MASALAH ORGAN RESPIRASISKDI 2006Lampiran 1

A. Daftar Masalah Individu (116)Masalah yang sering dijumpai (4)

B. Daftar masalah komunitas

1. BATUK 2. SESAK NAPAS 3. NYERI DADA 4. PANAS BADAN

= PROBLEMS =

HIPOTESIS : BATUK

GI tract : - GERD

Sistem Pertahanan Paru

REFLEKS BATUK

Komponen utama

Reseptor batuk

Serabut saraf aferen

Pusat batuk

Susunan saraf eferen

Efektor

Histologi bronkus

Surface view of bronchiolar epithelium shows tufts of cilia (Ci) forming on individual ciliated cells and microvilli (MV) on other cells. Note secretion droplet in process of release from goblet cell (arrow).

3 fase mekanisme batuk : (1) fase inspirasi

(2) fase kompresi dan (3) fase ekspirasi

4 fase :(1) fase iritasi(2) inspirasi

(3) kompresi (4) ekspulsi

Bronkitis Akut - Cindy Thung FKUPH

Komponen refleks batukReseptor Aferen Pusat

batukEferen Efektor

LaringTrakeaBronkusTelingaPleuraLambung

HidungSinus paranasalis

Faring

PerikardiumDiafragma

Cabang nervus vagus

Nervus trigeminus

Nervus glosofaringus

Nervus frenikus

Tersebar merata di medula oblongata dekat pusat pernafasan,di bawah kontrol pusat yang lebih tinggi

Nervus vagus

Nervus frenikus intercostal dan lumbaris

Saraf-saraf trigeminus, fasialis, hipoglosus, dan lain-lain

Laring. Trakea dan bronkus

Diafragma, otot-otot intercostal, abdominal, dan otot lumbal

Otot-otot saluran nafas atas, dan otot-otot bantu nafas

Penyebab Batukberdasarkan saraf aferen yang distimulasi

Sputum

Bening • Iritasi traktus respiratorius• Infeksi oleh virus

Kuning dan bau khas (nanah) •Bronkiektasis, abses paru, pneumoni karena stafilokok

Hijau keruh & bau busuk •Infeksi dengan kuman penyebab kuman anaerob

Bintik-bintik hitam dam dahak •Polusi udara berat

Warna seperti karat besi & panas tinggi •Pneumonia karena Pneumococcus

Seperti jelly kismis /kurma disertai panas tinggi •Pneumonia dengan Klebsiella

Klasifikasi Batuk Hati-hati awal batuk kronik!!

TRIA

D DIA

GNOSIS

BATUK KRONIK

Guideline for International Classification of Diseases, Ninth Revision [ICD-9]

URTI ACUTE BRONCHITIS

SINUSITIS VIRAL FOREIGN BODY ASPIRATION

LVHF

EPIDEMI - Symptoms usually last for more than 1 week but less than 4 weeks- Disease that swell the nasal mucous membrane, such as viral or allergic rhinitis, are usually the underlying cause

SYMPTOMS -Pain is usually unilateral over the maxillary sinus or is toothache-like- Change of secretions from mucoid to purulent green or yellow-Postnasal drainage, headache, and cough may also be present

SIGNS - Occasional visible swelling or erythema over a sinus

LAB. FINDING

ETIOLOGY - HIPOTESIS

HEMATOLOGI

HEART LUNG

MUSCULOSCELETAL

METABOLIC

JIWAKIDNEY

DYSPNEA GI

LAIN-LAIN :Anatomi, Fisiologi, Lingkungan

SESAK

Pulmo

Non-Pulmo

Obstruktif Pleura & parenkim Obs.Sal. Imm.DiagVas.

noninfeksius

Asma BPPOKOSA Antharx

pneumoni

• Efusi pleura

• pneumothoraks

Emboli paru

Hipertensi pulmonal

Kanker laring

Aspirasi paru

Tumor diafragma

Lesi N.phenicu

s

Fraktur iga

KifosisObesiti

scoliosis

HAPEBarotrau

ma

CO

hamil

AnxietasPanic attack

histeria

ALSGBSMGMS

GERDAnemia leukimia

sepsis

Kardiomyopathy

Pulmonary edema

CHFAVM

Anatomis Kardiovaskuler Hematogenik GI Neuromuskular Psikis Fisiologis Linkungan

Acute dyspnea

• Asthma• Pulmonary infection• Pulmonary edema• Pneumothorax• Pulmonary embolism• Metabolic acidosis• ARDS• Panic attacks

