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)
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WA/LINE 082122727364
 ILMU
P E N YA K I T
DALAM
 1. Toksisitas Statin
• Peningkatan ringan creatine kinase (CK) di plasma dijumpai pada sebagian pasien yang mendapat
statin, terutama terkait dengan aktivitas fisik berat.

• Faktor risiko miopati akibat statin:

– Usia >70 tahun
– Perempuan
– Dosis terapi > 1,5 kali dosis maksimum
– Gangguan fungsi hati/ginjal (creatinine clearance < 30 mL/min/1.73 m2
– Berat badan rendah

• Terapi dapat dilanjutkan pada pasien yang asimtomatik jika aminotransferase diawasi dan stabil.

• Jika timbul nyeri otot, nyeri tekan, atau kelemahan otot, maka CK harus diperiksa & obat dihentikan
jika aktivitas CK meningkat signifikan di atas nilai rujukan.

Basic & clinical pharmacology. 10th ed.

Considerations for Safe Use of Statins: Liver Enzyme Abnormalities and Muscle Toxicity. Am Fam Physician. 2011 Mar 15;83(6):711-716.
1. Toksisitas Statin
 2. Karsinogenik
• Aflatoksin adalah racun dari jamur (mikotoksin)
yang dihasilkan oleh spesies Aspergillus flavus &
sebagian strain Aspergillus parasiticus.

• Pada tahun 1998, International Agency for

Research on Cancer memasukkan aflatoksin B1
dalam daftar karsinogen karena terakit dengan
karsinoma hepar.

• Manusia terpajan aflatoksin dari kacang-

kacangan/polong yang terkontaminasi jamur.

• FDA membolehkan adanya sedikit kandungan

aflatoksin dalam produk kacang karena
kontaminasi tidak bisa dihindari & konsumsi yang
sedikit diyakini memiliki risiko yang kecil.
Aspergillus flavus
3. Hiperkalsemia

Pathophysiology of disease. 7th ed. 2014.

Klasifikasi Penyebab Hiperkalsemia

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

3. Hiperkalsemia

Pathophysiology of human disease.

• Primary hyperparathyroidism
– excessive production and release of PTH by the parathyroid glands, may be
caused by adenoma, hyperplasia, or carcinoma.

• Secondary hyperparathyroidism
– The overproduction of parathyroid hormone secondary to a chronic abnormal
stimulus for its production. Typically, this is due to chronic renal failure or
vitamin D deficiency.

• Tertiary hyperparathyroidism
– An excessive secretion of parathyroid hormone after longstanding secondary
hyperparathyroidism & resulting in hypercalcemia.
– Is observed most commonly in patients with chronic secondary
hyperparathyroidism and often after renal transplantation.
– The hypertrophied parathyroid glands fail to return to normal and continue to
oversecrete parathyroid hormone, despite serum calcium levels that are
within the reference range or even elevated
http://emedicine.medscape.com/article/127351-overview#a4
 4. Neuropati Diabetik
• Jenis-jenis neuropati diabetik:
– Peripheral neuropathy (the most common)
• Causes pain or loss of feeling in the toes, feet, legs, hands, and arms.
• Numbness or insensitivity to pain or temperature, a tingling, burning,
or prickling sensation, sharp pains or cramps, extreme sensitivity to
touch, even light touch, loss of balance and coordination.
– Autonomic neuropathy
• Causes changes in digestion, bowel and bladder function, sexual
response, and perspiration.
– Proximal neuropathy
• Causes pain in the thighs, hips, or buttocks and leads to weakness in
the legs.
– Focal neuropathy
• results in the sudden weakness of one nerve or a group of nerves,
causing muscle weakness or pain.
• Any nerve in the body can be affected.

Diabetic Neuropathies: The Nerve Damage of Diabetes. National Diabetes Information Clearinghouse
 4. Neuropati Diabetik
• Medications used to help relieve diabetic nerve pain:
– Tricyclic antidepressants
• amitriptyline, imipramine, & desipramine
– Other antidepressants
• duloxetine, venlafaxine, bupropion, paroxetine, & citalopram
– Anticonvulsants
• pregabalin, gabapentin, carbamazepine, & lamotrigine
– Opioids & opioidlike drugs
• controlled-release oxycodone & tramadol

Diabetic Neuropathies: The Nerve Damage of Diabetes. National Diabetes Information Clearinghouse
 4. Neuropati Diabetik

Evidence-based guideline: Treatment of painful diabetic neuropathy. Report of the American Academy of Neurology, the American Association of
Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology 76 May 17,
2011.
 5. Anaphylactic
Shock

World Allergy Organization

anaphylaxis guidelines:
Summary
 5. Anaphylactic
Shock

World Allergy Organization

anaphylaxis guidelines:
Summary
 6. Prinsip Memulai Terapi Insulin
• In patients on sulfonylureas and metformin who are starting
insulin therapy, sulfonylureas are generally tapered and
discontinued, while metformin is continued. Part of the
rationale for combination metformin and insulin therapy is that
by suppressing hepatic glucose production, the patient can
retain the convenience of oral agents while minimizing total
insulin requirements and therefore the degree of
hyperinsulinemia.

Gallwitz, B., & Bretzel, R. G. (2013). How Do We Continue Treatment in Patients With Type 2 Diabetes When Therapeutic Goals Are Not Reached With
Oral Antidiabetes Agents and Lifestyle? Incretin versus insulin treatment. Diabetes Care, 36(Suppl 2), S180–S189. http://doi.org/10.2337/dcS13-2012
 7. Diabetes mellitus
• Sasaran pertama terapi hiperglikemia adalah mengendalikan glukosa
darah basal (puasa, sebelum makan).
• Insulin yang dipergunakan untuk mencapai sasaran glukosa darah basal
adalah insulin basal (insulin kerja sedang atau panjang).
• Insulin kerja menengah harus diberikan jam 10 malam menjelang tidur,
sedangkan insulin kerja panjang dapat diberikan sejak sore sampai
sebelum tidur.

Konsensus Pengelolaan dan Pencegahan Diabetes Mellitus Tipe 2 di Indonesia 2015

 7. Diabetes
• Jika GDP belum mencapai target (70-130 mg/dL), maka dosis dapat
dinaikkan 2 unit setiap 3 hari. Jika GDP masih di atas 180 mg/dL,
dosis dapat dinaikkan 4 unit setiap 3 hari.

• Insulin prandial diberikan untuk menurunkan kadar glukosa darah

setelah makan, ketika pemberian insulin basal & obat oral gagal
mencapai target.

• Insulin prandial diberikan pada porsi makan yang menaikkan

glukosa darah prandial tertinggi (glukosa darah 1-2 jam setelah
makan >160-180 mg/dL)
Terapi insulin pada pasien diabetes melitus. PERKENI 2011.
 7. Diabetes

Diabetes technology & therapeutics Volume 13, Supplement 1, 2011

 8. Kelainan Elektrolit
• Hiperkalemia dengan manifestasi kelainan pada EKG harus
dianggap kegawatdaruratan medik yang perlu ditangani segera.

• Namun, pasien dengan hiperkalemia signifikan (6,5-7 mM) tanpa

kelainan EKG juga perlu ditangani dengan agresif karena
keterbatasan perubahan EKG sebagai prediktor toksisitas jantung.

• Penatalaksanaan segera hiperkalemia meliputi, rawat RS,

pemantauan jantung, & pengobatan segera.

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

 8. Kelainan Elektrolit
• Manifestasi klinis:
– Aritmia: sinus bradikardia, slow
idioventricular rhythms, VT, VF, &
asistol.
– Kelemahan otot (“rubbery” or
“spaghetti” legs).
– Pada hiperkalemia berat, gagal napas
dapat terjadi karena paralisis diafragma.

• Walaupun temuan EKG umumnya

berkorelasi dengan derajat
hiperkalemia, progresivitas efek jantung
dari ringgan sampai berat bisa tidak
terprediksi & tidak berkorelasi baik
dengan perubahan kadar Kalium.

Comprehensive Clinical Nephrology. 5th ed. 2015.

 8. Kelainan Elektrolit
• Tatalaksana hiperkalemia dibagi tiga tahap:
– Immediate antagonism of the cardiac effects of hyperkalemia.
• Ca meningkatkan potensial aksi & menurunkan eksitabilitas proteksi
jantung sementara tindakan lain dilakukan untuk koreksi hiperkalemia.

– Rapid reduction in plasma K+ concentration by redistribution into cells.

• Insulin menurunkan K+ dengan memasukkan K+ ke dalam sel.

– 2-agonists
• Albuterol memiliki efek aditif terhadap insulin, memasukkan K ke dalam sel.
• Dosis: 10–20 mg nebulized albuterol dalam 4 mL NaCL 0,9%, inhalasi selama
10 menit.

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

Comprehensive clinical nephrology. 5th ed. 2015.
 8. Hiperkalemia
• Kalium > 5,5 mmol/L
• Penurunan eksresi kalium
pada pasien CKD
• Tanda dan gejala:
iritabilitas otot dan saraf,
takikardia, diare,
perubahan EKG, aritmia
jantung, paralisis
 Analisis Soal
• Sebenarnya penanganan awal hyperkalemia tergantung pada ada/
tidaknya gangguan jantung akibat hyperkalemia.
– Ada gangguan jantung injeksi ca gluconas
– Tidak ada gangguan jantung obat-obat untuk menurunkan kalium
(misalnya insulin)

• Di soal tidak disebutkan ada tidaknya gangguan jantung. Namun

umumnya K>6,5 telah memberikan dampak pada irama jantung.
Oleh karena itu lebih dipilih jawaban ca gluconas.
 9. Tatalaksana Ulkus Diabetik
Kontrol Mekanik
Hindari tekanan & gunakan
bantalan untuk proteksi
Kontrol Luka
Debridemen/nekrotomi,
amputasi, balut luka
PERKENI: pedoman penatalaksanaan kaki diabetik, 2011.
Kontrol Metabolik Kontrol Vaskular
Perencanaan makan, kontrol Periksa ankle brachial indez,
glukosa, kontrol komorbiditas
transcutaneous oxygen
(ht, dislipidemia, ckd, anemia,
tension, toe pressure,
hipoalbuminemia, infeksi
penyerta) angiografi.
Kontrol Infeksi
Luka superfisial (tidak
sampai subkutan) AB utk
Gram (+). Kontrol Edukasi
Luka dalam AB utk Gram (-) Edukasi kondisi saat ini,
atau metronidazol utk
anaerob. rencana diagnosis,
terapi, serta prognosis.
Luka dalam, luas, gejala
sistemik AB yg mencakup
Gram (+), Gram (-), dan
anaerob.
 9. Tatalaksana Ulkus Diabetik
• Indikasi MUTLAK terapi insulin:
– DM tipe 1

• Indikasi RELATIF terapi insulin:

– Gagal mencapai target dengan antidiabetik oral dosis optimal
– DM tipe 2 rawat jalan dengan:
• Kehamilan
• Infeksi paru (tuberkulosis)
• Kaki diabetik terinfeksi
• Fluktuasi glukosa darah yang tinggi (brittle)
• Riwayat KAD berulang
• Riwayat pankreotomi

• Beberapa kondisi tertentu yang memerlukan insulin: penyakit hati kronik, gangguan fungsi
ginjal, & terapi steroid dosis tinggi.

PERKENI: terapi insulin pada pasien diabetes melitus, 2011.

10. Malignancy
• Multiple myeloma: a malignant proliferation
of plasma cells derived from a single clone.
• The classic triad of myeloma:
– marrow plasmacytosis (>10%),
– lytic bone lesions,
– serum and/or urine M component. "punched out" lesions represents
• In 20% of myelomas, only light chains are a purely osteolytic lesion with
produced and in most cases are secreted in little or no osteoblastic activity
the urine as Bence Jones proteins.
http://www.google.co.id/imgres?im
gurl=http://www.cancer.gov/images
/cdr/live/CDR763079750.jpg
10. Malignancy

Kriteria Diagnosis Multipel Mieloma

International Myeloma Workshop
Consensus Panel 3 Tahun 2011
 10. Malignancy
CLL CML ALL AML
The bone marrow makes abnormal leukocyte dont die when they
should crowd out normal leukocytes, erythrocytes, & platelets. This
makes it hard for normal blood cells to do their work.
Prevalence Over 55 y.o. Mainly adults Common in Adults &
children children
Symptoms & Grows slowly may Grows quickly feel sick & go to
Signs asymptomatic, the disease is found their doctor.
during a routine test.
Fever, swollen lymph nodes, frequent infection, weak,
bleeding/bruising easily, hepatomegaly/splenomegaly, weight loss,
bone pain.
Lab Mature Mature granulocyte, Lymphoblas Myeloblast
lymphocyte, dominant myelocyte t >20% >20%, aeur rod
smudge cells & segment may (+)
Therapy Can be delayed if asymptomatic Treated right away
CDC.gov
11. ACS
 12. Hepatitis
• Hepatitis Imbas Obat e.c. pirazinamid,
rifampisin, isoniazid.
• Bila klinis (+) (ikterik, mual/muntah) OAT
stop.
• Gejala (-), lab:
– Bilirubin >2x OAT stop
– SGOT, SGPT ≥5x OAT stop
– SGOT, SGPT ≥3x teruskan dengan pengawasan

Tuberkulosis: pedoman diagnosis dan penatalaksanaannya di Indonesia. PDPI

 12. Drug Induced Hepatits ec. OAT
(Pedoman Tb 2014)
• Apabila diperkirakan bahwa gangguan fungsi hati
disebabkan oleh karena OAT, pemberian semua OAT yang
bersifat hepatotoksik harus dihentikan.
• Pengobatan yang diberikan Streptomisin dan Etambutol
sambil menunggu fungsi hati membaik.
• Menghentikan pengobatan dengan OAT sampai hasil
pemeriksaan fungsi hati kembali normal dan keluhan
(mual, sakit perut dsb.) telah hilang sebelum memulai
pengobatan kembali.
• TB berat dan dipandang menghentikan pengobatan akan
merugikan pasien, dapat diberikan paduan pengobatan
non hepatatotoksik terdiri dari S, E dan salah satu OAT
dari golongan fluorokuinolon.
 12. Drug Induced Hepatits ec. OAT
(Pedoman Tb 2014)
• Apabila tidak bisa melakukan pemeriksaan fungsi hati, dianjurkan untuk
menunggu sampai 2 minggu setelah ikterus atau mual dan lemas serta
pemeriksaan palpasi hati sudah tidak teraba sebelum memulai kembali
pengobatan.
• Jika keluhan dan gejala tidak hilang serta ada gangguan fungsi hati berat,
paduan pengobatan non hepatotoksik terdiri dari: S, E dan salah satu
golongan kuinolon dapat diberikan (atau dilanjutkan) sampai 18-24 bulan.
• Setelah gangguan fungsi hati teratasi, paduan pengobatan OAT semula
dapat dimulai kembali satu persatu.
• Jika kemudian keluhan dan gejala gangguan fungsi hati kembali muncul atau
hasil pemeriksaan fungsi hati kembali tidak normal, OAT yang ditambahkan
terakhir harus dihentikan.
• Beberapa anjuran untuk memulai pengobatan dengan Rifampisin. Setelah
3-7 hari, Isoniazid dapat ditambahkan. Pada pasien yang pernah mengalami
ikterus akan tetapi dapat menerima kembali pengobatan dengan H dan R,
sangat dianjurkan untuk menghindari penggunaan Pirazinamid.
 12. Drug Induced Hepatits ec. OAT
(Pedoman Tb 2014)
• Paduan pengganti tergantung OAT apa yang telah menimbulkan gangguan fungsi
hati.
– Apabila R sebagai penyebab, dianjurkan pemberian: 2HES/10HE.
– Apabila H sebagai penyebab, dapat diberikan : 6-9 RZE.
– Apabila Z dihentikan sebelum pasien menyelesaikan pengobatan tahap awal, total
lama pengobatan dengan H dan R dapat diberikan sampai 9 bulan.
• Apabila H maupun R tidak dapat diberikan, paduan pengobatan OAT non
hepatotoksik terdiri dari : S, E dan salah satu dari golongan kuinolon harus
dilanjutkan sampai 18-24 bulan.
• Apabila gangguan fungsi hati dan ikterus terjadi pada saat pengobatan tahap
awal dengan H,R,Z,E (paduan Kategori 1), setelah gangguan fungsi hati dapat
diatasi, berikan kembali pengobatan yang sama namun Z digantikan dengan S
untuk menyelesaikan 2 bulan tahap awal diikuti dengan pemberian H dan R
selama 6 bulan tahap lanjutan.
• Apabila gangguan fungsi hati dan ikterus terjadi pada saat pengobatan tahap
lanjutan (paduan Kategori 1), setelah gangguan fungsi hati dapat diatasi,
mulailah kembali pemberian H dan R selama 4 bulan lengkap tahap lanjutan.
 13. Aritmia
• Sinus tachycardia is the most common rhythm disturbance and is
recorded in almost all patients with hyperthyroidism.
• However, it is atrial fibrillation that is most commonly identified
with thyrotoxicosis.
• The prevalence of atrial fibrillation in this disease ranges between
2% and 20%.

Thyroid Disease and the Heart. Circulation. 2007;116:1725-1735

 14. E.S. OAT Mayor
MAYOR Kemungkinan Penyebab HENTIKAN OBAT
Gatal & kemerahan Semua jenis OAT Antihistamin & evaluasi
ketat
Tuli Streptomisin Stop streptomisin
Vertigo & nistagmus Streptomisin Stop streptomisin
(n.VIII)
Ikterus Sebagian besar OAT Hentikan semua OAT
s.d. ikterik menghilang,
hepatoprotektor
Muntah & confusion Sebagian besar OAT Hentikan semua OAT &
uji fungsi hati
Gangguan penglihatan Etambutol Stop etambutol
Kelainan sistemik, syok Rifampisin Stop rifampisin
& purpura
Tatalaksana TB di Indonesia.
 14. E.S. OAT Minor
Minor Kemungkinan Tata Laksana
Penyebab
Tidak nafsu makan, Rifampisin OAT diminum malam
mual, sakit perut sebelum tidur
Nyeri sendi Pyrazinamid Aspirin/allopurinol
Kesemutan s.d. rasa INH Vit B6 1 x 100 mg/hari
terbakar di kaki
Urine kemerahan Rifampisin Beri penjelasan

1. Tatalaksana TB di Indonesia. 2. Physician drugs handbook

 15. Radiologi
• Kista hepar
– Umumnya asimtomatik, tetapi jika berukuran besar dapat
menimbulkan nyeri tumpul di abdomen kanan atas.
– Jika kista ruptur dapat timbul nyeri, demam, dan leukositosis.
– Gambaran radiologi: area bulat atau ovoid yang anekoik.

• Abses hepar
– Gejala klinis: nyeri dengan demam.
– USG: terutama hipoekoik & kadang hiperekoik.

Radiopedia.org
15. Abses hepar
• USG Abdomen
• Liver abscesses are typically
poorly demarcated with a
variable appearance,
ranging from
predominantly hypoechoic
(still with some internal
echoes however) to
hyperechoic.
• Gas bubbles may also be
seen
• Colour Doppler will
demonstrate absence of
central perfusion.
• Liver cyst
• round or ovoid anechoic
lesion, but almost
asymptomatic
16. Hepatitis B
• HBsAg (the virus coat, s= surface)
– the earliest serological marker in the serum.

• HBeAg
– Degradation product of HBcAg.
– It is a marker for replicating HBV.

• HBcAg (c = core)
– found in the nuclei of the hepatocytes.
– not present in the serum in its free form.

• Anti-HBs
– Sufficiently high titres of antibodies ensure
imunity.

• Anti-Hbe
– suggests cessation of infectivity.

• Anti-HBc
– the earliest immunological response to HBV
– detectable even during serological gap.
Principle & practice of hepatology.
Hepatitis B clinical course
Serologi Hepatitis B
 Tatalaksana
Hepatitis B
HBeAg (+)

Konsensus Nasional
Penatalaksanaan
Hepatitis B di Indonesia,
PPHI, 2012
 Tatalaksana
Hepatitis B
HBeAg (-)

Konsensus Nasional
Penatalaksanaan
Hepatitis B di Indonesia,
PPHI, 2012
 17. Tuberkulosis
• If the treatment is
inadequate or if host
defenses are impaired, the
infection may spread via
airways, lymphatic channels,
or the vascular system.

• Miliary pulmonary disease

occurs when organisms
draining through lymphatics
enter the venous blood &
circulate back to the lung.

Robbins & Cotran pathologic basis of disease. 8th ed. 2010.

 17. Tuberkulosis
• Snow storm appearance in chest
x-ray patient with miliary
tuberculosis.

• Miliary pulmonary disease

occurs when organisms draining
through lymphatics enter the
venous blood and circulate back
to the lung.

• Individual lesions are either

microscopic or small, visible (2-
mm) foci of yellow-white
consolidation scattered through
the lung parenchyma (the
adjective “miliary” is derived
from the resemblance of these
foci to millet seeds).

• Miliary lesions may expand and

coalesce, resulting in
consolidation of large regions or
even whole lobes of the lung
 17. Tuberkulosis
TB MILIER
• Rawat inap
• Paduan obat: 2 RHZE/ 4 RH

• Pada keadaan khusus (sakit berat), tergantung keadaan klinik, radiologik dan evaluasi pengobatan,
maka pengobatan lanjutan dapat diperpanjang sampai dengan 7 bulan 2RHZE/ 7 RH

• Pemberian kortikosteroid tidak rutin, hanya diberikan pada keadaan

– Tanda / gejala meningitis
– Sesak napas
– Tanda / gejala toksik
– Demam tinggi
• Kortikosteroid: prednison 30-40 mg/hari, dosis diturunkan 5-10 mg setiap 5-7 hari, lama pemberian 4
- 6 minggu.

