dr. Himawan, dr. Cemara, dr. Dini, dr. Yusuf, dr. Ratna, dr. Rini, dr. Valenchia, dr.

Alvin, dr. Anshari

1-2. Myocardial Infarct Complication

1-2. Myocardial Infarct Complication

Papillary Muscle Rupture Ischemic necrosis and rupture of an LV papillary muscle may be rapidly fatal because of acute severe mitral regurgitation. Partial rupture, with more moderate regurgitation, is not immediately lethal but may result in symptoms of heart failure or pulmonary edema. Because it has a more precarious blood supply, the posteromedial LV papillary muscle is more susceptible to infarction than the anterolateral one. Severe mitral regurgitation in myocardial infarction with or without papillary muscle rupture is mostly related to inferior infarction and often follows reinfarction, particularly in non-papillary muscle rupture cases.

Heberdens & Bouchards nodes

3. Arthritis

http://www.gentili.net/foot/ra.htm

3. Arthritis

Osteoarthritis:
space narrowing (white arrow),

Gout arthritis:
Acute gouty arthritis: soft tissue

swelling. Advanced gout: the erosion are slightly osteophytes/spur (arrowhead), removed from the joint space, have a subchondral cysts, rounded or oval shape, & are characterized by a hypertrophic subchondral sclerosis/eburnation calcified "overhanging edge." The joint (black arrow). space may be preserved or show osteoarthritic type narrowing. Current diagnosis & treatment in rheumatology. 2nd ed. McGraw-Hill; 2007.
Harrisons principles of internal medicine. 18th ed. McGraw-Hill; 2011.

Ciri Prevalens Awitan

OA
Female>male, >50 thn, obesitas gradual -

RA
Female>male 40-70 thn gradual +

Gout
Male>female, >30 thn, hiperurisemia akut +

SA
Male>female, dekade 2-3 Variabel +

Arthritis

Inflamasi

Patologi
Jumlah Sendi Tipe Sendi Predileksi

Degenerasi
Poli Kecil/besar Pinggul, lutut, punggung, 1st CMC, DIP, PIP Bouchards nodes Heberdens nodes Osteofit -

Pannus
Poli Kecil MCP, PIP, pergelangan tangan/kaki, kaki Ulnar dev, Swan neck, Boutonniere Osteopenia erosi Nodul SK, pulmonari cardiac splenomegaly RF +, anti CCP

Mikrotophi
Mono-poli Kecil-besar MTP, kaki, pergelangan kaki & tangan Kristal urat erosi Tophi, olecranon bursitis, batu ginjal Asam urat

Enthesitis
Oligo/poli Besar Sacroiliac Spine Perifer besar En bloc spine enthesopathy Erosi ankilosis Uveitis, IBD, konjungtivitis, insuf aorta, psoriasis

Temuan Sendi Perubahan tulang Temuan Extraartikular Lab

Normal

4. Penyakit Ginjal
Glomerular Disease:
hematuria, proteinuria, pyuria.

Sind. nefritik akut:

proteinuria 1-2 g/24 jam, hematuria dengan silinder eritrosit,

pyuria, hipertensi, retensi cairan, peningkatan kreatinin serum. Sind. nefrotik: proteinuria berat (>3.0 g/24 jam), hipoalbuminemia, hipertensi, hiperkolesterolemia,, edema/anasarka, & hematuria mikroskopik.

4. Renal Disorder
Diagnosis Acute glomerulonephritis Characteristic an abrupt onset of hematuria & proteinuria with reduced GFR & renal salt and water retention, followed by full recovery of renal function. recovery from the acute disorder does not occur. Worsening renal function results in irreversible and complete renal failure over weeks to months. renal impairment after acute glomerulonephritis progresses slowly over a period of years & eventually results in chronic renal failure. manifested as marked proteinuria, particularly albuminuria (defined as 24-h urine protein excretion > 3.5 g), hypoalbuminemia, edema, hyperlipidemia, and fat bodies in the urine. Rapidly progressive glomerulonephritis Chronic glomerulonephritis Nephrotic syndrome

Pathophysiology of disease: an introduction to clinical medicine. 5th ed.

5. Keracunan Sianida
Singkong mengandung linamarin yang dengan bantuan

enzim melepaskan cianida. Gejala keracunan singkong:

Mual, muntah, diare dan kepala terasa pusing. Sesak napas atau sukar bernaas dan dalam keadaan

keracunan berat bisa sampai pingsan. Jantung berdetak cepat Warna bibir, kuku, muka dan kulit kebiru-biruan dalam istilah medis cyanosis Kesadaran Menurun bahkan sampai koma Bisa timbul kejang kejang dan pingsan Dalam keracunan berat bisa sampai menimbulkan kematian.

6. PNH
PNH is characterized by attacks of intravascular

hemolysis and hemoglobinuria that occur chiefly at night while the patient is asleep. The complement attached in patients erythrocyte activated by low pH in the night hemolysis. Moderate splenomegaly & mild to moderate hepatomegaly are sometimes observed and should raise concerns about hepatic or splenic vein thrombosis.

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

7. Arthritis

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

Acute Gout

Tophy in chronic gout

8. DHF

9. Supraventricular Tachycardia

Lilly. Pathophysiology of heart disease.

10. Pharmacology
In patients with CVD or in primary prevention, it seems

prudent to continue ASA indefinitely unless side effects are present or a contraindication develops. Contraindications to Asetil salisylic acid (ASA):
intolerance and allergy Active bleeding,

hemophilia,
active retinal bleeding, severe untreated hypertension, an active peptic ulcer, or

another serious source of gastrointestinal or genitourinary

bleeding.

11. Myocardial Infarct Complication

12. Polycythemia Vera

Criteria PVSG (Polycythemia Vera Study Group) A1 Raised red cell mass (RCM), male > 36 ml/kg, female > 32 ml/kg A2 Normal arterial oxygen saturation > 92% A3 Splenomegaly B1 Platelet count > 400 x 109/l B2 White blood cell count (WBC) > 12 x 109/l B3 Leucocyte alkaline phosphatase > 100 B4 Serum B12 > 900 pg/ml or unbound B12 binding capacity > 220 pg/ml Diagnosis A1 + A2 + A3 establishes PV A1 + A2 + two of category B establishes PV

