Professional Documents
Culture Documents
GENERAL SURGERY
Kehrs sign
Kehrs sign : pain in
the left tip shoulder
cause by irritation of
peritoneum that
covers inferior
surface of left
diaphragm >> a sign
of rupture spleen
Hematoma
HistoryRetroperitoneal
& Physical:
Plain
Abdomen 3
LLD:
Abdomen
Posisi
Subdiaphragmatic Air
Anatomi Prostat
Ruptur
Uretra
Anterior
Straddle
Injury
Hematom penis
Butterfly
Hematome
Snake Bite
Eritem
(dalam
12jam)
< 3cm
3-12cm
>12-25cm
>25cm
> ekstremitas
Gejala
Sistemik
Mual,
pusing
Shock,
Gagal ginjal
Petechie, akut, coma,
echymosis perdarahan
DIGESTIVE SURGERY
Migrating pain
Acute Appendicitis
appendicitis
Clinical Sign
Rovsings sign :
palpation in the left
lower quadrant of
abdomen increase the
pain in the right lower
quadrant
Obturator sign
Pathophysiology
Ileus
Herring bone
Coil spring
Radiology Ileus
Stepladder pattern
Pneumoperitoneum
Colorectal Cancer
Clinical Manifestation
Apple Core
Filling Defect
>60 yo
Family history (+): mutasi gen
Familial adenomatous polyposis
Low fiber diet
IBD
Screening Test:
FOBT
Colonoscopy
CEA (Carcinoembryonic Antigen). Normal <2,5ng/ml
Genetic analysis
DUKEs Staging
Hemorrhoid
External Hemorrhoids
Internal Hemorrhoids
Internal Hemorrhoids
Internal hemorrhoidal plexus
V. Rectus Inferior
V. Rectus Media
External Hemorrhoids
external hemrroidal plexus
V. Rectus Inferior
Tx:
Non Farmakologis
Changing lifestyle
(menghindari risk
factor)
Diet tinggi serat
Endoskopi (Rubber
band & Sclerotherapy)
Farmakologis
Fecal softener
Fiber supplement
NSAID
Surgery
Electrocautery &
Cryosurgery
Hemorrhoidectomy
(excision or stapled)
Acute Cholecystitis
Gallstone in CBD
(choledocholithiasis)
Cholangitis
Congenital : Atresia
bilier
Pigmented stone
Konten : kalsium bilirubinat (dominan)
Biasa pd pasien chronic hemolytic disease
atau alcoholic cirrhosis
Dx :
Plain film > deteksi radiopaque kalsium (kasus: 10-15% kolesterol & 50%
pigmented stone)
USG
Temuan Klinis :
Fever (biasanya sdh komplikasi / peradangan)
Serum bilirubin (++)
Alkaline phospatase (++)
Cholecystitis
Berdasar penyebab :
Calculous cholecystitis (90-95%) :
terutama akibat obstruksi gallstone pada
ductus cysticus
Acalculous cholecystitis (5-10%) :
jarang, penyebab bervariasi: trauma
adenocarcinoma gallbladder
torsi gallbladder dan DM.
Patofisiologi :
Prinsipnya sama dgn di appendicitis (monggo dibaca lg)
Temuan Klinis :
Fever
Trias
Leukositosis (10.000-15.000 cells/uL)
diagnosis
RUQ tenderness
Serum bilirubin (mildly elevated, no symptom)
Murphy Sign (+)
Dx :
Berdasar triad &
temuan klinis lain
USG (identifikasi thickening of gallbladder wall)
CT-scan
Komplikasi :
Gangren & perforasi > bs diikuti abscess jika ada
superinfeksi bakteri > bs generalized peritonitis
Fistulization : biliary-enteric fistula
Treatment :
Non surgery :
Surgery :
Laparoscopic cholecystectomy
Open cholecystectomy
Choledocholithiasis
10-15% pasien cholelithiasis
Penyebab :
Gallstone (pigmented stone)
Sering pada pasien dgn kronik
hemolytic disease
Komplikasi :
Cholangitis
Terjadi akibat ascending infection dari bacteria di duodenum. Bisa
terjadi krn bile duct sudah terobstruksi oleh gallstone.
Medical emergency
Sign & symptom : jaundice, fever, malaise, rigor & abdominal pain
(severe : hypotension & confusion)
Gambaran duktus : dilated, sclerosed & strictured ducts
Initial Tx : IV fluid & antibiotik
Pancreatitis
Px penunjang :
cholangitis
Cholangiography
ERCP & MRCP
USG
Tx :
Choledocholithotomy
ERCP (Modalitas intervensi: endoscopic sphincterotomy,
stone removal, insertion of stent, dilation of stricture)
ERCP
Alat Dx sekaligus Tx
Pilihan Tx lihat slide
sebelumnya...