Tuberkulosis: pedoman diagnosis dan penatalaksanaannya di Indonesia. PDPI

18. Metabolik Endokrin

Human Physiology
 18. Metabolik Endokrin
Sindrom Cushing
(hiperadrenokortikalism/hiperkortisolism)
– Kondisi klinis yang disebabkan oleh
pajanan kronik glukokortikoid
berlebih.

• Penyebab:
– Sekresi ACTH berlebih dari hipofisis
anterior (penyakit Cushing).
– ACTH ektopik (C/: ca paru)
– Tumor adrenokortikal
– Glukokorticod eksogen (obat)

Silbernagl S, et al. Color atlas of pathophysiology. Thieme; 2000.

McPhee SJ, et al. Pathophysiology of disease: an introduction to clinical medicine. 5th ed.
McGraw-Hill; 2006.
19. Acute Kidney Injury

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

 • disebabkan oleh berbagai kondisi yang
GGA prerenal menimbulkan hipoperfusi ginjal →
(~55%) penurunan fungsi ginjal tanpa ada
kerusakan parenkim yang berarti.

• Kerusakan langsung pada parenkim ginjal. Proses

inflamasi memegang peranan penting pada
patofisiologi GGA yang terjadi karena iskemia..
GGA renal • Obstruksi renovaskular
• Penyakit pada glomerulus atau pembuluh darah
(~40%) • Nekrosis tubular akut
• Nefritis interstitial
• Obstruksi intratubular

• Gangguan yang berhubungan dengan

obstruksi saluran kemih.
GGA postrenal • Obstruksi ureter
(~5%) • Obstruksi leher vesica urinaria
• Obstruksi urethra
19. Acute Kidney Injury
19. Acute Kidney Injury
19. Acute Kidney Injury
 Pembahasan Soal
• Pada soal didapatkan kadar ureum 160, sehingga nilai BUN =
80/2.14. didapatkan hasil 74.76. Dari hasil tersebut, maka
didapatkan rasio BUN/Cr adalah 74.76/5.8=12.88. Rasio
BUN/Cr <20:1 sesuai dengan acute tubular necrosis, yang
termasuk dalam AKI renal.
• Pada pasien ini, ATN terjadi karena adanya hipoperfusi ke ginjal
akibat adanya hipovolemia sehingga terjadi iskemia yang
mengakibatkan nekrosis pada tubulus ginjal.
• Pada aki prenal akan diapatkan rasio BUN/creatinin > 20:1.
20. Farmakologi
 20. Farmakologi
• Dosis awal untuk amlodipin adalah 2,5-5 mg per hari.

• Dosis kemudian disesuaikan dengan respon terapi dan

toleransi pasien setiap 7-14 hari.

• Dosis yang biasa diberikan per hari adalah 2,5-10 mg, dengan
dosis maksimum 10 mg/hari.
 21.Intoksikasi Logam Berat
• Symptoms related to mercury toxicity are typically neurologic, such
as the following:
– Visual disturbance - Eg, scotomata, visual field constriction
– Ataxia
– Paresthesias (early signs)
– Hearing loss
– Dysarthria
– Mental deterioration
– Muscle tremor
– Movement disorders
– Paralysis and death - With severe exposure
 Metal poisoning
Substance Source
Lead Smelting process of copper, zinc and lead
Manufacture of chemicals and glass
paints, rat poison, wood preservatives
Nickel occurs exclusively in nickel refineries due to
inhalation of nickel carbonyl, Ni(CO)4, being part of
the Mond process
Silver Silver mining, refining, silverware and metal alloy
manufacturing, metallic films on glass
electroplating solutions, photographic processing
Mercury Mining operations, chloralkali plants, paper
industries Thermometers, dental amalgam (fillings)
Cadmium Mining and smelting of lead and zinc
batteries, PVC plastics, paint pigments
Cadmium iodide is used in lithography,
photography
Silica Mining, Milling, Glass industry, sand blasting,
foundry, pottery making
Symptoms/disease
Acute encephalopathy, renal failure
and severe GI symptoms
Pneumonia
irreversible pigmentation of the skin
(argyria) and/or the eyes (argyrosis).
accumulate in the skin, liver, kidneys,
corneas
insomnia, forgetfulness, anorexia,
mild tremor
progressive tremor and erethism
Chronic exposure – progressive renal
tubular dysfunction
impairment of pulmonary function
Lung silicosis, pneumonitis, fibrosis
of lung
Chronic cough, may be asymptomatic
 22. Pneumonia
• Pulmonary infiltrate, with/without
signs of infection (e.g., fever)
one of the most common &
serious complications in patients
whose immune defenses are
suppressed by:
– disease,
– immunosuppressive therapy for
organ transplants,
– chemotherapy for tumors, or
– irradiation.

Robbins & Cotran pathologic basis of diseases

 22. Pneumonia
• CMV infection:
– Prominent intranuclear basophilic
inclusions spanning half the nuclear
diameter are usually set off from
the nuclear membrane by a clear
halo.
– In the lungs, the alveolar
macrophages. epithelial and
endothelial cells are affected;
– Affected cells are strikingly
enlarged, often to a diameter of 40
μm, and they show cellular &
nuclear pleomorphism.

Robbins & Cotran pathologic basis of diseases

 22. Pneumoniae
• Pneumocystis jiroveci/carini:
– dyspnea, fever, nonproductive
cough.
– tachypnea, tachycardia, and
cyanosis, but lung auscultation
reveals few abnormalities.
– CXR: bilateral diffuse infiltrates
beginning in the perihilar regions.
– definitive diagnosis is made by
histopathologic staining
methenamine silver selectively stain
the wall of Pneumocystis cysts.

Robbins & Cotran pathologic basis of diseases.

Harrison’s principles of internal medicine.
 22. Pneumonia
• Mycoplasmal pneumonia is a disease of gradual and insidious onset of several
days to weeks.

• A recent Cochrane Review determined that M pneumoniae cannot be reliably

diagnosed in children and adolescents with community-acquired pneumonia
based on clinical signs and symptoms.

• The patient's history may include the following:

– Fever, generally low-grade
– Malaise
– Persistent, slowly worsening, incessant cough. The cough ranges from non-productive to
mildly productive with sputum discoloration developing late in the course of the illness. The
absence of cough makes the diagnosis of M pneumoniae unlikely.
– Headache
– Chills but not rigors
– Scratchy sore throat
– Sore chest and tracheal tenderness (result of the protracted cough)
– Pleuritic chest pain (rare)
– Wheezing
– Dyspnea (uncommon)

http://emedicine.medscape.com/article/1941994-clinical
23. Penyakit Endokrin
Hipertiroidisme

Kumar and Clark Clinical Medicine

20.
Radioactive Iodine
23. Penyakit Endokrin
24. Syok
 24. Syok Kardiogenik

• Gangguan fungsi
ventrikel kiri
gangguan perfusi
oksigen ke jaringan
• Disebabkan oleh
infark miokard akut
• Hilangnya >40%
jaringan otot pada
ventrikel kiri
24. Syok Kardiogenik
 25. Gagal Jantung
ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure
in Adult

• Evaluasi laboratorium: DPL, urinalisis, elektrolit (termasuk Ca & Mg), ureum, kreatinin, GDP,
profil lipid, tes fungsi hati, dan TSH.

• EKG-12 lead & roentgen toraks (PA dan lateral) pada semua pasien.

• Ekokardiografi dengan Doppler untuk menilai fraksi ejeksi ventrikel kiri, ukuran ventrikel kiri,
ketebalan dinding jantung, & fungsi katup.

• Arteriografi koroner untuk pasien dengan angina atau iskemia, kecuali pasien tidak
memenuhi syarat untuk revaskularisasi.
 25. Gagal Jantung

• B-type Natriuretic Peptide (BNP) adalah hormon yang dihasilkan

oleh otot jantung ketika otot bilik (ventrikel) jantung meregang
atau mengalami tekanan. BNP berfungsi mengatur keseimbangan
pengeluaran garam dan air, termasuk mengatur tekanan darah.
BNP diproduksi sebagai pre-hormon yang disebut proBNP.
• Jika jantung, khususnya ventrikel kiri fungsinya terganggu, kadar
NT-ProBNP di dalam darah akan meningkat. Karena itu, NT-proBNP
digunakan sebagai penanda untuk deteksi gagal jantung.
 26. Tuberkulosis
Tipe Pasien Definisi
Baru Belum pernah/sudah pernah OAT <1 bulan
Kambuh/relaps Pernah sembuh atau OAT lengkap, kembali BTA +
Defaulted/drop out OAT >1 bulan, tidak mengambil obat ≥2 bulan
Gagal Telah berobat tapi BTA tetap + pada akhir bulan ke-5
Kronik BTA + dengan OAT kategori 2
Bekas TB BTA -, Ro: tidak aktif
Paduan Obat Tipe Pasien
Kategori 1: Pasien baru, TB paru BTA (-), TB ekstra paru.
2RHZE/4(RH)3
Kategori 2 Kambuh, gagal, default/drop out
2RHZES/RHZE/5(RHE)3
Kategori anak Anak dengan skor TB ≥6
2RHZ/4RH
Profilaksis anak Anak dengan kontak penderita TB BTA (+)
6INH 5-10 mg/kgBB
27. Artritis
27. Artritis
 27. Artritis

(1) Heberden nodes.

(2) Bouchard nodes.
(1) joint space narrowing, (2) osteophytes, and (3) joint
Osteoarthritis: Diagnosis and Treatment. destruction. Also note changes at carpometacarpal joint (4),
Am Fam Physician. 2012;85(1):49-56. which are very common in osteoarthritis.
 28. Arthritis
• Ankylosing spondylitis (AS)
– an inflammatory disorder of unknown
cause that primarily affects the axial
skeleton; peripheral joints and
extraarticular structures are also
frequently involved.

• Characteristic:
– Inflammatory back pain in young adults.
– The pain worsens with rest, improves
with activity, and is accompanied by
morning stiffness that lasts 30 minutes
or longer
– Radiographic demonstration of
sacroiliitis.
– Association with anterior uveitis.
– Increased relative risk conferred by
inheritance of HLA-B27. Bamboo spine is a radiographic feature seen
– Positive family history. in ankylosing spondylitis that occurs as a result
of vertebral body fusion by marginal
syndesmophytes.
 Ciri OA RA Gout SA

Perevalens

Awitan
Female>male, >50
thn, obesitas
gradual
Arthritis
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 CMC, pergelangan pergelangan kaki & Spine
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, insuf
splenomegaly batu ginjal aorta, psoriasis

Lab Normal RF +, anti CCP Asam urat

 29. Poliuria
• Definisi
Ekskresi urin lebih dari 3 liter/hari

• Patofisiologi
Central diabetes insipidus rendahnya sekresi ADH (vasopresin) oleh pituitari
posterior
Nephrogenic diabetes inspidus Sekresi ADH normal tp tubulus tidak respon
thd ADH
Transient diabetes insipidus pd kehamilan terjadi peningkatan metabolisme
ADH
Primary polidipsia (psychogenic) intake cairan terlalu banyak sehingga BAK
akan sering (respon fisiologis)
29. Polyuria
 29. Polyuria
• If polyuria is shown to be dilute, pathophysiologic
mechanisms include:
1. Hypothalamic or central diabetes insipidus with inability
to synthesize and secrete vasopressin;

2. Nephrogenic diabetes insipidus with an inadequate renal

response to vasopressin;

3. Transient diabetes insipidus of pregnancy produced by

accelerated metabolism of vasopressin;

4. Primary polydipsia (psychogenic), in which the initiating

event is ingestion of excess fluid and the subsequent
hypotonic polyuria is an appropriate physiologic response.
 Manifestasi Klinis Diabetes Insipidus
• Poliuria
Frekuensi berkemih
Enuresis,
Nokturia mengganggu tidur lelah pada siang hari atau somnolen
• Peningkatan osmolaritas plasma
Haus polidipsia
• Tanda klinis dehidrasi
Tanda yang jelas jarang ditemukan kecuali pada pasien dengan asupan air yang terganggu.

Harrison’s principles of internal medicine

Diabetes Insipidus
29. Poliuria
 29. Polyuria
• During the dehydration or water deprivation test:
– primary polydipsia: able to concentrate
urine, blood not become hyperosmolar
– diabetes insipidus: blood becomes
hyperosmolar without concentrating the
urine.

• After the patient is given desmopressin:

– Hypothalamic DI has minimal concentration
of the urine & an additional in urine
osmolality of at least 50%.
– partial hypothalamic DI concentrate their
urine minimally with dehydration, but the
maximum urinary concentration is not
achieved, and there is an additional boost
with administered desmopressin
– Nephrogenic DI do not concentrate their
urine & no further increase in urine
osmolality after the administration of Harrison’s principles of internal medicine. 18th ed.
Greenspan’s clinical endocrinology.
desmopressin.
29. Poliuria
30. Penyakit Katup Jantung
30. Penyakit Katup Jantung

Lilly LS. Pathophysiology of heart disease.

30. Penyakit Katup Jantung
 30. Penyakit katup Jantung
• Demam reumatik disebabkan oleh infeksi streptokokus
beta hemolitikus grup A.

Harrison’s principles of internal medicine.

30. Penyakit katup Jantung
• Awalnya, kerusakan katup berupa
regurgitasi. Setelah bertahun-
tahun, katup menebal, scarring,
terkalsifikasi, & menimbulkan
stenosis.

• 40% pasien akan mengalami

stenosis mitral.

• 25% akan mengalami stenosis atau

regurgitasi katup aorta, di samping
kelainan mitral.

• Katup trikusp dapat terkena, tapi

jarang.

Lilly. Pathophysiology of heart disease.

 ILMU
BEDAH
 31. Brachial Plexus Injury
In Adults:
• Sports most commonly associated:
– Football, baseball, basketball,
– volleyball, wrestling, and
– gymnastics.
• Nerve injuries can result from: Blunt force trauma, poor
posture or chronic repetitive stress.
Anatomy
 Injury to Superior part of Plexus.
• Due to excessive increase in the • Clinical Appearance:
angle between neck and the – Motor Loss:
shoulder. • Adducted Shoulder
• Medially Rotated Arm
• Roots Involved:
• Extended Elbow
C5 and C6 – Sensory Loss:
• Muscles Involved: • Lateral aspect of Upper Limb
(uncommon)
Shoulder • Digiti 1-3
Arm
Mechanism of trauma
• The head and neck
move away from
shoulder
• Commonly injured the
suprascapular roots
 Burner Injury
• Common nerve injury resulting from
trauma to the neck and shoulder
• Caused by traction or compression of the
upper trunk of the brachial plexus or the
fifth or sixth cervical nerve roots
• Typically transient
• Can cause prolonged weakness
• Often recur
• Symptoms:
• feels burning pain in the
supraclavicular area
• Radiates down the arm, generally in a
circumferential, nondermatomal
pattern.
Spurling's test: anterior view (left) and lateral view • numbness, paresthesias or weakness
(right). The examiner passively hyperextends and in the extremity
laterally flexes the patient's neck toward the • Frequently, the discomfort resolves
involved side. The test is positive if axial loading spontaneously in one to two minutes
by the examiner's hands reproduces symptoms.
 Injury to Inferior part Of Plexus
• Hanging to an
object
• Comonly injured
lower roots
• Excessive
abduction of arm.
• Less common
• Clinical Appearance: • Roots Involved:
– Motor Loss: C8 and T1
• Small muscles of Hand
– Sensory Loss:
• Medial aspect of Upper Limb
32&33. Open fracture

Gustillo-Anderson
 Open Fracture Treatment
• Irigasi dan debriment yang adekuat tahapan yang paling penting
• Luka harus dibuka selebar-lebarnya untuk memeriksa adanya
kerusakan jaringan yang lain dan adanya kontaminasi
• Meticulous debridement should be performed, starting with the
skin and subcutaneous fat
• Pulsatile lavage irrigation, with or without antibiotic solution,
should be performed
– Some authors have demonstrated decreased infection rates with >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
 Choice of fixation
• several options to stabilize an • No consensus of what method to
open fracture use
– splinting, • Surgeons must make judgment of
– casting, which method is appropriate
– and traction
– external fixation,
– plating, and
– intramedullary nailing
Koval, Kenneth J.; Zuckerman, Joseph D.
Handbook of Fractures, 3rd Edition
 34. BPH
• The size of prostate enlarged microscopically since the age of
40.Half of all men over the age of 60 will develop an enlarged
prostate
• By the time men reach their 70’s and 80’s, 80% will experience
urinary symptoms
• But only 25% of men aged 80 will be receiving BPH treatment
 What’s LUTS?
Voiding (obstructive) Storage (irritative or
symptoms filling) symptoms
• Hesitancy • Urgency
• Weak stream • Frequency
• Straining to pass urine • Nocturia
• Prolonged micturition • Urge incontinence
• Feeling of incomplete
bladder emptying
• Urinary retention
LUTS is not specific to BPH – not everyone with
LUTS has BPH and not everyone with BPH has LUTS
Blaivas JG. Urol Clin North Am 1985;12:215–24
 Diagnosis of BPH
• Symptom assessment
– the International Prostate Symptom Score (IPSS) is recommended as it is used worldwide
– IPSS is based on a survey and questionnaire developed by the American Urological
Association (AUA). It contains:
• seven questions about the severity of symptoms; total score 0–7 (mild), 8–19 (moderate), 20–35
(severe)
• eighth standalone question on QoL
• Digital rectal examination(DRE)
– inaccurate for size but can detect shape and consistency
• PV determination- ultrasonography
• Urodynamic analysis
– Qmax >15mL/second is usual in asymptomatic men from 25 to more than 60 years of age
• Measurement of prostate-specific antigen (PSA)
– high correlation between PSA and PV, specifically TZV
– men with larger prostates have higher PSA levels 1

– PSA is a predictor of disease progression and screening tool for CaP

– as PSA values tend to increase with increasing PV and increasing age, PSA may be used as a
prognostic marker for BPH
 Grade Pembesaran Prostat
Rectal Grading
Dilakukan pada waktu vesika urinaria kosong :
• Grade 0 : Penonjolan prostat 0-1 cm ke dalam rectum.
• Grade 1 : Penonjolan prostat 1-2 cm ke dalam rectum.
• Grade 2 : Penonjolan prostat 2-3 cm ke dalam rectum.
• Grade 3 : Penonjolan prostat 3-4 cm ke dalam rectum.
• Grade 4 : Penonjolan prostat 4-5 cm ke dalam rectum.
• Pielografi Intravena (IVP)Pemeriksaan IVP dapat menerangkan
kemungkinan adanya:
– kelainan pada ginjal maupun ureter berupa hidroureter atau
hidronefrosis
– memperkirakan besarnya kelenjar prostat yang ditunjukkan oleh
adanya indentasi prostat (pendesakan vesica urinaria oleh kelenjar
prostat) atau ureter di sebelahdistal yang berbentuk seperti mata kail
– penyulit yang terjadi pada vesica urinaria yaitu adanya trabekulasi,
divertikel, atau sakulasi vesica urinaria
– foto setelah miksi dapat dilihat adanya residu urin
Biopsi Prostat
• Hanya dilakukan bila PSA >3
• Skrinning PSA untuk Ca Prostat, tidak
dapat meningkatkan survival rate
USG Prostat
• Hanya dapat melihat pembesaran
prostat
• Tidak menunjukkan derajat
obstruksinya
Diagnosis BPH
• Diagnosis BPH terutama
berdasarkan anamnesis dan
pemeriksaan fisik
• Anamnesis dilakukan dengan
IPSS Score
• Uroflowmetri pemeriksaan
penunjang yang digunakan
untuk menilai derajat
keparahan obstruksi
 Management
• Lifestyle modification
– Mengurangi intake cairan
– Stop diuretik bila memungkinkan
– Hindari minum air/alkohol/kafein di malam hari
– Kosongkan kandung kemih sebelum perjalanan atau rapat
 Management
• Drug therapy
– Alpha blockers
• Memperbaiki tonus otot
polos prostat dan vesika
urinaria
• Lebih efektif dibandingkan
5 alpha reductase inhibitors
• Tamsulosin and alfuzosin
require no dose titration
Drug therapy
5 alpha reductase inhibitors
Mereduksi Volume prostat
Reduces risk of prostate cancer,
increases risk of high grade disease
Combined therapy
Men with large prostate > 40g or PSA >4
or moderate to severe symptoms
combined therapy will prevent 2
episodes of clinical progression per
100men over 4yrs. Much less effective
for men with smaller prostates
 http://www.medscape.org/viewarticle/541739_2

http://www.medscape.org/viewarticle/456664
35. Hypertrophic Pyloric Stenosis
 CLINICAL MANIFESTATIONS
• The classic presentation of IHPS
– Bayi 3-6 minggu
– Mengalami muntah segera setelah makan, tidak berwarna hijau (non-
bilious) dan sering kali proyektil Muntah proyektil
• Muntah dapat berwarna seperti kopi karena iritasi lambung akibat tekanan
di pilorus yang tinggi
– Terlihat lapar dan makan setelah muntah (a "hungry vomiter")
 Palpable mass
• Massa
– Paling mudah teraba segera setelah muntah
karena sebelumnya tertutupi oleh antrum yang
distensi atau otot abdomen yang menegang
• Barium Meal:
– Mushroom sign
– String sign
– Double tract sign
https://www.med-ed.virginia.edu/courses/rad/peds/abd_webpages/abdominal15b.html

