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

Antidiabetic Drugs .16.

Hypertension .3.

ACE-I (kaptopril.1. lisinopril): Bradikinin & substansi P  batuk ARB (valsartan. 2. losartan): Tidak menyebabkan batuk .

A review. no association between coffee and dyspepsia is found. Samsom M. Coffee and gastrointestinal function: facts and fiction. other studies indicate that coffee does not affect gastric emptying or small bowel transit. – Coffee stimulates gastrin release and gastric acid secretion. • Although often mentioned as a cause of dyspeptic symptoms. Heartburn • Effect of caffeine on GI tract: – Coffee promotes gastro-oesophageal reflux. – Coffee also prolongs the adaptive relaxation of the proximal stomach. van Berge Henegouwen GP. suggesting that it might slow gastric emptying. . Boekema PJ. Scand J Gastroenterol Suppl. – Coffee increases rectosigmoid motor activity. – Coffee induces cholecystokinin release and gallbladder contraction.230:35-9. However. 1999.4. Smout AJ.

5. Anaphylactic Shock World Allergy Organization anaphylaxis guidelines: Summary .

5. Anaphylactic Shock World Allergy Organization anaphylaxis guidelines: Summary .

6. Hipersensitivitas .

Asthma: therapy • Asthma management has six interrelated parts: 1. regular followup GINA 2005 . Assess & monitor severity 3. Education 2. Avoid exposure to risk factors 4. individual medication plans 5.7. plans for managing exacerbations 6.

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7. Asthma: therapy .

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

Dyslipidemia • Estimation of LDL using Friedewald formula: – LDL = Total cholesterol – HDL – TG/5 – TG/5 is a representative of VLDL – This equation can’t be used if the TG is >400 mg/dL. • LDL = 500 – 30 – (350/5) = 400 mg/dL .8.

Hiperkortisolisme .9.

Hipertensi dengan Bradikardia .10.

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ikterik menghilang. hepatoprotektor Hentikan semua OAT & uji fungsi hati Stop etambutol Stop rifampisin Vertigo & nistagmus (n. 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.VIII) Streptomisin Muntah & confusion Gangguan penglihatan Kelainan sistemik. syok & purpura Sebagian besar OAT Etambutol Rifampisin .d.11. E.S.

11. OAT Minor Minor Kemungkinan Penyebab Tata Laksana Tidak nafsu makan.S. 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 . mual. E. sakit perut Nyeri sendi Kesemutan s.d.

hipernatremia . Hiperkortisolisme • Elektrolit: hipokalemia.12.

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

14. Arrhytmia • SVT: – young • AF: – Elderly – History of hypertension .

15. Arrhytmia • Second degree AV block 3:1 .

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

• Rujuk ke ahli paru. TB Paru Pada Gagal Ginjal • Jangan menggunakan streptomisin. kreatinin). & kapreomisin. • Sebaiknya hindari penggunaan etambutol karena waktu paruhnya memanjang & terjadi akumulasi etambutol. • Sedapat mungkin dosis disesuaikan dengan faal ginjal (CCT. .17. kanamisin. ureum.

CNS. • DUMBELS: diarrhea. especially acetylcholinesterase in synapses and on red-cell membranes. . urination. Organophosphate Intoxication • Organophosphorus pesticides inhibit esterase enzymes. lacrimation. • Acetylcholinesterase inhibition  accumulation of acetylcholine & overstimulation of acetylcholine receptors in synapses of the autonomic nervous system. salivation. bradycardia/bronchorea/bronchospasm.18. miosis. Journal compilation 2008 Blackwell Munksgaard. Allergy 2008: 63: 990–996. emesis. Review article: Allergic rhinitis management pocket reference 2008. and neuromuscular junctions  DUMBELS.

18. Organophosphate Intoxication .

19. Penyakit Paru .

– Ronki halus disebabkan oleh terbukanya saluran napas secara mendadak yang tadinya tertutup. red cells.20. Suara Napas Tambahan • Ronki: – Suara berisik & terputus akibat airan udara yang melewati cairan. • Pneumonia: – Congestion: vascular engorgement. and fibrin filling the alveolar spaces . . – Resolution: the consolidated exudate within the alveolar spaces undergoes progressive enzymatic digestion. and often the presence of numerous bacteria. – Hepatization: massive confluent exudation with neutrophils. – Ronki kasar disebabkan oleh aliran udara yang melewati cairan. intra-alveolar fluid with few neutrophils.

