Protap Penyakit

CARDIOPULMONOLOGI ABSES PARU Nekro Ne krosis sis jar jaring ingan an par paru u yan yang g ber berisi isi pus kar karena ena pen penyum yumbat batan an bronkus. DIAGNOSIS Keluhan pokok : • • •

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Terdapat riwayat aspirasi. Demam 1-3 mgg disertai menggigil. Batuk Batu k prod produkti uktif, f, barb barbau au busu busuk, k, puru purulent lent,, kuni kuning ng kehi kehijaua jauan n atau hemoptisis masif. Dyspnu, nyeri dada, malese, berat badan merosot.

Tanda penting : Higiene mulut buruk. Tampak sianosis. Clubbing finger/toes. Redup pada daerah abses. Tanda lain seperti pneumoni. Takikardi, takipnu. Pemeriksaan khusus : Diagnosis dg foto dada, tampak air fluid level. CT scan, bronkosko bronkoskopi. pi. Aspirasi jarum transtoracal. • • • • • •

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KOMPLIKASI Hemoptisis Pneumothoraks Pneumotho raks atau pyopneumotho pyopneumothoraks. raks. Metastasis abses. Kerusakan paru permanen. • • • •

PENATALAKSANAAN Istirahat Istir ahat postu postural ral drai drainage nage (pos (posisiny isinya a sedem sedemikian ikian rupa sehing seh ingga ga let letak ak abs abses es leb lebih ih tin tinggi ggi dar darii sal salura uran n nap napas as sehingga pus dapat mengalir keluar. Draina Dra inase se dap dapat at ju juga ga dil dilaku akukan kan dg bro bronko nkosko skopi pi unt untuk  uk  menyedot meny edot sekresi bronkus yg kenta kental. l. Disam Disamping ping itu juga menepuk-nepuk bagian yg kena abses. Obat pertama : anti antibioti biotik k yg sesuai, Ampicilin Ampicilin 1-2 juta unit/4-6 jam, Klindamisin 600 mg iv/8 jam, kemudian lanjut peroral. Obat alternatif : dapat juga diberi bronkodilator. bronkodilator. Operasi Oper asi untuk abses besar, bila abses terletak terletak sebe sebelah lah distal dis tal dar darii car carcin cinoma oma bro bronku nkus s ata atau u cor corpus pus ali alienu enum m dilakukan lobektomi. •

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Infark myocard akut. PROGNOSIS Dengan antimikroba yg sesuai prognosis baik.

PENATALAKSANAAN Mengh Me nghind indari ari / men mengat gatasi asi fak fakto tor r res resiko iko : die diet, t, ro roko kok, k, DM,hipertensi, dll. Waktu serangan : Nitrogliserin sublingual sublingual 0,3 - 0,6 mg. Penc Pe nceg egah ahan an se sera rang ngan an : Is Isos osor orbi bid d / di dini nitr trat at,, sa sale lep p nitrogli nitr ogliserin serin,, penghamba pengh ambatt betaadrene betaa drenergik, rgik, anta antagonis gonis kalsium dianjurkan diltiazem atau verapamil. ASMA BRONCHIALE Penyempita Peny empitan n jalan napas yang reversibel reversibel dalam waktu sing singkat kat oleh ol eh kar karena ena mu mukus kus ken kental tal,, spa spasme sme dan ede edema ma mu mukos kosa a ser serta ta deskuamasi epitel bronkus / bronkiolus, akibat inflamasi eosinofilik  dg kepekaan berlebihan. •

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ANGINA PECTORIS Merupa Meru paka kan n ra rasa sa ny nyer erii / ti tida dak k en enak ak di dida daer erah ah ja jant ntun ung g at atau au substernal subst ernal (chest disco discomfor mfort), t), teru terutama tama dipac dipacu u oleh kegia kegiatan tan  jasmani atau stres, akan mereda bila istirahat atau makan nitrat sublingual. Dapat pula menjalar sampai ke leher dan lengan kiri. Secara klinis dibagi mjd : Exertional angina : terjadi setelah kegiatan jasmani. Variable Vari able threshold threshold angin angina a : terja terjadi di bila ada perge pergeraka rakan n pembuluh pembu luh darah (vasomotion), (vasomotion), dapa dapatt munc muncul ul sewak sewaktu tu istirahat. Prinzmetal (variant) angina : hanya muncul waktu isirahat, terutama pagi / subuh hari. Unstable angina : awitan baru atau bila nyeri meningkat walaupun walau pun kegi kegiatan atan jasmani sanga sangatt mini minim m bahka bahkan n wakt waktu u iistirahat, berlangsung lama dan respons kurang terhadap pengobatan. • •

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DASAR KELAINAN Penyempitan pembuluh darah A. coronaria (iskemik myocard).

