Fatigue - Dr.

Stevent

-­‐ Gak mampu memulai aktifitas

-­‐ Reduced capacity to maintain activity
-­‐ Hard to concentrate, memory and emotional instability

Recent --> <1 Month

Prolonged --> 1 - 6 Months
Chronic --> >6 Months

Pathof = Inflammatory mediators (prostaglandins, cytokines, chemokines) pada brain -->

Microglia activation --> fatigue

* Fatigue which is not organ based --> TIRED ALL THE TIME!

Organic --> Lymph nodes, Cardiopulmonary examination , Thyroid (TSH), Neurologic -->
SINGKIRKAN dari PF dan Penunjang (CBC, Chemistry screen, Creatinine Kinase)!

Chronic Fatigue Syndrome

Unexplained, persistent or relapsing fatigue + 4/more assoc. symptoms
1. Masalah dengan short-term memory / konsentrasi
2. Sore throat
3. Tender cervical or axillary nodes
4. Muscle pain
5. Multijoint pain without redness or swelling
6. Headaches of new pattern or severity
7. Unrefreshing sleep
8. Post-exertional malaise lasting > 24 Hours

Treatment --> Antidepressant , Cognitive behavioral therapy, Graded exercise therapy

is symptoms not disease. Fatigue, tiredness, difficult to think, sleepy, hypotension, dyspnea
on effort, orthopnea.

PF
Smooth tongue --> pernicious anemia, severe iron deficiency
Hemolytic anemia --> scleral icterus
Thrombocytopenia, bone marrow replacement or aplastic anemia --> petechiae

Lab exam
Reticulocyte, Blood smear

MCV
Micro (<80), Normo (80-100), Macro (>100)

Micro --> Fe def. anemia, Anemia of chronic disease, Hemoglobinopathy/Thalassemia,

Sideroblastic anemia

Normocytic anemia --> Bone marrow failure, Bleeding, Hemolytic anemia (AIHA)
Non Immune Hemolytic anemia --> Microangiopathic hemolytic anemia (TTP,HUS,DIC),
Malaria, Cardiac valve.

Macrocytic
Megaloblastic --> Folic acid deficiency, B12 Deficiency, Drug induced
Non-Megaloblastic --> Liver dz, MDS, Hypothyroid, Drugs, Alcoholism

Anemia in CHF

Anemia in DM type 2
Metformin induced B12 Deficiency
Nephropathy diabetes --> reducing EPO
Anthropometric -- dr. Anita

Head Circumference --> glabella to occiput

Mid-upper arm circumference --> Children 1-5yrs, BW&Heigh can't be measured due to
edema/organomegaly.

Severe malnutrition --> Marasmus, Kwashiorkor, Mixed

Marasmus
Shrunken and wizened face
No subcutaneous fat (BAGGY PANTS)
Prominent bones
Muscle hypo/atophy
Liver/Spleen enlargement

Kwashiorkor
Moon Face
Edema
Crazy pavement dermatosis

Premature infants growth charts

Lubchenco
Babson & Benda / Fenton
IHDP (Infant health & development program)

Failure to Thrive
Criteria : Pengurangan berat badan yang melewati 2 garis percentile
Berat badan / usia, kurang dari 5 percentile.

Pada penggunaan Z-scores (WHO) --> datar atau penurunan pattern setidaknya 2 garis
dalam 2 bulan atau keadaan plot dibawah -3 dalam sekali pengukuran.

Breast feeding problems - dr. Fransisca

Kekurangan Asupan ASI --> poor weight gain <500gr/mo , urination <6x/day
The problems = Process, infants, and maternal problems.

Hal yang harus diperhatikan mengenai hiperbilirubinemia

1. Muncul saat lahir atau 24 jam pertama
2. Kenaikan >5 mg/dL per 24 jam
3. Bayi prematur
4. Kuning menetap >2 minggu
5. Peningkatan bilirubin direk >2 mg/dL

Breastfeeding jaundice & Breastmilk Jaundice

Hiperbilirubinemia terjadi di hari ke-2&3, saat proses menyusui belum optimal --> BFJ
Peningkatan kadar bilirubin setelah hari ke 4, s/d 3-12 minggu tanpa adanya penyakit
hiperbilirubinemia lain --> BMJ

A MU BI DA
Full breast Vs Mastitis

Pathof=
Saluran tersumbat --> Stasis ASI --> Mastitis tanpa infeksi --> Mastitis terinfeksi
Fever - Dr. Merlyn

Hypothalamus -- controls body temperature

Normal, 36,8 +- 0,4, Lowest level at 6 a.m, and higher at 4-6 p.m

Fever is happened if there is endogenous cytokines

Adanya infeksi --> mediator inflamasi --> monocytes/macrophages akan menghasilkan IL-
1, IL-6, TNF, IFN (pyrogenic cytokines), lalu dideteksi oleh hypothalamic --> menghasilkan
PGE2 --> mengaktifkan Cyclic AMP --> Elevated thermoregulatory set point --> heat
conservation & heat production --> Fever

Prostaglandin E2 --> reset hypothalamic set point.

Corticosteroids --> inhibisi phospholipase A (enzim untuk merubah membran bound
phospholipid menjadi arachidonic acid)
NSAIDs --> inhibisi dari cyclooxigenase (enzim penting untuk merubah arachidonic acid
menjadi Prostaglandin)

FUO (Fever Unknown Origin) --> Lebih dari 3 minggu dan demamnya >100,9 F
Alarm symptoms for fever
1. High fever >105,8 F
2. Rash
3. Mental status changes
4. Dizziness or light-headedness
5. Recent chemotherapy
6. SOB and Chest pain

Diagnostic approach of fever in childhood - dr. Vinia

Most cases --> self-limiting viral infection

3 mechanisms produce fever --> Pyrogens, Heat production > loss, Defective heat loss

Heat production > loss = e.g salicylate poisoning

Benefits & Harms

B= retardation of some bacteria & viruses, enhance immunologic function
H= increase metabolic rate, O2 comsumption, CO2 production

4 main etiology: infectious, inflammatory, neoplastic, and miscellaneous.

