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ILMU PENYAKIT DALAM
1. Anemia
1. Anemia
Classification of the Normocytic Anemias
Anemia associated with Decreased erythropoietin Anemia with impaired
appropriately increased secretion marrow response
erythrocyte production
Iodium Endemic goiter occurs in geographic areas where the soil, water,
and food supply contain low levels of iodine.
The lack of iodine leads to synthesis of thyroid hormone & a
compensatory in TSH follicular cell hypertrophy &
hyperplasia goitrous enlargement
Thyroid enlargement, T4, cretinism.
Fauci et al. Harrisons principles of internal medicine. 18th ed. McGraw-Hill; 2012.
7. Arterial Disease
a patient shall be said to have Takayasu arteritis if
at least 3 of these 6 criteria are present:
1. Age at disease onset < 40 years
2. Claudication of extremities
3. Decreased brachial artery pulse
4. BP difference >10 mm Hg in systolic blood pressure
between arms
5. Bruit over subclavian arteries or aorta
6. Arteriogram abnormality
Arteriographic narrowing or occlusion of the vessel.
American College of Rheumatology 1990 criteria for the classification of Takayasu's arteritis
8. Edema
8. Edema
Treatmen of edema in heart failure
Diureses for volume overload: furosemide (loop
diuretic)
Na/fluid restriction
Disease Characteristic
Leukemia Increased number of leukocyte.
Anemia Hb less than reference interval.
Trombocytopenia Spontaneous bleeding below 20.000/uL
Polycytemia An increase of all blood cell lineage caused by mutation of
hematopoietic stem cell (polycytemia vera).
Pancytopenia An increased number of erythrocyte, leukocytes, & platelets.
Caused by aplastic anemia, myelofibrosis, hypersplenism.
14. Hypervitaminosis
Vitamin Toxicity
Vitamin A Chronic toxicity: dry skin, cheilosis, glossitis, vomiting, alopecia,
bone demineralization and pain, hypercalcemia, lymph node
enlargement, hyperlipidemia, amenorrhea, and features of
pseudotumor cerebri.
Vitamin C Taking >2 g of vitamin C in a single dose may result in abdominal
pain, diarrhea, and nausea.
Vitamin D Hypercalcemia fatigue, depression, mental confusion, anorexia,
nausea, vomiting, constipation, a short QT interval.
Vitamin E High doses of vitamin E (>800 mg/d) may reduce platelet
aggregation and interfere with vitamin K metabolism. Nausea,
flatulence, and diarrhea have been reported at doses >1 g/d.
Vitamin K Toxicity from dietary phylloquinones and menaquinones has not
been described. High doses of vitamin K can impair the actions of
oral anticoagulants.
Tatalaksana TB di Indonesia.
15. E.S. OAT Minor
Minor Kemungkinan Penyebab Tata Laksana
Tidak nafsu makan, mual, Rifampisin OAT diminum malam
sakit perut sebelum tidur
Nyeri sendi Pyrazinamid Aspirin/allopurinol
Kesemutan s.d. rasa INH Vit B6 1 x 100 mg/hari
terbakar di kaki
Urine kemerahan Rifampisin Beri penjelasan
Hyperammonemia in cirrhosis
can be caused by:
GI bleeding breakdown of
blood protein by GI tract
microbes ammonia
Increased protein intake (eg,
a cheeseburger eaten by a
patient with cirrhosis).
sepsis increased
endogenous protein
catabolism
Clinical manifestation:
Flank pain
Colic abdomen
Oliguria
Hematuria
Review article: Allergic rhinitis management pocket reference 2008. Journal compilation 2008
Blackwell Munksgaard. Allergy 2008: 63: 990996.
23. Organophosphate Intoxication
24. Murmur & Heart Sounds
24. Murmur & Heart Sounds
Abnormality Characteristic
Mitral Valve Prolapse Often asymptomatic. Sudden tensing of the involved mitral
leaflet or chordae tendineae as the leaflet is forced back
toward the LA midsystolic click. Regurgitant flow through
the incompetent valve murmur.
Severe Anemia Hyperdinamic states increased flow diastolic murmur.
VSD Flow across VSD: pansystolic murmur & thrill over left lower
sternum.
ASD Increased flow across tricuspid valve Mid-diastolic murmur.
Increased flow across pulmonary valve Thrill & systolic
ejection murmur.
Pulmonic valve Its rare and its cause is almost always congenital deformity of
stenosis the valve. Blood flow across narrow valve opening ejection
systolic murmur.
24. Murmur & Heart Sounds: ASD
Murmur & Heart Sounds: ASD
Pathophysiology & Clinical Findings
- enlargement of RV, RA, &
Increased flow into right side of pulmonary artery ECG: right
the heart & lungs axis deviation
- increased vasvular marking
Flow across the septal defect doesnt produce murmur because the pressure gap
between LA & RA is not significant
1. Nelsons textbook of pediatrics. 18th ed.
25. Drugs Side Effects
Drugs Side Effects
Salbutamol Cardiovascular stimulation, skeletal muscle tremor,
hypokalemia, and irritability.
Ephedrin Arrhytmias, hypertension, palpitations, tachycardia.
Dexametason Reversible abnormalities in glucose metabolism, increased
appetite, fluid retention, weight gain, rounding of the face,
mood alteration, hypertension, peptic ulcer. These side effects
are generally not observed during a short course of oral or
parenteral therapy.
Chlopheniramin Sedation, dry mouth, urinary retention, blurry vision.
Phenilpropanolamin Arrhytmia, tachycardia.
26. COPD Exacerbation
Exacerbation symptoms:
Worsening dyspneu
Increased sputum production
Changed color of sputum (become
purulent)
Abses perianal Abses disekitar anus, nyeri yang tumpul, berdenyut yang
memburuk sesaat sebelum defekasi yang membaik
setelah defekasi tetapi pasien tetap tidak merasa nyaman
Fistula ani Saluran yang menyerupai pipa (fistula, latin = pipa).
