seminar 1

SEMINAR OPTIMA LEARNING UKDI BATCH 2 (MEI) 2013 dr. Himawan, dr. Yusuf, dr. Cemara, dr. Dini, dr. Ratna, dr. Valenchia, dr. Rini, dr. Fatia

Ilmu Penyakit Dalam

1. Iron Therapy  Common adverse effects of oral iron therapy include nausea, epigastric discomfort, abdominal cramps, constipation, & diarrhea.

 These effects are usually dose-related & can often be overcome by lowering the daily dose of iron or by taking the tablets immediately after or with meals.

 Some patients have less severe gastrointestinal adverse effects with one iron salt than another and benefit from changing preparations.

 Cereals, cheese, coffee, eggs, milk, tea, whole grain breads, yogurt may impair oral iron absorption.

Katzung BG. Basic & clinical pharmacology. 10th ed. New York: McGraw Hill.

2. Urinary Tract Infection

2. Urinary Tract Infection

3. Lymphadenopathy 

EBV causes infectious mononucleosis, a benign, self-limited lymphoproliferative disorder, and is associated with the development of a number of neoplasms, (lymphomas & nasopharyngeal carcinoma).



Infectious mononucleosis is characterized by:  fever,  generalized lymphadenopathy (principally in the posterior cervical, axillary, and groin

   



regions), splenomegaly, sore throat, atypical activated T lymphocytes (mononucleosis cells). some people develop hepatitis, meningoencephalitis, pneumonitis.

Enlarged lymph nodes are frequently tender and symmetric but are not fixed in place.

Harrison‘s principles of internal medicine

3. Lymphadenopathy 

HTLV-I is the cause of at least two important diseases:  Acute T-cell leukemia (ATL)  tropical spastic paraparesis or HTLV-I-associated myelopathy (HAM).

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HTLV-I may also play a role in infective dermatitis, arthritis, uveitis, and Sjögren's syndrome.

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HTLV-I infection is transmitted in at least three ways:  from mother to child, especially via breast milk;  through sexual activity, more commonly from men to women; and  through the blood.



Four clinical types of HTLV-I-induced neoplasia:  Acute Adult T-cell Leukemia (ATL)  Lymphomatous ATL  Chronic ATL  Smoldering ATL

Harrison‘s principles of internal medicine

3. Lymphadenopathy  Acute ATL:  short clinical prodrome (2 weeks between the first symptoms and the diagnosis) & an aggressive natural history.  The clinical picture is dominated by rapidly progressive skin lesions, pulmonary involvement, hypercalcemia, and lymphocytosis.

 Lymphomatous ATL:  similar to the acute form in its natural history & clinical course, except that circulating abnormal cells are rare & lymphadenopathy is evident.

Harrison‘s principles of internal medicine

3. Lymphadenopathy  Chronic ATL  generally have normal serum levels of calcium and lactate dehydrogenase and no involvement of the CNS, bone, or gastrointestinal tract.

 Smoldering ATL  In this form, the malignant cells have monoclonal proviral integration; 3,5 g/day Hypoalbuminemia Edema Hypercholesterolemia

 Treatment:    

Protein supplement Diuretics for edema Treat hyperlipidemia Na restriction (3.0 g/24 jam), hipoalbuminemia, hipertensi, hiperkolesterolemia,, edema/anasarka, & hematuria mikroskopik.

Harrison‘s principles of internal medicine. Pathophysiology of disease: an introduction to clinical medicine. 5th ed.

13. Renal Disorder Diagnosis

Characteristic

Acute glomerulonephritis

an abrupt onset of hematuria & proteinuria with reduced GFR & renal salt and water retention, followed by full recovery of renal function.

Rapidly progressive glomerulonephritis

recovery from the acute disorder does not occur. Worsening renal function results in irreversible and complete renal failure over weeks to months.

Chronic glomerulonephritis

renal impairment after acute glomerulonephritis progresses slowly over a period of years & eventually results in chronic renal failure.

Nephrotic syndrome

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.