Biliary Atresia
Kelainan kongenital yg cukup jarang
(1 per 15.000 kelahiran), tapi
kejadian ini 25-30% berhubungan
dgn anomali lain seperti
stenosis/atresia duodeni, pancreas
annulare, dll.
80% pd bile duct di atas level porta
hepatis, 15% pada ductus
choledochus, dan 5% pada ductus
hepaticus communis.
Etiologi : intrauterine inflammatory
process caused by fibrosis of both
the intrahepatic & extra hepatic
biliary tree.
Tx : Kasai hepatoportoenterostomy
PUDDLE SIGN
For ascites 120ml
SHIFTING DULLNESS
For ascites
500ml
Puddle Sign
Hernia
Trigonum hasselbach
Dibentuk tepi MRA, a.
epigastrica inferior, lig.
Inguinalis
Spatium Subinguinal
UROLOGIC SURGERY
Rectal toucher:
Suspect
malignancy IF
hard, nodular,
irregular
WATCHFUL WAITING
Sebagian besar tanpa keluhan
Tanpa penyulit / gejala
Kualitas hidup tetap baik
INDIKASI
BPH dengan IPSS ringan (<8)
Baseline data normal
Flowmetri : non obstruktif
FOLLOW-UP
Tiap 3-6 bulan
Ulangi :
IPSS
Flow (6 bulan)
PSA (6-12 bulan)
Prostate
PEMBEDAHAN BPH
TUR Prostat: 90 95%
Di Amerika : 300.000 400.000/tahun
Di Urologi RS Dr. Soetomo
Open prostatektomi
Ke 2 terbanyak setelah urolithiasis
: 5 10 %
150/tahun
BPH yang besar
(>50 100 gram)
INDIKASI TERAPI PEMBEDAHAN BPH
Tidak habis
Retensi urin akut
Retensi urin kronis (selalu > 300 ml)
direseksi dalam
Residual urin > 100 ml
1 jam
BPH dengan penyulit
Disertasi :
Terapi medikamentosa tidak berhasil
Batu buli besar
Flowmetri obstruktif
(> 2.5 cm)
INDIKASI KONTRA TERAPI PEMBEDAHAN BPH
Multipel
Infark miokard Akut
Fasilitas TUR tidak
CVA Akut
ada
Nephrolithiasis
Ureterolithiasis
Vesikulolithiasis
Uretrolithiasis
Lokasi
GINJAL
Gejala
Nyeri regio flank, dapat berupa
- Nyeri kolik akibat aktivitas peristaltik otot polos sistem kalises, atau
- Nonkolik akibat peregangan kapsul ginjal, hidronefrosis, atau infeksi
pada ginjal
URETHRA
Jenis-jenis batu
Diagnosis Px Penunjang
Urinalisis
Hematuria, kristal, tanda infeksi
Radiologi
Struvite Stones
>> women
Struvite (magnesium ammonium phosphate) stone
Infection with urease producing bacteria (e.g. Proteus,
Klebsiella, Pseudomonas and Enterobacter), resulting in
hydrolysis of urea into ammonium and increase in the
urinary pH 6,10.
They can grow very large and form a cast of the renal pelvis
and calices resulting in so-called staghorn calculi. The
struvite accounts for approximately 70% of these calculi,
and is usually mixed with calcium phosphate thus
rendering them opaque. Uric acid and cystine are also
found as minor components.
Staghorn
Hiperkalsiuri
absobtif
renal (reabsorbsi turun)
resorptif (kalsium tulang) pada hiperparatiroidisme
Hiperoksaluri
post operasi usus atau banyak konsumsi makanan yang kaya oksalat (teh, kopi
instan, soft drink, dll)
Hiperurikosuria
asam urat bertindak sebagai inti batu/nidus untuk terbentuknya batu kalsium
oksalat.
Hipositraturia
Di dalam urine, sitrat bereaksi dengan kalsium membentuk kalsium sitrat
cegah ikatan kalsium dengan oksalat atau fosfat.
Hipomagnesuria.
Di dalam urine magnesium bereaksi dengan oksalat menjadi magnesium
oksalat cegah ikatan kalsium dengan oksalat.