Keluarnya airan bisa berupa nanah atau cairan serupa
darah, nyeri pada anus, bengkak pada tepi anus yang
berulang, gatal pada anus. Kadang didahului dengan
keluhan hemoroid.
Hemoroid eksterna Pelebaran dan penonjolan pleksus hemoroid inferior
terdapat di sebelah distal linea dentata/garis mukokutan
di dalam jaringan di bawah epitel anus.
Prolaps ani Eversi bagian paling bawah dari rektum dan nampak
keluar melalui anus
Fisura ani Robekan atau luka dengan nanah pada daerah anus dekat
perbatasan dengan kulit
30. Gangguan Pasase Usus
31. Ulkus peptikum
Diagnosis :
- Pada pemeriksaan lokal didapatkan batang penis yang tegang tanpa diikuti oleh
ketegangan pada glans penis.
- USG Doppler yang dapat mendeteksi adanya pulsasi arteri kavernosa dan analisis
gas darah yang diambil intrakavernosa dapat membedakan priampismus jenis
iskemik atau non iskemik.
Terapi
mengembalikan aliran darah pada korpora kavernosa yang dicapai
dengan cara medikamentosa maupun operatif. Sebelum tindakan agresif
pasien diminta untuk melompat - lompat dengan harapan terjadi diversi
aliran darah dari kavernosa ke otot gluteus.
38.Splint gips
Splints digunakan untuk melumpuhkan tulang
dan sendi terluka
Karena cetakan melingkar dan tidak
mengakomodasi cedera pembengkakan, luka
akut biasanya harus ditangani dengan splints,
yang mempunyai risiko lebih rendah
kompartemen sindrom iatrogenik.
39. Flap lokal
Diindikasikan untuk defek pada persendian,
pembuluh darah dan tendon yang terpapar
40. Dislokasi Panggul
ANTERIOR POSTERIOR
JARANG TERJADI (10%) PALING SERING TERJADI AKIBAT
TRAUMA DASHBOARD SAAT
MENGEREM (90%)
Note:
The hernia sac
passes outside the
boundaries of
Hesselbach's
triangle and follows
the course of the
spermatic cord.
Tonometri utk
mengukur tekanan
cairan intraokuler
Tonometri applanasi Tonometri Schiotz
Tes konfrontasi utk
memeriksa lapang
pandang
Funduskopi utk
memeriksa fundus,
menggunakan
oftalmoskop
Oftamoskopi langsung Oftamoskopi tak langsung
Refraktometri utk mengukur kesalahan
refraksi mata
54. Presbiopia
Merupakan keadaan berkurangnya daya akomodasi pd
usia lanjut
Penyebab:
Kelemahan otot akomodasi
Lensa mata tdk kenyal / berkurang elastisitasnya akibat
sklerosis lensa
Diperlukan kacamata baca atau adisi :
+ 1.0 D : 40 thn
+ 1.5 D : 45 thn
+ 2.0 D : 50 thn
+ 2.5 D : 55 thn
+ 3 .0 D : 60 thn
Sumber: Ilmu Penyakit Mata. Sidarta Ilyas. 2000.
55. Konjungtivitis Vernal
Konjungtivitis vernal
56. Katarak Hipermatur
Insipien Imatur Matur Hipermatur
(kortikal)
Kekeruhan Ringan Sebagian Seluruh Masif
Blepharochalasis
59. Atrofi Difus
Glaukoma ditandai oleh
meningkatnya TIO yg disertai oleh
pencekungan diskus optikus dan
pengecilan lapang pandang
Glaukoma tekanan-normal kelainan
glaukomatosa pd diskus optikus atau
lapang pandang dgn TIO tetap di bwh 22
mmHg
Penilaian diskus optikus pd glaukoma
CD ratio (>0,5); atrofi lapisan serat
saraf
TIO normal : 10-24 mmHg
Hsl sekali pembacaan tdk
menyingkirkan kemungkinan
glaukoma Optic Nerve Cupping
Lesi satelit
Keratitis Virus
STROKE
STROKE :
Sudden brain damage
Lack of blood flow to the brain caused by a clot or rupture of a
blood vessel
85% 10% 5%
CEREBRAL ARTERY
Anterior Cerebral Artery
The Anterior Cerebral Artery (ACA) supplies
the frontal, pre-frontal and supplementary
motor cortex, as well as parts of the primary
motor and primary sensory cortex. ACA
infarcts are rare because of the collateral
circulation provided by the anterior
communicating artery.
Clinical Deficits
LEFT ACA RIGHT ACA
Right leg upper-motor neuron Left leg upper-motor neuron
weakness due to damage to motor weakness due to damage to
cortex and right leg cortical sensory
motor cortex and left leg cortical
loss due to damage to sensory
cortex. Grasp reflex, frontal lobe type sensory loss due to damage
behavioral abnormalities, and to sensory cortex. Grasp reflex,
transcortical aphasia can also be frontal lobe behavioural
seen if the prefrontal cortex and abnormalities and left
supplemental motor areas are hemineglect can also be seen if
involved.
the prefrontal cortex and non-
dominant association cortex are
involved.
Middle Cerebral Artery
The Middle Cerebral Artery (MCA) is the most
common site of stroke.
MCA infarcts occur in 2 general
regions: Superficial Divisions &
Lenticulostriate Branches
Areas supplied by the middle cerebral artery
include:
The bulk of the lateral surface of the hemisphere;
except for the superior inch of the frontal and
parietal lobe (anterior cerebral artery), and the
inferior part of the temporal lobe.