Pathophysiology of disease: an introduction to clinical medicine. 5th ed.

14. Reid‘s Classification Bronchiectasis 

Cylindrical bronchiectasis:  Bronchi enlarged and cylindrical in shape  Normal tapering of airway as it traverses to the periphery is not present  Distal airways end abruptly, owing to mucus plugging  Fewer generations of bronchi than normal  Parallel tram-track lines are seen on CXR or CT scan  CT cross-section views reveal 'signet ring' appearance of the dilated bronchus and its accompanying vessel.

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Varicose bronchiectasis:  Irregular bronchi, with alternating dilation and constriction  Bronchographic pattern resembles varicose veins.



Saccular or cystic bronchiectasis:  Most severe form  Commonly found in cystic fibrosis patients  Bronchi are dilated, forming a cluster of round air-filled or fluid-filled cysts  Only 25% of the normal number of bronchial subdivisions  Degree of bronchial dilation increases proximal to distal  Bronchial tree ends in blind sacs.

http://bestpractice.bmj.com/best-practice/monograph/1007/basics/classification.html

15. Antihypertensive Drugs

15. Antihypertensive Drugs Some -sympatholytics possess higher affinity for cardiac  1-receptors than for  2-receptors and thus display cardioselectivity (e.g., metoprolol, acebutolol, bisoprolol). None of these blockers is sufficiently selective to permit its use in asthma or DM

16. Komplikasi Tuberculosis  Komplikasi tb:  Batuk darah  Pneumotoraks  Luluh paru  Gagal napas  Gagal jantung  Efusi pleura

17. Dengue Hemorrhagic Fever

18. ECG

19. Asthma

19. Asthma

19. Asthma Moderate Episode

Severe Episode

20. Liver Disease

20. Liver Disease 

Acute viral hepatitis occurs after an incubation period that varies according to the responsible agent.



The prodromal symptoms of acute viral hepatitis are systemic and quite variable. Constitutional symptoms of anorexia, nausea and vomiting, fatigue, malaise, arthralgias, myalgias, headache, photophobia, pharyngitis, cough, and coryza may precede the onset of jaundice by 1–2 weeks.

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Dark urine and clay-colored stools may be noticed by the patient from 1–5 days before the onset of clinical jaundice.

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With the onset of clinical jaundice, the constitutional prodromal symptoms usually diminish, but in some patients mild weight loss (2.5–5 kg) is common and may continue during the entire icteric phase.



The liver becomes enlarged and tender and may be associated with right upper quadrant pain and discomfort.

21. STEMI

Lilly LS. Pathophysiology of heart disease. 5th ed. Lipincott Williams & Wilkins; 2011.

22. DM Complications

23. Degenerative Disease  Since OA is a mechanically driven disease, the mainstay of treatment involves altering loading across the painful joint and improving the function of joint protectors, so they can better distribute load across the joint. Ways of lessening focal load across the joint include 1. avoiding activities that overload the joint, as evidenced by their causing pain; 2. improving the strength and conditioning of muscles that bridge the joint, so as to optimize their function; and 3. unloading the joint, either by redistributing load within the joint with a brace or a splint or by unloading the joint during weight bearing with a cane or a crutch.

24. PEA 

PEA encompasses a heterogeneous group of organized electric rhythms that are associated with either absence of mechanical ventricular activity or mechanical ventricular activity that is insufficient to generate a clinically detectable pulse.



Drug Therapy for PEA/Asystole  A vasopressor can be given as



soon as feasible with the primary goal of increasing myocardial and cerebral blood flow during CPR and achieving ROSC Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit.

25. Tuberculosis

26. Rifampin Adverse Reactions  Rifampin imparts a harmless orange color to urine, sweat, tears, and contact lenses (soft lenses may be permanently stained).

 Occasional adverse effects include rashes, thrombocytopenia, and nephritis.  It may cause cholestatic jaundice and occasionally hepatitis.  Rifampin commonly causes light-chain proteinuria.  If administered less often than twice weekly, rifampin causes a flu-like syndrome characterized by fever, chills, myalgias, anemia, and thrombocytopenia and sometimes is associated with acute tubular necrosis.