DIAGNOSIS Keluhan pokok : Sesak napas, batuk. Dada terasa terikat yang datang secara tiba-tiba, terutama oleh suatu fc pencetus (trigger). Diluar serangan keluhan hilang. Ada riwayat alergi dalam keluarga. Tanda penting : Otot-otot pernapasan membesar. Terdengar mengik, ekspirasi memanjang. Udara pernapasan menurun. Pemeriksaan laboratorium : Dalam spiral ditemukan : Spiral Spir al Chur Churschma schman n (ceta (cetakan kan muku mukus s dala dalam m salur saluran an napas kecil). Kristal Charcot Leyden (kristal romboid memanjang berasal dari sitoplasma eosinofil). • •

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DIAGNOSIS Keluhan pokok : Nyerii prec Nyer precardia ardiall selama 15-20 menit, sesak napas, cape capek k dan keringat dingin. Tanda penting : Umumnya normal kecuali tanda dari faktor resiko.

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Istirahat, hindari alergen. Oksigen 1-3 l/mnt melalui kanula hidung. Penderita rawat jalan (outpatients) : Bronkodil Bron kodilator ator,, simpa simpatomim tomimetik etik (salb (salbutamo utamoll / albu albutero teroll /ventolin, metaproterenol / alupent, epinefrin / adrenalin), antikolinergik (ipratropium (ipratropium bromide / atrovent), Teofilin (teofilin, aminophylin) aminophylin).. Kort Ko rtik ikos oste tero roid id : pred pr edni niso son n / meti me till pred pr edni niso solo lon, n, hydrocortison sodium succinat, budesonide inhalasi. Antimediator : sodium kromolin (intal), sodium nedokromil 4-10 > kuat kromolin, antileukotrin. Antimikroba. Ekspektoran tanpa antihistamin. Penderita rawat inap (inpatients) : Nebulasi Nebu lasi ß2 agon agonis is (met (metopro oproteren terenol ol 0,3 ml laru larutan tan 5%, albuterol albut erol 0,5 ml lart 5%). Bila 30 meni menitt belu belum m memb memberi eri respons, dosis yang sama diulangi. Inhalasi kromolin 4x2 semprotan/hr. Inhalasi Inha lasi ipat ipatropiu ropium m brom bromide ide (atro (atrovent) vent) 2-4 sempr semprotan otan/6 /6  jam. Aminofilin IV, di USA tdk digunakan lagi. Bila sulit menggunakan inhalasi dapat diberikan terbutalin subkutan sampai 3 dosis, @ 0,25 mg setiap 60-90 mnt. Kortikos Kort ikostero teroid id IV diber diberikan ikan dala dalam m keada keadaan an gawa gawat. t. Dosis hidrocort hidro cortison ison 4 mg/k mg/kgbb, gbb, metil metilpredn prednisolo isolon n 1-2 mg/k mg/kgbb gbb setiap 6 jam. •

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Bila penyebabnya bakteri, sputumnya akan spt nanah. Ronki kering.