Regulasi Cairan Tubuh • Regulasi osmolaritas cairan ekstrasel diatur dengan vasopresin (ADH). .21.

However. 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. 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. these medications lose their selectivity and may also block other types of beta receptors throughout the body. which are another type of receptor found in the blood vessels. • 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. at the high doses often needed to control angina.22. These medications have the added benefit of dilating blood vessels. • . producing more side effects. Some beta blockers (such as labetalol or carvedilol) also block alpha receptors.

syok & purpura Sebagian besar OAT Etambutol Rifampisin . 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.VIII) Streptomisin Muntah & confusion Gangguan penglihatan Kelainan sistemik.23. hepatoprotektor Hentikan semua OAT & uji fungsi hati Stop etambutol Stop rifampisin Vertigo & nistagmus (n. ikterik menghilang.S. E.

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 .24.

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

Robbins & Cotran pathologic basis of diseases .. fever)  one of the most common & serious complications in patients whose immune defenses are suppressed by: – disease. Pneumoniae in the Immunocompromised Host • Pulmonary infiltrate.26. or – irradiation. – immunosuppressive therapy for organ transplants. with/without signs of infection (e.g. – chemotherapy for tumors.

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. Robbins & Cotran pathologic basis of diseases . – In the lungs. and they show cellular & nuclear pleomorphism. epithelial and endothelial cells are affected. often to a diameter of 40 μm. the alveolar macrophages. – Affected cells are strikingly enlarged.26.

Harrison’s principles of internal medicine. fever. tachycardia. – CXR: bilateral diffuse infiltrates beginning in the perihilar regions. Robbins & Cotran pathologic basis of diseases. – tachypnea. Pneumoniae in the Immunocompromised Host • Pneumocystis jiroveci/carini: – dyspnea. – definitive diagnosis is made by histopathologic staining methenamine silver selectively stain the wall of Pneumocystis cysts. but lung auscultation reveals few abnormalities.26. nonproductive cough. and cyanosis. .

Pneumonia .27.

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 – – – – .

Anticoagulant Therapy .28.

Anticoagulant Therapy • ISI: international sensitivity index – 1 is the best • MNPT: mean normal PT laboratory .28.

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Rheumatoid Arthritis .29.

29. in altering the underlying disease process. if any. Rheumatoid Arthritis • NSAIDs: – Are important for symptomatic relief but play only a minor role. – Aspirin is the oldest drug of the non-steroidal class. aspirin’s 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. a narrow window between toxic and anti-inflammatory serum levels. but because of its high rate of GI toxicity. . and the inconvenience of multiple daily doses.

30. • Bundle branch block: – Changes of width and configuration of the QRS complexes. 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. .

and AVL. I. . ECG • Criteria for Right Bundle Branch Block – QRS complex greater than 0.30. V6.12 s. – RSR' in V1 & V2 (rabbit ears) with ST segment depression & T wave inversion – Reciprocal changes in V5.

. V6.30. with ST segment depression and T wave inversion – Reciprocal changes in V1 and V2 – Left axis deviation may be present. 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. I. and AVL.

2011. or a sense of fatigue in the muscles. but up to 50% of patients do not have symptoms of neuropathy. Harrison’s principles of internal medicine.31. – Symptoms may include a sensation of numbness. it occurs during exercise and is relieved by rest. loss of ankle reflexes. and dysesthesia also may occur. paresthesia. or burning that begins in the feet and spreads proximally. which is defined as a pain. numbness. McGraw-Hill. – It most frequently presents with distal sensory loss. sharpness. • Peripheral artery disease: – The most common symptom is intermittent claudication. 18th ed. DM Complications • Diabetic neuropathy is distal symmetric polyneuropathy. – Physical examination reveals sensory loss. . ache. and abnormal position sense. tingling. – Hyperesthesia. cramp.

32. – 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. Cardiomegaly • Left Atrium – The two “popular” radiologic signs of left atrial enlargement—a double contour within the right cardiac border and elevation of the left main bronchus—are accurate when present. . but they are insensitive and seen in only about half the cases of mitral valve disease.