Pemeriksaan Penunjang
• Foto Polos Abdomen:
– Dapat ditemukan gambaran “single bubble”
• Dilatasi dari gaster akibat udara usus yang tidak dapat
melewati pilorus
– Gambaran “Caterpillar sign”
• Terjadi akibat hiperparistaltik pada gaster
GERD signs and symptoms
The margin of the left diaphragm is not
visulized. Barium study shows intrathoracic
herniation of the stomach through a left
diaphragmatic rupture (hourglass sign)
 National Immunization Program Centers for
Disease Control and Prevention. Revised
March 2002

36. Tetanus Wound Management

Clean, minor All other
wounds wounds
Vaccination History Td TIG Td TIG

Unknown or <3 doses Yes No Yes Yes

3+ doses No* No No** No

* Yes, if >10 years since last dose

** Yes, if >5 years since last dose
Perawatan luka
• Wound toilet
• Semua luka
harus
dibersihkan
sesegera
mungkin
• Debridement
• Bersihkan luka dari
tanah, debu
jaringan nekrotik
dan benda asing
lainnyaall foreign
bodies, soil, dust,
necrotic tissue

Dosis Profilaksis:
• HTIG 250-500 IU
• ATS 1500 IU
 37. Abdominal Injuries
Ruptur organ berongga
• Akan mengeluarkan udara dan
cairan/sekret GIT yang infeksius
• Sangat mengiritasi
peritoneum peritonitis
Ruptur Organ Solid
• Menyebabkan perdarahan
internal yang berat
• Darah pada rongga
peritoneum peritonitis
• Terlihat gejala syok akibat
perdarahan hebat
– Gejala peritonitis dapat tidak
terlalu terlihat
 Hollow and Solid Organs
• The
hollow
typeorgans include:
of injury will depend on whether the organ injured is
– stomach
solid or hollow.
– intestines
– gallbladder
– Bladder
solid organs include:
liver
spleen
kidneys
 Stomach/duodenum
• Not commonly injured by blunt trauma
• Protected location in abdomen
• Penetrating trauma may cause gastric transection or
laceration
– Signs of peritonitis from leakage of gastric contents
• Diagnosis confirmed during surgery
– Unless nasogastric drainage returns blood
 Stomach/duodenum
Perforation Bleeding
• Presentation : • Presentation :
– abdominal pain – Haematemesis +/-
– rigidity – Melaena
– peritonism, shock – Severity
– Air under diaphragm on X-ray • Increased PR>90
• Fall BP<100
• Treatment
– Antibiotics • Treatment :
– resuscitate – transfusion
– repair – inject DU
 Colon and Small Intestine
• Usually injured by penetrating trauma
• May be injured by compression forces:
– High-speed motor vehicle crashes
– Deceleration injuries associated with wearing
personal restraints
• Bacterial contamination common
 Liver
• Largest organ in abdominal cavity • After injury, blood and bile leak into
• Right upper quadrant peritoneal cavity
• Injured from trauma to: – Shock
– Eighth through twelfth ribs on right – Peritoneal irritation
side of body • Management:
– Upper central part of abdomen – Resuscitation
• Suspect liver injury when: – Laparotomy and repair or resection.
– Steering wheel injury – Avulsion of pedicle is fatal
– Lap belt injury
– Epigastric trauma
 Spleen
• Upper left quadrant
• Rich blood supply
• Slightly protected by organs
surrounding it and by lower rib
cage
– Most commonly injured organ
from blunt trauma
– Associated intraabdominal
injuries common
• Suspect splenic injury in:
– Motor vehicle crashes
– Falls or sports injuries
involving was an impact to
the lower left chest, flank, or
upper left abdomen
• Kehr’s sign
– Left upper quadrant pain
radiates to left shoulder
– Common complaint with
splenic injury
• Management :
– Resuscitation.
– Laparotomy (repair, partial
excision or splenectomy)
– Observation in hospital for
patients with sub-capsular
haematoma
 38. Triage
Triage Priorities
1. Red- prioritas utama
– memerlukan penanganan
segera berkaitan dengan kondisi
sirkulasi atau respirasi

2. Yellow- prioritas kedua

– Dapat menunggu lebih lama, sebelum
transport (45 minutes)

3. Green- Dapat berjalan

– Dapat menunggu beberapa jam untuk
transport

4. Black- Meninggal
– Akan meninggal dalam penanganan
emergensi memiliki luka yang
mematikan

*** mark triage priorities (tape, tag)

 Triage Category: Red
• Red (Highest) Priority: Pasien • Gangguan Airway dan breathing
yang memerlukan penanganan • Perdarahan banyak dan tidak
segera dan transport secepat- terkontrol
cepatnya • Decreased level of consciousness
• Severe medical problems
• Shock (hypoperfusion)
• Severe burns
 Yellow Green
• Yellow (Second) Priority:
Pasien yang penanganan • Green (Low) Priority:
dan traportnya dapat Pasien yang
ditunda sementara waktu penanganan dan
• Luka bakar tanpa gangguan
airway transportnya dapat
• Trauma tulang atau sendi ditunda sampai yang
besar atau trauma multiple terakhir
tulang
• Fraktur Minor
• Trauma tulang belakang
dengan atau tanpa • Trauma jaringan lunak
kerusakan medula spinalis Minor
 39. Congenital Malformation
Disorder Definition Radiologic Findings

Hirschprung Congenital Barium Enema: a transition zone that

aganglionic separates the small- to normal-diameter
megacolon aganglionic bowel from the dilated bowel
above
Intussusception A part of the Intussusception found in air or barium
intestine has enema
invaginated into
another section of
intestine
Duodenal Dueodenum Plain X-ray: Double Bubble sign
atresia
Anal Atresia birth defects in Knee chest position/invertogram: to
which the rectum is determined the distance of rectum stump
malformed to the skin (anal dimple)

http://emedicine.medscape.com/
 invertogram Intussusception Hirschprung

Classifcation:
• A low lesion
– colon remains close to the skin
– stenosis (narrowing) of the anus
– anus may be missing altogether,
with the rectum ending in a blind
pouch
• A high lesion
– the colon is higher up in the pelvis
– fistula connecting the rectum and
the bladder, urethra or the vagina
• A persistent cloaca
– rectum, vagina and urinary tract
are joined into a single channel
http://emedicine.medscape.com/ Learningradiology.om Duodenal atresia
 Classification
Males Females
1. Cutaneous (perineal fistula) 1. Cutaneous (perineal fistula)
2. Rectourethral fistula
2. Vestibular fistula
A. Bulbar
3. Imperforate anus without fistula
B. Prostatic
3. Recto–bladder neck fistula 4. Rectal atresia

4. Imperforate anus without fistula 5. Cloaca

5. Rectal atresia A. Short common channel

B. Long common channel

6. Complex malformations
• Menurut Berdon, membagi atresia
ani berdasarkan tinggi rendahnya
kelainan, yakni :
– Atresia ani letak tinggi
• bagian distal rectum berakhir di
atas muskulus levator ani (> 1,5cm
dengan kulit luar)
– Atresia ani letak rendah
• distal rectum melewati musculus
levator ani ( jarak <1,5cm dari kulit
luar)
• Menurut
Stephen, membagi atresia
ani berdasarkan pada garis
pubococcygeal.
– Atresia ani letak tinggi
• bagian distal rectum
terletak di atas garis
pubococcygeal.
– Atresia ani letak rendah
• bila bagian distal rectum
terletak di bawah garis
pubococcygeal.
 Management
Newborn Male Anorectal Malformation

Selama 24 jam pertama

• Puasa
• Cairan melalui infus
• Antibiotik
• Evaluasi adanya defek yang mungkin menyertai dan dapat mengancam nyawa.
– NGT exclude esophageal atresia
– Echocardiogram exclude cardiac malformations, esophageal atresia.
– Radiograph of the lumbar spine and the sacrum
– Spinal ultrasonogram evaluate for a tethered cord.
– Ultrasonography of the abdomen evaluate for renal anomalies.
– Urine analysis

Annals of pediatrics surgery. October 2007

 Setelah 24 jam
Re evaluate
• Bila pasien memiliki fistula perineal
• Tindakan Anoplasty, tanpa protective colostomy
• Dapat dilakukan dalam 48 jam pertama kehidupan
• Bila tidak ada mekonium di perineum, direkomendasikan untuk melakukan
pemeriksaan radiologi cross-table lateral radiograph dengan pasien dalam
posisi tengkurap (knee-chest position)
– Bila udara dalam rektum berada dibawah os koksigis dan pasoen dalam kondisi
baik, tanpa defek yang lain
• Pertimbangkan melakukan posterior sagittal operation (PSARP) dengan atau
tanpa protective colostomy
– Bila gas dalam rektum berada diatas os koksigis atau pasien memiliki mekonium
dalam urin, sakrum abnormal atau flat bottom
• Harus dilakukan kolostomi terlebih dahulu
• Kemudian posterior sagittal anorectoplasty(PSARP) , 1 sampai 2 bulan
kemudian, setelah pasien memiliki kenaikan berat badan yang cukup

Annals of pediatrics surgery. October 2007

 40. Priapism - definition/background
• Ereksi penis/klitoris yang persisten dan nyeri tanpa keinginan
seksual (purposeless erection)
• Seringkali idiopatik
• Dapat berkaitan dengan beberapa penyakit sistemik
• Terkadang terlihat setelah penyuntikan intra-cavernosal
 Priapism - causes
• Psychotropic drugs • calcium-channel blockers
– phenothiazines • anti-coagulants
– butyrophenones • tamoxifen
• hydralazine • omeprazole
• prazosin, labetolol, phentolamine • hydroxyzine
and other -blockers
• cocaine, marijuana, and ethanol
• testosterone
• metoclopramide
 Priapism - treatment
• Karena pharmacological agents
– Terbutaline 5 mg po diulang dalam
15 minutes resolusi pada 1/3 of
patients
– Injeksi intracavernous dari -
adrenergic
• phenylephrine 100 to 500 mcg (put 10
mg in 500cc NSS 20 mcg/ml. Inject
10 to 20 cc every 5-10 minutes
(maximum - 10 doses)
– Blok N. Dorsalis Penis
• Aspiration and irrigation
– Untuk priapismus yang lebih dari 2
jam
– discuss with urologist if at all
possible
– Harus memberitahukan pada
pasien bahwa terapi dapat
meyebabkan impotensi yang
permanen
– conscious sedation may be
necessary
 http://emedicine.medscape.com/article/ http://en.wikipedia.org/wiki/

Disorders Clinical
Fimosis Inability to retract the distal foreskin over the glans penis
Parafimosis Entrapment of a retracted foreskin behind the coronal sulcus

Peyronie’s disease Chronic Inflammation of the Tunica Albuginea (CITA), is a

connective tissue disorder involving the growth of fibrous
plaques, causing pain, abnormal curvature, erectile
dysfunction, indentation, loss of girth and shortening
Detumescence Detumescence is the reversal of erection, by which blood
erection leaves the erectile tissue, returning to the flaccid state
 41. Ankle Sprain
• Injury to the Talofibular • Riwayat trauma
ligament/ calcaneofibular • Bengkak/discoloration
ligament • Pain/tenderness
• Inversion restriction
• Anterior drawer test for ankle
• X-ray
 •
The anterior drawer
• Menilai integritas dari ligamen talofibular
anterior.
• Cara pemeriksaan:
• Posisi kaki sedikit plantar fleksi
• Pegang kaki dengan tang kiri
• Tarik tumit kearah antrior dengan
tangan kanan
• Positive test Laxity and poor
endpoint on forward translation
The inversion stress test
• Menilai integrotas ligamen
calcaneofibular
• Cara pemeriksaan:
• Pegang tumit dengan tangan
kiri
• Inversi kaki dengan tangan
kanan
• Compare to opposite side
 Grading

• Grade I: anterior talofibular

ligament (ATF)
• Grade II: ATF plus
calcaneofibular ligament (CF)
• Grade III: ATF plus CF plus
posterior talofibular ligament
Injury Clinical Findings Imaging
Ankle sprain Positive drawer/inversion X-Ray
test
Achilles Rupture Thompson test, tendon USG
gap, unable to plantaflex
foot
Metatarsal fracture Bone tenderness over the X-Ray
navicular bone or base of
the fifth metatarsal
Tarsal Tunnel Syndrome Tinnel test (+), paresthesias MRI
along tibial nerve
Plantar fasciitis Severe plantar pain, foot Not needed
cord tightness
 42. Electrical Injury
• Injury by 3 mechanisms
– Injury from current flow (direct contact)
– Arc injury (electricity passes through air)
• Electricity arcs at a temperature of 4000C, causing flash burns
– Flame injury by ignition of clothing or surroundings
 Types of electrical injury

Electrical injury

Arc Injury
High voltage
Low voltage (flash burn
(>1000V) Lightning
(<1000V) type injury)
 High voltage versus low voltage
• High voltage (>1000V) injuries tend to have higher rates of
complications
– Amputations, fasciotomies
– Compartment syndrome
– Longer hospital stays, ICU stays, mechanical ventilation
– Cardiac dysrhythmias, acute renal failure
– Higher body surface area burn
 Clinical features
• Head and neck
– Tympanic membrane rupture
– Temporary hearing loss
– Cataracts – may happen immediately
or be delayed
• Cardiovascular system
– Dysrhythmias – asystole, VF cardiac
arrest
– May also cause transient ST elevation,
QT prolongation, PVCs, Atrial
fibrillation, bundle branch blocks
• Nervous system
– Brain
• Loss of consciousness (usually transient)
• Respiratory arrest
• Confusion, flat affect, memory problems
• Seizures
– Spinal cord injury either immediate or
delayed
– Peripheral nerve damage
 Clinical features
• Skin
– Thermal burns at contact points
– Kissing burn – current causes
flexion of extremity burns at
flexor creases http://www.forensicmed.co.uk/wounds/bu
rns/chemical-and-electrical-burns/
– Burns around mouth common in (accessed July 2012)

children who chew on electrical

cord
• * Careful with these as
separation of eschar can cause
delayed bleeding of labial artery
Rosen’s Emergency Medicine. Chapter
140 page 1897 -see references at end of
presentation for full reference
 Electrical burn - fasciotomy
• Extremities
– Compartment syndrome – requires
fasciotomies
– Damaged muscle massive release
myoglobin rhabdomyolysis renal failure
• Vascular
– Thrombosis of vessels
– Damage to vessel walls delayed rupture
and hemorrhage
• Skeletal system
– Fractures/dislocations from trauma or from
tetanic muscle contractures (e.g. shoulder
dislocations)

http://burnssurgery.blogspot.ca/2012/07/electrical-contract-burns-
bilateral.html#!/2012/07/electrical-contract-burns-bilateral.html (accessed Sept 2012)
 Electrical injury Management
• ABCs, ATLS
• Dysrhythmias – ACLS
• Manage trauma and orthopedic injuries
• Consider need for amputations, fasciotomies, escharotomies
• Consider myoglobinuria and rhabdomyolysis
• Splinting, burn and wound care
• Consider need for cardiac monitoring
– Abnormal ECG, dysrhythmia, loss of consciousness, high voltage injury
• Consider transfer to burn centre
 Out of hospital
management
• Ensure scene safety
– Careful for live lines on the scene
• ACLS protocols as needed
• Fluid resuscitation with saline or
ringers lactate
• Spine immobilization if suspected
trauma
ED initial
management
• ABCs, ACLS, trauma
management as needed
• Fluid resuscitation
– Parkland formula not helpful
here as surface wounds not
reflective of more extensive
internal damage
– Fluids to maintain urine
output 1-1.5 cc/kg/hr for
rhabdomyolysis management
• ECG
• Analgesia!
 Cardiac monitoring
Low voltage injury Loss of High voltage injury
< 1000 V consciousness > 1000 V
or
Normal ECG
Documented Normal ECG
dysrhythmia
Discharge home or
??
Abnormal ECG
Low risk patients Intermediate
risk patients
Admission with telemetry

High risk patients

 Other cardiac issues
• Time of monitoring
not known – usually
up to 24 hours, but
data limited
• CK-MB may not be
accurate at
diagnosing cardiac
injury

Electrical Injuries: A Review For The Emergency Clinician Czuczman AD, Zane RD. October 2009; Volume
11, Number 10
 Extremity injury
• Monitor for compartment syndrome
– Feel compartments, assess for pain on passive extension, paraesthesias etc
– Compartment pressures should be < 30 mmHg
– Fasciotomy if needed
• May need carpal tunnel release if arm involvement
• Amputate non viable extremities/digits
• Splint in position of safety to prevent contractures
 Lightning injuries – clinical features
Special case as is a massive current • Cardiac
impulse for a very short time – Usually asystole instead of Vfib
Short time duration means minimal • ENT
burns, tissue destruction – Perforated tympanic membranes,
Main cause of death is cardiac arrest displacement of ossicles
Higher mortality than other electrical – Cataracts (often delayed)
injuries • Psychiatric
– PTSD, depression, chronic fatigue
 Lightning injuries continued...
• Neurologic
– LOC, confusion, anterograde amnesia, paraesthesias
– Keraunoparalysis – transient paralysis of lower limbs (sometime
upper) that are cold, mottled, blue and pulseless – usually self
resolves in few hours
 Lightning injuries - burns
4 patterns of burns http://www.scienceinseconds.com
/blog/By-the-Power-of-Zeus
(accessed July 2012)

Linear
http://atlas-
Punctate emergency-
medicine.org.ua/ch.1
6.htm (accessed
Feathering July 2012)

Thermal

http://atlas-
emergency-
medicine.org.ua/ch.1 Feathering
6.htm (accessed
July 2012)

Punctate

Linear
 Lightning injuries - management
• ECG
• Cardiac biomarkers if ECG abnormal, chest pain, altered
mentation
• CT head if altered mentation
• Does not usually require aggressive fluid resuscitation,
fasciotomies etc
 43. Olecranon Fracture
• Pasien datang dengan lengan atas dalam posisi fleksi dan
disangga oleh tangan kontralateralnya
• 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
The radiocapitellar line ends above the
capitellum.
This means that the radius is dislocated.
Did you also notice the olecranon fracture?
Whenever the radius is fractured or dislocated,
always study the ulna carefully.
http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.html
Radiocapitellar line
A line drawn through the centre of the
radial neck should pass throught the
centre of the capitellum, whatever the
positioning of the patient, since the radius
articulates with the capitellum (figure).
In dislocation of the radius this line will not
pass through the centre of the capitellum.
 44. Trauma Buli
• 86% trauma buli berkaitan dg trauma abdomen (KLL, jatuh dr
ketinggian)
• 90% berhubungan dg fraktur pelvis.
• Sebaliknya hanya 9 – 16 % fraktur pelvis yg disertai ruptur buli.
• 60% mrpk ruptur buli extraperitoneal, 30% intraperitoneal
 MEKANISME CEDERA
• Ruptur intraperitoneal terjadi akibat trauma pada abdomen bagian bawah atau jg
trauma pelvis pada saat buli2 penuh.
• Ruptur extraperitoneal lbh sering berkaitan dg fraktur pelvis
 Tanda dan gejala
• Hematuria
– dapat merupakan gejala tunggal
– 95% ruptur buli
• Nyeri perut bawah.
• Kesulitan berkemih
• Pruduksi urin menurun
 Pemeriksaan radiologis
• Cystography
– Kontras > 300 cc
– Foto pengosongan (drainase)
• CT scan cystography
 Trauma buli
• Kontusio buli
– Cedera mukosa tanpa extravasasi urin
• Ruptur interstisial
– Robekan sebagian dinding buli tanpa extravasasi
• Ruptur intraperitoneal
– Tampak kontras mengisi rongga intraperitoneal
• Ruptur extraperitoneal
– Kontras mengisi ruang perivesika dibawah garis asetabulum
• Hematoma perivesika : tear drop appearance
 Sistogram
Ruptur intraperitoneal Ruptur Ekstraperitoneal
 Penatalaksanaan
• Pada luka tembus buli2 explorasi + repair
• Ruptur intraperitoneal explorasi + repair

• Pada trauma tumpul yg hanya menimbulkan trauma dinding

buli yg tidak disertai extravasasi urin tidak memerlukan
tindakan pembedahan.
 45. Nipples Variations
• Erect or Everted Nipples
– Term “normal nipple”
– Nipples protrude a few millimeters
from the areola at their regular
state, but protrude further upon
arousal, temperature changes, or
tactile stimulation
– It is held erect by a cylindrical
column of small smooth muscles.
 Inverted Nipple
• Inverted nipple is defined as a
non-projectile nipple
• nipple is located on a plane lower
than the areola
• retracted into the breast
parenchymal and stromal tissue
 Grade
• Grade 1
– These nipples can occasionally become everted from arousal, temperature
changes, and stimulation
– They can also protrude through manipulation by lightly squeezing fingers
around the areola, a few centimeters behind the nipple
– Grade 1 nipples will maintain protrusion without retracting
– Breastfeeding is possible with Grade 1 nipples.
• Grade 2
– These nipples can be pulled out—though not as easily—through the same
manipulation method as Grade 1 nipples
– However, Grade 2 nipples retract back into the areola after finger pressure is
released.
– Breastfeeding is possible with Grade 2 nipples, but will present problems.
• Grade 3
– These nipples are severely retracted into the areola, meaning they cannot be
pulled out through physical manipulation, and typically require surgery in
order to protrude
– The milk ducts tend to be constricted, rendering breastfeeding impossible.