KOMPLIKASI Bronkopneumoni, Bronkopneu moni, pneumoni, pleuritis. Penyakit Peny akit lain akan diperberat diperberat seper seperti ti jant jantung, ung, peny penyakit akit  jantung rematik, rematik, hipertensi, bronkiektasis. bronkiektasis. • •

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PROGNOSIS Umumnya baik. Asma As ma ek ekst stri rins nsik ik se sema masa sa ke keci cill pr prog ogno nosi sis s le lebi bih h dibanding yang muncul setelah dewasa. Angka kematian meningkat bila tanpa fasilitas kesehatan • •

baik  ba ik 

PENATALAKSANAAN Istirahat dan bebas rokok.  Jika etiologinya virus diberi obat simptomatis dan bakteri diberikan antibiotik spt ampicilin, erythromicin, spiramicin, 3 x 500 mg/hr. • •

PROGNOSIS Baik. BRONKITIS KRONIS Hipersekresi mukus bronkus bronkus dan penyumbatan jalan napas. DIAGNOSIS Keluhan pokok : Batuk lama. Tanda penting : Kalau lanjut terdengar ronki kering atau basah. Ada beberapa bentuk yaitu : Pink Puffing (PP) = tipe A = tipe empisema : tampak merah muda, orangnya sangat kurus, batuk, kor pulmonale, sesak  napas. Blue Bloating Bloating Bronchitis Bronchitis (BB) = tipe B = tipe bron bronkiti kitis s : tampak tam pak sia siano nosis sis,, ora orangn ngnya ya gem gemuk, uk, bat batuk, uk, kel kelema emaha han n  jantung, umumnya umumnya tidak sesak. Bronkitis Asmatika. Bronkiti Bro nkiti kron kronis is seder sederhana hana : batu batuk k lama dengan sputum •

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PENATALAKSANAAN Tujuan Tuju an untu untuk k meng mengatasi atasi hipe hipersekr rsekresi esi bron bronkus, kus, sumba sumbatan tan jala jalan n napas, infeksi bronkus, kor pulmonale, gagal napas. Istirahat, stop rokok. Ekspektor Ekspe ktoran an bila batu batuk k berda berdahak, hak, antitusif bila batu batuk  k  kering. Bronkodilator. Sesak beri O2. Bila ada infeksi (sputum mukopurulen) diberi antimikroba. Kalau terjadi cor pulmonale diberi digoksin.

PENATALAKSANAAN Istirahat stop rokok. Pemilihan antibiotik berdasarkan pemeriksaan sputum dan bakteri, sementara menunggu hasil pemeriksaan sputum diberikan dibe rikan juga anti antibiot biotik ik spekt spektrum rum luas (dok (doksisik sisiklin) lin),, antibiotika distop bila sputum kurang kurang atau tidak purulent purulent lagi. Bronkodilator. Operasi dilakukan bila pengobatan selama 2 tahun kurang menunjukkan perbaikan, timbul hemoptisis yg masif.

PROGNOSIS Sering kambuh.

PROGNOSIS Sulit sembuh sempurna. Tergantung pada : banyaknya kerusakan, sputum yang purulen, adanya komplikasi

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BRONKIEKTASIS Terjadi Terja di pele pelebaran baran abnormal abnormal dan mene menetap tap dari bronkus akibat kerusakan keru sakan komp komponen onen elast elastis is dan musk muskulern ulernya. ya. Bron Bronkiekt kiektasis asis kongen kon genita itall (tr (trias ias Kar Kartag tagene ener) r) : Bro Bronki nkiekt ektasi asis, s, Dek Dekstr strok okard ardi, i, SInusitis. DIAGNOSIS Keluhan pokok : Batuk produktif berupa darah / nanah, berjumlah banyak  terutama jam 2 sampai 3 dinihari dan disebut Maulvolle Expectoration. Sering disertai : panas, anoreksi, anemi, malese, palpitasi, gelisah, hemoptisis. Tanda penting : Sputum dan napas berbau tidak enak. Ronki basah sedang sampai kasar didaerah yg terkena. Kadang-kadang didengar ronki kering dan bunyi mengik.  Jantung dan trakea tertarik ke tempat yg terkena.  Jari tabuh. Pemeriksaan laboratorium : •

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EDEMA PARU Tertimbunnya cairan dalam jaringan interstitiel paru dan alveoli akibat akib at penin peningkata gkatan n tekan tekanan an hydro hydrostati statik k atau ataupun pun perm permeabil eabilitas itas kapiler paru. DIAGNOSIS Keluhan pokok : Sesak napas tiba-tiba, biasanya nocturnal, ortopneu. Keringat dingin, batuk produktif (kemerahan). Hemoptisis, lemah. Tanda penting : Sianosis, DVS meningkat, stupor, koma. Takipneu, takikardi. Mengik (wheezing), ronki basah kedua basal paru. Pemeriksaan laboratorium : Analisa gas darah dan elektrolit. Foto dada : • • •