 Polycythemia vera (PV) develops slowly. The disease may not cause signs or

symptoms for years. When signs and symptoms are present, they're the result of the thick blood that occurs with PV. This thickness slows the flow of oxygen-rich blood to all parts of your body. Without enough oxygen, many parts of your body won't work normally. The signs and symptoms of PV include: Headaches, dizziness, and weakness Shortness of breath & problems breathing while lying down Feelings of pressure or fullness on the left side of the abdomen due to an enlarged spleen (an organ in the abdomen) Double or blurred vision and blind spots Itching all over (especially after a warm bath), reddened face, and a burning feeling on your skin (especially your hands and feet) Bleeding from your gums and heavy bleeding from small cuts Unexplained weight loss Fatigue (tiredness) Excessive sweating Very painful swelling in a single joint, usually the big toe (called gouty arthritis) In rare cases, people who have PV may have pain in their bones.
http://www.nhlbi.nih.gov/health/health-topics/topics/poly/signs.html

13. Cellular Changes

Metaplasia: the replacement of one type of cell with another

type. Dysplasia: literally means disordered growth. Dysplastic cells exhibit considerable pleomorphism and often contain large hyperchromatic nuclei. Hypertrophy: an increase in the size of cells, resulting in an increase in the size of the organ. Hyperplasia: an increase in the number of cells in an organ or tissue, usually resulting in increased mass of the organ or tissue. Atrophy: reduced size of an organ or tissue resulting from a decrease in cell size and number.

14. Acute Diarrhea

15. Cell Death

Apoptosis is a pathway of cell death that is induced by a

tightly regulated suicide program in which cells destined to die activate enzymes that degrade the cells' own nuclear DNA and nuclear and cytoplasmic proteins. Apoptotic cells break up into fragments, called apoptotic bodies, which contain portions of the cytoplasm & nucleus. Apoptosis eliminates cells that are injured beyond repair without eliciting a host reaction, thus limiting collateral tissue damage.

16. Blood Transfusion

WHO clinical use of blood.

Type
Whole blood

Descriptions
Up to 510 ml total volume Hb 12 g/ml, Ht 35%45% No functional platelets No labile coagulation factors (V & VIII)

Indications
Red cell replacement in acute blood loss with hypovolaemia Exchange transfusion Patients needing red cell transfusions where PRC is not available Replacement of red cells in anemic patients Use with crystalloid or colloid solution in acute blood loss Replacement of multiple coagulation factor deficiencies, DIC TTP Treatment of bleeding due to: Thrombocytopenia Platelet function defects Prevention of bleeding due to thrombocytopenia. Treatment of vWD, Haemophilia A, FXIII def, source of fibrinogen acquired coagulopathies (DIC)

PRC

150200 ml red cells from which most of the plasma has been removed Hb 20 g/dL (not less than 45 g per unit) Ht: 55%75% Plasma separated from whole blood within 6 hours of collection and then rapidly frozen to 25C or colder Contains normal plasma levels of stable clotting factors, albumin & immunoglobulin Single donor unit in a volume of 5060 ml of plasma should contain: At least 55 x 103 platelets, <1.2 x 103 red cells, <0.12 x 103 leucocytes

FFP

Platelet conc.

Cryopres Prepared by resuspending FFP presipitate. ipitate Contains about half of the Factor VIII and fibrinogen in the donated whole blood.

17. Ischemic Heart Disease

18. Arthritis
The management of

acute gout is to provide rapid & safe pain relief.

NSAID, Colchicine. Corticosteroid if NSAID is

contraindicated.

Preventing further attacks

by uric acid lowering agent:

Allopurinol Probenecid

Uric acid lowering agent

shouldnt be given on acute attack, unless the patient has consumed it since 2 weeks before.
Current diagnosis & treatment in rheumatology. 2nd ed. McGraw-Hill; 2007.

19. Obstructive Lung Disease

A working definition of COPD:
A disease state

characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive & associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

GOLD. WHO.

20. Marker of Coronary Risk

21.Unresponsiv e Patient

22. Shock

23. Calorie Calculator

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

Berlari kencang 10 menit sekitar 90 kkal.

Berjalan 20 menit: 48 kkal.

24. Urinary Tract Infection

Recurrent UTI
2 uncomplicated UTIs in 6 months or 3 positive cultures within the

preceding 12 months. Investigation: physical examination to evaluate urogenital anatomy & estrogenization of vaginal tissues & to detect prolapse. Post-void residual urine volume should be measured. Diabetes screening in patients with other risk factors (family history & obesity). Women who suffer infection with organisms that are not common causes of UTI, such as Proteus, Pseudomonas, Enterobacter, and Klebsiella may have structural abnormalities or renal calculi imaging & cystoscopy

24. Urinary Tract Infection

Women who are felt to be in the early stages of a problem with

recurrent UTI should have documented cultures gold standard for diagnosis & provides information about the uropathogen & antibiotic susceptibilities. The standard definition of a UTI on culture is >105 colony forming units per HPF. In women with symptoms of a UTI > 103 colony forming units per HPF is considered sufficient.

25. Shock

SKOR DALDIYONO Defisit cairan (cc) = SKOR/15 x Berat Badan (kg) x 100 Haus/Muntah (1) TD Sistolik 60-90 mmHg (1) TD Sistolik <60 (2) Frekuensi Nadi >120x (1) Kesadaran Apatis (1) Somnolen/sopor/koma (2) Frekuensi nafas >30x/menit (1) Facies Cholerica (2) Vox Cholerica (2) Turgor kulit menurun (1) "Washer Woman Hand" (1) Ekstremitas dingin (1) Sianosis (2) Umur 50-60 tahun (-1) Umur >60 tahun (-2)

26. Renal Disorder

Diagnosis Acute glomerulonephritis Characteristic an abrupt onset of hematuria & proteinuria with reduced GFR & renal salt and water retention, followed by full recovery of renal function. recovery from the acute disorder does not occur. Worsening renal function results in irreversible and complete renal failure over weeks to months. renal impairment after acute glomerulonephritis progresses slowly over a period of years & eventually results in chronic renal failure. manifested as marked proteinuria, particularly albuminuria (defined as 24-h urine protein excretion > 3.5 g), hypoalbuminemia, edema, hyperlipidemia, and fat bodies in the urine. Rapidly progressive glomerulonephritis (crescentic) Chronic glomerulonephritis

Nephrotic syndrome

Pathophysiology of disease: an introduction to

26. Renal Disorder

In early cases, the glomeruli may still show evidence of the primary disease. There eventually ensues obliteration of glomeruli, transforming them into acellular

eosinophilic masses, representing a combination of trapped plasma proteins, increased mesangial matrix, basement membranelike material, and collagen. Marked atrophy of associated tubules, irregular interstitial fibrosis, and mononuclear leukocytic infiltration of the interstitium also occur.