Bakteri --> ketika dikasih AB yang ampuh --> langsung turun demamnya
Virus --> turun secara perlahan lahan demamnya (self-limiting)

Tx fever
Antipyretic therapy -->
Acetaminophen 10-15mg/kgBB
Ibuprofen: 5-10mg/KgBB
Hemoptysis -- dr. Allen

the spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or
bronchial hemorrhage.

Hemoptysis
Massive = 200-1000mL/24 hours
Non- Massive = <200mL

Massive hemoptysis definition

Blood loss > 600 mL/24 hours
Blood loss > 250 mL, <600 mL/24 hours, Hb < 10g + hemoptysis
Blood loss > 250 mL, < 600 mL/24 hours, Hb > 10 g, observasi 2 hari + konservatif tx,
hemoptysis (+)

Etiology
Pulmonary Vs Extra Pulmonary

PULMONARY
Tuberculosis
Ex-Tuberculosis (Bronchitis, Bronchiectasis, Fungal infection)
Lung Cancer

Ex-PULMONARY
Upper Respiratory Tract
GIT
Dental/gum
PH-MS
Coagulopathy
Suggests lower respiratory tract source of hemoptysis --> X-Ray, kalau hasilnya normal, coba
kasih AB (kalau gak resolves) bronchoscopy!

Kalau X-Ray ditemukan mass --> CT! --> Bronchoscopy, kalau masih gak bisa didiagnosa --
> High resolution CT !

Kalau X-Ray ditemukan ada parenkimal dz --> langsung high resolution CT!

Management of Nonmassive hemoptysis

Management of Massive hemoptysis

1. Vital Sign
Oksigen
Resusitasi, blood transfusion if Ht <25%-30%, or Hb<10g + bleeding
Blood pressure (vasopressor --> dobutamin dan dopamin)

2. Avoid airway
Trendelenberg position
ETT
Suction
Mechanical ventilator

3. Stop Bleeding
Bronchoscopy cito (Forgathy catheter)
Antitussive (codein 10-20mg/4 hours)
Bronchial artery catheterization, embolization.

4. Specific therapy (through bronchoscope)

Bronchial washing, cold normal saline (NaCL 0,9)
Vasoconstrictor agent : Adrenaline

Without bronchoscope
1. Treat underlying disease
2. IV vasopressin 0,2-0,4 unit/min
3. Anti fibrinolitic
4. Radiasi --> vascular thrombosis

Cough - UptoDate
Acute <3 weeks
Sub Acute, 3-8 weeks
Chronic >8 weeks

Pathof:
Iritasi di receptor cough (epitel upper and lower respiratory tracts, pericardium, esophagus,
diaphragm, and stomach). memberikan impulse melalui vagus ke cough center di medulla lalu
generates to efferent signal ke vagus, phrenic, and spinal motor nerves to expiratory
musculature to produce the cough.

ACE inhibitors --> S.E nonproductive cough. Akumulasi dari bradykinin, stimulasi afferent
C-fibers in the airway. Treatment bisa ganti dengan angiotensin II receptor antagonist atau
losartan.

Bronchiectasis --> repeated or persistent airway inflammation --> progressive airway damage.
Bronchi become dilated and cystic, leading to poor mucus clearance, secretion pooling, and
chronic infection of the lower respiratory tract --> chronic cough.
PF: lung exam= focal or bilateral rhonchi, crackles, or wheezes.
Dyspepsia -- dr. Nata

Etiologi = Fungsional & Organic

Dispepsia fungsional --> keluhan berlangsung selama 3 bulan dengan awitan gejala 6 bulan
sebelum diagnosis ditegakkan.

Organic --> GERD, PUD, Gastric Ca, Medicine, Biliary pain, Lactose intolerance

Gejala
Nyeri epigastrium, rasa terbakar di epigastrium, rasa penuh setelah makan, rasa kembung,
mual, muntah, sendawa.

ROME III Criteria

1. Postprandial fullness --> postprandial distress syndrome
2. Early satiation --> postprandial distress syndrome
3. Epigastric pain or burning --> epigastric pain syndrome

Pathogenesis
adanya damaging forces and defensive forces. yang menyebabkan barrier mucus dari normal
- injury - peptic ulceration.

Damaging = Gastric acidity, Peptic enzymes

Defensive = Surface mucus, Bicarbonate secretion, Mucosal blood flow, Apical surface,
Epithelial regenerative, Elaboration of prostaglandins

Penegakan diagnosa fungsional dyspepsia

One or more of ROME III Criteria & no evidence of structural disease (including upper
endoscopy)

Kalau dispepsia tanpa GERD/NSAIDs, liat umur dulu.. Kalau >55 --> EGD (Upper
endoscopy), kalau <55 --> Test H.Pylori (pakai PPI Trial 4-6wks) --> gagal --> EGD
Kalau curiga Dispepsia fungsional
Gejala predominan --> nyeri/rasa terbakar pada epigastric --> PPI + prokinetik (tentative) --
tunggu 4 atau 8 minggu

Gejala predominan --> early satiety, kembung mual muntah --> prokinetik +PPI (tentative) -
- lihat 4 atau 8 minggu.

Antasida (MgOH)
Antisekresi asam lambung
PPI (Omeprazole, lansoprazole)
H2-Receptor Antagonis (Ranitidin, cimetidine)
Prokinetik (cisapride)
Sitoprotektor (rebamipide)
Hepatitis - dr. Nata

Hepatitis dapat disebabkan oleh

1. Immunologic damage
2. Infections = Virus, bakteri, fungi, protozoa
3. Toxic damage = Alkohol, Drugs, Poisons/Chemicals

Hepatitis A--> Progression ALT peak di bulan ke 1-2, dan Anti HAV stool progression
sudah ada di bulan 1-2, IgM anti-HAV peak di bulan ke 4.