Acute dyspnea• Orthopnea (dypnea on recombency) & nocturnal dyspnea :

asthma, GERD, left ventricular dysfunction or OSA• Rapid onset of severe dyspnea when supine :

phrenic nerve impairment leading to diaphragmatic weakness or paralysis

• Platypnea ( dyspnea that worsen in the upright position ):arteriovenous malformations at the lung basis or hepatopulmonary syndrome, resulting in increased shunting and hypoxemia in the upright position ( orthodeoxia )

Lain-lain :- Asma B : ringan-sedang-berat-mengancam jiwa- Pneumotoraks ventil – ikan koi- KAD : Kusmaul

Differential Diagnosis of Acute Dyspnea

• Anxiety / hyperventilation• Asthma• Chest trauma• Pneumothorax dan Spontaneous pneumothorax• Fractured ribs• Pulmonary contusion• Pulmonary edema• Pulmonary embolism

ASTHMA BR PNEUMOTORAKS SPONTAN

PULM EDEMA EMBOLI PARU(Pulm Venous Thromboembolism)

EPIDEMI - Predisposition to venous thrombosis, usually of lower extremities

SYMPTOMS -Episodic or chronic symptoms of airflow obstruction: breathlessness, cough, wheezing, and chest tightness.- Symptoms frequently worse at night or in the early morning

- Acute onset of unilateral chest pain and dyspnea.

-Acute onset or worsening of dyspnea at rest.

- One or more of following: dyspnea, chest pain, hemoptysis, syncope.

SIGNS - Prolonged expiration and diffuse wheezes on physical examination

-Minimal physical finding in mild cases; unilateral chest expansion, decreased tactile fremitus, hyperresonance, diminished breath sounds, mediastinal shift, cyanosis and hypotensionin tension pneumothorax.- Presence of pleural air on chest radiograph

-Tachycardia, diaphoresis, cyanosis.- pulmonary rales, ronchi; expiratory wheezing

Tachypnea and a widened alveolar-arterial PO₂

LAB. FINDING - Limitation of airflow on pulmonary function testing or positive bronchoprovocation challenge.- Complete or partial reversibility of airflow obstruction, either spontaneously or following bronchodilator therapy

- Radiograph shows interstitial and alveolar edema with or without cardiomegaly.- Arterial hypoxemia

- Characteristic defects on V-Q lung scan, helical CT scan on the chest, or pulmonary arteriogram

ANXIETY CHEST TRAUMA PULMONARY CONTUSION

RIBS FRACTURES

-This causes widespread fluffy shadowon the chest X-ray owing to intrapulmonary haemorrhage.- This may give rise to ARDS

- Caused by trauma or coughing (particularly in the elderly), and can occur in patients with osteoporesis.- Pathological fractures are due to metastatic spread from Ca of the the bronchus, breast, kidney, prostate or thyroid.

SYMPTOMS - Overt anxiety or an overt manifestation of a defence mechanism (eg, a phobia), or both.-Not limited to an adjusment disorder.- Somatic symptoms referable to the autonomic nervouss system (eg, dyspnea, palpitations, paresthesia).- Not a result of physical disorders, psychiatric conditions (eg, schizophrenia), or drug abuse.

-Rib can also become involved by a mesothelioma.- Pain prevents adequate chest expansion and coughing and this can lead to pneumonia.- Fractures may not be readily visible on a PA chest X-ray, so lateral X-rays and oblique views may be necessary.

SIGNS - Tx. Is with adequate oral analgesia, by local infiltration or an intercostal nerve block.-Two fractures in one rib can lead to a flail segment with paradoxical movement, ie part of the chest wall moves inwards during inspiration.

LAB. FINDING This can produce inefficient ventilation and may require IPPB, especially if several ribs are similarly affected.