27. Thyroid Disease

Graves disease: female predominant, thyroid stimulating immunoglobulin (+), diffuse nontender goiter with bruit, ophthalmopathy. Th: PTU/metimazol, propranolol.
Hyperthyroidism

28. Marker of Coronary Risk

29. Acute Coronary Syndrome

Henrys clinical diagnosis & management by laboratory method. Pathophysiology of heart disease.

29. Acute Coronary Syndrome

CK-MB or troponin I/T are a marker for infark miocard & used as

a diagnostic tool. Given their high sensitivity & specificity, cardiac troponins are the preferred serum biomarkers to detect myocardial necrosis.

30. Lung Abscess

Lung abscesses are pus-containing necrotic lesions of

the lung parenchyma that often contain an air-fluid level. Lung abscess may be associated with infections caused by pyogenic bacteria, mycobacteria, fungi, and parasites. Most diagnoses of lung abscess are made from chest radiographs. A true cavity has either a visible wall completely surrounding the lucency or an air-fluid level in the area of pneumonia

31. Arthritis
Acute Bacterial Arthritis
Bacteria enter the joint from the bloodstream; from a

contiguous site of infection in bone or soft tissue; or by direct inoculation during surgery, injection, animal or human bite, or trauma.

32. Tropic Infection

Shock Bleedin g

Primary infection: IgM: detectable by days 35 after the onset of illness, by about 2 weeks & undetectable after 23 months. IgG: detectable at low level by the end of the first week & remain for a longer period (for many years).

Secondary infection: IgG: detectable at high levels in the initial phase, persist from several months to a lifelong period. IgM: significantly lower in secondary infection cases.

33. HIV Screening

34. Pharmacology
Early phase hyperglycemia, associated with increased

rates of insulin and C-peptide secretion after oral administration of 100 g glucose, was observed among patients with pulmonary tuberculosis who were taking rifampicin. This early phase hyperglycemia appeared shortly after rifampicin was started and it disappeared completely a few days after rifampicin was discontinued.

35. Infection in DM Patient

Foot infections are the most

common problems in persons with diabetes. These individuals are predisposed to foot infections because of a compromised vascular supply secondary to diabetes. Local trauma and/or pressure (often in association with lack of sensation because of neuropathy), in addition to microvascular disease, may result in various diabetic foot infections that run the spectrum from simple, superficial cellulitis to chronic osteomyelitis

36. Arrhytmia
Irregular Tachycardias Atrial Fibrillation and Flutter An irregular narrow-complex or wide-complex tachycardia is most likely atrial fibrillation with an uncontrolled ventricular response. Therapy Management should focus on control of the rapid ventricular rate (rate control) and conversion of hemodynamically unstable atrial fibrillation to sinus rhythm (rhythm control). Electric or pharmacologic cardioversion (conversion to normal sinus rhythm) should not be attempted in these patients unless the patient is unstable or the absence of a left atrial thrombus is documented by transesophageal echocardiography. Magnesium, diltiazem, and -blockers have been shown to be effective for rate control in the treatment of atrial fibrillation with a rapid ventricular response in both the prehospital and hospital settings. Ibutilide & amiodarone have been shown to be effective for rhythm control in the treatment of atrial fibrillation in the hospital setting. Amiodarone, ibutilide, propafenone, flecainide, digoxin, clonidine, or magnesium can be considered for rhythm control in patients with atrial fibrillation of 48 hours duration.
ACLS

36. Arrhytmia
treatment of AF considers three aspects of the

arrhythmia:
ventricular rate control, consideration of methods to restore sinus rhythm,

assessment of the need for anticoagulation to prevent

thromboembolism.

Medicines used to control the heart rate: beta blockers (e.g., metoprolol and atenolol), calcium channel blockers (diltiazem and verapamil), digitalis (digoxin).

37. Typhoid Fever

A. Widal test:
B. Antibody detection to somatic antigen O & flagel antigen H from salmonella. C. Diagnostic result: the titer increase by >4 x after 5-10 days from the first result. D. Titer for antibody O increase at 6-8 days after the first symptoms, while antibody H increase at 10-12 days.

E. Tubex: Measure IgM anti lipopolysaccharide O9 of Salmonella typhi.

37. Typhoid Fever

Culture is the gold standard for diagnosis of typhoid. Blood cultures: often (+) in the 1st week. Stools cultures: yield (+) from the 2nd or 3rd week on. Urine cultures: may be (+) after the 2nd week. (+) culture of duodenal drainage: presence of Salmonella in carriers.
Jawetz medical microbiology.

38. Insulin Pada DM Tipe 2

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

39. Pseudomembranous Colitis

Clostridium difficile infection

(CDI)

Normal ileum

unique colonic disease that is

acquired almost exclusively in association with antimicrobial use and the consequent disruption of the normal colonic flora.

AB associated with CDI Clindamycin, ampicillin, & cephalosporins The 2nd & 3rd cephalosporins, (cefotaxime, ceftriaxone, cefuroxime, and ceftazidime) ciprofloxacin, levofloxacin, and moxifloxacin (hospital outbreak)
Harrisons principles of internal medicine. 18th ed. McGraw-Hill; 2011.

39. Pseudomembranous Colitis

Ingestion of spores vegetate secrete toxins diarrhea & pseudomembranous colitis
Harrisons principles of internal medicine. 18th ed. McGraw-Hill; 2011.

39. Pseudomembranous Colitis

Diagnostic criteria of CDI:
Diarrhea (3 unformed stools per 24 h for 2 days) with no other

recognized cause plus toxin A or B detected in the stool, toxin-producing C. difficile detected in the stool by PCR or culture, or pseudomembranes seen in the colon

Harrisons principles of internal medicine. 18th ed. McGraw-Hill; 2011.

40. Metabolic Syndrome

41. Lung Disease

Bronchitis symptoms The most common symptoms of acute bronchitis include:
A persistent cough; this may last 10 to 20 days

Some people cough up mucus, which may be clear,

yellow, or green in color

Fever and shorthness of breath are not common in

people with acute bronchitis, it may be an indication of pneumonia. Chest X-ray is usually clear.

41. Pneumonia Komunitas

Diagnosis pasti:

Infiltrat baru/infiltrat progresif + 2 gejala: 1. Batuk progresif 2. Perubahan karakter dahak/purulen 3. Suhu aksila 38 C/riw. Demam 4. Fisis: tanda konsolidasi, napas bronkial, ronkhi 5. Lab: Leukositosis 10.000/leukopenia 4.500

42. Antidiabetik Oral

Cara Pemberian OHO, terdiri dari: OHO dimulai dengan dosis kecil dan ditingkatkan secara bertahap sesuai respons kadar glukosa darah, dapat diberikan sampai dosis optimal Sulfonilurea: 15 30 menit sebelum makan Repaglinid, Nateglinid: sesaat sebelum makan Metformin : sebelum /pada saat / sesudah makan Penghambat glukosidase (Acarbose): bersama makan suapan pertama Tiazolidindion: tidak bergantung pada jadwal makan. DPP-IV inhibitor dapat diberikan bersama makan dan atau sebelum makan.