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

• Right ventricle: – Even moderate right ventricular enlargement may produce no abnormality in this view other than some prominence of the main pulmonary artery.32. – As right ventricular size increases. – 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. the transverse diameter of the heart enlarges to the left. 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. and the cardiac apex becomes blunted and elevated.

34. Nefropati Diabetik Perkeni 2011. .

penghambat ACE. . atau kombinasi keduanya – Jika terdapat kontraindikasi terhadap penyekat ACE atau reseptor angiotensin. Jika terjadi penurunan fungsi ginjal yang bertambah berat. diet protein diberikan 0. dapat diberikan antagonis kalsium non dihidropiridin.34. transplantasi). – Terapi dengan obat penyekat reseptor angiotensin II.6 – 0.8 gram/kg BB per hari. – 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. Nefropati Diabetik • Tatalaksana: – Kendalikan glukosa darah – Kendalikan tekanan darah – Diet protein 0.8 gram/kgBB per hari.

IMA. operasi besar. 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.34. 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 .

accelerated atherosclerosis Anemia due to erythropoietin deficiency. bleeding (due to platelet dysfunction) Hyperkalemia.35. glomerulonephritis. Signs & Symptoms of Uremia General Neurologic Nausea. pruritus Encephalopathy. anorexia. neuropathy Cardiovascular Hematologic Metabolic Pericarditis. 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. hyperphosphatemia. seizures. druginduced. malaise. hypocalcemia . myeloma. fetor uremicus. hypertension.

Chronic Kidney Disease Pathophysiology of disease.35. .

Hipovitaminosis .36.

Berjalan 20 menit: 48 kkal. Calorie Calculator • • • • • • Kalori dari telur goreng: 90 kkal. Bersepeda 5 menit: 25 kkal. Berlari kencang 5 menit: 50 kkal.37. . Bersepeda 10 menit: 50 kkal. Berlari kencang 10 menit sekitar 90 kkal.

DM Complications .38.

2010. – 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.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.

2010. 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. Necrosis • Gangrenous necrosis – Not a specific pattern of cell death.39.

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

Necrosis • Caseous necrosis – encountered most often in foci of tuberculous infection. Robbins & Cotran Pathologic basis of disease.39. 2010. – 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). .

– In this disorder pancreatic enzymes leak out of acinar cells & liquefy the membranes of fat cells in the peritoneum.39. . typically resulting from release of activated pancreatic lipases into the substance of the pancreas and the peritoneal cavity. The fatty acids combine with calcium to produce grossly visible chalky-white areas (fat saponification). – The released lipases split the triglyceride esters contained within fat cells. Robbins & Cotran Pathologic basis of disease. 2010. Necrosis • Fat necrosis – focal areas of fat destruction.

Robbins & Cotran Pathologic basis of disease. – Deposits of these “immune complexes. result in a bright pink and amorphous appearance in H&E stains. – This pattern of necrosis typically occurs when complexes of antigens and antibodies are deposited in the walls of arteries.” together with fibrin that has leaked out of vessels. 2010. called “fibrinoid” (fibrin-like) by pathologists. .39. Necrosis • Fibrinoid necrosis – a special form of necrosis usually seen in immune reactions involving blood vessels.

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 patient’s 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.

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. .42.

NSAID .43.

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

• Infeksi juga dapat masuk melalui luka yang terkontaminasi.44. . botulinum biasanya disebabkan oleh makanan yang terkontaminasi: – Daging yang tidak digoreng – Ikan yang tidak matang – Sayuran kaleng yang terbuka. Clostridium Botulinum • Infeksi C.

• Toksin memecah protein yang berperan pada proses fusi vesikel-berisi asetilkolin ke membran presinaps  asetilkolin tidak dapat disekresi  paralisis flaksid (lumpuh layu). ujung saraf postganglion parasimpatik.44. & terutama di neuromuscular junction. ganglia perifer. antara lain. . Clostridium Botulinum • Botulinum toksin dari saluran cerna atau luka  darah  ujung saraf kolinergik di perifer.

