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 ComplicationPapillary 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 posteromedialLV 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.
3. Arthritis
http://www.gentili.net/foot/ra.htm
Heberden’s & Bouchard’s nodes
3. Arthritis
Osteoarthritis: space narrowing (white arrow),
osteophytes/spur (arrowhead),
subchondral cysts,
subchondral sclerosis/eburnation(black arrow).
Gout arthritis: Acute gouty arthritis: soft tissue
swelling. Advanced gout: the erosion are slightly
removed from the joint space, have a rounded or oval shape, & are characterized by a hypertrophic calcified "overhanging edge." The joint space may be preserved or show osteoarthritic type narrowing.
Current diagnosis & treatment in rheumatology. 2nd ed. McGraw-Hill; 2007.Harrison’s principles of internal medicine. 18th ed. McGraw-Hill; 2011.
ArthritisCiri OA RA Gout SA
Prevalens Female>male, >50thn, obesitas
Female>male40-70 thn
Male>female, >30 thn, hiperurisemia
Male>female, dekade 2-3
Awitan gradual gradual akut Variabel
Inflamasi - + + +
Patologi Degenerasi Pannus Mikrotophi Enthesitis
Jumlah Sendi Poli Poli Mono-poli Oligo/poli
Tipe Sendi Kecil/besar Kecil Kecil-besar Besar
Predileksi Pinggul, lutut,punggung, 1st
CMC, DIP, PIP
MCP, PIP, pergelangan
tangan/kaki, kaki
MTP, kaki, pergelangan kaki
& tangan
SacroiliacSpine
Perifer besar
Temuan Sendi Bouchard’s nodesHeberden’s nodes
Ulnar dev, Swanneck, Boutonniere
Kristal urat En bloc spine enthesopathy
Perubahantulang
Osteofit Osteopeniaerosi
erosi Erosiankilosis
TemuanExtraartikular
- Nodul SK, pulmonari cardiac
splenomegaly
Tophi, olecranon bursitis,
batu ginjal
Uveitis, IBD, konjungtivitis,
insuf aorta,psoriasis
Lab Normal RF +, anti CCP Asam urat
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 kreatininserum.
Sind. nefrotik:
proteinuria berat (>3.0 g/24 jam), hipoalbuminemia, hipertensi, hiperkolesterolemia,, edema/anasarka, & hematuria mikroskopik.
4. Renal DisorderDiagnosis Characteristic
Acute glomerulonephritis an abrupt onset of hematuria & proteinuria with reduced GFR & renal salt and water retention, followed by full recovery of renal function.
Rapidly progressive glomerulonephritis
recovery from the acute disorder does not occur. Worsening renal function results in irreversible and complete renal failure over weeks to months.
Chronic glomerulonephritis
renal impairment after acute glomerulonephritisprogresses slowly over a period of years & eventually results in chronic renal failure.
Nephrotic syndrome 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.
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 patient’s 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 arthritisinitiated by crystallization of urates within & about joints,
leading eventually to chronic gouty arthritis & the appearance of tophi.
Tophi: large aggregates of uratecrystals & the surrounding inflammatory reaction.
Harrison’s 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 Descriptions Indications
Whole blood
• Up to 510 ml total volume• Hb ± 12 g/ml, Ht 35%–45%• No functional platelets• No labile coagulation factors (V & VIII)
• Red cell replacement in acute blood loss with hypovolaemia
• Exchange transfusion• Patients needing red cell transfusions
where PRC is not available
PRC • 150–200 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%
• Replacement of red cells in anemic patients
• Use with crystalloid or colloidsolution in acute blood loss
FFP • Plasma separated from whole blood within 6 hours of collection and then rapidly frozen to –25°C or colder
• Contains normal plasma levels of stable clotting factors, albumin & immunoglobulin
• Replacement of multiple coagulation factor
• deficiencies,• DIC• TTP
Plateletconc.
Single donor unit in a volume of 50–60 ml of plasma should contain:At least 55 x 103 platelets, <1.2 x 103 red cells, <0.12 x 103 leucocytes
• Treatment of bleeding due to:— Thrombocytopenia— Platelet function defects
• Prevention of bleeding due to thrombocytopenia.
Cryopresipitate
• Prepared by resuspending FFP presipitate.• Contains about half of the Factor VIII and
fibrinogen in the donated whole blood.