Tatalaksana
Bladder Carcinoma
Cancer age
Painless gross
hematuria all along
micturition, reccurent
Risk factor
Male
Cigarette
Amine aromatic
substance exposure
(paint, textile)
UTI
Retrograde Urethrography
4. Continuous: fistula
Urinary Incontinence
Scrotal Swelling
Disorders
Etiology
Clinical
Testicular torsion
Intra/extra-vaginal
torsion
Hidrocele
Varicocoele
Vein insufficiency
Hernia skrotalis
persistent patency of
the processus
vaginalis
Orchitis
Mumps virus
Testicular Torsion
Sign : Sudden pain in
scrotal, nausea and
vomiting, no fever
Physical Exam
Cremaster reflex ()
Phren sign (-)
Tx : Orchidectomy
Phrens sign
Prehn's sign, the physical lifting of the testicles
relieves the pain
Negative Prehn's sign indicates no pain relief with
lifting the affected testicle, which points towards
testicular torsion which is a surgical emergency
and must be relieved within 6 hours
Positive Prehn's sign indicates there is pain relief
with lifting the affected testicle, which points
towards orchidoepididymitis.
Orchitis
Varicocele
Hydrocele
Hydrocele Types
Translumination test
/ diapanoscopy
Positive : Hydrocele,
Hernia Scortalis
Negative : Mass
Cryptoorchidismus
Management
ORTHOPAEDIC SURGERY
Fracture
Complication of Fracture
Early complications
Local:
Vascular injury causing haemorrhage, internal or external
Visceral injury causing damage to structures such as brain, lung or
bladder
Damage to surrounding tissue, nerves or skin
Haemarthrosis
Compartment syndrome (or Volkmann's ischaemia)
Wound infection, more common for open fractures
Systemic:
Fat embolism
Shock
Thromboembolism (pulmonary or venous)
Fracture Complication
Late Complications
Local:
Delayed Union
Non-union
Malunion
Joint stiffness
Contractures
Osteomyelitis
Growth disturbance or deformity
Systemic:
Gangrene
Tetanus
Septicaemia
Fraktur clavicula:
>> di 1/3 lateral, pada anak2.
Fragmen medial clavicula terangkat
krn m. SCM, fragmen lateral jatuh
(shoulder drop), dan proksimal humerus
tertarik ke medial krn m. pectoralis major.
Pada anak, fraktur terjadi inkomplit,
disebut greenstick fracture.
Fraktur scapula:
Banyak terjadi pada acromion.
Fraktur Humerus:
>> di collum chirurgicum, pada lansia
osteoporosis.
Pada tuberculum majus : avulsion
fracture.
Direct contact bagian humerus dgn
nervus:
1) collum chirurgicum: n. axillaris,
2) sulcus radialis: n. radialis,
3) akhir distal: n. medianus,
4) epicondylus medial: n. ulnaris
Fraktur hamatum:
Bisa melukai n. et a. ulnaris
Fraktur scaphoid:
Fraktur carpal tersering.
Fraktur avaskuler nekrosis
degenerasi; diTx bedah penyatuan
os carpal = arthrodesis
Fraktur metakarpal:
Fraktur metakarpal 5 (boxers
fracture)
Fraktur falang:
Distal comminuted, painful
hematome. Proksimal hati2
tendon flexor
Humeral Fracture
Collum chirurgicum:
n. axillaris
Sulcus radialis (shaft) :
n. radialis
Distal end :
n. medianus/ n.radial
Epicondylus medial:
n. ulnaris
Nerve Injury
N. Axilaris :
m.deltoideus, sensoris:
bahu
N. Muskulokutaneus:
compartemen anterior
brachium
m.bisep brachii
m. brachialis
m.coracobrachialis
Carpal Tunnel
Syndrome
N. medianus
Cubital Tunnel
Syndrome
Epicondylus medial
GuyonTunnel
Syndrome
Claw hand
N. Ulnaris
Drop hand
N. Radialis
Preachers Hand
N. medianus
Orbita
Management of Fracture
4R :
1. Recognition
2. Reduction
3. Retention
4. Rehabilitation
Recognition
Anamnesis
History of trauma?
Mechanism of injury?
Localized pain, aggravated by movement
Decreased function
heard the bone break
feel the ends of the bone grating
Physical Examination
LOOK (Inspection)
Symetricity right-left
Swelling, wound, deformity (angulation, rotation,
shortening), abnormal movement, discoloration
(ecchymoses)
Bone exposure
FEEL (Palpation)
Localized tenderness
Distal neurological status (S&M), pulsation
Aggravation of pain and muscle spasm during even the
slightest passive movement
Feeling and listening the crepitus unnecesary!
