pembahasan seminar part 1.pdf

PEMBAHASAN SEMINAR BATCH IV SEPT-NOV 2013

Part I

ILMU PENYAKIT DALAM

1. Pharmacology

Antacids may affect a number of drugs by altering rates of dissolution & absorption, bioavailability, & renal elimination.

The dissolution of erythromycin was found to be markedly retarded in the presence of all the antacids studied except sodium hydrogen carbonate.

Al3+ & Mg2+ antacids have propensity to chelate other drugs in the GI tract forming insoluble complexes that pass through the GI tract without absorption.

Most interactions can be avoided by taking antacids 2 hours before or after ingestion of other drugs.

2. Diabetes

16. Antidiabetic Drugs

3. Hypertension

1. ACE-I (kaptopril, lisinopril): Bradikinin & substansi P batuk

2. ARB (valsartan, losartan): Tidak menyebabkan batuk

4. Heartburn

Effect of caffeine on GI tract: Coffee promotes gastro-oesophageal reflux. Coffee stimulates gastrin release and gastric acid secretion. Coffee also prolongs the adaptive relaxation of the proximal

stomach, suggesting that it might slow gastric emptying. However, other studies indicate that coffee does not affect gastric emptying or small bowel transit.

Coffee induces cholecystokinin release and gallbladder contraction.

Coffee increases rectosigmoid motor activity.

Although often mentioned as a cause of dyspeptic

symptoms, no association between coffee and dyspepsia is found. Boekema PJ, Samsom M, van Berge Henegouwen GP, Smout AJ. Coffee and gastrointestinal

function: facts and fiction. A review. Scand J Gastroenterol Suppl. 1999;230:35-9.

5. Anaphylactic Shock

World Allergy Organization anaphylaxis guidelines: Summary

6. Hipersensitivitas

7. Asthma: therapy

Asthma management has six interrelated parts: 1. Education 2. Assess & monitor

severity 3. Avoid exposure

to risk factors 4. individual

medication plans 5. plans for

managing exacerbations

6. regular followup

GINA 2005

7. Asthma: therapy

7. Asthma: therapy

Jika steroid jangka panjang terpaksa diberikan pada asma persisten sedang-berat karena tidak mampu, maka pertimbangkan:

Gunakan prednison, prednisolon, atau metilprednisolon karena efek mineralokortikoid minimal, waktu paruh pendek, & efek striae pada otot minimal

Bentuk oral, bukan parenteral

Penggunaan selang sehari atau 1x/hari pagi hari

8. Dyslipidemia

Estimation of LDL using Friedewald formula:

LDL = Total cholesterol HDL TG/5

TG/5 is a representative of VLDL

This equation cant be used if the TG is >400 mg/dL.

LDL = 500 30 (350/5)

= 400 mg/dL

9. Hiperkortisolisme

10. Hipertensi dengan Bradikardia

11. E.S. OAT Mayor

MAYOR Kemungkinan Penyebab HENTIKAN OBAT

Gatal & kemerahan Semua jenis OAT Antihistamin & evaluasi ketat

Tuli Streptomisin Stop streptomisin

Vertigo & nistagmus (n.VIII) Streptomisin Stop streptomisin

Ikterus Sebagian besar OAT Hentikan semua OAT s.d. ikterik menghilang, hepatoprotektor

Muntah & confusion Sebagian besar OAT Hentikan semua OAT & uji fungsi hati

Gangguan penglihatan Etambutol Stop etambutol

Kelainan sistemik, syok & purpura

Rifampisin Stop rifampisin

11. E.S. OAT Minor Minor Kemungkinan Penyebab Tata Laksana

Tidak nafsu makan, mual, sakit perut

Rifampisin OAT diminum malam sebelum tidur

Nyeri sendi Pyrazinamid Aspirin/allopurinol

Kesemutan s.d. rasa terbakar di kaki

INH Vit B6 1 x 100 mg/hari

Urine kemerahan Rifampisin Beri penjelasan

12. Hiperkortisolisme

Elektrolit: hipokalemia, hipernatremia

13. Tiroid

In the presence of corticosteroids, which lower TBG levels, the total thyroid hormone (bound + free) in the blood will be low.

Noted that free thyroid hormon is normal because of decrease TSH: Low TBG increase free thyroid hormone

decrease TSH normal free thyroid hormone.

B & D are correct.

14. Arrhytmia

SVT:

young

AF:

Elderly

History of hypertension

15. Arrhytmia

Second degree AV block 3:1

16. Pharmacology

Rifampin potently induces CYP1A2, 2C9, 2C19, and 3A4 decreased half-life for a number of compounds, including: HIV protease and non-nucleoside reverse transcriptase

inhibitors, digitoxin, digoxin, quinidine, ketoconazole, propranolol, metoprolol, verapamil, clofibrate, methadone, corticosteroids, oral contraceptives oral anticoagulants, theophylline, barbiturates, fluconazole, sulfonylureas

Goodman & Gillman Pharmacology.

17. TB Paru Pada Gagal Ginjal

Jangan menggunakan streptomisin, kanamisin, & kapreomisin.

Sebaiknya hindari penggunaan etambutol karena waktu paruhnya memanjang & terjadi akumulasi etambutol.

Sedapat mungkin dosis disesuaikan dengan faal ginjal (CCT, ureum, kreatinin).

Rujuk ke ahli paru.

18. Organophosphate Intoxication

Organophosphorus pesticides inhibit esterase enzymes, especially acetylcholinesterase in synapses and on red-cell membranes.

Acetylcholinesterase inhibition accumulation of acetylcholine & overstimulation of acetylcholine receptors in synapses of the autonomic nervous system, CNS, and neuromuscular junctions DUMBELS.

DUMBELS: diarrhea, urination, miosis, bradycardia/bronchorea/bronchospasm, emesis, lacrimation, salivation.

Review article: Allergic rhinitis management pocket reference 2008. Journal compilation 2008 Blackwell Munksgaard. Allergy 2008: 63: 990996.

18. Organophosphate Intoxication

19. Penyakit Paru

20. Suara Napas Tambahan

Ronki: Suara berisik & terputus akibat airan udara yang melewati cairan.

Ronki halus disebabkan oleh terbukanya saluran napas secara mendadak yang tadinya tertutup.

Ronki kasar disebabkan oleh aliran udara yang melewati cairan.

Pneumonia: Congestion: vascular engorgement, intra-alveolar fluid with few

neutrophils, and often the presence of numerous bacteria.

Hepatization: massive confluent exudation with neutrophils, red cells, and fibrin filling the alveolar spaces .

Resolution: the consolidated exudate within the alveolar spaces undergoes progressive enzymatic digestion.

21. Regulasi Cairan Tubuh

Regulasi osmolaritas cairan ekstrasel diatur dengan vasopresin (ADH).

22. Beta Blocker

Nonselective beta blockers (such as propranolol) block all types of beta receptors throughout the body and are therefore more likely to cause side effects.

At low doses, cardioselective beta blockers (such as atenolol and metoprolol) selectively block the beta receptors found in the heart and are less likely to cause side effects. However, at the high doses often needed to control angina, these medications lose their selectivity and may also block other types of beta receptors throughout the body, producing more side effects.

Some beta blockers (such as acebutolol and pindolol) are less likely to depress cardiac function or cause a slow resting heart rate and may be a better choice for people who have specific cardiac conditions or are more sensitive to the effects of beta blockers.