https://en.wikipedia.org/wiki/Inverted_nipple
• Flat
– Flat nipples are not everted at their normal state. blending into the
areola
– Flat nipples will protrude, albeit less so than "normal" nipples, upon
stimulation, temperature changes and arousal
– Flat nipples have the ability to turn into "normal" nipples when
breastfeeding draws them out.
• Retracted Nipples – Changed Position
– Nipples start out as raised tissue, but due to some underlying condition,
the nipple starts to pull inward, change position, or fold itself into a narrow
crease
– If the nipple is not normally inverted or flat, but changes so that it retracts
and will not return to its regular position when stimulated, it might be a
sign of a problem
– Caused by
• Aging
• duct ectasia
• or breast cancer

http://breastcancer.about.com/od/whatisbreastcancer/tp/nipple-changes.htm
 Sore Nipple
• Sore nipples are any persistent pain in the nipples that lasts
throughout the entire breastfeeding or hurts between
feedings most common couse in breastfeeding problem
• Signs and Symptoms-
– Pain when the baby latches on that lasts longer than 30 seconds
– Cracking
– Blisters
– Bleeding
– Nipples that are tender between feedings
http://emedicine.medscape.com/article/1101235-clinical#showall

Paget disease of the Breast

• Paget’s disease of the nipple or Signs and symptoms:
breast is a rare type of breast • Early stages: (appearance of nipple
cancer, which can occur in women skin)
and men – Redness erythematous patch is usually
• Most cases are found in menopausal sharply demarcated and infiltrated
women, but can also appear in – scaly and flaky skin
women that are as young as 20 – mild irritation of skin
• Cause:
– Underlying breast cancer • Advanced stages:
– nipple skin cells may spontaneously – tingling in nipple skin
change into cancer cells – itchiness that doesn’t respond to creams
– very sensitive skin on the nipple
– burning or painful nipple skin
– ooze or bloody discharge from the
nipple (not milk)
– nipple retraction (pulls into the breast)
– scaly rash on areola skin
– breast lump beneath the affected skin
46. Prostatic malignancy
 PSA—Prostate Cancer
• PSA >4.0 ng/mL mandatory
biopsy
• 50% of all the cancers detected
because of an elevated PSA level
are localized
• these patients are candidates for
potentially curative therapy
Biopsi Prostat
• Skrinning PSA untuk Ca
Prostat, tidak dapat
meningkatkan survival
rate
USG Prostat
• Hanya dapat melihat
pembesaran prostat
• Tidak menunjukkan
derajat obstruksinya
 What’s LUTS?
Voiding (obstructive) Storage (irritative or
symptoms filling) symptoms
• Hesitancy • Urgency
• Weak stream • Frequency
• Straining to pass urine • Nocturia
• Prolonged micturition • Urge incontinence
• Feeling of incomplete
bladder emptying
• Urinary retention
LUTS is not specific to BPH – not everyone with
LUTS has BPH and not everyone with BPH has LUTS
Blaivas JG. Urol Clin North Am 1985;12:215–24
 47. Batu Uretra
• Batu uretra biasanya berasal dari batu ginjal atau batu ureter
yang turun ke buli-buli, kemudian masuk ke uretra.
• Batu uretra yang merupakan batu primer terbentuk di uretra
sangat jarang, kecuali jika terbentuk di dalam divertikel uretra.
• Angka kejadian batu uretra ini tidak lebih 1% dari seluruh batu
saluran kemih.

http://emedicine.medscape.com/
 Batu Uretra
• Batu uretra:
– 2/3 batu uretra terletak di uretra posterior
– 1/3 batu uretra terletak di uretra anterior
• Gejala tidak spesifik, terdapat gejala-gejala obstruksi
– Asimptomatik
– Riwayat sering nyeri pinggang sebelumnya
– Retensi urin Keluhan tersering
– Disuria
– Aliran mengecil
– Frequency
– Dribbling
– Hematuria
– Mengeluar batu kecil saat kencing atau kencing berpasir
– Batu uretra posterior Nyeri yang menjalar ke perineum atau rectum
– Batu uretra anterior nyeri pada daerah tempat batu berada atau
menjalar ke penis
http://www.bjui.org/ContentFullItem.aspx?id=840&SectionType=1&title=Ob
structing-Calculi-within-the-Male-Urethra
 Gejala
• Nyeri kolik
• Hematuria
• Nyeri ketok pada daerah kosto-
vertebra, teraba ginjal pada sisi
yang sakit akibat hidronefrosis,
• Terlihat tanda-tanda gagal ginjal
• Adanya retensi urine
 Radiologi
• Foto Polos Abdomen
– Melihat kemungkinan adanya batu radioopak di saluran kemih. Batu
jenis kalsium oksalat dan kalsium fosfat bersifat radioopak dan paling
sering dijumpai, sedangkan batu asam urat bersifat radiolusen.
• Pielografi Intra Vena
– Menilai keadaan anatomi dan fungsi ginjal.
– Mendeteksi adanya batu semi opak ataupun batu non opak
– Tidak dapat digunakan pada situasi penurunan fungsi ginjal
• Ultrasonografi
– Dikerjakan bila pasien tidak mungkin menjalani pemeriksaan PIV, yaitu
pada keadaan alergi terhadap bahan kontras, faal ginjal yang menurun
dan pada wanita yang sedang hamil.
– Dapat menilai adanya batu di ginjal atau di buli-buli (yang ditunjukkan
sebagai echoic shadow), hidronefrosis, pionefrosis, atau adanya
pengkerutan ginjal
• CT Urografi
– Baku standar pemeriksaan batu saluran kemih
– Dapat digunakan pada pasien dengan penuruna fungsi ginjal
acoustic shadowing

Sumbatan di uretra
pars prostatika
 Tatalaksana
• Simple procedures like meatotomy, supra-pubic bladder
decompression and urethrolithotomy to evacuate stone
• Medikamentosa, bersifat simtomatis, yaitu bertujuan untuk
mengurangi nyeri, memperlancar aliran urine dengan minum
banyak supaya dapat mendorong batu keluar.
• Litotripsy uretroskopi
• Bedah terbuka

J Coll Physicians Surg Pak. 2012 Aug;22(8):510-3. doi: 08.2012/JCPSP.510513.

48. Komplikasi padaTotal Hip Arthroplasty – Heterotopic
Ossification
• Pembentukan tulang pada Terapi
jaringan yang secara normal – Pemanasan handuk
tidak menunjukkan sifat hangat, infrared
ossifikasi – Radiasi pre-op/post-op
– Sendi bengkak, nyeri, hangat
– Seringkali terjadi
500- 1000 Rad
pengurangan range of “lindungi implant”
movement – Indometasin
– Dapat terjadi sejak 2 minggu
post op – Ibuprofen
– Dapat berlanjut menjadi – Diphosphonates
pembentukan tulang
ekstensif dalam 3 bulan

Ashton et al. Prevention of heterotopic bone formation in high risk patients post-total hip
arthroplasty. Journal of Orthopaedic Surgery 2000, 8(2): 53–57
 Teknik: Total Hip Replacement
• Femoral head impaction Final implant
 49. GANGLION Cyst

• Kista ganglion merupakan tumor

yang sangat sering muncul pada
tangan dan pergelangan tangan
– Timbul pada daerah yang
berdekatan dengan sendi atau
tendon.
• Lokasi tersering: pergelangan
tangan (top of the wrist)
• Diagnosis
– Berdasarkan lokasi dari tumor dan penampakannya
• Karakteristik
– Bulat atau oval
– Lunak atau kenyal(oft or firm)
– Nyeri saat terkena tekanan, contohny pada saat menggenggam.
– Transillumination +

American Society for Surgery of the Hand •

www.handcare.org
 50. Hemoroid

Hemoroid eksterna Hemoroid Interna

Diluar anal canal, sekitar sphincter Didalam anal canal
Gejala terjadi karena thrombosis Gejala timbul karena perdarahan atau
iritasi mukosa
Tidak dapat dimasukkan ke dalam anal dapat dimasukkan ke dalam anal canal
canal sampai grade III
 ACG (American College of
Gastroenterology Guideline
Treatment for internal hemorrhoids by grade:
• Grade I hemorrhoids
– conservative medical therapy and avoidance of nonsteroidal
anti-inflammatory drugs (NSAIDs) and spicy or fatty foods
– Conservative therapy:
• Increased fiber intake and adequate fluids
– reducing both prolapse and bleeding
• Avoid straining and limit their time spent on the commode
• Topical and systemic analgesics; proper anal hygiene
• a short course of topical steroid cream
• Grade II or III hemorrhoids
– initially treated with nonsurgical procedures, rubber band
ligation, sclerotherapy, and infrared coagulation
– Rubber band Ligation is the treatment of choice for second-
degree hemorrhoids, and it is a reasonable first-line treatment
for third-degree hemorrhoids
Wald A, Bharucha AE, Cosman BC, et al. ACG clinical guideline: management of benign anorectal disorders. Am J
Gastroenterol. Aug 2014
• Very symptomatic grade III and grade IV hemorrhoids
– surgical hemorrhoidectomy, or stapled
– Very symptomatic gr. III continous bleeding, intractable pain, large
hemoroid gr. III
• Treatment of grade IV internal hemorrhoids or any
incarcerated or gangrenous tissue requires prompt surgical
consultation
American Society of Colon and Rectal Surgeons – ASCRS
Guidlines

http://www.cghjournal.org/article/S1542-3565%2813%2900017-7/fulltext
Rubber band ligation Stapled Hemorrhoidectomy
 51. Staghorn Kidney Stone
• Staghorn calculi are branched stones that occupy a large
portion of the collecting system.
• Typically, they fill the renal pelvis and branch into several or all
of the calices.
• "partial staghorn" calculus
– branched stone that occupies part but not all of the collecting system
– "complete staghorn" calculus occupies virtually the entire collecting
system
 Location and External Anatomy of
Kidneys
• Located retroperitoneally
• Lateral to T12–L3 vertebrae
• Average kidney
– 12 cm tall, 6 cm wide, 3 cm
thick
• Hilus
– On concave surface
– Vessels and nerves enter
and exit
• Renal capsule surrounds the
kidney
 Symptoms
• Staghorn calculi may contain mixed calcium/struvite or all
calcium stones
• Often no symptoms directly related to stone
• May present with UTI, flank pain, hematuria
• Passage of struvite stone is rare
• Can rapidly grow and lead to chronic pyelonephritis and
parenchymal scarring
• Struvite stones are radiopaque and can be seen on AXR and CT
Abdominal plain film showing b/l radiopaque
staghorn calculi
 Management of staghorn calculi
Medical Surgical management
• Dietary phosphorus • Open surgery
reduction • Percutaneous
• Antibiotics nephrolithotomy (PNL)
– rarely successful at • Shock wave lithotripsy
eradicating bacteria in
struvite stone (SWL)
• Acetohydoxamic acid (AHA,
Lithostat
– urease inhibitor to stop
stone growth in 80% vs. 40%
on placebo
– Use is limited by frequent
side effects including
palpitations, nausea, and
hemolytic anemia
 Retrospective study
• 112 patients with staghorn calculus with mean
follow up 7.7 years

• Renal deterioration occurred in 28%

• Worse outcome associated with solitary
kidney, recurrent stones, hypertension,
urinary diversion, and neurogenic bladder
J Urol 1995 May;153(5):1403-7
 52. Management BPH
• Lifestyle modification
– Mengurangi intake cairan
– Stop diuretik bila memungkinkan
– Hindari minum air/alkohol/kafein di malam hari
– Kosongkan kandung kemih sebelum perjalanan atau rapat
 Management
• Alpha blockers
o Memperbaiki tonus otot polos
prostat dan vesika urinaria
o Lebih efektif dibandingkan 5
alpha reductase inhibitors
o Tamsulosin and alfuzosin
require no dose titration
o European Association of Urology
recommendation
o Alpha 1-blockers can be offered to men
with moderate-to-severe LUTS due to BPH
• 5 alpha reductase inhibitors
o Mereduksi Volume prostat
o Reduces risk of prostate cancer, increases
risk of high grade disease
• Combined therapy
o Men with large prostate > 40g or PSA >4 or
moderate to severe symptoms combined
therapy will prevent 2 episodes of clinical
progression per 100men over 4yrs. Much
less effective for men with smaller
prostates
 • Alpha 1 Blockers
– Alfuzosin HCL
– Doxazosin mesylate
– silodosin
– Tamsulosin HCL
– Terazosin HCL

http://www.medscape.org/viewarticle/541739_2
http://www.medscape.org/viewarticle/456664
 Yasukawa (2001)
• During 13-week double-blind • Tamsulosin can be used in BPH
administration of once-daily patients who are hypertensive
tamsulosin or placebo, no without any restrictions on blood
statistically significant differences pressure control medication
were observed in blood pressure
or heart rate among
normotensive, controlled
hypertensive, and uncontrolled
hypertensive patients
http://radiologymasterclass.co.uk/tutorials/musculoskeletal/trauma/trauma_x-ray_page8.html

53. Complications of Fracture Healing

• Delayed Union
– Poor blood supply or infection.
• Non-Union
– Bone loss or wound contamination.
– Type:
• Atrophic non-union Suplai darah kurang, tulang mengecil, Radiologi: tampak atrofi
tulang
• Hypertrophic non-union suplai darah cukup sehingga dapat membentuk tulang baru,
namun tidak menyatu akibat fiksasi yang tidak baik, kedua fragmen tulang, sama-sama
hipertrofik (membesar
• Oligotrophic non union Posisi kedua fragmen tulang tidak baik
• Malunion
– Bone healed in a nonanatomic position
– Can be angulated, rotated, or shortened
• Affect function?
• Likely to affect function?
• Consequences with or without treatment
• Fibrous Union
– Improper immobilization
• Avascular necrosis (AVN)
– the death of bone cells through lack of blood supply
its internal blood supply is compromised
 Complications Late Complications
• Malunion
after Hand ORIF – Delayed fracture healing
Early complications • Malposition
• Swelling – Abnormal shape of
• Pain finger

• Joint stiffness
– Inability to move joints after period
of immobilization
• Infections Rare

Exercise to prevent joint stiffness

 Neglected Hand Fracture Complications
• Infections
– common if open fracture
• Synarthrosis
– Fusion of joints, possible if
intraarticular fracture
• Malunion
– Delayed or abnormal healing due to
inadequate reduction and fixation
 54. Supracondylar Fracture
• Fraktur siku tersering pada anak- Mechanism
anak
– Usia < 8 tahun
• Mekanisme
– Extension (95%) vs flexion
– Posisi menahan dengan tangan
ekstensi
– Posisi menahan dengan siku fleksi
 Clinically
• Mild swelling to gross deformity
• Arm held to side, immobile,
extension
• S-shaped configuration
angulasi lengan atas
• 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
• 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
 55. 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
 56. Gambaran radiology simple and
tension pneumothoraks
• Visible visceral pleural edge
see as a very thin, sharp white
line
• No lung markings (avascular)
are seen peripheral to this line
• The peripheral space is
radiolucent compared to
adjacent lung
• The lung may completely
collapse
• The mediastinum should not
shift away form the
pneumothorax unless a
tension pneumothorax is
present
• Subcutaneous emphysema
and pneumomediastinum may
also be present
 ILMU
P E N YA K I T
M ATA
 57. Komplikasi Pascaoperasi Katarak
EARLY COMPLICATION LATE COMPLICATION
• Corneal edema (10%) • Posterior capsule opacification
• Elevated IOP (2–8%) (10–50% by 2 years)
• Increased anterior inflammation • Cystoid macular edema (1–12%)
(2–6%). • Retinal detachment (0.7%)
• Wound leak (1%) • Corneal decompensation
• Iris prolapse (0.7%) • Chronic endophthalmitis
• Endophthalmitis (0.1%)
 Acute postoperative endophthalmitis
• Komplikasi yg mengancam penglihatan
yg harus segera diobati.
• Onset biasanya 1–7 hari setelah op.
• Etiologi tersering Staphylococcus
epidermidis, Staphylococcus aureus, &
Streptococcus species.
• Gejala:
– a painful red eye;
– reduced visual acuity, usually within a few
days of surgery
– a collection of white cells in the anterior
chamber (hypopyon).
– posterior segment inflammation
– lid swelling.
• Faktor risiko
– Pasien dengan blepharitis, konjungtivitis,
penyakit nasolakrimal, komorbid(diabetes),
dan complicated surgery (PC rupture with
vitreous loss, ACIOL, prolonged surgery).
• Diagnosis
– pemeriksaan mikrobiologi dari Anterior
chamber tap dan biopsi vitreous (dgn
antibiotik intravitreus scr simultan utk
pengobatan)
 Acute postoperative endophthalmitis
TATALAKSANA
• Antibiotic intravitreus: vancomycin 1 mg
dlm 0.1 mL (gram positive coverage)
dikombinasikan dengan amikacin 0.4 mg
dlm 0.1 mL atau ceftazidime 2 mg dlm 0.1
mL (gram-negative coverage).
• Ceftazidime bisa menimbulkan presipitasi
dengan vankomisin shg spuit harus dipisah
• Vitrectomy: jika tajam penglihatan hanya
berupa light perception atau lebih buruk
Oxford American Handbook of Ophthalmology
Pertimbangkan:
• Moxifloxacin atau gatifloxacin oral (broad
spectrum dan penetrasi intraokular baik)
• Antibiotik topikal (per jam): (moxifloxacin or
gatifloxacin) atau vancomycin DS (50
mg/mL), amikacin (20 mg/mL), atau
ceftazidime (100 mg/mL)
• Corticosteroids topikal (cth dexamethasone
0.1%/ jam), intravitreal (dexamethasone 0.4
mg in 0.1 mL), atau sistemic (prednisone PO
1 minggu) untuk mengurangi inflamasi.
Koroiditis:
 58. Keratokonjungtivitis toksik
• Definition :
– Corneal toxicity is caused by chemical trauma and by iatrogenic and
factitious disease, which are often overlooked

• Iatrogenic toxicity occurs in patients with acute or chronic ocular

surface disorders as a result of both the short-term and, more
often, the longtermuse of topical medications

• The commonest conjunctival reactions were toxic papillary, toxic

follicular, and delayed hypersensitivity

• The commonest associated drugs were :

– Idoxuridine (IDU), arabinoside A, aminoglycosides, pilocarpine,
chloramphenicol, and the preservatives benzalkonium chloride,
phenylmercuric nitrate (which is no longer used in the UK), thiomersal,
and EDTA

Dart J. Corneal toxicity : The epithelium and stroma in iatrogenic and factitious disease. Eye (2003) 17;886-92
• The clinical signs
– Both iatrogenic and factitious disease are usually nonspecific and
identical to those resulting from other causes of corneal epithelial
disease such as:
• punctate keratopathy,
• Coarse focal keratopathy,
• pseudodendrites,
• Filamentary keratopathy, and
• persistent epithelial defect
 59. KELAINAN REFRAKSI: HIPERMETROPIA
ANAMNESIS

MATA MERAH MATA MERAH MATA TENANG

MATA TENANG VISUS
VISUS NORMAL VISUS TURUN VISUS TURUN
TURUN MENDADAK
• struktur yang PERLAHAN
mengenai media
bervaskuler
refraksi (kornea, • uveitis posterior • Katarak
sklera konjungtiva •
uvea, atau perdarahan vitreous • Glaukoma
• tidak • Ablasio retina • retinopati
seluruh mata)
menghalangi • oklusi arteri atau vena penyakit sistemik
media refraksi retinal • retinitis
• neuritis optik pigmentosa
• Keratitis
• Konjungtivitis murni • neuropati optik akut • kelainan refraksi
• Keratokonjungtivitis
• Trakoma karena obat (misalnya
• Ulkus Kornea
• mata kering, etambutol), migrain,
• Uveitis
tumor otak
xeroftalmia • glaukoma akut
• Pterigium • Endoftalmitis
• Pinguekula • panoftalmitis
• Episkleritis
• skleritis
 59. HIPERMETROPIA
• Gangguan kekuatan pembiasan mata dimana sinar
sejajar jauh tidak cukup dibiaskan sehingga titik
fokusnya terletak di belakang retina (di belakang
makula lutea)
• Etiologi :
– sumbu mata pendek (hipermetropia aksial),
– kelengkungan kornea atau lensa kurang (hipermetropia
kurvatur),
– indeks bias kurang pada sistem optik mata (hipermetropia
refraktif)
• Gejala : penglihatan jauh dan dekat kabur, sakit kepala,
silau, rasa juling atau diplopia

Ilmu Penyakit Mata, Sidharta Ilyas ; dasar – teknik Pemeriksaan dalam Ilmu Penyakit Mata, sidarta Ilyas
 HIPERMETROPIA
• Pengobatan : Pemberian lensa sferis
positif akan meningkatkan kekuatan
refraksi mata sehingga bayangan
akan jatuh di retina
• koreksi dimana tanpa siklopegia
didapatkan ukuran lensa positif
maksimal yang memberikan tajam
penglihatan normal (6/6), hal ini
untuk memberikan istirahat pada
mata.
• Jika diberikan dioptri yg lebih kecil,
berkas cahaya berkonvergen namun
tidak cukup kuat sehingga bayangan
msh jatuh dibelakang retina,
akibatnya lensa mata harus
berakomodasi agar bayangan jatuh
tepat di retina.
• Contoh bila pasien dengan +3.0 atau
dengan +3.25 memberikan tajam
penglihatan 6/6, maka diberikan
kacamata +3.25
Ilmu Penyakit Mata, Sidharta Ilyas
 BENTUK HIPERMETROPIA
• Hipermetropia total = laten + manifest
– Hipermetropia yang ukurannya didapatkan sesudah diberikan siklopegia
• Hipermetropia manifes = absolut + fakultatif
– Yang dapat dikoreksi dengan kacamata positif maksimal dengan hasil visus 6/6
– Terdiri atas hipermetropia absolut + hipermetropia fakultatif
– Hipermetropia ini didapatkan tanpa siklopegik
• Hipermetropia absolut :
– “Sisa”/ residual dari kelainan hipermetropia yang tidak dapat diimbangi
dengan akomodasi
– Hipermetropia absolut dapat diukur, sama dengan lensa konveks terlemah
yang memberikan visus 6/6

Ilmu Penyakit Mata, Sidharta Ilyas

 BENTUK HIPERMETROPIA

• Hipermetropia fakultatif :
– Dimana kelainan hipermetropia dapat diimbangi sepenuhnya dengan
akomodasi
– Bisa juga dikoreksi oleh lensa
– Dapat dihitung dengan mengurangi nilai hipermetrop manifes – hipermetrop
absolut
• Hipermetropia laten:
– Hipermetropia yang hanya dapat diukur bila diberikan siklopegia
– bisa sepenuhnya dikoreksi oleh tonus otot siliaris
– Umumnya lebih sering ditemukan pada anak-anak dibandingkan dewasa.
– Makin muda makin besar komponen hipermetropia laten, makin tua akan
terjadi kelemahan akomodasi sehingga hipermetropia laten menjadi fakultatif
dan kemudia menjadi absolut

Ilmu Penyakit Mata, Sidharta Ilyas & Manual of ocular diagnosis and therapy
• Contoh pasien hipermetropia, 25 tahun, tajam penglihatan OD 6/20
– Dikoreksi dengan sferis +2.00 tajam penglihatan OD 6/6
– Dikoreksi dengan sferis +2.50 tajam penglihatan OD 6/6
– Diberi siklopegik, dikoreksi dengan sferis +5.00 tajam penglihatan OD 6/6
ARTINYA pasien memiliki:
– Hipermetropia absolut sferis +2.00 (masih berakomodasi)
– Hipermetropia manifes Sferis +2.500 (tidak berakomodasi)
– Hipermetropia fakultatif sferis +2.500 – (+2.00)= +0.50
– Hipermetropia laten sferis +5.00 – (+2.50) = +2.50
 60. RETINOPATI HIPERTENSI
• Kelainan retina dan pembuluh darah retina akibat tekanan darah
tinggi arteri besarnya tidak teratur, eksudat pada retina,
edema retina, perdarahan retina
• Kelainan pembuluh darah dapat berupa : penyempitan
umum/setempat, percabangan yang tajam, fenomena crossing,
sklerose

Ilmu Penyakit Mata, Sidarta Ilyas, 2005

 Retinopati Hipertensi
• Pemeriksaan rutin:
Pemeriksaan tajam penglihatan
Pemeriksaan biomikroskopi
Pemeriksaan fundus
• Pemeriksaan penunjang:
Foto fundus
Fundus Fluorescein Angiography
• Tatalaksana :
Kontrol tekanan darah dan faktor sistemik
lain (konsultasi penyakit dalam)
Bila keadaan lanjut terjadi pendarahan
vitreous dapat dipertimbangkan
Vitrektomi.

