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INTERNAL MEDICINE Flashcards

1
Q

Batas Diabetes
1. HbA1c
2. GDP
3. GD2PP
4. GDS
5. TTGO

A
  1. ≥6.5
  2. ≥126
  3. ≥200
  4. ≥200
  5. ≥200
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2
Q

Batas Prediabetes
1. HbA1c
2. GDP
3. GD2PP
4. GDS
5. TTGO

A
  1. 5.7-6.4
  2. 100-125
  3. 140-199
  4. 140-199
  5. 140-199
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3
Q

GDP prediabetes, TTGO normal

A

GLUKOSA DARAH PUASA TERGANGGU

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4
Q

GDP normal, TTGO prediabetes

A

TOLERANSI GLUKOSA TERGANGGU

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5
Q

4P, Autoantibodi (+), C-peptide (-), sensitivitas insulin (+), anak

A

DMT1

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6
Q

4P, Autoantibodi (-), C-peptide (±), sensitivitas insulin (-), dewasa

A

DMT2

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7
Q

Autoantibodi (-), C-peptide (±), DMT2 anak

A

MODY

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8
Q

4P, Autoantibodi (+), C-peptide (-), DMT1 dewasa

A

LADA

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9
Q

Tatalaksana dan Sasaran Diabetes

A

Lifestyle [diet 60-20-20, akfis aerobik ≥sedang 150m/wk 3-5x/wk] + monoterapi (<7.5%); dual terapi (≥7.5%/>9% asimtomatis/refrakter 3mo); triple terapi (>9% asimtomatis/refrakter 3mo); insulin (>9% simtomatis). Target A1c <7%, IMT 18.5-<23, TD <140/90, GDP 80-130, LDL<100, TG<150

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10
Q

Kussmaul, kesadaran turun, keton (+), pH<7.3, HCO3<18, GDS>250

A

KAD

NaCl 0.9% 1L/h, NaCl 0.45% 500mL/h (Na>145), D5%+NaCl 0.45% 250 mL/h (GDS 200 KAD/300 HHS); K+ 20-30mEq/L (K+<5.2, maintain 4-5), tunda insulin (K+<3.3); insulin 0.1U/kg bolus lalu 0.1U/kg/h infusion IV / 0.14U/kg infusion IV, turunkan 0.05U/kg/h (GDS 200 KAD/300 HHS); HCO3 100mmol dalam 400mL akuades dengan KCl 20mEq 2h (pH<6.9, hingga ≥7)

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11
Q

Dehidrasi berat, kesadaran turun, Osm>320, pH>7.3, GDS>600

A

HHS

NaCl 0.9% 1L/h, NaCl 0.45% 500mL/h (Na>145), D5%+NaCl 0.45% 250 mL/h (GDS 200 KAD/300 HHS); K+ 20-30mEq/L (K+<5.2, maintain 4-5), tunda insulin (K+<3.3); insulin 0.1U/kg bolus lalu 0.1U/kg/h infusion IV / 0.14U/kg infusion IV, turunkan 0.05U/kg/h (GDS 200 KAD/300 HHS); HCO3 100mmol dalam 400mL akuades dengan KCl 20mEq 2h (pH<6.9, hingga ≥7)

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12
Q

Klasifikasi KAD

A

MILD: pH 7.25-7.30, bikarbonat ≤18, anion gap >10, alert
MODERATE: pH 7.00-7.24, bikarbonat <15, anion gap >12, drowsy
SEVERE: pH <7.00, bikarbonat <10, anion gap >12, stupor/coma

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13
Q

Whipple triad: Gejala klasik (autonom: diaforesis, gelisah, palpitasi; neuroglikopenik: lemah, lesu, pusing), GDS <70, gejala berkurang dengan pengobatan
1. CM
2. Tidak sadar

A

HIPOGLIKEMIA
1. RINGAN
2. BERAT

Glukosa murni 15-20g (ringan: CM), D10% 150mL / D20% 75mL / D40% 25mL IV dalam 15m (berat: tidak sadar), D10% (<2) / D25% (2-12) / D50% (>12) 2mL/kg (anak)

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14
Q

Poliuria, polidipsia, osm plasma turun, water deprivation test urine osm >600

A

POLIDIPSIA PSIKOGENIK

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15
Q

Poliuria, polidipsia, osm plasma naik, water deprivation test urine osm <300, Tes desmopressin peningkatan urine osm ≥50%

A

CENTRAL DI

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16
Q

Poliuria, polidipsia, osm plasma naik, water deprivation test urine osm <300, Tes desmopressin tidak meningkat

A

NEPHROGENIC DI

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17
Q

Pembesaran tiroid, takikardi/palpitasi, tremor, heat intolerance, hiperhidrosis, penurunan BB, nafsu makan meningkat, index wayne>19

A

HIPERTIROIDISME

Propanolol 3x 40mg (simtomatis), metimazole 1x 10-20mg (dewasa/anak/trimester 2-3), PTU 3x 100-200mg (trimester 1); RAI ablation; tiroidektomi

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18
Q

Klasifikasi Hipertiroidisme
1. Primer
2. Sekunder
3. Subklinis

A
  1. FT4 naik, T3 naik, TSH turun
  2. FT4 naik, T3 naik, TSH naik
  3. FT4 normal, T3 normal, TSH turun

Lihat FT4, naik = hipertiroid. TSH untuk bedakan primer dan sekunder, naik = dari sentral = sekunder

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19
Q

Etiologi Hipertiroidisme
1. Nyeri (+), bakterial
2. Nyeri (+), viral, diikuti hipotiroid
3. Nyeri (-), RAIU (+) fokal, USG goiter nodular, TRAb/TSI (-)
4. Nyeri (-), RAIU (+) difus, USG goiter non nodular, TRAb/TSI (+)