Some beta blockers (such as labetalol or carvedilol) also block alpha receptors, which are another type of receptor found in the blood vessels. These medications have the added benefit of dilating blood vessels.

23. E.S. OAT Mayor

MAYOR Kemungkinan Penyebab HENTIKAN OBAT

Gatal & kemerahan Semua jenis OAT Antihistamin & evaluasi ketat

Tuli Streptomisin Stop streptomisin

Vertigo & nistagmus (n.VIII) Streptomisin Stop streptomisin

Ikterus Sebagian besar OAT Hentikan semua OAT s.d. ikterik menghilang, hepatoprotektor

Muntah & confusion Sebagian besar OAT Hentikan semua OAT & uji fungsi hati

Gangguan penglihatan Etambutol Stop etambutol

Kelainan sistemik, syok & purpura

Rifampisin Stop rifampisin

24. Hemolytic Anemia

Clinical & Lab signs are associated with: Heme catabolism

Bilirubinemia icterus

Dark/red urine (intravascular hemolysis)

Increased of erythropoiesis Reticulocytosis (polychromation)

Chronic severe bone marrow expansion cortical bone thinning

Extramedullar hematopoiesis hepatosplenomegaly

Blood smear: normocytic normochrome or macrocytic because of reticulocytosis.

If increased of erythropoiesis is not balanced by adequate Fe intake def Fe state microcytic hypochrome anemia

Clinical laboratory medicine

25.Intoksikasi Logam Berat

Symptoms related to mercury toxicity are typically neurologic, such as the following: Visual disturbance - Eg, scotomata, visual field constriction

Ataxia

Paresthesias (early signs)

Hearing loss

Dysarthria

Mental deterioration

Muscle tremor

Movement disorders

Paralysis and death - With severe exposure

26. Pneumoniae in the Immunocompromised Host

Pulmonary infiltrate, with/without signs of infection (e.g., fever) one of the most common & serious complications in patients whose immune defenses are suppressed by: disease,

immunosuppressive therapy for organ transplants,

chemotherapy for tumors, or

irradiation.

Robbins & Cotran pathologic basis of diseases


CMV infection: Prominent intranuclear basophilic

inclusions spanning half the nuclear diameter are usually set off from the nuclear membrane by a clear halo.

In the lungs, the alveolar macrophages. epithelial and endothelial cells are affected;

Affected cells are strikingly enlarged, often to a diameter of 40 m, and they show cellular & nuclear pleomorphism.

Robbins & Cotran pathologic basis of diseases


Pneumocystis jiroveci/carini: dyspnea, fever, nonproductive

cough.

tachypnea, tachycardia, and cyanosis, but lung auscultation reveals few abnormalities.

CXR: bilateral diffuse infiltrates beginning in the perihilar regions.

definitive diagnosis is made by histopathologic staining methenamine silver selectively stain the wall of Pneumocystis cysts.

Robbins & Cotran pathologic basis of diseases.

Harrisons principles of internal medicine.

27. Pneumonia

27. Pneumonia

Faktor modifikasi pada terapi pneumonia: Pneumokokus resisten terhadap penisilin

Umur lebih dari 65 tahun Memakai obat-obat golongan P laktam selama tiga bulan terakhir Pecandu alkohol Penyakit gangguan kekebalan Penyakit penyerta yang multipel

Bakteri enterik Gram negatif Penghuni rumah jompo Mempunyai penyakit dasar kelainan jantung paru Mempunyai kelainan penyakit yang multipel Riwayat pengobatan antibiotik

Pseudomonas aeruginosa Bronkiektasis Pengobatan kortikosteroid > 10 mg/hari Pengobatan antibiotik spektrum luas > 7 hari pada bulan terakhir Gizi kurang

28. Anticoagulant Therapy

28. Anticoagulant Therapy

ISI: international sensitivity index

1 is the best

MNPT: mean normal PT laboratory

29. Rheumatoid Arthritis

29. Rheumatoid Arthritis

NSAIDs: Are important for symptomatic relief but play only a minor role, if any, in

altering the underlying disease process. Aspirin is the oldest drug of the non-steroidal class, but because of its high

rate of GI toxicity, a narrow window between toxic and anti-inflammatory serum levels, and the inconvenience of multiple daily doses, aspirins use as the initial choice of drug therapy has largely been replaced by other NSAIDs

Glucocorticoid: The paradigm ("bridge therapy") is to shut off inflammation rapidly with

glucocorticoids, and then to taper these as the slower-acting DMARD begin to work.

30. ECG

Normal ventricular depolarization:

the QRS complex is narrow and the electrical axis lies between 0 and 90. All of this changes with bundle branch block.

Bundle branch block:

Changes of width and configuration of the QRS complexes.

30. ECG

Criteria for Right Bundle Branch Block QRS complex greater

than 0.12 s.

RSR' in V1 & V2 (rabbit ears) with ST segment depression & T wave inversion

Reciprocal changes in V5, V6, I, and AVL.

30. ECG

Criteria for Left Bundle Branch Block QRS complex widened to

greater than 0.12 seconds Broad or notched R wave

with prolonged upstroke in leads V5, V6, I, and AVL, with ST segment depression and T wave inversion

Reciprocal changes in V1 and V2

Left axis deviation may be present.

31. DM Complications

Diabetic neuropathy is distal symmetric polyneuropathy. It most frequently presents with distal sensory loss, but up to

50% of patients do not have symptoms of neuropathy. Hyperesthesia, paresthesia, and dysesthesia also may occur. Symptoms may include a sensation of numbness, tingling,

sharpness, or burning that begins in the feet and spreads proximally.

Physical examination reveals sensory loss, loss of ankle reflexes, and abnormal position sense.

Peripheral artery disease: The most common symptom is intermittent claudication, which

is defined as a pain, ache, cramp, numbness, or a sense of fatigue in the muscles; it occurs during exercise and is relieved by rest.

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

32. Cardiomegaly

Left Atrium The two popular radiologic signs of left atrial enlargementa double

contour within the right cardiac border and elevation of the left main bronchusare accurate when present, but they are insensitive and seen in only about half the cases of mitral valve disease.

when the right atrium also enlarges a continuous curve on the posterior cardiac border with the enlarged left atrium the double contour is not seen with mild left atrial enlargement or in severe cases of mitral valve disease.

32. Cardiomegaly

Left ventricle The shape of the dilated left

ventricle depends to a large extent on the underlying cause. When it is due to insufficiency of

the aortic or mitral valve, the ventricle elongates and its apex is displaced downward, to the left, and posteriorly.

When the dilation is due to coronary artery disease or primary myocardial disease, the ventricle tends to assume a more globular shape.

32. Cardiomegaly

Right Atrium Dilation of the right atrium causes an accentuation and outward

bowing of the curvature on the lower half of the right cardiac contour in the frontal view.

Right ventricle: Even moderate right ventricular enlargement may produce no

abnormality in this view other than some prominence of the main pulmonary artery.

As right ventricular size increases, the transverse diameter of the heart enlarges to the left, and the cardiac apex becomes blunted and elevated.

Enlargement of either or both ventricles displaces the apex of the heart to the left. It is not often possible to distinguish between biventricular enlargement and dilation of one or the other ventricle.