Panduan Praktik Klinik RSCM Kirana

Gambaran Funduskopi Akibat Sklerosis pada Retinopati
Hipertensi
• Lumen pembuluh irreguler
• A-V crossing phenoment
– Assess using arterio-venous crossing
changes
– Due to compression of hard artery an
veins (sharing common adventitia)
• venous deflection at crossing site
(Salus’ sign)
• localised venous narrowing (Tapering of
vein on either side of crossing) (nipping;
Gunns sign)
• right-angled crossing caused by venous
deflection
• venous distal banking (dilating)
(Bonnet’s sign)
• Perubahan refleks aksial
pembuluh darah Ratio
AV menyempit (Normal
2:3)
– Assess using the arteriolar reflex
• brightness
• thickness ratio
– A:V ratio of 25% (1:4) &
arterial reflex ratio of 60%
“copper wiring” (tembaga)
– A:V ratio of <20% (1:5) &
arterial reflex ratio of 100%
“silver wiring” (perak)
 Gambaran Funduskopi (cont…)
• Perdarahan vena (flame shaped)
• Pembuluh darah retina pucat
• Kaliber pembuluh lebih kecil
• Percabangan arteriol lebih tegas
• Soft exudates, cotton wool spot
• Hard Exudates
• macular star
• Papil edema (pada hipertensi maligna)
• Dinding arteriol normalny tidak terlihat;
arteri terlihat sebagai “erythrocyte
column” / “pipa merah” dengan “central • Penebalan yg progresif akan
light reflex” pada funduskopi terjadi menutup gambaran “pipa
penebalan dinding pada retinopati HT merah” sepenuhnya
“central light reflex” lebih difus dan lebar menjadi silver wire
memberikan gambaran dinding arteriol yg
kekuningan/copper wire appearance. • Bersamaan dengan itu,
terjadi fenomena
arteriovenous crossing (AV
crossing) vena yang
berjalan bersilangan di
bawah arteri yang
mengalami arterosklerosis
mengalami deformitas,
berbelok, bulging,
menyempit seperti jam
pasir, atau tampak seperti
terputus akibat penekanan
dari arteri.
Schema of ophthalmoscopic grading of arteriolar sclerosis. (Scheie HG:
Evaluation of ophthalmoscopic changes of hypertension and arteriolar
sclerosis. Arch Ophthalmol 49:117, 1953) http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v3/v3c013.html

http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v3/ch013/005f.html
Hypertensive Retinopathy – Classification
Grade 2
Hypertensive Retinopathy Grade 3 – Diagnostic
Techniques & Signs

Early malignant
Dot and blot haemorrhages
Hard and soft exudates
Diffuse arteriolar narrowing
Arterio-venous crossing defects
Hypertensive Retinopathy Grade 4 – Diagnostic
Techniques & Signs

Advanced malignant
Macular star
Pailloedema
http://www.theeyepractice.com.au/optometrist-sydney/high_blook_pressure_and_eye_disease
Hypertensive Retinopathy – Clinical Pearls
Hypertensive Retinopathy Diabetic Retinopathy
Dry retina: Wet retina:
few haemorrhages multiple haemorrhages
rare oedema extensive oedema
rare exudate multiple exudates
multiple cotton wool spots few cotton wool spots
flame-shaped rare flame-shaped
haemorrhages haemorrhages
visibly abnormal retinal visibly abnormal retinal
arteries veins and capillaries
 Definisi dan gejala

Oklusi Penyumbataan arteri sentralis retina dapat disebabkan oleh radang arteri,
arteri thrombus dan emboli pada arteri, spsame pembuluh darah, akibat
sentral terlambatnya pengaliran darah, giant cell arthritis, penyakit kolagen, kelainan
retina hiperkoagulasi, sifilis dan trauma. Secara oftalmoskopis, retina superficial
mengalami pengeruhan kecuali di foveola yang memperlihatkan bercak merah
cherry(cherry red spot). Penglihatan kabur yang hilang timbul tanpa disertai
rasa sakit dan kemudian gelap menetap. Penurunan visus mendadak biasanya
disebabkan oleh emboli
Oklusi Kelainan retina akibat sumbatan akut vena retina sentral yang ditandai dengan
vena penglihatan hilang mendadak.
sentral Vena dilatasi dan berkelok, Perdarahan dot dan flame shaped , Perdarahan
retina masif pada ke 4 kuadran , Cotton wool spot, dapat disertai dengan atau tanpa
edema papil

Retinopati Mata tenang visus turun perlahan dengan tanda AV crossing – cotton wol spot-
Hipertensi hingga edema papil; copperwire; silverwire

Retinopati Mikroaneorisme, Hard Exudate, Daerah Hipoksia dan Iskemik (cotton wool
Diabetik spot); Neovaskularisasi (NVD, NVE); perdarahan bintik dan bercak; perdarahan
intraretinal
 61. Konjungtivitis
Conjunctivitis is swelling (inflammation) or infection of
the membrane lining the eyelids (conjunctiva)

Pathology Etiology Feature Treatment

Bacterial staphylococci Acute onset of redness, grittiness, topical antibiotics
streptococci, burning sensation, usually bilateral Artificial tears
gonocci eyelids difficult to open on waking,
Corynebacter diffuse conjungtival injection,
ium strains mucopurulent discharge, Papillae
(+)
Viral Adenovirus Unilateral watery eye, redness, Days 3-5 of → worst, clear
herpes discomfort, photophobia, eyelid up in 7–14 days without
simplex virus edema & pre-auricular treatment
or varicella- lymphadenopathy, follicular Artificial tears →relieve
zoster virus conjungtivitis, pseudomembrane dryness and inflammation
(+/-) (swelling)
Antiviral →herpes simplex
virus or varicella-zoster
http://www.cdc.gov/conjunctivitis/about/treatment.html virus
Pathology Etiology Feature Treatment
Fungal Candida spp. can Not common, mostly occur in Topical antifungal
cause immunocompromised patient,
conjunctivitis after topical corticosteroid and
Blastomyces antibacterial therapy to an
dermatitidis inflamed eye
Sporothrix
schenckii
Vernal Allergy Chronic conjungtival bilateral Removal allergen
inflammation, associated atopic Topical antihistamine
family history, itching, Vasoconstrictors
photophobia, foreign body
sensation, blepharospasm,
cobblestone pappilae, Horner-
trantas dots
Inclusion Chlamydia several weeks/months of red, Doxycycline 100 mg PO
trachomatis irritable eye with mucopurulent bid for 21 days OR
sticky discharge, acute or Erythromycin 250 mg
subacute onset, ocular irritation, PO qid for 21 days
foreign body sensation, watering, Topical antibiotics
unilateral ,swollen lids,chemosis
,Follicles
 Konjungtivitis Inklusi
• Disebabkan oleh infeksi Chlamydia trachomatis, biasanya
terdapat pada dewasa muda yang aktif secara seksual.
• Gejala dan tanda :
– Mata merah, pseudoptosis, bertahi mata (terutama pagi hari)
– Papila dan folikel pada kedua konjungtiva tarsus (terutama inferior)
– Keratitis superfisial mungkin ditemukan tapi jarang
 CHLAMYDIAL KONJUNGTIVITIS
EPIDEMIOLOGY SIGNS
• Adult chlamydial conjunctivitis is a • Preauricular lymphadenopathy
sexually transmitted disease (STD) • Mucopurulent discharge
• All ages but particularly young adults • Conjunctival injection
• More women than men affected C. • Chemosis
trachomatis serotypes D-K • Follicular reaction (especially bulbar or
plica semilunaris follicles)
Histopathology: basophilic intracytoplasmic • Superior micropannus
epithelial inclusion bodies (on Giemsa • Fine or coarse epithelial or subepithelial
staining) corneal infiltrates

SYMPTOMS TREATMENT
• Unilateral or bilateral involvement Options include one of the following:
• Purulent discharge, crusting of lashes, • Azithromycin 1000mg single dose
swollen lids, or lids "glued together" • Doxycycline 100mg BID for 7 days
• Patient may also complain of: • Tetracycline 100mg QID x 7 days (avoid in
◦ red eyes pregnant women and in children)
◦ irritation • Erythromycin 500 mg QID x 7 days
◦ tearing Patient and sexual contacts should be
◦ photophobia evaluated and treated for other STDs.
◦ blurred vision
http://www.aao.org/theeyeshaveit/red-eye/chlamydial-conjunctivitis.cfm
 Etiologi Diagnosis Karakteristik
Viral Konjungtivitis folikuler Merah, berair mata, sekret minimal, folikel sangat
akut mencolok di kedua konjungtiva tarsal
Klamidia Trachoma Seringnya pd anak, folikel dan papil pd konjungtiva
tarsal superior disertai parut, perluasan pembuluh
darah ke limbus atas
Konjungtivitis inklusi Mata merah, sekret mukopurulen (pagi hari), papil
dan folikel pada kedua konjungtiva tarsal (terutama
inferior)
Alergi/hiper- Konjungtivitis vernalis Sangat gatal, sekret berserat-serat, cobblestone pd
sensitivitas konjungtiva tarsal superior, horner-trantas dots
(limbus)
Konjungtivitis atopik Sensasi terbakar, sekret berlendir, konjungtiva
putih spt susu, papil halus pada konjungtiva tarsal
inferior
Konjungtivitis Reaksi hipersensitif tersering akibat protein TB,
fliktenularis nodul keabuan di limbus atau konjungtiva bulbi,
mata merah dan berair mata
Autoimun Keratokonjungtivitis sicca Akibat kurangnya film air mata, tes shcirmer
abnormal, konjungtiva bulbi hiperemia, sekret
mukoid, semakin sakit menjelang malam dan
berkurang pagi
62. GERAK BOLA MATA
GERAK BOLA MATA
 63. Sildenafil
• Used in the treatment of erectile dysfunction.
• Ocular side-effects include a bluish tinge to the visual field,
hypersensitivity to light, and hazy vision.
• These effects are reversible and may last only a few minutes or
hours.
• It has been reported that only 3% of patients have visual side-
effects with the standard 50 milligram dose.
• With increased dosage, the ocular side-effect incidence rate
significantly increases.
 64. OKLUSI VENA RETINA SENTRALIS (CENTRAL RETINA
VEIN OCCLUSION)
• Kelainan retina akibat sumbatan
akut vena retina sentral yang
ditandai dengan penglihatan
hilang mendadak.
• Predisposisi :
– Usia diatas 50 thn
– Hipertensi sistemik 61%
– DM 7% -Kolestrolemia
– TIO meningkat
– Periphlebitis (Sarcoidosis, Behset
disease)
– Sumbatan trombus vena retina
sentralis pada daerah posterior
lamina cribrosa)
 Gejala Klinis
1. Tipe Noniskemik : 2. Tipe Iskemik :
• FFA (Fundus Fluorescein Angiography) • FFA area nonperfusi diatas 10 disc
area nonperfusi kecil 10 disc - Gejala lebih
ringan. • Vena dilatasi lebih nyata
• Vena dilatasi ringan dan sedikit • Perdarahan masif pada ke 4
berkelok kuadran
• Perdarahan dot dan flame shaped • Cotton wool spot
• dapat disertai dengan atau tanpa • Rubeosis iridis
edama papil • Marcus Gunn +
• Perdarahan vitreous
• Edama retina dan edama makula
• Pemeriksaan : • Penatalaksanaan :
– FFA (Fundus Fluorescein • Memperbaiki underlying disease
Angiography)
• Fotokoagulasi laser
– ERG (Electroretinogram)
– Tonometri
• Vitrektomi
• Kortikosteroid belum terbuti
efektivitasnya
• Anti koagulasi sistemik tidak
direkomendasikan
 Defini dan gejala
Oklusi arteri Penyumbataan arteri sentralis retina dapat disebabkan oleh radang arteri, thrombus dan
sentral emboli pada arteri, spsame pembuluh darah, akibat terlambatnya pengaliran darah, giant
retina cell arthritis, penyakit kolagen, kelainan hiperkoagulasi, sifilis dan trauma. Secara
oftalmoskopis, retina superficial mengalami pengeruhan kecuali di foveola yang
memperlihatkan bercak merah cherry (cherry red spot). Penglihatan kabur yang hilang
timbul tanpa disertai rasa sakit dan kemudian gelap menetap. Penurunan visus
mendadak biasanya disebabkan oleh emboli
Oklusi vena Kelainan retina akibat sumbatan akut vena retina sentral yang ditandai dengan
sentral penglihatan hilang mendadak.
retina Vena dilatasi dan berkelok, Perdarahan dot dan flame shaped , Perdarahan masif pada ke
4 kuadran , Cotton wool spot, dapat disertai dengan atau tanpa edema papil
Ablatio suatu keadaan lepasnya retina sensoris dari epitel pigmen retina (RIDE). Gejala:floaters,
retina photopsia/light flashes, penurunan tajam penglihatan, ada semacam tirai tipis berbentuk
parabola yang naik perlahan-lahan dari mulai bagian bawah hingga menutup

Retinopati suatu kondisi dengan karakteristik perubahan vaskularisasi retina pada populasi yang
hipertensi menderita hipertensi. Mata tenang visus turun perlahan dengan tanda AV crossing –
cotton wol spot- hingga edema papil; copperwire; silverwire
Amaurosis Kehilangan penglihatan tiba-tiba secara transient/sementara tanpa adanya nyeri,
Fugax biasanya monokular, dan terkait penyakit kardiovaskular
 65. Uveitis
Anterior Intermediate Posterior Panuveitis

Fuchs’ Sarcoidosis Toxoplasmosis Tuberculosis

heterochromic
uveitis
Posner Tuberculosis Acute retinal Sarcoidosis
Schlossman necrosis
syndrome
Infective uveitis Lyme’s disease Behcet’s disease

Arthritis Vogt-Koyanagi-
associated Harada
uveitis
Deepankur Mahajan, Pradeep Venkatesh, S.P. Garg ; Uveitis and glaucoma: a critical review : Journal of Current
Glaucoma Practise, September December 2011; 5(3): 14-30
 Behcet’s Disease

• Chronic, relapsing, occlusive systemic vasculitis

• Etiology unknown
• Affects both anterior & posterior segment
• Type:
– Neuro BD
– Ocular BD
– Intestinal BD
– Vascular BD
 Behçet disease
Oral or genital sores • Uveitis Anterior/Media/Posterior (Panuveítis)
Uveitis • HLA-B51+
Skin lesions

Criteria for Behçet's disease:

Mouth sores (oral ulcers) at least 3 times in 12 months
Any 2 of the following:
•Recurring genital sores/ulcers
•Uveitis
•Skin: Pustules or erythema nodosum
•Positive pathergy (skin prick test)
 Vogt-Koyanagi-Harada Syndrome
• Uncommon multisystem disease of Autoimmune etiology
• Chronic, bilateral, diffuse, granulamatous pan-uveitis
• Associated with Integumentary, Neurologic, Auditory involvement
• Commonly affects darkly pigmented ethnic groups
• History of the disease:
1. Prodromos flu-like-syndrome
2. Acute fase:
– Neurologic symptoms: meningismus, tinnitus, pleocytosis in CFS
– Uveitis
3. Convalescent phase: poliosis, skin/uveal discoloration, poliosis, Sigiura sign (perilimbic
discoloration), vitiligo, alopecia areata
4. Chronic recurrent phase: recurrent anterior uveitis
 Vogt Koyanagi Harada syndrome
1. Prodromus
• Posterior uveitis with serous detachments
2. Neurologic symptoms+ Bilateral
uveitis
• Granulomatous bilateral uveitis
• Late: poliosis, Sigiura sign, sunset-glow fundus
3. Late cutaneous symptoms
 Posner- Schlossman syndrome
• Glaucomatocyclitic crisis
• Mild anterior uveitis with very high IOP
• Discomfort, blurring of vision, haloes, No
pain, No redness
• PG level in aqueous
• unilateral recurrent episodes of mild
cyclitis and heterochromia.
• Its pathogenesis still remains unknown,
with suggested possible associations
including an immunogenetic factor
involving HLA-Bw54, viral infections (HSV
and CMV)
CLINICAL FEATURES:
• mild ciliary flush
• a dilated or sluggishly reactive pupil
• corneal epithelial edema
• open angles (No shallow AC)
• The IOP is in the range of 40 – 70 mmHg
during an acute attack
• Minimal flare
• Few cells
• Few Keratic precipitate
• No pheripheral anterior synechiae and
posterior synechiae
 Reiter syndrome/Reactive arthritis
Urethritis /gastroenteritis
1-5weeks before: • Keratoconjunctivitis+urethritis +arthritis
Ocular
yellowish serous papules at • Previously: urethritis ( can be seen as genital
soles and palms ulcer too) /gastroenteritis
HLAB27+

Infectious
agents: Chlamydiae, Salmonella, Shi
gella, Yersinia, Campylobacter
yellowish serous papules at soles
and palms even nails, scrotum,
scalp and trunk.
66. KELAINAN REFRAKSI – KOREKSI MIOPIA

• Pada miopia, pemilihan kekuatan lensa untuk koreksi

prinsipnya adalah dengan dioptri yang terkecil dengan
visual acuity terbaik.
• Pemberian lensa dgn kekuatan yg lebih besar akan
memecah berkas cahaya terlalu kuat sehingga
bayangan jatuh di belakang retina, akibatnya lensa
mata harus berakomodasi agar bayangan jatuh di
retina.
• Sedangkan lensa dgn kekuatan yg lebih kecil akan
memecah berkas cahaya dan jatuh tepat di retina
tanpa lensa mata perlu berakomodasi lagi.
 MYOPIA
Myopia Concave lens. The smallest
Dioptri to corret the visual
aquity to 6/6
Minus lenses to be used to
correct myopia should be no
stronger than abso-
lutely necessary.
Accommodative asthenopia
(rapid ocular fatigue) results
from the excessive stress
caused by chronic con-
traction of the atrophic ciliary
muscle.
 66. Asthenopia
• Asthenopia (Eyestrain)
– subjective symptoms of ocular fatigue,
discomfort, lacrimation, and headaches arising
from the use of eyes. Weakness or tiring of eyes
accompanied by pain, headache, and dimness of
vision

