CBT 4

PEMBAHASAN TO 4 OPTIMAPREP BATCH II UKMPPD 2015 dr. Widya, dr. Cemara, dr. Yolina, dr. Retno, dr. Yusuf, dr. Reza

OFFICE ADDRESS: Jl padang no 5, manggarai, setiabudi, jakarta selatan (belakang pasaraya manggarai) phone number : 021 8317064 pin BB 2A8E2925 WA 081380385694

Medan : Jl. Setiabudi no. 65 G, medan Phone number : 061 8229229 Pin BB : 24BF7CD2 www.Optimaprep.Com

ILMU PENYAKIT DALAM

1. Pneumonia • Diagnosis pneumonia: Infiltrat baru/infiltrat progresif + ≥2 gejala: 1. Batuk progresif 2. Perubahan karakter dahak/purulen 3. Suhu aksila ≥38 oC/riw. Demam 4. Fisis: tanda konsolidasi, napas bronkial, ronkhi 5. Lab: Leukositosis ≥10.000/leukopenia ≤4.500 • Gambaran radiologis: – Infiltrat sampai konsolidasi dengan “air bronchogram”, penyebaran bronkogenik & interstisial serta gambaran kaviti. – Air bronchogram: gambaran lusen pada bronkiolus yang tampak karena alveoli di sekitarnya menjadi opak akibat inflamasi.

Pneumonia komuniti, pedoman diagnosis & penatalaksanaan di Indoneisa. Perhimpunan Dokter Paru Indonesia. 2003.

1. Pneumonia Petunjuk terapi empiris menurut PDPI • Rawat jalan – Tanpa faktor modifikasi: golongan β laktam atau β laktam + anti β laktamase – Dengan faktor modifikasi: golongan β laktam + anti β laktamase atau fluorokuinolon respirasi (levofloksasin, moksifloksasin, gatifloksasin) – Bila dicurigai pneumonia atipik: makrolid baru (roksitrosin, klaritromisin, azitromosin)

• Rawat inap – Tanpa faktor modifikasi : golongan beta laktam + anti beta laktamase i.v atau sefalosporin G2,G3 i.v atau Fluorokuinolon respirasi i.v – Dengan faktor modifikasi: sefalosporin G2,G3 i.v atau gluorokuinolon respirasi i.v – Bila curiga disertai infeksi bakteri atipik ditambah makrolid baru

1. Pneumonia Faktor modifikasi pada terapi pneumonia: • Pneumokokus resisten terhadap penisilin – – – – –

•

Bakteri enterik Gram negatif – – – –

•

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

1. Pneumonia • Lobar pneumonia is characterized by the presence of neutrophilic infiltration in the alveoli. The inflammation spreads through the pores of Khon and the Lambert channels, and it consequently often affects a whole lobe. This pattern is most characteristic of pneumonia due to S. pneumoniae, Klebsiella spp., and H. influenzae. • Bronchopneumonia is characterized by purulent exudate in terminal bronchioles and adjacent alveoli. Endobronchial spread results in multiple foci of consolidation in lung segments, subsegments, or smaller anatomic units. Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and other gram-negative bacilli often cause this pattern of disease.

2. Anemia Hemolitik

•

Sebagian besar anemia hemolitik berhubungan dengan sedikit gejala/tanda yang spesifik. Pada kasus hemolisis intravaskular akut dapat timbul gejala demam, menggigil, dan low back pain. Pada hemolisis kronik dapat ditemukan splenomegali karena hiperfungsi dalam mendestruksi eritrosit di limpa.

2. Anemia Hemolitik

Pada hemolisis intravaskular terdapat hemoglobinemia, hemoglobinuria, dan hemosiderinuria, sedangkan pada hemolisis ekstravaskular tidak ada.

2. Anemia Hemolitik

2. Anemia Hemolitik Anemia megaloblastik

Anemia yang disebabkan defisiensi folat atau vitamin B12. Eritrosit berukuran besar karena def B12/folat menghambat maturasi inti sel pada tahap perkembangan normoblas.

Anemi defisiensi besi

Anemia mikrositik hipokrom dengan sel pensil. Riwayat konsumsi Fe kurang atau perdarahan kronik yang mengakibatkan besi tubuh terbuang.