Hepatitis B, periksa HBeAg --> Lalu periksa DNA VHB & ALT (Sebagai tolak ukur, pantau
selama 5x pemeriksaan)

Terapi dengan analog nukleos(t)ida [ETV, Ldt, LAM] --> Sirosis hati + DNA VHB> 2x103 +
ALT> 5x batas atas normal (Hepatitis flare)

Kalau hepatitis gak flare + Sirosis hati + DNA VHB> 2x103 --> IFN based ETV,ADV, Ldt,
LAM

Sirosis hati dekompensata --> supportive + Antiviral therapy + consider transplant

Golongan analog nukleos(t)ida (seumur hidup --> oral 1x1)

Lamivudin, Adefovir, Entecavir, Telbivudin, Tenofovir

Golongan interferon (maksimal 48 minggu, 1 tahun, injeksi subkutan)

Interferon konvensional
Pegylated interferon alpha-2a & 2b

Hep C (?)
Liver Function tests -- dr. Haryanto

AST (SGOT) meningkat menandakan ada damage involve to mitochondria enzyme -->
complete cell destruction and necrosis. Origin = muscles and many other tissues

ALT, exculuively found in the liver

Jadinya buat cek bener bener ada liver damage --> AST dan ALT meningkat.

ALP & GGT = Test for cholestases

1. Integrity liver cells test
2. Test for cholestases
3. Synthetic function tests
4. Exretory function tests
5. Detoxifying function test --> ureum
6. Tests for etiologic factors --> Autoimmune, Hepatitis marker
7. Coagulation test --> PT, PTT, INR

Acute Hepatitis A
AST/ALT = 0,4
Anti HAV, IgM antibodies +

Acute Hepatitis B
AST/ALT = 0,6
Anti HBs, HBc, HBe
HbeAg (-) = Clinically inactive
HBeAg (+) = High infectivity

Hepatitis C = Risk for hepatoma and chronic hepatitis

STEP OF EXAMINATION : Anti HCV ( + ) --- HCV Immunblot / HCV RNA (+) --
Viral load.
HCV RNA (+) after 6 days infection.
HCV RNA ( - ) ------- disease has resolved
HCV RNA ( + ) Anti HCV ( + ) ------- Chronic Hepatitis C
Alcohol related liver disease
AST/ALT >2
Macrocytic (MCV>95)

Hepatocellular cancer
Elevated AFP>500 + US + CT abdomen
dr. Vinia -- Vomiting in children
Vomiting center, lateral medullary reticular formation brainstem
M1, H1, Neurokinin 1, dan serotonin receptors.
Dipengaruhi oleh 4 hal, CTZ, CN system, Vagal afferent system, Vestibular system
CTZ
Caudal dari 4th ventricle, mainly D2 receptors, influenced by blood and CSF
Vagal
Distention or irritation of GI tract, Serotonin receptors,
Vestibular system
Motion sickness & Labyrinthine disorders, M1 & H1 receptors
Higher cortical Centers
Nonanatomical causes --> stress, behavioral or psychiatric

Phases of vomiting
1. Preejection phase, relaksasi gaster & retroperistalsis
2. Retching phase, kontraksi otot respiratory, perut, intercostal, diafragma, secara ritmik
3. Ejection phase, intense contraction dari otot perut + relaksasi dari
pharyngoesophageal spinchter.

Characteristics of Vomitting
1. Nonbilious --> consists of ingested food, and is clear or yellow
2. Bilious --> presence of bile, light green to dark green, obs. of intestine beyond
ampulla vater
3. Bloody --> presence of blood, active upper GI bleeding. Coffee-ground material
vomitus indicates blood has been acted on gastric acid.

Common causes vomiting in infancy

1. GER and GERD
GER= effortless and nonprojectile passage of stomach content to esophagus -->
could be normal physiologic
Peaks 3 - 4 Mo. Mostly reslove by 12 months of age
2. Pyloric Stenosis
3 to 6 week old --> progressive or intermittent vomitting after eading.
PE: An olivelike mass in right midepigastrium, mostly after emesis.
DX: Abdominal USG
3. Intestinal Atresia
Duodenal atresia (49%), Jejunal (36%), Ileal (14%)
Bilious vomiting, abd. distention, failure to pass meconium.
History of maternal: polyhydramnios
RadiographL Double bubble sign.

Common cause of Vomiting Beyond Infancy

1. Acute Gastroenteritis
Viruses are the most common cause -- bacteria -- parasites
Presentation: vomiting + diarrhea
2. Acute intestinal Obstruction
Symptoms: abd. pain, nause, vomiting (often bilious), abd. distension
Sign of peritonitis --> kalau prolonged period

Initial management
i. Bowel rest
ii. Gastric decompression --> NGT
iii. Managing dehydration
iv. Electrolyte
v. Symptomatic control
vi. Radiologic studies
vii. Abdomen X-ray
viii. Barium study of Upper GIT --> most helpful for SBO
ix. Barium enema --> evaluation obstruction in Lowert GIT
Antiemetic Medications
Serotonin receptor antagonists : ondansetron
Dopamine receptor antagonists : metoclopramide and domperidone
H1-receptor antagonists : diphenhydramine
Muscarinic receptor antagonist : scopolamine
Neurokinin receptor antagonists: aprepitant
Cannabinoid receptor agonist : dronabinol

Acute Diarrhea in Childhood -- dr. Anita

Diarrhea = passage of unusual loose or watery stools, at least 3 times in a 24 hour.

Acute : 2-7 day
Prolonged : 8-14 day
Chronic/Persistent > 14 day

Etiologies
Infection
Virus = Rotavirus
Bakteri : Shigella, campilobacter, E.Coli, V.Cholera
Parasit & Jamur
Non-infectious
Food intolerance, allergy, nutrition problems, Drug induced

Pathophysiology of diarrhea
1. Inflammatory & Infectious diarrhea
Epitel rusak --> inefisien water reabsorption
2. Secretoric
Water secretion > absorption
3. Osmotic
Water can't be absorbed, malabsorption. Dependent on adequate absorption of solutes
4. Deranged motility
Accelerate transit time --> decrease absorption

Treatment
1. Zinc
10 mg daily for <6months, 10 days
20 mg daily for >6months, 10 days
2. Antibotik
Shigella / Disentri --> Kotrimoksazol (1) , Asam Nalidiksat (2), kalau ga ampun 2 2
nya, ganti dengan metronidazole
Kolera --> Tetrasiklin (1), Kotrimoksazol [Trimetorprim + Sulfametoksazol] (2)

RencanaTerapi A,B, dan C : Penanganan Dehidrasi

Terapi A:
1. Beri cairan tambahan
50 - 100 mL setiap BAB pada usia <2 Tahun
100 - 200 mL setiap BAB pada usia >2 Tahun
2. Tablet zinc
Umur <6 bulan -- 1/2 tablet 10mg / hari
Umur >6 bulan -- 1 tablet 10mg / hari
3. Lanjutkan Pemberian Makan
4. Edukasi kapan harus kembali

Terapi B (observasi klini periode 3 jam) : Terapi A + ..