Reduction
Restore a fracture to correct allignment
Closed Reduction
Traction : Skin traction, skeletal traction
Open Reduction
ORIF
OREF
Traction
Skeletal Traction
Femur fracture managed with skeletal traction and use of a Steinmann pin in the
distal femur.
ORIF vs OREF
Retention / Immobilization
Bidai /Splint adalah alat yang digunakan untuk mengimobilisasi
bagian tubuh, alat tersebut dapat bersifat lunak ataupun kaku
(rigid)
Plaster slab adalah lempengan gips untuk imobilisasi sendi atau
daerah cidera sehingga terjadi penyembuhan. Sebagian besar
fraktur dislab untuk 24-48 pertama untuk mengakomodasi
pembengkakan, sebelum dipasang gips sirkuler.
Lempengan Gips/CAST Dapat Digunakan Pada
Imobilisasi Fraktur
Imobilisasi pada penyakit tulang dan sendi
Pencegahan deformitas muskuloskeletal
* Aryadi K, Syaiful AH. Penggunaan Gips Paris. In: Petunjuk pemasangan gips paris pada kasus orthopaedi, Divisi Orthopaedi dan
traumatologi, 2006. hal 2-6
GIPS/CAST
Arm Sling
U Slab
Humeral shaft
fracture
Volar Slab
Compartment Syndrome
6 P of Compartment
Syndrome
Pain
Pallor
Pulseless
Paresthesis
Paralysis
Pressure
Tx : Fasciotomy
Compartment Syndrome
Fasciotomy
Muscle of Calf
Artery of Calf
Pagets Disease
Paget disease is a localized disorder of bone
remodeling that typically begins with
excessive bone resorption followed by an
increase in bone formation. This osteoclastic
overactivity followed by compensatory
osteoblastic activity leads to a structurally
disorganized mosaic of bone (woven bone),
which is mechanically weaker, larger, less
compact, more vascular, and more susceptible
to fracture than normal adult lamellar bone.
Multiple Myeloma
Sign : bone pain
X-ray
punched out lession
Multiple Myeloma
Symptomatic myeloma:
Clonal plasma cells >10% on bone marrow biopsy or (in
any quantity) in a biopsy from other tissues
(plasmacytoma)
A monoclonal protein (paraprotein) in either serum or
urine (except in cases of true non-secretory myeloma)
Evidence of end-organ damage felt related to the plasma
cell disorder (related organ or tissue impairment, ROTI,
commonly referred to by the acronym "CRAB"):
Osteomyelitis
Inflammation of the bone and bone marrow
caused by an infecting organism.
Although bone is normally resistant to bacterial
colonization, events such as trauma, surgery,
presence of foreign bodies, or prostheses may
disrupt bony integrity and lead to the onset of
bone infection
Pathogenesis (Waldvogel, 1971) :
1.
2.
3.
Hematogenous
Contiguous focus of infection
Direct inoculation
Osteomyelitis
Osteomyelitis is often diagnosed clinically with nonspecific
symptoms
fever,
chills,
fatigue,
lethargy,
irritability.
The classic signs of inflammation, including local pain,
swelling, or redness, may also occur and normally disappear
within 5-7 days
Osteomyelitis
S aureus is the most common pathogenic
organism recovered from bone, followed
by Pseudomonas and Enterobacteriaceae.
Less-common organisms involved include
anaerobe gram-negative bacilli.
Intravenous drug users may acquire
pseudomonal infections
Acute hematogenous osteomyelitis has a
predilection for the long bones of the body.
The ends of the bone near the growth
plate (the metaphysis) is made of a maze
like bone called cancellous bone.
It is here in the rapidly growing metaphysis
that osteomyelitis often develops
Supracondylar Fracture
Outstretched arm
>> children
Elbow Dislocation
Elbow dislocations are not common
Falls onto an outstretched hand, usually there is a
turning motion in this force drive and rotate
the elbow out of its socket
Elbow dislocations can also happen in car
accidents
The elbow is stable because of the combined
stabilizing effects of bone surfaces, ligaments,
and muscles. When an elbow dislocates, any or
all of these structures can be injured to different
degrees.
Osteoporosis
A systemic skeletal disease characterized
by low bone mass and micro architectural
deterioration of bone tissue lead to bone
fragility and susceptibility to fracture
Densitometri Osteoporosis
World Health Organization Definitions Based on Bone Density Levels
Level
Definition
Normal
Osteoporosis
Severe
(established)
osteoporosis
Bone density is more than 2.5 SD below the young adult mean,
and there have been one or more osteoporotic fractures.
