik Pemeriksaan Penunjang Urea breath test (+): H. epigastrium Fourty. Gray Turner: pinggang). Nyeri kanan atas/ Risk: Female. perdarahan retroperitoneal (Cullen: periumbilikal. pylori Endoskopi: eritema (gastritis akut) atropi (gastritis kronik) luka sd submukosa (ulkus) Peningkatan enzim amylase & lipase di darah Diagnosis Dispepsia Terapi PPI: ome/lansoprazol H. batu empedu (35%) Nyeri kanan atas/ Prodromal epigastrium (demam. HBSAg. mual) kuning. pylori: klaritromisin+amok silin+PPI Nyeri epigastrik menjalar ke punggung Gejala: mual & muntah. Serologi HAV. Fat. kanan atas Demam menjalar ke bahu/ punggung Nyeri tekan & defans. malaise. Hamil Prepitasi makanan berlemak.32. 3 + metronidazol Kolesistektomi . Hipotensi Ikterus. Anti HBS Nyeri tekan USG: hiperekoik abdomen dgn acoustic Berlangsung 30-180 window menit Murphy Sign USG: penebalan dinding kandung empedu (double rims) Hepatitis Akut Suportif Kolelitiasis Kolesistektomi Asam ursodeoksikolat Kolesistitis Resusitasi cairan AB: sefalosporin gen.
Rheumatic Fever Acute rheumatic fever (ARF) is a multisystem disease resulting from an autoimmune reaction to infection with group A streptococcus. .34.
BP should be decreased in minutes/hours. BP should be decreased in 24-48 hours. . Emergency hypertension: target organ damage (+). Ringkasan eksekutif krisis hipertensi.35. Urgency hypertension: target organ damage (-). which needs immediate treatment. Hypertension Hypertension crisis: Suddenly elevated blood pressure (systole ≥180 mmHg or diastole ≥120 mmHg) in hypertensive patient. Perhimpunan hiperensi Indonesia.
drug abuse. pheochromocytoma. convulsion. pregnancy. collagen disease. Renal: azotemia. edema papil. Risk Factors: noncompliance. unconsciousness. high sympathetic stimulation (severe burn. trauma) Ringkasan eksekutif krisis hipertensi. Perhimpunan hiperensi Indonesia. . Obsteric: severe preeklampsia. Hypertension Clinical manifestation of hypertension crisis: Neurology: headache. vascular disease. lung edema. Eye: retinal hemorrhage. oliguria. neurological deficit. Cardiovascular: chest pain. blurred vision. proteinuria. retinal exudate.35.
Drugs: ACE-I (Captopril): sublingual 6. Hypertension Management: Management should be done in hospital. Ringkasan eksekutif krisis hipertensi. Clonidine 900 mcg into 500 mL of 5% glucose infusion. however primary care service can give oral antihypertension as a first aid. Perhimpunan hiperensi Indonesia. .25-50 mg Nicardipine 10-30 mcg/kgBW bolus.35. Parenteral drug is given via bolus or infusion ASAP. given in 12 drops/minute.
frequency. close f/u. et al. known voiding abnormalities. Urinary Tract Infection Woman with symptoms of UTI (acute onset dysuria. other diagnoses) Bent S. co-morbid conditions -> complicated UTI) No back pain (if present -> consider pyelonephritis) No vaginal discharge (if present -> consider STD) then > 90% probability of acute cystitis If history not clear dipstick Positive: 80% cystitis (consider tx for UTI) Negative: 20% cystitis (dipstick not very specific so 1/5th of these cases might still have real UTI – consider urine culture.36. or urgency) No complicating conditions (if pregnant. 2002.287(20):2701-2710 . JAMA.
Usia > 60 tahun: indeks Barthel. GDS. Usia > 40 tahun: roentgen thoraks. lab darah dan urine. Wanita usia subur: tes kehamilan Vaksinasi: meningitis. & EKG.37. . LDL. kolesterol. Pemeriksaan Kesehatan Haji/Umrah Pemeriksaan fisik.
Rheumatic Heart Disease ARF is exclusively caused by infection of the upper respiratory tract with group A streptococci.38. Harrison‘s principles of internal medicine. .
40% of patients will develop mitral stenosis. Over ensuing years. Infrequently. and valvular stenosis may develop. . usually as a result of recurrent episodes. Lilly. Pathophysiology of heart disease. the tricuspid valve is affected as well. An additional 25% will develop aortic stenosis or regurgitation in addition to the mitral abnormality. calcification. leaflet thickening. Rheumatic Heart Disease Early valvular damage leads to regurgitation.38. scarring.
cauliflower. water. Cassava contains a thiocyanate that inhibits iodide transport within the thyroid. Variations in the prevalence of endemic goiter in regions with similar levels of iodine deficiency point to the existence of other causative influences.39. . Endemic Goiter Endemic goiter: occurs in geographic areas where the soil. Native populations subsisting on cassava root are particularly at risk.. cabbage. The term endemic is used when goiters are present in more than 10% of the population in a given region. and cassava). has been documented to be goitrogenic. particularly dietary substances. worsening any possible concurrent iodine deficiency. Such conditions are particularly common in mountainous areas The lack of iodine leads to decreased synthesis of thyroid hormone and a compensatory increase in TSH. and food supply contain low levels of iodine. turnips. The ingestion of substances that interfere with thyroid hormone synthesis at some level.g. leading to follicular cell hypertrophy and hyperplasia and goitrous enlargement. such as vegetables belonging to the Brassicaceae (Cruciferae) family (e. referred to as goitrogens. Brussels sprouts.
Murmur & Heart Sounds .40.
Murmur & Heart Sound Lilly LS.40. . Pathophysiology of heart disease.