Treatment of vWD, Haemophilia A, FXIII def, source of fibrinogen acquired coagulopathies (DIC)
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 attacksby uric acid lowering agent: Allopurinol Probenecid
Uric acid lowering agent shouldn’t 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 inflammatoryresponse of the lungs to noxious particles or gases.
GOLD. WHO.
20. Marker of Coronary Risk
21.Unresponsive 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 calculiimaging & 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 100Haus/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 DisorderDiagnosis Characteristic
Acute glomerulonephritis an abrupt onset of hematuria & proteinuria with reduced GFR & renal salt and water retention, followed by full recovery of renal function.
Rapidly progressive glomerulonephritis(crescentic)
recovery from the acute disorder does not occur. Worsening renal function results in irreversible and complete renal failure over weeks to months.
Chronic glomerulonephritis renal impairment after acute glomerulonephritis progresses slowly over a period of years & eventually results in chronic renal failure.
Nephrotic syndrome 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.
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 membrane–like 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
Henry’s 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. ArthritisAcute 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
ShockBleedin
g
Primary infection:• IgM: detectable by days 3–5 after the onset of
illness, by about 2 weeks & undetectable after 2–3 months.
• IgG: detectable at low level by the end of thefirst 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 microvasculardisease, may result in various diabetic foot infections that run the spectrum from simple, superficial cellulitis to chronic osteomyelitis
36. ArrhytmiaIrregular 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) 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)
Normal ileum
Harrison’s principles of internal medicine. 18th ed. McGraw-Hill; 2011.
39. Pseudomembranous ColitisIngestion of spores
vegetate
secrete toxins
diarrhea & pseudomembranous
colitis
Harrison’s 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. difficiledetected in the stool by PCR or culture, or pseudomembranes seen in the colon
Harrison’s principles of internal medicine. 18th ed. McGraw-Hill; 2011.
40. Metabolic Syndrome
41. Lung DiseaseBronchitis 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. PharmacologyThiazid 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 5–15% increase in total serum cholesterol and low-density 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.
Harrison’s principles of internal medicine. 18th ed. 2011.
44. Gastrointestinal BleedingDiagnosis Characteristic
Peptic ulcer The most common cause of upper GI bleeding. H. pylori& NSAID-induced injury (gastropathy NSAID) account for the majority of DUs
Esophageal varices hemorrhage
Portal hypertension varices around portosystemicanastomoses esophageal varices
Portal hypertensive gastropathy
Portal hypertension altered vascular microarchitecturewith dilatation and/or narrowing of the capillaries & veins bleeding risk
Hemorrhoid Bright red bleeding per rectum, a sense of rectal fullness or discomfort, may prolapse into the anal canal.
Erosive gastropathy Subepithelial hemorrhages & erosions. Cause: NSAID, alcohol, & stress. These are mucosal lesions, thus, do not cause major bleeding.
Harrison’s principles of internal medicine. 18th ed. 2011.
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
Pasien baru BTA (+), OAT kategori 1
Akhir tahap intensif
(-) Tahap lanjutan dimulai
(+) OAT sisipan 1 bulan, jika masih (+) tahap lanjutan tetap diberikan
Sebulan sebelum akhir atau di akhir pengobatan
(-) Sembuh
(+) Gagal, mulai OAT kategori 2
Pasien baru BTA (-)& Roentgen (+) OAT kategori 1
Akhir intensif (-) Berikan pengobatan tahap lanjutan s.d.selesai, kemudian pasien dinyatakan pengobatan lengkap
(+) Ganti dengan kategori 2 mulai dari awal
Pasien baru BTA (+),OAT kategori 2
Akhir intensif (-) Teruskan pengobatan dgn tahap lanjutan
(+) OAT sisipan 1 bulan, jika masih (+) tahap lanjutan tetap diberikan. Uji resistensi.