A
  1. ACUTE/SUPPURATIVE THYROIDITIS
  2. DE QUERVAIN/SUBACUTE GRANULOMATOUS THYROIDITIS
  3. TOXIC MULTINODULAR GOITER, TOXIC SOLITARY ADENOMA
  4. GRAVES DISEASE
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20
Q

Demam sangat tinggi, takiaritmia, altered mental status, gejala GI berat, burch-wartofsky point scale >45

A

THYROID STORM

Stabilisasi, PTU 500-1000MG LOADING LALU 4X 250MG PO, propanolol 4x 60-80mg PO, hidrokortison 3x 100mg IV, lugol 3x 10tts

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21
Q

Bradikardi, gangguan konsentrasi, cold intolerance, kulit kering, peningkatan BB, nafsu makan menurun

A

HIPOTIROIDISME

Levotiroksin 1.6-1.8mcg/kg/d

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22
Q

Klasifikasi Hipotiroidisme
1. Primer
2. Sekunder
3. Subklinis

A
  1. FT4 turun, T3 turun, TSH naik
  2. FT4 turun, T3 turun, TSH turun
  3. FT4 normal, T3 normal, TSH naik

Lihat FT4, turun = hipotiroid. TSH untuk bedakan primer dan sekunder, naik = dari sentral = sekunder

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23
Q

Etiologi Hipotiroidisme
1. Anti TPO (+), PA limfosit
2. Riwayat tinggal di pegunungan
3. Gejala obstruksi faring/laring, PA fibrosis

A
  1. HASHIMOTO THYROIDITIS
  2. GOITER ENDEMIK
  3. REIDEL THYROIDITIS
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24
Q