Superior division supplies lateroinferior frontal lobe
(location of Broca's area i.e. language expression)
Inferior division supplies lateral temporal lobe
(location of Wernicke's area i.e. language
comprehension)
Deep branches supply the basal ganglia as well as the
internal capsule
Deficits
Left MCA Superficial Division :
Right face and arm upper-motor weakness due to
damage to motor cortex, nonfluent (Brocas)
aphasia due to damage to Brocas area. There
may also be right face and arm cortical type
sensory loss if the infarct involves the sensory
cortex. Other deficits include a fluent
(Wernickes) aphasia due to damage to
Wernickes area.
Deficits
Right MCA Superficial Division :
Left face and arm upper-motor weakness due
to damage to motor cortex. Left hemineglect
(variable) due to damage to non-dominant
association areas. There may also be left face
and arm cortical type sensory loss if the infarct
involves the sensory cortex.
Deficits
Left MCA Lenticulostriate Branches
Right pure upper-motor hemiparesis due to
damage to the basal ganglia (globus pallidus
and striatum) and the genu of the internal
capsule on the left side. Larger infarcts
extending to the cortex may produce cortical
deficits such as aphasia.
Deficits
Right MCA Lenticulostriate Branches :
Left pure upper-motor hemiparesis due to
damage to the basal ganglia (globus pallidus
and striatum) and the genu of the internal
capsule on the right side. Larger infarcts
extending to the cortex may produce cortical
deficits such as aphasia.
Posterior Cerebral Artery
The Posterior Cerebral Artery (PCA) supplies
the occipital lobe, the inferior part of the
temporal lobe, and various deep structures
including the thalamus and the posterior limb
of the internal capsule.
Clinical Deficits
Left PCA Right PCA
Right homonymous hemianopsia due Left homonymous hemianopsia
to damage to left visual cortex in the due to damage to right visual
occipital lobe. Extension to the cortex in the occipital lobe. Larger
splenium of the corpus collusom
infarcts involving the internal
therefore interfering with
capsule and thalamus may cause
comunication between the two visual
association areas can cause alexia left hemisensory loss and left
without agraphia. Larger infarcts hemiparesis due to disruption of
involving the internal capsule and the ascending and descending
thalamus may cause right information passing through
hemisensory loss and right these structures.
hemiparesis due to disruption of the
ascending and descending
information passing through these
structures.
No. 69
STROKE
Stroke Symptoms
Headache
Neck stiffness
Neck pain
Light intolerance
Nausea, vomiting
Decreased consciousness
No. 71
TETANUS
Tetanus
Tetanus is an illness characterized by an acute onset
of hypertonia, painful muscular contractions (usually
of the muscles of the jaw and neck), and generalized
muscle spasms without other apparent medical
causes.
Caused by CLOSTRIDIUM TETANI
An anaerobic, motile, gram positive rod that forms
oval, colourless, terminal spores tennis racket or
drumstick shape.
Symptoms
Tetanic seizures (painful, powerful bursts of
muscle contraction)
if the muscle spasms affect the larynx or chest wall, they may
cause asphyxiation
stiffness of jaw (also called lockjaw)
stiffness of abdominal and back muscles
contraction of facial muscles
fast pulse
fever
sweating
Methods of diagnosis
Based on the patients account and physical findings that are
characteristic of the disease.
Generalised seizures
Unclassified seizures
Partial Seizure
Simple Complex
Seizure activity in the brain Characterized by altered
causing: awareness
Rhythmic movements -
isolated twitching of arms, face, Confusion, inability to
legs respond
Sensory symptoms -
tingling, weakness, sounds, Automatic, purposeless
smells, tastes, feeling of upset behaviors such as picking at
stomach, visual distortions clothes, chewing or
Psychic symptoms - mumbling.
dj vu, hallucinations, feelings of
fear or anxiety Emotional outbursts
Usually last less than one minute May be confused with:
May precede a generalized Drunkenness or drug use
seizure Willful belligerence,
aggressiveness
GENERALIZED SEIZURES
INVOLVE WIDE AREAS OF THE BRAIN AND LOSS
OF CONSCIOUSNESS
PETIT MAL : CONSCIOUSNESS IS TRANSIENTLY LOST
AND THE EEG DISPLAYS SPIKE AND WAVE ACTIVITY
GRAND MAL : CONSCIOUSNESS LOST FOR A LONGER
PERIOD AND THE INDIVIDUAL WILL FALL IF
STANDING WHEN SEIZURE STARTS.
TONIC PHASE: GENERALIZED INCREASED MUSCLE
TONE.
CLONIC PHASE: SERIES OF JERKY MOVEMENTS.
BOWEL AND BLADDER MAY EVACUATE.
No. 73
MIGRAINE
Ocular (Retinal) Migraines
Transient (or very rarely permanent) visual
disturbance in ONE eye
May last from seconds to hours but usually just
several minutes
Headache before or after the visual episode
Retinal Migraine
Believed to be due to an interruption in ciliary or
retinal circulation from a vascular spasm
Usually under age 40
Need to distinguish from amaurosis fugax based on
patient demographics and symptoms
Old term of ocular migraine no longer in
classification scheme : historically referred to
monocular aura without a headache
Amaurosis fugax (Latin fugax meaning fleeting, Greek
amaurosis meaning darkening, dark, or obscure) is atransient
monocular visual loss (i.e. loss of vision in one eye that is not
permanent)
Transient ischemic attack is a transient episode of neurologic
dysfunction caused by ischemia without acute infarction
(tissue death)
Retinal detachment is a disorder of the eye in which the
retina peels away from its underlying layer of support tissue.
Symptoms : central visual loss, a dense shadow that start at
the peripheral vision and slowly progress to the central
vision.
