dr. Himawan, dr. Cemara, dr.

Dini,
dr. Yusuf, dr. Ratna, dr. Rini,
dr. Valenchia, dr.Alvin, dr. Anshari
1-2. Myocardial Infarct Complication
1-2. Myocardial Infarct Complication
Papillary Muscle Rupture
 Ischemic necrosis and rupture of an LV papillary muscle may be
rapidly fatal because of acute severe mitral regurgitation.
 Partial rupture, with more moderate regurgitation, is not
immediately lethal but may result in symptoms of heart failure or
pulmonary edema.
 Because it has a more precarious blood supply, the posteromedial
LV papillary muscle is more susceptible to infarction than the
anterolateral one.
 Severe mitral regurgitation in myocardial infarction with or without
papillary muscle rupture is mostly related to inferior infarction
and often follows reinfarction, particularly in non-papillary muscle
rupture cases.
 Heberden’s & Bouchard’s nodes

3. Arthritis

http://www.gentili.net/foot/ra.htm
 3. Arthritis

 Osteoarthritis:  Gout arthritis:

 Acute gouty arthritis: soft tissue
 space narrowing (white arrow), swelling.
 osteophytes/spur (arrowhead),  Advanced gout: the erosion are slightly
removed from the joint space, have a
 subchondral cysts, rounded or oval shape, & are
 subchondral sclerosis/eburnation
characterized by a hypertrophic
calcified "overhanging edge." The joint
(black arrow). space may be preserved or show
Current diagnosis & treatment in rheumatology. 2nd ed. McGraw-Hill; 2007.
osteoarthritic type narrowing.
Harrison’s principles of internal medicine. 18th ed. McGraw-Hill; 2011.
 Ciri OA RA Gout SA

Arthritis
Prevalens

Awitan
Female>male, >50
thn, obesitas
gradual
Female>male
40-70 thn
gradual
Male>female, >30
thn, hiperurisemia
akut
Male>female,
dekade 2-3
Variabel

Inflamasi - + + +

Patologi Degenerasi Pannus Mikrotophi Enthesitis

Jumlah Sendi Poli Poli Mono-poli Oligo/poli

Tipe Sendi Kecil/besar Kecil Kecil-besar Besar

Predileksi Pinggul, lutut, MCP, PIP, MTP, kaki, Sacroiliac

punggung, 1st pergelangan pergelangan kaki Spine
CMC, DIP, PIP tangan/kaki, kaki & tangan Perifer besar

Temuan Sendi Bouchard’s nodes Ulnar dev, Swan Kristal urat En bloc spine
Heberden’s nodes neck, Boutonniere enthesopathy
Perubahan Osteofit Osteopenia erosi Erosi
tulang erosi ankilosis

Temuan - Nodul SK, Tophi, Uveitis, IBD,

Extraartikular pulmonari cardiac olecranon bursitis, konjungtivitis,
splenomegaly batu ginjal insuf aorta,
psoriasis
Lab Normal RF +, anti CCP Asam urat
4. Penyakit Ginjal
 Glomerular Disease:
 hematuria, proteinuria, pyuria.
 Sind. nefritik akut:
 proteinuria 1-2 g/24 jam, hematuria dengan silinder eritrosit,
pyuria, hipertensi, retensi cairan, peningkatan kreatinin
serum.
 Sind. nefrotik:
 proteinuria berat (>3.0 g/24 jam), hipoalbuminemia,
hipertensi, hiperkolesterolemia,, edema/anasarka, &
hematuria mikroskopik.
4. Renal Disorder
Diagnosis
Acute glomerulonephritis
Rapidly progressive
glomerulonephritis
Chronic
glomerulonephritis
Nephrotic syndrome
Pathophysiology of disease: an introduction to clinical medicine. 5th ed.
Characteristic
an abrupt onset of hematuria & proteinuria with
reduced GFR & renal salt and water retention,
followed by full recovery of renal function.
recovery from the acute disorder does not occur.
Worsening renal function results in irreversible and
complete renal failure over weeks to months.
renal impairment after acute glomerulonephritis
progresses slowly over a period of years & eventually
results in chronic renal failure.
manifested as marked proteinuria, particularly
albuminuria (defined as 24-h urine protein excretion
> 3.5 g), hypoalbuminemia, edema, hyperlipidemia,
and fat bodies in the urine.
5. Keracunan Sianida
 Singkong mengandung linamarin yang dengan bantuan
enzim melepaskan cianida.
 Gejala keracunan singkong:
 Mual, muntah, diare dan kepala terasa pusing.
 Sesak napas atau sukar bernaas dan dalam keadaan
keracunan berat bisa sampai pingsan.
 Jantung berdetak cepat
 Warna bibir, kuku, muka dan kulit kebiru-biruan dalam
istilah medis cyanosis
 Kesadaran Menurun bahkan sampai koma
 Bisa timbul kejang kejang dan pingsan
 Dalam keracunan berat bisa sampai menimbulkan kematian.
6. PNH
 PNH is characterized by attacks of intravascular
hemolysis and hemoglobinuria that occur chiefly at
night while the patient is asleep.
 The complement attached in patient’s erythrocyte
activated by low pH in the night  hemolysis.
 Moderate splenomegaly & mild to moderate
hepatomegaly are sometimes observed and should
raise concerns about hepatic or splenic vein
thrombosis.
 7. Arthritis
 Gout:
 transient attacks of
acute 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.

Harrison’s principles of internal medicine. 18th ed.

McGraw-Hill; 2011.
Robbins’ pathologic basis of disease. 2007.
7. Arthritis

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

Acute Gout Tophy in chronic gout
8. DHF
9. Supraventricular Tachycardia
Lilly. Pathophysiology of heart disease.
10. Pharmacology
 In patients with CVD or in primary prevention, it seems
prudent to continue ASA indefinitely unless side effects are
present or a contraindication develops.
 Contraindications to Asetil salisylic acid (ASA):
 intolerance and allergy
 Active bleeding,
 hemophilia,
 active retinal bleeding,
 severe untreated hypertension,
 an active peptic ulcer, or
 another serious source of gastrointestinal or genitourinary
bleeding.
11. Myocardial Infarct Complication
12. Polycythemia Vera
 Criteria PVSG (Polycythemia Vera Study Group)
 A1 Raised red cell mass (RCM), male > 36 ml/kg, female > 32 ml/kg
 A2 Normal arterial oxygen saturation > 92%
 A3 Splenomegaly
 B1 Platelet count > 400 x 109/l
 B2 White blood cell count (WBC) > 12 x 109/l
 B3 Leucocyte alkaline phosphatase > 100
 B4 Serum B12 > 900 pg/ml or unbound B12 binding capacity > 220
pg/ml

 Diagnosis
 A1 + A2 + A3 establishes PV
 A1 + A2 + two of category B establishes PV
 Polycythemia vera (PV) develops slowly. The disease may not cause signs or
symptoms for years.
 When signs and symptoms are present, they're the result of the thick blood that
occurs with PV. This thickness slows the flow of oxygen-rich blood to all parts of
your body. Without enough oxygen, many parts of your body won't work normally.
 The signs and symptoms of PV include:
 Headaches, dizziness, and weakness
 Shortness of breath & problems breathing while lying down
 Feelings of pressure or fullness on the left side of the abdomen due to an
enlarged spleen (an organ in the abdomen)
 Double or blurred vision and blind spots
 Itching all over (especially after a warm bath), reddened face, and a burning
feeling on your skin (especially your hands and feet)
 Bleeding from your gums and heavy bleeding from small cuts
 Unexplained weight loss
 Fatigue (tiredness)
 Excessive sweating
 Very painful swelling in a single joint, usually the big toe (called gouty arthritis)
 In rare cases, people who have PV may have pain in their bones.