Hipotermia, bradiaritmia, altered mental status, kulit edema non pitting

A

KOMA MIKSEDEMA

Levotiroksin 5-8 mcg/kg loading lalu 50-100mcg/d IV

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25
Hypercalcemia (bone pain, kidney stone, muscle weakness, fatigue, GI issues, polydipsia/uria), PTH naik, serum fosfat turun-normal, serum kalsium tinggi, QT pendek Adenoma/carcinoma
PRIMARY HYPERPARATHYROIDISM ## Footnote Paratiroidektomi
26
Kifosis, fr. patologis, arteriosklerosis, PTH naik, serum fosfat naik, serum kalsium rendah-normal, kompensasi hipokalsemia kronis (CKD/vit D def)
SECONDARY HYPERPARATHYROIDISM ## Footnote Kalsitriol 2mcg/d; paratiroidektomi
27
PTH naik, serum fosfat naik, serum kalsium naik, tHPT berkepanjangan
TERTIARY HYPERPARATHYROIDISM ## Footnote Paratiroidektomi
28
Hypocalcemia (muscle crap, tetany, paresthesia, chvostek (+) kontraksi ketukan, trosseau (+) spasme dengan manset), post thyroidectomy
HYPOPARATHYROIDISM ## Footnote Kalsium 1-3g/d, kalsitriol 0.25mcg/d
29
Hypercortisolism (obesitas sentral, buffalo hump, striae ungu, hiperpigmentasi, moon facies, muscle weakness, metabolic ds, psychiatric ds), late night salivary cortisol (+) tinggi, 24h urine free cortisol (+) tinggi, low dose dexa test (+) tinggi 1. ACTH rendah 2. ACTH tinggi, high dose dexa supresi, CRH test (+) 3. ACTH tinggi, high dose dexa tidak supresi, CRH test (-)
CUSHING SYNDROME 1. ACTH INDEPENDENT (ADRENAL/EKSOGEN) 2. ACTH DEPENDENT: CUSHING DISEASE 3. ACTH DEPENDENT: ECTOPIC ACTH SYNDROME | Urutan penunjang: low dose dexa --> ACTH --> high dose dexa ## Footnote Mitotan 500mg/d uptitrasi / metirapon 3x 500mg, bedah transfenoid (ACTHd), adrenalektomi (ACTHi)
30
Hypocortisolism (fatigue, anorexia, BB turun, hipoglikemi), hypoaldosteronism (hipotensi, salt craving), cosyntropin test kortisol tidak naik 1. ACTH tinggi 2. ACTH rendah
INSUFISIENSI ADRENAL 1. PRIMER (ADDISON DISEASE) 2. SEKUNDER ## Footnote Hidrokortison 15-25mg/d bagi 2-3 dosis, fludrokortison 0.2mg/d PO
31
Penghentian CS mendadak, hipoglikemia, hiponatremia, hiperkalemia, penurunan kesadaran
KRISIS ADRENAL ## Footnote HIDROKORTISON 100MG IV LALU 3X 100MG IV, NaCl 0.9%, D5NS (hipoglikemia)
32
Batas Dislipidemia
KT≥240 (200) TG≥200 (150) LDL≥160 (130) HDL<40 ## Footnote Dislipidemia (Borderline)
33
Tatalaksana Dislipidemia
Lifestyle (0 RF), +statin sedang (ada RF/DM+CKD) / +statin kuat (CAD/HF/DM+CKD+RF) RF: merokok, HT, HDL rendah, CAD, ≥45y/≥55y Ezetimibe 10mg, statin sedang [rosuvastatin 5-10mg, atorvastatin 10-20mg, simvastatin 20-40mg], statin kuat [atorvastatin 40-80mg, rosuvastatin 20-40mg]
34
≥3/5 [obesitas sentral (LP ≥102/≥88), HT ≥130/≥85, TG ≥150, HDL <40/<50, GDP ≥100]
METABOLIC SYNDROME
35
Klasifikasi Obesitas (BMI-ASIAN)
Underweight: <18.5 Normal: 18.5-22.9 Overweight: 23-24.9 Obesitas I: 25-29.9 Obesitas II: >30
36
Tatalaksana Obesitas
Diet rendah kalori + makanan sehat, akfis ≥30m/d / 150m/wk, orlistat 3x 120mg (BMI>30+sindrom metabolik), bedah bariatrik (BMI≥40)
37
Edema anasarka, proteinuria >3.5g/d, hipoalbuminemia <3.5, hiperkolesterolemia, oval fat body (+) urin
SINDROM NEFROTIK ## Footnote Rendah garam, restriksi cairan, furosemid 1-3mg/kg ± spironolakton 2-4mg/kg (edema), statin (dyslipidemia), PREDNISON 1-2MG/KG lanjut tapering off
38
Edema, proteinuria <3.5/d, hematuria, HT, oliguria, azotemia, RBC cast urin (+) 1. Rw ISPA/kulit, ASTO (+), C3 turun 2. Biopsi crescentic formation
SINDROM NEFRITIK 1. GNAPS 2. RPGN ## Footnote anti-HT, diuretik, Ab (GNAPS), CS (RPGN)
39
Disuria, frekuensi, urgensi, nyeri tekan suprapubik
ISK SISTITIS ## Footnote Nitrofurantoin 2x 100mg 5d / TMP-SMX 2x 960mg 3d / ciprofloksasin 2x 250mg 3d / fosfomisin trometamol 3g SD (non komplikata), seperti pielonefritis komplikata (komplikata: laki, wanita hamil, anatomical/functional dysf, kateter, komorbid)
40
Demam, menggigil, mual muntah, nyeri pinggang + ketok CVA
ISK PIELONEFRITIS ## Footnote Siprofloksasin 2x 500mg 7d / levofloksasin 1x 750mg 5d / TMP-SMX 2x 960mg 14d / ceftriaxone 1x 1g 3d IV (non komplikata), siprofloksasin 2x 400 mg IV / levofloksasin 1x 500mg IV / cefepime 2x 1g IV / ampisilin 4x 2g + gentamisin 1x 5mg/kg IV @5d (komplikata: laki, wanita hamil, anatomical/functional dysf, kateter, komorbid), ampisilin 4x 250mg / amoksisilin 3x 500mg (hamil)
41
Morning stiffness (+) weight bearing joint, unilateral, usia tua, nyeri dengan aktivitas, krepitasi (+), heberden (+) bengkak DIP jari /bouchard node (+) bengkak PIP jari, x-ray osteofit (+)
OSTEOARTRITIS ## Footnote NSAID [indometasin 3x 50mg / diklofenak 3x 50mg / ibuprofen 3x 800mg / naproxen 2x 500mg / celecoxib 2x 200mg]
42
Derajat Osteoarthritis