40. Murmur & Heart Sound .
GINA 2005 PDPI. Asma: pedoman diagnosis & penatalaksanaan di Indonesia. Asthma Measurements of lung function enhance diagnostic confidence. 2004 . Spirometry: Airway obstruction: FEV1/FVC <75% or FEV 1 <80% Reversibility: improvement of FEV1 ≥15% after bronchodilator inhalation.41. Classification of asthma severity Peak expiratory flow meter: Reversibility: improvement of PEF ≥15% after bronchodilator inhalation Variability: daily PEF measured at night after bronchodilator & morning before bronchodilator >20%.
Tuberculosis Drugs .42.
43. Nyeri Dada .
Diabetes Mellitus .44.
Hyperglycemic Crises in Patients With Diabetes Mellitus. .44. Diabetes Mellitus American Diabetes Association.
Obstructive Lung Disease a working definition of COPD: a disease state characterized by airflow limitation that is not fully reversible. GOLD. WHO. The airflow limitation is usually both progressive & associated with an abnormal inflammatory response of the lungs to noxious particles or gases.46. .
anticholinergics. Obstructive Lung Disease The choice of bronchodilator drugs (ß2-agonists.46. . & methylxanthines) depends on the availability of medication and the patient‘s response.
Obat-obatan PPOK berdasarkan gejala: Gejala intermiten (saat aktivitas): 2 agonis Gejalan terus menerus: Antikolinergik kerja singkat: Ipratropium bromida Antikolinergik kerja lama: tiotropium bromida Inhalasi 2 agonis kerja cepat: salbutamol/fenoterol/terbutalin Kombinasi terapi: Ipratropium bromida+salbutamol . PPOK Pemilihan bentuk obat diutamakan inhalasi.46.
Lung Abscess .47.
• Septic embolism: Infected emboli from thrombophlebitis in any portion of the systemic venous circulation or from the vegetations of infective bacterial endocarditis on the right side of the heart are trapped in the lung. coma. sinobronchial infections. Posttransplant or otherwise immunosuppressed individuals are at special risk. pneumoniae. Lung Abscess LUNG ABSCESS The term “pulmonary abscess” describes a local suppurative process within the lung. . • Miscellaneous: Direct traumatic penetrations of the lungs. • Neoplasia: Secondary infection is particularly common in the bronchopulmonary segment obstructed by a primary or secondary malignancy (postobstructive pneumonia). and debilitation in which the cough reflexes are depressed. K.47. Etiology and Pathogenesis The causative organisms are introduced by the following mechanisms: • Aspiration of infective material (the most frequent cause): This is particularly common in acute alcoholism. • Antecedent primary lung infection: Post-pneumonic abscess formations are usually associated with S. gingivodental sepsis. anesthesia. spine. characterized by necrosis of lung tissue. spread of infections from a neighboring organ. Oropharyngeal surgical procedures. sinusitis. and hematogenous seeding of the lung by pyogenic organisms all may lead to lung abscess formation. subphrenic space. aureus. and bronchiectasis play important roles in their development. such as suppuration in the esophagus. and the type 3 pneumococcus. or pleural cavity. dental sepsis.
the finding of Heinz bodies is a sign of either chemical poisoning.g. They also occur when one or other of the globin chains of haemoglobin is unstable. drug intoxication.. . as well as by inorganic oxidizing agents. Hb Köln). In man. or the presence of an unstable haemoglobin (e. glucose-6phosphate dehydrogenase (G6PD) deficiency.48. Hemolytic Anemia Heinz bodies can be produced by the action on red cells of a wide range of aromatic nitroand amino-compounds.
electrolyte. Acute Kidney Injury Acute kidney injury (AKI) heterogenous syndrome defined by a rapid (over hours to days) decline in GFR resulting in the retention of metabolic waste products. . and dysregulation of fluid.49. including urea and creatinine. & acidbase homeostasis.
abnormalities of blood flow due to atherosclerotic coronary artery disease and microvascular disease. Heart Heart disease is the most common cause of death in hypertensive patients. . Aggressive control of hypertension can regress or reverse left ventricular hypertrophy and reduce the risk of cardiovascular disease. and cardiac arrhythmias. Hypertension Pathologic Consequences of Hypertension Hypertension is an independent predisposing factor for heart failure. left ventricular hypertrophy can be diagnosed by electrocardiography. and peripheral arterial disease (PAD). CHF. stroke. renal disease. coronary artery disease.50. Clinically. Hypertensive heart disease is the result of structural and functional adaptations leading to left ventricular hypertrophy. although echocardiography provides a more sensitive measure of left ventricular wall thickness.
and other gramnegative bacilli often cause this pattern of disease. Pneumonia Lobar pneumonia is characterized by the presence of neutrophilic infiltration in the alveoli. The inflammation spreads through the pores of Khon and the Lambert channels. or smaller anatomic units. Bronchopneumonia is characterized by purulent exudate in terminal bronchioles and adjacent alveoli.51. Pseudomonas aeruginosa. and it consequently often affects a whole lobe. Endobronchial spread results in multiple foci of consolidation in lung segments. Staphylococcus aureus. and H. Klebsiella spp.. subsegments. . pneumoniae. This pattern is most characteristic of pneumonia due to S. influenzae. Escherichia coli.
52. Miliary Tuberculosis
Snow storm appearance in chest x-ray patient with miliary tuberculosis.
Miliary pulmonary disease occurs when organisms draining through lymphatics enter the venous blood and circulate back to the lung.
Individual lesions are either microscopic or small, visible (2-mm) foci of yellowwhite consolidation scattered through the lung parenchyma (the adjective ―miliary‖ is derived from the resemblance of these foci to millet seeds).
Miliary lesions may expand and coalesce, resulting in consolidation of large regions or even whole lobes of the lung
54. Shoulder Dislocation Shoulder is the most commonly dislocated joint Traumatic Dislocations Anterior 96% Posterior 2-4% Diverse group of patients experience dislocations. Male and Female young and old active and inactive .
