VERTIGO, MENIERE DISEASE AND BELL’S PALSY

excess of acetylcholine in the brain. The goal of treatment is to restore dopamine neurotransmitter function as close to normal as possible and relieve symptoms caused by “excessive” acetylcholine. Therapy must be individualized, but selegiline therapy is often started first to slow the development of symptoms. As selegiline becomes less effective, levodopa is started with or without selegiline. Dopamine agonists amantadine, bromocriptine, pergolide, ropinirole, pramipexole may be added to directly stimulate dopamine receptors. Entacapone may be added to levodopa therapy to reduce the metabolism of levodopa, prolonging its action. Anti cholinergic agents may be added at any time to reduce the effects of the excessive acetylcholine. Non pharmacologic treatment e.g., diet, exercise, physical therapy of Parkinson’s disease is equally important in maintaining the long-term well being of the patient. SCENARIO Mrs X, 55 years old, is being started on an anti cholinergic drug as part of the treatment plan for Parkinson’s disease. LEARNING TASK 1. What symptoms can be expected to improve ? 2. What problems could also arise from starting this medication ? 3. Discuss the normal course of progsession of Parkinson’s disease and include the rationale for drug therapy to alleviate the symptoms 4. List drugs which will give to the patient who has parkinsonism ? 5. Explain why do you choose l-dopa and not dopamine to treat Parkinson’s disease ? 6. Explain why levo-dopa could not be combined with pyridoxine? 7. Describe the benefit combination of levodopa with carbidopa in the treatment od Parkinsonism ? 8. Describe why dipenhydramine used to treat Parkinsonism caused by neuroleptic ? SELF ASSESMENT 1. Describe the rationale drugs used to treat parkinson’s disease 2. Describe the side effect of drugs that used for parkinson’s diseas 3. Develop an education plan for people diagnosed with parkinson’s disease LEARNING PROGRAM CLINICAL NEUROSCIENCE DAY 1 st April 9 th

2015. VERTIGO, MENIERE DISEASE AND BELL’S PALSY

dr. IA Sri Wijayanti, M.Biomed, Sp.S VERTIGO Aims: Describe diagnosis, initial management and or referral patients with vertigo Learning outcome: Can describe the: 1. Type of dizziness Faculty of Medicine Udayana University, DME 30 2. Differentiation between peripheral vestibular vertigo and central vestibular vertigo 3. Differentiation between vestibular vertigo and non vestibular vertigo 4. Examinations of dizzy patients 5. Initial management principle for vertigo 6. Evaluation the need for urgent investigations and referrals Curriculum contens: 1. History taking of Dizziness 2. Physical Examination of dizzy patients 3. Investigation routine and specific of vertigo 4. Initial Management for vertigo Abstracts Vertigo is an unpleasant disturbance of spatial orientation or illusory perception of movement of the body spinning and wobbing andor of the surrounding that usually results in a disturbance of equilibrium system. The sense of balance the equilibrium system is provided by integration of inputs from the visual, proprioceptive, and vestibular system into the brain. Pathologies along these pathways results in dizziness with various forms and severity. Dizziness as general term, can be subdivided into vertigo, disequilibrium, and dizziness. The patients whose dizziness is considered vertiginous, the evaluation should be directed toward differentiating between peripheral and central pathology Self directing learning Basic knowledge that must be known: 1. The Equilibrium System and The Vestibular System 2. Peripheral vestibular vertigo 3. Central vestibular vertigo 4. Non vestibular vertigo Scenario A 38-year old- man rolled over in the bed early morning and suddenly developed severe nausea as well as the unpleasant sensation that room was spinning around him. The spinning resolved within 30 seconds but recurred again in the opposite direction when he rolled back to his original position. This had never happened to him before. The patient denied tinnitus, hearing loss, recent viral illness and head trauma. Learning Task: 1. From the history above, what need to be asking to the patient ? remember the secret seven and fundamental four 2. Make the physical examination of patient with imagination in correlation with the story above 3. How to differentiate between patient with peripheral and central vestibular vertigo? 4. How to differentiate betweenvestibular vertigo and non vestibular vertigo? 5. What is the differential diagnosis of this patient? 