No. 74
Tinels sign
Phalens maneuver
Treatment
CONSERVATIVE TREATMENTS
GENERAL MEASURES
WRIST SPLINTS
ORAL MEDICATIONS
LOCAL INJECTION
ULTRASOUND THERAPY
Predicting the Outcome of Conservative
Treatment
SURGERY
No. 75
STROKE
Ischemic Stroke
Thrombotic Stroke
Blood flow is blocked to the
brain
Symptoms
sudden numbness, weakness face, arm, leg
(one side of body)
sudden severe headache
difficulty seeing in one or both eyes
confusion, trouble speaking or understanding
dizziness, loss of balance/coordination
Emergent Stroke Workup
All patients
Non-contrast brain CT or brain MRI Blood
glucose
Serum electrolytes/renal function tests
ECG
Markers of cardiac ischemia
Complete blood count, including platelet count
Prothrombin time/INR
aPTT
Oxygen saturation
Kaplan and Sadocks Synopsis of Psychiatry. 10th ed. Lippincott Williams and Wilkins
No. 86
Delirium
Delirium is defined by the acute onset of
fluctuating cognitive impairment and a
disturbance of consciousness. Delirium is a
syndrome, not a disease, and it has many
causes, all of which result in a similar pattern
of signs and symptoms relating to the
patient's level of consciousness and cognitive
impairment.
Kaplan and Sadocks Synopsis of Psychiatry. 10th ed. Lippincott Williams and Wilkins
Delirium
Kaplan and Sadocks Synopsis of Psychiatry. 10th ed. Lippincott Williams and Wilkins
Kaplan and Sadocks Synopsis of Psychiatry. 10th ed. Lippincott Williams and Wilkins
No. 87
Antipsychotic
Antipsikotik tipikal
Phenothiazine: Chlorpromazine, Fluphenazine,
Thioridazine
Butyrophenone: Haloperidol
Diphenyl-butyl-piperidine: Pimozide
Antipsikotik atipikal
Benzamide: Sulpiride
Dibenzodiazepine: Clozapine, Olanzapine, Quetiapine
Benzisoxazole: Risperidone
Tetrasiklik
Maprotiline, Amoxapine
MAO Inhibitor
Moclobemide
SSRI
Sertraline, Paroxetine, Fluvoxamine, Fluoxetine, Citalopram
Antidepresan atipikal
Trazodone, Mirtazapine
Ascaris lumbricoides
Pada paru-paru
menyebabkan Loeffler
syndrome
Telur cacing ascaris
berbentuk bulat/oval
berdinding tebal
dengan ovum di
dalamnya
TAENIASIS SCHISTOSOMIASIS
NECATORIASIS
FILARIASIS
112. Enterobius vermicularis
ANCYLOSTOMA DUODENALE
NECATOR AMERICANUS
ASCARIS LUMBRICOIDES
TRICHURIS TRICHIURA
ENTEROBIUS VERMICULARIS
ILMU KESEHATAN ANAK
113 Demam rematik
Penyakit sistemik akibat
pasca infeksi GABHS di
faring (faringitis)
Komplikasi utama:
penyakit jantung rematik
Gejala: riwayat nyeri
tenggorokan 1-5 minggu
sebelumnya, demam,
malaise, bisa disertai
nyeri sendi, nodul
subkutan
Terapi: penisilin
Chin TK. Pediatric rheumatic fever.
http://emedicine.medscape.com/article/1007946
-overview
114. Pneumonia
Signs and symptoms :
Non respiratory: fever, headache, fatigue, anorexia, lethargy,
vomiting and diarrhea, abdominal pain
Respiratory: cough, chest pain, tachypnea , grunting, nasal
flaring, subcostal retraction (chest indrawing), cyanosis, crackles
and rales (ronchi)
Pneumonia: Simple Clinical Signs (WHO)
Respiratory thresholds
Age Breaths/minute
< 2 months 60
2 - 12 months 50
1 - 5 years 40
Chest Indrawing
(subcostal retraction)
WHO recommendations for treatment of children aged 2
months to 4 years who have cough or difficulty breathing using
clinical classifications of pneumonia
No No tachypnea, no chest indrawing
Do not administer an antibiotic
pneumonia
Tachypnea, no chest indrawing
Pneumonia Home tratment with cotrimoxazole or amoxicillin or
procaine penicillin
Very severe Chest indrawing with cyanosis and not able to feed
Admit, administer chloramphenicol IM every 6 hour
pneumonia and oxygen
Muka 4 -8
Dada/punggung 5 -12
Perut dan paha 8 -16
Tangan dan kaki 11-18
Telapal tangan/kaki >15
Breastfeeding jaundice Breastmilk jaundice
AAP, 2004
Panduan transfusi tukar
AAP, 2004
124 Atresia bilier
Ditandai dengan diskontinuitas sistem bilier
ekstrahepatik obstruksi empedu
Gejala: ikterus, urin gelap, tinja pucat (acholic)
Hepatomegali, hiperbilirubinemia direk
edema
rambut kemerahan, mudah
dicabut
kurang aktif, rewel/cengeng
pengurusan otot
Kelainan kulit berupa bercak
merah muda yg meluas &
berubah warna menjadi coklat
kehitaman dan terkelupas (crazy
pavement dermatosis)
Marasmik-kwashiorkor
Tata laksana malnutrisi:
Penilaian status gizi, penghitungan kebutuhan gizi, cara
pemberian, pemilihan formula, monitoring
Cara penilaian status nutrisi:
Z-score menggunakan kurva WHO weight-for-height
>3 obesitas
>2 overweight
>1 possible overweight
<-2 moderate wasted
<-3 severe wasted
BB/IBW menggunakan kurva CDC
120% obesity
110 -120% overweight
90-110% normal
80-90% mild malnutrition
70-80% moderate malnutrition
70% severe malnutrition.