1. Tentukan jumlah Oralit untuk 3 jam pertama (periode 3 jam)
75 ml/kgBB
Headache and Facial pain -- dr. Vivien

Causes of headache
1. Increased ICP from tumor or hemorrhage
Stretching or distorting blood vessels
Compressing or irritating cranial or CN
2. Vascular distention and dilatation
3. Inflammation of mucosal structures, nasal sinuses, meninges, or perivascular areas
4. Contraction of skeletal muscle of neck and scalp.

Classification of Headache
1. Primary Headache
Tension
Migraine
Cluster
Trigeminal Neuralgia -- demyelination in trigeminal nerve, >40 years old,
compression of trigeminal nerve by blood vessel, Tumor or angioma, multiple
sclerosis.
2. Secondary Headache
Vascular
Subarachnoid Hemorrhage -- (Thunderclap) + meningismus
Intra cerebral Hemorrhage
Cerebral Infarction
Infectious
Meningitis
Sinusitis
Post-Traumatic Headache
Increased Intracranial Pressure --> Aggravated by bending or coughing, worse in morning
Intracranial mass lesion: brain tumor, hemorrhage
Idiopathic intracranial hypertension
Temporal Arteritis
Drugs exposure or withdrawal
Non-Neurological causes of headache
1. Sinuses
2. Ocular
3. Dental disease
4. Systemic Causes
Hypoglycemia, hypertension, hypercalcemia
Dug induced -- bronchodilators, antihistamines (vasodilatation)

Treatment of Trigeminal Neuralgia

First line: Carbamazepine
Second line: Baclofen, phenytoin, gabapentine

Post-Herpetic Neuralgia
Herpes Zoster -- result of varicella infection in childhood
Pathof : Cell-mediated immune declined -- the virus re-emerges in sensory ganglion -
- spreading both central and peripheral -- causing neurological injury -- pain.
Radiculopathy -- dr. Yusak

Nerve root --> nerve that leaves the spinal cord to branch out to other areas of the body.
Radiculopathy --> nerve root which is pinched or irritated.

Radiculopathy
Changes in the tissues (spinal vertebrae, tendons, and intervertebral discs) surrounding the
nerve roots --> it narrows the spaces called foramina (roots travel inside and exit from the
spine)

Radiculopathy
Herniated disc
Cauda equina syndrome -- compromise pelvic organ and lower extremity function
Bone Spurs
Spinal Tumors
Osteoarthritis
Scoliosis

Pain characteristics of radiculopathy Diagnosis

1. Following a dermatome distribution X-ray, MRI, CT-scans, EMG
2. May be accompanied by paresthesia (pins and needles)
3. Loss of power in the muscles innervated by root (loss of reflexes)

Cervical radiculopathy

Lumbal radiculopathy
Infeksi Saluran Genitourinaria -- dr. Edwin

Klasifikasi dari bakteriuri berulang

1. Bakteriuri persisten
Infeksi batu, prostatitis, abses ginjal
2. Reinfeksi

Urine midstream : 25mL urine pertama dibuang, 50 - 100mL urine kedua ditampung
Koloni urine midstream >100.000 koloni/mL --> infeksi

Terapi bakteriuri asimptomatik

Selama kehamilan: Amoxicillin, Cefalosporin, TMP/SMX

Terapi untuk berkteriemi & Shock sepsis

Gram(+) = Ampicilin & Cephalosporin
Anaerob = Clindamycin, Metronidazole, generasi 2 cephalosporin

Infeksi saluran kemih atas

Pyelonephritis akut
Etiologi --> E.coli >> staphylococcus, Enterococcus, Proteus mirabilis, Klebsiella sp
Gejala --> Demam + nyeri pinggang + dysuria
Pemeriksaan fisik : Nyeri ketuk CVA + abdomen tenderness
Lab : Urinalisis --> pyuria, bakteriuria, hematuria, kultur urine > 100.000 koloni/mL
Imaging : x-ray (kalsifikasi ginjal/ureter), USG, IVU, CT
Pathogenesis --> ascending infection -- refluks vesikoureteral -- obstruksi -- penyebaran hematogen
Tipe dari Pyelonephritis akut
1. Xanthogranulomatous pyelonephritis
Kombinasi obstruksi renalis + UTI kronis
Pada IVU / Kontras CT : Nonvisualized kidney(80%) dengan batu di collecting
system (70%)
2. Papillary necrosis
Radiologi : Kalsifikasi (+)
3. Renal and perirenal abscess

Infeksi saluran kemih bawah

Acute bacterial cystitis
Hematuria mikroskopik (lab), dysuria + frekuensi + urgensi + nyeri suprapubik
Tx: TMP/SMX, Fluoroquinolone, amoxcyillin, cephalosporin 3-7 hari.

Candida albicans --> akan menjadi patogen pada immunocompromised / pemakai AB lama.

Prostatitis akut
Abses pada prostat -- biasanya E.coli 70%
Demam + nyeri perineum & pinggang + dysuria
Pemeriksaan: perabaan prostat bengkak, nyeri tekan + hangat, pyuria * bakteriuria
Therapy: rawat apabila retensi urin --> cystotomi + AB intervena, apabila ada pus --> drainase
Aminoglikosida + penicilin --> parenteral, atau fluoroquinolones atau TMP/SMX

Prostatitis kronik
Etiologi --> bakteri [Gram (-), enterococcus], non bakteri (mikoplasma, klamidia, trichomonas)
Therapy --> sama dengan prostatitis akut, tapi 4-6 minggu
Hematuria in children -- dr. Melanie
Hematuria (abnormal amounts of RBC) berbeda dengan hemoglobinuria (free Hb in urine)

Causes of hematuria in children

1. Infection
Bakteri, TB, Viral
2. Hematologic
3. Stones & Hypercalciuria
4. Anatomic abnormalities
Congenital, Trauma, Polycystic kidneys, Tumors, Vascular abn.