Anemia penyakit kronik

Pada penyakit/inflamasi kronik, terjadi sekresi hepsidin yang menghambat pengeluaran besi dari makrofag sehingga terjadi defisiensi besi fungsional. Kadar besi serum rendah, tetapi cadangan besi (ferritin) normal/tinggi

3. JNC VIII

3. JNC VIII • JNC VIII tidak mewajibkan satu obat tertentu untuk memulai terapi hipertensi.

• Namun, ditinjau dari keluaran gagal jantung, diuretik & CCB lebih efektif dibanding golongan lain.

4. Penyakit Paru

4. Penyakit Paru A. Gambaran Klinis PPOK a. Anamnesis - Riwayat merokok atau bekas perokok dengan atau tanpa gejala pernapasan - Riwayat terpajan zat iritan yang bermakna di tempat kerja - Riwayat penyakit emfisema pada keluarga - Terdapat faktor predisposisi pada masa bayi/anak, mis berat badan lahir rendah (BBLR), infeksi saluran napas berulang, lingkungan asap rokok dan polusi udara - Batuk berulang dengan atau tanpa dahak - Sesak dengan atau tanpa bunyi mengi b. Pemeriksaan fisis (PPOK dini umumnya tidak ada kelainan) • Inspeksi - Pursed - lips breathing (mulut setengah terkatup mencucu) - Barrel chest (diameter antero - posterior dan transversal sebanding) - Penggunaan otot bantu napas - Hipertropi otot bantu napas - Pelebaran sela iga - Bila telah terjadi gagal jantung kanan terlihat denyut vena jugularis di leher dan edema tungkai

4. Penyakit Paru Pemeriksaan fisis PPOK • Palpasi: pada emfisema fremitus melemah, sela iga melebar • Perkusi: pada emfisema hipersonor dan batas jantung mengecil, letak diafragma rendah, hepar terdorong ke bawah • Auskultasi - suara napas vesikuler normal, atau melemah - terdapat ronki dan atau mengi pada waktu bernapas biasa atau pada ekspirasi paksa - ekspirasi memanjang - bunyi jantung terdengar jauhgagal jantung kanan terlihat denyut vena jugularis i leher dan edema tungkai •

Pink puffer –

•

Blue bloater –

•

Gambaran yang khas pada emfisema, penderita kurus, kulit kemerahan dan pernapasan pursed – lips breathing Gambaran khas pada bronkitis kronik, penderita gemuk sianosis, terdapat edema tungkai dan ronki basah di basal paru, sianosis sentral dan perifer

Pursed - lips breathing –

Adalah sikap seseorang yang bernapas dengan mulut mencucu dan ekspirasi yang memanjang. Sikap ini terjadi sebagai mekanisme tubuh untuk mengeluarkan retensi CO2 yang terjadi sebagai mekanisme tubuh untuk mengeluarkan retensi CO2 yang terjadi pada gagal napas kronik.

4. PPOK Spirometri penyakit obstruktif paru: • FEV1 ↓ • Vital capacity ↓ • Hiperinflasi mengakibatkan: – Residual volume ↑ – Functional residual capacity ↑

Normal

COPD

Nilai FEV1 pascabronkodilator 20% baseline, atau frekuensi nadi > 20% baseline

1. PPOK: diagnosis dan penatalaksanaan. PDPI 2011

4. PPOK • Penatalaksanaan eksaserbasi akut ringan dilakukan dirumah oleh penderita yang telah diedukasidengan cara : – Menambahkan dosis bronkodilator atau dengan mengubah bentuk bronkodilator yang digunakan dari bentuk inhaler, oral dengan bentuk nebuliser – Menggunakan oksigen bila aktivitas dan selama tidur – Menambahkan mukolitik – Menambahkan ekspektoran

• Indikasi rawat : – – – –

Eksaserbasi sedang dan berat Terdapat komplikasi Infeksi saluran napas berat Gagal napas akut pada

1. PPOK: diagnosis dan penatalaksanaan. PDPI 2011

5. Hipertensi

5. Hipertensi

1. 2.