34. Nefropati Diabetik

Perkeni 2011.


Tatalaksana: Kendalikan glukosa darah Kendalikan tekanan darah Diet protein 0,8 gram/kgBB per hari. Jika terjadi penurunan fungsi

ginjal yang bertambah berat, diet protein diberikan 0,6 0,8 gram/kg BB per hari.

Terapi dengan obat penyekat reseptor angiotensin II, penghambat ACE, atau kombinasi keduanya

Jika terdapat kontraindikasi terhadap penyekat ACE atau reseptor angiotensin, dapat diberikan antagonis kalsium non dihidropiridin.

Apabila serum kreatinin >2,0 mg/dL sebaiknya ahli nefrologi ikut dilibatkan

Idealnya bila klirens kreatinin


Insulin pda DM tipe 2 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 gestasional yang

tidak terkendali dengan perencanaan makan Gangguan fungsi ginjal atau hati yang berat Kontraindikasi dan atau alergi terhadap OHO

35. Chronic Kidney Disease

Chronic kidney disease (CKD)

encompasses a spectrum of different pathophysiologic processes associated with abnormal kidney function and a progressive decline in GFR.

Etiology: DM, hypertension, glomerulonephritis, drug-induced, myeloma.

Signs & Symptoms of Uremia

General Nausea, anorexia, malaise, fetor uremicus, pruritus

Neurologic Encephalopathy, seizures, neuropathy

Cardiovascular Pericarditis, accelerated atherosclerosis

Hematologic Anemia due to erythropoietin deficiency, bleeding (due to platelet dysfunction)

Metabolic Hyperkalemia, hyperphosphatemia, hypocalcemia

35. Chronic Kidney Disease

Pathophysiology of disease.

36. Hipovitaminosis

37. 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.

38. DM Complications

39. Necrosis

Coagulative necrosis a form of necrosis in which the architecture of dead tissues is

preserved for a span of at least some days. The injury denatures not only structural proteins but also enzymes and

so blocks the proteolysis of the dead cells. Ischemia caused by obstruction in a vessel may lead to coagulative

necrosis of the supplied tissue in all organs except the brain

Robbins & Cotran Pathologic basis of disease. 2010.

39. Necrosis

Gangrenous necrosis Not a specific pattern of cell death, but commonly

used in clinical practice.

It is usually applied to a limb that has lost its blood supply & has undergone necrosis (typically coagulative necrosis).

When bacterial infection is superimposed there is more liquefactive necrosis because of the actions of degradative enzymes in the bacteria & the attracted leukocytes (wet gangrene).


39. Necrosis

Liquefactive necrosis characterized by digestion of

the dead cells, resulting in transformation of the tissue into a liquid viscous mass.

It is seen in focal bacterial or, occasionally, fungal infections, because microbes stimulate the accumulation of leukocytes and the liberation of enzymes from these cells.

The necrotic material is frequently creamy yellow because of the presence of dead leukocytes (pus)


39. Necrosis

Caseous necrosis encountered most often in

foci of tuberculous infection. The term caseous

(cheeselike) is derived from the friable white appearance of the area of necrosis

the necrotic area appears as a collection of fragmented or lysed cells and amorphous granular debris enclosed within a distinctive inflammatory border (granuloma).


39. Necrosis

Fat necrosis focal areas of fat destruction, typically resulting from release of

activated pancreatic lipases into the substance of the pancreas and the peritoneal cavity.

In this disorder pancreatic enzymes leak out of acinar cells & liquefy the membranes of fat cells in the peritoneum.

The released lipases split the triglyceride esters contained within fat cells. The fatty acids combine with calcium to produce grossly visible chalky-white areas (fat saponification).


39. Necrosis

Fibrinoid necrosis a special form of necrosis

usually seen in immune reactions involving blood vessels.

This pattern of necrosis typically occurs when complexes of antigens and antibodies are deposited in the walls of arteries.

Deposits of these immune complexes, together with fibrin that has leaked out of vessels, result in a bright pink and amorphous appearance in H&E stains, called fibrinoid (fibrin-like) by pathologists.


40. Cyanide Intoxication

Source: the vasodilator drug nitroprusside, natural sources are found in

cassava.

Mechanism of toxicity: Cyanide binds to cellular cytochrome oxidase blocking the

aerobic utilization of oxygen metabolic acidosis.

Symptoms headache, nausea, dyspnea, & confusion.

Syncope, seizures, coma, agonal respirations, & cardiovascular collapse ensue rapidly after heavy exposure.

Poisoning & drug overdose by the faculty, staff and associates of the California Poison Control System third edition

40. Cyanide Intoxication Treatment:

A. Emergency and supportive measures. Treat all cyanide exposures as potentially lethal.

1. Maintain an open airway and assist ventilation if necessary.

2. Treat coma, hypotension, & seizures if they occur.

3. Start an IV line and monitor the patients vital signs and ECG

B. Specific drugs and antidotes

1. The cyanide antidote package consists of amyl & sodium nitrites, which produce cyanide-scavenging methemoglobinemia, & sodium thiosulfate, which accelerates the conversion of cyanide to thiocyanate.

C. Prehospital.

Immediately administer activated charcoal if available. Do not induce vomiting unless victim is more than 20 minutes from a medical facility and charcoal is not available.

41. Leukemia CLL CML ALL AML

The bone marrow makes abnormal leukocyte dont die when they should crowd out normal leukocytes, erythrocytes, & platelets. This makes it hard for normal blood cells to do their work.

Prevalence Over 55 y.o. Mainly adults Common in children

Adults & children

Symptoms & Signs

Grow slowly may asymptomatic, the disease is found during a routine test.

Grow quickly feel sick & go to their doctor.

Fever, swollen lymph nodes, frequent infection, weak, bleeding/bruising easily, hepatomegaly/splenomegaly, weight loss, bone pain.

Lab Mature lymphocyte, smudge cells

Mature granulocyte, dominant myelocyte & segment

Lymphoblast >20%

Myeloblast >20%, aeur rod may (+)

Therapy Can be delayed if asymptomatic Treated right away

CDC.gov

41. Leukemia

Clinical Manifestation More common in AML

Leukostasis (when blas count >50.000/uL): occluded microcirculation headache, blurred vision, TIA, CVA, dyspnea, hypoxia

DIC (promyelocitic subtype) Leukemic infiltration of skin, gingiva (monocytic subtype) Chloroma: extramedullary tumor, virtually any location.

More common in ALL Bone pain, lymphadenopathy, hepatosplenomegaly (also seen in

monocytic AML) CNS involvement: cranial neuropathies, nausea, vomiting, headache,

anterior mediastinal mass (T-cell ALL) Tumor lysis syndrome

Pocket medicine.

42. Regulasi Cairan Tubuh

Regulasi osmolaritas cairan ekstrasel diatur dengan vasopresin (ADH).

Olahraga berkeringat (cairan hipotonik) volume menurun & osmolaritas meningkat minum air volume meningkat & osmolaritas menurun.

43. NSAID

43. NSAID

PPI is chosen for prophylaxis because it produces maximal acid supression, better than H2 receptor inhibitor.

Misoprostol has more side effects when acid supression dosage is used.

44. Clostridium Botulinum

Infeksi C. botulinum biasanya disebabkan oleh makanan yang terkontaminasi:

Daging yang tidak digoreng

Ikan yang tidak matang

Sayuran kaleng yang terbuka.