RCT: more common in older patients . Glenohumeral stabilization mechanisms Passive: joint conformity. Anatomic Consideration ligamentous and capsular restraints. vacuum effect. labrum Active: long head of Biceps and Rotator Cuff Pathoanatomy of shoulder dislocations Bankart Lesion: avulsion of anteroinferior labrum Hill-Sachs Lesion: posterolateral humeral head defect Assoc.
palpable humeral head anteriorly Neuro integrity of axillary and musculcutaneous nerves Apprehension Test: reproduces sense of instability and pain in shoulder reduced prior to exam .Clinical Evaluation PE: Prominent acromion. sulcus sign.
Radiographic Evaluation AP vs true AP Axillary vs Valpeau Axillary Special Views: West Point axillary: for visualization of glenoid rim Hill-Sach view: internal rotation view Stryker Notch: view 90% of posterolateral humeral head .
Pre-Medication Management None Intraarticular LidocainePreferred over IV Sedation IV Sedation Supraclavicular Block Suprascapular Block Reduction Maneuvers • Is there an Ideal Method for Reduction? – Over 24 Techniques Described Reduction Maneuvers • Most Common Techniques – Kocher (71-100%) – External Rotation (7890%) – Milch (70-89%) – Stimson (91-96%) – Traction/Countertraction – Scapular Manipulation (79-96%) Post-Reduction Immobilization .
Bladder Injuries • Causes: – Iatrogenic injury • Transurethral resection of bladder tumour (TURBT) • Cystoscopic bladder biopsy • Transurethral resection of prostate (TURP) • Cystolitholapaxy • Caesarean section. especially as an emergency • Total hip replacement (very rare) Penetrating trauma to the lower abdomen or back Blunt pelvic trauma—in association with pelvic fracture or ‗minor‘ trauma in the inebriated patient Rapid deceleration injury—seat belt injury with full bladder in the absence of a pelvic fracture Spontaneous rupture after bladder augmentation – – – – .55.
B. but not into the peritoneal cavity. has been breached along with the wall of the bladder.Types of Perforation A-intraperitoneal perforation the peritoneum overlying the bladder. no peritonitis symptoms .extraperitoneal perforation the peritoneum is intact and urine escapes into the space around the bladder. allowing urine to escape into the peritoneal cavity.
difficulty or inability in passing urine. – Leakage causes peritonitis – Associated other organ injury. and virtually all were healed in 3 weeks – Obstruction of the catheter by clots or tissue debris must be prevented for healing to occur suprapubic pain and tenderness. – Usually large defects. European Association of Urology guidelines 2012 . even in the presence of extensive retroperitoneal or scrotal extravasation – 87% of the ruptures were healed in 10 days. and haematuria – Intra peritoneal : • open repair…why? – Unlikely to heal spontaneously. Presentation: Recognized intraoperatively The classic triad of symptoms and signs that are suggestive of a bladder rupture • Management: – Extraperitoneal – catheter drainage alone.
cirp.org/library/disease/balanitis/escala1/ 56.http://www. Balanitis • More likely to affect boys under four years of age • Approximately 1 in every 25 boys and 1 in 30 uncircumcised males (at some time in their life .
Symptoms usually begin to appear after 3 days Systemic symptoms such as fever and nauseamay uncommon It is more common in patients with phimosis Lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema .
Phimosis Paraphimosis Inability to retract the distal foreskin over the glans penis Entrapment of a retracted foreskin behind the coronal sulcus Physiologic in newborn Complications Balanitis Postitis Balanopostitis Emergency Superficial vein obstruction edema and pain penile glands necrosis Treatment Manual reposition Dorsum incision Treatment Dexamethasone 0.1% (6 weeks) for spontaneous retraction .
Volume Perdarahan Fraktur Femur Femur bone anatomy Near major blood vessel (femoral artery) Femur Fracture blood loss Up to 1.500 ml per femur .57.
Fluid Resuscitation Crystalloids Non-protein colloids Are as effective as albumin in post-operative patients Should be used as secondline agents in patients who do not respond to crystalloid Are the initial resuscitation fluid of choice for: Hemorrhagic shock / traumatic injury Septic shock Hepatic resection Thermal injury Cardiac surgery Dialysis induced hypotension 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. (3:1 rule) . It has been empirically observed that approximately 300 cc of crystalloid is required to compensate for each 100 cc of blood loss.
Fluid resuscitation target: Euvolemia Improve perfusion Improve oxygen delivery British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients 2011 .
Trauma patient .58.
Airway Management Simple management maneuvers Suction Chin lift Jaw thrust ―Definitive airway:‖ Cuffed tube in trachea Patient can‘t response GCS Score<9 Obstruction due to Tongue Aspiration Foreign body Maxillofacial injury Neck injury Management: Careful endoscopic exam Careful and gentle intubation. or Surgical airway? .
Tongue/jaw lift 2. Modify for suspected spinal injury: 1. Modified jaw thrust .
vomit) Wheezing .Airway Obstruction Snoring .due to narrowing of the lower airways .due to obstruction of upper airway by liquids (blood.due to obstruction of upper airway by the tongue Gurgling .
H-E stain) shows extensive granulomatous inflammation with epithelioid and Langhans giant cells. ×200. Tuberculosis Of The Breast Photomicrograph (original magnification.59. Foci of necrosis are seen in one of these granulomas .
Shukla.S.Classified into five different types by Mckeown and Wilkinson Breast tuberculosis: diagnosis. clinical features & management. Mallika Tewari & H. Indian J Med Res 122. August 2005. pp 103-110 .