6. Please explain the pathogenesis from each of differential diagnosis that has been mention above 7. What is the initial management of this patient ? Self Assessment 1. How to do a good history taking in vertigo cases? 2. How to do a good physical examination in vertigo cases? Faculty of Medicine Udayana University, DME 31 3. What is the etiology of peripheral and central vertigo? 4. What is the pathogenesis of Benign Paroxysmal Positional Vertigo BPPV and Meniere’s disease ? 5. When do you refer the patient with vertigo? MENIERE DISEASE Aims: Describe diagnosis, initial management and or referral patients with meniere disease Learning outcome: Can describe the: 1. Diagnosis of meniere disease 2. Differential Diagnosis of meniere disease 3. Management for meniere disease 4. Prognosis of meniere disease 5. Further investigations and referrals Curriculum contens: 1. History taking of meniere disease 2. Physical Examination of meniere disease 3. Investigation routine and specific of meniere disease 4. Management for meniere disease Abstracts Meniere disease also called endolymphatic hydrops, is a disorder that can affect hearing and balance to a varying degree. Meniere disease is chronic disorder in inner ear, it’s not fatal but disturb the quality of life. It is characterized by episodes of vertigo , low-pitched tinnitus , and hearing loss. The hearing loss is fluctuating rather than permanent, meaning that it comes and goes, alternating between ears for some time, then becomes permanent with no return to normal function. It is named after the French physician Prosper Meniere , who, in an article published in 1861, first reported that vertigo was caused by inner ear disorders. The condition affects people differently; it can range in intensity from being a mild annoyance to a lifelong condition. Meniere often begins with one symptom, and gradually progresses. However, not all symptoms must be present to confirm the diagnosis although several symptoms at once is more conclusive than different symptoms at separate times. Other conditions can present themselves with Meniere-like symptoms, such as syphilis , Cogans syndrome , autoimmune inner ear disease , dysautonomia , perilymph fistula , multiple sclerosis , acoustic neuroma , and both hypo- and hyperthyroidism . The symptoms of Meniere are variable; not all sufferers experience the same symptoms. According guidelines of the American Academy of Otolaryngology-Head and Neck Surgery AAO-HNS, Meniere disease have four symptoms: 1. Attacks of rotational vertigo that can be mild to severe, unpredictable, and minimal 20 minutes for 1 episode, but generally no longer than 24 hours. 2. Fluctuating, progressive, unilateral in one ear or bilateral in both ears hearing loss , usually in lower frequencies. Getting worsen during attack. 3. Unilateral or bilateral tinnitus , with characteristic low frequency or roaring noise. 4. A sensation of fullness or pressure in one or both ears. Some may have parasympathetic symptoms, which arent necessarily symptoms of Meniere, but rather side effects from other symptoms. These are typically nausea , vomiting , and sweating which are typically symptoms of vertigo, and not of Meniere. Vertigo may induce nystagmus , or uncontrollable rhythmical and Faculty of Medicine Udayana University, DME 32 jerky eye movements, usually in the horizontal plane, reflecting the essential role of non-visual balance in coordinating eye movements. Sudden, severe attacks of dizziness or vertigo, known informally as drop attacks, can cause someone who is standing to suddenly fall. Drop attacks are likely to occur later in the disease, but can occur at any time. Scenario A 38-year old- woman come to a clinic with chief complaint vertigo with mild symptoms, then progress to severe from this morning. She also hear roaring noise and fullness in her ears, and there also hearing loss that more severe in right ear. One week before the symptoms appear, she feel tired and eat much salty food. Learning task: 1. From the history above, what need to be asking to the patient ? remember the secret seven and fundamental four 2. Make the physical examination of patient with imagination in correlation with the story above 3. What is the differential diagnosis of this patient? 4. Where is topical lesion on this case? 5. How to differentiate between Meniere and BPPV patient? 6. Please explain the pathogenesis from each of differential diagnosis that has been mention above 7. What is the management of this patient ? 