Incidence of osteoporotic Fx
Forearm
Fracture
Vertebral
Fracture
Hip
Fracture
Osteoporosis
ATLS
Shoulder Dislocation
Anterior Shoulder
Subluxation/Dislocation
Radiographs:
Axillary View
True AP
Y view
Subluxation:
Abnormal translation of humeral
head on glenoid without
complete separation of articular
surfaces
Mechanism:
Forced extension, abduction,
external rotation
Direct blow to posterior or
posterolateral shoulder
Repeated episodes of overuse
(subluxation)
Physical Exam:
Intense pain
Arm held in adduction & external
rotation
Humeral head palpable anteriorly
Unable to completely internally
rotate or abduct the shoulder
Thorough neuro exam (close
relation of axillary nerve)
Hip Dislocation
Posterior
(flexi, adduksi, endorotasi)
Anterior
Osteosarcoma
X-rays of area of suspected infection would
not demonstrate darkened areas typical of
osteomyelitis.
Conventional features
Destruction of normal trabecular bone pattern
a mixture of radiodense and radiolucent areas
periosteal new bone formation
formation of Codman's triangle (triangular
elevation of periosteum)
No osteoblastic appearance,
fracture can be seen
Periosteal reactions
onion-skin
(Ewings sarkoma)
Codman's triangle
Ewings Sarkoma
Annual
incidence at
birth to 20 y.o
(teenagers and
young adult)
Most common
site : pelvis
Radiologic :
onion peel
Ewings Sarkoma
Acute Achilles
Tendon Rupture
Diagnosis
Open Fracture
Vertebral Fracture
ONCOLOGIC SURGERY
The Breast
Tumors
Onset
Feature
Breast cancer
30-menopause
Fibroadenoma
mammae
< 30 years
Fibrocystic
mammae
20 to 40 years
Mastitis
18-50 years
Philloides
Tumors
30-55 years
Duct Papilloma
45-50 years
Breast Cancer
Biopsy
Excisional or incisional biopsy
In this type of biopsy, a surgeon cuts through the skin to remove the entire tumor
(called an excisional biopsy) or a small part of a large tumor (called an incisional
biopsy).
Enucleation
surgical removal of a mass without cutting into or dissecting it. Eg: eye, oral pathology,
uterine fibroids (without hysterectomy)
FNA
does not require an incision
Core biopsy
uses needles that are slightly larger than those used in FNA
Local anasthesia
Sometimes uses a special vacuum tools to get larger core biopsies from breast tissue
Epidermoid Cyst
Benign cyst underneath
skin that arise with
ruptured pilosebaceous
follicle
Associated with trauma
(piercing-needle)
Common location :
auricular lobe, plantar
Demoid Cyst
An abnormal growth
(teratoma) containing
epidermis, hair follicles,
and sebaceous glands,
derived from residual
embryonic cells.
Common site :
Periorbital
Ovarian
Spinal
Atheroma
Cause by blockage of
the duct of
sebacceous gland
Also known as
Retention Cyst
Puncta (+)
Fibroadenoma
mammae (FAM)
Kelainan fibrokistik
Kistosarkoma
filoides
Galaktokel
Galactocele
Galaktokel
merupakan massa
berisi susu yang
tersumbat apada
duktus laktiferus.
Px :
Solid mass
Tanda radang (-)
TERIMA KASIH
Brief Introduction
Appendicitis
The most common
general surgical
emergency
Peak 10-30 y.o
Male > 1.3x
Obstruction: lymphoid
hyperplasia, fecalith, etc
Ileus
Peritonitis
Obstructive Ileus:
-Primary, secondary
- Inside lumen, In the - Localized,
wall, outside the wall generalized
- High level, low level
Anamnesis
Cardinal
symptoms
Appendicitis
Ileus
Peritonitis
- migrating pain
(periumbilical to
RLQ)
- nausea and
vomiting
- abdominal pain
- vomiting
- no defecation
and flatus
- meteorismus,
distension
- abdominal pain
- meteorismus
- nausea, vomiting
- no defecation
and flatus
- restlessness
Physical
Examination
Appendicitis
Ileus
Peritonitis
Physical
Examination
tenderness and
rebound
tenderness at
McBurney point
Rovsings sign
Psoas sign
Obturator sign
absence of
bowel sound
loss of liver
dullness
(perforation)
shifting dullness
defans muscular
Rectal touche
tenderness
impact faeces
rectal tumour
blood or mucus
collapse of ampulla
recti (obstructive)
tenderness