10 Langkah Utama
No Tindakan Stabilisasi Transisi Rehabilitasi Tindak lanjut
H 1-2 H 3-7 H 8-14 mg 3-6 mg 7-26
1. Atasi/cegah
hipoglikemia
2. Atasi/cegah
hipotermia
3. Atasi/cegah
dehidrasi
4. Perbaiki gang-
guan elektrolit
5. Obati infeksi
6. Perbaiki def. tanpa Fe + Fe
Nutrien mikro
7. Makanan stab & trans
8. Makanan Tumb.kejar
9. Stimulasi
10. Siapkan tindak
lanjut
Pemberian Makanan
Fase stabilisasi
Energi: 80-100 kal/kg/hari
Protein: 1-1,5 gram/kg/hari
Cairan: 130 ml/kg/hari atau 100 ml/kg/hari (edema)
Fase transisi
Energi: 100-150 kal/kg/hari
Protein: 2-3 gram/kg/hari
Fase rehabilitasi
Energi: 150-220 kal/kg/hari
Protein: 3-4 gram/kg/hari
130
Kattwinkel J. Neonatal
resuscitation: 2010
American Heart
Association guidelines for
cardiopulmonary
resuscitation and
emergency cardiovascular
care.
http://pediatrics.aappubli
cations.org/content/126/
5/e1400.full
ALGORITME PENANGANAN KEJANG AKUT & STATUS KONVULSIF 3
Diazepam 5-
Prehospital 10mg/rekt max 2x 0-10 mnt
jarak 5 menit
Parsial sederhana
Parsial Parsial kompleks
Secondary-generalized
Amubiasis
Giardiasis
V. cholerae
Shigella
No. 135-137 Diare
Bentuk klinis diare:
Diare cair akut: bentuk cair, >3 kali sehari, dapat
disertai deman & muntah, penyebab utama
rotavirus (50-60%), kolera, E. coli, Salmonella
Sindrom disenteri: diare berlendir dan berdarah,
penyebab utama Shigella, E. histolytica,
Campylobacter jejuni
Diare persisten: diare >14 hari, penyebab: diare
osmotik & sekretorik
Firmansyah A. Management of gastrointestinal problems. PPT presentation.
WHO/UNICEF Joint Statement. Clinical management of acute diarrhea. 2006.
Pilar penanganan diare
Rehidrasi: dapat diberikan oral/parenteral tergantung
status dehidrasinya
Tanpa dehidrasi
5 cc/kg ORS setiap habis muntah
10cc/kg ORS setiap habis mencret
Dehidrasi ringan sedang
75 cc/kg ORS dalam 3 jam
Bila per oral tidak memungkinkan, dapat diberikan parenteral
tergantung kebutuhan maintenance cairan + defisit cairan
Dehidrasi berat (parenteral)
Score 0 1 2
General condition Healthy Irritability, Delirium, coma
sleepy, apathy or shock
Skin elasticity Normal Decreased Very decreased
Eye Normal Sunken Very sunken
Fontanel Normal Sunken Very sunken
Mouth Normal Dry Dry & cyanotic
Pulse Normal 120-140 > 140
Bakteri tumbuhlampau
Infeksi persisten Diare sekretorik
Antibiotic-Associated
Diarrhea
138 Syok hipovolemik
Tanda klinis:
KV Takikardi
SSP Gangguan kesadaran, hipotoni
Ginjal Oliguri
Kulit Pucat, dingin, kelabu
Denyut nadi lemah
Bila hipotensi, bradikardi, nafas ireguler tanda akhir
ILMU OBSTETRI DAN GINEKOLOGI
Soal No : 139
12/2/2015 292
Assessment of Contractions
Palpation: Use the fingertips to palpate the
fundus of the uterus
Mild: Uterus can be indented with gentle pressure
at peak of contraction
Moderate: Uterus can be indented with firm
pressure at peak of contraction (feels like chin)
Strong: Uterus feels firm and cannot be indented
during peak of contraction
12/2/2015 293
Soal No : 142
HIPEREMESIS GRAVIDARUM
Hiperemesis Gravidarum
Definisi, keluhan mual,muntah pada ibu hamil yang
berat hingga mengganggu aktivitas sehari-hari.
Etiologi : ?
Predisposisi ; primigravida, mola hidatidosa dan
kehamilan ganda.
HCG ?