ACE-I (kaptopril, lisinopril): Bradikinin & substansi P  batuk ARB (valsartan, losartan): Tidak menyebabkan batuk

6. Hipertensi

“Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure”

6. Hipertensi

“Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure”

7. Tuberkulosis • Pemeriksaan mikroskopik: – Mikroskopik biasa : pewarnaan Ziehl-Nielsen, pewarnaan Kinyoun Gabbett – Mikroskopik fluoresens: pewarnaan auramin-rhodamin

7. Tuberkulosis • Pemeriksaan biakan M.tuberculosis dengan metode konvensional ialah dengan cara : – Egg base media (Lowenstein-Jensen, Ogawa, Kudoh) – Agar base media : Middle brook

Lowenstein-Jensen: tumbuh lambat, 3 minggu-3 bulan, akan seperti kembang kol

8. Diabetes meglitinide

TZD

Glucose undergoes oxidative metabolism in the β cell to yield ATP. ATP inhibits an inward rectifying K+ channel receptor on the β-cell surface. Inhibition of this receptor leads to membrane depolarization, influx of Ca [2]+ ions, and release of stored insulin from β cells. The sulfonylurea class of oral hypoglycemic agents bind to the SUR1 receptor protein.

8. Diabetes

16. Antidiabetic Drugs

9. Rekomendasi Diet American Heart Association •

Choose lean meats and poultry without skin and prepare them without added saturated and trans fat.

•

Eat fish at least twice a week. Recent research shows that eating oily fish containing omega-3 fatty acids (for example, salmon, trout and herring) may help lower your risk of death from coronary artery disease.

•

Select fat-free, 1 percent fat and low-fat dairy products.

•

Cut back on foods containing partially hydrogenated vegetable oils to reduce trans fat in your diet.

•

To lower cholesterol, reduce saturated fat to no more than 5 to 6 percent of total calories. For someone eating 2,000 calories a day, that’s about 13 grams of saturated fat.

•

Cut back on beverages and foods with added sugars.

•

Choose and prepare foods with little or no salt. To lower blood pressure, aim to eat no more than 2,400 milligrams of sodium per day. Reducing daily intake to 1,500 mg is desirable because it can lower blood pressure even further.

•

If you drink alcohol, drink in moderation. That means one drink per day if you’re a woman and two drinks per day if you’re a man.

10. Penyakit Katup Jantung • Gejala klasik stenosis aorta: – Angina, – Effort syncope, Secara umum, sinkop terjadi karena perfusi serebral yang inadekuat. Sinkop sering terjadi saat exercise. – Gagal jantung kongestif.

11-12. Diabetes

11-12. Diabetes • Dalam buku PERKENI 2011 tidak dicantumkan obat pertama, yang digunakan. Sedangkan American Diabetic Association mencantumkan metformin sebagai obat awal.

11-12. Diabetes 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.

11-12. Diabetes • Tabel di kanan dari PERKENI 2011.

• PERKENI 2006: – GDP 80-100 mg/dL – G2PP 80-140 mg/dL.

13. Efek Samping Obat • Cimetidine – Diare, neutropenia, hipersensitif, impotensi, ginekomastia, pusing, sakit kepala, neuropati perifer, artralgia, mialgia

• Famotidine – Sakit kepala, parestesia, flushing, palpitasi, tinnitus, edema orbita, diare, konstipasi, nyeri muskuloskeletasl, acne

• Omeprazol – Pusing, sakit kepala, nyeri abdomen, diare, konstipasi, mual, muntah, nyeri punggung, batuk, ruam

• Lansoprazol – Sakit kepala, konstipasi, diare, mual, nyeri abdomen

• Nizatidine – Demam, aritmia, faringitis, anemia, eosinofilia, hepatotoksisitas, hiperurikemia, batuk, diaforesis, ruam, urtikaria

14-15. Intoksikasi Asam Jengkolat • Jengkol mengandung asam jengkolat & sulfur yang dapat mengkristal di tubulus renal menimbulkan uropati obstruktif, acute kidney injury, atau penyakit ginjal kronik. • Intoksikasi akut dapat terjadi 5-12 jam setelah makan jengkol • Manifestasi klinis: – – – –

Nyeri pinggang Kolik abdomen Oliguria Hematuria

• Terapi: – Hidrasi agresif untuk meningkatkan aliran urine – Alkalinisasi (biknat) untuk melarutkan kristal asam kengkolat

14-15. Djenkolic Acid Intoxication

Kidney International Supplements (2012) 2, 8–12; doi:10.1038/kisup.2012.7

16. Penyakit Katup Jantung

16. Penyakit Katup Jantung

Lilly LS. Pathophysiology of heart disease.