http://www.nhlbi.nih.gov/health/health-topics/topics/poly/signs.html
13. Cellular Changes
 Metaplasia: the replacement of one type of cell with another
type.
 Dysplasia: literally means disordered growth. Dysplastic cells
exhibit considerable pleomorphism and often contain large
hyperchromatic nuclei.
 Hypertrophy: an increase in the size of cells, resulting in an
increase in the size of the organ.
 Hyperplasia: an increase in the number of cells in an organ or
tissue, usually resulting in increased mass of the organ or tissue.
 Atrophy: reduced size of an organ or tissue resulting from a
decrease in cell size and number.
14. Acute
Diarrhea
15. Cell Death
 Apoptosis is a pathway of cell death that is induced by a
tightly regulated suicide program in which cells destined to
die activate enzymes that degrade the cells' own nuclear DNA
and nuclear and cytoplasmic proteins.
 Apoptotic cells break up into fragments, called apoptotic
bodies, which contain portions of the cytoplasm & nucleus.
 Apoptosis eliminates cells that are injured beyond repair
without eliciting a host reaction, thus limiting collateral
tissue damage.
16. Blood Transfusion

WHO clinical use of blood.

 Type Descriptions Indications
Whole • Up to 510 ml total volume • Red cell replacement in acute blood
blood • Hb ± 12 g/ml, Ht 35%–45% loss with hypovolaemia
• No functional platelets • Exchange transfusion
• No labile coagulation factors (V & VIII) • Patients needing red cell transfusions
where PRC is not available
PRC • 150–200 ml red cells from which most of • Replacement of red cells in anemic
the plasma has been removed patients
• Hb ± 20 g/dL (not less than 45 g per unit) • Use with crystalloid or colloid
• Ht: 55%–75% solution in acute blood loss
FFP • Plasma separated from whole blood within • Replacement of multiple coagulation
6 hours of collection and then rapidly factor
frozen to –25°C or colder • deficiencies,
• Contains normal plasma levels of stable • DIC
clotting factors, albumin & • TTP
immunoglobulin
Platelet Single donor unit in a volume of 50–60 ml of • Treatment of bleeding due to:
conc. plasma should contain: — Thrombocytopenia
At least 55 x 103 platelets, <1.2 x 103 red cells, — Platelet function defects
<0.12 x 103 leucocytes • Prevention of bleeding due to
thrombocytopenia.
Cryopres • Prepared by resuspending FFP presipitate. Treatment of vWD, Haemophilia A,
ipitate • Contains about half of the Factor VIII and FXIII def, source of fibrinogen acquired
fibrinogen in the donated whole blood. coagulopathies (DIC)
17. Ischemic
Heart Disease
 18. Arthritis
 The management of
acute gout is to provide
rapid & safe pain relief.
 NSAID,
 Colchicine.
 Corticosteroid if NSAID is
contraindicated.
 Preventing further attacks
by uric acid lowering
agent:
 Allopurinol
 Probenecid
 Uric acid lowering agent
shouldn’t be given on acute
attack, unless the patient
has consumed it since 2
weeks before.
Current diagnosis & treatment in rheumatology. 2nd ed. McGraw-Hill; 2007.
 19. Obstructive Lung Disease
 A working definition of COPD:
 A disease state
characterized by airflow
limitation that is not fully
reversible.
 The airflow limitation is
usually both progressive &
associated with an
abnormal inflammatory
response of the lungs to
noxious particles or gases.

GOLD. WHO.
20. Marker of Coronary Risk
21.Unresponsiv
e Patient
22. Shock
23. Calorie Calculator
 Kalori dari telur goreng: 90 kkal.
 Bersepeda 5 menit: 25 kkal.
 Bersepeda 10 menit: 50 kkal.
 Berlari kencang 5 menit: 50 kkal.
 Berlari kencang 10 menit sekitar 90 kkal.
 Berjalan 20 menit: 48 kkal.
24. Urinary Tract Infection
 Recurrent UTI
 2 uncomplicated UTIs in 6 months or 3 positive cultures within the
preceding 12 months.
 Investigation:
 physical examination to evaluate urogenital anatomy &
estrogenization of vaginal tissues & to detect prolapse.
 Post-void residual urine volume should be measured.
 Diabetes screening in patients with other risk factors (family history
& obesity).
 Women who suffer infection with organisms that are not common
causes of UTI, such as Proteus, Pseudomonas, Enterobacter, and
Klebsiella may have structural abnormalities or renal calculi 
imaging & cystoscopy
24. Urinary Tract Infection
 Women who are felt to be in the early stages of a problem with
recurrent UTI should have documented cultures  gold standard
for diagnosis & provides information about the uropathogen &
antibiotic susceptibilities.
 The standard definition of a UTI on culture is >105 colony forming
units per HPF.
 In women with symptoms of a UTI > 103 colony forming units per
HPF is considered sufficient.
25. Shock

SKOR DALDIYONO
Defisit cairan (cc) = SKOR/15 x Berat Badan (kg) x 100
Haus/Muntah (1)
TD Sistolik 60-90 mmHg (1)
TD Sistolik <60 (2)
Frekuensi Nadi >120x (1)
Kesadaran Apatis (1)
Somnolen/sopor/koma (2)
Frekuensi nafas >30x/menit (1)
Facies Cholerica (2)
Vox Cholerica (2)
Turgor kulit menurun (1)
"Washer Woman Hand" (1)
Ekstremitas dingin (1)
Sianosis (2)
Umur 50-60 tahun (-1)
Umur >60 tahun (-2)
26. Renal Disorder
Diagnosis
Acute glomerulonephritis
Rapidly progressive
glomerulonephritis
(crescentic)
Chronic glomerulonephritis
Nephrotic syndrome
Pathophysiology of disease: an introduction to
Characteristic
an abrupt onset of hematuria & proteinuria with reduced
GFR & renal salt and water retention, followed by full
recovery of renal function.
recovery from the acute disorder does not occur. Worsening
renal function results in irreversible and complete renal
failure over weeks to months.
renal impairment after acute glomerulonephritis progresses
slowly over a period of years & eventually results in chronic
renal failure.
manifested as marked proteinuria, particularly albuminuria
(defined as 24-h urine protein excretion > 3.5 g),
hypoalbuminemia, edema, hyperlipidemia, and fat bodies
in the urine.
26. Renal Disorder

 In early cases, the glomeruli may still show evidence of the primary disease.
 There eventually ensues obliteration of glomeruli, transforming them into acellular
eosinophilic masses, representing a combination of trapped plasma proteins,
increased mesangial matrix, basement membrane–like material, and collagen.
 Marked atrophy of associated tubules, irregular interstitial fibrosis, and
mononuclear leukocytic infiltration of the interstitium also occur.
27. Thyroid Disease
 Graves’ disease: female predominant, thyroid stimulating
immunoglobulin (+), diffuse nontender goiter with bruit,
ophthalmopathy. Th: PTU/metimazol, propranolol.
Hyperthyroidism
28. Marker of Coronary Risk
 29. Acute Coronary
Syndrome

Henry’s clinical diagnosis & management by laboratory method.