 Rifampin strongly induces most cytochrome P450 isoforms (CYPs 1A2, 2C9, 2C19, 2D6, and 3A4), which increases the elimination of methadone, anticoagulants, cyclosporine, some anticonvulsants, protease inhibitors, some nonnucleoside reverse transcriptase inhibitors, contraceptives, and a host of others.

27. Hepatitis A Prophylaxis  When administered before exposure or during the early incubation period, IG is effective in preventing clinically apparent hepatitis A.

 For postexposure prophylaxis of intimate contacts (household, sexual, institutional) of persons with hepatitis A, the administration of 0.02 mL/kg is recommended as early after exposure as possible; it may be effective even when administered as late as 2 weeks after exposure.

 Prophylaxis is not necessary for:    

those who have already received hepatitis A vaccine, casual contacts (office, factory, school, or hospital), most elderly persons, who are very likely to be immune, or those known to have anti-HAV in their serum. Harrison‘s principles of internal medicine. 18th eds.

27. Hepatitis B Prophylaxis • Three IM injections of hepatitis B vaccine are recommended at 0, 1, and 6 months for pre-exposure prophylaxis against hepatitis B in settings of frequent exposure:  health workers exposed to blood;  hemodialysis patients and staff;  residents and staff of custodial institutions for the developmentally handicapped;  injection drug users;  inmates of long-term correctional facilities;  persons with multiple sexual partners;  persons such as hemophiliacs who require long-term, high-volume therapy with blood derivatives;  household and sexual contacts of HBsAg carriers;  persons living in or traveling extensively in endemic areas;  unvaccinated children under the age of 18; Harrison‘s principles of internal medicine. 18th eds.

28. Infective Endocarditis

28. Infective Endocarditis  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 

Lilly LS. Pathophysiology of heart disease. 5th ed. Lipincott Williams & Wilkins; 2011.

29. Dyspepsia  Advice for patient with dyspepsia:  Avoiding fatty foods (which can slow the emptying of the stomach)  Eating small, frequent meals. Instead of three large meals, eat five or six small meals  Avoiding food that make feel worse.

UpToDate.com

30. Lupus Nephritis  Lupus nephritis affects up to 50% of SLE patients. The principal mechanism of injury is immune complex deposition in the glomeruli, tubular or peritubular capillary basement membranes, or larger blood vessels.

30. Lupus Nephritis

31. Acute Coronary Syndrome

32. Dyspepsia Lokasi Nyeri

Anamnesis

Pemeriksaan Fisis

Nyeri epigastrik Kembung

Membaik dgn makan (ulkus duodenum), Memburuk dgn makan (ulkus gastrikum)

Tidak spesifik

Nyeri epigastrik menjalar ke punggung

Gejala: mual & muntah, Demam Penyebab: alkohol (30%), batu empedu (35%)

Nyeri tekan & defans, perdarahan retroperitoneal (Cullen: periumbilikal, Gray Turner: pinggang), Hipotensi Ikterus, Hepatomegali

Nyeri kanan atas/ Prodromal epigastrium (demam, malaise, mual)  kuning. Nyeri kanan atas/ Risk: Female, Fat, epigastrium Fourty, Hamil Prepitasi makanan berlemak, Mual, TIDAK Demam Nyeri epigastrik/ Mual/muntah, kanan atas Demam menjalar ke bahu/ punggung

Pemeriksaan Penunjang

Diagnosis

Terapi

Urea breath test (+): H. pylori Endoskopi: eritema (gastritis akut) atropi (gastritis kronik) luka sd submukosa (ulkus) Peningkatan enzim amylase & lipase di darah

Dispepsia

PPI: ome/lansoprazol H. pylori: klaritromisin+amok silin+PPI

Transaminase, Serologi HAV, HBSAg, Anti HBS Nyeri tekan USG: hiperekoik abdomen dgn acoustic Berlangsung 30-180 window menit Murphy Sign

USG: penebalan dinding kandung empedu (double rims)

Pankreatitis

Hepatitis Akut

Resusitasi cairan Nutrisi enteral Analgesik

Suportif

Kolelitiasis

Kolesistektomi Asam ursodeoksikolat

Kolesistitis

Resusitasi cairan AB: sefalosporin gen. 3 + metronidazol Kolesistektomi

33. Obesity

34. Rheumatic Fever  Acute rheumatic fever (ARF) is a multisystem disease resulting from an autoimmune reaction to infection with group A streptococcus.