43. Pharmacology
Thiazid side effects:
Hypokalemic Metabolic Alkalosis and Hyperuricemia Impaired Carbohydrate Tolerance

The effect is due to both impaired pancreatic release of insulin and diminished tissue utilization of glucose Hyperlipidemia Thiazides cause a 515% increase in total serum cholesterol and lowdensity lipoproteins (LDL). These levels may return toward baseline after prolonged use. Hyponatremia Allergic Reactions The thiazides are sulfonamides and share cross-reactivity with other members of this chemical group. Serious allergic reactions are extremely rare but do include hemolytic anemia, thrombocytopenia, and acute necrotizing pancreatitis.

44. Gastrointestinal Bleeding

Bleeding from the gastrointestinal (GI) tract may present in 5 ways: Hematemesis: vomitus of red blood or "coffee-grounds" material. Melena: black, tarry, foul-smelling stool. Hematochezia: the passage of bright red or maroon blood from the rectum. Occult GI bleeding: may be identified in the absence of overt bleeding by a fecal occult blood test or the presence of iron deficiency. Present only with symptoms of blood loss or anemia such as lightheadedness, syncope, angina, or dyspnea.

44. Gastrointestinal Bleeding

Epigastric pain described as a

burning or gnawing discomfort can be present in both DU & GU. H. pylori and NSAID-induced injury account for the majority of DUs DU: Pain occurs 90 minutes to 3 hours after a meal relieved by antacids or food. Pain that awakes the patient from sleep (between midnight and 3 A.M.) GU: discomfort may actually be precipitated by food.
Harrisons principles of internal medicine. 18th ed. 2011.

44. Gastrointestinal Bleeding

Diagnosis Peptic ulcer Characteristic The most common cause of upper GI bleeding. H. pylori & NSAID-induced injury (gastropathy NSAID) account for the majority of DUs Portal hypertension varices around portosystemic anastomoses esophageal varices Portal hypertension altered vascular microarchitecture with dilatation and/or narrowing of the capillaries & veins bleeding risk Bright red bleeding per rectum, a sense of rectal fullness or discomfort, may prolapse into the anal canal. Subepithelial hemorrhages & erosions. Cause: NSAID, alcohol, & stress. These are mucosal lesions, thus, do not cause major bleeding.
Harrisons principles of internal medicine. 18th ed. 2011.

Esophageal varices hemorrhage Portal hypertensive gastropathy Hemorrhoid Erosive gastropathy

45. Typhoid Fever

Culture is the gold standard for diagnosis of typhoid. Blood cultures: often (+) in the 1st week. Stools cultures: yield (+) from the 2nd or 3rd week on. Urine cultures: may be (+) after the 2nd week. (+) culture of duodenal drainage: presence of Salmonella in carriers.
Jawetz medical microbiology.

46. Pharmacologyy
Drugs which may cause folate deficiency include: phenytoin, isoniazid, barbiturates, oral contraceptives, ethanol, sulfasalazine, cycloserine, methotrexate, pyrimethamine, trimethoprin

47. Typhoid Fever

48. Breath Sound

Amphoric breath sound an abnormal, resonant, hollow, blowing sound heard with a stethoscope over the thorax. It indicates a cavity opening into a bronchus or a pneumothorax.

49. Diabetes Management

PERKENI 2011

50. TB Management
Pasien tidak mendapat regimen OAT dengan benar selama

3 bulan. Lakukan pemeriksaan BTA ulang & uji resistensi untuk menentukan regimen terapi.

International standards for tuberculosis care.

 Untuk pemantauan pengobatan dilakukan pemeriksaan spesimen

sebanyak 2 kali (sewaktu, pagi). Bila salah satu/keduanya (+), maka hasil dinyatakan BTA (+)
Tipe pasien TB Waktu Periksa Hasil BTA (-)
(+) (-) (+) (-)

Tindak Lanjut Tahap lanjutan dimulai

OAT sisipan 1 bulan, jika masih (+) tahap lanjutan tetap diberikan Sembuh Gagal, mulai OAT kategori 2 Berikan pengobatan tahap lanjutan s.d. selesai, kemudian pasien dinyatakan pengobatan lengkap Ganti dengan kategori 2 mulai dari awal Teruskan pengobatan dgn tahap lanjutan OAT sisipan 1 bulan, jika masih (+) tahap lanjutan tetap diberikan. Uji resistensi.

Pasien baru BTA (+), Akhir tahap OAT kategori 1 intensif Sebulan sebelum akhir atau di akhir pengobatan Pasien baru BTA (-) Akhir intensif & Roentgen (+) OAT kategori 1 Pasien baru BTA (+), Akhir intensif OAT kategori 2

(+) (-) (+)

Sebulan sebelum akhir atau di akhir pengobatan

(-)
(+)

Sembuh
Belum ada obat, disebut kasus kronik. Rujuk.

Pelatihan DOTS. Departemen Pulmonologi & Ilmu Kedokteran Respirasi FKUI; 2008.

51. Hepatology
Liver Abscess Cause: Protozoa (E. histolytica) or bacteria (gram-negative enteric bacilli (E.coli) , anaerobic gram-negative bacilli, & microaerophilic streptococci). Clinical features:

fever, malaise, weight loss, and right upper quadrant abdominal pain. Hepatomegaly and right upper quadrant abdominal tenderness Jaundice is seen in approximately 25% of cases.

Laboratory findings: leukocytosis & anemia, elevations of the

alkaline phosphatase and GGT, & hyperbilirubinemia in about 25% of cases. USG: a round or oval area within the liver that is less echogenic than the surrounding hepatic parenchyma
Current diagnosis & treatment in gastroenterology.