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Obat pertama : Nitr Ni trog ogli lise seri rin n subl su blin ingu gual al/i /iv v : 0,30, 3-0, 0,5 5 mg/k mg /kgb gbb b atau at au nitroprosit : 15 mikrogram per menit sampai ada perbaikan atau hipotensi. Ditingkatkan tiap 5 menit, maksimal 400 mcg/mnt. Morfin Sulfat 3-5 mg iv/15 mnt, total 15 mg. Furosemid Furo semid 40-80 mg iv, dosis dina dinaikka ikkan n setel setelah ah 4 jam, dilanjutkan dengan dengan drips sampai produksi urine cukup 1 ml/kg/jam. Obat alternatif : Vasodilator. Inotropik 

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PROGNOSIS Tergantung penyakit dasar dan penanggulangan penanggulangan.. EFUSI PLEURA (PLEURITIS EXUDATIVA) Tertimbunnya cairan dalam cavum pleura DIAGNOSIS Keluhan pokok : Dari asimptomatis sampai sesak napas berupa : Nyeri dada, sesak napas. Batuk-batuk, panas. Lebih senang tidur / baring kearah satu sisi (sisi yg berisi cairan). Keluhan tsb tgtg dari jumlah dan jenis cairan, kalau banyak atau purulen keluhan lebih berat. Tanda penting : Pada sisi yg sakit : Dinding dada lebih cembung dan gerakan tertinggal. Vocal fremitus melemah. Pekak, Peka k, bata batasnya snya meru merupakan pakan garis leng lengkung kung dari media mediall bawah ke lateral atas disebut garis Ellis Damoiseau. • • •

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Obat per Obat pertam tama a : Tu Tuber berku kulos lostat tatika ika (um (umumn umnya ya EF mrp komplikasi TB), antibiotika bila ada infeksi. Obatt alt Oba altern ernati atiff : ter terapi api sim simpto ptomat matis, is, pre predni dnison son,, bil bila a cairannya caira nnya cukup banyak dan dise disebabka babkan n oleh tb paru paru,, enzym proteolitik, roborantia. Punksi pleura (torakosentesis) kalau cairan masif, jangan lebih dari 1000-1500 cc tiap kali punksi, jika ada empyema dipasang WSD.

PROGNOSIS Tergantung pada penyakit dasarnya. Prognosi Pro gnosis s buru buruk k pd efusi pleur pleura a berat terutama terutama pH atau kadar gula cairan rendah. • •

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EMFISEMA Pelebaran Pele baran dan destr destruksi uksi sinus alveo alveoli, li, sehin sehingga gga udar udara a masu masuk  k   jaringan interstitiel interstitiel paru. DIAGNOSIS Keluhan pokok : Trias emfisema : batuk-batuk, sputum banyak, sesak napas. Tanda penting : Inspeksi Dada berbentuk tong (barrel chest). Sela iga melebar. Perkusi Sonor, hipersonor. Pekak absolut jantung mengecil. Auskutasi Ronki bila disertai bronkitis. Bunyi pernapasan melemah. Pemeriksaan laboratorium : Kapasitas paru total meningkat. • •

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Kor pulmonale.

PENATALAKSANAAN Penicilin G dosis tinggi 6-12 juta unit/hr. Ampicilin / Amoksisilin 3-4x(500-1000) mg/hr. Erythromicin 3-4x500 mg/hr. Sefalosforin dosis sesuai jenis preparat. Kotrimoxazole Kotrimoxazo le 2x(1-2) tablet. • •

PENATALAKSANAAN Istirahat stop rokok. Bronkodil Bron kodilator ator : Teof Teofilin ilin 10-15 mg/k mg/kgbb gbb peroral peroral,, Beta 2 Agonis peroral atau nebulizer Corticost Cort icosteroid eroid,, ekspe ekspektor ktoran, an, muko mukolitik litik,, kuran kurangi gi sekresi sekresi mukus. • •

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PROGNOSIS Prognosis dipengaruhi oleh : Umur Bnayaknya lobus yg terkena. Renjatan septik. Gagal napas. Mulai Mu lainya nya ter terapi api ant antibi ibioti otik, k, seb sebelu elum m mas masa a ant antibi ibioti otik  k  mortalitas 33%, sesudah ada antibiotik menjadi 5%. Gagal jantung, gagal ginjal. •

PROGNOSIS Pada Pad a usi usia a mu muda da pro progno gnosis sis leb lebih ih bur buruk, uk, pada usi usia a leb lebih ih tua prognosis lebih baik.