35. 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.

35. Hypertension  Clinical manifestation of hypertension crisis:  Neurology: headache, blurred vision, convulsion, neurological    

deficit, unconsciousness. Eye: retinal hemorrhage, retinal exudate, edema papil. Cardiovascular: chest pain, lung edema. Renal: azotemia, proteinuria, oliguria. Obsteric: severe preeklampsia.

 Risk Factors:  noncompliance, pregnancy, drug abuse, high sympathetic stimulation (severe burn, pheochromocytoma, collagen disease, vascular disease, trauma)

Ringkasan eksekutif krisis hipertensi. Perhimpunan hiperensi Indonesia.

35. Hypertension  Management:  Management should be done in hospital, however primary care service can give oral antihypertension as a first aid.  Parenteral drug is given via bolus or infusion ASAP.  Drugs:  ACE-I (Captopril): sublingual 6,25-50 mg  Nicardipine 10-30 mcg/kgBW bolus.  Clonidine 900 mcg into 500 mL of 5% glucose infusion, given in 12 drops/minute.

Ringkasan eksekutif krisis hipertensi. Perhimpunan hiperensi Indonesia.

36. Urinary Tract Infection  Woman with symptoms of UTI (acute onset dysuria, frequency, or urgency)  No complicating conditions (if pregnant, known voiding abnormalities, co-morbid conditions -> complicated UTI)  No back pain (if present -> consider pyelonephritis)  No vaginal discharge (if present -> consider STD)  then > 90% probability of acute cystitis

 If history not clear  dipstick  Positive: 80% cystitis (consider tx for UTI)  Negative: 20% cystitis (dipstick not very specific so 1/5th of

these cases might still have real UTI – consider urine culture, close f/u, other diagnoses)

Bent S, et al. JAMA. 2002;287(20):2701-2710

37. Pemeriksaan Kesehatan Haji/Umrah  Pemeriksaan fisik, lab darah dan urine.

 Usia > 40 tahun: roentgen thoraks, GDS, kolesterol, LDL, & EKG.

 Usia > 60 tahun: indeks Barthel.

 Wanita usia subur: tes kehamilan  Vaksinasi: meningitis.

38. Rheumatic Heart Disease  ARF is exclusively caused by infection of the upper respiratory tract with group A streptococci.

Harrison‘s principles of internal medicine.

38. Rheumatic Heart Disease  Early valvular damage leads to regurgitation. Over ensuing years, usually as a result of recurrent episodes, leaflet thickening, scarring, calcification, and valvular stenosis may develop.

 40% of patients will develop mitral stenosis.

 An additional 25% will develop aortic stenosis or regurgitation in addition to the mitral abnormality.

 Infrequently, the tricuspid valve is affected as well. Lilly. Pathophysiology of heart disease.

39. Endemic Goiter  Endemic goiter:  occurs in geographic areas where the soil, water, and food supply    



contain low levels of iodine. The term endemic is used when goiters are present in more than 10% of the population in a given region. Such conditions are particularly common in mountainous areas The lack of iodine leads to decreased synthesis of thyroid hormone and a compensatory increase in TSH, leading to follicular cell hypertrophy and hyperplasia and goitrous enlargement. Variations in the prevalence of endemic goiter in regions with similar levels of iodine deficiency point to the existence of other causative influences, particularly dietary substances, referred to as goitrogens. The ingestion of substances that interfere with thyroid hormone synthesis at some level, such as vegetables belonging to the Brassicaceae (Cruciferae) family (e.g., cabbage, cauliflower, Brussels sprouts, turnips, and cassava), has been documented to be goitrogenic. Native populations subsisting on cassava root are particularly at risk. Cassava contains a thiocyanate that inhibits iodide transport within the thyroid, worsening any possible concurrent iodine deficiency.