8. When do we start to rehabilitate the patient ? BELL’S PALSY Aims: Describe diagnosis, management and or referral patients with facial palsy Learning outcome: Can describe the: 1. Diagnosis of Bell’s Palsy 2. Differential Diagnosis of Bell’s Palsy 3. Management for Bell’s Palsy 4. Prognosis of Bell’s Palsy 5. Further investigations and referrals Curriculum contens: 1. History taking of Bell’s Palsy 2. Physical Examination of facial palsy patients 3. Investigation routine and specific of Bell’s Palsy 4. Management for Bell’s Palsy Abstracts Bell’s Palsy is clinical syndrome of idiopathic acute unilateral facial paralysis. Patients may report the exposure to cold preceded their symptoms. The face often described as feeling stiff and numb without any objective sensory deficit. Decrease tearing and hyperacusis may appear in some cases may precede weakness. The condition is thought to be related to a viral infection, the swollen nerve being entrapment in the facial canal. Although not life threatening, Bell’sPalsy may have severe functional, aesthetic, and psychological consequences. Faculty of Medicine Udayana University, DME 33 Self directing learning Basic knowledge that must be known: 1. The anatomy of Facial nerve 2. Facial Palsy 3. Bell’s Palsy 4. Factors that affect Bell’s Palsy Scenario A 24-year old- medical student noticed while shaving one morning that he was unable to move the left side of his face. He worried that a serious problem, possibly a stroke, might be have occurred. He had had influenza-like symptoms the week before this sudden attack. Learning task: 1. From the history above, what need to be asking to the patient ? remember the secret seven and fundamental four 2. Make the physical examination of patient with imagination in correlation with the story above 3. What is the differential diagnosis of this patient? 4. Where is lesion base on facial nerve pathway make topical diagnosis? 5. How to differentiate between facial palsy in Bell’s Palsy and Stroke patient? 6. Please explain the pathogenesis from each of differential diagnosis that has been mention above 7. What is the management of this patient ? 8. When do we start to rehabilitate the patient ? Self assessment 1. How to do a good history taking in Facial Palsy cases? 2. How to do a good physical examination in Facial Palsy cases? 3. When do you refer the patient with Facial Palsy? Refferences: 1. PERDOSSI. Pedoman dan Tatalaksana Vertigo 2012 2. Adam and Victor’s. Principles of Neurology 8 th . 3. Wikipedia. Meniere Disease HEARING LOSS dr. Made Wiranadha, Sp. THT-KL Abstract There are two major categories of hearing loss that are key concepts for the clinician to understand. The first, conductive hearing loss, is due to an outer or middle ear problem—a problem “conducting” sound waves through the ear canal to the eardrum and then through the middle ear apparatus toward the inner ear. Causes of conductive loss might include obstruction of the ear canal by cerumen wax, impairment of middle ear function by fluid, or fixation of the middle ear ossicles by disease. With conductive loss, sounds coming from within, such as one’s own voice, are perceived as louder because of reduced competing ambient noise. Plug your right ear with your finger, creating a conductive loss, and note how your own voice sounds louder on this side. This phenomenon is known as autophony. A patient with a conductive loss often feels like he or she is talking “in a barrel,” or “under water.” Sensorineural hearing loss is due to a malfunction somewhere in the inner ear, from the cochlea inward through the auditory nerve. This is often termed “nerve deafness” and with this type of loss even one’s Faculty of Medicine Udayana University, DME 34 own voice does not sound loud. The distinction between these two types of loss is obviously important for determining the cause of a patient’s hearing complaint. Both conductive and sensorineural loss in the same ear. This would be referred to as a mixed loss. Tuning-fork evaluation can differentiate between the two hearing loss. The 512-Hz tuning fork is themost accepted frequency for assessing hearing using the Weber and Rinne tests. Audiometry is the precise method of hearing assessment Learning Objective 1. Describe general strategy in the approach to patients with hearing loss a trough history and physical examination supported by selected and supporting tests or special technique investigations. 2. Describe etiopathogenesis and pathophysiology of hearing loss with it’s clinical implication such as congenital hearing loss, hearing loss due to trauma, hearing loss due to an infection, and others. 