KELLGREN LAWRENCE 0: normal I: doubtful (osteofit minim) II: mild (osteofit definitif) III: moderate (osteofit multipel, penyempitan celah sedang) IV: severe (osteofit kissing, penyempitan celah berat, sclerosis berat)
43
Morning stiffness (+) small distal joint, bilateral, bengkak, swan neck (+) hiperekstensi PIP jari/boutonniere (+) hiperfleksi PIP jari/deviasi ulna (+), asp cairan sendi [RF (+), anti-CCP (+)]
RHEUMATOID ARTRITIS ## Footnote NSAID [indometasin 3x 50mg / diklofenak 3x 50mg / ibuprofen 3x 800mg / naproxen 2x 500mg / celecoxib 2x 200mg] (akut), MTX 7.5-15MG/WK PO / sulfasalazin 2x 500mg PO (definitif)
44
Morning stiffness (-), nyeri sendi mendadak (predileksi jempol), asp cairan sendi [monourate crystal (+) jarum negative birefringent], podagra (+), tophus (+), rat-bite erosion (+)
GOUT ARTRITIS ## Footnote Kolkisin 1.8mg/d lalu 0.6mg/d, NSAID [indometasin 3x 50mg / diklofenak 3x 50mg / ibuprofen 3x 800mg / naproxen 2x 500mg / celecoxib 2x 200mg] (akut<24h), allopurinol 100mg/d / febuxostat 120mg/d, probenesid 500mg/d (kronis). Target asam urat <6
45
Ca pyrophosphate crystal (+) romboid negative birefringent, lutut
PSEUDOGOUT
46
Morning stiffness (-), gejala sistemik (+), asp cairan sendi bakteri (+)
SEPTIK ARTRITIS ## Footnote Ab IV empiris: vankomisin 2x 15-20mg/kg IV (kokus gram (+)), ceftriaxone 1x 1-2g IV (gram (-))
47
Sendi bengkak lokasi beragam, <16y, demam/uveitis/limfadenopati/ruam, ANA test (+)
JIA
48
SOAPBRAINMD [serositis, oral ulcer, arthritis, photosensitivity, blood all low, renal, ANA(+), immunologic (dsDNA), neurologic, malar rash, discoid rash]
SLE ## Footnote Hidroksiklorokuin 400mg/d ± CS dan NSAID (ringan: kulit + artritis), metilprednisolon 0.5-1mg/kg/d IV 3d lalu azatioprin 1-2mg/kg/d + CS 0.5mg/kg/d taper off (sedang: nefritis ringan, PLT<50), metilprednisolon 0.5-1mg/kg/d IV 3d + siklofosfamid 500mg/m2 (berat: nefritis berat, PLT<20, ancaman nyawa)
49
BMD ≤-2.5, dowager hump/kifosis dorsal (+) 1. Postmenopause 2. Usia >75 th 3. Penyakit sistemik, obat
OSTEOPOROSIS 1. OSTEOPOROSIS PRIMER/INVOLUSIONAL TIPE 1 2. OSTEOPOROSIS PRIMER/INVOLUSIONAL TIPE 2 3. OSTEOPOROSIS SEKUNDER ## Footnote Vit D 400-800IU/d, intake ca2+ 1000-1500mg/d, bifosfonat
50
CREST (calsinosis, raynaud phenomenon, esophageal dysfunction, sclerodactyly/morphea, telangiectasia)
SYSTEMIC SCLEROSIS/SCLERODERMA
51
Kelemahan otot simetris panggul dan bahu progresif, CK naik, EMG (+) miopati, biopsi otot atrofi/nekrosis 1. Gottron sign (+), heliotrope rash (+), shawl sign (+)
POLIMIOSITIS 1. DERMATOMIOSITIS ## Footnote PREDNISON 2MG/KG; azatioprin 1-2mg/kg/d / MTX 7.5-15mg/wk
52
Derajat Anemia
ANEMIA (LAKI / PEREMPUAN / HAMIL) Anemia ringan: <13 / <12 / <11 Anemia sedang: <11 / <11 / <11 Anemia berat: <8 / <8 / <7
53
Anemia, MCV <80, serum Fe rendah, TIBC tinggi, ferritin rendah, pencil/cigar cell (+)
ADB ## Footnote Ferro sulfat 3x 325mg / ferro fumarat 2x 325mg / furro glukonat 4x 325mg, vit C; transfusi PRC (Hb<7). Target Hb+1 2-3wk, lanjut 6-12mo jika sudah Hb = 11
54
Anemia, MCV ≤100, serum Fe rendah, TIBC -/rendah, ferritin -/tinggi
ANEMIA PENYAKIT KRONIS ## Footnote Etiologis
55
Anemia, MCV <80, ikterik, facies cooley, hepatosplenomegali, x-ray (+) hair on end app, target cell/kodosit(+), Hb elekroforesis HbH/Hb barts naik (alfa), HbA1 turun HbA2 naik HbF naik (beta)
THALASSEMIA ## Footnote Transfusi darah (Hb<7 / Hb>7+klinis), as folat 2x 1mg, deferoksamin (overload Fe); splenektomi
56
Anemia, MCV <80, BST ring sideroblast (+), basophilic stippling (+), pappenheimer body (+)
SIDEROBLASTIC ANEMIA
57
Anemia, MCV 80-100, retikulosit >2, bilirubin tinggi, LDH tinggi, haptoglobin rendah, coombs test (+), bite cell (+), skistosit (+), sferosit (+), trias (anemia, ikterus, organomegali) 1. Anti-IgG, DAT IgG 2. Anti-IgM, DAT C3
(AUTOIMMUNE) HEMOLYTIC ANEMIA 1. WARM TYPE 2. COLD TYPE ## Footnote PREDNISON 1MG/KG PO; splenektomi
58
Anemia, MCV 80-100, pansitopenia, FNAB fat infiltrated hypocellularity
ANEMIA APLASTIK ## Footnote Suportif (transfusi darah Hb<7, cegah infeksi), siklofosfamid, TRANSPLANTASI SUMSUM TULANG
59
Anemia, MCV 80-100, AIHA, rw obat (primakuin, TMP-SMX, dapson, nitrofurantoin)/konsumsi fava, heinz body (+)
ANEMIA DEFISIENSI G6PD
60
Anemia, MCV >100, hypersegmented neutrophil (+), aniso/poikilo/makrositosis, homosistein tinggi, tes schilling B12 rendah, methylmalonic acid (MMA) tinggi, gejala neurologis (+), rw gastrektomi/vegan
ANEMIA DEFISIENSI B12 ## Footnote Vit B12 (kobalamin) 1mg/d IM/SC 1wk lalu 1mg/wk
61
MCV >100, hypersegmented neutrophil (+), aniso/poikilo/makrositosis, homosistein tinggi, B9 rendah, rw malabsorbsi/hamil
ANEMIA DEFISIENSI B9 ## Footnote Vit B9 (as folat) 1-5mg/d PO
62