PNEUMONIA Kerusakan jaringan parenkim paru oleh infeksi. DIAGNOSIS Keluhan pokok : Demam menggigil, menggigil, batuk dg sputu sputum m puru purulen, len, sakit dada dada,, berat badan menurun. Tanda penting : Takikardi, pernapasan cepat / alanasi. Herpes labialis. Bunyi krepitasi, bunyi gesekan pleura. Bunyi pernapasan bronkial dan whispering pectoriloquy. Vocal fremitus mengeras pada sisi sakit. Pekak relatif pada sisi sakit. Pemeriksaan laboratorium : Darah : lekositosis. Sputum Spu tum : ku kuman man pen penyeb yebabn abnya ya (su (sulit lit dip diperc ercaya aya seb sebab ab banyak kontaminasi). Foto dada tampak infiltrat • • • • •

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PNEUMOTHORAKS Adanya udara dalam cavum pleura. DIAGNOSIS Keluhan pokok : Ada riwayat aktivitas. Sakit dada, sesak napas, keringat dingin, batuk kering. Tanda penting : Iktus cordis terdorong ke arah paru yg sehat. Trakea terdorong ke arah paru yg sehat. Pada sisi yg sakit : pergerakan hemithoraks terbatas, sela iga (ICS) cembung, vocal fremitus melemah, pada perkusi terdengar bunyi hipersonor atau timpani pada sisi yg sakit, bunyi bun yi per pernap napasa asan n mel melema emah, h, dia diafra fragma gma ter terdor dorong ong ke bawah. • •

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Pneumothoraks tertutup yang berat. Pneumothoraks Istirahat di RS. Obat simptomatis, laksansia. Tindakan khusus : ♦ Pneumothor Pneumothoraks aks terbuka : Pengisapan udara terus menerus dg alat pnu. Melekatkan kedua pleura dg penyuntikan larutan glukose 40-50%, 40-50 %, 40-5 40-50 0 cc atau bedak talk yang steril ke dalam cavum pleura. ♦ Pneumothor Pneumothoraks aks ventil : Dipasang WSD. • •

Tanda penting : Ronki kering / basah, suara pernapasan melemah, waktu ekspirasi memanjang, udara pernapasan kurang. Pemeriksaan laboratorium : Foto dada •

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Bia fistel sudah tertutup diisap dg pompa / alat pnu. Bila pasien berada di luar RS, tusukkan jarum yg besar. Tindakan operasi (thoracotomi) dilakukan bila : Pneumothoraks Pneumothora ks kambuh. • •

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KOMPLIKASI Bronkitis akut, pneumoni, emboli paru, korpulmona korpulmonale, le, pneumothoraks, pneumothor aks, hemoptisis. •

PENATALAKSANAAN Istirahat stop rokok, fisioterapi dada. Bronkodilator Bronkodilato r : Teofilin. Antikolinergik Antikoliner gik : Ipratropium bromida (atrovent). Beta Be ta 2 ago agonis nistt : Alb Albute uterol rol,, Bit Bitolt oltero erol, l, Iso Isopre preter tereno enol, l, Terbutalin. • • • •

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Pemeriksaan laboratorium : Kortisol serum rendah. ACTH tinggi.

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Operasi tumo Operasi tumor r hypo hypofisis fisis (pen (penyaki yakitt Cush Cushing) ing) dan adren adrenal al (syndrom Cushing).

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PENATALAKSANAAN Istirahat. Hidrocortison Hidrocortiso n 20 mg pagi, 1 0 mg sore. • •

PROGNOSIS Tergantun Terga ntung g peny penyebabn ebabnya, ya, tanpa terapi dapa dapatt semb sembuh, uh, denga dengan n operasi prognosis lebih baik.