3. Implement the differential diagnosis of congenital hearing loss, trauma or aging. 4. refer patient with hearing loss cases that can be treated eg sudden deafness. Learning Objective CASE 1 A 19 years woman complained of impaired hearing in the right ear suddenly after swimming, the ear feels full, and pain. Patients do not complain of cough and colds. Learning Task 1. What question is needed to complete anamnesis? 2. Describe etiology and pathophysiology of this hearing loss? 3. Describe about diagnose of the disease and learn symptoms and sign, plan of the treatment and complication could be of the disease? Case 2 A 3 years old boy was brought to the ENT-HNS clinic with complaints has not been able to speak to the present, the patient does not respond when called upon. The patient does not respond well to hear the sound of thunder or a loud closed door. Learning Task 1. What question is needed to complete anamnesis? 2. What investigations are needed? 3. Describe about plan of the treatment of the disease? From Menner, A Pocket Guide to the Ear © 2003 Thieme DAY 2 nd April 10 th 2015 FEBRILE SEIZURE IN CHILDREN dr. Dewi Sutriani Mahalini, SpA Aims: Describes definition, pathophysiology, classification and consensusguideline management of febrile seizures. Learning outcome: 1. Describe definition and classification of febrile seizure in children. Faculty of Medicine Udayana University, DME 35 2. Describe etiology and risk factors of febrile seizure in children. 3. Describe the sign, symptom and diagnosis criteria of febrile seizure in children. 4. Describe the management febrile seizure and long term management for prevention recurrent seizure. 5. Describe the necessary information and education for parents and social environment. Curriculum contents: 1. Consensus of diagnosis and management febrile seizure 2. Classification of febrile seizure 3. Risk factors of recurrent febrile seizure and genetic epilepsy with febrile seizures plus GEFS+ 4. Immediate medical management of acute seizure and status epilepticus 5. Long term management for prevention of recurrent febrile seizure intermittent and long term prophylaxis Abstract of Lecture Febrile seizures FS are the most common seizure disorder in childhood. Seizures with fever occur in 3- 5 of children in North America and Europe, and in up to 14 of children IN Asia. It affects both boys and girls equally, mainly between 6 and 36 months with a peak at an age of 18 months. A febrile seizure FS is a disorder that presents between 3 months and 6 years of age with convulsions and fever but without evidence of intracranial infection or defined cause. It is defined as a seizure occurring in the context of a febrile illness, not secondary to a central nervous system CNS infection or an altered metabolic state in children who have not had neonatal or previous afebrile seizures. There are two main clinical forms: Simple febrile seizure are a short generalized seizure, of a duration lasting than 15 minutes, not recurring within 24 hours, occurring during a febrile episode, not caused by an acute disease of the nervous system. Simple febrile seizures usually occurring during the first 24 hours of a febrile illness. Majority 70-75 of FS are simple febrile seizure. Complex febrile seizure are a focal, or generalized and prolonged seizure, of a duration of greater than 15 minutes, recurring more than once in 24 hours, andor associated with post-ictal neurologic abnormalities, more frequently a post ictal palsy Todd’s palsy, or with previous neurologic deficits American Academy of Pediatrics 1996; Berg Shinnar, 1996; Knudsen, 2000. Risk of further febrile seizures: Approximately 30-40 of children who have a febrile seizure will have a recurrence, usually within 12 months. A higher risk of recurrence exists if the first seizure occurs when the patient is younger than 15 months, there is a history of febrile seizure in a first-degree. The majority are simple febrile seizures and therefore last a shorter duration and may abort spontaneously. The risk factors for developing febrile seizures are multiple and include both genetic factors such as positive family history of FS and environmental factors such as day care attendance, specific infections such as human herpes virus 614, influenza A virus15 and metapneumovirus16, prolonged stay in a neonatal unit, neuronal abnormality and iron deficiency anaemia. The etiology of FS is considered to multifactorial model; however, an autosomal dominant inheritance with reduced penetrance has been described in several