52. Pneumoconiosis

53. SIRS

54-55. Supracondylar Fracture

Mechanism
Usually < 8 yo Extension (95%) vs flexion

Clinically
Mild swelling to gross deformity Arm held to side, immobile, extension S-shaped configuration Gartland
I - nondisplaced II - displaced with intact posterior cortex III - displaced fracture, no intact cortex A: posteromedial rotation of distal fragment B: posterolateral rotation

Gartland type I

Gartland type II

Gartland type III

Management
If NeuroVascular compromise - urgent ortho consult If no response from ortho in 60 min may attempt 1

reduction Watch brachial artery and median nerve Gartland I splint+ sling and ortho f/u 24h Gartland II - controversy but most get pinned Gartland III - closed reduction and pin

http://www.rch.org.au/clinicalguide/guideline_index/fractures/Supracondylar_fracture_of_the_humerus_Emergency_Department/

Supracondylar Fracture-Reduction

U-slab
http://orthoinfo.aaos.org/topic.cfm?topic=A00513

GENERAL TREATMENT PRINCIPLES

Operative
Anatomic articular reduction Stable internal fixation of the

Conservative
indicated for nondisplaced or

articular surface Restoration of articular axial alignment Stable internal fixation of the articular segment to the metaphysis and diaphysis Early range of elbow motion

minimally displaced fractures, severely comminuted fractures in elderly patients with limited functional ability. Posterior long arm splint is placed in at least 90 degrees of elbow flexion with the forearm in neutral. Posterior splint immobilization is continued for 1 to 2 weeks. The splint may be discontinued after approximately 6 weeks, when radiographic evidence of healing is present. Frequent radiographic evaluation is necessary

 Conservative treatments take longer time, risk of

malunion, need more radiographic examination Surgery is the treatment of choice Temporary immobilization with arm-sling, surgery as soon as possible

Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition Lippincott Williams & Wilkins 2006

56. Tetanus
The incubation periodis

usually 4 to 21 days. The average incubation period is about 10 days. Muscle spasms and stiffness

http://www.nhs.uk/Conditions/Tetanus/Pages/Symptoms.aspx

NOTE: Large rectangular

gram-positive bacilli

NOTE: Double zone of hemolysis

Inner beta-hemolysis = toxin Outer alpha-hemolysis = toxin

57. Massive Hemorrhage

Metabolic changes in traumatic-hemorrhagic shock patient:
Hypermetabolism Increased oxygen demands anaerobs metabolismlactate Increased energy expenditure Enhanced protein catabolism Insulin resistance associated with hyperglycemia Failure to tolerate glucose load High plasma insulin levels The alterations of the physiological metabolic pathways

leads

Hyperglycemia Metabolic acidosis with hyperlactatemia

 During hemorrhagic shock,

metabolic acidosis is common and conventionally considered to be due essentially to hyperlactatemia. The increase in blood lactate generally originates from both increased lactate production and reduced lactate metabolism

Critical Care 2007, 11:R130 doi:10.1186/cc6200

58. Blunt Abdominal Trauma

Signs of intraperitoneal injury
Abdominal tenderness, peritoneal

irritation
Distention - pneumoperitoneum,

gastric dilation, or ileus

Ecchymosis of flanks (gray-turner

sign) or umbilicus (cullen's sign) retroperitoneal hemorrhage

Abdominal contusions seat belts

sign
Bowel sounds suggests

intraperitoneal injuries
DRE: blood or subcutaneous

emphysema
http://regionstraumapro.com/post/663723636

 Dullness in Traube's space

above the left midaxillary costal

Injury to the membranous

margin suggests an enlarged spleen, and can occur on inspiration Kehr's sign 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

urethra occurs on trauma leading to fracture separation of the symphysis pubis or fracture of the pubic rami. The membranous urethra is torn and the prostate is pulled upwards During rectal examination the prostate will found too high to beexamined by finger (high overriding prostate)

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

 Organs
Spleen (Traubes space

dullness, Kehrs sign) Intestine (free air, sphincter tone decreased) Urethra(high overriding prostate)

59. Anaphylactic Shock

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

60. Airway Obstruction

Snoring - due to obstruction of upper airway by the

tongue Gurgling - due to obstruction of upper airway by liquids (blood, vomit) Wheezing - due to narrowing of the lower airways

PATENT Vs COLLAPSED AIRWAY

2006 American Academy of Sleep medicine

Obstructive Sleep Apnea

Episodes of complete or partial collapse of airway 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. Precordial stab wound

Precordial
an area limited by the

clavicles superiorly the costal margin inferiorly the midclavicular lines laterally Penetrating heart injury should be presumed

 Tamponade suspected
Echocardiography Pericardiocentesis

done immediately for diagnosis and treatmenta brief delay might be life threatening.

Needle pericardiocentesis is

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

62. Resuscitation
Crystalloid solution rapidly equilibrates between the

intravascular and interstitial compartments

Adequate restoration of hemostatic stability may require large

volumes of ringer's lactate.

It has been empirically observed that approximately 300 cc of

crystalloid is required to compensate for each 100 cc of blood loss. (3:1 rule)

63. Burn injury Initial Assessment

Burn Resuscitation with Lactated Ringers Figure out burn size by rule of nines or entire palmar surface of

patients 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, titrate to UOP of 0.5mL/kg/hr in adults and 1mL/kg/hr in children Do not give colloid in first 24 hrs

education.surgery.ufl.edu

64. Diabetic Foot

Wagner Classification
0- Intact skin (may have bony deformities. 1- Localized superficial ulcer. 2- Deep ulcer to tendon, bone, ligament or joint. 3- Deep abscess or osteomyelitis. 4- Gangrene of toes or forefoot. 5- Gangrene of whole foot.

X-ray osteomyelitis, osteolysis, fractures, dislocations medial arterial calcication, and softtissue gasgangrene

http://www.annalsofvascularsurgery.com/article/S0890-5096(11)00060-4

soft-tissue gas

osteomyelitis, osteolysis, fractures

65. Urachal abnormalities

Failure of obliteration of urachus resulting complete or partial

patency of urachus < 1/1000 live births Inflammation or drainage from umbilicus USG, CT, contrast studies, or injection of dye into tract can confirm diagnosis

the beefy red appearance of the umbilical end of a patent urachus

 Patent Urachus (50%) Urachal cyst (30%) Urachal sinus (15%)

Vesicourachal diverticulum (5%)

bladder

Patent Urachus
As a result of total lack of involution free communication between the bladder and the umbilicus 1-3 months of age The presenting complaint Periumbilical discharge42% of the patients

serous, purulent, or bloodyurachal sinus or cyst Persistent clear fluid leakage (likely urine) in an infant is highly suggestive of a patent urachus persists beyond a few weeks

Umbilical mass pain due to infection

www.mssurg.net/.../Pediatric%20Umbilical%20Abnormalities%20-

Superior vesica fissure(Exstrophy bladder variants) Widely separated pubic symphysis The umbilicus is low or elongated A small superior bladder opening or a patch of isolated bladder mucosa Infraumbilica Genitalia are intact

Umbilical Herniaoutward bulging (protrusion) of the abdominal lining or part of the abdominal organ(s) through the area around the belly button Omphalitis infection of the umbilical stump most commonly occurs after day 3 the stump appears reddened,oedematous, exudative discharge, signs of cellulitis ("cord flare")

66. Hirschsprung disease

Frequency
approximately 1 per 5000 live

Predilection
Classical HD (75% of cases): Rectosegmoid Long segment HD (20% of

births. Sex: 4 times more common in males than females. Age:

Nearly all children with

Hirschsprung disease are diagnosed during the first 2 years of life. one half are diagnosed before they are aged 1 year. Minority not recognized until later in childhood or adulthood.