PROGNOSIS Kaheksi.

DIABETES INSIPIDUS Kekurangan hormon hormon ADH (DI Sentral) atau ginjal tidak berespons berespons terhadap ADH (DI Nefrogenik).

CUSHING SYNDROME Akibat Aki bat pen pening ingkat katan an ho hormo rmon n glu glukok kokor ortic ticoi oid d / co corti rtisol sol.. Bil Bila a penyebabnya akibat adenoma hipofisis, sekresi ACTH meningkat disebut Penyakit Cushing. DIAGNOSIS

DIAGNOSIS Keluhan pokok : Poliuri (2-40 ltr/hr) dan polidipsi tiba-tiba. Penderita Pend erita tahu tang tanggal gal bahk bahkan an jam terja terjadinya dinya peristiwa peristiwa tersebut. • •

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Pada tahap awal ditemukan tiga poli (3p atau 3 banyak) yaitu poliuria (banyak kencing), polidipsi (banyak minum), polifagi (banyak makan). Lemah, berat badan merosot. Fluor albus / keputihan. Pada tahap lanj lanjut ut ditem ditemukan ukan rasa kesem kesemutan utan,, kuli kulitt rasa panas, impotensi, gatal-gatal, visus menurun, sering bisul atau luka yang tida tidak k mau sembuh, gigi mudah goyah, keguguran, anak lahir besar. Tanda penting : Umumnya sulit ditemukan pada tahap awal. Kelainan lanjut : tanda garukan dikulit, katarak, bisul-bisul, TB paru. Pemeriksaan laboratorium : GDP sama / lebih 126 mgr%, gula darah 2 jam post prandial lebih >200 mgr%. Reduksi urine positif. •

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Gemuk : RBW >110 Gemuk >110% % Obesitas : RBW >120% Contoh seorg ps DM berat 50 kg, tinggi 150 cm, maka RBW = 50/( 50/(150-10 150-100) 0) x 100% = 100% 100%,, bera berarti rti masuk kate kategori gori normal, jadi kebutuhan kalori = 50 (berat) x 30 (normal) = 1500 kal. Medik Me dikame amento ntosa, sa, gol golon ongan gan sul sulfon fonilu ilurea rea : Dia Diaben benese ese,, Amaryl, Diamicron, Euglucon, Daonil, Glurenorm. Diberikan 15 menit sebelum makan. Golongan Golo ngan bigu biguanida anida : Diabe Diabex, x, Metf Metformin ormin,, Gluc Glucopha ophage. ge. Kedua Ke dua gol golon ongan gan ini ter termas masuk uk Oba Obatt Hip Hipog oglik likemi emik k Ora Orall (OHO). Akarb Ak arbose ose (Ce (Cepob pobay) ay) dib diber erika ikan n ber bersam sama a den dengan gan sua suap p pertama tiap makan. Umumnya 3 x 1 tab/hr. Repaglinide (Novonorm), diberikan setiap sebelum makan utama.

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Koma Nonketotik Hiperglkemik  Biasanya Biasa nya terj terjadi adi perla perlahan han bebe beberapa rapa hari atau ming minggu, gu, keluhan berupa loyo, poliuria dan polidipsi. Tanda-tanda berupa dehidrasi, stupor, konvulsi dan koma, tanda pernapasan Kussmaul (cepat dan dalam). Tindakan yang perlu dilakukan segera rawat inap RS, atasi dehidrasi dehid rasi dg laru larutan tan gara garam m fisio fisiologi logis, s, beri insulin mulai dosis dos is ren rendah dah,, kal kalau au dap dapat at den dengan gan pom pompa pa ins insuli ulin n IV, pemberian kalium seperti pada komaketoasi komaketoasidosis dosis diabetik, monitor gula darah. •

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DIABETES MELLITUS GESTATIONAL (DMG) Intoleransi karbohydrat yang terjadi pertama kali diketahui pada saat hamil.