Rw infeksi, palpable purpura, nyeri perut, artritis, hematuria, IgA (+), PLT normal
HENOCH-SCHONLEIN PURPURA (HSP) ## Footnote Suportif. Prednisone 1 mg/kg/d 1-2 wk (inflamasi); IVIG
63
BT memanjang, Rw infeksi, pendarahan (purpura/ptekie/ekimosis, mukosa, GI jika berat), PLT <100, megakariosit/megatrombosit
IMMUNE THROMBOCYTOPENIC PURPURA (ITP) ## Footnote Prednisone 1 mg/kg/d 1-2 wk (PLT<20)
64
CT memanjang, aPTT memanjang, X-linked resesif, pendarahan sendi/mukosa spontan susah berhenti: 1. Faktor VIII 2. Faktor IX 3. Faktor XI
HEMOFILIA 1. HEMOFILIA A 2. HEMOFILIA B 3. HEMOFILIA C ## Footnote RICE, analgesik, FVIII/kriopresipitat (A), FIX/FFP (B), FXI/FFP (C)
65
BT memanjang, aPTT memanjang, Autosomal dominan, pendarahan, vWF rendah, tes ristocetin aggregrasi turun, VIII rendah
VON WILLEBRAND DISEASE (VWD) ## Footnote vWF, desmopressin, as traneksamat
66
CT, aPTT, PT memanjang, Inj vit K lahir (-), usia <8mo, pendarahan intrakranial/GI
VITAMIN K DEFICIENCY BLEEDING ## Footnote Profilaksis (vit K1 0.5-1 mg IM), vit K1 1-2 mg IV/SC
67
CT memanjang, BT memanjang, aPTT memanjang, PT memanjang, Rw infeksi/kanker, perdarahan luas, purpura fulminan, disfungsi organ, PLT rendah, D-dimer tinggi
DISSEMINATED INTRAVASCULAR COAGULATION (DIC) ## Footnote TX penyebab, suportif-simptomatik
68
Painless lymphadenopathy, simptom B, reed-sternberg cell (+), rw EBV, demam pel-ebstein (1-2wk lalu remisi 1-2wk)
HODGKIN LYMPHOMA
69
Painless lymphadenopathy, simptom B, starry sky appearance (+)
NON HODGKIN LYMPHOMA
70
Gejala leukemia, Limfoblas imatur, FNAB hiperselular dengan limfoblas >20%, >anak
ALL ## Footnote Kemoterapi, TRANSPLANTASI SUMSUM TULANG
71
Gejala leukemia, Mieloblas imatur, FNAB hiperselular dengan mieloblas >20%, auer rod (+)
AML ## Footnote Kemoterapi, TRANSPLANTASI SUMSUM TULANG
72
Gejala leukemia, Limfosit matur abnormal, FNAB infiltrasi limfosit matur, smudge/basket/gumprecht cell (+)
CLL ## Footnote Kemoterapi, TRANSPLANTASI SUMSUM TULANG
73
Gejala leukemia, Granulosit abnormal, FNAB hiperselular dengan mielosit, philadelphia chromosome (+) translokasi
CML ## Footnote Kemoterapi, TRANSPLANTASI SUMSUM TULANG
74
Hb >16.5/>16, Hct >49%/>48%, mutasi JAK2 (+), EPO rendah
POLISITEMIA VERA ## Footnote Flebotomi hingga Hct 45%, aspirin 80mg/d
75
CRAB (hyperCalcemia, renal failure, anemia, bone lytic punched out lesion), biopsy fried egg app (+), protein elektroforesis M spike, urinalisis protein bence jones
MULTIPLE MYELOMA
76
Gejala akut dari sistem: kulit-mukosa + ≥1 respirasi/CV ATAU ≥2 kulit-mukosa/respirasi/CV/GI + alergen dugaan ATAU SBP <90/>30% drop + alergen pasti
ANAFILAKSIS ## Footnote ABCDE, trendelenburg, ADRENALIN/EPINEFRIN IM 1:1000 1MG/ML 0.3-0.5ML @5-15M
77
Infeksi + qSOFA ≥2 (RR ≥22, GCS<15, SBP ≤100) 1. Butuh vasopressor MAP ≥65 + laktat >18mg/dl / >2mmol/L
SEPSIS 1. SYOK SEPTIK ## Footnote 1h bundle: ukur laktat, kultur darah, Ab broad spektrum [ceftriaxone 1x 2g / piperacillin tazobactam 4x 4.5g / vankomisin 3x 15-20mg/kg], kristaloid 30mL/kg jika hipotensi/laktat≥4, vasopressor [NE 0.05-0.15mcg/kg/m] hingga MAP≥65
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Stadium Klinis HIV
I (CD4 >500): asimptomatik, limfadenopati generalisata II (CD4 <500): penurunan BB <10%, ISPA berulang, herpes zoster, angular cheilitis, ulkus mulut, papular eruption, derm. seboroik, onikomikosis III (CD4 <200): penurunan BB >10%, diare kronis >1 bulan, demam menetap, oral kandidiasis, oral hairy leukoplakia, TB paru, infeksi bakteri berat, stomatitis nekrotikans, anemia/neutropenia/trombositopenia IV (CD4 <200 + AIDS): wasting syndrome, PCP, herpes simplex >1mo, esophageal candidiasis, TB ekstraparu, kaposi sarcoma, CMV, cerebral toxoplasmosis, ensefalopati, cryptococcosis, cryptosporidiosis/isosporiasis kronis, histoplasmosis/coccidiomycosis/leishmaniasis diseminata, septikemia berulang, limfoma, nefropati/kardiomiopati
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Alur Pemeriksaan HIV dan Interpretasi
A1: donor/transplan A2: studi epidemiologi A3: diagnosis individu POSITIF: A1+A2+A3 (+) INDETERMINATE: 2 (+) / 1 (+) berisiko NEGATIF: 1 (+) tidak berisiko / pengulangan (-) / (-) ## Footnote ARV (positif) Periksa ulang 2wk; PCR (indeterminate) Periksa ulang 3,6,12mo (negatif berisiko) Perilaku sehat (negatif tidak berisiko)
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Tatalaksana HIV
2 NRTI + 1 NNRTI 1. TLE (LINI 1) 2. ZLE/N 3. TLN TMP-SMX 1x 960mg/d (St III/IV / CD<200 / TB(+)) Isoniazid 600mg/d (TB(-)) ## Footnote NRTI: Z / L / T / Em NNRTI: E / N
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Tatalaksana Khusus 1. HIV + TB 2. HIV + TB (CD4<50) 3. HIV + TB + Meningitis Kriptokokus