Pathophysiology of heart disease.
29. Acute Coronary Syndrome
 CK-MB or troponin I/T are a marker for infark miocard & used as
a diagnostic tool.
 Given their high sensitivity & specificity, cardiac troponins are
the preferred serum biomarkers to detect myocardial necrosis.
30. Lung Abscess
 Lung abscesses are pus-containing necrotic lesions of
the lung parenchyma that often contain an air-fluid
level.
 Lung abscess may be associated with infections caused
by pyogenic bacteria, mycobacteria, fungi, and
parasites.
 Most diagnoses of lung abscess are made from chest
radiographs. A true cavity has either a visible wall
completely surrounding the lucency or an air-fluid
level in the area of pneumonia
31. Arthritis
Acute Bacterial Arthritis
 Bacteria enter the joint from the bloodstream; from a
contiguous site of infection in bone or soft tissue; or by
direct inoculation during surgery, injection, animal or
human bite, or trauma.
32. Tropic Infection

Shock
Bleedin
g
Primary infection:
• IgM: detectable by days 3–5 after the onset of
illness,  by about 2 weeks & undetectable after
2–3 months.
• IgG: detectable at low level by the end of the
first week & remain for a longer period (for
many years).
Secondary infection:
• IgG: detectable at high levels in the initial
phase, persist from several months to a lifelong
period.
• IgM: significantly lower in secondary infection
cases.
33. HIV Screening
34. Pharmacology
 Early phase hyperglycemia, associated with increased
rates of insulin and C-peptide secretion after oral
administration of 100 g glucose, was observed among
patients with pulmonary tuberculosis who were taking
rifampicin.
 This early phase hyperglycemia appeared shortly after
rifampicin was started and it disappeared completely a
few days after rifampicin was discontinued.
35. Infection in DM Patient
 Foot infections are the most
common problems in persons with
diabetes.
 These individuals are predisposed
to foot infections because of a
compromised vascular supply
secondary to diabetes.
 Local trauma and/or pressure
(often in association with lack of
sensation because of neuropathy),
in addition to microvascular
disease, may result in various
diabetic foot infections that run
the spectrum from simple,
superficial cellulitis to chronic
osteomyelitis
36. Arrhytmia
Irregular Tachycardias
Atrial Fibrillation and Flutter
 An irregular narrow-complex or wide-complex tachycardia is most likely atrial fibrillation
with an uncontrolled ventricular response.

Therapy
 Management should focus on control of the rapid ventricular rate (rate control) and
conversion of hemodynamically unstable atrial fibrillation to sinus rhythm (rhythm
control).
 Electric or pharmacologic cardioversion (conversion to normal sinus rhythm)
should not be attempted in these patients unless the patient is unstable or the
absence of a left atrial thrombus is documented by transesophageal echocardiography.
 Magnesium, diltiazem, and -blockers have been shown to be effective for rate control in
the treatment of atrial fibrillation with a rapid ventricular response in both the
prehospital and hospital settings.
 Ibutilide & amiodarone have been shown to be effective for rhythm control in the
treatment of atrial fibrillation in the hospital setting.
 Amiodarone, ibutilide, propafenone, flecainide, digoxin, clonidine, or magnesium can be
considered for rhythm control in patients with atrial fibrillation of 48 hours duration.

ACLS
36. Arrhytmia
 treatment of AF considers three aspects of the
arrhythmia:
 ventricular rate control,
 consideration of methods to restore sinus rhythm,
 assessment of the need for anticoagulation to prevent
thromboembolism.
 Medicines used to control the heart rate:
 beta blockers (e.g., metoprolol and atenolol),
 calcium channel blockers (diltiazem and verapamil),
 digitalis (digoxin).
37. Typhoid Fever

A. Widal test:
B. Antibody detection to somatic antigen O & flagel antigen H from
salmonella.
C. Diagnostic result: the titer increase by >4 x after 5-10 days from the first
result.
D. Titer for antibody O increase at 6-8 days after the first symptoms, while
antibody H increase at 10-12 days.
E. Tubex: Measure IgM anti lipopolysaccharide O9 of Salmonella typhi.
37. Typhoid Fever

Culture is the gold standard for diagnosis of typhoid.

Blood cultures: often (+) in the 1st week.
Stools cultures: yield (+) from the 2nd or 3rd week on.
Urine cultures: may be (+) after the 2nd week.
(+) culture of duodenal drainage: presence of Salmonella in carriers.
Jawetz medical microbiology.
38. Insulin Pada DM Tipe 2
 Insulin diperlukan pada keadaan:
 Penurunan berat badan yang cepat
 Hiperglikemia berat yang disertai ketosis
 Ketoasidosis diabetik
 Hiperglikemia hiperosmolar non ketotik
 Hiperglikemia dengan asidosis laktat
 Gagal dengan kombinasi OHO dosis optimal
 Stres berat (infeksi sistemik, operasi besar, IMA, stroke)
 Kehamilan dengan DM/diabetes melitus gestasionalyang
 Tidak terkendali dengan perencanaan makan
 Gangguan fungsi ginjal atau hati yang berat
 Kontraindikasi dan atau alergi terhadap OHO
39. Pseudomembranous Colitis
 Clostridium difficile infection
(CDI) Normal ileum
 unique colonic disease that is
acquired almost exclusively in
association with
antimicrobial use and the
consequent disruption of the
normal colonic flora.
 AB associated with CDI
 Clindamycin, ampicillin, &
cephalosporins
 The 2nd & 3rd cephalosporins,
(cefotaxime, ceftriaxone,
cefuroxime, and ceftazidime)
 ciprofloxacin, levofloxacin,
and moxifloxacin (hospital
outbreak)
Harrison’s principles of internal medicine. 18th ed. McGraw-Hill; 2011.
 39. Pseudomembranous Colitis
Ingestion of spores

vegetate

secrete toxins

diarrhea &
pseudomembranous
colitis

Harrison’s principles of internal medicine. 18th ed. McGraw-Hill; 2011.

39. Pseudomembranous Colitis
 Diagnostic criteria of CDI:
 Diarrhea (3 unformed stools per 24 h for 2 days) with no other
recognized cause plus
 toxin A or B detected in the stool, toxin-producing C. difficile
detected in the stool by PCR or culture, or pseudomembranes seen
in the colon

Harrison’s principles of internal medicine. 18th ed. McGraw-Hill; 2011.