families. Several chromosomal loci, particularly those on 19q and chromosome 2, have been identified. Gene mutations on voltage gated ion channels such as the alpha 1 subunit, the alpha 2 subunit and beta 1 subunit of sodium channel SCN1A , SCN2A and SCN1B and those affecting the gamma amino butyric acid GABA receptor have been shown to be strongly associated with the epilepsy syndrome of ‘genetic epilepsy with febrile seizures plus’ GEFS+. Although a change in body temperature is required for occurrence of FS, the convulsions are not specifically related to the rise in temperature or height of the temperature. They are considered to be due to increased neuronal excitability due to release of various pyrogens. Faculty of Medicine Udayana University, DME 36 Diagnosis is essentially based on physical examination and history taking American Academy of Pediatrics, 1996. The initial evaluation includes exclusion of infection in the CNS. Immediate medical management includes treatment of the seizure if still continuing. Benzodiazepines administered rectally, buccally or nasally are useful for rapid control. Since most FS are simple and abort spontaneously the use of intermittent or long term prophylaxis is not recommended. Diazepam over the first 24- 48 hours of each febrile illness has been in use since 1978 for intermittent prophylaxis; however its efficacy in the meta-analysis is controversial. In children with very frequent atypical febrile seizures, particularly those with recurrent prolonged seizures, long term treatment with sodium valproate may be beneficial. Scenarios Case 1 A girl, 12 months of age, came to the emergency unit with main complaint seizure. Seizure occur once at 2 hours before admission, the tipe of seizure were tonic clonic, general, both eyes looking upward, the duration 10 minutes and stopped spontaneously. She look weak after seizure and next cried loudly after 15 minutes. The physical examination revealed, alert, respiration 28 timesminutes, pulse 100 timesminutes, rectal temperature 39.5 o C. She also had cough, running nose.The urination was clear and yellow, but the patient had vomiting about 5 times and diarrhea 4 times since 2 days before admission. Learning task 1. What is the diagnosis and differential diagnosis? Explains the reason of your answers? 2. What are the risk factor that you have to know? 3. Explain possible causes of the acute seizure? 4. What are the necessary diagnosis work up to support your diagnosis? 5. What are the management at emergency unit? 6. Should the patient hospitalized? Explain the reasons of your answer 7. Explain long term management to the patient 8. What are information and education that should be you done? Case 2 A boy, 4 years of age, came to the emergency unit with main complaint serial seizure. The first seizure occur 4 hours before admission, second seizure occur since 15 minutes ago and the seizure still continued until the patient arrive at emergency unit and still continued after treatment with diazepam rectally. Tipe of seizure were tonic clonic, general, both eyes looking upward. She look weak after seizure and still unconscious. The past history : patient already had seizure 3 times episode since 12 months of age, History of delivery were spontaneous, body weight 2000 grams and severe asphyxia. The physical examination revealed, respiration 30 timesminutes, pulse 120 timesminutes, rectal temperature 40.0 o C. She also had history of cough and difficult breathing since 2 days before admission. The urination was clear and yellow, defecation normal. Learning task 1. What is the diagnosis and differential diagnosis? Explains the reason of your answers? 2. What are the risk factor of recurrent seizure in this patient? 3. What are past history of seizure that you need to know for long term management? 4. Explain possible causes or etiology of the acute seizure? 5. What are the necessary diagnosis work up to support your diagnosis? 6. What are the management for acute seizure? 7. Explain long term management to the patient 8. What are information and education that should be you done? Faculty of Medicine Udayana University, DME 37 Self assessment 1. Describe definition of febrile seizure in children 2. Describe classification of febrile seizure in children and its differentiation 3. Describe etiology and risk factors of febrile seizure in children 4. Describe the management of acute seizure in febrile seizure 5. Describe the long term management for prevention recurrent seizure EPILEPSY AND STATUS EPILEPTICUS Dr. dr. DPG Purwa Samatra, Sp.SK: Aims: Describe pathophysiology, diagnosis, early manage and referral patien with seizures Learning Outcome : 1. Describe the role of neurotransmitters on patophysiology of seizures 2. Describe the neurological sign and symptom of seizures. 