1. Obati TB, ARV setelah 2-8wk 2. Obati TB, ARV setelah 2wk 3. Obati TB + Kriptokokus, ARV setelah 5wk
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Demam, pusing, nyeri otot betis, suffusi konjungtiva, mual muntah, DFM (+) spirochaeta, MAT (+): 1. Ikterus, pendarahan spontan, gagal ginjal
LEPTOSPIROSIS 1. LEPTOSPIROSIS IKTERIK/WEIL'S SYNDROME ## Footnote DOKSISIKLIN 2X 100MG / amoksisilin 4x 500mg / ampisilin 4x 500 mg PO 7d, doksisiklin 1x 200mg / azitromisin 1x 500mg (profilaksis) PENISILIN G 4X 1.5JT IU / ampisilin 4x 1g / amoksisilin 4x 1g / ceftriaxone 1x 1g / cefotaxime 4x 1g / eritromisin 4x 500mg IV 7d (berat)
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Minggu 1 (demam stepladder, rose spot, GI), minggu 2 (demam konstan, bradikardia relatif, hepatomegali, tifoid tongue), kultur darah/feses/urin (+) minggu 1/2/3, widal titer O 1/320 (+) minggu 1
DEMAM TIFOID ## Footnote Simtomatis, diet rendah serat, SIPROFLOKSASIN 2x 500MG 14D (dewasa), KLORAMFENIKOL 50-100MG/KG 14D (anak)
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Demam, menggigil, berkeringat, daerah endemis
MALARIA
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Tipe Malaria dan Tatalaksana
1. Demam tak tentu, maurer spot (+), tropozoit accole ring, bulan sabit/pisang: FALSIPARUM 2. Demam tertiana (setiap 2 hari), schuffner dot (+): VIVAX 3. Demam tertiana (setiap 2 hari), james dot (+), skizont komet: OVALE 4. Demam kuartana (setiap 3 hari), ziemann dot (+), band form, rosette form: MALARIAE ## Footnote ANTIMALARIA [ACT 1x4/1x3 tab (BB>60/BB<60), primakuin 0.25mg/kg/d / 0.75 mg/kg/d (vivax-ovale/falsiparum), kina 3x 10mg/kg, klindamisin 2x 10mg/kg] FALSIPARUM —> ACT 3d + primakuin SD VIVAX —> ACT 3d + primakuin 14d OVALE —> ACT 3d + primakuin 14d MALARIAE —> ACT 3d
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Tatalaksana Malaria Berat
Artesunat 2.4mg/kg IV 0,12,24h IV ATAU Artemeter 1x 1.6mg/kg lalu 2x 1.6mg/kg IM
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Profilaksis Malaria
Klorokuin 2x 500/wk (sensitif klorokuin) Doksisiklin 100mg/d / Atovaquone 250mg/d / Meflokuin 250mg/wk (resisten klorokuin)
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A. lumbricoides, inf telur, telur tebal berlapis-bergerigi-unsegmented, obstruksi GI-sindrom loeffler
ASKARIASIS ## Footnote ALBENDAZOLE 400MG SD / mebendazole 2x 100mg 3d
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A. duodenale / n. americanus, inf filariform, telur tipis-unsegmented, anemia, harada mori (+)
HOOKWORM
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E. vermicularis, inf telur, telur bikonkav asimetris huruf D, gatal dubur, graham scotch tape (+)
ENTEROBIASIS ## Footnote ALBENDAZOLE 400MG SD / mebendazole 2x 100mg 3d
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T. trichiura, inf telur, telur tempayan, diare-prolaps rekti
TRIKURIASIS ## Footnote MEBENDAZOLE 2X 100MG 3D / albendazole 1x 400mg 3d
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S. spp, inf serkaria, telur spina samping (mansoni)/ujung (hematobium)/tidak ada (japonicum), diare-hematuria
SCHISTOSOMIASIS ## Footnote Prazikuantel 10mg/kg SD
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F. spp, inf metaserkaria, telur satu operkulum, diare-nyeri RUQ
FASCIOLIASIS ## Footnote Prazikuantel 10mg/kg SD
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T. spp, inf sistiserkus/telur (taeniasis/sistiserkosis), telur radial berkait seperti pedati, proglottid saginata >> solium, diare-neurosistiserkosis
TAENIASIS/SISTISERKOSIS ## Footnote Prazikuantel 10mg/kg SD (taeniasis), albendazole 2x 400mg 8-30d (neurosistiserkosis)
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Limfedema, elefantiasis 1. Lebar:panjang 1:1, sarung tidak berwarna, inti halus rapi, inti terminal 0, ekor pita 2. Lebar:panjang 1:2, sarung merah muda, inti kasar, inti terminal 2, ekor tumpul 3. Lebar:panjang 1:3: sarung tidak berwarna, inti kasar, inti terminal 2, ekor tumpul
FILARIASIS 1. W. BANCROFTI 2. B. MALAYI 3. B. TIMORI ## Footnote Dietilcarbamazine 6mg/kg 12d / ivermektin 150mcg/kg SD (kuratif), DEC 6mg/kg + albendazole 400mg @1y (profilaksis)
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Anemia, atrofi papil lidah, licin, nyeri (+)
GLOSSITIS ATROFI
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Atopi, lidah geografis, asimtomatis
BENIGN MIGRATORY GLOSSITIS
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Merokok, lidah eritem bagian tengah
MEDIAN RHOMBOID GLOSSITIS
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Merokok/alkohol, plak putih tidak bisa dikerok asimtomatis
LEUKOPLAKIA
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Merokok/alkohol, plak merah asimtomatis
ERITROPLAKIA