The Cytological picture of tubercular breast lump (n=42)
Puneet, S.K. Tiwary, R. Ragini, S. Singh, S. Gupta, V. Shukla: Breast Tuberculosis: Still Common In India. The Internet Journal of Tropical Medicine. 2005 Volume 2 Number 2. DOI: 10.5580/af8
60. Airway Obstruction
Snoring - due to obstruction of upper airway by the
Gurgling - due to obstruction of upper airway by liquids
Wheezing - due to narrowing of the lower airways
PATENT Vs COLLAPSED AIRWAY
2006 American Academy of Sleep medicine
Episodes of complete or partial collapse of airway
Obstructive Sleep Apnea
apnea and hypopnea events Apnea = cessation of airflow > 10 seconds Hypopnea = Decreased airflow > 10 seconds associated
with: Arousal Oxyhemoglobin desaturation
Cardinal symptoms "3 S ‘s―
S noring S leepiness S ignificant-other report of sleep apnea episodes
61. Trauma Uretra Suspect that a patient may have injured his lower urinary tract if: he has some injury which makes this likely (especially a fractured pelvis) cannot pass urine after an accident there is blood at the tip of his urethra .
Don't pass a diagnostic
catheter up the patient's urethra because: The information it will give will
Primary imaging modality for
evaluating traumatic injuries and inflammatory and stricture diseases of the male urethra
May contaminate the
haematoma round the injury.
May damage the slender
bridge of tissue that joins the two halves of his injured urethra
Posterior urethral rupture above the intact urogenital diaphragm following blunt trauma
Urinary tract stone disease Signs:
Irritative voiding symptom Nausea microscopic hematuria
Urinary crystals of calcium
oxalate, uric acid, or cystine may occasionally be found upon urinalysis
optimized by optima
vomiting. ureteral or pelvic tumors. and sometimes fever suggestive for urinary tract stone . extrinsic ureteral compression ureteral or pelvic stones ureteral strictures. Urinary Tract Obstruction Etiology : Acquired urinary tract obstruction may be due to inflammatory or traumatic urethral strictures. • Previous history of Loin/flank pain. bladder outlet obstruction neuropathic bladder.63.
For stones > 5 mm. ultrasound has a sensitivity of 96% and specificity of nearly 100% . and pyelo-ureteric and vesicoureteric junctions. If available. pelvis. as well as upper urinary tract dilatation. ultrasonography should be used as the primary diagnostic imaging. It can identify stones located in the calices.
and pain. Painful. round. Retraction of the nipple. rubbery lumps that move freely in the breast when pushed upon and are usually painless. Grow fast. “leaf-like”configuration. Peau d’orange . The Breast Tumors Breast cancer Onset 30-menopause Feature Invasive Ductal Carcinoma .Firm.64. discharge/blood. Paget’s disease (Ca Insitu).Axillary mass They are solid. May be lactating and may have recently missed feedings.fever. Fibroadenoma mammae Fibrocystic mammae Mastitis < 30 years 20 to 40 years 18-50 years Philloides Tumors 30-55 years .occasionally have nipple discharge Localized breast erythema. Breast skin over the tumor may become reddish and warm to the touch. infiltrative. not clear border. hard. lumps in both breasts that increase in size and tenderness just prior to menstrual bleeding. intralobular stroma . smooth-sided. bumpy (not spiky). warmth.
tender or painful Fat necrosis. Irregular fatty spaces are surrounded by foamy histiocytes and multinucleated giant cells .
foot or hand May contain areas of fat necrosis with histiocytes. with obvious large cells up to 300 microns Cytoplasmic vacuoles are relatively uniform May have intranuclear vacuoles. infarct or calcification Rarely contains bone or cartilage No mitotic figures .Lipoma: Mature white adipose tissue without atypia 2-5x variation in cell size (more than normal white adipose tissue). thickened fibrous septa in buttocks.
Acute Pancreatitis Clinical Continuous mid-epigastric / peri-umbilical abdominal pain Radiating to back. lower abdomen or chest Emesis Fever Aggravated by eating Progressive Restless and uncomfortable .65.
Diagnosis – Amylase Elevation Pancreatic Source Biliary obstruction Bowel obstruction Perforated ulcer Appendicitis Mesenteric ischemia Peritonitis Unknown Source Renal failure Head trauma Burns Postoperative Salivary Parotitis DKA Anorexia Fallopian tube Malignancies .
Diagnosis – Lipase The preferred test for diagnosis Begins to increase 4-8H after onset of symptoms and peaks at 24H Remains elevated for days Sensitivity 86-100% and Specificity 60-99% >3X normal S&S ~100% .
or cystine may occasionally be found upon urinalysis Diagnosis: IVP optimized by optima . Urolithiasis Urinary tract stone disease Signs: Flank pain Irritative voiding symptom Nausea microscopic hematuria Urinary crystals of calcium oxalate. uric acid.66.
67. ASA Classification E for Emergency Patients PS Physical status .
Sudden sharp pain.Tachypnea Decreased Breath Sounds on Affected Side.hipersonor Opening in chest cavity that allows air to enter pleural cavity.http://emedicine.Subcutaneous Emphysema Decreased lung sounds on affected side Red Bubbles on Exhalation from wound Simple/Closed Pneumothorax Open Pneumothorx Penetrating chest wound .Flat Neck Veins. Chest Trauma Disorders Etiology Clinical Hemothorax lacerated blood Anxiety/Restlessness. Chest Pain.Tachypnea.Tachycardia Frothy. Dullness to percussion Blunt trauma spontaneous Opening in lung tissue that leaks air into chest cavity. Dyspnea. Bloody Sputum Diminished Breath Sounds on Affected Side.medscape.Signs vessel in thorax of Shock.com/article/2047916 68.Dyspnea.
decreased tactile fremitus. diminished or delayed expansion on the side of the effusion Fever.cough.rales in ausultation Pleural Efusion congestive heart failure. malignancy. cough. 3 ribs broken in 2 or more places.Tachycardia Absent Breath sounds on affected side. hypersonor Flail Chest Trauma a segment of the rib cage breaks becomes detached from the rest of the chest wall.Poor Color Dyspnea. Accessory Muscle Use.Tachypnea. decreased tactile fremitus. or pulmonary embolism infection Pneumonia Infection. chest pain. JV Distention Narrowing Pulse Pressures. and asymmetrical chest expansion.painful when breathing. which results from pleural irritation.dysnea. and asymmetrical chest expansion.Paradoxical breathing Dyspnea. Dullness to percussion. Severe . pneumonia.Disorders Tension Penumothorax Etiology Clinical Anxiety/Restlessness.Hypotension Tracheal Deviation. with diminished or delayed expansion on the side of the effusion. inflammation .
medscape.http://emedicine.com/ Th/ • ABC‘s with C-spine control • Airway Assistance as needed • If not contraindicated transport in semi-sitting position • Provide supportive care • Contact Hospital and/or ALS unit as soon as possible • Usually self correcting Simple/Closed Pneumothorax .