Differential diagnosis of chronic dyspnea :

1. Respiratory– Airway disease

• Upper airway obstruction– Asthma– COPD– Cystic fibrosis

– Parenchymal lung disease• Interstitial lung disease• Malignancy – primary or metastatic• pneumonia

– Pulmonary vascular disease• Arteriovenous malformations• Intravascular obstruction• Vasculitis• Venous occlusive disease

– Pleural disease• Effusion• Fibrosis• Malignancy

– Chest wall disease• Deformities (e.g. kyphoscoliosis)• Abdominal “loading” (e.g. ascites, pregnancy, obesity)

– Respiratory muscle disease• Neuromuscular disorders (e.g. myasthenia gravis, polio)• Phrenic nerve dysfunction• Weakness

2. Cardiovascular– Decreased cardiac output• Cardiomyopathy– Dilated– Hypertrophic– Infiltrative– Ischemic– Valvular disease– Pericardial disease– Congenital disease

– Increased pulmonary venous pressure• Diastolic dysfunction– Hypertrophic disease– Ischemia

• Mitral stenosis• Pulmonary venous occlusive disease• Right-to-left shunt

3. Hematology : Anemia 4. Anatomy : Kyphoscoliosis berat5. Psychological : anxiety 6. Neurology : GBS, myasthenia gravis , polio 7. Deconditioning 8. GIT : gastric asthma9. High altitude : Acute Mountains Sickness, HAPE; Barotrauma, 10. Renal : Chronic renal failure11. Endocrinology : KAD

CHEST PAIN

CARDIOVASCULAR

PULMONARY

GASTROINTESTINALMUSCULOSKLETAL

PSYCHOGENIC

Pleural Mediastinal Gastrointestinal Muskuloskeletal

Sifat Tajam, menusuk-nusuk, seperti di iris

Tumpul, rasa terbakar Tumpul , rasa terbakar Tajam

Lokasi Terlokalisir Sentral/retrosternal/substernal

Retrosternal Setempat (sesuai kelainan otot dada )

Penjalaran - Menjalar ke leher, bahu, lengan kiri

Menjalar ke punggung, bahu dan lengan

Sepanjang perjalanan otot

Faktor memperberat

Semakin berat saat batuk/inspirasi

Aktifitas fisik Makan dan menelan Bertambah berat saat inspirasi Dan gerakan otot/skletal. Akktivitas fisik.

Faktor memperingan

Menahan nafas atau sisi dada yang sakit digerakan

nitrogliserin Antasid Istirahat

NYERI DADA

Table : DD of Chest Pain1. Angina pectoric / myocardial infarction2. Other cardiavascular caues

a. Likely ischemic in origin(1) Aortic stenosis (2) Hypertrophic cardiomyopathy(3) Severe Systemic hypertension (4) Severe anemia/hypoxia(5) Severe right ventricular hypertension (6) Aortic regurgitation

b. Nonischemic in origin(1) Aortic dissection (2) Pericarditis (3) Mitral valve prolapse

3. Gastrointestinala. Esophageal b. Esophageal refluxb. Esophageal rupture d. Peptic ulcer disease

4. Psychogenica. Anxiety b. Depression c. Cardiac psychosis d. Self gain

5. Neuromusculoskeletala. Thoracic outlet syndrome b. Costochondritis (Tietze’s syndrome)c. Herpes zoster d. Chest wall pain and tendernesse. Degenerative joint diseaseof cervical/thoracic spine

6. Pulmonary a. Pneumothorax b. Pneumonia with pleural involvementc. Pulmonary embolus with or without plmonary infarction

7. Pleurisy

CARDIOVASCULAR

ANGINA PECTORIS

MYOCARDIAL INFARCTION

PERICARDITIS

AORTA DISEKANS

Ardiac failure

Angina pectoris Myocardial infarction Pericardits Aortic dissection

EPIDEMIOLO

A history of hypertension or Marrfan’s syndrome is often present

SYMPTOMS

Precordial chest pain, usually precipitated by stress or exertion, relieved rapidly by rest or nitrates

Sudden but not instantaneous development of prolonged (30 minutes) anterior chest discomfort (sometimes felt as “gas” or pressure) that may produce arrhythmias, hypotension, shock, or cardiac failure.Sometimes painless, masqueriding as acute CHF, syncope, stroke, or shock.

Substernal chest pain, which is relieved by sitting forward. Pain is less common in purulent pericarditis & has a gradual onset in TB dis.

- Sudden severe chest pain with radiation to the back, occasionally migrating to the abdomen and hips.

SIGNS 3 component friction rub early; rub later disapears with increased pericardial fluid.Pulsus paradoxicus (exceeding 10 mmHg is abnormal

-Patient appears to be in shock, but blood pressure isnormal or elevated; pulse discrepancy in many patients- acute aortic regurgitation may develop

LABORATORY FINDING

ECG or scintigraphic evidence of ischemia during pain or stress testing.Angiographic demonstration of significant obstruction of major coronary vessels.