Eye wiki, American Academy of Ophtalmology

Mukhrejee PK. Clinical Examinattion in Ophtalmology. 2nd edition. Elsevier. 2016
 Classification Of Asthenopia
1. Based on symptoms
– Internal asthenophia
• sensation of strain and aches inside the eye,
• caused by:
– uncorrected refractive error
– convergence insufficiency
– External asthenopia
• dryness, irritation on the ffront of surface of the eye, related to condition in
the viewing environment, associated with glare from lighting, altered quality
of the viewed image owing to poor contrast, improper optimal gaze angles,
flickering stimuli such as computer displays, and dry eye.
2. Based on etiology
• Accommodative asthenopia:
• strain of ciliary muscle and refractive error
• Photogenous asthenopia:
• excessive or improper illumination
• Muscular asthenopia:
• due to imbalance of the extraocular muscles
• Nervous asthenopia:
• due to functional or organize nervous disease

• Differentiate muscular vs accomodative/refractive error

asthenopia
• patch one eye during near vision for 1 week
• If asthenopia persist, it is due to an error refraction
 Aniseikonia
• Condition which images seen by two eyes are unequal in size and shape.
The perception of an image size disparity between the two eyes is due to
the image on the retina not falling on corresponding retinal points
• Etiology:
– High degree of anisometropia
– Congenital or acquired macular dragging
– Cortical disorder
• Symptoms:
– Ocular discomfort, heaviness of the eye, double vision, headache
• Management:
– Refractive correction glasses, contact lense, LASIK
 67. Strabismus/ heterotropia
• Def: deviasi mata yang bermanifestasi (deviasi mata yang laten
Pembagian:
1. Paralitik (nonkonkomitan)
– Sudut deviasi tidak sama ke semua arah
– Disebabkan hilangnya fungsi dari salah satu /lebih dari otot salah satu
mata. Paralisis bisa bersifat parsial ataupun total
2. Non paralitik (konkomitan)
– Seudut deviasi tetap untuk semua arah
– Terdiri dari:
• Akomodatif: berhubungan dengan kelainan refraksi
• Nonakomodatif: tidak ada hubungan dengan kelainan refraksi
• Etiology :
– Genetics,
– Inappropriate development in the brain,
– Problems with the controlled center of the brain,
– Injuries to muscles or nerves or other problems involving the muscles
or nerves.
– Surprisingly, most cases of strabismus are not a result of a muscle
problem, but are due to the control system -- the brain.
 67. Strabismus
A condition in which the eyes are not properly aligned with each other
A lack of coordination between the extraocular muscles

http://www.oculist.net/others/ebook/
 Klasifikasi strabismus berdasarkan arah deviasi:
• Esotropia/ strabismus konvergen/ crossed eye: deviasi mata ke
nasal
• Eksotropia/ stabismus divergen/ wall eye: deviasi mata ke
temporal
• Hipertropia: deviasi mata ke arah atas
• Hipotropia: deviasi mata ke arah bawah
 Esotropia
• Esotropia is a type of strabismus
• One or both eyes turned in toward the nose inward
deviation of the eyes
• Can begin as early as infancy, later in childhood, or even into
adulthood.
• Esotropia can be classified by age of onset (congenital/infantile
vs. acquired); by frequency (intermittent vs. constant); or by
whether it can be treated with glasses (accommodative vs.
non-accommodative).
 Esotropia nonakomodatif
• Deviasi sudah timbul pada waktu lahir/ tahun-tahun pertama
kehidupan
• Deviasi sama ke semua arah dan tidak berhubungan dengan
kelainan refraksi atau kelumpuhan otot
• Penyebab: insersi otot horisontal yang salah, kelainan
persarafan supranuklear
 Esotropia akomodatif
• Accommodative esotropia is defined as the convergent deviation of
the eyes associated with activation of the accommodative reflex.
• Patients with refractive esotropia are typically farsighted
(hyperopic).
• It is classically divided into three categories:
– Refractive accommodative esotropia (low accommodative
convergence/accommodation or AC/A ratio of less than 5),
– Nonrefractive accommodative esotropia (high AC/A ratio), and
– Partially accommodative esotropia
• Calculation of Accommodative Convergence/Accommodation
(AC/A) ratio by the gradient method (measurements with and
without the additional lens are done at the same distance):
 Esotropia akomodatif
• Pada esotropia akomodatif non refraktif, deviasi pada
pengelihatan dekat lebih besar jika dibandingkan penglihatan
jauh.
• Pada esotropia akomodatif refraktif, deviasi pada penglihatan
jauh lebih besar dibandingkan penglihatan dekat
Hirschberg Test
• Corneal light reflex test
• Mengetahui ada tidaknya
strabismus
 Hirschberg method
•The patient fixates a light at a distance of about 33 cm
(13 inches)
•Decentering of the light reflection is noted in the
deviating eye. By allowing 18⁰for each millimeter of
decentration, an estimate of the angle of deviation can
be made

http://www.oculist.net/others/ebook/
 68. Normal Funduscopy

normal
 What to observe

• Optic disc- colour/size/edges

• Cup – size
• Blood vessels – number/width/tortuosity
• Macular / fovea
• Other findings –hemorrhages, soft and hard
exudates, edema
Normal Ocular Fundus

Vessels:
Arterial/venous
Arterioles
diameter ratio 2 to 3;
the arteries appear a
bright red, the veins a
slightly purplish Optic cup
colour.
Fovea

Optic disc

Vein
 Disc: Clear outline
optic cup is pale and
centrally located.
Normal cup/disc ratio <
0.5

http://cms.revoptom.com/osc/3146/Analysis.jpg
Retina: Normal red/orange
colour, macula is dark. The
macula is approximately 2
disc diameters away from disc
and 1.5 degrees below
horizon.
Flame-shaped hemorrhage

Microaneurysm / dot blot hemorrhage

Exudates
Macular edema
Cotton-wool spot
Vitreous hemorrhage
Neovascularization
hard exudate, Hard exudate (infiltrasi lipid ke dalam retina akibat dari peningkatan
permeabiitas kapiler), warna kekuningan
soft exudate/ Soft exudate (cotton wall patches) adalah iskemia retina tampak sebagai
cotton wool spot bercak kuning bersifat difus / warna putih

flame Rupture of superficial pre-capillary arterioles, small veins. Causes:

hemorrhage Systemic hypertension, leukemia, severe anemia, thrombocytopenia,
retinal vein occlusion, trauma
dot hemorrhage Rupture of deep capillaries or venules. They are common in diabetes.
Pada retina terjadi mikroaneurisma (penonjolan dinding kapiler)
Perdarahan dalam bentuk titik, garis, bercak yang letaknya dekat dengan
mikroaneurisma di polus posterior (dot hemorrhage)

Boat Rupture of large superficial retinal veins into the space between the
Hemorrhage retina and vitreous; sometimes these bleeds break into the vitreous
cavity. Causes: Sudden increase in intracranial pressure, anemia,
thrombocytopenia, trauma
drusen Tiny yellow or white accumulations of extracellular material that build
up between Bruch's membrane and the retinal pigment epithelium of
the eye; scattered around the macular region They are the most
common early sign of dry age-related macular degeneration. Drusen are
made up of lipids
http://www.aao.org/theeyeshaveit/optic-fundus/hemorrhages-table.cfm
 69. Defisiensi vitamin A
• Vitamin A meliputi retinol, retinil ester, retinal
dan asam retinoat. Provitamin A adalah semua
karotenoid yang memiliki aktivitas biologi β-
karoten
• Sumber vitamin A: hati, minyak ikan, susu &
produk derivat, kuning telur, margarin, sayuran
hijau, buah & sayuran kuning
• Fungsi: penglihatan, diferensiasi sel, keratinisasi,
kornifikasi, metabolisme tulang, perkembangan
plasenta, pertumbuhan, spermatogenesis,
pembentukan mukus

Kliegman RM. Nelson’s textbook of pediatrics, 19th ed. McGraw-Hill; 2011

• Konjungtiva normalnya memiliki sel goblet. Hilangnya/
berkurangnya sel goblet secara drastis bisa ditemukan pada
xerosis konjungtiva.
• Gejala defisiensi:
– Okular (xeroftalmia): rabun senja, xerosis konjungtiva & kornea,
keratomalasia, bercak Bitot, hiperkeratosis folikular, fotofobia
– Retardasi mental, gangguan pertumbuhan, anemia, hiperkeratosis
folikular di kulit
 Xerophthalmia (Xo)
Stadium :
XN : night blindness (hemeralopia)
X1A : xerosis conjunctiva
X1B : xerosis conjunctiva (with bitot’s spot)
X2 : xerosis cornea
X3A : Ulcus cornea < 1/3
X3B : Ulcus cornea > 1/3, keratomalacea
XS : Corneal scar
XF : Xeroftalmia fundus
 Xeroftalmia
XN. NIGHT BLINDNESS
• Vitamin A deficiency can interfere with rhodopsin production,
impair rod function, and result in night blindness.
• Night blindness is generally the earliest manifestation of
vitamin A deficiency.
• “chicken eyes” (chickens lack rods and are thus night-blind)
• Night blindness responds rapidly, usually within 24—48 hours,
to vitamin A therapy
X1A, X1B. CONJUNCTIVAL XEROSIS AND BITOT’S
SPOT
• The epithelium of the • Conjunctival xerosis first appears
conjunctiva in vitamin A billateraly, in the temporal quadrant,
deficiency is transformed as an isolated oval or triangular patch
from the normal columnar adjacent to the limbus in the
to the stratified squamous, interpalpebral fissure.
with loss of goblet cells,
formation of a granular cell
layer, and keratinization of
the surface.
• Clinically, these changes are
expressed as marked
dryness or unwettability,
the affected area appears
roughened, with fine
droplets or bubbles on the
surface.
 X1A, X1B. CONJUNCTIVAL XEROSIS AND BITOT’S
SPOT
• In some individuals, keratin and • Conjunctival xerosis and Bitot’s
saprophytic bacilli accumulate spots begin to resolve within 2—
on the xerotic surface, giving it a 5 days, most will disappear
foamy or cheesy appearance, within 2 weeks.
known as Bitot’s spots and
they’re easily wiped off)
• Generalized conjunctival xerosis,
involving the inferior and/or
superior quadrants, suggests
advanced vitamin A deficiency.
 X2 CORNEAL XEROSIS
• Corneal changes begin early in vitamin A • Clinically, the cornea develops classical
deficiency, long before they can be seen xerosis, with a hazy, lustreless, dry
with the naked eye which characteristic appearance, first observable near the
are superficial punctate lesions of the inferior limbus
inferior—nasal aspects of the cornea, • Corneal xerosis responds within 2—5 days
which stain brightly with fluorescein to vitamin A therapy, with the cornea
• Early in the disease the lesions are visible regaining its normal appearance in 1—2
only through a slit- lamp biomicroscope weeks
• With more severe disease the punctate
lesions become more numerous,
spreading upwards over the central
cornea, and the corneal stroma becomes
oedematous
X3A, X3B. Corneal ulceration/keratomalacia
• Ulceration/keratomalacia • Superficial ulcers heal with little
indicates permanent scarring, deeper ulcers, especially
destruction of a part or all perforations, form dense peripheral
of the corneal stroma, adherent leukomas.
resulting in permanent • Localized keratomalacia is a rapidly
structural alteration progressive condition affecting the
• Ulcers are classically full thickness of the cornea
round or oval “punched-
out” defects
• The ulceration may be
shallow, but is commonly
deep
 XS. SCARS
• Healed sequelae of prior
corneal disease related to
vitamin A deficiency include
opacities or scars of varying
density (nebula, macula,
leukoma), weakening and
outpouching of the
remaining corneal layers
(staphyloma, and
descemetocele), and
phthisis bulbi.
XF. XEROPHTHALMIC FUNDUS
• The small white retinal
lesions described in some
cases of vitamin A
deficiency
• They may be accompanied
by constriction of the visual
fields and will largely
disappear within 2—4
months in response to
vitamin A therapy
• Gambaran funduskopi “
fenomena cendol”
 Pemeriksaan Penunjang
• A serum retinol study is a costly • The serum retinol level may be
but direct measure using high- low during infection because of a
performance liquid transient decrease in the RBP.
chromatography. • A zinc level is useful because zinc
– A value of less than 0.7 mg/L in deficiency interferes with RBP
children younger than 12 years is production.
considered low.
• A serum RBP study • An iron panel is useful because
iron deficiency can affect the
– easier to perform and less metabolism of vitamin A.
expensive than a serum retinol
study, because RBP is a protein and • Albumin levels are indirect
can be detected by an measures of vitamin A levels.
immunologic assay.
• Obtain a complete blood count
– RBP is also a more stable (CBC) with differential if anemia,
compound than retinol
– However, RBP levels are less
infection, or sepsis is a possibility.
accurate, because they are
affected by serum protein
concentrations and because types
of RBP cannot be differentiated.
 Therapy & Prevention
• Therapy :
- Day 1 : 100.000 IU im or 200.000 IU oral
- Day 2 : 100.000 IU im or 200.000 IU oral
- Day 14 / worsened / before discharge :
200.000 IU im / oral

• Prevention (every 6 months):

- < 6 months : 50.000 IU oral
- 6 – 12 months : 100.000 IU oral
- > 1 year : 200.000 IU oral
 70. Klasifikasi MIOPIA
• Miopia secara klinis :
– Simpleks: kelainan fundus ringan, < -6D
– Patologis: Disebut juga sebagai miopia degeneratif, miopia maligna atau
miopia progresif, adanya progresifitas kelainan fundus yang khas pada
pemeriksaan oftalmoskopik, > -6D
• Miopia berdasarkan ukuran dioptri lensa :
– Ringan (levior): lensa koreksinya 0,25 s/d 3,00 Dioptri
– Sedang (moderate) : lensa koreksinya 3,25 s/d 6,00 Dioptri.
– Berat (gravior): lensa koreksinya > 6,00 Dioptri.
• Miopia berdasarkan umur :
– Kongenital : sejak lahir dan menetap pada masa anak-anak.
– Miopia onset anak-anak : di bawah umur 20 tahun.
– Miopia onset awal dewasa : di antara umur 20 sampai 40 thn.
– Miopia onset dewasa : di atas umur 40 tahun (> 40 tahun).
NEUROLOGI
 71. Post Traumatic Seizures
• Post traumatic seizures (PTS)
– <7 hari, early PTS
– >7 hari, late PTS
• Insidens terjadinya PTS sebesar 50% pada pasien dengan trauma tembus.
Pada pasien-pasien berisiko tinggi lain insiden early PTS 4-25%, late PTS 9-
42%.
• PTS merupakan salah satu komplikasi dari traumatic injury yang dapat
mempengaruhi prognosis
• Pada serangan akut dapat menyebabkan
• penigkatan TIK dan tekanan darah,
• penurunan distribusi oksigen ke otak
• pelepasan neurotransmitter yang berlebih.
Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury. Journal of
Neurotrauma. 2007
• PTS juga berkaitan dengan accidental injury, perubahan
psikologis, dan loss driving of privileges.
• Tindakan pencegahan early PTS terbukti dapat mencegah
terjadinya epilepsi kronik pada pasien dengan cedera
kepala akibat trauma.
• Berikut ini, faktor risiko terbentuknya PTS pada pasien
dengan cedera kepala traumatik:
– GCS <10
– Fraktur depresi tulang kepala
– Hematoma subdural
– Hematoma epidural
– Hematoma intracerebral
– Trauma tembus kepala
– Kejang dalam waktu <24 jam pasca trauma.
• Phenytoin dan asam valproat direkomendasikan untuk
profilaksis early PTS.
Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury. Journal of
Neurotrauma. 2007
Tatalaksana Kejang
 72. Status Epileptikus
• Definisi:
– Kondisi 5 menit atau lebih dari (i) kejang klinis kontinu dan/ atau aktifitas
elektrografi atau (ii) kejang rekuren tanpa ada keadaan sadar diantara dua
kejang.
– Definisi SE diubah dari awalnya 60 menit, 30 menit, pada akhirnya 5 menit
atau lebih:
– Alasan:
• Kejang yang berlangsung lebih dari 5 menit tidak akan berhenti secara spontan
• Kejang >30 menit sudah terdapat kerusakan di substantia nigra, 45 menit – 120
menit dapat terjadi kerusakan di lapis ketiga dan keempat neurokorteks, CA1 dan
CA4 neuron piramidal dari hipokampus.
• Jejas neuronal dan farmakoresisten dapat terjadi sebelum 30 menit kejang kontinu.

Guidelines for the Evaluation and Management of Status Epilepticus. Neurocrit Care DOI
10.1007/s12028-012-9695-z
 Tatalaksana Status Epileptikus
• Status epileptikus adalah keadaan yang mengancam nyawa.

• Tujuan pengobatan : menghentikan kejang yang terjadi secara

klinis dan elektrofisiologis.

• Tatalakana :
1. Lakukan CAB (Circulation, Airway, Breathing)
2. Hentikan kejang
3. Cari penyebab
4. Mengatasi penyebab
Behrouz, R. : JAOA • Vol 109 • No 4 • April 2009 •
 Algorithm for the Initial Management of Status Epilepticus
1. Assess and control airway
2. Monitor vital signs (including temperature)
3. Conduct pulse oximetry and monitor
cardiac function
4. Perform rapid blood glucose assay

Start intra venous infusion

Administer thiamine (100 mg)
and glucose (50 ml of 50 percent dextrose)

Start anticonvulsant therapy

Take focused history and examine patient Perform laboratory studies

Known seizure disorder or other illnesses? Complete blood count
Trauma? Serum electrolytes and
Focal neurologic signs? calcium
Signs of medical illnesses (e.g., infection, Arterial-blood gas
hepatic or renal disease, substance abuse)? Liver function
Renal function
Toxicology
Serum antiepileptic-drug
concentrations

Undertake further workup to

DANIELH. LOWENSTEIN, M.D.,AND BRIAN K. ALLDREDGEPHARM.D . define cause
The New England Journal of Medicine April 2, 1998 Manage other medical problems
73. Neuralgia Trigeminal (Tic Douloureux)
74. N. Iskhiadikus

• Nyeri neuropati
• Paresthesia
• Kelemahan progresif pada ekstremitas
bawah dengan kesulitan berjalan
Penatalaksanaan

1. Penatalaksanaan umum
– Istirahat lebih kurang 2-3 minggu
– Analgetik
– NSAID
– Rehabilitasi (Mobilisasi)
2. Penatalaksanaan khusus
– Diberikan sesuai dengan etiologi ischialgia
 75. HNP
• HNP (Hernia Nukleus Pulposus) yaitu : keluarnya
nucleus pulposus dari discus melalui robekan annulus
fibrosus keluar ke belakang/dorsal menekan medulla
spinalis atau mengarah ke dorsolateral menakan saraf
spinalis sehingga menimbulkan gangguan.

Fakultas Kedokteran UI, Kapita Selekta Kedokteran Jilid 2, Media Acsculapius, Jakarta 2000, hal; 54-57.
 Gejala Klinis
• Adanya nyeri di pinggang bagian bawah yang menjalar ke bawah (mulai
dari bokong, paha bagian belakang, tungkai bawah bagian atas).
Dikarenakan mengikuti jalannya N. Ischiadicus yang mempersarafi kaki
bagian belakang.
1. Nyeri mulai dari pantat, menjalar kebagian belakang lutut, kemudian ke tungkai
bawah. (sifat nyeri radikuler).
2. Nyeri semakin hebat bila penderita mengejan, batuk, mengangkat barang berat.
3. Nyeri bertambah bila ditekan antara daerah disebelah L5 – S1 (garis antara dua
krista iliaka).
4. Nyeri Spontan, sifat nyeri adalah khas, yaitu dari posisi berbaring ke duduk nyeri
bertambah hebat. Sedangkan bila berbaring nyeri berkurang atauhilang.