. patients who have undergone a cholecystectomy may find that they are less able to tolerate large fatty meals.45. • Thus. 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.

aeur rod may (+) Therapy Can be delayed if asymptomatic CDC. erythrocytes. weak. hepatomegaly/splenomegaly. bone pain. dominant myelocyte & segment Lymphobla st >20% Myeloblast >20%. bleeding/bruising easily.o. smudge cells Mature granulocyte. Mainly adults Common in children Adults & children Symptoms & Grow slowly  may asymptomatic. Lab Mature lymphocyte. Grow quickly  feel sick & go to their doctor. Prevalence Over 55 y. This makes it hard for normal blood cells to do their work.gov Treated right away .46. frequent infection. swollen lymph nodes. Leukemia CLL CML ALL AML The bone marrow makes abnormal leukocyte  dont die when they should  crowd out normal leukocytes. Signs the disease is found during a routine test. weight loss. & platelets. Fever.

Hipertiroidisme .47.

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

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

Leukemia Granulositik Kronik • • The marrow aspirate and biopsy are essential to the diagnosis of the myeloproliferative disorders. Chromosomal studies of peripheral blood and marrow are important. primarily to distinguish CML from the other 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.49.

50. Asma .

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51. Asthma .

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

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

Current diagnosis & treatment in rheumatology. • Preventing further attacks by uric acid lowering agent: – Allopurinol – Probenecid • Uric acid lowering agent shouldn’t be given on acute attack. 2007. – Corticosteroid if NSAID is contraindicated. McGraw-Hill. Arthritis • The management of acute gout is to provide rapid & safe pain relief.52. . unless the patient has consumed it since 2 weeks before. – NSAID. – Colchicine. 2nd ed.

and severe cramping abdominal pain. – Gastrointestinal side effects include gas. but other NSAIDs may be just as effective. diarrhea. vomiting. nausea. . • Colchicine: – is effective but less well tolerated than NSAIDs.52. Arthritis • NSAID: – Indomethacin is historically the NSAID of choice for acute gout.

Primary polydipsia (psychogenic). 4. in which the initiating event is ingestion of excess fluid and the subsequent hypotonic polyuria is an appropriate physiologic response. Nephrogenic diabetes insipidus with an inadequate renal response to vasopressin. Polyuria • If polyuria is shown to be dilute. . Transient diabetes insipidus of pregnancy produced by accelerated metabolism of vasopressin.53. Hypothalamic or central diabetes insipidus with inability to synthesize and secrete vasopressin. pathophysiologic mechanisms include: 1. 3. 2.

Greenspan’s clinical endocrinology. •   Harrison’s principles of internal medicine. 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. Polyuria • During the dehydration or water deprivation test: – primary polydipsia: concentrate his urine without becoming hyperosmolar – diabetes insipidus: become hyperosmolar without concentrating the urine. 18th ed.53. . – partial hypothalamic DI concentrate their urine minimally with dehydration. but the maximum urinary concentration is not achieved. After the patient is given desmopressin: – Hypothalamic DI has minimal concentration of the urine & an additional  in urine osmolality of at least 50%.

ANESTESIOLOGI & RADIOLOGI .ILMU BEDAH.

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 .

radial displacement and angulation and avulsion of ulnar styloid process .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.

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 .

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Femur Fractures • • • • Common injury due to major violent trauma 1 femur fracture/ 10. motorcycle.55. auto-pedestrian. and gunshot wound accidents are most frequent causes .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. aircraft.

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.Symptoms in children • • • • • child has severe pain The thigh is noticeably swollen or deformed Expanding thigh hematoma unable to stand or walk. greenstick fractures) .

56. Hernia
HERNIA HIATALHERNIA 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.

Directusually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle

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

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 .57.

Complications of Fracture Healing • Delayed Union – Poor blood supply or infection.co. rotated.uk/tutorials/musculoskeletal/trauma/trauma_x-ray_page8. • Non-Union – Bone loss or wound contamination.html 58. • Malunion – Bone healed in a nonanatomic position – Can be angulated. 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 .http://radiologymasterclass.

59. • Femoral head – most common by far • Shoulder – humeral head • Odontoid (Neck) • Scaphoid (Wrist) • Lunate (Wrist) • Talus (Ankle) . Avascular Necrosis • Definition Loss of blood flow to the bone leading to death of the cellular components of bone.