16. Penyakit Katup Jantung

17. Penyakit Jantung Iskemik • Komplikasi angina stabil: ruptur plak  trombosis.

17. Penyakit Jantung Iskemik • Medical Therapy to Prevent MI and Death – Aspirin 75-162 mg daily should be continued indefinitely in the absence of contraindications in patients with stable ischemic heart disease. – Treatment with clopidogrel is reasonable when aspirin is contraindicated. – Beta-blocker therapy should be started & continued for 3 years in all patients with normal LV function after MI or ACS. – ACE inhibitors should be prescribed in all patients with SIHD who also have hypertension, diabetes mellitus, LV ejection fraction 40% or less, or chronic kidney disease, unless contraindicated 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease

17. Penyakit Jantung Iskemik • Medical Therapy for Relief of Symptoms – Beta blockers should be prescribed as initial therapy for relief of symptoms in patients with stable ischemic heart disease. – CCB or long-acting nitrates should be prescribed for relief of symptoms when beta blockers are contraindicated or cause unacceptable side effects in patients with stable ischemic heart disease. – CCB or long-acting nitrates, in combination with beta blockers, should be prescribed for relief of symptoms when initial treatment with beta blockers is unsuccessful in patients with stable ischemic heart disease. – Sublingual nitroglycerin or nitroglycerin spray is recommended for immediate relief of angina in patients with stable ischemic heart disease. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease

18. Diare Berdarah • IBD: a chronic condition resulting from inappropriate mucosal immune activation. • Ulcerative colitis – a severe ulcerating inflammatory disease that is limited to the colon and rectum and extends only into the mucosa and submucosa.

• Crohn disease – Also been referred to as regional enteritis (because of frequent ileal involvement) may involve any area of the GI tract and is typically transmural.

Robbins & Kumar Pathologic basis of disease. 2010.

18. Diare Berdarah Diagnosis

Characteristic

Crohn disease

Diare; nyeri abdomen kuadran kanan bawah, sering timbul setelah makanan; turun berat badan & terdapat nyeri tekan abdomen. Diare biasanya tidak berdarah.

Colitis ulcerative

Diare, dengan atau tanpa darah. Jika inflamasi terdapat di rektum (proktitis), darah dapat muncul di permukaan feses; gejala lain: tenesmus, urgensi, nyeri rektum, keluar mukus tanpa diare.

Disentri

Diare akut dengan BAB berdarah, tenesmus, demam.

IBS

Nyeri perut hilang dengan defekasi, hilang timbul, terkait stres, tidak ada kelainan anatomis.

Fauci et al. Harrison’s principles of internal medicine. 18th ed. McGraw-Hill; 2012.

19. Dislipidemia

19. Dislipidemia

19. Dislipidemia

20. Lung Disease • Bronchiectasis: – Major causes: obstruction & infection – Bronchial obstruction  impaired clearing mechanisms  pooling of secretions distal to the obstruction & airway inflammation – Bronchiectasis causes severe, persistent cough; expectoration of foulsmelling, sometimes bloody sputum; dyspnea and orthopnea in severe cases; and occasional life-threatening hemoptysis. – Paroxysms of cough are particularly frequent when the patient rises in the morning, when changes in position lead to drainage of collections of pus and secretions into the bronchi.

Robbins & Cotran pathologic basis of disease. 8th ed. Philadelphia: Saunders; 2010.

20. Lung Disease • Bronchiectasis – Treatment of infectious bronchiectasis is directed at the control of active infection and improvements in secretion clearance and bronchial hygiene so as to decrease the microbial load within the airways and minimize the risk of repeated infections. – Antibiotic Treatment • Antibiotics targeting the causative or presumptive pathogen (with Haemophilus influenzae and P. aeruginosa isolated commonly) should be administered in acute exacerbations, usually for a minimum of 7–10 days. – Bronchial Hygiene • The numerous approaches employed to enhance secretion clearance in bronchiectasis include hydration and mucolytic administration, aerosolization of bronchodilators and hyperosmolar agents (e.g., hypertonic saline), and chest physiotherapy. Harrison’s principles of internal medicine. 18th ed. McGraw-Hill; 2011.