Psikologik
Penanganan khusus :
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Eclampsia
HEELP Syndrome
Hypertensive Disease Associated with
Pregnancy
Chronic Hypertension
Diagnosed before the 20th week or
present before the pregnancy
Mild hypertension
> 140-180 mmHg systolic
> 90-100 mmHg diastolic
Gestational Hypertension
Preeclampsia
Eclampsia
HEELP Syndrome
Hypertensive Disease Associated with
Pregnancy
Chronic Hypertension
Gestational Hypertension
Criteria
Develops after 20 weeks of gestation
Proteinuria is absent
Blood pressures return to normal postpartum
Morbidity is directly related to the degree
of hypertension
Preeclampsia
Eclampsia
HEELP Syndrome
Hypertensive Disease Associated with
Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Criteria
Develops after 20 weeks
Blood pressure elevated on two occasions at
least 6 hours apart
Associated with proteinuria and edema
May occur less than 20 weeks with gestational
trophoblastic neoplasia
Eclampsia
HEELP Syndrome
Hypertensive Disease Associated with
Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Eclampsia
Diagnosis of preeclampsia
Presence of convulsions not explained by
a neurologic disorder
Grand mal seizure activity
Occurs in 0.5 to 4% or patients with
preeclampsia
HEELP Syndrome
Hypertensive Disease Associated with
Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Eclampsia
HELLP Syndrome
A distinct clinical entity with:
Hemolysis, Elevated Liver enzymes, Low Platelets
Occurs in 4 to 12 % of patients with severe
preeclampsia
Microangiopathic hemolysis
Thrombocytopenia
Hepatocellular dysfunction
Soal No : 145
PELVIC PAIN
Pendahuluan
Nyeri Pelvis Akut adalah diagnosa yang paling
sering pada kasus kegawatdaruratan
ginekologi yang memerlukan perawatan
Rumah Sakit
Diagnosis Diferensial
Ginekologi Diagnosis
Kehamilan Kehamilan ektopik
Abortus
Ovarium Kista (torsi, ruptur)
Sindroma hiperstimulasi ovarium
Infeksi Pelvic Inflammatory Disease
Tumor Jinak
Ganas
Fisiologis Mittelschmerz (nyeri saat ovulasi)
Menstruasi
Diagnosis Diferensial
(Lanjutan)
Pemeriksaan
Anamnesa Nyeri pelvis akut
Nyri bertambah bila pasien berubah posisi
Discharge vagina purulen
Pemeriksaan Fisik Demam
Nyeri, tegang pada abdomen bagian
bawah
Lab Leukosit
Mikrobiologi; kultur (+)
USG
Laparoskopi
Etiologi
Neisseria Gonorrhoea 40 % Kasus
Chlamydia Trachomatis 70 % pada wanita < 25 tahun
Menyebabkan kerusakan tuba
Terapi
Bed Rest
IVFD
Medikamentosa:
Analgesik
Antibiotik spektrum luas
Cefotaxim + metronidazol
(10 hari)
Operasi
Soal No : 147
Mothers:
(1) Infection : intrauterine
puerperal
(2) Placental abruption
(3) Preterm delivery
Infants:
(1) Preterm Baby and their Complications :
(RDS / Fetal and Neurologic dysfunction
Intracranial hemorrhage)
(2) neonatal pneumoniasepsis
(3) Pulmonary hypoplasia and fetal
compression syndrone
(4) Prolapse or compression of umbilical cord
(5) Abruptio placenta
Clinical manifestation
PROM at term:
(1) Awaiting the onset of spontaneous labor for 12-24h
(2) Termination of pregnancy after 24 hours
KALA PERSALINAN
Definisi
Persalinan :
CHLAMYDIASIS
CHLAMYDIA
4 species in the Genus Chlamydia
C. trachomatis,
C. pneumoniae, affects humans
C. psittaci and
C. pecorum affects ruminants
A monolayer of tissue
culture cells has been
exposed to cells of
chlamydia
trachomatis. Infected
cells within the cell
sheet have a
cytoplasm with a
granular appearance.
PEMERIKSAAN DALAM
Tujuan
Untuk menentukan apakah penderita
benar dalam keadaan inpartu
Untuk menentukan faktor janin dan
panggul
Menentukan ramalan persalinan
INDIKASI KONTRA INDIKASI
anterior
MOLA HIDATIDOSA
What Is A Hydatidiform Mole?
A hydatidiform mole is an abnormality of fertilization
ANAEMIA IN PREGNANCY
ANAEMIA IN PREGNANCY
Definition: By WHO
Hb. < 11 gm /dl
(or haematocrit <32%).
Mild anaemia -------- 9 -10.9 gm /dl
Moderate anaemia--- 7-8.9 gm /dl
Severe anaemia-------- < 7gm /dl
Very severe anaemia-- < 4gm/dl
ETIOLOGY
There are 3 main causes:
1- Erythrocyte production (hypo proliferative
anemia )
. Fe deficiency
. Folic acid
. Vitamin B12
2- RBC destruction:
3- RBC loss:
90% anemia in pregnancy is due to Fe deficiency
Physiological changes in pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Eclampsia
HEELP Syndrome
Hypertensive Disease Associated with
Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Criteria
Develops after 20 weeks
Blood pressure elevated on two occasions at
least 6 hours apart
Associated with proteinuria and edema
May occur less than 20 weeks with gestational
trophoblastic neoplasia
Eclampsia
HEELP Syndrome
Preeclampsia vs. Severe Preeclampsia
Previously BP > 160 systolic or >110 diastolic
> 5 gr of protein in 24 hour urine or
normotensive woman > 3+ on 2 dipstick urines greater
> 140 mmHg systolic than 4 hours apart
Oliguria < 500 mL in 24 hours
> 90 mmHg diastolic Cerebral or visual distrubances
(headache, scotomata)
Proteinuria > 300 mg Pulmonary edema or cyanosis
in 24 hour collection or Epigastric or RUQ pain
> +1 on dipstick Evidence of hepatic dysfunction
Thrombocytopenia
Nondependent edema Intrauterine growth restriciton
(IUGR)
HYPERCHOLESTEROLEMIA AND
PREGNANCY
HMG CoA reductase inhibitors,or statins are
widely prescribed drugs. Indicated for the
treatment of hipercholesterolemia.
HMG CoA reductase inhibitors competitively
inhibit the activity of HMG CoA reductase, the
rate-limiting enzyme in cholesterol synthesis.
HMG-CoA inhibitors are contraindicated in
pregnancy. Limited evidence from animal and
human studies indicates that statins should
not be taken during pregnancy
Currently, the drugs of this group that are
available are:
Atorvastatin
Fluvastatin
Lovastatin
Mevastatin
Pitavastatin
Pravastatin
Rosuvastatin
Simvastatin
Soal No : 157
SIKLUS MENSTRUASI
Source Undetermined
Soal No : 158
PROLAPSUS UTERI
GENITAL PROLAPSE
Definition
Genital prolapse is the downward descent of the uterus
and /or the vagina towards or through the introitus .
The bladder , urethra , rectum and bowel may be
secondarily involved
Incidence :
Genital prolapse occurred in about 10-30% of
multiparous women and in 2% of nulliparous women .
Types
1. Uterine prolapse: 3 degrees of uterine prolapse
First degree : is the descent of the cervix
within the vagina .
Second degree :is the descent of the cervix
through the introitus .
Third degree (Procidentia ): is the descent of
the cervix and the whole uterus through the
introitus.