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

usually with sudden starting or stopping • “Snap” in heel with pain. Acute Achilles Tendon Rupture • Adults 40-50 y. which may subside quickly .60. primarily affected (M>F) • Athletic activities.o.

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

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fast. reproducable.Imaging of Achilles tendon • Ultrasound – Inexpensive. dynamic examination possible – Operator dependent – Best to measure thickness and gap – Good screening test for complete rupture .

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

Gallbladder Disorder .61&62.

Cholelitihiasis Choledocholithiasis Appendicitis . 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. © 2009.no icteric.recurrent dyspepsia.specific signs(rovcing.USG:may be calculus/not.no fever.recurrent RUQ pain.McBurney. Gallbladder stone Clinical symptoms Acute: fever. only use this terms if the stone location is not established Colicky pain(biliary colic). 8th edition.Mosby's Medical Dictionary.pain after fatty meal.nausea.may be with cholangitis signs(charcoats triads) Pain on right lower quadrant.icteric. Elsevier.right upper quadrant(RUQ) pain.Ro:radioopaque RUQ Symptoms depend on stone location.migratory pain.cyst wall thickening Recurrent RUQ pain.murphy’s sign +.no icteric.vomiting.etc) Term Cholecystitis Definition Inflammation of the gallbladder Cholecystolitiasis the presence of gallstones in the gallbladder. may be icteric Chronic:no fever.

Cholelitiasis laboratorium Findings • No sign of obstruction – Normal Liver function test.Urobilinogen • Sign of obstructionCholedocholithiasis – Increase LFT – Increase Bilirubin – Increase alkaline phosphatase . Bilirubin.62.

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 .

com/article/437884-overview#a0104 • Pathophysiology – testosterone and LH levels are normal. FSH levels are increased .http://emedicine.medscape. but due to lack of inhibin.

• the diagnosis of appendicular tuberculosis is usually made on histopathological examination of the appendectomy specimen .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.

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

Tamponade Jantung .65.

• Needle pericardiocentesis is often best when the etiology is known or the presence of tamponade is in question .• Tamponade suspected – Echocardiography – Pericardiocentesis • done immediately for diagnosis and treatmenta brief delay might be life threatening.

wikipedia.org/wiki/Burn 66. Burn Injury prick test (+) .http://en.

• 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. kelamin. persendian. pernapasan . tangan-kaki.

traumaburn.shtml .org/referring/fluid.To estimate scattered burns: patient's palm surface = 1% total body surface area Total Body Surface Area Parkland formula = baxter formula http://www.

Le Fort Fracture .67.

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Prostatic malignancy .68.

PSA—Prostate 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 .

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69. Management of Trauma Patient .

70. Syok Anafilaktik .

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

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 .71.

• hollow organs include: – stomach – intestines – gallbladder – bladder  solid organs include:  liver  spleen  kidneys .Hollow and Solid Organs The type of injury will depend on whether the organ injured is solid or hollow.

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 .

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 .Blunt Abdominal Trauma • Signs of intraperitoneal injury – Abdominal tenderness. peritoneal irritation – Distention pneumoperitoneum.

• 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

Cullen’s sign: purple-blue discoloration around umbilicus (peritoneal hemorrhage)

Grey Turner’s 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 • Kehr’s 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

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 .Tachypnea. Bloody Sputum Diminished Breath Sounds on Affected Side.Tachycardia Frothy.com/article/2047916 73.medscape.http://emedicine. Dullness to percussion Opening in lung tissue that leaks air into chest cavity. Dyspnea.Tachypnea Decreased Breath Sounds on Affected Side.hipersonor Opening in chest cavity that allows air to enter pleural cavity.Flat Neck Veins.Sudden sharp pain. Chest Pain.Signs of Shock.Dyspnea. Chest Trauma Disorders Etiology Clinical Hemothorax lacerated blood vessel in thorax Anxiety/Restlessness.