20. Lung Disease • Are bronchodilators of use in bronchiectasis? – It seems appropriate to assess patients with airflow obstruction for reversibility to b2 agonist and anticholinergic bronchodilators and to institute therapy where lung function or symptoms improve on therapy. – Methylxanthines have no routine role in bronchiectasis.

• Are inhaled corticosteroids a useful treatment for bronchiectasis? – Inhaled steroids should not be used routinely in children with bronchiectasis (outside of use for those patients with additional asthma). – In adults, current evidence does not support routine use of inhaled corticosteroids in bronchiectasis (outside of use for those patients with additional asthma).

• Leukotriene receptor antagonists and other anti-inflammatory agents – There is no evidence for a role for leukotriene receptor antagonists or other anti-inflammatory drugs in bronchiectasis.

21. Endokarditis Infektif

21. Endokarditis Infektif • Clinical Manifestations: – Persistent bacteremia: fever, weight loss, anorexia, night sweat, fatigue – Valvular/perivalvular infection: murmur, CHF, conduction abnormality – Septic emboli – Immune complex phenomena: arthritis, glomerulonephritis, ESR 

21. Endokarditis Infektif

21. Endokarditis Infektif

22. TB

Suspek TB paru Pemeriksaan dahak sewaktu-pagi-sewaktu

BTA: + + + / + + -

BTA: + - -

BTA: - - -

Antibiotik spektrum luas, nonOAT, nonkuinolon Tidak ada perbaikan Foto toraks & pertimbangan dokter

ada perbaikan

Pemeriksaan dahak mikroskopis BTA: ≥ 1+

BTA: - - -

Foto toraks & pertimbangan dokter

TB

Bukan TB Pelatihan DOTS. Departemen Pulmonologi & Ilmu Kedokteran Respirasi FKUI; 2008.

23. Hypertension

23. Hypertension • Hypertension crisis: – Suddenly elevated blood pressure (systole ≥180 mmHg or diastole ≥120 mmHg) in hypertensive patient, which needs immediate treatment. – Emergency hypertension: target organ damage (+). BP should be decreased in minutes/hours. – Urgency hypertension: target organ damage (-). BP should be decreased in 24-48 hours.

Ringkasan eksekutif krisis hipertensi. Perhimpunan hiperensi Indonesia.

24. Angina

25. Intoksikasi Organofosfat • Organofosfat menghambat enzim esterase, terutama asetilkolinesterase di sinaps dan membran eritrosit.

• Inhibisi asetilkolinesterase  akumulasi asetilkolin & overstimulasi reseptor asetilkolin di sistem saraf otonom, SSP, & neuromuscular junctions  DUMBELS. • DUMBELS: diarrhea, urination, miosis, bradycardia/bronchorea/ bronchospasm, emesis, lacrimation, salivation.

• Terapi: atropin. Tanda atropinisasi: muka merah, mulut kering, takikardi, Midriasis Review article: Allergic rhinitis management pocket reference 2008. Journal compilation 2008 Blackwell Munksgaard. Allergy 2008: 63: 990–996.

25. Intoksikasi Organofosfat

26. Asma

26. Asma

26. Asma Moderate Episode

Severe Episode

27. TB-HIV • TB is the most common cause of death in HIV & increase progresivity of AIDS. • The problems in TB-HIV: – TB drugs & ARV have overlapping side effects – Drug interaction between TB drugs & ARV – Paradoxal therapy (immune reconstitution inflammatory syndrome/IRIS): worsening symptoms (fever, lymph node enlargement, infiltrate) after receive TB drugs /ARV/both which are not caused by therapeutic failure, but caused by reactivation of immune system to TB antigen.