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Plak putih kuning lidah, kerok dasar eritem
CANDIDIASIS ORAL ## Footnote Nistatin drop 100rb IU
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Luka mukosa berupa ulkus, nyeri
STOMATITIS AFTOSA ## Footnote Klorheksidin glukonat kumur 0.2% / triamsinolon asetonid krim 0.1%
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Heartburn, regurgitasi, nyeri ulu hati 1. Endoskopi (GS) mucosal break (+): 2. Endoskopi (GS) mucosal break (-):
GERD 1. EROSIVE REFLUX DISEASE (ERD) 2. NON EROSIVE REFLUX DISEASE (NERD) ## Footnote PPI pantoprazole 40mg / esomeprazole 40mg / lansoprazole 30mg / omeprazole 20mg / rabeprazole 20mg @1x/d 2 wk, dosis ganda (refrakter)
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Alur Pemeriksaan GERD
Gejal GERD: GER-Q ≥8, alarm symptom (+) [age>50, loss of weight>5%, anemia, melena/hematemesis, restriction disfagia/odinofagia] RUJUK ENDOSKOPI. Jika alarm symptom (-), PPI TEST dosis ganda 1-2wk, jika membaik = DX GERD —> terapi 8 wk. Refrakter = endoskopi
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≥3mo, onset ≥6mo, nyeri epigastrium, rasa terbakar, alarm symptom (-)
DISPEPSIA TIPE ULCER ## Footnote PPI pantoprazole 40mg / esomeprazole 40mg / lansoprazole 30mg / omeprazole 20mg / rabeprazole 20mg @1x/d
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≥3mo, onset ≥6mo, begah setelah makan, cepat kenyang, alarm symptom (-)
DISPEPSIA TIPE DISMOTILITAS ## Footnote Prokinetik metoklopramid 10 mg / dompreidone 10mg
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Rw NSAID, nyeri epigastrium, PSCBA, UBT (+), ENDOSKOPI BIOPSI (+) ulkus >0.5cm + h. pylori 1. Nyeri dengan makan 2. Membaik dengan makan, nyeri beberapa jam kemudian
ULKUS PEPTIKUM 1. ULKUS GASTER 2. ULKUS DUODENUM ## Footnote Triple therapy [omeprazole 2x 20mg + klaritromisin 2x 500mg + amoksisilin 2x 1000mg] 14d (suseptibel klaritromisin), quadruple therapy [omeprazole 2x 20mg + metronidazole 3x 500mg + tetrasiklin 4x 250mg + bismuth 300mg] 14d (resisten klaritromisin)
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Disfagia progresif padat ke cair, relaksasi LES gagal karena degenerasi pleksus auerbach, barium swallow (+) bird beak, MANOMETRI ESOFAGUS (+) tek LES tinggi
AKALASIA ## Footnote ISDN 5mg sebelum makan, injeksi botox; dilatasi pneumatik/heller myotomy (definitif)
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1. Hematemesis, melena: 2. Hematokezia:
1. PSCBA 2. PSCBB ## Footnote Stabilisasi, PPI IV (ulkus), somatostatin 250mcg bolus lalu 250mcg/h drip / oktreotid 50mcg bolus IV lalu drip 50 mcg/h (varises), endoskopis (definitif)
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Hipertensi porta, PSCBA, anemia, sirosis, HVPG ≥10, endoskopi red wale mark (+)
VARISES ESOFAGUS ## Footnote Stabilisasi, somatostatin 250mcg bolus lalu 250mcg/h drip / oktreotid drip 50 mcg/h, transfusi PRC jika anemia berat (awal), ENDOSKOPI ligasi vena, TIPS (definitif), propanolol 2x 20mg/d (profilaksis)
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≥3mo, onset ≥6mo, ≥1x/wk nyeri abdomen + ≥2 (perbaikan dengan defekasi, perubahan frekuensi BAB, perubahan bentuk BAB)
IBS ## Footnote Diet tinggi serat (IBS-C), hindari pencetus (IBS-D), diet FODMAP
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Skip lesion, diare ± darah, endoskopi cobblestone, PA inflamasi transmural + granuloma non kaseosa, enema string sign (+) skip lesion
PENYAKIT CROHN ## Footnote CS, 5-ASA
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Continuous lesion usus besar distal, diare + darah, endoskopi ulkus/eritema, PA inflamasi submukosal + abses kripta, enema lead pipe sign (+)
KOLITIS ULSERATIF ## Footnote CS, 5-ASA
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Fekal oral, demam, ikterus, urine teh, IGM ANTI-HAV (+)
HEPATITIS A ## Footnote Simtomatis
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Rw seks bebas/jarum, ikterus, urin gelap, hepatomegali, HBV DNA (+)
HEPATITIS B ## Footnote Simtomatis, tenofovir AF 1x 300mg / tenofovir DF 1x 25mg, entecavir 1x 0.5mg PO. Stop jika serokonversi HbeAg —> anti-Hbe, HbsAg (-), HBV DNA (-) ≥12mo
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Serologi Hepatitis B 1. HbsAg (+), HbsAb (-), HbcAb (+) IgM, HbeAg (+): 2. HbsAg (-), HbsAb (-), HbcAb (+) IgM, HbeAg (-): 3. HbsAg (-), HbsAb (+), HbcAb (+) IgG, HbeAg (-): 4. HbsAg (-), HbsAb (+), HbcAb (-), HbeAg (-): 5. HbsAg (+), HbsAb (-), HbcAb (+) IgG, HbeAg (+): 6. HbsAg (+), HbsAb (+), HbcAb (+) IgG, HbeAg (-):
1. AKUT 2. WINDOW 3. SEMBUH 4. IMUNISASI 5. KRONIK AKTIF 6. KRONIK INAKTIF
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Rw seks bebas/jarum, ikterus, urin gelap, hepatomegali, HCV RNA (+)