3. Describe the classification of epilepsy 4. Describe the Electroencephalography to diagnose epilepsy. 5. Describe early manage the patiens with seizures and know indication dan adverse effect of anti epileptic drugs AEDs, Curriculum Contens : 1. Anatomy of cerebral cortex and hypocampus. 2. Role of neurotransmitters 3. Classification of epilepsy and seizures type. 4. Etiology of epilepsy 5. Role of Anti Epileptic Drugs AEDs 6. Adverse effect of AEDs 7. Psychosocial aspect of epileptic patiens Abstract of Lectures. Epilepsy is defined as a condition in which to prone epileptic seizures. Epilepsy is recurrent of convulsion and stereotype. An epileptic seizures is caused by a trancient, excessive and abnormal discharge of nerve cells. The abnormal discharges my involve a small part of the brain or a much more extensive area in a both hemispheres. Epilepsy may be classified according to: seizurestype, EEG finding, aetiology, anatomical finding and age. International league Agants Epilepsy had a concensus to classified epileptic seizures as a: A. Partial epilepsy : simple partial . partial complex and partial become general B. General seizure : absence , tonic-clonic, clonic, tonic. C. Non classified ] Pathophysiology of seizures is underlying of abnormality between inhibition and excitatory neurotransmitters. Less of inhibition or over of excytatory neurotransmitter may be causes. In Faculty of Medicine Udayana University, DME 38 the figure less of inhibitory neurotransmitter GABA gamma amino butyric acid and over of the excitatory neurotransmitters Glutamate may be causes of the seizures. Common causes of epileptic seizures are listed: A. Idiophaticcryptogenic unknown causes. B. Cerebral infections . C. Head trauma traffic accident. D. Cerebrovascullar disease, E. Congenital disorders,. F. Metabolic disorders renal, hepatic, hematological. G. Disorder during pregnance. H. Disorder during labour. Diagnosis of epilepsy is essentially by a clinical features. Although investigation as EEG, Brain- scan and MRI may provide assistance. The diagnosis of epilepsy is made largely on the basis of the clinical history. The drug treatment of epileptic patients has improved over recent years. There is much understanding of the principles of effective drug treatment with Anti Epileptic Drugs AED. Practice point to manage patient with epilepsy is : Drugs treatment should be instituted only if the diagnosis of epilepsy is firm. Monotheray should be the role in the initial treatment of epilepsy and all drugs should be stated at low dosage, and built up over a period of weeks. Treatment of epilepsy is long life. The treatment will be stop if the patiens have two years seizures free and EEG within normal limit. Psycososial problem in epileptic patiens shoul be manage because many patient with epilepsy have a psycososial problem. TriggerScenario. Case 1 day 1 A 20-year-old women has history automobile accident 5 years ago, and has a decreas of the consciousness 30 minute after accident. 3 days before she go to hospital she has general convulsion and a automatism movement like a behavior changes. Neurological examination, no neurological deficit, physical examination within normal limit. Learning task 1. What is the diagnosis? 2. Explain why the traffic accident become to convulsion? 3. What is the diagnosis tool you made to definite diagnosis? Self assessment 1. Describe the function of neurotransmitters. Faculty of Medicine Udayana University, DME 39 2. Describe the type of accident will become a seizures. 3. Describe the classification of epilepsy, in the patiens like this case. 4. Describe the diagnosis tool, in patiens whit seizures. Disscusion in groups Where the TOPICAL DIAGNOSIS in patient with : 1. Hemiplegia on right side. 2. Monoplegia superior extremity on left side 3. Hemiplegia alternans N III on left side 4. Tetraplegia 5. Paraplegia. Case 2 day 2 Pregnacy women 25 years old, has a convulsion 3 days before she come to neurologic ward. The conculsion is generalized type. Physical examination within normal limit. No deficit neurology. Learning task 1. What is the diagnosis of the patiens? 2. Why the pregnancy can induced seizuresconvulsion? 