Terminal hematuria + dysuria --> posterior urethritis

Painless gross hematuria --> Glomerulonephritis
Previous heart murmur --> bacterial endocarditis
VP shunt for hydrocephalus --> shunt nephritis

Idiopathic hypercalciuria --> Gross hematuria & absence of stone formation -- excessive GIT absorption
of normal dietary calcium intake. Therapy oral thiazide -- stimulates Ca reabsorption in distal tubule.

Post Streptococcal Acute GN

Most common in childhood 5-12 y.o
Usually presented the history of skin (serotype 49) or throat (serotype 12) + hematuria / ARF.
Urinalysis : RBCs, RBC casts, Protein, WBCs
Therapy: Penicilin

Glaukoma -- dr. Karliana

Ketidak seimbangan antara pembentukan + pengaliran humor aqueous.

Aliran humor aqueous:

Corpus ciliaris -- COP -- Pupil -- COA -- Trabecula -- canalis chlemm -- Sal. Kolektor -- Plexus vena --
sclera -- episclera -- vena ciliaris anterior.

Gejala: Tekanan Intra ocular meningkat + Gangguan & Atrofi N.II + Defek visi

Klasifikasi:
1. Glaukoma Primer
Dewasa
Glaukoma simplex (sudut terbuka, kronis)
Glaukoma akut (sudut tertutup) -- Therapy: Mannitol 20% -- 30 tetes per menit, Gliserin 30cc
CITO, Acetazolamide (midriatik 1 tablet), Carpine 2% (2 jam pertama / 15 menit, 3 jam
berikutnya / 30 menit, seterusnya / 1 jam)
Kongenital/juvenil
2. Glaukoma Sekunder (perubahan lensa, Perubahan uvea, Trauma, Operasi)
Terbuka
Tertutup

Glaukoma primer -- sudut terbuka (Simplex)

Bersifat kronik, umur >40th (90%)
Etiologi: Sudut COA terbuka, penebalan trabecula/sclerosis trabecula + canalis chlemm (degenerasi)
Plexus vena intrasclera mengalami sclerosis
Therapy:
Menurunkan humor aqueous --> Simpatomimetik (Epinefrin) / Beta-Blocker (Timolol maleat) / CAI
(Acetazolamide 250mg 4x1)
Meningkatkan outflow --> Parasimpatomimetik -- myoticum (pilocarpin, Esserin)

Glaukoma primer akut (sudut tertutup)

Sudut COA sempit --> aliran humor aqueous dari COP ke COA terhambat --> blokade pupil
Gejala klinis:
Fase prodromal
Subjektif -- Visus kabur, halo, sakit kepala, sakit bola mata, lemah akomodasi
Objektif -- Cornea suram, COA dangkal, Pupil membesar, Reaksi lambat, TIO meningkat
Fase glaukoma akut
Subjektif -- Sakit kepala hebat (N.V), Visus menurun, Muntah, Sakit bola mata
Objektif -- TIO meningkat, Cornea oedem, Palpebra oedem, COA dangkal, pupil reaksi (-)

Uvea - dr. Karliana

terdiri dari:
1. Iris -- Uvea anterior
2. Ciliary body -- Uvea anterior
3. Choroid -- Uvea posterior

Iris membagi bilik mata COA & COP

Otot: M. Sphincter pupil (sirkuler)(N.3, parasimpatis) & M. Dilator pupil (Radier)(Simpatis)
 Cherry red spot: Arteri dari maculae yang masih membantu
memperdarahi retinae

Triage Corneal Ulcer: Lacrimasi + Photophobia + Blepharospasme

Gawat Darurat Mata - Dr. Endang
Keadaan dimana mata terancam kehilangan fungsi penglihatan atau terjadi kebutaan bila tidak dilakukan
tindakan atau pengobatan secepatnya.
1. Sudden Loss Vision
A. Centralis Retinae Occlusion -- Kelainan agregasi darah, emboli, spontan (hypertension, rokok)
Gejala klinis : Visus turun mendadak, painless, cherry red spot, dilated pupil & reflex(-). T
Therapy: Trendelenberg, massage hangat, Acetazolamide (midriatika)/glycerin.

V. Centralis Retinae Occlusion -- Emboli, Thrombus. Gejala klinis -- painless + visus turun, terasa
saat bangun tidur, gangguan lapang pandang, papil edem, vena membesar & berkelok.
Therapy: tunggu reabsorbsi 3 bulan / injeksi intra vitreal anti VEGF.

Amaurosis Fugax -- Visus hilang mendadak selama beberapa menit lalu membaik kembali.
Therapy: Trendelenberg, massage, vasodilator

Perdarahan Badan Kaca -- visus menurun tanpa rasa sakit, floaters, flashes, bagian penglihatan
menghilang tergantung posisi kepala/gerakan, riwayat pemakaian aspirin lama / anti coagulant.
Therapy: anti vegf, vitrectomi (kalau sedikit), tunggu reabsorbsi 3 bulan.

Ablatio Retina -- Flashes, Floaters, Hilangnya lapang padang sebagian, Retina bulging keabuan
dengan vasa diatasnya
Therapy: Operasi Ablasio + Laser

2. Infeksi Emergency
Blennorhoe -- Opthalmia Neonatorium, pencegahan hari pertama --> Ag NO3 / Chloramphenicol
Infeksi hari:
1-3 : Gonorrhoe
3-7: Conjunctivitis viral
11-21: Staphylococ, Pneumococ, Pseudomonas
GO --> Palpebra spasme (wooden hard sign), excessive secrete purulent, destructive -- ulcus
cornea

HZO - Herpes Zoster Ophthalmicus, Rash/vesikel akut pada kulit (ganglion dermatome N.V),
pusing, demam, mata merah & sakit, Lesi pada satu sisi tidak menyebrang midline, palpebra
superior, dahi, hidung.
Therapy: Anti viral

3. Trauma
• Non-penetrating / Non Perforating Injury
1. Superficial -- Aberasi/Lacerasi & Corpus Alienum
2. Chemis/Phisis -- Basa -> Berbahaya -- Penetrasi & Destruksi || Asam -- Coagulasi -- Precipitasi
TherapyL Irigasi L Basa -- Ringer/Aquadest 2000cc/30 menit