40. Murmur & Heart Sounds

40. Murmur & Heart Sound

Lilly LS. Pathophysiology of heart disease.

40. Murmur & Heart Sound

41. Asthma 

Measurements of lung function enhance diagnostic confidence.

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Spirometry:  Airway obstruction:

 



FEV1/FVC 10 L of irrigation under pulsatile lavage Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition

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

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

88. 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

89. Trauma to Anterior Compartment of tibia • Action •

Ankle dorsiflexion

• Muscles • • • •

Tibialis Anterior Extensor Digitorum Longus Extensor Hallucis Longus Peroneus Tertius

• Vessels • Anterior Tibial A./V.

• Nerves • Deep Peroneal N.  1st webspace sensation

90. Obstruction Ileus The Universal Features Colicky abdominal pain, vomiting, constipation (absolute), abdominal distension. Complete HX ( PMH, PSH, ROS, Medication, FH, SH)

High •Pain is rapid •Vomiting copious and contains bile jejunal content •Abdominal distension is limited or localized •Rapid dehydration

Distal small bowel

Colonic

•Pain: central and colicky •Vomitus is feculunt •Distension is severe •Visible peristalsis •May continue to pass flatus and feacus before absolute constipation

• Preexisting change in bowel habit •Colicky in the lower abdomin •Vomiting is late •Distension prominent •Cecum ? distended

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

2. Examination General •Vital signs: P, BP, RR, T, Sat •dehydration •Anaemia, jaundice, LN •Assessment of vomitus if possible •Full lung and heart examination

Abdominal •Abdominal distension and it‘s pattern •Hernial orifices •Visible peristalsis •Cecal distension •Tenderness, guarding and rebound •Organomegaly •Bowel sounds –High pitched (metallic sound) –Absent

•Rectal examination

 Darm kontur: visible shape of intestines on the abdomen

 Darm Steifung: visible peristaltic movement on the abdomen

Others Systemic examination If deemed necessary. •CNS •Vascular •Gynaecological •muscuoloskeltal

Radiological Evaluation Normal Scout Always request: Supine, Erect and CXR Gas pattern:  

Gastric, Colonic and 1-2 small bowel

Fluid Levels:  

Gastric 1-2 small bowel

Check gasses in 4 areas: 1. 2. 3. 4.

Caecal Hepatobiliary Free gas under diaphragm

Rectum

Look for calcification Look for soft tissue masses, psoas shadow Look for fecal pattern

91. Pelvic Trauma

 Bladder Rupture (BR) in the setting of blunt trauma may be classified as extraperitoneal or intraperitoneal

 About 70–97% of patients with BR from blunt trauma have associated pelvic fractures

 The two most common sign and symptoms are gross haematuria (82%–100%) and abdominal tenderness (62%)

 The classic combination of pelvic fracture and gross haematuria constitutes an absolute indication for immediate cystography in blunt trauma victims

 Standard CT Is Not Reliable In The Diagnosis Of BR.

 Ct Cystography, However, When Properly Performed With 350 Cc Of Dilute (2%) Contrast Is An Excellent Substitute For Standard Cystography

T.H. Lynch et al. / European Urology 47 (2005) 1–15

http://emedicine.medscape.com/article/120034

92. Thyroid Enlargement (goiter)

 Abnormal enlargement of the thyroid gland and can occur for a number of different reasons

Multinodular Goiter

Diffuse Goiter

http://emedicine.medscape.com/article/120034

Toxic goiter

Classification

 associated with hyperthyroidism  Examples:  diffuse toxic goiter (Graves disease)  toxic multinodular goiter  toxic adenoma Nontoxic goiter