ECG:ST-segment elevation or depression, evolving Q waves, symmetric inversion of Twaves.Elevatin of cardiac markers(CK-MB, troponin T, or troponin I ).Appearance of segmental wall motion abnormality by imaging techniques.

PULMONARY

Emboli paru

Pneumothorax

Pneumonia

Pleuritis/efusi pleura

Tracheobronchitis

PNEUMOTHORAX PNEUMONIA PLEURAL EFFUSION

PULM VENOUS THROMBOEMBOLISM

TRACHEOBRONCHITIS

EPIDEMIO Occurs out side of the hospital or less than 48 hours after admission in a patient who is not hospitalized or residing in a long-term care facility for more than 14 days before the onset of symptoms

Predisposition to venous thrombosis, usually of the lower extremities

SYMPTOMS Acute onset of unilateral chest pain & dyspnea

Fever or hypothermia, cough with or without sputum, dysnea, chest discomfort, sweat, or rigors.

May be asymptomatic; chest pain frequently seen in the setting of pleuritis, trauma, or infection; dyspnea is common with large effusions

One or more of the following: dyspnea, chest pain, hemoptysis, syncope

SIGNS Minimal physical findings in mild cases; unilateral chest expansion, decreased tactile fremitus, hyperresonance, diminihed breath sounds, medistinal shift, cyanosis & hypotension in tension

Bronchial breath sounds or rales are frequent auscultatory findings

Dullness to percussion & decreased breath sounds over the effusion

Tachypnea & a widened alveolar-arterial PO₂ difference

LABORATORY FINDING

Presence of pleural air on chest radiograph

Parenchymal infiltrates on chest radiograph

Radiographic evidence of pleural effusionDiagnostic finding on thoracentesis

Characteristic defects on V-Q lung scan, helical CTscan of the chest, or pulmonary arteriogram

PENYAKIT PARU KOMPETENSI DOKTER UMUM

PNEUMOTHORAK PNEUMONIA EFUSI PLEURA

EPIDEMIOLOGI

LAKI-LAKI KURUS USIA 10-30 TAHUN

RESIKO KEMATIAN MENINGKAT DI AMERIKA SERIKAT PADA USIA LANJUT DAN PECANDU ALKOHOL

PADA PRIA DAN WANITA DISEMUA USIA DI NEGARA BERKEMBANG

SIGN •PENURUNAN SUARA NAFAS•PENURUNAN VOCAL FREMITUS•PENURUNAN PERGERAKAN DINDING DADA•PADA PERKUSI DIDAPATKAN HIPERSONOR•ADA EFEK DESAKAN PADA DAERAH MEDIASTINUM DAN TRAKEA

•DEMAM ATAU HIPOTERMI•TAKIPOE, TAKIKARDY,•RONKHI

•PENURUNAN SUARA NAPAS VOCAL FREMITUS PADA PALPASI•DIDAPATKAN SUARA REDUP PADA PERKUSI

SYMPTOMS •NYERI DADA MINIMAL –BERAT PADA SELURUH LAPANG PARU •SESAK NAFAS

•DEMAM AKUT ATAU SUBAKUT•BATUK DENGAN ATAU TANPA SPUTUM•SESAK NAPAS •GEJALA LAIN: RIGORS,BERKERINGAT, RASA TIDAK NYAMAN PADA DADA, BATUK DARAH, LEMAH LESU, ANOREXIA, SAKIT KEPALA, NYERI PERUT, DAN PLEURISY

•KADANG KADANG ASIMPTOMATIK, TETAPI BIASANYA ADA NYERI DADA YANG DISERTAI PLEURITIS, TRAUMA DAN INFEKSI•TERDAPAT SESAK NAPAS PADA EFUSI YANG MASIF

PENUNJANG •RONTGEN THORAK RONTGEN THORAK •RONTGEN THORAX

GASTROINTESTINAL

GASTRITIS

GERD

INFECTIOUS ESOPHAGITIS

PEPTIC ULCER DISEASE

GERD GASTRITIS(GASTROPATHY)

INFECTIOUS ESOPHAGITIS

PEPTIC ULCER DISEASE

EPIDEMIOLOGY Most commonly seen in alcoholics, critically ill patients, or patients taking NSAIDS