Infeksi juga dapat masuk melalui luka yang terkontaminasi.

44. Clostridium Botulinum

Botulinum toksin dari saluran cerna atau luka darah ujung saraf kolinergik di perifer, antara lain, ujung saraf postganglion parasimpatik, ganglia perifer, & terutama di neuromuscular junction.

Toksin memecah protein yang berperan pada proses fusi vesikel-berisi asetilkolin ke membran presinaps asetilkolin tidak dapat disekresi paralisis flaksid (lumpuh layu).

45. Kolesistektomi

The consequence of removal of the gallbladder relates to the inability to form concentrated bile & to secrete it in a coordinated fashion when the meal enters the duodenum.

Thus, patients who have undergone a cholecystectomy may find that they are less able to tolerate large fatty meals.

46. Leukemia CLL CML ALL AML

The bone marrow makes abnormal leukocyte dont die when they should crowd out normal leukocytes, erythrocytes, & platelets. This makes it hard for normal blood cells to do their work.

Prevalence Over 55 y.o. Mainly adults Common in children

Adults & children

Symptoms & Signs

Grow slowly may asymptomatic, the disease is found during a routine test.

Grow quickly feel sick & go to their doctor.

Fever, swollen lymph nodes, frequent infection, weak, bleeding/bruising easily, hepatomegaly/splenomegaly, weight loss, bone pain.

Lab Mature lymphocyte, smudge cells

Mature granulocyte, dominant myelocyte & segment

Lymphoblast >20%

Myeloblast >20%, aeur rod may (+)

Therapy Can be delayed if asymptomatic Treated right away

CDC.gov

47. Hipertiroidisme

48. Pneumoconiosis

International Labour Organization (ILO) defines pneumoconiosis as "the accumulation of dust in the lungs and the tissue reactions to its presence."

The main reaction to mineral dust in the lungs is fibrosis.

48. Pneumoconiosis

Coal workers' pneumoconiosis is a distinct pathologic entity resulting from the deposition of coal dust in the lungs.

The tissue reactions to deposits of dust include the coal macule and the coal nodule and progressive massive fibrosis (PMF).

CXR: Macule: opacities < 1,5 mm Nodule: small rounded opacities PMF: parenchymal opacities >1 cm

49. Leukemia Granulositik Kronik The marrow aspirate and biopsy are essential to the diagnosis of the

myeloproliferative disorders.

The marrow aspirate provides information as to individual cell morphology and the distribution of cell types. It also provides essential information in diagnosis and management of patients with CML as they become increasingly dysplastic and evolve to acute leukemia.

Chromosomal studies of peripheral blood and marrow are important, primarily to distinguish CML from the other myeloproliferative disorders

50. Asma

51. Asthma

51. Asthma Posisi duduk agar mengurangi volume darah di vascular bed paru

paru lebih terisi udara

Moderate Episode Severe Episode

52. Arthritis

Gout: transient attacks of

acute arthritis initiated by crystallization of urates within & about joints,

leading eventually to chronic gouty arthritis & the appearance of tophi.

Tophi: large aggregates of urate crystals & the surrounding inflammatory reaction.

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

Robbins pathologic basis of disease. 2007.

52. Arthritis

The management of acute gout is to provide rapid & safe pain relief. NSAID, Colchicine. Corticosteroid if NSAID is

contraindicated.

Preventing further attacks by uric acid lowering agent: Allopurinol Probenecid

Uric acid lowering agent shouldnt be given on acute attack, unless the patient has consumed it since 2 weeks before.

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

52. Arthritis

NSAID:

Indomethacin is historically the NSAID of choice for acute gout, but other NSAIDs may be just as effective.

Colchicine:

is effective but less well tolerated than NSAIDs.

Gastrointestinal side effects include gas, nausea, vomiting, diarrhea, and severe cramping abdominal pain.

53. Polyuria

If polyuria is shown to be dilute, pathophysiologic mechanisms include: 1. Hypothalamic or central diabetes insipidus with inability

to synthesize and secrete vasopressin;

2. Nephrogenic diabetes insipidus with an inadequate renal response to vasopressin;

3. Transient diabetes insipidus of pregnancy produced by accelerated metabolism of vasopressin;

4. Primary polydipsia (psychogenic), in which the initiating event is ingestion of excess fluid and the subsequent hypotonic polyuria is an appropriate physiologic response.

53. Polyuria

During the dehydration or water deprivation test:

primary polydipsia: concentrate his urine without becoming hyperosmolar

diabetes insipidus: become hyperosmolar without concentrating the urine.

After the patient is given desmopressin:

Hypothalamic DI has minimal concentration of the urine & an additional in urine osmolality of at least 50%.

partial hypothalamic DI concentrate their urine minimally with dehydration, but the maximum urinary concentration is not achieved, and there is an additional boost with administered desmopressin

Nephrogenic DI do not concentrate their urine & no further increase in urine osmolality after the administration of desmopressin. Harrisons principles of internal medicine. 18th ed.

Greenspans clinical endocrinology.

ILMU BEDAH, ANESTESIOLOGI & RADIOLOGI

Montegia Fracture Dislocation

It is a fracture of the proximal 1/3rd of the Ulna with dislocation of head of radius anteriorly. Posteriorly or laterally

Head of Radius dislocates same direction as fracture

It requires ORIF or it will redisplace

54. Forehand Fracture

Lateral displacement

Galleazzi Fracture

It is a fracture of distal Radius and dislocation of inferior Radio- Ulnar joint

Like Monteggia fracture if treated conservatively it will redisplace

This fracture appeared in acceptable position after reduction and POP

Greenstick Fractures

Colles Fracture

Most common fracture in Osteoporotic bones

Extra-Articular : 1 inch of distal Radius

Results from a fall on dorsi flexed wrist

Typical deformity : Dinner Fork

Deformity is : Impaction, dorsal displacement and angulation, radial displacement and angulation and avulsion of ulnar styloid process

Colles Fracture

optimized by optima

# distal 1 Impaction ,Dorsal displacement and dorsal tilt

Smith Fracture

Almost the opposite of Colles fracture

Much less common compared to colles

Results from a fall on palmer flexed wrist

Typical deformity : Garden Spade

Management is conservative : MUA and Above Elbow POP

Smith Fracture

55. Femur Fractures

Common injury due to major violent trauma

1 femur fracture/ 10,000 people

More common in people < 25 yo or >65 yo

Femur fracture leads to reduced activity for 107 days, the average length of hospital stay is 25 days

Motor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are most frequent causes

Symptoms in children

child has severe pain

The thigh is noticeably swollen or deformed

Expanding thigh hematoma

unable to stand or walk, and/or

There is a limited range of motion of the hip or knee allowed by the child because of pain

Symptoms in children may be obscured related to fracture patterns (e.g. greenstick fractures)

56. Hernia

/VENTRAL HERNIA

HERNIA HIATALHERNIA DIAFRAGMATIKA

Additional: Spigellian hernia: very rare, a hernia through the spigelian fascia and in most cases, it has a small size Ventral hernia: hernia in the abdominal wall, for example: incisional, umbilical and paraumbilical hernia

Types of Hernia Definition

Reponible The sac can be inserted into the peritoneal cavity either manually or spontaneously

Irreponible The sac cannot be reinserted into the peritoneal cavity

Incarserated Passage obstruction of the small intestine in the hernia sac

Strangulated Passage obstruction and vascular obstruction of the hernia sac

Indirect follows the tract through the inguinal canal Results from a persistent process

vaginalis The processus vaginalis outpouching

of peritoneum attached to the testicle that trails behind as it descends retroperitoneally into the scrotum.

