View
110
Download
7
Category
Tags:
Preview:
DESCRIPTION
a
Citation preview
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
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
26. Pneumoniae in the Immunocompromised Host
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
26. Pneumoniae in the Immunocompromised Host
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.
34. Nefropati Diabetik
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
34. Nefropati Diabetik
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).
Robbins & Cotran Pathologic basis of disease. 2010.
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)
Robbins & Cotran Pathologic basis of disease. 2010.
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).
Robbins & Cotran Pathologic basis of disease. 2010.
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).
Robbins & Cotran Pathologic basis of disease. 2010.
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.
Robbins & Cotran Pathologic basis of disease. 2010.
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
Recommended