Mortality/Morbidity:

The overall mortality of Hirschsprung enterocolitis is 2530%,.

cases) Total colonic aganglionosis (3-12% of cases) rare variants include the following: Total intestinal aganglionosis Ultra-short-segment HD (involving the distal rectum below the pelvic floor and the anus)

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

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

Symptoms in newborn age(enterocolitis) Life-threatening condition Diarrhea: it can be an early sign Toxic megacolon Abdominal distension Bile-stained vomiting Fiver and signs of dehydration Rectal tube:explosive expulsion of gas and foul-smelling stools

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

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

 Darm kontur: visible shape of intestines on the

abdomen Darm Steifung: visible peristaltic movement on the abdomen

Rontgen : Plain abdominal radiography
Dilated bowel Air-fluid levels. Empty rectum

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

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

67. Gallbladder Disorder

Cholangitis
An infection of the biliary

tract The charcot triad Fever Abdominal (right upper quadrant) pain Jaundice

Tests may include: Abdominal ultrasound Endoscopic retrograde cholangiopancreatography (ERCP) Magnetic resonance cholangiopancreatography (MRCP) Percutaneous transhepatic cholangiogram (PTCA) The following blood tests may be done: Bilirubin level Liver enzyme levels Liver function tests White blood count (WBC)

http://emedicine.medscape.com/article/184043-clinical

Disorder
Pancreatitis

Clinical Feature
Chronic Abdominal pain, normal or mildly elevated pancreatic enzyme levels, malabsorbsion (steatorrhea), diabetes mellitus (CHRONIC) sudden in onset abdominal pain radiates the back, worse in supine position,Profuse vomiting, fever(ACUTE) Acute right upper quadrant pain and tenderness, radiates to back or below the right shoulder blade,Fever and leukocytosis, Clay-colored stools, jaundice, Nausea and vomiting,Palpable gallbladder/fullness of the RUQ ,Murphy sign Episodic abdominal pain (increases when consuming fat), pain resolves over 30 to 90 minutes.localizes the pain to the epigastrium or right upper quadrant radiation to the right scapular tip (Collins sign).Dyspepsia,Gallstones on cholecystography or ultrasound scan,4F. Dx:USG, MRCP Choledocholithiasis at least one gallstone in the common bile duct >50 years,abdominal pain, lower back pain,jaundice, Dark urine and clay-colored stools,Fatigue and weakness, Painless Jaundice, palpable gallbladder (ie, Courvoisier sign),Loss of appetite and weight loss,Nausea and vomiting, Trousseau sign, in which blood clots form spontaneously in the portal blood vessels, the deep veins of the extremities, or the superficial veins anywhere on the body, Diabetes mellitus, Tumor marker CA 19-9

Acute cholesistis

Cholelithiasis

Pancreatic Tumor

68. Olecranon Fracture

Patients typically present with the upper extremity

supported by the contralateral hand with the elbow in relative flexion Physical examination may demonstrate a palpable defect at the fracture site An inability to extend the elbow actively against gravity indicates discontinuity of the triceps mechanism.

Classification (Mayo)
Nonoperative treatment

indicated for nondisplaced fractures and displaced fractures in poorly functioning older individuals. Immobilization in a long arm cast with the elbow in 45 to 90 degrees of flexion is favored by many authors

Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition Lippincott Williams & Wilkins 2006

69. Kidney Stone

 Calcium oxalate stones

the most common They tend to form when the urine is acidicit has a low pH

Some of the oxalate in urine is produced by the body

Calcium and oxalate in the diet play a part but are not the only

factors that affect the formation of calcium oxalate stones Dietary oxalate an organic molecule found in many vegetables, fruits, and nuts Calcium from bone may also play a role in kidney stone formation. Calcium phosphate stones less common tend to form when the urine is alkalineit has a high pH

 Struvite stones
Found more often in women almost always the result of urinary tract infections

Uric acid stones

These are a byproduct of protein metabolism commonly seen with gout,and may result from certain genetic

factors and disorders of your blood-producing tissues fructose also elevates uric acid, and there is evidence that fructose consumption is helping to drive up rates of kidney disease Cystine stones Representing only a very small percentage these are the result of a hereditary disorder that causes kidneys to excrete massive amounts of certain amino acids (cystinuria)

70. 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, 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

Treatment
Nonoperative
Fracture reduction followed by

application of a long leg cast with progressive weight bearing can be used for isolated, closed, lowenergy fractures with minimal displacement and comminution. Cast above knee, with the knee in 0 to 5 degrees of flexion After 4 to 6 weeks, the long leg cast may be exchanged for a patella-bearing cast or fracture brace. Union rates as high as 97%

Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition Lippincott Williams & Wilkins 2006

https://www2.aofoundation.org

71. Alvarado Score

72. Proximal Humerus Fracture

Proximal humerus fractures
The axillary nerve courses just

comprise 4% to 5% of all fractures the most common humerus fracture (45%). The increased incidence in the older population is thought to be related to osteoporosis. 2:1 female-to-male ratio

anteroinferior to the glenohumeral joint, traversing the quadrangular space. It is at particular risk for traction injury. it is susceptible to injury during anterior dislocation and anterior fracturedislocation.

73-75.Osteomyelitis
Inflammation of the bone and bone marrow caused by

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

Pathogenesis
Waldvogel, 1971

1.
2. 3.

Hematogenous Contiguous focus of infection Direct inoculation

Symptoms
Osteomyelitis is often diagnosed clinically with nonspecific

symptoms fever, chills, fatigue, lethargy, irritability. The classic signs of inflammation, including local pain, swelling, or redness, may also occur and normally disappear within 5-7 days

http://emedicine.medscape.com/article/1348767-overview#a0112

 S aureus is the most common pathogenic organism

recovered from bone, followed by Pseudomonas and Enterobacteriaceae. Less-common organisms involved include anaerobe gramnegative bacilli. Intravenous drug users may acquire pseudomonal infections

76. Trauma patient

Airway Management
Simple management maneuvers
Suction Chin lift Jaw thrust

Definitive airway: Cuffed tube

in trachea

Patient cant 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?