40. Metabolic Syndrome
41. Lung Disease
Bronchitis symptoms
 The most common symptoms of acute bronchitis
include:
 A persistent cough; this may last 10 to 20 days
 Some people cough up mucus, which may be clear,
yellow, or green in color
 Fever and shorthness of breath are not common in
people with acute bronchitis, it may be an indication
of pneumonia.
 Chest X-ray is usually clear.
41. Pneumonia Komunitas
 Diagnosis pasti:
Infiltrat baru/infiltrat progresif + ≥2 gejala:
1. Batuk progresif
2. Perubahan karakter dahak/purulen
3. Suhu aksila ≥38 C/riw. Demam
4. Fisis: tanda konsolidasi, napas bronkial, ronkhi
5. Lab: Leukositosis ≥10.000/leukopenia ≤4.500
42. Antidiabetik Oral
 Cara Pemberian OHO, terdiri dari:
 OHO dimulai dengan dosis kecil dan ditingkatkan secara
bertahap sesuai respons kadar glukosa darah, dapat diberikan
sampai dosis optimal
 Sulfonilurea: 15 –30 menit sebelum makan
 Repaglinid, Nateglinid: sesaat sebelum makan
 Metformin : sebelum /pada saat / sesudah makan
 Penghambat glukosidase (Acarbose): bersama makan suapan
pertama
 Tiazolidindion: tidak bergantung pada jadwal makan.
 DPP-IV inhibitor dapat diberikan bersama makan dan atau
sebelum makan.
43. Pharmacology
Thiazid side effects:
 Hypokalemic Metabolic Alkalosis and Hyperuricemia
 Impaired Carbohydrate Tolerance
The effect is due to both impaired pancreatic release of insulin and
diminished tissue utilization of glucose
 Hyperlipidemia
Thiazides cause a 5–15% increase in total serum cholesterol and low-
density lipoproteins (LDL). These levels may return toward baseline after
prolonged use.
 Hyponatremia
 Allergic Reactions
The thiazides are sulfonamides and share cross-reactivity with other
members of this chemical group. Serious allergic reactions are extremely
rare but do include hemolytic anemia, thrombocytopenia, and acute
necrotizing pancreatitis.
44. Gastrointestinal Bleeding
 Bleeding from the gastrointestinal (GI) tract may present in 5 ways:
 Hematemesis: vomitus of red blood or "coffee-grounds" material.
 Melena: black, tarry, foul-smelling stool.
 Hematochezia: the passage of bright red or maroon blood from the rectum.
 Occult GI bleeding: may be identified in the absence of overt bleeding by a fecal
occult blood test or the presence of iron deficiency.
 Present only with symptoms of blood loss or anemia such as lightheadedness,
syncope, angina, or dyspnea.
44. Gastrointestinal Bleeding
 Epigastric pain described as a
burning or gnawing discomfort
can be present in both DU & GU.
 H. pylori and NSAID-induced
injury account for the majority of
DUs
 DU:
 Pain occurs 90 minutes to 3
hours after a meal
 relieved by antacids or food.
 Pain that awakes the patient
from sleep (between
midnight and 3 A.M.)
 GU:
 discomfort may actually be
precipitated by food.
Harrison’s principles of internal medicine. 18th ed. 2011.
44. Gastrointestinal Bleeding
Diagnosis Characteristic
Peptic ulcer The most common cause of upper GI bleeding. H. pylori
& NSAID-induced injury (gastropathy NSAID) account
for the majority of DUs
Esophageal varices Portal hypertension  varices around portosystemic
hemorrhage anastomoses  esophageal varices
Portal hypertensive Portal hypertension  altered vascular microarchitecture
gastropathy with dilatation and/or narrowing of the capillaries & veins
 bleeding risk
Hemorrhoid Bright red bleeding per rectum, a sense of rectal fullness or
discomfort, may prolapse into the anal canal.
Erosive gastropathy Subepithelial hemorrhages & erosions. Cause: NSAID,
alcohol, & stress. These are mucosal lesions, thus, do
not cause major bleeding.

Harrison’s principles of internal medicine. 18th ed. 2011.

45. Typhoid Fever

Culture is the gold standard for diagnosis of typhoid.

Blood cultures: often (+) in the 1st week.
Stools cultures: yield (+) from the 2nd or 3rd week on.
Urine cultures: may be (+) after the 2nd week.
(+) culture of duodenal drainage: presence of Salmonella in carriers.
Jawetz medical microbiology.
46. Pharmacologyy
 Drugs which may cause folate deficiency include:
 phenytoin,
 isoniazid,
 barbiturates,
 oral contraceptives,
 ethanol,
 sulfasalazine,
 cycloserine,
 methotrexate,
 pyrimethamine, trimethoprin
47. Typhoid Fever
48. Breath Sound
 Amphoric breath sound
 an abnormal, resonant, hollow, blowing sound heard
with a stethoscope over the thorax.
 It indicates a cavity opening into a bronchus or a
pneumothorax.
49. Diabetes Management

PERKENI 2011
50. TB Management
 Pasien tidak mendapat regimen OAT dengan benar selama
3 bulan. Lakukan pemeriksaan BTA ulang & uji resistensi
untuk menentukan regimen terapi.

International standards for tuberculosis care.

  Untuk pemantauan pengobatan dilakukan pemeriksaan spesimen
sebanyak 2 kali (sewaktu, pagi). Bila salah satu/keduanya (+), maka
hasil dinyatakan BTA (+)
Tipe pasien TB Waktu Periksa Hasil BTA Tindak Lanjut
Pasien baru BTA (+), Akhir tahap (-) Tahap lanjutan dimulai
OAT kategori 1 intensif
(+) OAT sisipan 1 bulan, jika masih (+) tahap
lanjutan tetap diberikan
Sebulan sebelum (-) Sembuh
akhir atau di
(+) Gagal, mulai OAT kategori 2
akhir pengobatan
Pasien baru BTA (-) Akhir intensif (-) Berikan pengobatan tahap lanjutan s.d.
& Roentgen (+) OAT selesai, kemudian pasien dinyatakan
kategori 1 pengobatan lengkap
(+) Ganti dengan kategori 2 mulai dari awal
Pasien baru BTA (+), Akhir intensif (-) Teruskan pengobatan dgn tahap lanjutan
OAT kategori 2
(+) OAT sisipan 1 bulan, jika masih (+) tahap
lanjutan tetap diberikan. Uji resistensi.
Sebulan sebelum (-) Sembuh
akhir atau di
(+) Belum ada obat, disebut kasus kronik.
akhir pengobatan
Rujuk.
Pelatihan DOTS. Departemen Pulmonologi & Ilmu Kedokteran Respirasi FKUI; 2008.
51. Hepatology
 Liver Abscess
 Cause: Protozoa (E. histolytica) or bacteria (gram-negative
enteric bacilli (E.coli) , anaerobic gram-negative bacilli, &
microaerophilic streptococci).
 Clinical features:
 fever, malaise, weight loss, and right upper quadrant abdominal
pain.
 Hepatomegaly and right upper quadrant abdominal tenderness
 Jaundice is seen in approximately 25% of cases.
 Laboratory findings: leukocytosis & anemia, elevations of the
alkaline phosphatase and GGT, & hyperbilirubinemia in
about 25% of cases.
 USG: a round or oval area within the liver that is less
echogenic than the surrounding hepatic parenchyma

Current diagnosis & treatment in gastroenterology.

52. Pneumoconiosis
53. SIRS
54-55. Supracondylar Fracture
Mechanism
 Usually < 8 yo
 Extension (95%) vs flexion
Clinically
 Mild swelling to gross deformity
 Arm held to side, immobile,
extension
 S-shaped configuration
 Gartland
 I - nondisplaced
 II - displaced with intact posterior cortex
 III - displaced fracture, no intact cortex
 A: posteromedial rotation of distal fragment
 B: posterolateral rotation
Gartland type I

Gartland type II

Gartland type III

Management
 If NeuroVascular compromise - urgent ortho consult
 If no response from ortho in 60 min may attempt 1
reduction
 Watch brachial artery and median nerve
 Gartland I – splint+ sling and ortho f/u 24h
 Gartland II - controversy but most get pinned
 Gartland III - closed reduction and pin
http://www.rch.org.au/clinicalguide/guideline_index/fractures/Supracondylar_fracture_of_the_humerus_Emergency_Department/
Supracondylar Fracture-Reduction

U-slab
http://orthoinfo.aaos.org/topic.cfm?topic=A00513
GENERAL TREATMENT PRINCIPLES
Operative
 Anatomic articular reduction
 Stable internal fixation of the
articular surface
 Restoration of articular axial
alignment
 Stable internal fixation of the
articular segment to the
metaphysis and diaphysis
 Early range of elbow motion
Conservative
 indicated for nondisplaced or
minimally displaced fractures, severely
comminuted fractures in elderly
patients with limited functional
ability.
 Posterior long arm splint is placed in
at least 90 degrees of elbow flexion
with the forearm in neutral.
 Posterior splint immobilization is
continued for 1 to 2 weeks. The splint
may be discontinued after
approximately 6 weeks, when
radiographic evidence of healing is
present.
 Frequent radiographic evaluation is
necessary
 Conservative treatments take longer time, risk of
malunion, need more radiographic examination
 Surgery is the treatment of choice
 Temporary immobilization with arm-sling, surgery as
soon as possible

Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition

Lippincott Williams & Wilkins 2006
56. Tetanus

 The incubation periodis

usually 4 to 21 days.
 The average incubation
period is about 10 days.
 Muscle spasms and
stiffness

http://www.nhs.uk/Conditions/Tetanus/Pages/Symptoms.aspx
NOTE: Large rectangular NOTE: Double zone of hemolysis
gram-positive bacilli

Inner beta-hemolysis = θ toxin

Outer alpha-hemolysis = α toxin
57. Massive Hemorrhage
 Metabolic changes in traumatic-hemorrhagic shock
patient:
 Hypermetabolism
 Increased oxygen demands  anaerobs
metabolismlactate↑↑
 Increased energy expenditure
 Enhanced protein catabolism
 Insulin resistance associated with hyperglycemia
 Failure to tolerate glucose load
 High plasma insulin levels
 The alterations of the physiological metabolic pathways
leads
 Hyperglycemia
 Metabolic acidosis with hyperlactatemia
  During hemorrhagic shock,
metabolic acidosis is common
and conventionally considered to
be due essentially to
hyperlactatemia.
 The increase in blood lactate
generally originates from both
increased lactate production and
reduced lactate metabolism

Critical Care 2007, 11:R130 doi:10.1186/cc6200

58. Blunt Abdominal Trauma
 Signs of intraperitoneal injury
 Abdominal tenderness, peritoneal
irritation
 Distention - pneumoperitoneum,
gastric dilation, or ileus
 Ecchymosis of flanks (gray-turner
sign) or umbilicus (cullen's sign) -
retroperitoneal hemorrhage
 Abdominal contusions – seat belts
sign
 ↓Bowel sounds suggests
intraperitoneal injuries
 DRE: blood or subcutaneous
emphysema
http://regionstraumapro.com/post/663723636
• Dullness in Traube's space
– above the left midaxillary costal
margin
– suggests an enlarged spleen, and
can occur on inspiration
• Kehr's sign
– the occurrence of acute pain in
the tip of the shoulder due to
the presence of blood or other
irritants in the peritoneal cavity
when a person is lying down and
the legs are elevated
– Kehr's sign in the left shoulder is
considered a classical
symptom of a ruptured
spleen
http://www.sharinginhealth.ca/clinical_assessment/abdominal_exam.html
• Injury to the membranous
urethra occurs on trauma
leading to fracture separation of
the symphysis pubis or fracture
of the pubic rami.
• The membranous urethra is torn
and the prostate is pulled
upwards
• During rectal examination
the prostate will found too high
to beexamined by finger (high
overriding prostate)
 Organs
 Spleen (Traube’s space
dullness, Kehr’s sign)
 Intestine (free air, sphincter
tone decreased)
 Urethra(high overriding
prostate)
59. Anaphylactic Shock

www.resus.org.uk/pages/reaction.pdf
60. Airway Obstruction
 Snoring - due to obstruction of upper airway by the
tongue
 Gurgling - due to obstruction of upper airway by liquids
(blood, vomit)
 Wheezing - due to narrowing of the lower airways
PATENT Vs COLLAPSED AIRWAY

2006 American Academy of Sleep medicine

Obstructive Sleep Apnea
 Episodes of complete or partial collapse of airway  apnea and
hypopnea events
 Apnea = cessation of airflow > 10 seconds
 Hypopnea = Decreased airflow > 10 seconds associated with:
 Arousal

 Oxyhemoglobin desaturation

 Cardinal symptoms  "3 S ’s“

 S noring
 S leepiness
 S ignificant-other report of sleep apnea episodes
61. Precordial stab wound
 Precordial
 an area limited by the
clavicles superiorly
 the costal margin inferiorly
 the midclavicular lines
laterally
 Penetrating heart injury
should be presumed
• Tamponade suspected
– Echocardiography
– Pericardiocentesis
• done immediately for
diagnosis and
treatmenta brief
delay might be life
threatening.
• Needle pericardiocentesis is
often best when the etiology
is known or the presence of
tamponade is in question
62. Resuscitation
 Crystalloid solution rapidly equilibrates between the
intravascular and interstitial compartments

 Adequate restoration of hemostatic stability may require large

volumes of ringer's lactate.

 It has been empirically observed that approximately 300 cc of

crystalloid is required to compensate for each 100 cc of blood
loss. (3:1 rule)
63. Burn injury Initial Assessment
 Burn Resuscitation with Lactated Ringer’s
 Figure out burn size by “rule of nines” or entire palmar surface of
patient’s hand = 1%
 Parkland/Baxter formula
 4 x Wt(kg) x %TBSA = mL to give in 1 day
 Half over 1st 8hrs (subtract what was given)
 Give other Half over next 16 hours
 In reality, titrate to UOP of 0.5mL/kg/hr in adults and
1mL/kg/hr in children
 Do not give colloid in first 24 hrs

education.surgery.ufl.edu
64. Diabetic Foot
Wagner Classification  X-ray
0- Intact skin (may have bony  osteomyelitis,
deformities. osteolysis, fractures,
1- Localized superficial ulcer. dislocations
2- Deep ulcer to tendon, bone,
ligament or joint.  medial arterial
3- Deep abscess or osteomyelitis. calcification, and soft-
4- Gangrene of toes or forefoot. tissue gasgangrene
5- Gangrene of whole foot.

http://www.annalsofvascularsurgery.com/article/S0890-5096(11)00060-4
 osteomyelitis, osteolysis,
soft-tissue gas fractures
65. Urachal abnormalities
• Failure of obliteration of urachus resulting complete or partial
patency of urachus
• < 1/1000 live births
• Inflammation or drainage from umbilicus
• USG, CT, contrast studies, or injection of dye into tract can
confirm diagnosis

the beefy red appearance

of the umbilical end of a
patent urachus
 • Patent Urachus (50%)
• Urachal cyst (30%)
• Urachal sinus (15%)
• Vesicourachal diverticulum (5%)

bladder
 Patent Urachus
 As a result of total lack of involution
 free communication between the bladder and the
umbilicus
 1-3 months of age
 The presenting complaint
 Periumbilical discharge42% of the patients
 serous, purulent, or bloodyurachal sinus or cyst
 Persistent clear fluid leakage (likely urine) in an infant is
highly suggestive of a patent urachus
 persists beyond a few weeks
 Umbilical mass pain due to infection

www.mssurg.net/.../Pediatric%20Umbilical%20Abnormalities%20-
Superior vesica fissure(Exstrophy bladder
variants)
• Widely separated pubic symphysis
• The umbilicus is low or elongated
• A small superior bladder opening or a patch of
isolated bladder mucosa
• Infraumbilica
• Genitalia are intact

• Umbilical Herniaoutward bulging

(protrusion) of the abdominal lining or
part of the abdominal organ(s) through
the area around the belly button