Immunosuppressed patient

HISTORY OF NONSPECIFIC EPIGASTRIC PAIN PRESENT IN 80-90% OF PATIENTS WITH VARIABLE RELATIONSHIP TO MEALS

SYMPTOMS Heartburn; may be exacerbatad by meals, bending, or recumbency

Often asymptomatic; may cause epigastric pain, nausea, and vomiting.May cause hematemesis; usually not significant bleeding

Odynophagia, dysphagia, and chest pain

ULCER SYMPTOMS CHARACTERIZED BY RHYTHMICITY & PERIODICITYOF NSAIDS-INDUCED ULCERS, 30-50% ARE ASYMPTOMATIC10-20% OF PATIENTS PRESENT WITH ULCER COMPLICATIONS WITHOUT ANTECEDENT SYMPTOMS

SIGNS

LABORATORY FINDING Endoscopy demonstrates abnormalities in 50% of patients.Barium esophagoscophy seldom helpfull

Endoscopy with biopsy establishes diagnosis

UPPER ENDOSCOPY WITH ANTRAL BIOPSY FOR h PYLORI IS THE DIAGNOSTIC PROCEDURE OF COISE IN MOST PATIENTS

MUSKULOSKLETAL

Chest wall pain and tenderness

Kostokondritis (tietze’s syndrome)

Herpes zoster

Thoracic outlet syndrome

Degenerative joint disease of cervical/thoracic spine

Chest wall pain and tenderness

Herpes zoster Kostokondritis (tietze’s syndrome)

Thoracic outlet syndrome

Degenerative joint disease of cervical/thoracic spine

EPIDEMI

SYMPTOMS

SIGNS

LAB. FINDING

PSIKOGENIK

Anxietas

Depression

Cardiac neurosis

ANXIETAS DEPRESSION CARDIAC NEUROSIS

EPIDEMIOLOGY

SYMPTOMS Overt anxiety or an overt manifestation of a defense mechanism (such as a phobia), or both.Not limited to an adjustment disorder.Somatic symptoms referable to the autonomic nervous systemor to a specific organ system (eg., dyspnea, palpitations, paresthesias).Not a result of physical disorders, psychiatric conditions (eg, schizophrenia), or drug abuse (eg, cocaine)

Lowered mood, varying from mild sadness to intense feeling of guilt, worthlessness, & hopelessness.Difficulty in thinking, including inability to concentrate, ruminations, & lack of decisiveness.Loss of interest, with diminished involvement in work recreation.Somatic complaints such as headache, disrupted, lessened, excessive sleep; lost of energy; change in appetite; decseaed sexual driveanxiety

SIGNS

LABORATORY FINDING

FEVER

• A regulated rise to a new "set point" of body temperature.

• Elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point [e.g., from 37°C to 39°C

PATHOGENESIS OF FEVER

Patofisiologi Demam

HYPERTHERMIA• Characterized by an uncontrolled increase in body

metabolic heat production that exceeds the body's ability to lose heat

• Hypothalamic thermoregulatory center is unchanged

• Hyperthermia does not involve pyrogenic molecules

• Heat stroke, drug-induced hyperthermia, malignant hyperthermia

• Does not respond to antipyretics

FEVER OF UNKNOWN ORIGIN( FUO)

“Demam selama lebih dari 3 minggu dengan suhu badan di atas 38,3°C dan tetap belum ditemukan penyebabnya walaupun telah di teliti selama satu

minggu secara intensif dengan menggunakan sarana laboratorium dan penunjang medis

lainnya”

(Buku Ajar Ilmu Penyakit Dalam)

FEVER OF UNKNOWN ORIGIN

• Illness of at least 3 weeks duration.

• Fever over 38.3 °C on several occasions.

• Diagnosis has not been made after three outpatient visits or 3 days of hospitalization

BIG 3

1. Infection, 2. Neoplasm, and 3. Autoimmune Disease

LITTLE 6

1. Drug fever, 2. Granulomatous disease, 3. Regional enteritis, 4. Familial mediterranean fever, 5. Pulmonary emboli, and 6. Factitious fever

DIFFERENTIAL DIAGNOSIS FUO

BIG 3 – 1 . INFECTION

• PYOGENIC ABSCESS• TBC • INFECTIVE ENDOCARDITIS• EBV• CMV• BRUCELLOSIS• FUNGAL INFECTION• PARASITIC INFECTION

TBC 1 PYOGENIC ABSCESS

INFECTIVE ENDOCARDITIS

PARASITIC INFECTION

FUNGAL INFECTION

EBV BRUCELLOSIS

CMV

EPIDEMI -Human are the only reservoir of the disease.-Person-to-personspread occurs via aerosolized infectious droplets from sneezes or coughs.a. Laryngeal TB is highly

infectious.b. Patients w/ HIV

release large numbers of organism

c. Large cavitary lesions are also highly infectious.