Fakultas Kedokteran UI, Kapita Selekta Kedokteran Jilid 2, Media Acsculapius, Jakarta 2000, hal; 54-57.
 76. Parkinson
• Parkinson:
– Penyakit neuro degeneratif karena gangguan pada ganglia basalis akibat
penurunan atau tidak adanya pengiriman dopamine dari substansia nigra
ke globus palidus.
– Gangguan kronik progresif:
• Tremor resting tremor, mulai pd tangan, dapat meluas hingga bibir & slrh kepala
• Rigidity cogwheel phenomenon, hipertonus
• Akinesia/bradikinesia gerakan halus lambat dan sulit, muka topeng, bicara lambat,
hipofonia
• Postural Instability berjalan dengan langkah kecil, kepala dan badan
doyong ke depan dan sukar berhenti atas kemauan sendiri
• Hemibalismus/sindrom balistik
– Gerakan involunter ditandai secara khas oleh gerakan melempar dan
menjangkau keluar yang kasar, terutama oleh otot-otot bahu dan
pelvis.
– Terjadi kontralateral terhadaplesi
• Chorea Huntington
– Gangguan herediter autosomal dominan, onset pada usia
pertengahan dan berjalan progresif sehingga menyebabkan kematian
dalam waktu 10 ± 12 tahun
 Parkinson Disease
Gejala dan Tanda Parkinson
Gejala awal tidak spesifik Gejala Spesifik

• Nyeri • Tremor
• Gangguan tidur • Sulit untuk berbalik badan
•Ansietas dan depresi di kasur
•Berpakaian menjadi lambat •Berjalan menyeret
•Berjalan lambat •Berbicara lebih lambat

Tanda Utama Parkinson :

1. Rigiditas : peningkatan tonus otot

2. Bradykinesia : berkurangnya gerakan spontan (kurangnya kedipan mata, ekspresi
wajah berkurang, ayunan tangan saat berjalan berkurang ), gerakan
tubuh menjadi lambat terutama untuk gerakan repetitif
3. Tremor : tremor saat istirahat biasanya ditemukan pada tungkai, rahang dan
saat mata agak menutup
4. Gangguan berjalan dan postur tubuh yang membungkuk
 Penatalaksanaan Parkinson
• Prinsip pengobatan parkinson adalah
meningkatkan aktivitas dopaminergik di
jalur nigrostriatal dengan memberikan :
– Levodopa diubah menjadi dopamine
di substansia nigra
– Agonis dopamine
– Menghambat metabolisme dopamine
oleh monoamine oxydase dan cathecol-
O-methyltransferase
– Obat- obatan yang memodifikasi
neurotransmiter di striatum seperti
amantadine dan antikolinergik

Wilkinson I, Lennox G. Essential Neurology 4th edition. 2005

77. Inervasi Otot Ekstraokuler

Goetz, Christopher G. Textbook of clinical neurology. 3rd ed. Philadelphia:

Saunders; 2007.
Goetz, Christopher G. Textbook of clinical neurology. 3rd ed. Philadelphia:
Saunders; 2007.
 78. Klasifikasi Nyeri
• Klasifikasi Nyeri - Nyeri secara esensial dapat dibagi atas dua
tipe yaitu nyeri adaptif dan nyeri maladaptif.
• Nyeri adaptif berperan dalam proses survival dengan
melindungi organisme dari cedera atau sebagai petanda
adanya proses penyembuhan dari cedera.
• Nyeri maladaptif terjadi jika ada proses patologis pada sistem
saraf atau akibat dari abnormalitas respon sistem saraf. Kondisi
ini merupakan suatu penyakit (pain as a disease).
Woolf, C. J., 2004: Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management,
Ann Intern Med; 140:441-451
 Klasifikasi Nyeri
1. Nyeri Nosiseptif
• Nyeri dengan stimulasi singkat dan tidak menimbulkan kerusakan
jaringan.
• Pada umumnya, tipe nyeri ini tidak memerlukan terapi khusus
karena perlangsungannya yang singkat.
• Nyeri ini dapat timbul jika ada stimulus yang cukup kuat sehingga
akan menimbulkan kesadaran akan adanya stimulus berbahaya,
dan merupakan sensasi fisiologis vital.
• Intensitas stimulus sebanding dengan intensitas nyeri.
• Contoh: nyeri pada operasi, nyeri akibat tusukan jarum, dll.
Woolf, C. J., 2004: Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management,
Ann Intern Med; 140:441-451
2. Nyeri Inflamatorik
• Nyeri dengan stimulasi kuat atau berkepanjangan yang
menyebabkan kerusakan atau lesi jaringan.
• Nyeri tipe II ini dapat terjadi akut dan kronik dan pasien
dengan tipe nyeri ini, paling banyak datang ke fasilitas
kesehatan.
• Contoh: nyeri pada rheumatoid artritis.

3. Nyeri Neuropatik
• Merupakan nyeri yang terjadi akibat adanya lesi sistem
saraf perifer
• Seperti pada neuropati diabetika, post-herpetik neuralgia,
radikulopati lumbal, dll) atau sentral (seperti pada nyeri
pasca cedera medula spinalis, nyeri pasca stroke, dan nyeri
pada sklerosis multipel).
Woolf, C. J., 2004: Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management,
Ann Intern Med; 140:441-451
4. Nyeri Fungsional

• Bentuk sensitivitas nyeri ini ditandai dengan tidak ditemukannya

abnormalitas perifer dan defisit neurologis.
• Nyeri disebabkan oleh respon abnormal sistem saraf terutama
hipersensitifitas aparatus sensorik.
• Beberapa kondisi umum memiliki gambaran nyeri tipe ini yaitu
fibromialgia, iritable bowel syndrome, beberapa bentuk nyeri dada
non-kardiak, dan nyeri kepala tipe tegang.
• Tidak diketahui mengapa pada nyeri fungsional susunan saraf
menunjukkan sensitivitas abnormal atau hiper-responsifitas
Woolf, C. J., 2004: Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management,
Ann Intern Med; 140:441-451
 79. Migrain
• Migren: nyeri kepala primer dengan kualitas vaskular (berdenyut), diawali
unilateral yang diikuti oleh mual, fotofobia, fonofobia, gangguan tidur dan
depresi
• Penyebab Idiopatik (belum diketahui hingga saat ini) :
• Gangguan neurobiologis
• Perubahan sensitivitas sistem saraf
• Avikasi sistem trigeminalvaskular
• Pada wanita migren lebih banyak ditemukan dibanding pria dengan skala 2:1.
Faktor Predisposisi
• Menstruasi biasa pada hari pertama menstruasi atau sebelumnya/
perubahan hormonal.
• Puasa dan terlambat makan
• Makanan misalnya akohol, coklat, susu, keju dan buahbuahan.
• Cahaya kilat atau berkelip
• Banyak tidur atau kurang tidur
• Faktor herediter
• Faktor kepribadian
Kriteria Diagnosis Migrain
 Alur Tatalaksana Migrain Akut

Gilmore B, Michael B. Treatment of Acute Migrain. AAFP Volume 83, Number 3 . 2011
 Penatalaksanaan Migrain
• Pada saat serangan pasien dianjurkan untuk menghindari stimulasi sensoris berlebihan.
• Bila memungkinkan beristirahat di tempat gelap dan tenang dengan dikompres dingin

Pengobatan Abortif :
1. Analgesik spesifik analgesik khusus untuk nyeri kepala.
– Lebih bermanfaat untuk kasus yang berat atau respon buruk dengan NSAID. Contoh: Ergotamin,
Dihydroergotamin, dan golongan Triptan (agonis selektif reseptor serotonin / 5-HT1)
– Ergotamin dan DHE migren sedang sampai berat apabila analgesik non spesifik kurang terlihat
hasilnya atau memberi efek samping.
– Kombinasi ergotamin dengan kafein bertujuan untuk menambah absorpsi ergotamin sebagai
analgesik. Hindari pada kehamilan, hipertensi tidak terkendali, penyakit serebrovaskuler serta
gagal ginjal.

IDI. Panduan praktik klinis bagia dokter di fasilitas pelayanan kesehatan primer. Ed I.2013
2. Analgesik non-spesifik
Yakni: analgesik yang dapat digunakan pada nyeri selain nyeri kepala

Respon terapi dalam 2 jam (nyeri kepala residual ringan atau hilang
dalam 2 jam)
• Aspirin 600-900 mg + metoclopramide
• Asetaminofen 1000 mg
• Ibuprofen 200-400 mg

Terapi Profilaksis (The U.S. Headache Consortium’s)

• Diberikan pada orang yang memiliki KI atau intoleransi terhadap terapiabortif
• Nyeri kepala muncul lebih dari 2 hari/minggu
• Nyeri kepala yang berat dan mempengaruhi kualitas hidup (walau telah diberi
terapi abortif)
• Gejala migrain jarang including hemiplegic migraine, basilar migraine, migraine
with prolonged aura, or migrainous infarction
• Terapi preventif jangka pendek pasien akan terkena faktor risiko yang telah
dikenal dalam jangka waktu tertentu, misalnya migren menstrual.
• Terapi preventif kronis diberikan dalam beberapa bulan bahkan tahun tergantung
respon pasien.
Terapi Profilaksis
 Nyeri Kepala Kluster
Trigeminal Autonomic Cephalgias
Nyeri kepala yang bersifat lateral dan sering disertai dengan gejala otonom parasimpatis
nervus kranial

Nyeri Kepala Kluster

• Nyeri kepala berat
• Lokasi unilateral (orbital, supraorbital, temporal atau gabungan ketiganya),
• Berlangsung 15 – 18 menit,
• Dapat muncul sekali sehari hingga delapan kali per hari
•Disertai injeksi konjungtiva ipsilateralm lakrimasi, kongesti nasal, rhinorea, keringat
pada dahi atau wajah, miosis, Ptosis dan/atau edema kelopak mata, agitasi
 Kriteria Diagnosis Nyeri Kepala Klaster

Setidaknya 5 kali serangan nyeri kepala yang sesuai kriteria A-C

A. Nyeri orbita, supraorbita,
dan/atau temporal
unilateral yang sifatnya
berat atau sangat berat.
Berlangsung selama 15 –
180 menit (bila tidak
diobati)
B. Frekuensi serangan antara
satu kali hingga 8 kali per
hari
C. Salah satu atau kedua dari berikut :
1. Setidaknya satu atau lebih gejala
ini menyertai nyeri kepala
ipsilateral
a. Injeksi konjungtiva dan/atau lakrimasi
b. Kongesti nasal dan/atau rhinorea
c. Edema palpebra
d. Keringat atau kemerahan pada dahi
dan wajah
e. Rasa penuh pada telinga
f. Miosis dan/atau ptosis
2. Adanya agitasi atau gelisah
 Penatalaksanaan Nyeri Kepala Klaster

• Tidak ada pengobatan definitif untuk nyeri kepala klaster.

• Tujuan terapi yaitu mengurangi derajat nyeri, memperpendek periode
nyeri kepala dan mencegah serangan berikutnya

Pengobatan Akut Obat Pencegah

1. Oksigen : dosis 12 L/menit gejala 1. CCB (verapamil)
menghilang dalam waktu 15 2. Kortikosteroid
menit 3. Lithium karbonat
2. Triptan (Sumatriptan) 4. Blok nervus (injeksi obat
3. Ocreotide (somatostatin sintetis) anastesi dan kortikostreoid di
4. Anastesi Lokal (intranasal) nervus oksipitalis)S
5. Dihydroergotamine 5. Ergot
6. Melatonin
80. Circulus arteriosus Wilisi
Anatomy and Vascular Territories of the 3 Main Cerebral Arteries:
Middle Cerebral Artery
Anterior Cerebral Artery and Posterior Cerebral Artery
Cortical Areas Supplied by the
MCA, ACA and PCA
DEFICITS IN A PATIENT WITH A STROKE CAN BE EXPLANED BY:

1. AREAS OF THE BRAIN

2. CIRCULATION OF THE BRAIN
3. AND/OR A COMBINATION OF BOTH

385
 A STROKE IN
FRONTAL LOBE

BLOOD SUPPLIED
BY ACA AND MCA

THIS PATIENT MAY EXPERIENCE:

• Contralateral paralysis or paresis of face, arm, leg

• Difficulty expressing language “ stuttering, using wrong word,

articulation, repeating word(s)”
(BROCA’S APHASIA)

• Urinary incontinence

• Personality changes and emotional lability

386
 A STROKE IN
PARIETAL LOBE

BLOOD SUPPLIED BY
ACA, MCA, PCA

THIS PATIENT MAY EXPERIENCE

• Sensory deficit – loss of sensation i.e. pain, pressure, touch

• Neglect – patient does not recognize a body part

• Denial of deficits (often with neglect)

387
 A STROKE IN
TEMPORAL LOBE

BLOOD SUPPLIED
BY MCA AND PCA

THIS PATIENT MAY EXPERIENCE

• Severe communication problem : loss of comprehension of spoken language

( Receptive Aphasia also called Wernicke’s Aphasia)

• Memory loss or disturbances in memory

• Aggressiveness

388
 A STROKE IN
OCCIPITAL LOBE

BLOOD SUPPLIED BY
MCA AND PCA

THIS PATIENT MAY EXPERIENCE

VISUAL DISTURBANCES
• Types of blindness- total or hemianopsia’s

• Loss of recognition of objects when shown them

• Hallucinations

389
 Oxford Stroke Classification
Diagnosis:

All three of the following:

1. Unilateral weakness (and/or sensory
deficit) of face, arm and leg
2. Homonymous hemianopia
TACS 3. Higher cerebral dysfunction (dysphasia,
visuospatial disorder)
Total anterior circulation stroke
Large cortical stroke in middle / anterior
cerebral artery areas. Diagnosis:

PACS: Two of:

1. Unilateral weakness (and/or sensory
Partial Anterior Circulation Syndrome deficit) of face, arm and leg
(PACS) Cortical stroke in middle / anterior 2. Homonymous hemianopia
cerebral artery areas. 3. Higher cerebral dysfunction (dysphasia,
Oxford Stroke visuospatial disorder)

Classification POCS:
(Arteri cerebri posterior, arteri vertebralis,
Diagnosis:
arteri basiler )
Posterior Circulation Syndrome One of
1. Cerebellar or brainstem syndromes
LACS: 2. Loss of consciousness
3. Isolated homonymous hemianopia
Also known as Bamford classification
Lacunar Syndrome (LACS)
Subcortical stroke due to small vessel dis.
Diagnosis:
No evidence higher cerebral dysfunction
and
one of:
Unilateral weakness (and/or sensory deficit)
of face and arm, arm and leg or all three.
Pure sensory stroke.
Ataxic hemiparesis.
80. Lokasi Anatomi Stroke
Harrison’s Principle of Internal Medicinie. 7th ed.
 ILMU
PSIKIATR I
 81. Gangguan Somatoform
• Dalam DSM IV, gangguan somatoform meliputi:
– Gangguan somatisasi
– Gangguan konversi
– Hipokondriasis
– Gangguan dismorfik tubuh
– Gangguan nyeri somatoform

• Gangguan Dismorfik Tubuh

– ditandai oleh preokupasi adanya cacat pada tubuhnya hingga menyebabkan
penderitaan atau hendaya yang bermakna secara klinis.
– Jika memang ada kelainan fisik yang kecil, perhatian pasien pada kelainan
tersebut akan dilebih-lebihkan.

Sadock BJ, Sadock VA. Somatoform disorders. Kaplan & Sadock’s Synopsis of Psychiatry. 10th ed.
Philadelphia: Lipincott William & Wilkins; 2007. p.634-51.
 Gangguan Somatoform
Diagnosis Karakteristik
Gangguan somatisasi Banyak keluhan fisik (4 tempat nyeri, 2 GI tract, 1
seksual, 1 pseudoneurologis).
Hipokondriasis Keyakinan ada penyakit fisik.

Disfungsi otonomik Bangkitan otonomik: palpitasi, berkeringat,

somatoform tremor, flushing.

Nyeri somatoform Nyeri menetap yang tidak terjelaskan.

Gangguan Dismorfik Preokupasi adanya cacat pada tubuhnya

Tubuh Jika memang ada kelainan fisik yang kecil,
perhatian pasien pada kelainan tersebut akan
dilebih-lebihkan

PPDGJ
 DSM-IV-TR Diagnostic Criteria for
Body Dysmorphic Disorder

A. Preokupasi terhadap kelainan yang tidak

nyata atau sedikit defek yang terlihat. Bila
terdapat sedikit anomali fisik yang terlihat, maka
pasien akan merasa khawatir atau
memperhatikan secara berlebihan
B. Preokupasi menyebabkan distres dan disfungsi
dalam sosial, pekerjaan dan bidang lainnya.

• Avoidance of social situations or anxiety in social situations, depression,

behaviors to modify appearance, etc.
 Appearance Complaints in
Patients with BDD

Hair Nose Head

shape
Skin Eyes Body
build
Lips Chin Entire
face
Stomach Teeth Breasts
 BDD?
Further Evaluation and Treatment
If BDD appears to be present:
A) referral for psychological/psychiatric evaluation
ask for evaluation of BDD, along with other possible co-
morbid conditions (e.g., depression, anxiety)
B) if any of these conditions are present, consider referral
for
psychological treatment (cognitive-behavioral therapy,
medications)
C) if BDD and other conditions ruled out, consider
treatment:
extensive pre-treatment briefings regarding
expectations of outcome
 82. Methadone Treatment
Outcome Data: • Increased employment
• 8-10 fold reduction in death rate • Improved physical and mental
• Reduction of drug use health
• Reduction of criminal activity • Reduced spread of HIV
• Engagement in socially • Excellent retention
productive roles; improved family
and social function
 Methadone vs Heroin
• Can be taken by mouth
• Slow onset of action
• No continuing increase in tolerance
levels after optimal dose is reached;
relatively constant dose over time
• Patient on stable dose rarely
experiences euphoric or sedating
effects; is able to perceive pain and
have emotional reactions; can
perform; can perform daily tasks
normally and safely
• Long acting; prevents withdrawal
for 24-36 hours (4x-6x as long as
heroin), permitting once-a day-
dosing
• At sufficient dosage, blocks
euphoric effect of normal street
doses of heroin
• Medically safe when used on long-
term basis (10 years or more)
Starting dose
 Titration
To achieve effective maintenance
dose:
– eliminates withdrawal symptoms
for more than 24 hours
– blocks the euphoric effects of
opioids
– reduces or eliminates drug craving
– does not induce excess sedation
– dose increases should be no more
than 5–10 mg at a time
– the interval between dose
adjustments should never be less
than five days, but may need to be
longer due to the above risk factors
– patients should be seen frequently
(at least weekly) during titration
phase
• Most patients will achieve stability on maintenance doses of
60 to 120 mg daily
• Once a daily dose of 80 mg is reached further dose increases
should be made with caution, not exceeding 10 mg every five
to seven days
• Those who receive a dose of 40 mg a day or less are five times
more likely to drop out of treatment
 83. Defense Mechanism IN OCD
• Defence/defense mechanisms : psychological strategies
brought into play by the unconscious mind to manipulate,
deny, or distort reality and to maintain a socially acceptable
self-image or self-scheme
• From a psychoanalytic perspective, 3 major psychological
defensive mechanisms of obsessive-compulsive symptoms
and character traits : isolation, undoing, and reaction
formation
Isolation :
• Splitting/separating an idea from the affect
that accompanies it but is repressed.
• Protects an individual from anxiety-provoking
affects and impulses
• Characteristic of the orderly, controlled
people. Remember the truth in fine detail but
without affect
Undoing :
• a compulsive act that is performed in an
attempt to prevent or undo the consequences
that the patient irrationally anticipates from a
frightening obsessional thought or impulse

Reaction Formation :
• manifest patterns of behavior and consciously
experienced attitudes that are exactly the
opposite of the underlying impulses
Defense Mech. Definition
Projection Attributing one’s own
thoughts, feelings or motives
to another
Conversion Cognitive tensions manifest
themselves in physical
symptoms. The symptom may
well be symbolic and dramatic
and it often acts as a
communication about the
situation, such as paralysis,
blindness, deafness, becoming
mute or having a seizure.
Identification Bolstering self-esteem by
forming an imaginary or real
alliance with some person or
group
Rasionalization Creating false but plausible
excuses to justify
unacceptable behavior
Example
if you have a strong dislike for
someone, you might instead
believe that he or she does
not like you
A person's arm becomes
suddenly paralyzed after they
have been threatening to hit
someone else.
An insecure young man joins a
fraternity to boost his self-
esteem
a student stealing money from
a wealthy friend of his, telling
himself “Well he is rich, he can
afford to lose it.
Defense Mechanism
84. Defense Mechanism
• Almost always
pathological
• Appears insane and
irrational
• These are the psychotic
defense
• Found in dreams and
throughout childhood
Acting Out
Projection
85. PERVASIVE DEVELOPMENTAL DISORDER (PDD)

mild severe

Asperger’s PDD Not Autistic Rett’s disorder Childhood

disorder Otherwise disorder disintegrative
Classified disorder
(PDD-NOS)

Autism spectrum disorder (ASD)

Autism Spectrum Disorder (ASD)
 Asperger, PDD-NOS, Autism
PDD-NOS
Impaired social interaction
OR
Impaired communication
OR
Restricted repetitive and
stereotyped patterns or
behaviors
Autism
Impaired social interaction
AND
Impaired communication
AND
Restricted repetitive and
stereotyped patterns or
behaviors
Asperger
Impaired social interaction
AND
Normal communication/
language development
AND
Restricted repetitive and
stereotyped patterns or
behaviors
Pedoman Diagnosis Autisme (DSM-IV)
 86. Reaksi Terhadap Stres Berat
• Gangguan stres pascatrauma
– kondisi yang ditandai oleh munculnya gejala (gangguan otonomik,
afek, & tingkah laku) setelah melihat, mengalami, atau mendengar
peristiwa traumatis dalam kurun waktu 6 bulan.

• Gangguan stres akut

– Gangguan yang serupa dengan gangguan stres pascatrauma, yang
muncul segera setelah kejadian
 Reaksi Terhadap Stres Berat
• Kriteria Diagnosis reaksi stres pascatrauma
– Individu terpajan situasi (melihat, mengalami, menghadapi) yang melibatkan
ancaman kematian atau cedera serius atau ancaman lain yang serupa.
– Adanya bayang-bayang kejadian yang persisten, berupa gambaran, pikiran,
persepsi, atau mimpi buruk. Individu mengalami gejala penderitaan bila terpajan
pada ingatan akan trauma aslinya.
– perilaku menghindar dari bayang-bayang dan pikiran tentang kejadian traumatis
(termasuk orang, tempat, dan aktivitas), dan dapat tidak ingat aspek tertentu
dari kejadian.
– Adanya gejala peningkatan kesiagaan yang berlebih seperti insomnia,
iritabililta, sulit konsentrasi, waspada berlebih.
– Gejala menyababkan hendaya pada fungsi sosial atau pekerjaan.
87. CHILDHOOD ANXIETY DISORDER (1)

• Children worry excessively about a variety of things such as

grades, family issues, relationships with peers, and
Generalized Anxiety performance in sports.
Disorder
• Children with GAD tend to be very hard on themselves and
strive for perfection.

• If child suffers at least two unexpected panic or anxiety

attacks—which means they come on suddenly and for no
Panic Disorder
reason—followed by at least one month of concern over
having another attack or losing control.