Pelvic support
PERDARAHAN ANTEPARTUM
KLASIFIKASI PERDARAHAN
ANTEPARTUM
1. Kelainan implantasi plasenta
PLASENTA PREVIA
PLASENTA LETAK RENDAH
3. SOLUSIO PLASENTA
SOLUSIO PLASENTA
Solutio plasenta adalah
pelepasan plasenta
sebelum waktunya.
Solusio plasenta
pelepasan sebagian atau
seluruh placenta yang
normal implantasinya
antara minggu ke22
sampai lahirnya anak.
SOLUSIO PLASENTA PLASENTA PREVIA
ABORTUS
Abortus
Definisi :
Perdarahan dari uterus yang disertai dengan
keluarnya sebagian atau seluruh hasil konsepsi pada
usia kehamilan < 20-24 minggu dan atau Berat <
500gr
Patofisiologi :
Pada awal abortus terjadi perdarahan dalam desidua
basalis + nekrosis jaringan sekitarnya hasil
konsepsi terlepas sebagian atau seluruhnya (benda
asing dalam uterus) uterus berkontraksi untuk
mengeluarkannya.
Jenis dan Derajat Abortus Spontan
Abortus Iminens
Abortus Insipiens
Abortus Inkomplit
Abortus Komplit
Retensi Embrio (Missed
Abortion)
DERAJAT ABORTUS
Gejala :
Mules sering & kuat, perdarahan bertambah banyak.
Penanganan
Penanganan : pengeluaran hasil konsepsi bisa dengan kuret
vakum atau cunam ovum, disusul dengan kerokan.
Pada kehamilan > 12 mg, perdarahan tidak banyak, bahaya
perforasi > besar Infus oksitosin.
Bila janin sudah keluar, plasenta tertinggal pengeluaran
plasenta secara digital kerokan.
Soal No : 162
PERSALINAN
Persalinan Normal
Pembukaan serviks.
Tanda-tanda dan gejala inpartu :
1. Penipisan dan pembukaan serviks.
2. Kontraksi uterus yang mengakibatkan perubahan serviks
(frekuensi minimal 2 kali dalam 10 menit ).
3. Cairan lender bercampur darah (show) melalui vagina.
4. Adanya HIS
FASE-FASE KALA I
1. Fase Laten
- Dimulai sejak awal berkontraksi yang menyebabkan penipisan
dan pembukaan serviks.
- Berlangsung hingga serviks membuka kurang dari 4 cm.
- Pada umumnya fase laten berlangsung hampir atau hingga 8 jam.
2. Fase Aktif
- Frekuensi dan lama kontraksi uterus akan meningkat secara bertahap
(kontraksi dianggap adekuat, memadai jika terjadi tiga kali atau lebih
dalam waktu 10 menit dan berlangsung selama 40 detik atau lebih).
- Dari pembukaan 4 cm hingga mencaspai pembukaan lengkap atau 10 cm,
akan terjadi dengan kecepatan rata-rata 1 cm per jam (nulipara atau
primigravida) atau lebih dari 1 cm hingga 2 cm (multipara)
Proses Persalinan pada kala1
Definisi:
Klien dengan Risiko adalah perempuan dengan
penyakit yang sudah ada sebelumnya dan kisaran
usia tertentu yang memerlukan konseling khusus
untuk menggunakan atau mempunyai risiko
tertentu apabila menggunakan alat kontrasepsi.
Kontrasepsi Klien
Berisiko
Perempuan perokok:
Kontrasepsi dengan kadar EE 50 g atau lebih
berhubungan dengan peningkatan bermakna
terjadinya infark miokardial pada perokok
terutama apabila usianya > age 35 (Croft and
Hannaford 1989).
AMENORE
Amenorrhea
Amenorrhea is the absence of menstruation.
Primary
Absence of menses by age 16 with normal
secondary sexual characteristics.
Absence of menses by age 14 without
secondary sexual development.
Secondary
Absence of menses for 6 months in a
previously menstruating female.
Diagnosis
History
Physical examination
Physical examination begins with vital signs,
including height and weight, and with sexual
maturity ratings
Laboratory evaluation
VE- preg test
TSH ,PROLACTIN,
Prog.challenge test
hypoestrogenic compromised
anovulation outflow tract.
+ve.est,progest.c -ve.est,progest
hallenge test .challenge test
2wk
Normal FSH
FSH norm. FSH>30-40
Contoh tindakan
Dokter bersikap profesional, bersikap jujur, dan luhur pribadi (integrity);
menghormati pasien, peduli pada kesejahteraan pasien, kasih sayang,
dedikatif mempertahankan kompetensi pengetahuan dan keterampilan
teknisnya
Misalnya memilih keputusan terbaik pada pasien yang tidak otonom
(kurang mampu memutuskan bagi dirinya), misalnya anak, pasien dengan
gangguan jiwa, pasien dalam kondisi gawat
Non-maleficence
(Tidak Merugikan)
Sisi komplementer beneficence dari sudut pandang pasien: tidak
boleh berbuat jahat (evil) atau membuat derita (harm) pasien;
minimalisasi akibat buruk
Variable Methode
Independent Dependent
Nominal Nominal Chi-square (analitik);
Fischer (deskriftif)
Nominal (dichotom) Numeric T-test (independent,
paired)
Nominal (> 2 score) Numeric Anova
Numeric Numeric Regression
correlation
186 IKK dan Forensik
1. Medical Indication
( terkait prosedur diagnostik dan terapi yang sesuai dari sisi etik kaidah yang
digunakan adalah beneficence dan nonmaleficence )
2. Patient Preferrence
(terkait nilai dan penilaian pasien tentang manfaat dan beban yang akan
diterimanya cerminan kaidah otonomi)
3. Quality of Life
(aktualisasi salah satu tujuan kedokteran :memperbaiki, menjaga atau
meningkatkan kualitas hidup insani terkait dengan beneficence,
nonmaleficence & otonomi)
4. Contextual Features
(menyangkut aspek non medis yang mempengaruhi pembuatan keputusan, spt
faktor keluarga, ekonomi, budaya kaidah terkait justice )
Etika Klinis
(Jonsen, siegler & winslade, 2002)
187 IKK dan Forensik
Type of data and appropriate hypothesis test
(Univariate analysis)
Variable Methode
Independent Dependent
Nominal Nominal Chi-square (analitik);
Fischer (deskriftif)
Nominal (dichotom) Numeric T-test (independent,
paired)
Nominal (> 2 score) Numeric Anova
Numeric Numeric Regression
correlation
189 IKK dan Forensik
Skala nominal adalah skala yang hanya digunakan untuk memberikan
kategori saja
Contoh: Wanita 1, Laki-laki 2
Skala Rasio adalah skala pengukuran yang sudah dapat digunakan untuk
menyatakan peringkat antar tingkatan, dan jarak atau interval antar
tingkatan sudah jelas, dan memiliki nilai 0 (nol) yang mutlak .