Directusually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle

http://emedicine.medscape.com/article/

Phimosis

Inability to retract the distal foreskin over the glans penis

Physiologic in newborn

Complications Balanitis

Postitis

Balanopostitis

Treatment Dexamethasone 0.1% (6

weeks) for spontaneous retraction

Paraphimosis

Entrapment of a retracted foreskin behind the coronal sulcus

Emergency Superficial vein

obstruction edema and pain penile glands necrosis

Treatment Manual reposition

Dorsum incision

57. Phimosis

58. Complications of Fracture Healing

Delayed Union Poor blood supply or infection.

Non-Union Bone loss or wound contamination.

Malunion Bone healed in a nonanatomic position Can be angulated, rotated, or shortened

Affect function? Likely to affect function? Consequences with or without treatment

Fibrous Union Improper immobilization

Avascular necrosis (AVN) the death of bone cells through lack of blood supply its internal blood supply is compromised

http://radiologymasterclass.co.uk/tutorials/musculoskeletal/trauma/trauma_x-ray_page8.html

59. Avascular Necrosis

Definition

Loss of blood flow to the bone leading to death of the cellular components of bone.

Femoral head most common by far

Shoulder humeral head

Odontoid (Neck)

Scaphoid (Wrist)

Lunate (Wrist)

Talus (Ankle)

Etiologies

Trauma

Alcohol

Steroids

Diving (Caissons Disease)

Sickle Cell

Idiopathic (up to 30% of cases)

Risk Factor

Alcoholism

Pancreatitis

Diabetes

Gout

Elderly

60. Acute Achilles Tendon Rupture

Adults 40-50 y.o. primarily affected (M>F)

Athletic activities, usually with sudden starting or stopping

Snap in heel with pain, which may subside quickly

Diagnosis

Weakness in plantarflexion

Gap in tendon

Palpable swelling

Positive Thompson test

Imaging of Achilles tendon

Ultrasound

Inexpensive, fast, reproducable, dynamic examination possible

Operator dependent

Best to measure thickness and gap

Good screening test for complete rupture

Imaging

MRI

Expensive, not dynamic

Better at detecting partial ruptures and staging degenerative changes, (monitor healing)

61&62. Gallbladder Disorder

Gallbladder stone Term Definition Clinical symptoms

Cholecystitis Inflammation of the gallbladder Acute: fever,right upper quadrant(RUQ) pain,murphys sign +, may be icteric Chronic:no fever,recurrent RUQ pain,no icteric,USG:may be calculus/not,cyst wall thickening

Cholecystolitiasis the presence of gallstones in the gallbladder.

Recurrent RUQ pain,recurrent dyspepsia,no fever,no icteric,pain after fatty meal,Ro:radioopaque RUQ

Cholelitihiasis The presence or formation of gallstones in the gallbladder or bile ducts

Symptoms depend on stone location, only use this terms if the stone location is not established

Choledocholithiasis the presence of gallstones in the common bile duct

Colicky pain(biliary colic),icteric,may be with cholangitis signs(charcoats triads)

Appendicitis Inflammation of the vermiform appendix.

Pain on right lower quadrant,migratory pain,nausea,vomiting,specific signs(rovcing,McBurney,etc)

Mosby's Medical Dictionary, 8th edition. 2009, Elsevier.

62. Cholelitiasis laboratorium Findings

No sign of obstruction

Normal Liver function test, Bilirubin,Urobilinogen

Sign of obstructionCholedocholithiasis

Increase LFT

Increase Bilirubin

Increase alkaline phosphatase

63. Sertoli Cell Only-syndrome

Sertoli cells respond FSH Epidemiology:

men between age 20-40 years

Sign&Symptoms: infertility without sexual abnormality normal- or small-sized testes Azoospermic

Diagnosis Testicular biopsy absence of spermatozoa and only

Sertoli cells line the seminiferous tubules

Pathophysiology

testosterone and LH levels are normal, but due to lack of inhibin, FSH levels are increased

http://emedicine.medscape.com/article/437884-overview#a0104

64. Apendicitis TB

Tuberculosis of the appendix presenting with the signs and symptoms of acute appendicitis

it is not possible to make the correct diagnosis because the clinical picture is that of acute appendicitis,

the diagnosis of appendicular tuberculosis is usually made on histopathological examination of the appendectomy specimen

the presence of caseating granulomas, epitheloid cells and Langhans giant cells, characteristic of tuberculous inflammation.

important because of the risk of post-operative fistula

On diagnosis, these patients must be started on anti-tubercular treatment

65. Tamponade Jantung

Tamponade suspected Echocardiography

Pericardiocentesis done immediately for

diagnosis and treatmenta brief delay might be life threatening.

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

66. 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

Total Body Surface Area

To estimate scattered burns: patient's palm surface = 1% total body surface area

http://www.traumaburn.org/referring/fluid.shtml

Parkland formula = baxter formula

67. Le Fort Fracture

68. Prostatic malignancy

PSAProstate Cancer

PSA >4.0 ng/mL mandatory biopsy

50% of all the cancers detected because of an elevated PSA level are localized

these patients are candidates for potentially curative therapy

Manifestations of Metastatic Prostate Cancer

Anemia

Dispnoe

Bone marrow suppression

Weight loss

Pathologic fractures

Spinal cord compression LMN Paralisis

Paresthesia

Sensory deficit

Pain

Hematuria

Ureteral and/or bladder outlet obstruction

Urinary retention

Chronic renal failure

Urinary incontinence

Symptoms related to bony or soft-tissue metastases

69. Management of Trauma Patient

70. Syok Anafilaktik

www.resus.org.uk/pages/reaction.pdf 2012.

71. Abdominal Injuries

abdominal injuries can be either open or closed

open injuries are caused by sharp or high velocity objects that create an opening between the peritoneal cavity and the outside of the body

closed injuries are caused by compression trauma associated with deceleration forces and include:

contusions

ruptures

lacerations

shear injuries

The type of injury will depend on whether the organ injured is solid or hollow.