Buckle fracture Force to side of bone may cause break in only one cortex= GREENSTICK fracture The other cortex only BENDS In very young children. neither cortex may break= PLASTIC DEFORMATION/bowing . Pediatric Fractures In growing bones: Bones tend to BOW rather than BREAK Compressive force= TORUS fracture Aka.69.
Fractures Peculiar to Children A. Torus or buckling B. Bowing D. Epiphyseal Often only incomplete fracture line is seen A B C D . Greenstick C.
break in only one cortex= GREENSTICK fracture The other cortex only BENDS .
html .merckmanuals.http://www.com/professional/injuries_poisoning/fractures _dislocations_and_sprains/fractures.
resuscitation and intensive monitoring Obstruction A mechanical blockage arising from a structural abnormality that presents a physical barrier to the progression of gut contents.70-72. Obstruction Accounts for 5% of all acute surgical admissions Patients are often extremely ill requiring prompt assessment. Ileus is a paralytic or functional variety of obstruction Obstruction is: Partial or complete Simple or strangulated .
Causes. lumbricoides Mural Neoplasims lipoma polyps leiyomayoma hematoma lymphoma carcimoid carinoma secondary Tumors Crohns TB Stricture Intussusception Congenital Extraluminal Postoperative adhesions Congenital adhesions Hernia Volvulus . Body Bezoars Gall stone Food Particles A.Small Bowel Luminal F.
.edu. haemorrhage and wash with irritant solutions iodine and other foreign bodies..Small Bowel Adhesions Accounts for 60-70% of All SBO Results from peritoneal injury. The majority of patients present between 1-5 years Colorectal Surgery 25% Gynaecological 20% Appendectomy 14% 70% of patients had a single band Patients with complex bands are more likely to be readmitted Readmission in surgically treated patients is 35% uqu.ppt Ahmed Badrek-Amoudi FRCS . As early as 4 weeks post laparotomy./intes tinal%20obstruction2. Associated with starch covered gloves.sa/files2/tiny_mce/plugins/. platelet activation and fibrin formation. intraperitoneal sepsis.
Medication. ROS. FH. SH) High •Pain is rapid •Vomiting copious and contains bile jejunal content •Abdominal distension is limited or localized •Rapid dehydration Distal small bowel •Pain: central and colicky •Vomitus is feculunt •Distension is severe •Visible peristalsis •May continue to pass flatus and feacus before absolute constipation Colonic • Preexisting change in bowel habit •Colicky in the lower abdomin •Vomiting is late •Distension prominent •Cecum ? distended Persistent pain may be a sign of strangulation Relative and absolute constipation . History The Universal Features Colicky abdominal pain. PSH.1. constipation (absolute). vomiting. abdominal distension. Complete HX ( PMH.
RR. •CNS •Vascular •Gynaecological •muscuoloskeltal Darm kontur: visible shape of intestines on the abdomen •Rectal examination Darm Steifung: visible peristaltic movement on the abdomen . Sat •dehydration •Anaemia. BP. guarding and rebound •Organomegaly •Bowel sounds –High pitched (metallic sound) –Absent Others Systemic examination If deemed necessary. jaundice.2. LN •Assessment of vomitus if possible •Full lung and heart examination Abdominal •Abdominal distension and it‘s pattern •Hernial orifices •Visible peristalsis •Cecal distension •Tenderness. T. Examination General •Vital signs: P.
Colonic and 1-2 small bowel Fluid Levels: Gastric 1-2 small bowel Check gasses in 4 areas: 1. 2. Caecal Hepatobiliary Free gas under diaphragm Rectum Look for calcification Look for soft tissue masses. psoas shadow Look for fecal pattern .Radiological Evaluation Normal Scout Always request: Supine. Erect and CXR Gas pattern: Gastric. 4. 3.
The Difference between small and large bowel obstruction Large bowel •Peripheral ( diameter 8 cm max) •Presence of haustration Small Bowel •Central ( diameter 5 cm max) •Vulvulae coniventae •Ileum: may appear tubeless .
3. 2. Step-ladder arrangement or parallel bowel loops .Radiology: Flat and upright (or decubitus) abdominal X-Ray A. B. 1. Sensitivity: 60% (up to 90%) Typical findings of Bowel Obstruction 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. 4.
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.Initial Management in the ER Resuscitate: Air way (O2 60-100%) Insert 2 lines if necessary at IVF : Crytloids least 120 ml/h. Add K+ at 1mmmol/kg Draw blood for lab investigations Inform a senior member in the team. NPO. (determined by estimated fluid loss and cardiac function). .
etc) Signs of peritonitis resulting from perforation or ischemia .Indications for Surgery Immediate intervention: Evidence of strangulation (hernia….
and great vessels High Flow oxygen including BVM Treat for S/S of Shock Notify Hospital and ALS unit as soon as possible If Open Pneumothorax and occlusive dressing present BURP occlusive dressing http://www.Treatment ABC‘s with c-spine as indicated Needle Decompression of Affected Side • Air builds in pleural space with no where for the air to escape • collapse of lung on affected side • increased pressure on mediastium.php/main/article/199/ .org/index.the other lung.trauma.
