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