3. People w/ these characteristic are at increased risk:

a. immigrants from developing countries b. alcoholics c. urban poor d. single men e. IV drug abusers f. migrant farm

workers g. Prison inmates h. people infected

w/ HIV i.

SYMPTOMS

SIGNS

LAB. FINDING

TBC2 PYOGENICHepatic ABSCESS

INFECTIVE ENDOCARDITIS

PARASITIC INFECTION

FUNGAL INFECTION

EBV BRUCELLOSIS CMV

EPIDEMI - Often in the setting of biliary disease but up to 40% are “cryptogenic” in origin

- Preexisting organic heart lesion

- Spread by oral secretions, with 95% of adults carrying the virus

-Transmitted to human by infected domestic & wild animals:a).cattle,buffalo,camels,yaks &sheepb).swine,fox,caribou,antelope&elk

SYMPTOMS - cough, (sesak, nyeri dada)- fever, fatique, weight loss, night sweat

- Fever -Fever-Evidence of systemic emboli

- Fever, sore throat, and lymphadenopathy are the classic triad of mononucleosis

-Incubation period is 2-4 weeks; symptoms include fever, chills, malaise, anorexia, headache, & back pain

SIGNS - -Jaundice-Right upper quadrant pain

- New or changing heart murmur

Important cause of FUO; lymphadenopathy & splenomegaly are the only positive physical finding

LAB. FINDING

-Positive tuberculin skin test reaction-Pulmonary infiltrates on chest radiograph, most often apical--AFB on smear of sputum or sputum culture positive for MTB

- Detected by imaging studies

-Positive blood culture- Evidence of vegetation on echocardiography

-blood cultures are positive in 70% of cases; hold for 21 days-bone marrow cultures are often positive- Serologic diagnosis is frequently helpful

BIG 3 – 2 . NEOPLASM• LYMPHOMA• LEUKEMIA• RENAL CELL CA• HEPATOCELLULAR CA

BIG 3 - 3. AUTO-IMMUNE DISEASE

SLE

NONLEUKEMIA LYMPHOMA

HODGKINLYMPHOMA NON-HODGKIN

HEPATOCELLULAR CA

RENAL CELL CA

EPIDEMI

SYMPTOMS

SIGNS

LAB. FINDING

SLE STILL’S DISEASE CRYOGLOBULINEMIA POLYARTERITIS NODOSA

EPIDEMI

SYMPTOMS

SIGNS

LAB. FINDING

LITTLE 6 – 1.DRUG FEVER• ANTIMICROBIAL AGENTS : carbapenems,

cephalosporins, minocycline, nitrofurantoin, penicillins, rifampin, sulfonamides

• CARDIOVASCULAR drugs : hydralazine HCl, procainamide HCl, Quinidine)

• H2 BLOCKERS : cimetidine, ranitidine• NSAIDs : Ibuprofen• ANTI CONVULSANTS : barbiturates,

carbamazepine, phenytoine)• IODIDES, PHENOTHIAZIDES,

ANTIHISTAMINES, SALICYLATES

LITTLE 6 – 2.REGIONAL ENTERITIS / CROHN DISEASE

o Insidious onseto Intermittent bouts of low grade fever, diarrhea,

and right lower quadrant paino Right lower quadrant mass and tendernesso Perianal disease with abscess, fistulaso Radiographic evidence of ulceration, stricturing,

or fistulas of the small intestine or colon

LITTLE 6 – 3.FAMILIAL MEDITERRANEAN FEVER

• Rare autosomal recessive disorder, unknown pathogenesis• Affect people of mediterranean ancestry• Lack of protease in serosal fluid – inactivate IL-8 and

chemotactic complement factor• Episodic acute peritonitis : fever, severe abdominal pain,

abdominal pain and abdominal tenderness with guarding• Resolve 24-48 hours• Tx Colchicine 0,6 mg PO 3 x 1 (decrease frequency and

severity)