Locate 2-3 Intercostal space
Cleanse area using aseptic
Insert catheter ( 14g or larger) at
least 3‖ in length over the top of the 3rd rib( nerve, artery, vein lie along bottom of rib) of air
Remove Stylette and listen for rush Place Flutter valve over catheter Reassess for Improvement
75. Acute Pyelonephritis
rapid onset (hours to a day) ❏ lethargic and unwell, fever, tachycardia, shaking, chills, nausea and vomiting, myalgias ❏ marked CVA or flank tenderness; possible abdominal pain on deep palpation ❏ symptoms of lower UTI may be absent (urgency, frequency, dysuria)
76. Head Injury
77. malaise. and myalgia Fever Breast pain Decreased milk outflow Breast warmth Breast tenderness Breast firmness Breast swelling Breast erythema Breast mass If left untreatedbreast abscess spontaneous drainage from the mass or nipple PalpationFluctuation + . Mastitis Flu-like symptoms.
78. Hemorrhaegic Shock .
5 .5 1.79.5 1.5 1. Breast Cancer Screening High risk FACTORS 1st degree relatives with BC 1 vs none 2 vs none First child Breast feeding Menarche Number of child Alcohol age >30 vs <20 none vs 4 children <11 vs >15 none vs 3 2 drinks vs none RR Screening Tests • Breast self examination (BSE) • • • Clinical breast examination (CBE) Mammography Ultrasonography 2 3-5 2-3 2.
The USPSTF recommends against teaching breast self-examination (BSE). Grade: C recommendation. Grade: D recommendation.USPSTF Breast Cancer Screening Recommendations (2009) The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. including the patient's values regarding specific benefits and harms. Grade: B recommendation. Grade: I Statement. biennial screening mammography before the age of 50 years should be an individual one and take patient context into account. . The USPSTF concludes The decision to start regular. that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
yearly after 40 BSE option. beginning at 20 .Other Groups‘ Recommendations AAFP (2009) – all recommendations in agreement with new USPSTF guidelines ACS Begin annual mammography at 40 CBE q 3 yr 20-40.
Loss of power in the hand (particularly for precision grips involving the thumb) . Carpal Tunnel syndrome Carpal tunnel syndrome (CTS) is a collection of characteristic symptoms and signs that occurs following entrapment of the median nerve within the carpal tunnel. Weakness/clumsiness .80. Symtomps: Numbness and tingling Pain Autonomic symptoms Many patients also report sensitivity to changes in temperature (particularly cold) and a difference in skin color.
If you can hold your hands in this position for 30 seconds without pain. numbness or tingling. then you probably do not have .
Carpal tunnel anatomy .
Colloid For Resuscitation Colloids are large molecules that do not pass across diffusional barriers as readily as crystalloid Colloid fluids infused into the vascular space therefore have a greater tendency to stay put and enhance the plasma volume than do crystalloid fluids Much of this potency is related to the colloid osmotic pressure exerted by each fluid .81.
disposable and made of hard plastic. Guedel is tubular and has a hollow center. Displaces the tongue away from the posterior pharyngeal wall. Guedel and Berman are the frequent types. Prevents tongue from collapsing to hypopharynx . Oropharyngeal Airway Semicircular. Berman is solid and has channeled sides.82.
83-84. Syok Anafilaktik .
org.uk/pages/reaction.resus.pdf 2012. If there are symptoms of airway obstructionconsider early intubation .www.
rch.org.au/clinicalguide/guideline_index/anaphylaxis/ .Anaphylaxis flowchart http://www.
Urinary Tract Infection .85.
86. Ruptur Uretra .
in http://www.com/article/S03022838%2810%2900024-2/fulltext Colapinto and McCallum Classification of blunt anterior and posterior urethra .EAU Guidelines on Urethral Trauma. 2010.europeanurology.
Open fracture Gustillo-Anderson .87.
Joseph D.Open Fracture Treatment Adequate irrigation and debridement the most important steps The wound should be extended proximally and distally to examine the zone of injury Meticulous debridement should be performed. Handbook of Fractures. Some authors have demonstrated decreased infection rates with >10 L of irrigation under pulsatile lavage Koval. starting with the skin and subcutaneous fat Pulsatile lavage irrigation. 3rd Edition . Zuckerman.. with or without antibiotic solution. Kenneth J. should be performed.
Joseph D..Koval. Zuckerman. Handbook of Fractures. 3rd Edition . Kenneth J.
3rd Edition . Handbook of Fractures. Kenneth J. Zuckerman.. Joseph D.Koval.
Massive Hemorrhage Metabolic changes in traumatic-hemorrhagic shock patient: Hypermetabolism Increased oxygen demands anaerobs The alterations of the physiological metabolic pathways leads Hyperglycemia Metabolic acidosis with hyperlactatemia metabolismlactate↑↑ Increased energy expenditure Enhanced protein catabolism Insulin resistance associated with hyperglycemia Failure to tolerate glucose load High plasma insulin levels .88.
11:R130 doi:10. During hemorrhagic shock. The increase in blood lactate generally originates from both increased lactate production and reduced lactate metabolism Critical Care 2007.1186/cc6200 . metabolic acidosis is common and conventionally considered to be due essentially to hyperlactatemia.
1st webspace sensation .89. Trauma to Anterior Compartment of tibia • Action • • • • • Ankle dorsiflexion • Muscles Tibialis Anterior Extensor Digitorum Longus Extensor Hallucis Longus Peroneus Tertius • Vessels • Anterior Tibial A./V. • Nerves • Deep Peroneal N.
SH) High •Pain is rapid •Vomiting copious and contains bile jejunal content •Abdominal distension is limited or localized •Rapid dehydration Distal small bowel •Pain: central and colicky •Vomitus is feculunt •Distension is severe •Visible peristalsis •May continue to pass flatus and feacus before absolute constipation Colonic • Preexisting change in bowel habit •Colicky in the lower abdomin •Vomiting is late •Distension prominent •Cecum ? distended Persistent pain may be a sign of strangulation Relative and absolute constipation . ROS. Obstruction Ileus The Universal Features Colicky abdominal pain. FH. vomiting.90. Medication. Complete HX ( PMH. abdominal distension. PSH. constipation (absolute).