Hollow and Solid Organs

hollow organs include:

stomach

intestines

gallbladder

bladder

solid organs include:

liver

spleen

kidneys

Abdominal Injuries

Hollow Organ Injuries

when hollow organs rupture, their highly irritating and infectious contents spill into the peritoneal cavity, producing a painful inflammatory reaction called peritonitis

Solid Organ Injuries

damage to solid organs such as the liver can cause severe internal bleeding

blood in the peritoneal cavity causes peritonitis

when patients injure solid organs, the symptoms of shock may overshadow those from peritonitis

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

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

Cullens sign: purple-blue discoloration around umbilicus (peritoneal hemorrhage)

Grey Turners sign:flank discoloration (retroperitoneal hemorrhage)

Spleen Upper left quadrant Rich blood supply Slightly protected by organs surrounding it and

by lower rib cage Most commonly injured organ from blunt

trauma Associated intraabdominal injuries

common Suspect splenic injury in:

Motor vehicle crashes Falls or sports injuries involving was an

impact to the lower left chest, flank, or upper left abdomen

Kehrs sign Left upper quadrant pain radiates to left

shoulder Common complaint with splenic injury

Management : Resuscitation. Laparotomy (repair,

partial excision or splenectomy)

Observation in hospital for patients with sub-capsular haematoma

Stomach/duodenum

Not commonly injured by blunt trauma

Protected location in abdomen

Penetrating trauma may cause gastric transection or laceration Signs of peritonitis from

leakage of gastric contents

Diagnosis confirmed during surgery Unless nasogastric drainage

returns blood

Perforation

Presentation : abdominal pain

rigidity

peritonism, shock

Air under diaphragm on X-ray

Treatment Antibiotics

resuscitate

repair

72. Cara Kerja Lidokain

73. Chest Trauma

Disorders Etiology Clinical

Hemothorax lacerated blood vessel in thorax

Anxiety/Restlessness,Tachypnea,Signs of Shock,Tachycardia Frothy, Bloody Sputum Diminished Breath Sounds on Affected Side,Flat Neck Veins, Dullness to percussion

Simple/Closed Pneumothorax

Blunt trauma spontaneous

Opening in lung tissue that leaks air into chest cavity, Chest Pain,Dyspnea,Tachypnea Decreased Breath Sounds on Affected Side,hipersonor

Open Pneumothorx Penetrating chest wound

Opening in chest cavity that allows air to enter pleural cavity, Dyspnea,Sudden sharp pain,Subcutaneous Emphysema Decreased lung sounds on affected side Red Bubbles on Exhalation from wound (Sucking chest wound)

http://emedicine.medscape.com/article/2047916

Disorders Etiology Clinical

Tension Penumothorax Anxiety/Restlessness, Severe ,Poor Color Dyspnea,Tachypnea,Tachycardia Absent Breath sounds on affected side, Accessory Muscle Use, JV Distention Narrowing Pulse Pressures,Hypotension Tracheal Deviation, hypersonor

Flail Chest Trauma a segment of the rib cage breaks becomes detached from the rest of the chest wall, 3 ribs broken in 2 or more places,painful when breathing,Paradoxical breathing

Pleural Efusion congestive heart failure, pneumonia, malignancy, or pulmonary embolism infection

Dyspnea, cough, chest pain, which results from pleural irritation, Dullness to percussion, decreased tactile fremitus, and asymmetrical chest expansion, with diminished or delayed expansion on the side of the effusion, decreased tactile fremitus, and asymmetrical chest expansion, diminished or delayed expansion on the side of the effusion

Pneumonia Infection, inflammation

Fever,dysnea,cough,rales in ausultation

Pemeriksaan Penunjang

Trauma dada dapat ditentukan dengan pemeriksaan X-Ray dada, untuk menentukan jenis trauma yang timbul

Montegia Fracture Dislocation

It is a fracture of the proximal 1/3rd of the Ulna with dislocation of head of radius anteriorly. Posteriorly or laterally

Head of Radius dislocates same direction as fracture

It requires ORIF or it will redisplace

74. Forehand Fracture

Lateral displacement

Galleazzi Fracture

It is a fracture of distal Radius and dislocation of inferior Radio- Ulnar joint

Like Monteggia fracture if treated conservatively it will redisplace

This fracture appeared in acceptable position after reduction and POP

75. Treatment of Poison ingestion

Gastric lavage

Flexible tube is inserted through the

nose into the stomach

Stomach contents are then suctioned

via the tube

A solution of saline is injected into

the tube

Recommended for up to 2 hrs in

trichloro acetate & up to 4hrs in

Salicylate OD

Induced Vomiting Ipecac - Not routinely recommended Risk of aspiration

Activated charcoal In conscious patients Adsorbs toxic substances or irritants,

thus inhibiting GI absorption Addition of sorbitol laxative effect Oral: 25-100 g as a single dose repetitive doses useful to enhance

the elimination of certain drugs (eg, theophylline, phenobarbital, carbamazepine, aspirin, sustained-release products)

not effective for cyanide, mineral acids, caustic alkalis, organic solvents, iron, ethanol, methanol poisoning, lithium

Renal elimination Medication to stimulate

urination or defecation may be given to try to flush the excess drug out of the body faster.

Forced alkaline diuresis Infusion of large amount of

NS+NAHCO3 Used to eliminate acidic drug

that mainly excreted by the kidney eg salicylates

Serious fluid and electrolytes disturbance may occur

Need expert monitoring

Hemodialysis or haemoperfusion:

Reserved for severe poisoning Drug should be dialyzable i.e.

protein bound with low volume of distribution

may also be used temporarily or as long term if the kidneys are damaged due to the overdose.

76. Hemorrhoid

External Hemorrhoids Internal Hemorrhoids

Outside anal canal, around sphincter Inside anal canal

Symptoms due to thrombosis Symtomps due to bleeding and/or irritation of mucosa

Can not be inserted to anal canal Can be inserted to anal canal up to grade III

Internal Hemorrhoids

Internal hemorrhoidal plexus V. Rectus Inferior

V. Rectus Media

External Hemorrhoids external hemrroidal plexus V. Rectus Inferior

Histological Feature

Hemorrhoids vascular structures in the anal canal

Histological Feature simple columnar

epithelium and stratified squamous epithelium with distention of veins in the lamina propria and submucosa of the anal canal

77. Bladder Stone

Bladder calculi are usually associated with urinary stasis

Urinary infections increase the risk of stone formation

Foreign bodies (e.g. suture material) can also act as a nidus for stone formation

They can however form in a normal bladder

There is no recognized association with ureteric calculi

Bladder calculi can be asymptomatic Common symptoms include

Suprapubic pain Dysuria Haematuria

Abdominal examination may be normal can be identified on

Plain abdominal x-ray Bladder ultrasound CT scan Cystoscopy

Uric acid stones are radiolucent but may have an opaque calcified layer

78. Hirschsprungs disease

Clinical symptoms The disease can considered to be incomplete

intestinal obstruction

The lenght of the aganglionic segment is variable

The symptoms are variable too

The symptoms appears in different ages

Symptoms in newborn age

Fail to pass meconium (in 24 hours of life)

Abdominal distension, but the abdomen is palpable

Vomiting The rectal tube cant be put

easily After irrigation the signs and

symptoms return again in a few days

Symptoms in newborn age(enterocolitis)

Life-threatening condition Diarrhea: it can be an early

sign Toxic megacolon Abdominal distension Bile-stained vomiting Fiver and signs of dehydration Rectal tube:explosive

expulsion of gas and foul-smelling stools

Symptoms in infants

Constipation Meteorism Palpable faecaloma Sometimes

putrescent diarrhea Ulceration,

bleeding Hypoproteinaemia,

anaemia Electrolyt disorders

Symptoms in childhood

Gracile limbs

Dilated drumlike belly

Long history of constipation

Defecation in 7-10 days

Multiple fecal masses

The stimulus of defecation is missing

Rectum is empty and narrow

Darm kontur: visible shape of intestines on the abdomen

Darm Steifung: visible peristaltic movement on the abdomen

Rontgen :

Plain abdominal radiography Dilated bowel

Air-fluid levels.