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
Usually < 8 yo
Extension (95%) vs flexion
Mechanism
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-slabhttp://orthoinfo.aaos.org/topic.cfm?topic=A00513
GENERAL TREATMENT PRINCIPLESOperative Conservative
Anatomic articular reduction
Stable internal fixation of the articular surface
Restoration of articular axial alignment
Stable internal fixation of the articular segment to the metaphysis and diaphysis
Early range of elbow motion
indicated for nondisplaced or 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 EditionLippincott Williams & Wilkins 2006
56. Tetanus
The incubation periodisusually 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
Inner beta-hemolysis = θ toxin Outer alpha-hemolysis = α toxin
NOTE: Double zone of hemolysis
Metabolic changes in traumatic-hemorrhagic shock patient: Hypermetabolism
Increased oxygen demands anaerobsmetabolismlactate↑↑
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
57. Massive Hemorrhage
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 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
• Injury to the membranous 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 examinationthe prostate will found too high to beexamined by finger (high overriding prostate)
http://www.sharinginhealth.ca/clinical_assessment/abdominal_exam.html
Organs
Spleen (Traube’s space dullness, Kehr’s 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
• Tamponadesuspected
– 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 Ringer’s
Figure out burn size by “rule of nines” or entire palmar surface of patient’s hand = 1%
Parkland/Baxter formula
4 x Wt(kg) x %TBSA = mL to give in 1 day
Half over 1st 8hrs (subtract what was given)
Give other Half over next 16 hours
In reality, 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 FootWagner 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 calcification, and soft-tissue gasgangrene
http://www.annalsofvascularsurgery.com/article/S0890-5096(11)00060-4
osteomyelitis, osteolysis, fracturessoft-tissue gas
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 diseaseFrequency
• approximately 1 per 5000 live 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 25-30%,.
Predilection
• Classical HD (75% of cases): Rectosegmoid
• Long segment HD (20% of 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)
Hirschsprung’s diseaseClinical 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 can’t be put easily
After irrigation the signs and symptoms return again in a few days
Symptoms in newborn age(enterocolitis)
• Life-threatening condition
• Diarrhea: it can be an early sign
• Toxic megacolon
• Abdominal distension
• Bile-stained vomiting
• Fiver and signs of dehydration
• Rectal tube:explosive expulsion of gas and 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)
Disorder Clinical Feature
Pancreatitis 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 cholesistis 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
Cholelithiasis 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, MRCPCholedocholithiasis at least one gallstone in the common bile duct
Pancreatic Tumor >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
http://emedicine.medscape.com/article/184043-clinical
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 nondisplacedfractures 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 EditionLippincott 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
TreatmentNonoperative Fracture reduction followed by
application of a long leg cast with progressive weight bearing can be used for isolated, closed, low-energy 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%
https://www2.aofoundation.org
Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd EditionLippincott Williams & Wilkins 2006
71. Alvarado Score
72. Proximal Humerus Fracture Proximal humerus fractures
comprise 4% to 5% of all fractures
the most common humerusfracture (45%).
The increased incidence in the older population is thought to be related to osteoporosis.
2:1 female-to-male ratio
The axillary nerve courses just 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 fracture-dislocation.
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
PathogenesisWaldvogel, 1971
1. Hematogenous
2. Contiguous focus of infection
3. 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 gram-negative bacilli.
Intravenous drug users may acquire pseudomonalinfections
76. Trauma patient
Airway Management Simple management maneuvers
Suction
Chin lift
Jaw thrust
“Definitive airway:” Cuffed tube in trachea
Patient can’t response
GCS Score<9
Obstruction due to
Tongue
Aspiration
Foreign body
Maxillofacial injury
Neck injury
Management:
Careful endoscopic exam
Careful and gentle intubation, or
Surgical airway?
Modify for suspected spinal injury:
1. Tongue/jaw lift
2. Modified jaw thrust
77. Kidney Stone FormationCauses:
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 purinemetabolism are relatively insoluble and can precipitate when urinary pH is low
http://emedicine.medscape.com/article/983759-overview
78. Colonic CarcinomaTime Course Symptoms Findings
Early None None
Occult blood in stool
Mid Rectal bleeding
Change in bowel
habits
Rectal mass
Blood in stool
Late Fatigue
Anemia
Abdominal pain
Weight loss
Abdominal mass
Bowel obstruction
Site Distribution
Screening For Colon Cancer SAVES LIVES!!!