• Omphalitis  infection of the umbilical

stump
• most commonly occurs after day 3
• the stump appears reddened,oedematous,
exudative discharge, signs of cellulitis ("cord
flare")
66. Hirschsprung disease
Frequency Predilection
• approximately 1 per 5000 live
• Classical HD (75% of cases):
births.
Rectosegmoid
• Sex: 4 times more common in
males than females. • Long segment HD (20% of
cases)
• Age:
– Nearly all children with
• Total colonic aganglionosis
Hirschsprung disease are (3-12% of cases)
diagnosed during the first 2 years • rare variants include the
of life.
following:
– one half are diagnosed before
they are aged 1 year. • Total intestinal aganglionosis
– Minority not recognized until • Ultra-short-segment HD
later in childhood or adulthood. (involving the distal rectum
• Mortality/Morbidity: below the pelvic floor and the
– The overall mortality of anus)
Hirschsprung enterocolitis is 25-
30%,.
Hirschsprung’s disease
Clinical symptoms
 The disease can considered to be incomplete intestinal
obstruction
 The length of the aganglionic segment is variable
 The symptoms are variable too
 The symptoms appears in different ages
Symptoms in newborn age
 Fail to pass meconium (in
24 hours of life)
 Abdominal distension, but
the abdomen is palpable
 Vomiting
 The rectal tube can’t be put
easily
 After irrigation the signs
and symptoms return again
in a few days
Symptoms in newborn
age(enterocolitis)
• Life-threatening condition
• Diarrhea: it can be an early sign
• Toxic megacolon
• Abdominal distension
• Bile-stained vomiting
• Fiver and signs of dehydration
• Rectal tube:explosive expulsion
of gas and foul-smelling stools
Symptoms in infants Symptoms in childhood
 Constipation • Gracile limbs
 Meteorism • Dilated drumlike belly
 Palpable faecaloma • Long history of constipation
 Sometimes putrescent • Defecation in 7-10 days
diarrhea • Multiple fecal masses
 Ulceration, bleeding • The stimulus of defecation is
 Hypoproteinaemia, missing
anaemia • Rectum is empty and narrow
 Electrolyt disorders
 Darm kontur: visible shape of intestines on the
abdomen
 Darm Steifung: visible peristaltic movement on the
abdomen
Rontgen :
• Plain abdominal radiography
– Dilated bowel
– Air-fluid levels.
– Empty rectum
• Contrast enema
– Transition zone
– Abnormal, irregular contractions of
aganglionic segment
– Delayed evacuation of barium
• Biopsy :
– absence of ganglion cells
– hypertrophy and hyperplasia of nerve
fibers,
67. Gallbladder Disorder
Cholangitis • Tests may include:
 An infection of the biliary • Abdominal ultrasound
tract • Endoscopic retrograde
 The charcot triad cholangiopancreatography (ERCP)
 Fever • Magnetic resonance
cholangiopancreatography (MRCP)
 Abdominal (right upper
• Percutaneous transhepatic
quadrant) pain
cholangiogram (PTCA)
 Jaundice • The following blood tests may be done:
• Bilirubin level
• Liver enzyme levels
• Liver function tests
• White blood count (WBC)
http://emedicine.medscape.com/article/184043-clinical

Disorder Clinical Feature

Pancreatitis Chronic Abdominal pain, normal or mildly elevated pancreatic enzyme levels,
malabsorbsion (steatorrhea), diabetes mellitus (CHRONIC)
sudden in onset abdominal pain radiates the back, worse in supine
position,Profuse vomiting, fever(ACUTE)

Acute cholesistis Acute right upper quadrant pain and tenderness, radiates to back or below the
right shoulder blade,Fever and leukocytosis, Clay-colored stools, jaundice, Nausea
and vomiting,Palpable gallbladder/fullness of the RUQ ,Murphy sign

Cholelithiasis Episodic abdominal pain (increases when consuming fat), pain resolves over 30 to
90 minutes.localizes the pain to the epigastrium or right upper quadrant radiation
to the right scapular tip (Collins sign).Dyspepsia,Gallstones on cholecystography or
ultrasound scan,4F. Dx:USG, MRCP
Choledocholithiasis  at least one gallstone in the common bile duct

Pancreatic Tumor >50 years,abdominal pain, lower back pain,jaundice, Dark urine and clay-colored
stools,Fatigue and weakness, Painless Jaundice, palpable gallbladder (ie,
Courvoisier sign),Loss of appetite and weight loss,Nausea and vomiting,
Trousseau sign, in which blood clots form spontaneously in the portal blood
vessels, the deep veins of the extremities, or the superficial veins anywhere on the
body, Diabetes mellitus, Tumor marker CA 19-9
68. Olecranon Fracture
 Patients typically present with the upper extremity
supported by the contralateral hand with the elbow in
relative flexion
 Physical examination may demonstrate a palpable defect
at the fracture site
 An inability to extend the elbow actively against
gravity indicates discontinuity of the triceps mechanism.
Classification (Mayo)
 Nonoperative treatment
indicated for nondisplaced
fractures and displaced fractures
in poorly functioning older
individuals.
 Immobilization in a long arm
cast with the elbow in 45 to 90
degrees of flexion is favored by
many authors

Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition

Lippincott Williams & Wilkins 2006
69. Kidney Stone
 Calcium oxalate stones
 the most common
 They tend to form when the urine is acidicit has a low pH
 Some of the oxalate in urine is produced by the body
 Calcium and oxalate in the diet play a part but are not the only
factors that affect the formation of calcium oxalate stones
 Dietary oxalate an organic molecule found in many
vegetables, fruits, and nuts
 Calcium from bone may also play a role in kidney stone
formation.
 Calcium phosphate stones
 less common
 tend to form when the urine is alkalineit has a high pH
 Struvite stones
 Found more often in women
 almost always the result of urinary tract infections
 Uric acid stones
 These are a byproduct of protein metabolism
 commonly seen with gout,and may result from certain genetic
factors and disorders of your blood-producing tissues
 fructose also elevates uric acid, and there is evidence that fructose
consumption is helping to drive up rates of kidney disease
 Cystine stones
 Representing only a very small percentage
 these are the result of a hereditary disorder that causes kidneys to
excrete massive amounts of certain amino acids (cystinuria)
70. Tibia-fibula Shaft Fracture
 Tscherne Classification
 0-3
 Based on degree of
displacement and
comminution
• C0simple fracture configuration
with little or no soft tissue injury
• C1superficial abrasion, mild to
moderately severe fracture
configuration
• C2deep contamination with local
skin or muscle contusion, moderately
severe fracture configuration
• C3extensive contusion or crushing
of skin or destruction of muscle,
severe fracture
Treatment
Nonoperative
 Fracture reduction followed by
application of a long leg cast with
progressive weight bearing can be
used for isolated, closed, low-
energy fractures with minimal
displacement and comminution.
 Cast above knee, with the knee in
0 to 5 degrees of flexion
 After 4 to 6 weeks, the long leg
cast may be exchanged for a
patella-bearing cast or fracture
brace.
 Union rates as high as 97%

Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition

Lippincott Williams & Wilkins 2006
https://www2.aofoundation.org
71. Alvarado Score
72. Proximal Humerus Fracture
 Proximal humerus fractures
comprise 4% to 5% of all
fractures
 the most common humerus
fracture (45%).
 The increased incidence in the
older population is thought to
be related to osteoporosis.
 2:1 female-to-male ratio
 The axillary nerve courses just
anteroinferior to the
glenohumeral joint, traversing
the quadrangular space.
 It is at particular risk for traction
injury. it is susceptible to injury
during anterior dislocation
and anterior fracture-
dislocation.
73-75.Osteomyelitis
 Inflammation of the bone and bone marrow caused by
an infecting organism.
 Although bone is normally resistant to bacterial
colonization, events such as trauma, surgery, presence of
foreign bodies, or prostheses may disrupt bony integrity
and lead to the onset of bone infection
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
76. Trauma patient
Airway Management
 Simple management maneuvers Patient can’t response
 Suction GCS Score<9
 Chin lift Obstruction due to
 Jaw thrust  Tongue
 “Definitive airway:” Cuffed tube  Aspiration
in trachea  Foreign body
 Maxillofacial injury
 Neck injury
Management:
 Careful endoscopic exam
 Careful and gentle intubation, or
 Surgical airway?
 Modify for suspected spinal injury:
1. Tongue/jaw lift
2. Modified jaw thrust
77. Kidney Stone Formation
 Causes:
 Highly concentrated urine, urine stasis
 Imbalance of pH in urine
 Acidic: Uric and oxalat Stones