Disorders Tension Penumothorax Etiology Clinical Anxiety/Restlessness. inflammation . pneumonia.painful when breathing. Dullness to percussion. chest pain. 3 ribs broken in 2 or more places. cough.dysnea. and asymmetrical chest expansion.Tachypnea. diminished or delayed expansion on the side of the effusion Fever. with diminished or delayed expansion on the side of the effusion.Tachycardia Absent Breath sounds on affected side.Paradoxical breathing Dyspnea.Hypotension Tracheal Deviation. which results from pleural irritation. JV Distention Narrowing Pulse Pressures.rales in ausultation Pleural Efusion congestive heart failure. decreased tactile fremitus. Accessory Muscle Use. or pulmonary embolism infection Pneumonia Infection.Poor Color Dyspnea.cough. and asymmetrical chest expansion. decreased tactile fremitus. Severe . hypersonor Flail Chest Trauma a segment of the rib cage breaks becomes detached from the rest of the chest wall. malignancy.

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

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 .74.

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

Rectus Inferior . Rectus Media • External Hemorrhoids external hemrroidal plexus – V. Rectus Inferior – V.• Internal Hemorrhoids Internal hemorrhoidal plexus – V.

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 .

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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 . Bladder Stone • Bladder calculi are usually associated with urinary stasis • Urinary infections increase the risk of stone formation • Foreign bodies (e.77.g.

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Hirschsprung’s 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 .78.

Symptoms in newborn age • Fail to pass meconium (in 24 hours of life) • Abdominal distension. but the abdomen is palpable • Vomiting • The rectal tube can’t 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 .

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 .Symptoms in infants • • • • Constipation Meteorism Palpable faecaloma Sometimes putrescent diarrhea • Ulceration.

irregular contractions of aganglionic segment – Delayed evacuation of barium • Biopsy : – absence of ganglion cells – hypertrophy and hyperplasia of nerve fibers. – Empty rectum • Contrast enema – Transition zone – Abnormal.• 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. .

Pain and crepitus detected on palpation – Careful NV exam is essential. Humerus Fractures • Proximal Humerus Fractures • Clinical Evaluation – Patients typically present with arm held close to chest by contralateral hand. particularly with regards to the axillary nerve. Deltoid atony does not necessarily confirm an axillary nerve injury . Test sensation over the deltoid.79.

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 .

Urine Incontinence .80.

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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 .81.

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confirmed by color Doppler sonogram in a patient with complete resolution of symptomsdefinitive surgical fixation of the testes before leaving the hospital • Surgical detorsion definitive treatment • Orchiectomyif the testis is necrotic .Treatment • Manual detorsion – If it is successful (ie.

82. Pathophysiology of Foot Ulceration  Neuropathic Ischemic Neuro -ischemic .

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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.83. 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. and sweat glands may be seen in the cyst wall – Benign cystic teratoma • Resembles a dermoid cyst • Treatment – Surgical excision . sebaceous glands.

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

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 .84.

Hernia Skrotalis .85.

86. Head Injury .

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Trauma Olahraga .87.

Kidney reaches adult position. 5th week Testis begins its primary descent. C. kidney ascends. 8th-9th weeks.88. 189 . B. 7th month. D. Testis at internal inguinal ring.Undescended Testis A. gubernaculum (in inguinal fold) thickens and shortens. Postnatal life.

B. Undescended testes. Perineal ectopia not shown. Ectopic testes. Percentages of testes arrested at different stages of normal descent 190 .A.

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 .

o. primarily affected (M>F) • Athletic activities. Acute Achilles Tendon Rupture • Adults 40-50 y. which may subside quickly . usually with sudden starting or stopping • “Snap” in heel with pain.89.

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

Humeral Shaft Fractures • Holstein-Lewis Fractures – Distal 1/3 fractures – May entrap or lacerate radial nerve as the fracture passes through the intermuscular septum .91.

Ileus is a paralytic or functional variety of obstruction Obstruction is: Partial or complete Simple or strangulated . 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.92.

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 .Causes.

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

Examination General •Vital signs: P. jaundice. Sat •dehydration •Anaemia. T.2. •CNS •Vascular •Gynaecological •muscuoloskeltal •Rectal examination • Darm kontur: visible shape of intestines on the abdomen • Darm Steifung: visible peristaltic movement on the abdomen . 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. BP. guarding and rebound •Organomegaly •Bowel sounds –High pitched (metallic sound) –Absent Others Systemic examination If deemed necessary. RR.