Empty rectum

Contrast enema Transition zone

Abnormal, irregular contractions of aganglionic segment

Delayed evacuation of barium

Biopsy : absence of ganglion cells hypertrophy and hyperplasia of nerve

fibers,

79. Humerus Fractures

Proximal Humerus Fractures

Clinical Evaluation

Patients typically present with arm held close to chest by contralateral hand. Pain and crepitus detected on palpation

Careful NV exam is essential, particularly with regards to the axillary nerve. Test sensation over the deltoid. Deltoid atony does not necessarily confirm an axillary nerve injury

Humeral Shaft Fractures

Clinical evaluation

Thorough history and physical

Patients typically present with pain, swelling, and deformity of the upper arm

Careful NV exam important as the radial nerve is in close proximity to the humerus and can be injured

Humeral Shaft Fractures

Holstein-Lewis Fractures

Distal 1/3 fractures

May entrap or lacerate radial nerve as the fracture passes through the intermuscular septum

80. Urine Incontinence

81. Testicular torsion

Signs and symptoms of testicular torsion include:

Sudden or severe pain in the scrotum the loose bag of skin under your penis that contains the testicles

Swelling of the scrotum

Abdominal pain

Nausea and vomiting

A testicle that's positioned higher than normal or at an unusual angle

Treatment

Manual detorsion

If it is successful (ie, confirmed by color Doppler sonogram in a patient with complete resolution of symptomsdefinitive surgical fixation of the testes before leaving the hospital

Surgical detorsion definitive treatment

Orchiectomyif the testis is necrotic

82. Pathophysiology of Foot Ulceration

Neuropathic

Ischemic

Neuro -ischemic

83. Clavus

A clavus is a thickening of the skin due to intermittent pressure and frictional forces. These forces result in hyperkeratosis

Conditions associated with clavus formation

Advanced patient age

Amputation (ie, stump callosities)]

Doxorubicin toxicity[20]

Keratoderma palmaris et plantaris

Obesity

Minor trauma

Relief of symptoms may be achieved by thinning and cushioning of the involved lesion

Surgical Care Surgical options should be

used when conservative measures fail.

Chronic foot pain despite conservative therapy is the number one indication for surgery.

Epidermal Cyst

A raised nodule on the skin of the face or neck May be noted intraorally on occasion Histologic

Lined by keratinizing epithelium the resembles the epithelium of the skin

The lumen is usually filled with keratin scales

Treatment Surgical excision

Dermoid Cyst and Benign Cystic Teratoma

A developmental cyst often present at birth or noted in

young children It is usually found on the floor of the mouth when it is located in

the oral cavity. May have a doughy consistency when palpated

Histologic Lined by orthokeratinized, stratified squamous epithelium

surrounded by a connective tissue wall The lumen is usually filled with keratin Hair follicles, sebaceous glands, and sweat glands may be seen

in the cyst wall Benign cystic teratoma

Resembles a dermoid cyst Treatment

Surgical excision

Diagnosis Histologic

Lipoma Soft mass, pseudofluctuant with a slippery edge

Atherom cyst Occur when a pilosebaceous unit or a sebaceous gland becomes blocked. Skin Color is usually normal, and there is a punctum (comedo, blackhead) on the dome

84. Resusitasi Monitoring

Fluid resuscitation target:

Euvolemia

Improve perfusion Urine Output

Improve oxygen delivery

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

85. Hernia Skrotalis

86. Head Injury

87. Trauma Olahraga

189

A, 5th week Testis begins its primary descent; kidney ascends. B, 8th-9th weeks. Kidney reaches adult position. C, 7th month, Testis at internal inguinal ring; gubernaculum (in inguinal fold) thickens and shortens. D, Postnatal life.

88.Undescended Testis

190

A, Ectopic testes. Perineal ectopia not shown. B, Undescended testes. Percentages of testes arrested at different stages of normal descent

Management

Hormone therapy

Orchidopexy

Orchidectomy

Laparoscopic surgery Surgery should be done by

the age of 5 years but it is unnecessary to do this operation before completion of second birthday of the child

89. Acute Achilles Tendon Rupture

Adults 40-50 y.o. primarily affected (M>F)

Athletic activities, usually with sudden starting or stopping

Snap in heel with pain, which may subside quickly

Diagnosis

Weakness in plantarflexion

Gap in tendon

Palpable swelling

Positive Thompson test

90. Basic Life Support

Indication for CPR

No response

Not breathing

No pulse

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

91. Humeral Shaft Fractures

Holstein-Lewis Fractures

Distal 1/3 fractures

May entrap or lacerate radial nerve as the fracture passes through the intermuscular septum

92. Obstruction

Accounts for 5% of all acute surgical admissions Patients are often extremely ill requiring prompt

assessment, resuscitation and intensive monitoring

Obstruction A mechanical blockage arising from a

structural abnormality that presents a

physical barrier to the progression of gut

contents.

Ileus is a paralytic or functional variety of

obstruction

Obstruction is: Partial or complete

Simple or strangulated

Causes- Small Bowel

Extraluminal Mural Luminal

Postoperative adhesions

Congenital adhesions

Hernia

Volvulus

Neoplasims

lipoma

polyps

leiyomayoma

hematoma

lymphoma

carcimoid

carinoma

secondary Tumors

Crohns

TB

Stricture

Intussusception

Congenital

F. Body

Bezoars

Gall stone

Food Particles A. lumbricoides

1. History

The Universal Features

Colicky abdominal pain, vomiting, constipation (absolute), abdominal distension.

Complete HX ( PMH, PSH, ROS, Medication, FH, SH)

Colonic

Preexisting change in bowel habit

Colicky in the lower abdomin

Vomiting is late

Distension prominent

Cecum ? distended

Distal small bowel

Pain: central and colicky

Vomitus is feculunt

Distension is severe

Visible peristalsis

May continue to pass flatus and feacus before absolute constipation

High

Pain is rapid

Vomiting copious and contains bile jejunal content

Abdominal distension is limited or localized

Rapid dehydration Persistent pain may be a sign of strangulation Relative and absolute constipation

2. Examination

Others

Systemic examination

If deemed necessary.

CNS

Vascular

Gynaecological

muscuoloskeltal

Abdominal

Abdominal distension and its pattern

Hernial orifices

Visible peristalsis

Cecal distension

Tenderness, guarding and rebound

Organomegaly

Bowel sounds

High pitched (metallic sound)

Absent

Rectal examination

General

Vital signs:

P, BP, RR, T, Sat

dehydration

Anaemia, jaundice, LN

Assessment of vomitus if possible

Full lung and heart examination

Darm kontur: visible shape of intestines on the abdomen

Darm Steifung: visible peristaltic movement on the abdomen

Radiological Evaluation

Normal Scout

Always request: Supine, Erect and CXR

Gas pattern: Gastric,

Colonic and 1-2 small bowel

Fluid Levels: Gastric

1-2 small bowel

Check gasses in 4 areas: 1. Caecal

2. Hepatobiliary

3. Free gas under diaphragm

4. Rectum

Look for calcification

Look for soft tissue masses, psoas shadow

Look for fecal pattern

The Difference between small

and large bowel obstruction

Small Bowel Large bowel

Central ( diameter 5 cm max)

Vulvulae coniventae

Ileum: may appear tubeless

Peripheral ( diameter 8 cm max)

Presence of haustration

Radiology: Flat and upright (or decubitus) abdominal X-Ray

A. Sensitivity: 60% (up to 90%) B. Typical findings of Bowel Obstruction

1. Bowel distention proximal to obstruction 2. Bowel collapsed distal to obstruction 3. Upright or decubitus view: Air-fluid levels 4. Supine view findings

a. Sharply angulated distended bowel loops

b. Step-ladder arrangement or parallel bowel loops

Initial Management in the ER

Resuscitate:

Air way (O2 60-100%)

Insert 2 lines if necessary

at IVF : Crytloids least 120 ml/h. (determined by estimated fluid loss and cardiac function). Add K+ at 1mmmol/kg

Draw blood for lab investigations

Inform a senior member in the team.