Phisis -- UV (6-10 jam sesudahnya, edema palpebra, conjuncttiva, cornea)

Infrared (matahari, pabrik gelas) , Insect Bite, Combustio
3. Contussi/Concussi

• Penetrating / Perforating Injury -- Conjunctiva, Cornea, Sclera, COA, Iris

4. Glaukoma Akut
5. Neuro-Opthalmologic Emergency
Hyphaema: Perdarahan pada oculi anterior (melalui flash light, dapat dilihat genangan darah)
Darah yang menumpuk --> secondary glaucoma
Kornea bisa berwarna kecoklatan
Initial treatment = Bed rest total, tidur 35o / 3 bantal
Red Eye without Blurred Vision -- dr. Werlinson Tobing

Red eye disebabkan karena enhance blood supply, congestion, or leakage of the blood vessel
Lokasi -- a. posterior conjunctiva and/or a. anterior ciliary

Blepharitis -- Inflamasi pada lid margin

Bacterial Conjunctivitis -- Tear & Exudate

Tearing, foreign body sensation, burning, stinging and photophobia
Conjunctival swab for culture
Therapy: Topical broad spectrum

Viral Conjunctivitis -- Tear

Acute, watery red eye with soreness, foreign, body sensation and photophobia -- adenoviral inf. (m.c)
Often hyperaemic, follicles, hemorrhage, inflam. membranes, and a preauricular node.

Allergic Conjunctivitis -- Itchy

Often history of rhinitis, asthma, family history of atophy
Mildly red eyes, watery discharge, chemosis, papillary hypertrophy and giant papillae
Therapy: Antihistamines, mast cells stabilizers, topical cortico & cyclosporine

Giant papillary conjunctivitis

Contact lens wearer, ocular itching, mucous discharge in tears, blurred vision and inj. conjunctival
Therapy : Contact lens hygiene & steroids.

Dry eye syndrome

Symptoms: Burning, Tearing, Bilateral. PE: Conjunctival edema, hyperemic, Therapy: artificial tear
Decrease of tear function!
1. Lipid component (blepharitis)
2. Meibomian gland dysfunction (Sjogren, diuretics, geriatric)
3. Mucin deficiency (benign ocular phempygoid)
4. Excessive evaporation (non humid air)

Pterygium
Fibrovascular tissue of conjunctiva, degenerative and invasive.
Chronic of dust, sunglight, and heat exposure
Therapy: Sunglasses, steroid, surgery, and artificial tear

Scleritis || Episcleritis
Pain + tearing + photophobia || Localized, asymptomatic, self limited, Tx" Topical / systemic NSAIDs

Subconjunctival hemorrhage
Asymptomatic, blood underneath the conjunctiva, Et: Valsava, trauma, HT, bleeding disorder
Tambahan - catatan mata dr. Irma (blok mata)

Red Eye

Visus = tanda vital dibidang mata.

Injeksi Conjunctiva --> gangguan pada posterior conjunctival arteries., blanching in adrenalin
drop, mobile with movement.
Mixed --> hiperemis di limbus
Injeksi ciliar --> banyak di daerah limbus, peripher lebih loose (karena anterior ciliary
arteries, immobile with movement, tetesan adrenalin gak kasih reaksi apapun)
Conjunctiva --> di peripher banyak
Pericorneal --> seperti ciliary tapi gak ada inflamasi di deket limbus

Conjunctivitis
S&S = Discharge --> watery, mucoid, purulent or mucopurulent. (Membedakan bakteri /
virus), fotofobia, injeksi konjungtiva, eyelid welling, terdapat papil/folikel/membrak di tarsal
conjunctiva.

Perbedaan bakteri & virus (bagan)

Conjunctiva tarsal --> bakteri gak spesifik, virus (FOLIKEL).

Virus --> Onset awal udah ada membrane
Bakteri --> membrane di akhir akhir.

Papil --> Ada anchoring septa (tampak seperti parit) , tengah ada titik merah (karena ada
pembuluh darah)

Folikel --> di tengah gak ada titik merah, dan gak punya anchoring septa

Gonnococcal --> bisa menembus kornea intact, purulent discharge. Sudah dicuci tetep keluar
terus.

Tx conjunctivitis --> pemberian steroid *DENGAN CATATAN GAK ADA DEFECT PADA
KORNEA)
PTERYGIUM
Triangular fibrovascular tissue
EtL hot climate, chronic dryness, and high sunlight exposure.

Mengganggu visus apabila sudah terkena ke pupil, ataupun eksisi yang meninggalkan scar
tissue.
TX= Rujukan ke sp. mata --> eksisi dengan konjungtiva graft, dan lamellar keratoplasty

SUBCONJUNCTIVAL HEMORRHAGE
No pain, no discharge, well-demarcated
Kalau ada penambahan darah --> bisa periksa coagulation factornya.
Trauma, minum pengencer darah, kucek kucek berlebihan, biasanya bisa keserap sendiri 10 -
14 hari.
KALAU GAK ADA Penurunan visus / nyeri & penambahan darah--> ga masalah.
Tx ==> kalau memang dibutuhkan + progress cepat --> topical nsaids dan artificial
EPISCLERITIS dan SCLERITIS
Sclera ada 3 vascular layer
Deep vascular plexus
Superfisial episcleral vessels

Episcleritis
Common, benign, self-limiting, related to systemic disease. Types --> nodular & simples

SCLERITIS
Infeksi granulomatous, biasanyaa karena RA & connective tissue disorder. GAK BERDIRI
SENDIRI, cari etiologynya. Types --> Anterior and posterior, (Necrotizing & non-
necrotizing)

Necrotizing --> Nyeri sekali

TX --> steroid oral / eyedrop.