3. What kind of the drugs you can give to the patiens? Case 3 day 2 As a doctor who work in health-centre, you care the patienswith convulsion and after convultion the patiens had neurological deficit as a hemipharesis on right side and disappear before 24 hours. Learning task 1. When you conclusion hemipharesis in this patients ? 2. How you differential diagnosed hemipharesis doe to organic lesion in the brain ? Where the topical diagnosis the patients with hemipharesis on right side ? 3. How to manage the patients who had hemipharesis after seizures ? Self assessment 1. Describe the epileptic patients with hemipharesis ? 2. Describe the epileptic patiens with psyco-social handicap. 3. Describe the manage patients with seizures and hemipharesis. DAY 3 rd and 4 th April 13 th 14 th 2015 HEADACHE TENSION TYPE HEADACHE, CLUSTER HEADACHE AND MIGRAIN AND TRIGEMINALNEURALGIA dr.Made Oka Adnyana, SpSK Aims : Diagnosis work up, management of primary headaches.tension type headache, cluster headache, migraine and trigeminal neuralgia. Learning outcome; 1. To describe the definitionof headache. 2. To describe the pathophysiology of headache, 3. To defrentiate primary and secondary of headache. Faculty of Medicine Udayana University, DME 40 4. To diagnosis primary headaches tension type headache, migraine and cluster headache. 5. How to manage primary headache pharmacology , non pharmacology, and trigeminal neuralgia Curiculum content. 1. Nerve inervation of head. 2. Pain sensitive structures of the head 3. Physiology of trigeminal nociception. 4. Clasification of primary headaches. 5. Clinical sign and symptom of primary headaches. 6. Treatment of primary headaches. Abstracts of lecture. Headache is the most common complain in neurology medical practice. Headache divided into primary and secondary. In differentiating both classes, we need to find the red flag sign. Secondary headache is assumed for their existence. Red flag sign are sign and symptoms those need further investigation because of their more dangerous underlined disease. Primary headache consist of tension type hedache, migraine, cluster headache and other primary headache. To diagnosic primary headache we need more about of headache, because physical examination and laboratory result usually normal. Treatment of primary headache consist of pharmacology analgetic and non pharmacology management. Treatment with analgetic must be carefully, because over use of analgetic could make a drug over use headache. Trigeminal neuralgia is a group of symptoms characterized by severe pain attacks accompanied sudden spasm of the face in a short time, which is limited to the areas served by dermatomes of the trigeminal nerve. Between attacks there is usually pain free .Treatment of trigeminal neuralgia is with anticonvulsants and surgery Triggerscenario. 1 st case A 17 years old woman, came to the neurology clinic, with complain of headache, tight or pressing sensation on head, bilateral each episode lasts in 30 minutes – 7 days. Learning task. 1. 1.What symptom we should ask to the patient? 2. What is diagnosis of this case?. 3. How to manage this patient. 2 nd case A 21 yers old boy complain of uinilteral headache since yesterday. He experienced severe pain around the eye ball. With red and watery eye as well. While having the attack in experienced vomitting, nausea. First attack was occurred at age of 20, happened 8 timesday. And finally the distance between eyelids got soaller when he had headache. Learning task. 1. What other symptom we should know to diagnose this case?. 2. What could be the possible diagnosis. 3. How is the management. Faculty of Medicine Udayana University, DME 41 3 rd. case. A 18 years old women complain unilateral headache since 2 days ago. She exprerienced moderat pain in the left side of head. She also experienced blured vision about 60 minute before headache. Blurred vision lasting about 10 minutes. First attack was occurred by age 15 years old. Her mother has the same symptom. Learning task 1. What other symptom we should know to diagnose this case?. 2. What could be the possible diagnosis. 3. How is the management. Self assessment. 1. Describe pain sensitive structure of the head. 2. Describe phathophysiology of headache. 3. How to defrenteate primary and secondary headache. 4. Describe what is the red flag. 4 th case. A 40 year sold man complaints severe pain on left side of the face especially when washing the face, sensation of pain as such as burning and lasting a few minutes. Learnig task. 1. What other symptom we should know to diagnosis this case. 2. What could be the possible diagnosis. 3. How is the management. Self assessment. 