HEPATITIS C ## Footnote Sofosbuvir/velpatasvir 1x 400/100mg 12 wk / glecaprevir/pibrentasvir 1x 300/120mg 12wk
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Nyeri RUQ, demam, ±ikterus, ludwig sign (+) nyeri tekan ICS VI AAL, air fluid level (+) 1. USG hipoekoik tunggal/multipel, rw infeksi bilier 2. USG hipoekoik tunggal, rw disentri
ABSES HEPAR 1. PIOGENIK 2. AMOEBIK ## Footnote Metronidazole 3x 750mg PO/IV 7-10d (amebik), seftriakson 2x 1-2g IV + metronidazole 3x 500mg 10-14d (piogenik); aspirasi (refrakter, dekat perikardium, >5cm)
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SEGASIH [Splenomegali, eritema palmar, ginekomastia, asites, spider nevi, invers albumin, hematemesis melena], asteriksis/ensefalopati, LFT naik, USG hati kecil ireguler nodular
SIROSIS HEPATIS ## Footnote Terapi varises (HT portal), laktulosa 3x 30mL (ensefalopati), spironolakton 100mg/d (asites), parasentesis + sefotaksim 3x 2g IV (asites)
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Hepar membesar, USG berdungkul dungkul, alfa fetoprotein (+)
HCC
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Rf dislipidemia/kolesistektomi, alkohol (-), nyeri RUQ, hepatomegali, LFT naik, AST/ALT<1, ALP naik, USG bright liver (+), BIOPSI >5% steatosis 1. Inflamasi (+)
NAFLD 1. NASH
122
4F, kolik bilier, nyeri RUQ setelah makanan berlemak menjalar skapula kanan, demam (-), ikterus (-), USG acoustic shadow
KOLELITIASIS ## Footnote Observasi (asimtomatis), UDCA 2x 250mg PO; kolesistektomi (definitif)
123
Nyeri RUQ menjalar skapula kanan, demam (+), ikterus (-), murphy sign (+), USG penebalan dinding empedu ± batu, HIDA SCAN (+)
KOLESISTITIS AKUT ## Footnote Stabilisasi, NPO, simtomatis, seftriakson 1x 2g IV + metronidazole 3x 500mg IV; kolesistektomi (definitif)
124
Nyeri RUQ menjalar skapula kanan, demam (-), ikterus (+), USG dilatasi CBD, ERCP filling defect
KOLEDOKOLITIASIS ## Footnote ERCP/kolesistektomi
125
Trias charcot [nyeri RUQ, demam (+), ikterus (+)], USG dilatasi CBD, penebalan traktus biliaris
KOLANGITIS ## Footnote Stabilisasi, simtomatis, ampisilin-sulbaktam 4x 500mg IV; kolesistektomi (definitif)
126
Nyeri epigastrik menjalar skapula, mual muntah, grey turner sign (+) flank, cullen sign (+) periumbilikal, amilase lipase naik ≥3x normal, USG cairan peripankreas
PANKREATITIS AKUT ## Footnote Stabilisasi RL loading 15-20mL/kg lalu maintenance 3mL/kg, NPO, morfin; ERCP/sfingterektomi/kolesistektomi
127
Usia tua, merokok, BB turun, ikterus, palpable painless gallbladder (courvoisier sign), nyeri epigastrik, CA 19-9 (+)
CA CAPUT PANKREAS ## Footnote Whipple procedure
128
Fekal oral, nyeri perut, diare berdarah tidak berbau, frekuensi ≥10x volum sedikit, demam (++), leukositosis, FL leukosit dan darah, KULTUR AGAR MACCONKEY (+)
DISENTRI BASILER ## Footnote Rehidrasi, SIPROFLOKSASIN 2X 500MG PO 3D / 2x 15mg/kg PO 3d (anak) / seftriakson 1x 50-100mg/kg IM 5d (anak)
129
Fekal oral, nyeri perut, diare berdarah bau busuk, frekuensi 6-8x volum banyak, demam (+), FL kristal charcot leyden/piknotik, MIKROSKOPI FESES (+) e. histolytica
DISENTRI AMOEBA ## Footnote Rehidrasi, METRONIDAZOLE 3X 500MG PO 7-10D / 35-50mg/kg PO 7-10d (anak)
130
Diare profuse air cucian beras
KOLERA ## Footnote Rehidrasi, zinc, azitromisin 15mg/kg/d lalu setengah dosis (anak) 5d, azitromisin 3x 500mg (hamil), TETRASIKLIN 4X 500MG 5D / azitromisin 3x 500g / doksisiklin 300mg SD
131
Rw penggunaan Ab panjang, diare, c. difficile, kolonoskopi pseudomembran kuning
KOLITIS PSEUDOMEMBRAN ## Footnote Hentikan Ab, metronidazole 3x 500mg 10-14d; vankomisin 15-20mg/kg 10-14d
132
Fekal oral, basilus gram (-), diare 1. Watery, demam (-), RW BERPERGIAN, toksin LT/ST 2. Watery, demam (±), BAYI/ANAK, toksin (-) 3. Bloody, demam (+), SPT DISENTRI, toksin (-) 4. Bloody, demam (-), KOMP HUS, toksin shiga-like, O157:H7
DIARE E. COLI 1. ETEC/TRAVELER'S DIARRHEA 2. EPEC 3. EIEC 4. EHEC
133
Rw makan kalengan, Gejala GI lalu paresis NVII, disartria, paresis, c. botulinum
BOTULISME ## Footnote Stabilisasi, antitoksin [equine serum heptavalen (>1y), human derived IG (<1y)], PPI sukralfat
134
Usia tua, hematokezia, nyeri LLQ, demam (+), konstipasi, CT SCAN OUTPOUCHING
DIVERTIKULITIS ## Footnote Ab; pembedahan (perforasi)
135
Usia tua, rw IBD/polip, BB turun, perubahan pola BAB lalu menjadi feses kotoran kambing, hematokezia, CEA >2.5, apple core sign (+) 1. Kolitis, diare, darah samar, anemia (+) 2. Obstruksi, konstipasi, darah samar/makro, anemia (-) 3. Obstruksi, tenesmus, darah makro, anemia (-), feses kotoran kambing
CA KOLORECTAL 1. KOLON KANAN 2. KOLON KIRI 3. REKTOSIGMOID

GAS (14 decks)

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