 Without hyperthyroidism or hypothyroidism  It may be diffuse or multinodular  Examples:  goiter identified in early Graves disease  endemic goiter  chronic lymphocytic thyroiditis (Hashimoto disease) Underactive (hypothyroid goiter)

93. Shoulder dislocation

Anterior Shoulder Subluxation/Dislocation  Dislocation:  Complete separation of articular surfaces

 Subluxation:  Abnormal translation of humeral head on glenoid without complete separation of articular surfaces

 Humeral head can dislocate anteriorly, posteriorly or inferiorly

 Anterior dislocation most common  Mechanism:  Forced extension, abduction, external rotation  Direct blow to posterior or posterolateral shoulder  Repeated episodes of overuse (subluxation)

Anterior Shoulder Subluxation/Dislocation  Physical Exam:  Intense pain  Arm held in abduction & external rotation  Humeral head palpable anteriorly  Unable to completely internally rotate or abduct the shoulder  Thorough neuro exam (close relation of axillary nerve)

Anterior Shoulder Subluxation/Dislocation  Radiographs:

Axillary View

True AP

Y view

94. 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

Nonoperative

Treatment

 Fracture reduction followed by application of a long leg cast with progressive weight bearing can be used for isolated, closed, lowenergy 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 patellabearing 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

Operative fracture management

 Operative treatment of displaced unstable tibia shaft fractures is the treatment of choice if it can be performed in facilities with the necessary equipment and skills

 Surgical treatment is necessary for open fractures (wound debridement), compartment syndromes, and repair of arterial injuries

Fiksasi Fraktur

* Aryadi K, Syaiful AH. Penggunaan Gips Paris. In: Petunjuk pemasangan gips paris pada kasus orthopaedi, Divisi Orthopaedi dan traumatologi, 2006. hal 2-6

Bidai /Splint adalah alat yang digunakan untuk mengimobilisasi bagian tubuh, alat tersebut dapat bersifat lunak ataupun kaku (rigid) • Plaster slab adalah lempengan gips untuk imobilisasi sendi atau daerah cidera sehingga terjadi penyembuhan. Sebagian besar fraktur dislab untuk 24-48 pertama untuk mengakomodasi pembengkakan, sebelum dipasang gips sirkuler.

• Lempengan Gips/CAST Dapat Digunakan Pada – Imobilisasi Fraktur – Imobilisasi pada penyakit tulang dan sendi – Pencegahan deformitas muskuloskeletal

Imobilisasi Fraktur

Temporer •Akomodasi pembengkakan

Definitif

Imobilisasi cedera ekstremitas bawah  Anterior Slab  Indikasi*:  ruptur tendon achilles (pascaoperasi).  Ruptur tendon flexor pedis.  ruptur muscle belly (flexor).

   

Gips 6 inch, 20 lapis. Posisi plantar fleksi 30-55 derajat. Dimulai dari setinggi kaput fibula sampai jari-jari kaki. Dipertahankan 4-6 minggu

McGarvey WC. Injuries of the foot and ankle In: Brinker Review of Orthopaedic Trauma. Ed Brinker MR, W.B. Saunders, 2001 p 153-80

 Posterior Slab  Indikasi*:  imobilisasi sementara untuk fraktur tibia (plateu, shaft, plafond), fraktur pergelangan kaki.  fraktur metatarsal.  ruptur tendon esktensor pedis.

   

Gips 6 inch, 8-12 lapis. Posisi plantigrade. Dimulai dari kaput fibula hingga jari-jari kaki Dipertahankan 4-6 minggu

Gorczyca JT. Tibial Shaft Fracture In: Brinker Review of Orthopaedic Trauma. Ed Brinker MR, W.B. Saunders, 2001 p 127-30. McGarvey WC. Injuries of the foot and ankle In: Brinker Review of Orthopaedic Trauma. Ed Brinker MR, W.B. Saunders, 2001 p 153-80

First aid for tibial fractures 

An important step in treating a tibia shaft fracture is promptly to realign the deformed leg and to splint it in corrected alignment.