Red Eyes, Decreased Vision [terkena media refraksi (kornea, lensa, dan posterior)]
KERATITIS
Inflamasi pada kornea. 70% komponen refraksi. Terdapat lapisan Tear film --> indeks
refraksi.
Et: infetion, dry eyes, trauma, contact lens (karena gram negatif yang cepat
menyebar), allergy, UV exposure.
Dapat berkembang ke Cornea Ulcer
S&S => sensasi benda asing, fotofobia, periocular pain, ciliary flush (mix).
DX= Reduced cornea sensibility, assessment of corneal regularity, pemeriksaan
warna ( meneteska strip fluorescein lihat perubahan warna pakai lampu slit red - lift filter).
CORNEA ULCER
ANTERIOR UVEITIS
Peradangan uvea (iris, badan ciliar, dan koroid), Nyeri, fotofobia.
Anteroir Uveitis --> Cells (gunain slit lamp / lampu celah, Seperti ketombe melayang
di anterior chamber) and flare (keruhannya) in Anterior Cornea. Periksa intraocular pressure.
KPs --> Sel radang yang menempel di enodthel kornea, diameter lebih besar di
pigmen iris.
Hypopyon --> Reaksi peradangna yang lebih hebat, nanah di bilik mata depan.Berada
di anterior chamber, kalau lama dan gak diatasi --> Bisa menempel dan membentuk plaque
hypopyon. Harus diliat lampu slit --> apakah nempel atau hypopyon.
Sinekia --> pelekatan iris, ke anterior (ke kornea) atau posterior (ke lensa)
TX --> Oral corticosteroids
ACUTE GLAUCOMA (Dilated pupil, Mata merah, dan Fotofobia)
Ocular Emergency! Blockage aqueous humor outflow! Nervus optikus diserang,
kornea menjadi edema --> penurunan visus

Acute angle-closure Glaucoma --> Paling nyeri, ada Heziy (kornea edem), adanya
sakit kepala dan mula dan muntah, terdapat Corneal oedema & Dilated pupil, dan fotofobia

TX = Anti glaucoma, Pilocarpine, Timolol, Oral glycerin/IV manitol (kalau severe) --> kalau
gak ada perkembangan, di surgery.

Acute angle-open Glaucoma --> Kompetensi dr. mata, hraus cek sudutnya.
ENDOPHTHALMITIS (hypopion, penurunan visus mata, hiperemis, kornea keruh
sekali)
Infeksi berat, melibatkan daerh anterior sampai ke posterior.
Infeksi intraocular purulent, adanya luka terbuka pada kornea (post cataract, atau
trauma tembus kornea), penyebabnya staph. aureus (most common), Sangat sangat turun
visusnya, biasanya disertai hypopion (harus lebih berhati hati)
TX --> Vitreous tap, intravitreal antibiotic, panoftalmitis --> evisceration

Geographican Infiltrate (Pada pemeriksaan lampu slit) --> Khas pada kasus viral
Gangguan pendengaran -- dr. Michael

1. Tuli Konduksi
2. Tuli Saraf -- Cochlea & Retrocochlea dysfunction
3. Tuli Campur

Audiometri
Tuli sensori -- Air & Bones berhimpit > 25 db
Tuli Konduksi -- Bone normal, AC>25db
Tuli campur -- Terdapat gap pada BC & AC > 25db

Gangguan keseimbangan -- dr. Michael

1. Sentral
Nukleus vestibularis - batang otak = TIA/stroke vertebrobasilaris, tumor, trauma,
migren basilaris, multipel sklerosis (degeneratif)
Serebelum = stroke, tumor, kelainan degeneratif
Otak = Epilepsi, kelainan degeneratif
2. Perifer
• BPPV -- Right dix-hallpike • Oklusi pembuluh darah labirin
maneuver • Trauma
• Menier's disease • Tumor (neuroma akustik)
• Infeksi (OMSK, Neuritis • Kelainan degeneratif
vestibuler)
• Ototoksik

Gejala dan tanda gangguan keseimbangan

• Vertigo -- Nystagmus Sentral (berbagai arah), Perifer (1 arah)
• Disequilibrium (rasa mau jatuh/goyang/sempoyongan)
• Dizziness
• Sinkope
• Otonom = Berdebar-debar, keringat dingin, abdominal discomfort, cemas & takut

Therapy Vertigo
Beta Histine
Antagonist H3 Receptors -- block histamine, acethycholine, NE, serotonin (inhibits activity
of vestibular nuclei) and GABA
Agonist H1 Receptors -- vasodilation inner ear blood supply
Tinitus - dr. Michael
Mendengar suara tanpa adanya stimulus dari luar. Kronik >3 bulan
Macam Tinitus = Subjektif & Objektif || Pulsasi & Non-Pulsasi

Medikamentosa
Vasodilator, Anti kejang, Psikoaktif (perbaikan depresi), antipsikotik, bezodiazepin
Myelopathy -- dr.
1. Trauma -- SCI (Spinal Cord Injury)
2. Inflamasi -- Myelitis
3. Kompresi -- Spinal Cord Tumor, Myelopathy

Tulang vertebrae lebih panjang dibandingkan dengan medulla

spinalis, oleh karena itu -->
Medulla spinalis T1 --> Keluarnya di vertebrae Cervical 7
Medulla spinalis T4 --> Keluarnya di vertebrae Thoracal 3
Medulla Spinalis L1 --> Keluarnya di vertebrae Thoracal 1

Clinical signs
• UMN weakness
• Anterior syndrome
• Posterior syndrome -- impaired position (proprioceptive), vibration, discrimination, s
tereognosis, + Rhomberg sign, Gait Ataxia
• Hemisection syndrome (Brown-Sequard) -- deficit posisi, vibrasi, tactile, weakness
(ipsilateral) || pain & temperature (contralateral)
• Total Transection syndrome --> SCI, weakness, complete sensory loss, involuntary
function (bowel & sex)

Dermatomal
Cervical 6 -- Jari Jempol Lumbar 4 -- Paha & atas lutut
Cervical 7 -- Jari Telnjuk & tengah Lumbar 5 -- Punggung kaki
Cervical 8 -- Jari Kelingking Spinal 1 -- Kelingking kaki

Etiologies of Myelopathy
1. Vascular 5. Metabolic
2. Inflammation 6. Idiopathic
3. Trauma 7. Neoplasm
4. Autoimmune

Transverse myelitis
Most common causes by viral (varicella zoster, HSV, CMV, EBV) or TB --
Clinical sign: Weakness of the legs and arms + Pain + Sensory alteration + Bowel and Bladder dysf.
Diagnosis : MRI || Therapy : Corticosteroids, Acyclovir

Spinal Cord Injury

Biasanya berbarengan dengan head injury, terdapat baal atau kelemahan ekstremitas sesuai letak lesi
Therapy: <8 Hours -- Methylprednisolone bolus IV 30 mg / KgBB / 15 mins
Methylprednisolone IV infusion 5.4mg/ KgBB / hour for next 23 hours.