 Alkaline: Phosphat Stones

 Gout
 Hyperparathyroidism
 Inflammatory Bowel Disease
 UTI
 Medications
 Lasix, Topamax, Crixivan

http://www.pilotfriend.com/aeromed/medical/images2/25.jpg
Types of Stones
 Calcium Oxalate
 Most common
 Calcium Phosphate
 Struvite
 More common
in woman than men.
 Commonly a result of UTI.
 Uric Acid
 Caused by high protein diet and gout.
 Cystine
 Fairly uncommon; generally linked to a hereditary disorder.
  Uric acid stones are the
most common cause of
radiolucent kidney stones
 Several products of purine
metabolism are relatively
insoluble and can precipitate
when urinary pH is low

http://emedicine.medscape.com/article/983759-overview
78. Colonic Carcinoma
Time Course Symptoms Findings
Early None None
Occult blood in stool
Mid Rectal bleeding Rectal mass
Change in bowel Blood in stool
habits
Late Fatigue Weight loss
Anemia Abdominal mass
Abdominal pain Bowel obstruction
Site Distribution
 Screening For Colon Cancer
SAVES LIVES!!!
Mortality
Test Reduction
Fecal occult blood testing (FOBT 33%
Flexible sigmoidoscopy 66%
(in portion of colon examined)

FOBT + flexible sigmoidoscopy 43%

(compared to sigmoidoscopy alone)

Colonoscopy ~76-90%
(after initial screening and polypectomy)
Colorectal cancer screening
First assess RISK
AVERAGE RISK INDIVIDUAL
 All patients age 50 years and older, the asymptomatic general
population

HIGH RISK
 Personal history – polyp or cancer
 Family history – polyp or cancer in first degree relatives
 Double-contrast Barium Enema
 Advantage
 Examines entire colon
 Relatively low cost
 Disadvantge
 Never studied as a screening test
 Missed 50% of polyps > 1cm
in one study
 Detects 50-75% of cancers in those
with positive FOBT
 Interval between exams unknown

Winawer et al. Gastroenterology 1997; 112:599

Rex, Endoscopy 1995; 27:200
Lieberman et al. N Engl J Med 2000; 343:163
Colonoscopy
 Advantage
 Examines entire colon
 Removal of polyps performed at time of exam
 Well-tolerated with sedation
 Easier bowel preparation, usually done without sedation
 Disadvantage
 Expensive
 Risk of perforation, bleeding low but not negligible
 Requires high level of training to perform
 Miss rate of polyps < 1 cm ~25%, > 1 cm ~5%

Rex et al. Gastroenterology 1997; 112:24-8

Postic et al. Am J Gastroenterol 2002; 97:3182-5
79. Complications of Casts &
Splints
 Loss of reduction
 Pressure necrosis – may occur as early as 2 hours
 Tight cast  vascular compromise and compartment
syndrome (first 24 hours)
Complications of Casts & Splints
 Thermal Injury - avoid plaster > 10 ply, water >24°C,
unusual with fiberglass
 Cuts and burns during removal

Keloid formation as a result of an injury during cast

removal. From Halanski M, Noonan KJ. J Am Acad
Orthop Surg. 2008.
Complications of Casts & Splints
 DVT/PE - increased in lower extremity fracture
 Ask about prior history and family history
 Birth Control Pills are a risk factor
 Indications for prophylaxis controversial in patients without risk
factors
 Joint stiffness
 Leave joints free when possible (ie. thumb MCP for below elbow
cast)
 Place joint in position of function

Closed Reduction, Traction, and Casting Techniques

www.ota.org/.../G09_CRC_Traction_Casts%20JTG%20rev%202-4-1
80. CPR
 Indication for CPR
 No response
 Not breathing
 No pulse

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

81. Adverse Effect of Beta Blocker

 Nausea  Heart block
 Diarrhea  Fatigue
 Bronchospasm  Dizziness
 Dyspnea  Alopecia (hair loss)
 Cold extremities  Abnormal vision
 Exacerbation of raynaud's  Hallucinations, insomnia,
syndrome nightmares
 Bradycardia  Sexual dysfunction, erectile
dysfunction
 Hypotension
 Alteration of glucose and lipid
 Heart failure
metabolism
Erectile dysfunction(ED) after
therapy with beta-blockers
 Beta-blockers induce ED through central and peripheral
(genital) effects
 increases the latency to ex copula ejaculation
 the latency to initial erection
 reduces the number of erectile reflexes
 Despite the common belief of the induction of ED with beta-
blocker use, clinical studies failed to confirm a relationship
between use of such drugs and ED.
  ED in patients with cardiovascular disease may be related to psychological
factors involving the fear of the disease and of the effect of the drugs
prescribed
 The knowledge and prejudice about side effects of beta-blockers can
produce anxiety, that may cause erectile function

Silvestri et al. Report of erectile dysfunction after therapy with beta-blockers is related to patient
knowledge of side effects and is reversed by placebo. Italy: February, 2003.
Counseling
Hatzimouratidis K, et al. Guidelines on Male Sexual Dysfunction: Erectile Dysfunction and Premature Ejaculation. Eur Urol
(2010), doi:10.1016/j.eururo.2010.02.020
82. Identification Of Cardiac Arrest
 Healthcare Providers should
check for a pulse before
performing chest compressions
on a suspected victim of cardiac
arrest.
 For Adults and Children, a pulse
should be assessed in the
carotid artery for 5 to 10
seconds
 No pulsecardiac arrest

http://www.cardiopulmonaryresuscitation.net/
http://en.wikipedia.org/wiki/Burn

83.Burn Injury

prick test (+)

• Berat luka bakar:
• Ringan: derajat 1 luas
< 15% a/ derajat II <
2%
• Sedang: derajat II 10-
15% a/ derajat III 5-10%
• Berat: derajat II > 20%
atau derajat III > 10%
atau mengenai wajah,
tangan-kaki, kelamin,
persendian,
pernapasan
 84. Male Genital Disorder
Phimosis Paraphimosis
 Inability to retract the distal  Entrapment of a retracted
foreskin over the glans penis foreskin behind the coronal
sulcus
 Physiologic in newborn
 Emergency
 Complications
 Superficial vein
 Balanitis
obstruction  edema
 Postitis and pain  penile
 Balanopostitis glands necrosis
 Treatment  Treatment
 Dexamethasone 0.1% (6  Manual reposition
weeks) for spontaneous  Dorsum incision
retraction
Paraphimosis
 Paraphimosis leading to vascular engorgement and
edema of the distal glans.
 This condition is a medical emergency when identified
acutely and requires prompt effective treatment to
prevent loss of the distal glans penis
Treatment • Manipulation
• Ice packs
• Compression
• Osmotic agent
• Puncture technique
• Surgical reduction followed by
circumcision
• dorsal slit procedure

https://online.epocrates.com
www.stacommunications.com/journals/diagnosis

85. Wrist Pain

 Routine radiographic views 
Wrist Joint
 posterior-anterior (PA),
lateral, oblique
 B
A