Splinting can be done with two firm boards, or sticks alongside the leg, from above the knee to below the ankle



It is essential to apply padding between a splint and the injured leg. Any soft material such as clothing, blankets, etc. can be used as emergency padding.



The splints should then be kept together by bandages around both splints and the leg.



Additional stabilization can be achieved by splinting the fractured leg to the contralateral normal lower extremity



Any padded splintage is better than none, but circumferential wraps must not be so tightly applied that they interfere with blood flow

https://www2.aofoundation.org

95. 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 gram-positive bacilli

NOTE: Double zone of hemolysis

Inner beta-hemolysis = θ toxin Outer alpha-hemolysis = α toxin

96. Extrication

97 .

98. Zygomatic Fractures  Signs & Symptoms:  Pain  Mastication  speaking  Numbness of the cheek,

    

infraorbital region & upper teeth on injured side Eyelid swelling Inability to close mouth properly Swelling, Edema, Ecchymoses Flattened cheekbone Palpable depression at fracture site

Zygomatic bone complex  Anatomy Star-shape like with four processes

 Frontal process  Temporal process  Buttress  Orbital floor (Maxilla and GWSB)  Zygoma fracture often related with maxilla fractures Temporal fascia and muscle Masseter muscle 203

Nasal Fractures  May be associated with more extensive injuries  Orbital rim or floor  Ethmoid or frontal sinuses

 Signs & Symptoms:     

Pain Swelling Epistaxis Lacerations Respiratory Obstruction

99. Complication Thyroide Surgery  Hypoparathyroidism  the most common immediate surgical complication of total thyroidectomy  low blood levels of calcium hypocalcemia  Treatment: calcium gluconate IV

 Voice change  the recurrent laryngeal nerve lost voice  the external branch of the superior laryngeal nervecant yell  Temporary voice changes, such as mild hoarseness, voice tiring, and weakness  more than 6 months after the operation, they are likely to be permanent

http://endocrinediseases.org/thyroid/surgery_complications.sht

 Bleeding in the neck  can compress the windpipe and cause difficulty breathing

 Seroma  a fluid collection under the incision which feels like fullness or swelling

 Infection

ramsayhealth.co.uk

100. Posterior Hip Dislocation Symptoms • knee pain • pain in the back hip • difficulty moving the lower extremity • The leg is shortened and internally rotated with flexion and adduction at the hip Risk Factor • Accident • Improper seating adjustment • sudden break in the car netterimages.com

soundnet.cs.princeton.edu

101. Wrist Slitting

 Associated tendons  frequently superficial tendons  Central WristTendon m. Palmaris Longus (most superficial)  Lateral WristTendon m. Flexor Carpi Radialis  Deep cutProfunda tendons  Flexor Digitorum Superficial(FDS)  Flexor Digitorum Profunda(FDP)

 Median nerve sometimes injured‖ape hand‖

 The arteries are so small in the wrist; people rarely die from this type of suicide attempt

102. Scaphoid Fracture  The most common fracture after fall with outstretched hand

 Blood supplied from distal pole

 In children, 87% involve distal pole

 In adults, 80% involve waist

Imaging  Initial plain films often normal

 Bone scan 100% sensitive and 92% specific at 4 days

 MRI, CT scan

 TREATMENT  Initial radiographs positive  distal third heal in approx 6-8 weeks  middle third frx heal in 8-12 weeks  proximal third heal in 12-23 weeks

 Initial radiographs negative  Immobilize thumb spica cast x 714 days  Take out of cast, re-evaluate for tenderness  If +tenderness but neg radiographs….

103. Alvarado Score

104. Trauma patient

105. Chest X-Ray

The PA (posterioranterior) film is obtained with the patient facing the cassette and the x-ray tube 6 feet away

in the supine AP (anteriorposterior) position the x-ray tube is 40 inches from the patient

This is a PA film on the left compared with a AP supine film on the right. The AP shows magnification of the heart and widening of the mediastinum. Whenever possible the patient should be imaged in an upright PA position. AP views are less useful and should be reserved for very ill patients who cannot stand erect.

106. 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