Sekresii ho Sekres hormo rmon n per pertum tumbuh buhan an (gr (grow owth th ho hormo rmone) ne) men mening ingkat kat abnormal abno rmal sebel sebelum um dewa dewasa sa (giga (gigantism ntisme) e) atau sebel sebelum um epifi epifisis sis tertutup (akromegali) DIAGNOSIS Keluhan pokok : Akibat penekanan tumor (makro adenoma) : Sefalgi. Gangguan penglihatan : hemianopsi bitemporal, skotoma atau buta. Kejang-kejang, keluar banyak keringat. Keluhan-keluhan Keluhan-keluh an DM. Tanda penting : Produksi GH meningkat (mikro adenoma). Gangguan pertumbuhan tulang : Bentuk muka berubah (frontal bossing). Pertumbuhan gigi tidak rapat (prognatisme) dan maloklusi. • •

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DIAGNOSIS

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PROGNOSIS Tergantung pada : Lamanya proses berlangsung. Besarnya tumor. Tingginya kadar GH preoperatif. • • •

Gangguan fungsi seks (libi Gangguan (libido do menu menurun), run), erek ereksi si kura kurang ng kuat. Amenore, kelemahan. Daya tahan terhadap stres menurun. Kurang subur. Mual muntah, hipotensi orthostatik. Sudut mata bergetar halus / ringan. Tanda penting : Bulu axilla hilang, bulu pubis hilang, tensi menurun. Pemeriksaan laboratorium : Free Thyroxine (FT4) rendah. Testosteron darah turun. Pemeriksaan khusus : Pemindaian CT (Computerized Tomography scan). Magnetic Resonance Imaging (MRI) •

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GOITER ENDEMIK  Kekurangan diet jodium. DIAGNOSIS Keluhan pokok : Keluhan Kelu han pembe pembesaran saran kelen kelenjar jar seper seperti ti disfa disfagi, gi, gang gangguan guan pernapasan. Kelenjar tiroid membesar selama hamil. •

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LDH meninggi bila perjalanan penyakit progresif. Pemeriksaan khusus : Biopsi kelenjar. Biopsi sumsum tulang. CT scan / USG abdomen. Foto dada. •

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Nyeri tulan Nyeri tulang g (tida (tidak k selalu ada) terut terutama ama pada tung tungkai kai bawah. Perdarahan. Tanda penting : Anemia selalu ada, selanjutnya sangat berat. Splenomegali selalu ada, kadang sangat masif. Hepatomegali, penderita kurus. Tanda-tanda akibat hemopoeisis extrameduler : hipertensi pulmonal pulm onal,, obstr obstruksi uksi inte intestina stinall dan uret uretral, ral, hipe hipertens rtensii intracranial, tamponade jantung, tekanan medula spinalis, tanda tand a hiper hipertens tensii port portal al (asit (asites, es, varis varises es esofa esofagus, gus, gaga gagall hepar). •

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KOMPLIKASI Penekanan organ: jalan nafas, usus, s araf. Mudah kena infeksi. • •

PENATALAKSANAAN Istirahat, bila ditemukan tanpa keluhan tidak perlu terapi. Terapi umumnya bersifat paliatif. Obat pertama CHOP dan CEOP. CHOP:: Chor CHOP Chorambu ambucil cil 0,6-1 mg/k mg/kgbb gbb setiap 3 ming minggu gu atau kombinasi dg Siklofosfamid 750 mg/m² (permukaan tubuh) IV hari 1. Dokso Doksorubis rubisin in 50 mg/m² IV hari ke 1, Oncovin (Vincristin) 2 mg IV, Prednison 100 mg oral hr ke 1 sampai 5. CEOP: Cyclofosfamid dosis sama, Epirubisin 75 mg/m² IV hr pertama, Oncovin dosis sama, Prednison dosis sama hr 16. Transplantasi SST.