•CNS •Vascular •Gynaecological •muscuoloskeltal •Rectal examination Darm kontur: visible shape of intestines on the abdomen Darm Steifung: visible peristaltic movement on the abdomen . BP. guarding and rebound •Organomegaly •Bowel sounds –High pitched (metallic sound) –Absent Others Systemic examination If deemed necessary. RR.2. Examination General •Vital signs: P. T. LN •Assessment of vomitus if possible •Full lung and heart examination Abdominal •Abdominal distension and it‘s pattern •Hernial orifices •Visible peristalsis •Cecal distension •Tenderness. Sat •dehydration •Anaemia. jaundice.
Erect and CXR Gas pattern: Gastric. psoas shadow Look for fecal pattern . 2. Caecal Hepatobiliary Free gas under diaphragm Rectum Look for calcification Look for soft tissue masses. 3. Colonic and 1-2 small bowel Fluid Levels: Gastric 1-2 small bowel Check gasses in 4 areas: 1.Radiological Evaluation Normal Scout Always request: Supine. 4.
Bladder Rupture (BR) in the setting of blunt trauma may be classiﬁed as extraperitoneal or intraperitoneal 91. Pelvic Trauma About 70–97% of patients with BR from blunt trauma have associated pelvic fractures The two most common sign and symptoms are gross haematuria (82%–100%) and abdominal tenderness (62%) The classic combination of pelvic fracture and gross haematuria constitutes an absolute indication for immediate cystography in blunt trauma victims .
However. Lynch et al. When Properly Performed With 350 Cc Of Dilute (2%) Contrast Is An Excellent Substitute For Standard Cystography T. / European Urology 47 (2005) 1–15 .H. Ct Cystography. Standard CT Is Not Reliable In The Diagnosis Of BR.
com/article/120034 92. Thyroid Enlargement (goiter) Abnormal enlargement of the thyroid gland and can occur for a number of different reasons Multinodular Goiter Diffuse Goiter .http://emedicine.medscape.
medscape.http://emedicine.com/article/120034 Toxic goiter Classification associated with hyperthyroidism Examples: diffuse toxic goiter (Graves disease) toxic multinodular goiter toxic adenoma Nontoxic goiter Without hyperthyroidism or hypothyroidism It may be diffuse or multinodular Examples: goiter identified in early Graves disease endemic goiter chronic lymphocytic thyroiditis (Hashimoto disease) Underactive (hypothyroid goiter) .
93. Shoulder dislocation .
posteriorly or inferiorly Anterior dislocation most common Mechanism: Forced extension.Anterior Shoulder Subluxation/Dislocation Dislocation: Complete separation of articular surfaces Subluxation: Abnormal translation of humeral head on glenoid without complete separation of articular surfaces Humeral head can dislocate anteriorly. abduction. external rotation Direct blow to posterior or posterolateral shoulder Repeated episodes of overuse (subluxation) .
Anterior Shoulder Subluxation/Dislocation Physical Exam: Intense pain Arm held in abduction & external rotation Humeral head palpable anteriorly Unable to completely internally rotate or abduct the shoulder Thorough neuro exam (close relation of axillary nerve) .
Anterior Shoulder Subluxation/Dislocation Radiographs: Axillary View True AP Y view .
mild to moderately severe fracture configuration • C2deep contamination with local skin or muscle contusion. moderately severe fracture configuration • C3extensive contusion or crushing of skin or destruction of muscle. severe fracture . Tibia-fibula Shaft Fracture Tscherne Classification 0-3 Based on degree of displacement and comminution • C0simple fracture configuration with little or no soft tissue injury • C1superficial abrasion.94.
org . Union rates as high as 97% Kenneth J.Nonoperative Treatment Fracture reduction followed by application of a long leg cast with progressive weight bearing can be used for isolated..aofoundation. Cast above knee. closed. Handbook of Fractures. the long leg cast may be exchanged for a patellabearing cast or fracture brace. lowenergy fractures with minimal displacement and comminution. Joseph D. Zuckerman. 3rd Edition Lippincott Williams & Wilkins 2006 https://www2. with the knee in 0 to 5 degrees of flexion After 4 to 6 weeks.
Operative fracture management Operative treatment of displaced unstable tibia shaft fractures is the treatment of choice if it can be performed in facilities with the necessary equipment and skills Surgical treatment is necessary for open fractures (wound debridement). and repair of arterial injuries . compartment syndromes.
sebelum dipasang gips sirkuler. • Lempengan Gips/CAST Dapat Digunakan Pada – Imobilisasi Fraktur – Imobilisasi pada penyakit tulang dan sendi – Pencegahan deformitas muskuloskeletal . hal 2-6 Bidai /Splint adalah alat yang digunakan untuk mengimobilisasi bagian tubuh. 2006. In: Petunjuk pemasangan gips paris pada kasus orthopaedi. Penggunaan Gips Paris. Divisi Orthopaedi dan traumatologi. alat tersebut dapat bersifat lunak ataupun kaku (rigid) • Plaster slab adalah lempengan gips untuk imobilisasi sendi atau daerah cidera sehingga terjadi penyembuhan. Syaiful AH. Sebagian besar fraktur dislab untuk 24-48 pertama untuk mengakomodasi pembengkakan.Fiksasi Fraktur * Aryadi K.
Imobilisasi Fraktur Temporer •Akomodasi pembengkakan Definitif .