Contoh:
1. Berat Badan
2. Pendapatan
3. Hasil Penjualan
IKK dan Forensik
Ringkasan Tentang Skala
Skala Tipe Pengukuran
Interval Ya Ya Ya Tidak
Rasio Ya Ya Ya Ya
Essentials of diagnosis:
Chronic or recurrent otorrhea or both.
Hearing loss.
Tympanic membrane perforation.
1) Lecture notes on diseases of the ear, nose, & throat. 2) Buku Ajar THT-KL FKUI; 2007.
189. Otitis Media
Chronic suppurative otitis media
Classification:
Benign/mucosal type:
Not involving bone.
Perforation type: central. Large central perforation
Th: ear wash with H2O2 3% for 3-5
days, ear drops AB & steroid,
systemic AB
Malignant/bony type:
Involving bone or cholesteatoma.
Perforation type: marginal or attic.
Th: mastoidectomy.
Cholesteatoma at attic
type perforation
1) Diagnostic handbook of otorhinolaryngology. 2) Buku Ajar THT-KL FKUI; 2007.
189. Otitis Media
Acute Otitis Media
The bacteria responsible:
Streptococcus pneumoniae 35%,
Haemophilus influenzae 25%,
Moraxella catarrhalis 15%.
Vocal nodules
Vocal cord polyp
Glotis: between
plica ventricularis &
plica vocalis
Subglotis: laryngeal
space below the
plica vocalis
Grays anatomy for students. 2nd ed. Saunders.
193. Vocal Cord Anatomy
Quiet Respiration
During quiet respiration, the laryngeal
inlet, vestibule, rima vestibuli, and rima
glottidis are open. The arytenoid cartilages
are abducted and the rima glottidis is
triangular shape.
Phonation
When phonating, the arytenoid cartilages
and vocal folds are adducted and air is
forced through the closed rima glottidis.
This action causes the vocal folds to vibrate
against each other & produce sounds,
which can then be modified by the upper
parts of the airway and oral cavity.
Tension in the vocal folds can be adjusted
by the vocalis & cricothyroid muscles.
Angina plaut vincent Caused by Treponema vincentii and Spirochaeta denticulata and arises
most often in conditions of overcrowding. Sighs: fever, unilateral pain
on swallowing, and ipsilateral cervical lymphadenopathy; unilateral
deep ulcer on the upper pole of the tonsil, which is covered by a white
exudative membrane.
Ca tonsil Painful ulceration with induration of the tonsil. Lymph node
enlargement.
Syphilitic pharyngitis Painless ulcer in primary syphillis. Secondary syphilis: headache,
malaise, low-grade fever, sore throat, rhinorrhea, neck mass, and rash.
Pharynx : oval, red maculopapules & white patches. The tonsils
(unilateral or bilateral) may be enlarged and red.
Tonsilitis TB hypertrophic tonsils with ulceration & white exudates. Granulomatous
inflammation, Ziehl-Neelsen stain (+).
1) Cummings otolaryngology head & neck surgery. 2) Current diagnosis & treatment in otorhinolaryngology.
195. Laryngeal Disease
Laryngomalacia
The most common cause of stridor in infants.
The inspiratory stridor of laryngomalacia results from collapse
of the supraglottic larynx, creating a narrow airway and
turbulent airflow.
The newborn typically will develop intermittent, inspiratory,
low-pitched stridor within the first 2 weeks of life, which
resolves slowly over several months.
The median time to spontaneous resolution of stridor is 9
months of age, and 75% will have no stridor by 18 months of
age.
Severe laryngomalacia feeding difficulties, failure to thrive,
apnea, pectus excavatum, or cyanosis surgical intervention is
recommended to prevent cardiac failure.
Treatment:
Approximately 10% of cases will
require surgical intervention for their
laryngomalacia supraglottoplasty
(aryepiglottoplasty)
1) Cummings otolaryngology head & neck surgery. Infant larynx pre- & post-supraglottoplasty.
196. Hearing Testing
Hearing test can be done qualitatively using tune fork or
quantitatively using audiometry.
Benign/mucosal type:
Not involving bone.
Perforation type: central. Large central perforation
Th: ear wash with H2O2 3% for 3-5
days, ear drops AB & steroid,
systemic AB
Malignant/bony type:
Involving bone or cholesteatoma.
Perforation type: marginal or attic.
Th: mastoidectomy.
Cholesteatoma at attic
type perforation
1) Diagnostic handbook of otorhinolaryngology. 2) Buku Ajar THT-KL FKUI; 2007.
200. Otitis Media With Cholesteatoma
Aural cholesteatomas are epidermal inclusion cysts of the middle
ear or mastoid. It contains the desquamated debris (principally
keratin) from their keratinizing, squamous epithelial lining.