A. Foto Antebrachii
B. Foto Manus
C. Foto Cubiti
C
http://en.wikipedia.org/wiki/

86. Efek Samping Anti Kejang

Drugs Adverse Effects
Phenitoin Neurologic horizontal gaze nystagmus, sedation, cerebellar ataxia,
ophthalmoparesis
Hematologicfmegaloblastic anemia(folic acid deficiency, agranulocytosis,
aplastic anemia, leukopenia, thrombocytopenia
Teratogen, gingival enlargement, Hypertrichosis, rash, exfoliative dermatitis,
pruritis, Hirsuitism, and coarsening of facial features, SSJ, NET

Diazepam confusion, hallucinations, no fear of danger, depressed mood, hyperactivity, new or

worsening seizures, weak or shallow breathing, tremor,loss of bladder control; or
urinating less than usual or not at all
Carbamaz drowsiness, headaches and migraines, motor coordination impairment, and/or
epine upset stomach, aplastic anemia,Unusual bruising or bleeding,Worsening of
seizures Hallucinations, Depression
Phenobarb Sedation, hypnosis,dizziness, nystagmus and ataxia, excitement and
ital confusion,paradoxical hyperactivity(children), amelogenesis imperfecta

Asam Diarrhea, dizziness, drowsiness, hair loss, blurred/double vision, change in

Valproat menstrual periods, ringing in the ears, shakiness (tremor), unsteadiness, weight
changes, impairments in liver and impairments of hematopoietic and/or pancreatic
function
87. X-ray Diagnosis
Osteosarcoma
 X-rays of area of suspected infection would not
demonstrate darkened areas typical of osteomyelitis.
 Conventional features
 Destruction of normal trabecular bone pattern
 a mixture of radiodense and radiolucent areas
 periosteal new bone formation
 formation of Codman's triangle (triangular elevation of
periosteum)
No osteoblastic appearance,
fracture can be seen
Notice the osteoblastic-
osteolytic appearance
88. Filariasis
 Chyluria is the passage of milky urine due to a
lymphourinary fistula,
 the cause of which may be parasitic or non-parasitic.
 Filariasis is the commonest cause of chyluria.
Lymphatic Filariasis
Infection with 3 closely related Nematodes
 Wuchereria bancrofti
 Brugia malayi
 Brugia timori
* Transmitted by the bite of infected mosquito
responsible for considerable sufferings/deformity and
disability
* All the parasites have similar life cycle in man
* Adults seen in Lymphatic vessels
* Offsprings seen in peripheral blood during night
Stages in Lymphatic
Filariasis  Chronic (Obstructive)
lesions takes 10-15 years.
 There are 4 stages :
1. Asymptomatic  due to the permanent
amicrofilariaemic stage damage to the lymph vessels
2. Asymptomatic caused by the adult worms,
microfilariaemic stage  endothelial proliferation
3. Stage of Acute and inflammatory
manifestation granulomnatous reaction
4. Stage of Obstructive around the
(Chronic) lesions parasiteobstruction of
lymph
 Hydrocele (40-60%),
Elephantiasis of Scrotum,
Penis, Leg, Arm, Vulva,
Breast, Chyluria.
 Pathogenesis of Lymphatic Disease in
Bancroftian Filariasis:: A Clinical Perspective
G. Dreyer, J. Norões. J. Figueredo-Silva, W.F.
Piessens
89. Open Fracture
 Acute bacterial culture of open fracture wounds,
before or shortly after initial debridement, is of little
clinical utility.
 Organisms isolated in the acute phase of treatment do
not correlate well with clinical infections that result
from open fractures.
 Therefore, the routine use of cultures at this stage of
care is of little benefit to the patient and is not cost-
effective.

http://emedicine.medscape.com/article/1269242-overview#a17
 Infection commonly caused by bacteria from the skin and
environment
 Speciment from the skin near the wound
 Swab must be taken from the infected wound after
dead tissue and debris cleansed with sterile saline
 Mot common organism: Staphylococcus aureus,
Acinetobacter Spp

African Journal of Microbiology Research Vol. 3(12) pp. 939-951 December, 2009
90. Derajat Parrish (Gigitan Ular)
 Derajat 0  Derajat 2
 Tidak ada gejala sistemik  Sama dengan derajat 1
setelah 12 jam  Ptechiae, echimosis
 Pembengkakan minimal  Nyeri hebat dalam 12
diameter 1 cm jam pertama
 Derajat 1  Derajat 3
 Bekas gigitan 2 taring  Sama dengan derajat 2
 Bengkak dengan diameter  Syok dan distress
1-5 cm pernafasan/ptechiae,
 Tidak ada tanda-tanda echimosis seluruh tubuh
sistemik sampai 12 jam  Derajat 4
 Sangat cepat memburuk
Venomous Snakebites in the United States: Management Review and
Update at http://www.aafp.org/afp/2002/0401/p1367.html
91-93. Urine Incontinence
94. Hemorrhaegic Shock
 95. Anaphylactic Shock

www.resus.org.uk/pages/reaction.pdf
96. Triage
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)
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 Green
 Yellow (Second) Priority: • Minor fractures
Patients whose treatment • Minor soft-tissue
and transportation can be injuries
temporarily delayed • Green (Low) Priority:
 Burns without airway Patients whose
problems treatment and
 Major or multiple bone or transportation can be
joint injuries delayed until last
 Back injuries with or
without spinal cord
damage
97. Fluid Resuscitation
Crystalloids Non-protein colloids
 Are as effective as albumin in  Should be used as second-line
post-operative patients agents in patients who do not
 Are the initial resuscitation fluid respond to crystalloid
of choice for:  May be used in the presence of
 Hemorrhagic shock / capillary leak with pulmonary or
traumatic injury peripheral edema
 Septic shock  Are favored over albumin due to
 Hepatic resection their lower cost
 Thermal injury
 Cardiac surgery
 Dialysis induced
hypotension
 Fluid resuscitation target:
 Euvolemia
 Improve perfusion
 Improve oxygen
delivery

British Consensus Guidelines on

Intravenous Fluid Therapy for Adult
Surgical Patients 2011
 98. Food Choking  4 main stages in the swallowing
process:
 Oral Preparatory Stage, in which
the food is mixed with saliva,
and formed into a cohesive ball
(bolus)
 Oral Stage, in which the food is
moved back through the mouth
primarily by the tongue
 Pharyngeal Stage, which begins
pharyngeal swallowing
response:
• When talking, breathing, or  The food enters the upper throat
area (above the voice box)
laughingepiglottis opens  The soft palate elevates
• Possibility of choking if talking  The epiglottis closes off the
trachea, as the tongue moves
during meal backwards and the pharyngeal wall
moves forward .
 Esophageal Stage, in which the
food bolus enters the esophagus
http://calder.med.miami.edu/pointis/tbifam/swal1.html
99. Foreign Body Obstruction
Jackson (1936) membagi sumbatan 4. Sumbatan total (stop valve
bronkus menjadi 4 tingkat obstruction)
1. Sumbatan sebagian (bypass valve • tidak terdengar stridor
obstruction=katup bebas)
• terdengar wheezing
2. Sumbatan seperti pentil, ekspirasi
terhambat, atau katup satu arah
(expiratory check valve obstruction)
• Stridor inspirasi
3. Seperti pentil namun hambatan
inspirasi (Inspiratory check valve)
• stridor ekspirasi

Iskandar N. Sumbatan Traktus Trakeo-bronkial.

Buku ajar THT edisi 6 FKUI 2007