Asia Impairment Scale

A. Complete loss
B. Sensory Incomplete (ada beberapa yang masih berfungsi)
C. Motor Incomplete, muscle grade <3
D. Motor Incomplete, muscle grade >3
E. Normal

Spinal Cord Tumor

1. Extra Dural Extra Medullary
2. Extra Medullary Intradural -- Nyeri
3. Intra Medullary -- keluhan motorik

Therapy: Corticosteroid
Definitive -- Laminectomy / Removal surgery

Gibbus -- Compresi karena fracture vertebrae yang

disebabkan exudate Tuberculosis
dr. Yusak -- Pain
Pain pathway || A-Delta & C-Fiber
1. Nociceptor
2. Dorsal root ganglion
3. Dorsal horn --> Spinal cord
4. Brain --> Pain perception

Kalau reflex, langsung aliran stimulus di interneuron ||

NMDA & AMPA Receptor yang mengatur treshold pain.

Pain
Nociceptive -- Throbbing pain, hilang dengan analgesic biasa, sakitnya pada lesi tersebut
Therapy: PCT, NSAIDs, Tramadol (kombinasi PCT, NSAID & Sintetik Morphin),
OPIOID, Intervention pain procedure
Neuropathic -- Radicular pain, shooting, burning, freezing || Pada sistem syaraf yang menggangu
Therapy: Obat epilepsy -- Carbamazepine, Gabapentine, Pregabaline
Hiperalgesia -- Peningkatan reaksi / sensasi terhadap suatu rangsangan sakit (noxious)
Alodinia -- Sensasi rasa sakit terhadap non-noxious stimuli || e.g: Herpes, gigi, diabetic neuropathic pain
Skin insensitibility -- dr. Vonny

Sensory receptors
Somatic
Chemoreceptors, Thermoreceptors, Photoreceptors, Baroreceptors
Visceral
Baroreceptors, Chemoreceptors

Sensory Pathyways
First Order Neuron
Sensasi (stimulus) ke batang otak
Second-Order Neuron
Batang otak - Thalamus
Thrid-Order Neuron
Thalamus - Otak

Ant. & Lat. Spinothalamic & Posterior collumnar (fasiculus gracilis & cuneatus)

Pathways
Spinothalamic (suhu dan nyeri)
Langsung menyilang di medulla spinalis (dari dorsal root ganglion, menyilang selevel
dengan medulla spinalis) -- naik ke thalamus -- primary somatosensory cortex

Dorsal collumn (peraba & proprioceptive)

Naik dlu ke medulla oblongata -- menyilang -- thalamus -- primary somatosensory cortex

Brown-Sequard Syndrome
contralateral --> pain dan suhu
ipsilateral --> proprioceptive

Medial dari posterior collumn --> tungkai kaki

Lateral dari posterior collumn --> tungkai tangan

Homonculus cerebri --> daerah tungkai lebih di medial, daerah tangan wajah, lidah, lebih ke
lateral.

ACA --> lebih kena ke bagian depan

PCA --> lebih kena ke tungkai lemah
MCA --> Lebih kena ke bagian lateral (lengan lebih berat ditimbang tungkai)

Polyneuropathy diabetes --> Glove and Stocking

(Akut atau Kronik)

Stroke --> gangguan sensoris, hemiparesthesia.

Nerve entrapment --> Gangguin sensoris sesuai dengan syaraf yang terkena (Ulnaris --> pada
bag. satu setengah jari)

CTS (median nerve)--> 3 setengah jari

Myelopathy --> Dermatomal, sesuai levelnya.

Radiculopathy --> Sesuai dermatomal juga, L4-L5 = Banyak ngeluh di lateral paha & betis
L5-S1 = Ngeluh pada betis bagian belakang

Peripheral Neuropathy
Trauma or pressure on the nerve
Diabetes
B12 Deficiency
Alcohol, GBS, Autoimmune, Tumors, Infections
Post-Chemotherapy
Gangguan syaraf bisa kena di myelin atau di axon.

Kalau kena di myelin --> prognosa lebih bagus

Gangguan sensoris
- symptoms, , vibration berkurang, hyporeflexia, pain berkurang , berkurang proprioceptive
+ symptoms, kesemutan, allodynia, hyperalgesia

CTS the most common of nerve entrapment

• Kesemutan sesuai distribusi syaraf medianus
• Thenar hypotrophy
• Terlalu banyak flexi pergelangan tangan

Harus bisa bedakan dengan radiculopathy cervical --> distribusinya berbeda! ada perasaan
nyeri secara radicular, ada gangguan motorik pada kejadian berlanjut

Pemeriksaan -->
Fisik --> parasthesia di 3 setengah jari, lalu tinnel sign (diketuk), phallang sign
Pencitraan --> EMG

Ulnar neuropathy --> Cubital Tunnel Syndrome

Ulnar neuropathy di pergelangan tangan
(Guyon tunnel syndrome?)
Cara membedakan ^ , melakukan tinnel sign + di siku gak? lalu ada riwayat trauma di siku?

Pengobatan
FIsioterapi
Release --> apabila ada nerve entrapment yang berat
Injeksi Steroid --> kalau entrapment ringan

Tarsal Tunnel Syndrome --> Syaraf tibialis posterior tertekan.

Gejala --> Ketika jalan --> kesemutan

(conduction velocity) Needle EMG --> untuk memastikan suatu radiculopathy atau tidak,
tusuk jarum di otot yang kita curiga syarafnya terjepit. Kalau entrapment baru terganggu.
EMG untuk mengetahuinya.segala kejadian di LMN.

Kalau radiculopathy (LMN) --> refleks fisiologis biceps atau triceps bisa menurun

LMN --> anterior collumn --> radix --> plexus --> peripheral nerve --> neuromuscular
junction --> muscle