27. TB-HIV • Principles of medication: – TB medication is a priority – Do not give TB drugs & ARV simultaneously because of drugs interaction, toxicity, & IRIS – In life threatening case (disseminated TB or CD4 60years), no gender predilection 75% of all parotid tumours

B) Warthin's tumour • Over 60 years Male to female ratio is 4:1

2. Carcinomas • Acinic cell Carcinoma: Low grade malignancy – Overall 5-year survival is 82%, and 10-year survival is 68%

• Adenoid Cystic carcinoma – may remain quiescent for a long time fatal due to perineural spread, pulmonary metastasis – Overall 5-year survival is 35%, and 10-year survival is approximately 20%

• Malignant mixed tumors – Overall 5-year survival is 56%, and 10-year survival is 31% • Adenocarcinoma and Squamous Cell Carcinoma – Both have poor prognosis5 year survival is 25%

• Mucoepidermoid carcinoma – most common malignant tumor Low grade and high grade

38. Massa pada Skrotum DICTUM FOR ANY SOLID SCROTAL SWELLINGS • All patients with a solid, Firm Intratesticular Mass that cannot be Transilluminated should be regarded as Malignant unless otherwise proved.

Scrotal ultrasound • Ultrasonography of the scrotum is a rapid, reliable technique to exclude hydrocele or epididymitis or cancer • basically an extension of the physical examination. • Hypoechoic area within the tunica albuginea is markedly suspicious for testicular cancer.

Cystic lesionepidermoid cyst

PRINCIPLES OF TREATMENT • Transscrotal biopsy is to be condemned.

• The inguinal approach permits early control of the vascular and lymphatic supply as well as en-bloc removal of the testis with all its tunicae. • Frozen section in case of dilemma.

Yolk Sac Tumor (Endodermal Sinus Tumor) • Most common testicular tumor in children 10 % ( < 10 tahun / > 50 tahun ). • LB derajat II > 20 % ( 10 – 50 tahun ) • LB derajat II > 30 % ( 10 – 50 tahun )ICU • LB yang mengenai : wajah, leher, mata, telinga, tangan, kaki, sendi, genitalia. • LB derajat III > 5 %, semua umur.

• LB Listrik / Petir dengan kerusakan jaringan dibawah kulit • LB Kimia / Radiasi / Inhalasi dengan penyulit. • LB dengan penyakit Penyerta. • LB dengan Trauma Inhalasi

http://emedicine.medscape.com/article/1277360-overview#showall

Indikasi resusitasi cairan • American Burn Association

• Unit Luka Bakar RSCM

– LB derajat II > 10 % ( < 10 tahun / > 50 tahun ). – LB derajat II > 20 % ( 10 – 50 tahun )

– LB derajat II > 10 % ( < 10 tahun / > 50 tahun ). – LB derajat II > 15% ( 10 – 50 tahun )

• Cairan RL 4cc x BB (Kg)x % luas luka bakar (Baxter) dibagi 8 jam pertama dan 16 jam berikutnya http://emedicine.medscape.com/article/1277360 SOP Unit Pelayanan Khusus Luka Bakar RSUPNCM 2011

41. Medial Epicondylitis (golfer’s elbow)

• Penggunaan berlebihan otot dan tendon yang berada di lengan dan siku – melakukan gerakan berulang-ulang seperti berkebun, mencangkul, memalu

• Nyeri saat menekuk pergelangan tangan dan menggenggam

Tennis Elbow

42. The Breast Tumors

Onset

Feature

Breast cancer

30-menopause

Invasive Ductal Carcinoma , Paget’s disease (Ca Insitu), Peau d’orange , hard, Painful, not clear border, infiltrative, discharge/blood, Retraction of the nipple,Axillary mass

Fibroadenoma mammae

< 30 years

They are solid, round, rubbery lumps that move freely in the breast when pushed upon and are usually painless.

Fibrocystic mammae

20 to 40 years

lumps in both breasts that increase in size and tenderness just prior to menstrual bleeding.occasionally have nipple discharge

Mastitis

18-50 years

Localized breast erythema, warmth, and pain. May be lactating and may have recently missed feedings.fever.

Philloides Tumors

30-55 years

intralobular stroma . “leaf-like”configuration.Firm, smooth-sided, bumpy (not spiky). Breast skin over the tumor may become reddish and warm to the touch. Grow fast.