NPO.

Decompress with Naso-gastric tube and secure in position

Insert a urinary catheter (hourly urinary measurements) and start a fluid input / output chart

Intravenous antibiotics (no clear evidence)

If concerns exist about fluid overloading a central line should be inserted

Follow-up lab results and correction of electrolyte imbalance

The patient should be nursed in intermediate care

Rectal tubes should only be used in Sigmoid volvulus.

Indications for Surgery

Immediate intervention:

Evidence of strangulation (hernia.etc)

Signs of peritonitis resulting from perforation or ischemia

93. Hemorrhaegic Shock

94. Osteoporosis

A systemic skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue lead to bone fragility and susceptibility to fracture

Prevalence of osteoporosis

Osteopenia Osteoporosis

Female

Age > 50 year

37-50% 13-18%

Male

Age > 50 year

28-47% 3-6%

Incidence of osteoporotic Fx

Vertebral

Fracture Forearm

Fracture

Hip

Fracture

Osteoporosis Tipe 1 (POSTMENOPAUSAL)

optimized by optima

affects primarily trabecular bone 5 years after menopause weight-bearing bones fractures vertebrae, ankle, and distal radius

Osteoporosis

(A) Normal right hip with trabecular pattern well demonstrated.

(B) (B) Osteoporotic right hip with poorly defined trabeculae (arrows)

http://www.msdlatinamerica.com/ebooks/MusculoskeletalImagingCompanion/sid250409.html

95. Peritonitis Peritonitis

an inflammation of the peritoneum, the thin membrane that lines the abdominal wall and covers the organs inside

caused by a bacterial or fungal infection of this membrane

Types of peritonitis Primary peritonitis

caused by the spread of an infection from the blood and lymph nodes to the peritoneumliver disease

Fluid builds up in the abdomen, creating an environment for bacteria to grow

rare less than 1% of all cases of peritonitis

Secondary peritonitis More common Happens when the infection comes into the peritoneum from the

gastrointestinal or biliary tract

http://www.umm.edu/altmed/articles/peritonitis-000127.htm#ixzz28YAqqYSG

Secondary peritonitis

caused by other conditions that allow bacteria, enzymes, or bile into the peritoneum from a hole or tear in the gastrointestinal or biliary tracts.

Such tears can be caused by

Pancreatitis

a ruptured appendix

stomach ulcer

Crohn's disease

Diverticulitis

Typhoid complication

Signs & Symptoms

Swelling & tenderness in the abdomen

Fever & Chills Loss of Appetite Nausea & Vomiting Increased breathing & Heart

Rates Shallow Breaths Low BP Limited Urine Production Inability to pass gas or feces

Exam : The usual sounds made by

the active intestine and heard during examination with a stethoscope will be absent, because the intestine usually stops functioning.

The abdomen may be rigid and boardlike

Accumulations of fluid will be notable in primary due to ascites.

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. Choking

Child choking

Abdominal thrust = Heimlich manouvre

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

98. Total Body Surface Area

To estimate scattered burns: patient's palm surface = 1% total body surface area

http://www.traumaburn.org/referring/fluid.shtml

Parkland formula = baxter formula

99. Osteomyelitis

Inflammation of the bone and bone marrow caused by an infecting organism.

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

Pathogenesis Waldvogel, 1971

1. 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 pseudomonal infections

Acute hematogenous osteomyelitis has a predilection for the long bones of the body.

The ends of the bone near the growth plate (the metaphysis) is made of a maze like bone called cancellous bone.

It is here in the rapidly growing metaphysis that osteomyelitis often develops

http://www.hawaii.edu/medicine/pediatrics/pedtext/s19c04.html

100. Radiologic Findings Of OA

In knee (genu) x-ray

Narrowing of joint space

(due to loss of cartilage)

Osteophytes

Subchondral (paraarticular) sclerosis

Bone cysts

AUR:Acute urinary retention PUC:Perurethral catheter SPC:Suprapubic catheter TWOC:Trial without catheter

101. BPH-associated Acute Urinary Retention

-Blocker relaxing smooth muscle

fibers located in the prostate and its capsule, bladder neck and prostatic urethra

TWOC when a catheter is

removed from the bladder for a trial period to determine whether the patient are able to pass urine spontaneously.

http://www.indianjurol.com/article.asp?issn=0970-1591;year=2007

Treatment Urinary Retention

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

PUC:Perurethral catheter

SPC:Suprapubic catheter

102. Volume Perdarahan Fraktur Femur

Femur bone anatomy

Near major blood vessel (femoral artery)

Femur Fracture blood loss up to 1,500 ml per femur

Fluid Resuscitation

Crystalloids 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

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)

Fluid resuscitation target:

Euvolemia

Improve perfusion

Improve oxygen delivery

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

103. Male Genital Disorders Disorders Etiology Clinical

Testicular torsion Intra/extra-vaginal torsion

Sudden onset of severe testicular pain followed by inguinal and/or scrotal swelling. Gastrointestinal upset with nausea and vomiting.

Hidrocele Congenital anomaly, blood blockage in the spermatic cord Inflammation or injury

accumulation of fluids around a testicle, swollen testicle,Transillumination +

Varicocele Vein insufficiency Scrotal pain or heaviness, swelling. Varicocele is often described as feeling like a bag of worms

Hernia skrotalis persistent patency of the processus vaginalis

Mass in scrotum when coughing or crying. Bowel sound on scrotum. Strangulated nausea, vomiting, fever, edematous, erythematous, discolored

Spermatokel diverticulum from the tubules found in the head of the epididymis, possibly trauma

retention cyst of a tubule of the rete testis or the head of the epididymis distended with barely watery fluid that contains spermatozoa

http://en.wikipedia.org/wiki/ http://emedicine.medscape.com/article/

104. Muscle Atrophy

Weakening and shrinking of a muscle

May be caused

Immobilization

Due to trauma

Reluctant to move limbs because of pain

Unable to move secondary to neurologic process

Loss of neural stimulation

Lower motor neuron paralysis

105. Orchitis

Etiology Mumps

Testicular congestion

Viral

Parasitic

Trauma

Signs & Symptoms

Pain

Swollen

Treatment

Rest - bed

Elevate scrotum

Ice pack

Antibiotics

Analgesics

Anti-inflammatory

Orchitis is an inflammation of the testes.

106. Orbital Wall Anatomy

The 4 Walls of orbit are:

Roof frontal bone

Floor maxillary and zygomatic

Lateral sphenoid and zygomatic

Medial ethmoid, lacrimal, maxilla, and lesser wing of the sphenoid

Left zygoma

Maxillary process of zygomaone of the components of lateral orbital floor

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