LITTLE 6 – 4.PULMONARY EMBOLI

• Emboli predisposition : venous thrombosis of the lower extrimity

• One or more of the symptoms below : dyspnea, chest pain, hemoptysis, syncope

• Tachyneaa and widened alveolar-arterial P02 difference

• Characteristic defects on ventilation-perfusion lung scan, helical CT scan of the chest, or pulmonary angiogram

LITTLE 6 – 5. FACTITIOUS FEVER

• Psychiatric condition in which a patient deliberately produces or falsifies symptoms of illness for the sole purpose of assuming the sick role, in this case fever

• Personal characteristics– Typically female– Health-related professions– Articulate and well educated– Surprisingly stoic about procedures used to diagnose and

treat them

LITTLE 6 – 6.NEUROLEPTIC MALIGNANT SYNDROME

• Occurs in the setting of the use of neuroleptic agents (antipsychotic pheneothiazides, haloperidol, prochlorperazine, metcoclopramide) or the withdrawl of dopaminergic drugs.

• Characterized by "lead-pipe" muscle rigidity, extrapyramidal side effects, autonomic dysregulation, and hyperthermia

• Inhibition of central dopamine receptors in the hypothalamus, which is result in increased heat generation and decreased heat dissipation

1.DRUG FEVER 2.REGIONAL ENTERITIS / CROHN DISEASE

3.FAMILIAL MEDITERRANEAN FEVER

4.PULMONARY EMBOLI

5.FACTITIOUS FEVER

6.NEUROLEPTIC MALIGNANT SYNDROME

EPIDEMI

SYMPTOMS

SIGNS

LAB. FINDING

THANK YOU FOR YOUR ATTENTION

ABOUT “PROBLEM OF RESPIRATIONS ”

HYPERTHERMIAKEY FEATURES

- A rapidly life-threatening complication- May be due to poisoning by amphetamines (espicially ectasy),

atropine and other anticholinergic drugs, cocaine, dinitrophenol and pentachlorophenol, phencyclidine, salicylates, strychnine, tricyclic antidepressants, other agents

- Overdose of serotonin reuptake inibitors (eg, fluoxetine, paroxetine, sertraline) or use in patient taking MAO (monoamine oxidase) inhibitor may cause agitation, hyperactivity, hyperthermia (serotonin syndrome) vs Cyproheptedine

- Haloperidol and other antipsychotic agents can cause rigidity and hyperthermia (neuroleptic malignant syndrome) vs Bromocriptin

- Malignant hyperthermia is associated with general anesthetic agents (rare) vs Dantrolen

CLINICAL FINDINGSevere hyperthermia ( temperature 40-41°C ) may rapidly cause brain damage

and multiorgan failure

TREATMENT- Remove clothing: spray with tepid (hangat-hangat kuku) water; fan patient- If rectal temp. not normal in 30-60 min or there significant muscle rigidity or

hyperreactivity, include neuromuscular paralysis with nondepolarizing neuromuscular blocker (pancuronium, vecuronium)

- Once paralyzed, patient must be intubated and mechanically ventilated- With seizures, absence of visible muscular convulsive movements may give

false impression that brain seizure activity has ceased; this must be confirmed by EEG.

- Dantrolene, 2-5 mg/kg IV, may be effective for muscle rigidity unresponsive to neuromuscular blockade (ie, malignant hyperthermia) x

- Bromocriptine, 2.5-7.5 mg mg PO daily, for neuroleptic malignant syndrome.

- Cyproheptadine , 4 mg PO Q h for 3-4 doses, for serotonin syndrome

1. Clinical Medicine 7th edition Parveen Kumar, Michael Clark. Saunders publishers 2009.

2. Community Medicine with Recent Advances 2th editionAH Suryakantha Jaypee brothers Medical Publishers LTD 2010

3. Current Medical Diagnosis and Treatment 2007 46th Edition Stephen J Mcphee, Maxim A Papadaks Mc Grau. Hill Medical International edition.

4. Infectious Deseases : A clinical Shortcourse 2nd edition Frederick Southurick Mc Graw. Hill Medical Publishing Devision 2008 LANGE International editor.

5. Primary Care Medicine: Office Evaluation and Management of the adult patient six th edition. Allan H Govall, Albert G Mulley Wolfers Kluwen Lippincott Williams and Wilkins,2009

6. Standar Kompetensi Dokter, Konsil Kedokteran Indonesia Jakarta 2006.7. 2006 Current Consult Medicine

Maxime A Papadaks, Stephen J. Mc Phee 45th edition Lange Medical Books / Mc Graw Hill Medical Publishing Division.