Injuries of the foot and ankle In: Brinker Review of Orthopaedic Trauma. W. Saunders. Dimulai dari setinggi kaput fibula sampai jari-jari kaki. Ruptur tendon flexor pedis.B. 20 lapis.Imobilisasi cedera ekstremitas bawah Anterior Slab Indikasi*: ruptur tendon achilles (pascaoperasi). Dipertahankan 4-6 minggu McGarvey WC. Posisi plantar fleksi 30-55 derajat. Ed Brinker MR. 2001 p 153-80 . ruptur muscle belly (flexor). Gips 6 inch.
Ed Brinker MR. 8-12 lapis. W. Posisi plantigrade. 2001 p 153-80 . fraktur pergelangan kaki. Ed Brinker MR. Posterior Slab Indikasi*: imobilisasi sementara untuk fraktur tibia (plateu. fraktur metatarsal. McGarvey WC. Injuries of the foot and ankle In: Brinker Review of Orthopaedic Trauma. Tibial Shaft Fracture In: Brinker Review of Orthopaedic Trauma. Saunders. W.B.B. Gips 6 inch. ruptur tendon esktensor pedis. Dimulai dari kaput fibula hingga jari-jari kaki Dipertahankan 4-6 minggu Gorczyca JT. 2001 p 127-30. shaft. Saunders. plafond).
or sticks alongside the leg. blankets. etc. Any soft material such as clothing.First aid for tibial fractures An important step in treating a tibia shaft fracture is promptly to realign the deformed leg and to splint it in corrected alignment.aofoundation. Additional stabilization can be achieved by splinting the fractured leg to the contralateral normal lower extremity Any padded splintage is better than none. from above the knee to below the ankle It is essential to apply padding between a splint and the injured leg. can be used as emergency padding. but circumferential wraps must not be so tightly applied that they interfere with blood flow https://www2. Splinting can be done with two firm boards. The splints should then be kept together by bandages around both splints and the leg.org .
uk/Conditions/Tetanus/Pages/Symptoms.nhs.95.aspx . The average incubation period is about 10 days. Muscle spasms and stiffness http://www. Tetanus The incubation periodis usually 4 to 21 days.
NOTE: Large rectangular gram-positive bacilli NOTE: Double zone of hemolysis Inner beta-hemolysis = θ toxin Outer alpha-hemolysis = α toxin .
97 . .
infraorbital region & upper teeth on injured side Eyelid swelling Inability to close mouth properly Swelling. Edema.98. Zygomatic Fractures Signs & Symptoms: Pain Mastication speaking Numbness of the cheek. Ecchymoses Flattened cheekbone Palpable depression at fracture site .
Zygomatic bone complex Anatomy Star-shape like with four processes Frontal process Temporal process Buttress Orbital floor (Maxilla and GWSB) Zygoma fracture often related with maxilla fractures Temporal fascia and muscle Masseter muscle 203 .
Nasal Fractures May be associated with more extensive injuries Orbital rim or floor Ethmoid or frontal sinuses Signs & Symptoms: Pain Swelling Epistaxis Lacerations Respiratory Obstruction .
voice tiring. Complication Thyroide Surgery Hypoparathyroidism the most common immediate surgical complication of total thyroidectomy low blood levels of calcium hypocalcemia Treatment: calcium gluconate IV Voice change the recurrent laryngeal nerve lost voice the external branch of the superior laryngeal nervecant yell Temporary voice changes.99. they are likely to be permanent http://endocrinediseases.sht . and weakness more than 6 months after the operation.org/thyroid/surgery_complications. such as mild hoarseness.
Bleeding in the neck can compress the windpipe and cause difficulty breathing Seroma a fluid collection under the incision which feels like fullness or swelling Infection ramsayhealth.uk .co.
com soundnet.100.cs.edu . Posterior Hip Dislocation Symptoms • knee pain • pain in the back hip • difficulty moving the lower extremity • The leg is shortened and internally rotated with flexion and adduction at the hip Risk Factor • Accident • Improper seating adjustment • sudden break in the car netterimages.princeton.
Wrist Slitting .101.
Associated tendons frequently superficial tendons Central WristTendon m. people rarely die from this type of suicide attempt . Flexor Carpi Radialis Deep cutProfunda tendons Flexor Digitorum Superficial(FDS) Flexor Digitorum Profunda(FDP) Median nerve sometimes injured‖ape hand‖ The arteries are so small in the wrist. Palmaris Longus (most superficial) Lateral WristTendon m.
80% involve waist . 87% involve distal pole In adults.102. Scaphoid Fracture The most common fracture after fall with outstretched hand Blood supplied from distal pole In children.
Imaging Initial plain films often normal Bone scan 100% sensitive and 92% specific at 4 days MRI. CT scan .
re-evaluate for tenderness If +tenderness but neg radiographs…. TREATMENT Initial radiographs positive distal third heal in approx 6-8 weeks middle third frx heal in 8-12 weeks proximal third heal in 12-23 weeks Initial radiographs negative Immobilize thumb spica cast x 714 days Take out of cast. .
Alvarado Score .103.
Trauma patient .104.
105. Chest X-Ray The PA (posterioranterior) film is obtained with the patient facing the cassette and the x-ray tube 6 feet away in the supine AP (anteriorposterior) position the x-ray tube is 40 inches from the patient .
. The AP shows magnification of the heart and widening of the mediastinum.This is a PA film on the left compared with a AP supine film on the right. AP views are less useful and should be reserved for very ill patients who cannot stand erect. Whenever possible the patient should be imaged in an upright PA position.
ufl.surgery. titrate to UOP of 0. Burn injury Initial Assessment Burn Resuscitation with Lactated Ringer‘s Figure out burn size by ―rule of nines‖ or entire palmar surface of patient‘s hand = 1% Parkland/Baxter formula 4 x Wt(kg) x %TBSA = mL to give in 1 day Half over 1st 8hrs (subtract what was given) Give other Half over next 16 hours In reality.edu .5mL/kg/hr in adults and 1mL/kg/hr in children Do not give colloid in first 24 hrs education.106.