• A child experiences excessive anxiety away from home or

when separated from parents or caregivers. Extreme
homesickness and feelings of misery at not being with loved
Separation Anxiety ones are common.
Disorder
• Other symptoms include refusing to go to school, camp, or a
sleepover, and demanding that someone stay with them at
bedtime.

https://adaa.org/living-with-anxiety/children/childhood-anxiety-disorders
CHILDHOOD ANXIETY DISORDER (2)

• Social anxiety disorder, or social phobia, is characterized by an intense

Social Anxiety Disorder fear of social and performance situations and activities such as being
called on in class or starting a conversation with a peer.

• Children who refuse to speak in situations where talking is expected or

necessary, to the extent that their refusal interferes with school and
making friends, may suffer from selective mutism.
Selective Mutism • These children can be very talkative and display normal behaviors at
home or in another place where they feel comfortable. Parents are
sometimes surprised to learn from a teacher that their child refuses to
speak at school.

• Most children with OCD are diagnosed around age 10, although the
Obsessive-Compulsive disorder can strike children as young as two or three. Boys are more
Disorder (OCD) likely to develop OCD before puberty, while girls tend to develop it
during adolescence.

• A specific phobia is the intense, irrational fear of a specific object, such

as a dog, or a situation, such as flying. Common childhood phobias
Specific Phobias
include animals, storms, heights, water, blood, the dark, and medical
procedures.

https://adaa.org/living-with-anxiety/children/childhood-anxiety-disorders
 87. Ansietas Masa Kanak
• Gangguan ansietas perpisahan masa kanak:
– Ansietas berkaitan dengan perpisahan dari tokoh yang
akrab (orang tua atau kerabat)
– Bentuk ansietas:
• Kekhawatiran mendalam tokoh itu pergi & tidak kembali
• Enggan masuk sekolah karena takut berpisah
• Terus-menerus enggan/menolak tidur tanpa ditemani tokoh
kesayangannya tsb
• Terus-menerus takut yang tidak wajar untuk ditinggal seorang
diri)
• Mimpi buruk berulang tentang perpisahan.
• Sering timbul gejala fisik (rasa mual, sakit kepala, sakit perut,
muntah) pada peristiwa perpisahan.
• Rasa susah berlebihan pada saat sebelum, selama, atau sehabis
berlangsungnya perpisahan.

PPDGJ
 88. Conversion Disorder
DSM-IV-TR Criteria
• One or more symptoms or deficits affecting voluntary motor
or sensory function that suggest a neurological or other
general medical condition.
• Psychological factors are judged to be associated with the
symptom or deficit because the initiation or exacerbation of
the symptom or deficit is preceded by conflicts or other
stressors
• The symptom or deficit is not intentionally produced or
feigned (as in factitious disorder or malingering).
• The symptom or deficit cannot, after appropriate
investigation, be fully explained by a general medical
condition, or by the direct effects of a substance, or as a
culturally sanctioned behavior or experience
 Conversion Disorder
DSM-IV-TR Criteria
• The symptom or deficit causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning or warrants medical evaluation.
• The symptom or deficit is not limited to pain or sexual
dysfunction, does not occur exclusively during the course of
somatization disorder, and is not better accounted for by
another mental disorder.
– Specify type of symptom or deficit:
• with motor symptom or deficit
• with sensory symptom or deficit
• with seizures or convulsions
• with mixed presentation
 Conversion Disorder
Clinical Features and Differential Diagnosis

• Most common symptoms

– Paralysis
– Blindness
– Mutism
• The most important conditions in the differential
diagnosis are neurological or other medical disorders
and substance-induced disorders
89. Gangguan Pengendalian Impuls
Diagnosis:
• Tidak dapat menahan suatu perilaku yang
membahayakan bagi dirinya atau orang lain
• Penderita biasaya merasakan adanya
peningkatan intensitas ketegangan sebelum
melakukan tindakan tersebut
• Pasien akan merasakan kesenangan,
kenikmatan, dan kelegaan setelah melakukan
tindakan tersbut
• Dapat diikuti dengan perasaan menyesal,
atau merasa bersalah
 Intermittent Explosive
Kleptomania
Disorder
Characteristics: Characteristics
• These clients have episodes • Irresistible impulse to steal
during which they act out unneeded objects repeatedly.
aggressively. • “Tension and release"
• They physically harm others or characterizes this behavior.
destroy property.
• Not due to any other mental
disorder.
 Pathological
Pyromania
Gambling
Characteristics: Characteristics:
• Deliberate and purposeful fire • Repeatedly gambling, often until
setting on more than one
occasion. money is lost, jobs are given up,
• Fire setting not done for and friends leave.
monetary gain or other • Gamblers are often
"objective reasons."
restless/irritable when cut down
• Tension or arousal before act.
or gambling is stopped.
• Fascination with fire and its
situational contexts.
• Pleasure and relief in setting and
witnessing fires.
 Trichotillomania
Characteristics
• High comorbidity with:
• Pulling hair from various parts – Mood disorders
of the body – Anxiety disorders (especially obsessive
• Accompanied by feelings of compulsive disorder)
“tension and release” from – Substance abuse
distress or – Eating disorders
pleasure/gratification. – Personality disorders
Epidemiologi – Mental retardation
• Seems to be equally common
among males and females in
children
• Among adults, more common
in females
• Overall prevalence is unclear,
but it is relatively uncommon
 Trichotillomania
• Sites of hair pulling include anywhere on the body where hair may
grow
• May occur in brief periods scattered throughout the day or in less
frequent but longer periods that can continue for hours
• Hair pulling often occurs while the person is in a state of relaxation
or distraction (e.g., while reading a book or watching TV.) but can
also occur during stressful circumstances
• For some, tension does not necessarily precede the hair pulling but
is associated with attempts to resist the impulse
– Some people experience an “itch like” sensation that is eased by pulling
the hair
 Trichotillomania
• Hair pulling usually does not occur around other people (except family
members) but social situations may be avoided
• Individuals frequently try to find ways to hide their behavior or camouflage
the results
• Some may have impulses to pull hair from other people or objects
• Associated behaviors include:
– Examining the hair root
– Pulling the hair strand between teeth
– Eating hairs
– Nail biting
– scratching
 90. Intoksikasi opiate
Physical exams • Neurological
• Vitals – Sedation or coma
– HR decreased or unchanged – Seizure (meperidine, propoxyphene,
– BP decreased or unchanged tramadol, or 2/2 hypoxia)
– RR decreased (decreased tidal volume) • Ophthalmologic
– Temp decreased or unchanged – miosis
• GI
– Decreased bowel sounds
 Management
• Initial focus on airway and breathing
• Administer IV naloxone
– Apneic pts and pts with extremely
low RR should be ventilated by bag-
valve mask attached to O2 to
reduce ALI.
• Apneic pts should receive 0.2-
1mg
• Pts in cardiopulmonary arrest
should be given minimum of
2mg
• When spontaneous ventilations are
present, give initial dose of 0.05mg
and titrate upward every few minutes
until RR >12.
– The goal of naloxone is NOT a
normal level of consciousness, but
adequate ventilation.
• In the absence of signs of opioid
withdrawal, there is no maximum safe
dose; if clinical effect does not occur
after 5-10mg, reconsider your
diagnosis
91. Psychiatry Emergency
 Bunuh Diri
• Definisi:
– sebuah perilaku pemusnahan secara sadar yang ditujukan pada diri sendiri
oleh seorang individu yang memandang bunuh diri sebagai solusi terbaik
dari sebuah isu
• Percobaan bunuh diri (Suicidal attempt)
– upaya untuk membunuh diri sendiri dengan intensi mati tetapi belum
berakibat pada kematian
• Pikiran bunuh diri (Suicidal ideation)
– pikiran untuk membunuh diri sendiri tanpa melakukan bunuh diri secara
eksplisit

Maris dkk.,2000 http://id.wikipedia.org/wiki/Bunuh_diri

 92. Ansietas
Diagnosis Characteristic
Gangguan panik Serangan ansietas yang intens & akut disertai dengan
perasaan akan datangnya kejadian menakutkan.
Tanda utama: serangan panik yang tidak diduga tanpa
adanya provokasi dari stimulus apapun & ada keadaan yang
relatif bebas dari gejala di antara serangan panik.
Gangguan fobik Rasa takut yang kuat dan persisten terhadap suatu objek atau
situasi, antara lain: hewan, bencana, ketinggian, penyakit,
cedera, dan kematian.
Gangguan Gejala emosional (ansietas/afek depresif ) atau perilaku
penyesuaian dalam waktu <3 bulan dari awitan stresor. Tidak
berhubungan dengan duka cita akibat kematian orang lain.
Gangguan cemas Ansietas berlebih terus menerus disertai ketegangan motorik
menyeluruh (gemetar, sulit berdiam diri, dan sakit kepala), hiperaktivitas
otonomik (sesak napas, berkeringat, palpitasi, & gangguan
gastrointestinal), kewaspadaan mental (iritabilita).
• Gangguan panik
– Serangan ansietas yang intens & akut disertai dengan
perasaan akan datangnya kejadian menakutkan.
– Tanda utama: serangan panik yang tidak diduga tanpa
adanya provokasi dari stimulus apapun & ada keadaan
yang relatif bebas dari gejala di antara serangan panik
– Tanda fisis:
• Takikardia, palpitasi, dispnea, dan berkeringat.
• Serangan umumnya berlangsung 20-30 menit, jarang
melebihi 1 jam.
– Tatalaksana: terapi kognitif perilaku + antidepresan.

PPDGJ
Kaplan & Sadock synopsis of psychiatry.
 Tatalaksana Gangguan Panik
• Cognitive-Behavioral Therapy
– This is a combination of cognitive
therapy
– Cognitive therapy modify or
eliminate thought patterns
contributing to the patient’s
symptoms
– Behavioral therapy aims to
help the patient to change his or
her behavior.
– Cognitive-behavioral therapy
generally requires at least eight
to 12 weeks
• Some people may need a longer
time in treatment to learn and
implement the skills
http://www.aafp.org/afp/2005/0215/p733.html
• Medication
– SSRIs
• the first line of medication treatment
for panic disorder
– Tricyclic antidepressants
– High-potency benzodiazepines
• Ex: Clonazepam
• may cause depression and are
associated with adverse effects during
use and after discontinuation of
therapy
• Poorer outcome and global functioning
than antidepresant
– monoamine oxidase inhibitors
(MAOIs)
• Combination Therapy
• Psychodynamic therapy
– help to relieve the stress that
contributes to panic attacks, they do
not seem to stop the attacks directly
 Ven XR :Venlafaxine extended release
• SNRI : Serotonin norephinephrine
reuptake inhibitor

http://www.currentpsychiatry.com/home/article/panic-
disorder-break-the-fear-
circuit/990b7a325883ba278cdf8e46222a61f9.html
 93. Patofisiologi depresi
Neurochemistry and Brain Areas • Anti-depressant drugs such as
• Depression - (SER, NE, DA) in limbic Prozac increase brain SER
system function in animal studies.
• OCD - (SER) in orbitofrontal • It is inferred that decreased brain
cortex, cingulate cortex, caudate SER function is one of the causes
nucleus of depression in humans.
• Indirect evidence supports this
• Acetylcholine (ACh)
• Dopamine (DA)
• Serotonin (SER)
• Gamma aminobutyric acid
(GABA)
• Endorphins (END)
• Glutamate (GLU)
 94. Post Partum Blues
• Post partum blues
– Sering dikenal sebagai baby blues
– Mempengaruhi 50-75% ibu setelah proses melahirkan
– Sering menangis secara terus-menerus tanpa sebab yang pasti dan
mengalami kecemasan
– Berlangsung pada minggu pertama setelah melahirkan biasanya
kembali normal setalah 2 minggu tanpa penanganan khusus
– Tindakan yang diperlukan menentramkan dan membantu ibu
• Post partum Depression
– Kondisi yang lebih serius dari baby blues
– Mempengaruhi 1 dari 10 ibu baru
– Mengalami perasaan sedih, emosi yang meningkat, tertekan, lebih
sensitif, lelah, merasa bersalah, cemas dan tidak mampu merawat
diri dan bayi
– Timbul beberapa hari setelah melahirkan sampai setahun sejak
melahirkan
– Tatalaksana psikoterapi dan antidepresan
• Postpartum Psychosis
– Kondisi ini jarang terjadi
– 1 dari 1000 ibu yang melahirkan
– Gejala timbul beberapa hari dan berlangsung beberapa minggu
hingga beberapa bulan setelah melahirkan
– Agitasi, kebingungan, hiperaktif, perasaan hilang harapan dan malu,
insomnia, paranoia, delusi, halusinasi, bicara cepat, mania
– Tatalaksana harus segera dilakukan, dapat membahayakan diri dan
bayi
 95. Mental Retardation
• Three major criteria for mental retardation:
1) significant limitations in intellectual functioning,
2) significant limitations in adaptive functioning, and
3) onset before age 18 years.

• Classification of MR based on IQ should be tested

 Mental Retardation
Diagnosis of Mental Retardation (continued)
• Mild mental retardation is the designation for those with IQ
scores between 50–55 and 70.
• People with mild mental retardation typically have few, if any,
physical impairments, generally reach the sixth-grade level in
academic functioning, acquire vocational skills, and typically live
in the community with or without special supports.

Copyright © Prentice Hall 2007

 Mental Retardation
Diagnosis of Mental Retardation (continued)
• People with moderate mental retardation have IQs between 35–40
and 50–55.
• They may have obvious physical abnormalities such as the features of
Down syndrome.
• Academic achievement generally reaches second-grade level, work
activities require close training and supervision, and special
supervision in families or group homes is needed for living in the
community.
Copyright © Prentice Hall 2007
 Mental Retardation
Diagnosis of Mental Retardation (continued)
• Severe mental retardation is defined by IQ scores between
20–25 and 35–40.
• At this severity level, motor development typically is
abnormal, communicative speech is sharply limited, and
close supervision is needed for community living.

Copyright © Prentice Hall 2007

 Mental Retardation
Diagnosis of Mental Retardation (continued)
• Profound mental retardation is characterized by an IQ below
20–25.
• Motor skills, communication, and self-care are severely
limited, and constant supervision is required in the
community or in institutions.

Copyright © Prentice Hall 2007

 American
Association on
Mental
Retardation
(AAMR)

http://pedsinreview.aappublications.org/content/27/6/204.full
KULIT & KELAMIN,
MIKROBIOLOGI,
PARASITOLOGI
96
 97. Reaksi Reversal
REAKSI LESI
Eritema nodosum -Pada tipe MB (BL,LL)
leprosum -Nodus eritema dan nyeri
-Predileksi : lengan dan tungkai
-Tidak terjadi perubahan tipe
Reaksi -Pada tipe borderline (Li,BL,BB,BT,Ti)
reversal/borderline/ -Terjadi perubahan tipe
upgrading - Lesi menjadi lebih aktif/timbul lesi baru
-Peradangan pada saraf dan kulit
-Pada pengobatan 6 bulan pertama
Fenomena lucio -Reaksi kusta yang sangat berat
-Pada tipe lepromatosa non-nodular difus
-Plak/infiltrat difus, merah muda, bentuk tidak teratur, nyeri
(+). Jika lebih berat dapat disertai purpura dan bula
-Dimulai dari ekstremitas lalu menyebar ke seluruh tubuh
Djuanda A., Hamzah M., Aisah S., 2008, Ilmu Penyakit Kulit dan Kelamin edisi 5. Jakarta: FKUI hal 82-83
• L

E.N.L

Lucio’s phenomenone

Reversal reaction of leprosy

 98. Pemfigoid Bullosa
Kelainan Penjelasan
Pemfigus vulgaris Penyakit kulit autoimun berbula kronik, menyerang kulit
dan membran mukosa yang secara histologik ditandai
dengan bula intraepidermal akibat proses akantolisis dan
secara imunopatologik ditemukan antibodi terhadap
komponen desmosom pada permukaan keratinosit jenis
IgG, baik terikat maupun beredar dalam darah. Khas: bula
kendur, bila pecah menjadi krusta yang bertahan lama,
nikolsky sign (+)
Pemfigoid bulosa Perbedaan dengan pemfigus vulgaris: keadaan umum
baik, dinding bula tegang , bula subepidermal, terdapat
IgG linear
 Pemphigus Vulgaris Pemphigus Vulgaris Bullous Pemphigoid

Pemphigus Foliceus
Cicatricial Pemphigoid
Paraneoplastic Pemphigus e.c
Castleman tumor
Cleared when the tumor removed
 99. Entamoeba Histolytica
• Kista matang dikeluarkan bersama tinja
penderita Infeksi Entamoeba histolytica
(berinti empat) tinja mengkontaminasi
pada makanan, air, atau oleh tangan. Terjadi
ekskistasi (3) terjadi dalam usus dan
berbentuk tropozoit (4) selanjutnya,
bermigrasi ke usus besar. Tropozoit
memperbanyak diri dengan cara membelah
diri (binary fission) dan menjadi kista (5),
menumpang dalam tinja.
• Kista dapat bertahan beberapa hari -
berminggu-minggu pada keadaan luar
• Dalam banyak kasus, tropozoit akan kembali
berkembang menuju lumen usus (A:
noninvasive infection) pada carier yang
asimtomatik, kista ada dalam
tinjanya. Pasien yang diinfeksi oleh tropozoit
di dalam mukosa ususnya (B: intestinal
disease), atau, menuju aliran darah, secara
ekstra intestinal menuju hati, otak, dan paru
(C: extraintestinal disease), dengan berbagai
kelainan patologik.
Morfologi Entamoeba histolytica memiliki bentuk trofozoit dan kista. Trofozoitnya
memiliki ciri-ciri morfologi :
– Ukuran 10 – 60 μm
– Sitoplasma bergranular dan mengandung eritrosit, yang merupakan penand
penting untuk diagnosisnya
– Terdapat satu buah inti entamoeba, ditandai dengan karyosom padat yang
terletak di tengah inti, serta kromatin yang tersebar di pinggiran inti
– Bergerak progresif dengan alat gerak ektoplasma yang lebar, disebut
pseudopodia.
 Terapi Entamoeba Hystolitica
• Metronidazole (DOC)
– 3x500-750 mg selama 5-10 hari

• Tinidazole
– Dewasa 2 gr / hari selama 3 hari dalam dosis
terbagi

• Emetin hidroklorida
– Dewasa: maks. 65 mg / hari
– Anak dibawah 8 tahun: 10 mg / hari
– Lama pengobatan: 4-6 hari

• Klorokuin
– Dewasa 1 gr/ hari selama 2 hari, kemudian 500
mg sehari selama 2-3 minggu

• Antibiotika: Tetrasiklin & Eritromisin

– Dosis: 25 mg/kgBB/hari selama 5 hari dalam
dosis terbagi
 Giardiasis
Anerior membulat

Trofozoit
Kista

Trofozoit:
- Pear shaped
Flagel Inti - Sepasang
nukleus seperti mata
- Pada bagian ventral
Posterior tajam terdapat alat
isap untuk menempel
di mukosa usus
 Giardiasis
• Etiologi: Giardia interstinalis dikenal sebagai Giardia
lamblia (protozoa)
Akut: berbau, mual, distensi
• Gejala klinis: abdomen, demam, tidak ada darah
dalam tinja
Dapat asimptomatik
Diare bisa menjadi akut/kronik
Ekskresi lemak meningkat steatorrhea Kronik: nyeri dan distensi
• Terapi: abdomen, tinja berlendir, dan BB
turun
DOC: metronidazole 2x500 mg selama 5-7hari
Alternatif: Tinidazole 2 gr PO SD (anak: 50 mg/kgBB
PO SD)
 Balantidiasis
• Etiologi: Balantidium coli
• Morfologi:
- Bentuk oval, ukuran panjang 50-80µ, lebar 60 µ
- Dua nukleus (makro dan mikro)
- Cillia, vakuol
- Bentuk kista: oval atau bulat

~70 x 45 m ~55 m
(up to 200 m)
 Balantidium Coli: Gejala dan Tanda

• Kebanyakan asimptomatik meskipun terdapat kista atau

trofozoit dalam feses

• Diare kronik, disentri sesekali, mual, napas bau, kolitis, nyeri

perut
 Balantidiasis: Terapi
• Tetracycline
– Dewasa: 500 mg, PO, 4x/hari selama 10 hari
– Anak ≥ 8 tahun: 40 mg/kg/hari (max. 2 gram), PO, 4x/hari
selama 10 hari
– Note: kontraindikasi pada wanita hamil dan anak < 8 tahun

• Metronidazole
– Dewasa: 500-750 mg, PO, 3x/hari selama 5 hari
– Anak: 35-50 mg/kg/hari, PO, 3x/hari selama 5 hari

• Iodoquinol
– Dewasa: 650 mg, PO, 3x/hari selama 20 hari
– Anak: 30-40 mg/kg/hari (max 2 g), PO, 3x/hari selama 20 hari

http://www.cdc.gov/dpdx/balantidiasis/tx.html
 100. Uretritis Non GO
• Etiologi:
– Chlamydia trachomatis dan beberapa jenis bakteri
lainnya termasuk ureaplasma urealyticum,
mycoplasma, dan trichomonas
– gejala seperti pada GNO. GNO disebarkan secara
seksual terutama kontak seksual tanpa
perlindungan, seksual per oral, atau pun seksual
per anal.
• Gejala: menyerupai uretritis GO
• Pewarnaan Gram: Tidak dijumpai diplokokus
 Uretritis Non GO
• Terapi:
– Azitromisin 1 g PO
– Doxisiklin
• Dosis : Awal : 200 mg/hari terbagi 2 kali sehari PO/IV atau IV diberikan
1x/hari,
• Lanjut : dosis rumatan : 100 – 200 mg/ hari terbagi tiap 12 jam PO/IV