Radiological Evaluation Normal Scout Always request: Supine. 3. Erect and CXR Gas pattern: • • • • 1. psoas shadow Look for fecal pattern . 4. 2. 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. Gastric.

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 .

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

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Add K+ at 1mmmol/kg • • • • • • • • • • Draw blood for lab investigations Inform a senior member in the team. . 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. 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….

Hemorrhaegic Shock .93.

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 .94.

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 .

and distal radius optimized by optima .Osteoporosis Tipe 1 (POSTMENOPAUSAL) • affects primarily trabecular bone • 5 years after menopause • weight-bearing bones fractures vertebrae. ankle.

Osteoporosis .

msdlatinamerica.(A) Normal right hip with trabecular pattern well demonstrated. (B) (B) Osteoporotic right hip with poorly defined trabeculae (arrows) http://www.ht ml .com/ebooks/Mu sculoskeletalImagingCompanion/sid250409.

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 peritoneumliver disease • Fluid builds up in the abdomen.95.umm. Peritonitis • Peritonitis – an inflammation of the peritoneum. 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.edu/altmed/articles/peritonitis-000127.htm#ixzz28YAqqYSG .

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

.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. • The abdomen may be rigid and boardlike • Accumulations of fluid will be notable in primary due to ascites. because the intestine usually stops functioning.

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

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 .

org.Child choking Abdominal thrust = “Heimlich manouvre” www.resus.uk/pages/pchkalgo.pdf .

shtml . Total Body Surface Area Parkland formula = baxter formula http://www.traumaburn.To estimate scattered burns: patient's palm surface = 1% total body surface area 98.org/referring/fluid.

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

1971 1.Pathogenesis Waldvogel. Hematogenous 2. Contiguous focus of infection 3. Direct inoculation .

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

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

• Acute hematogenous osteomyelitis has a predilection for the long bones of the body.hawaii.html . • 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.edu/medicine/pediatrics/pedtext/s19c04.

Radiologic Findings Of OA In knee (genu) x-ray • Narrowing of joint space (due to loss of cartilage) • Osteophytes • Subchondral (paraarticular) sclerosis • Bone cysts .100.

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asp?issn =0970-1591. http://www.indianjurol. BPH-associated Acute Urinary Retention AUR:Acute urinary retention PUC:Perurethral catheter SPC:Suprapubic catheter TWOC:Trial without catheter α-Blocker • relaxing smooth muscle fibers located in the prostate and its capsule.101. 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.year=2007 .com/article.

org/wiki/Urinary_retention .Treatment Urinary Retention PUC:Perurethral catheter SPC:Suprapubic catheter http://en.wikipedia.

500 ml per femur . Volume Perdarahan Fraktur Femur • Femur bone anatomy – Near major blood vessel (femoral artery) • Femur Fracture blood loss up to 1.102.

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 .

(3:1 rule) .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.

• Fluid resuscitation target: – Euvolemia – Improve perfusion – Improve oxygen delivery British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients 2011 .

swelling. Bowel sound on scrotum. 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. accumulation of fluids around a testicle.com/article/ http://en.http://emedicine. vomiting. 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. Gastrointestinal upset with nausea and vomiting. fever.org/wiki/ 103. Male Genital Disorders Disorders Testicular torsion Etiology Intra/extra-vaginal torsion Congenital anomaly.wikipedia. Varicocele is often described as feeling like a bag of worms Mass in scrotum when coughing or crying. possibly trauma . edematous. Strangulated  nausea. swollen testicle.Transillumination + Hidrocele Varicocele Hernia skrotalis Scrotal pain or heaviness.medscape.

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 .

Orchitis • Orchitis is an inflammation of the testes.105.bed • Elevate scrotum • Ice pack • Antibiotics • Analgesics • Anti-inflammatory . • Etiology – Mumps – Testicular congestion – Viral – Parasitic – Trauma • Signs & Symptoms – Pain – Swollen Treatment • Rest .

106. Orbital Wall Anatomy • The 4 Walls of orbit are: – Roof – frontal bone – Floor – maxillary and zygomatic – Lateral – sphenoid and zygomatic – Medial – ethmoid. and lesser wing of the sphenoid . maxilla. lacrimal.

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• Left zygoma • Maxillary process of zygomaone of the components of lateral orbital floor .