MortalityTest Reduction
Fecal occult blood testing (FOBT 33%
Flexible sigmoidoscopy 66%(in portion of colon examined)
FOBT + flexible sigmoidoscopy 43%(compared to sigmoidoscopy alone)
Colonoscopy ~76-90%(after initial screening and polypectomy)
Colorectal cancer screeningFirst 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; 112:599Rex, 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; 112:24-8Postic 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 >24°C,
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
81. Adverse Effect of Beta Blocker Nausea
Diarrhea
Bronchospasm
Dyspnea
Cold extremities
Exacerbation of raynaud's syndrome
Bradycardia
Hypotension
Heart failure
Heart block
Fatigue
Dizziness
Alopecia (hair loss)
Abnormal vision
Hallucinations, insomnia, nightmares
Sexual dysfunction, erectile dysfunction
Alteration of glucose and lipid metabolism
http://www.cardiachealth.org/
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 beta-blocker 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/
83.Burn Injury http://en.wikipedia.org/wiki/Burn
prick test (+)
• Berat luka bakar:
• Ringan: derajat 1 luas < 15% a/ derajat II < 2%
• Sedang: derajat II 10-15% a/ derajat III 5-10%
• Berat: derajat II > 20% atau derajat III > 10% atau mengenai wajah, tangan-kaki, kelamin, persendian, pernapasan
84. Male Genital DisorderPhimosis
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
85. Wrist Pain Routine radiographic views
Wrist Joint
posterior-anterior (PA), lateral, oblique
www.stacommunications.com/journals/diagnosis
BA
C
A. Foto AntebrachiiB. Foto ManusC. Foto Cubiti
86. Efek Samping Anti Kejang Drugs Adverse Effects
Phenitoin Neurologic horizontal gaze nystagmus, sedation, cerebellar ataxia,ophthalmoparesisHematologicfmegaloblastic anemia(folic acid deficiency, agranulocytosis, aplastic anemia, leukopenia, thrombocytopeniaTeratogen, 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; orurinating less than usual or not at all
Carbamazepine
drowsiness, headaches and migraines, motor coordination impairment, and/or upset stomach, aplastic anemia,Unusual bruising or bleeding,Worsening of seizures Hallucinations, Depression
Phenobarbital
Sedation, hypnosis,dizziness, nystagmus and ataxia, excitement and confusion,paradoxical hyperactivity(children), amelogenesis imperfecta
AsamValproat
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
http://en.wikipedia.org/wiki/
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 osteoblastic-osteolytic 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 FilariasisInfection with 3 closely related Nematodes
Wuchereria bancrofti
Brugia malayi
Brugia timori
* Transmitted by the bite of infected mosquitoresponsible for considerable sufferings/deformity anddisability
* 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 There are 4 stages :
1. Asymptomatic amicrofilariaemic stage
2. Asymptomatic microfilariaemic stage
3. Stage of Acute manifestation
4. Stage of Obstructive (Chronic) lesions
Chronic (Obstructive) 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 PerspectiveG. Dreyer, J. Norões. 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 cost-effective.
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 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
Derajat 2
Sama dengan derajat 1
Ptechiae, echimosis
Nyeri hebat dalam 12 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
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)
96. Triage
Triage Category: Red Red (Highest) Priority:
Patients who need immediate care and transport as soon as possible
Airway and breathing difficulties
Uncontrolled or severe bleeding
Decreased level of consciousness
Severe medical problems
Shock (hypoperfusion)
Severe burns
Yellow Yellow (Second) Priority:
Patients whose treatment and transportation can be temporarily delayed
Burns without airway problems
Major or multiple bone or joint injuries
Back injuries with or without spinal cord damage
• Minor fractures
• Minor soft-tissue injuries
• Green (Low) Priority: Patients whose treatment and transportation can be delayed until last
Green
97. Fluid ResuscitationCrystalloids Are as effective as albumin in
post-operative patients
Are the initial resuscitation fluid of choice for:
Hemorrhagic shock / traumatic injury
Septic shock
Hepatic resection
Thermal injury
Cardiac surgery
Dialysis induced hypotension
Non-protein colloids Should be used as second-line
agents in patients who do not respond to crystalloid
May be used in the presence of capillary leak with pulmonary or peripheral edema
Are favored over albumin due to their lower cost
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 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
• When talking, breathing, or laughingepiglottis opens
• Possibility of choking if talking during meal
http://calder.med.miami.edu/pointis/tbifam/swal1.html
99. Foreign Body ObstructionJackson (1936) membagi sumbatanbronkus menjadi 4 tingkat
1. Sumbatan sebagian (bypass valve obstruction=katup bebas)
• terdengar wheezing
2. Sumbatan seperti pentil, ekspirasiterhambat, atau katup satu arah(expiratory check valve obstruction)
• Stridor inspirasi
3. Seperti pentil namun hambataninspirasi (Inspiratory check valve)
• stridor ekspirasi
4. Sumbatan total (stop valve obstruction)
• tidak terdengar stridor
Iskandar N. Sumbatan Traktus Trakeo-bronkial. Buku ajar THT edisi 6 FKUI 2007