 Modify for suspected spinal injury:

1. Tongue/jaw lift 2. Modified jaw thrust

77. Kidney Stone Formation

Causes:
Highly concentrated urine, urine stasis

Imbalance of pH in urine Acidic: Uric and oxalat Stones

Alkaline: Phosphat Stones

Gout

Hyperparathyroidism
Inflammatory Bowel Disease UTI Medications Lasix, Topamax, Crixivan

http://www.pilotfriend.com/aeromed/medical/images2/25.jpg

Types of Stones
Calcium Oxalate
Most common

Calcium Phosphate
Struvite
More common

in woman than men. Commonly a result of UTI. Uric Acid Caused by high protein diet and gout. Cystine Fairly uncommon; generally linked to a hereditary disorder.

 Uric acid stones are the

most common cause of radiolucent kidney stones Several products of purine metabolism are relatively insoluble and can precipitate when urinary pH is low

http://emedicine.medscape.com/article/983759-overview

78. Colonic Carcinoma

Time Course Symptoms Findings

Early
Mid

None
Rectal bleeding Change in bowel habits Fatigue Anemia Abdominal pain

None Occult blood in stool

Rectal mass Blood in stool Weight loss Abdominal mass Bowel obstruction

Late

Site Distribution

Screening For Colon Cancer SAVES LIVES!!!

Test
Fecal occult blood testing Flexible sigmoidoscopy
(in portion of colon examined)

Mortality Reduction (FOBT 33% 66% 43% ~76-90%

FOBT + flexible sigmoidoscopy

(compared to sigmoidoscopy alone)

Colonoscopy
(after initial screening and polypectomy)

Colorectal cancer screening First assess RISK

AVERAGE RISK INDIVIDUAL All patients age 50 years and older, the asymptomatic general population HIGH RISK Personal history polyp or cancer Family history polyp or cancer in first degree relatives

Double-contrast Barium Enema

Advantage
Examines entire colon Relatively low cost

Disadvantge
Never studied as a screening test Missed 50% of polyps > 1cm

in one study Detects 50-75% of cancers in those with positive FOBT Interval between exams unknown

Winawer et al. Gastroenterology 1997; 112:599 Rex, Endoscopy 1995; 27:200 Lieberman et al. N Engl J Med 2000; 343:163

Colonoscopy
Advantage
Examines entire colon

Removal of polyps performed at time of exam

Well-tolerated with sedation Easier bowel preparation, usually done without sedation

Disadvantage
Expensive Risk of perforation, bleeding low but not negligible Requires high level of training to perform Miss rate of polyps < 1 cm ~25%, > 1 cm ~5%

Rex et al. Gastroenterology 1997; 112:24-8 Postic et al. Am J Gastroenterol 2002; 97:3182-5

79. Complications of Casts & Splints

Loss of reduction Pressure necrosis may occur as early as 2 hours Tight cast vascular compromise and compartment

syndrome (first 24 hours)

Complications of Casts & Splints

Thermal Injury - avoid plaster > 10 ply, water >24C,

unusual with fiberglass Cuts and burns during removal

Keloid formation as a result of an injury during cast removal. From Halanski M, Noonan KJ. J Am Acad Orthop Surg. 2008.

Complications of Casts & Splints

DVT/PE - increased in lower extremity fracture
Ask about prior history and family history

Birth Control Pills are a risk factor

Indications for prophylaxis controversial in patients without risk

factors Joint stiffness Leave joints free when possible (ie. thumb MCP for below elbow cast) Place joint in position of function

Closed Reduction, Traction, and Casting Techniques www.ota.org/.../G09_CRC_Traction_Casts%20JTG%20rev%202-4-1

80. CPR
Indication for CPR
No response Not breathing No pulse

http://circ.ahajournals.org/content/112/24_suppl /IV-156/F2.expansion.html

http://www.cardiachealth.org/

81. Adverse Effect of Beta Blocker

Nausea Diarrhea Bronchospasm Dyspnea Cold extremities Exacerbation of raynaud's Heart block Fatigue

Dizziness
Alopecia (hair loss) Abnormal vision Hallucinations, insomnia,

syndrome Bradycardia Hypotension Heart failure

nightmares Sexual dysfunction, erectile dysfunction Alteration of glucose and lipid metabolism

Erectile dysfunction(ED) after therapy with beta-blockers

Beta-blockers induce ED through central and peripheral

(genital) effects increases the latency to ex copula ejaculation the latency to initial erection reduces the number of erectile reflexes Despite the common belief of the induction of ED with betablocker use, clinical studies failed to confirm a relationship between use of such drugs and ED.

 ED in patients with cardiovascular disease may be related to psychological

factors involving the fear of the disease and of the effect of the drugs prescribed The knowledge and prejudice about side effects of beta-blockers can produce anxiety, that may cause erectile function

Silvestri et al. Report of erectile dysfunction after therapy with beta-blockers is related to patient knowledge of side effects and is reversed by placebo. Italy: February, 2003.

Counseling

Hatzimouratidis K, et al. Guidelines on Male Sexual Dysfunction: Erectile Dysfunction and Premature Ejaculation. Eur Urol (2010), doi:10.1016/j.eururo.2010.02.020

82. Identification Of Cardiac Arrest

Healthcare Providers should

check for a pulse before performing chest compressions on a suspected victim of cardiac arrest. For Adults and Children, a pulse should be assessed in the carotid artery for 5 to 10 seconds No pulsecardiac arrest

http://www.cardiopulmonaryresuscitation.net/

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

83.Burn Injury

prick test (+)

 Berat luka bakar: Ringan: derajat 1 luas < 15% a/ derajat II < 2% Sedang: derajat II 1015% a/ derajat III 5-10% Berat: derajat II > 20% atau derajat III > 10% atau mengenai wajah, tangan-kaki, kelamin, persendian, pernapasan

84. Male Genital Disorder

Phimosis Inability to retract the distal foreskin over the glans penis Physiologic in newborn Complications Balanitis Postitis Balanopostitis Treatment Dexamethasone 0.1% (6 weeks) for spontaneous retraction Paraphimosis Entrapment of a retracted foreskin behind the coronal sulcus Emergency Superficial vein obstruction edema and pain penile glands necrosis Treatment Manual reposition Dorsum incision

Paraphimosis
Paraphimosis leading to vascular engorgement and

edema of the distal glans. This condition is a medical emergency when identified acutely and requires prompt effective treatment to prevent loss of the distal glans penis