Duct Papilloma

45-50 years

occurs mainly in large ducts, present with a serous or bloody nipple discharge

Nipple Discharge 1. Galactorrhea 2. Intraductal papilloma 3. Duct ectasia 4. Carcinoma

Oral Contraceptive • Penggunaan kontrasepsi oral yang lama tidak menyebabkan terjadinya papiloma intraduktal • Long term use of OCs >8 years  pronounced protective effect against benign breast disease (oliveira 1995) • Young women with BRCA1or BRCA2 mutations who have used oral contraceptives may have an increased risk of breast cancer the same may be true for young women with a family history of breast cancer (Marchbanks 2002) • Associated with an increased risk of cervical intraepithelial neoplasia (CIN) and cervical cancer (Cogliano 2006)

43. Labiognatopalatoshisis • Celah pada bibir, gusi dan langitan • RULE OF TEN : – Berat badan 10 lb (5 kg) – Usia 10 minggu – Kadar hemoglobin darah 10 g/dL

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

http://www.scribd.com/doc/55885689/labio-gnato-palatoschisis

• Cleft palate • the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined • The soft palate is in these cases cleft as well • Cleft lip • formed in the top of the lip • a small gap or an indentation in the lip (partial or incomplete cleft) • continues into the nose (complete cleft) • due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate)

44. Maxillofacial Fracture

Nasal Fractures • Dapat disertai dengan cedera yang lebih luas – Orbital rim or floor – Ethmoid or frontal sinuses

• Gejala dan tanda: – – – – –

Nyeri Bengkak Epistaxis Lacerations Respiratory Obstruction

45. Male Breast Cancer • Massa payudara pada laki-laki jarang terjadicuriga ganas sampai dibuktikan tidak – Mayoritas Ca mamae pada pria (50% to 97%) memiliki gejala klinis adanya massa pada payudara  biasanya timbul di dekat puting sebagai massa yang keras dan tidak nyeri, lebih sering melibatkan KGB – Karakteristik massa dapat seperti pada kanker payudara pada wanita

• Biasanya timbul setelah usia 65 thn • Faktor risiko: – – – –

Ginekomastia Kanker prostat Terekspos radiasi Memiliki penyakit yang berkaitan dengan kadar estrogen yang tinggi seperti sirosis atau sindrome klinefelter – Memiliki riwayat penyakit keluarga kanker payudara, terutama bila memiliki gen BRCA2

• Bila terdapat keragu-raguanbiopsi jarum atau operasi • Sindrom Klinefelter meningkatkan kecenderungan untuk ganas • Pemeriksaan penunjang dan tatalaksanasama sepert pada wanita

Gynicomastia • Hipertrofi jaringan payudara normal pada priaJaringan payudara dan duktus-duktusnya – pubertal hypertrophy (ages 13–17), senescent hypertrophy (age >50) – Dikaitkan dengan obat terapetik atau rekreasional:digoxin, thiazides, estrogens, phenothiazines, theophylline marijuana – Dapat berkaitan dengan penyakit genetiksindrome klinefelter • Gejala dan tanda: – Pembesaran payudara unilateral atau bilateral – Palpasi: jaringan payudara yang homogen

http://www.cancer.gov/cancertopics/pdq/treatment/malebr east/Patient/page1/AllPages

46. The Breast Tumors

Onset

Feature

Breast cancer

30-menopause

Invasive Ductal Carcinoma , Paget’s disease (Ca Insitu), Peau d’orange , hard, Painful, not clear border, infiltrative, discharge/blood, Retraction of the nipple,Axillary mass

Fibroadenoma mammae

< 30 years

They are solid, round, rubbery lumps that move freely in the breast when pushed upon and are usually painless.

Fibrocystic mammae

20 to 40 years

lumps in both breasts that increase in size and tenderness just prior to menstrual bleeding.occasionally have nipple discharge

Mastitis

18-50 years

Localized breast erythema, warmth, and pain. May be lactating and may have recently missed feedings.fever.

Philloides Tumors

30-55 years

intralobular stroma . “leaf-like”configuration.Firm, smooth-sided, bumpy (not spiky). Breast skin over the tumor may become reddish and warm to the touch. Grow fast.

Duct Papilloma

45-50 years

occurs mainly in large ducts, present with a serous or bloody nipple discharge

Pemeriksaan Radiologis Payudara • USG Mamae – Tujuan utama USG mamae adalah untuk membedakan massa solid dan kistik – Sebagai pelengkap mamografi

pemeriksaan

klinis

dan

– Merupakan pemeriksaan yang dianjurkan untuk wanita usia muda (