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PROGNOSIS Bila diagnosis patologis ditegakkan berarti stadium sudah lanjut. Setengahnya dapat hidup sampai 6-8 tahun. Dengan kombinasi terapi agresif respons sekitar 40-60%. •

Pemeriksaan laboratorium : Gambaran darah perifer : diagnosis myelofibrosis, trias : teardrop tear drop poikilocy poik ilocytosis tosis,, leukoeritr leuko eritrobla oblastik, stik, trom trombosit bosit raksasa abnormal. Anemia dapat sangat berat. Leko Le kosi sitt bisa bi sa re rend ndah ah,, norm no rmal al at atau au ti ting nggi gi sa samp mpai ai 50.000/mm³.  Jumlah trombosit trombosit bervariasi. LDH dan alkalifosfatase serum naik. Pemeriksaan khusus : Aspirasi Aspi rasi sumsum tula tulang ng : fibro fibrosis, sis, hipe hiperselu rseluler ler denga dengan n retikulin reti kulin atau fibro fibrosis sis kola kolagen, gen, kada kadang-ka ng-kadang dang dry tap (hasil aspirasi nihil). Tes Te s kh khus usus us : pe peng ngec ecat atan an pe pera rak k un untu tuk k me mend ndet etek eksi si peningkatan serabut retikulin. •

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KOMPLIKASI Gagal sumsum tulang, organomegali. Infeksi organ dalam (paru). Berkembang ke lekemi akut. Fever of unknown origin. •

MYELOFIBROSIS Fibros Fib rosis is sum sumsum sum tul tulang ang aki akibat bat pen pening ingkat katan an sek sekres resii pla platel telet et derived growth factor (PDGF). Sebagai respons terjadi hemopoeisis

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PROGNOSIS 50% meninggal dalam 5 tahun. Fase terakhir: kelemahan umum, gagal hepar, perdarahan. Beberapa menjadi lekemia mieloblaster akut. MULTIPEL MYELOMA Prolifera Prol iferasi si sel plas plasma, ma, prod produksi uksi para paraprot protein ein yang berle berlebihan bihan akibat keganasan sel plasma.

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DIAGNOSIS Keluhan pokok : Nyeri tulang : collumna vertebra, tulang iga, os femur. Syndrom Syndr om hiper hipervisko viskositas sitas : verti vertigo, go, nause nausea, a, gang gangguan guan penglihatan, perdarahan. Tanda penting : Umumnya pada orang tua >60 tahun. Anemis, pucat. Mungkin fraktur Collum femoris. Nyeri tulang dan massa jaringan. Neuropati. Pemeriksaan laboratorium : Preparat darah tepi: pembentukan rouleaux meningkat, sel plasma positif. Hiperkalsemi. Pemeriksaan khusus : Elektroforesis paraprotein: paraprotein: IgG, IgA, rantai pendek. Radiologi: bone survey: osteoporosis tulang-tulang. • •

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Lebih jelek bila diser disertai tai penin peningkata gkatan n parap paraprote rotein, in, gagal ginjal, hiperkalsemi, kerusakan banyak tulang. tulang. Keadaan ini diseb disebut ut low tumor burd burden, en, seten setengahny gahnya a meni meninggal nggal (median survival) dalam 5-6 th. Pada high tumor burden bila fraksi IgG >7 g/dl, hematocrit hematocrit 12 mg/dll atau lebih dari 3 tula mg/d tulang ng meng mengalam alamii oste osteopor oporosis, osis, median survival sekitar 1 tahun.

POLISITEMI Suatu keadaan yang ditandai oleh proliferasi yang berlebihan dari sel-sel eritrosit. Ada PS relatif dan absolut (sekunder dan primer = PS rubra vera = eritremi). DIAGNOSIS Keluhan pokok : Sefalgi, pusing, tinitus, penglihatan kabur. Capek, epistaksis, arthralgi (gout). Tanda penting : Wajah merah padam seperti orang marah. Pruritus, splenomegali. Pemeriksaan laboratorium : Hemoglobin tinggi, eritrosit tinggi. Hematocrit, lekosit dan trombosit juga diatas normal. Hyperurisemi. • •

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KOMPLIKASI Infeksi, gagal ginjal, amiloidosis. •

PENATALAKSANAAN Istirahat. Melpha Mel phalan lan (A (Alke lkeran ran)) 0,2 0,25 5 mg/ mg/kgb kgbb/h b/hr r + Pre Predn dniso ison n mg/kgbb/hr selama 4 hr, diulangi setiap 6 minggu.

PENATALAKSANAAN Istirahat. Flebotomi, pengeluaran darah sekitar 500 cc / mgg sampai hematocrit