Treatment

Manipulation Ice packs Compression Osmotic agent Puncture technique Surgical reduction followed by circumcision dorsal slit procedure

https://online.epocrates.com

www.stacommunications.com/journals/diagnosis

85. Wrist Pain

Routine radiographic views

Wrist Joint posterior-anterior (PA), lateral, oblique

A. Foto Antebrachii B. Foto Manus C. Foto Cubiti

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

86. Efek Samping Anti Kejang

Drugs Adverse Effects
Phenitoin Neurologic horizontal gaze nystagmus, sedation, cerebellar ataxia, ophthalmoparesis Hematologicfmegaloblastic anemia(folic acid deficiency, agranulocytosis, aplastic anemia, leukopenia, thrombocytopenia Teratogen, gingival enlargement, Hypertrichosis, rash, exfoliative dermatitis, pruritis, Hirsuitism, and coarsening of facial features, SSJ, NET Diazepam confusion, hallucinations, no fear of danger, depressed mood, hyperactivity, new or worsening seizures, weak or shallow breathing, tremor,loss of bladder control; or urinating less than usual or not at all drowsiness, headaches and migraines, motor coordination impairment, and/or upset stomach, aplastic anemia,Unusual bruising or bleeding,Worsening of seizures Hallucinations, Depression

Carbamaz epine

Phenobarb Sedation, hypnosis,dizziness, nystagmus and ataxia, excitement and ital confusion,paradoxical hyperactivity(children), amelogenesis imperfecta

Asam Valproat

Diarrhea, dizziness, drowsiness, hair loss, blurred/double vision, change in menstrual periods, ringing in the ears, shakiness (tremor), unsteadiness, weight changes, impairments in liver and impairments of hematopoietic and/or pancreatic function

87. X-ray Diagnosis

Osteosarcoma
X-rays of area of suspected infection would not

demonstrate darkened areas typical of osteomyelitis. Conventional features

Destruction of normal trabecular bone pattern

a mixture of radiodense and radiolucent areas

periosteal new bone formation formation of Codman's triangle (triangular elevation of

periosteum)

No osteoblastic appearance, fracture can be seen

Notice the osteoblasticosteolytic appearance

88. Filariasis
Chyluria is the passage of milky urine due to a

lymphourinary fistula, the cause of which may be parasitic or non-parasitic. Filariasis is the commonest cause of chyluria.

Lymphatic Filariasis
Infection with 3 closely related Nematodes Wuchereria bancrofti Brugia malayi Brugia timori * Transmitted by the bite of infected mosquito responsible for considerable sufferings/deformity and disability * All the parasites have similar life cycle in man * Adults seen in Lymphatic vessels * Offsprings seen in peripheral blood during night

Stages in Lymphatic Filariasis

1. 2. 3. 4.

Chronic (Obstructive)

There are 4 stages : Asymptomatic amicrofilariaemic stage Asymptomatic microfilariaemic stage Stage of Acute manifestation Stage of Obstructive (Chronic) lesions

lesions takes 10-15 years. due to the permanent damage to the lymph vessels caused by the adult worms, endothelial proliferation and inflammatory granulomnatous reaction around the parasiteobstruction of lymph Hydrocele (40-60%), Elephantiasis of Scrotum, Penis, Leg, Arm, Vulva, Breast, Chyluria.

Pathogenesis of Lymphatic Disease in Bancroftian Filariasis:: A Clinical Perspective G. Dreyer, J. Nores. J. Figueredo-Silva, W.F. Piessens

89. Open Fracture

Acute bacterial culture of open fracture wounds,

before or shortly after initial debridement, is of little clinical utility. Organisms isolated in the acute phase of treatment do not correlate well with clinical infections that result from open fractures. Therefore, the routine use of cultures at this stage of care is of little benefit to the patient and is not costeffective.

http://emedicine.medscape.com/article/1269242-overview#a17

 Infection commonly caused by bacteria from the skin and

environment Speciment from the skin near the wound Swab must be taken from the infected wound after dead tissue and debris cleansed with sterile saline Mot common organism: Staphylococcus aureus, Acinetobacter Spp

African Journal of Microbiology Research Vol. 3(12) pp. 939-951 December, 2009

90. Derajat Parrish (Gigitan Ular)

Derajat 0
Tidak ada gejala sistemik

Derajat 2
Sama dengan derajat 1 Ptechiae, echimosis Nyeri hebat dalam 12

setelah 12 jam Pembengkakan minimal diameter 1 cm Derajat 1 Bekas gigitan 2 taring Bengkak dengan diameter 1-5 cm Tidak ada tanda-tanda sistemik sampai 12 jam

jam pertama Derajat 3 Sama dengan derajat 2 Syok dan distress pernafasan/ptechiae, echimosis seluruh tubuh Derajat 4 Sangat cepat memburuk

Venomous Snakebites in the United States: Management Review and Update at http://www.aafp.org/afp/2002/0401/p1367.html

91-93. Urine Incontinence

94. Hemorrhaegic Shock

95. Anaphylactic Shock

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

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

will die during emergency care (have lethal injuries)

*** mark triage priorities (tape, tag)

Triage Category: Red

Red (Highest) Priority: Airway and breathing

Patients who need immediate care and transport as soon as possible

difficulties Uncontrolled or severe bleeding Decreased level of consciousness Severe medical problems Shock (hypoperfusion) Severe burns

Yellow
Yellow (Second) Priority:

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

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

97. Fluid Resuscitation

Crystalloids
Are as effective as albumin in

Non-protein colloids
Should be used as second-line

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

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

 Fluid resuscitation target:

Euvolemia Improve perfusion Improve oxygen

delivery

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

98. Food Choking

4 main stages in the swallowing

When talking, breathing, or laughingepiglottis opens Possibility of choking if talking during meal

process: Oral Preparatory Stage, in which the food is mixed with saliva, and formed into a cohesive ball (bolus) Oral Stage, in which the food is moved back through the mouth primarily by the tongue Pharyngeal Stage, which begins pharyngeal swallowing response:
The food enters the upper throat

area (above the voice box) The soft palate elevates The epiglottis closes off the trachea, as the tongue moves backwards and the pharyngeal wall moves forward .

Esophageal Stage, in which the

food bolus enters the esophagus

http://calder.med.miami.edu/pointis/tbifam/swal1.html

99. Foreign Body Obstruction

Jackson (1936) membagi sumbatan 4. bronkus menjadi 4 tingkat 1. Sumbatan sebagian (bypass valve obstruction=katup bebas) terdengar wheezing 2. Sumbatan seperti pentil, ekspirasi terhambat, atau katup satu arah (expiratory check valve obstruction) Stridor inspirasi 3. Seperti pentil namun hambatan inspirasi (Inspiratory check valve) stridor ekspirasi Sumbatan total (stop valve obstruction)

tidak terdengar stridor

Iskandar N. Sumbatan Traktus Trakeo-bronkial. Buku ajar THT edisi 6 FKUI 2007