1. Describe anatomy trigeminal nerve. 2. Describe pathophysiology neuralgia trigemini. 3. How to defrenteate trigeminal neuralgia and primary headache cluster headache. NEUROIMAGING dr. Made Widhi Asih, Sp.Rad Self Assesment : 1. At emergency case, the advanced radiology modality that should be choosen is : a. Skull foto b. Waters c. Head CT Scan d. Head MRI e. PET Scan 2. For the suspicious of the thoracolumbal intra dural SOL, conventional radiology that using contrast agent is called : a. Hysterosalphyngography b. Intra venous pyelography c. Caudography d. Fistulography e. Urethrography Faculty of Medicine Udayana University, DME 42 3. At new born neonatal with convulsion and history of manual labor, the radiology modality that most safe for baby is : a. Cranial Ultrasonografi b. Skull foto c. Head MRI d. Head CT Scan e. Caudography Learning Task : 1. A 28 year-old male patient came with paraparesa inferior since 2 weeks ago, accompanied with lump on the upper back. a. Mention about conventional radiology examination that you suggest for this patient b. Mention about advanced radiology examination that should be done c. What is radiology findings that you will might be found 2. A 65 year-old male patient with history of hypertension, was brought by his family to the emergency department with complain of sudden weakness of his left upper and inferior extremities a. What is diagnosis that you suspect for this patient ? b. What is the most appropriate radiological examination that suggest ? c. Explain about radiological findings that you can see in that examination 3. A 9 year-old girl patient came to hospital with chief complain fever since 3 days ago accompanied with convulsion a. What is the radiological examination that can be choosed for this patient ? d. What is diagnosis that you suspect for this patient ? e. Explain about radiological findings that you can see in that examination 4. A 44 year-old female patient with low back pain that reffered to the left leg, and numbness on her leg, came to the hospital a. What kind of position that should you suggest for conventional radiology, especially for evaluated intervertebral foramina b. What is the next advanced radiology examination should be suggest for this patient ? c. Explain about the radiological finding that you wiil might be found 5. A young male came with chronic headache that getting worsen progressively a. What kind of conventional radiology examination will you suggest for this patient ? b. What do you try to find out from that examination ? Mention about the signs c. What kind of advanced radiology examination you should suggest to performed, if from conventional radiology showed abnormality? DAY 5 th April15 th 2014 HNP AND RADICULAR SYNDROME dr. Kumara Tini, Sp.S, FINS Aim : Describe the the structure of lumbar spine and sacrum and understand how they normally operate. Clinical characteristic, risk factors , diagnostic work-up including history, clinical examination and treatment of Low Back Pain. Learning outcome : 1. Know the the structure of lumbar spine and sacrum and understand how they normally operate. 2. Understand and be able explain how back pain and somatic referred pain differ from radicular pain, radiculopathy and sciatica. Faculty of Medicine Udayana University, DME 43 3. understand the lack of validity of diagnostic labels commonly applied to acute and chronic low back pain. 4. Be able to obstain a comprenhensive history of LBP, physical examination, psychososial factor in the assessment of patients with LBP. 5. Understand the natural history of acute low back pain back pain 6. Understand the use of diagnostic tool and lack of validity of conventional medical imaging in assessment of LBP 7. Understand management of LBP. 8. Understand the reasons for the limited efficacy of surgical treatment of low back pain Abstract In the United State, low back pain LBP is the fifith most common reason for all physician office visits and the second most common symptomatic reason. Low back pain is common and costly medical condition. The annual prevalence of low back pain in United States is estimated at 15 to 20 while in Indonesia prevalence rate is 18 Pain Study Club Indonesian Neurological Association survey 2002 Idiopathic low back pain is the most common cause of work-related disability for people age 45 year in US For most patients back symptoms are nonspecific, no evidence for radicular symptoms or underlying systemic disease. The history and physical examination usually provide clues to the rare but potentially serious cause of low back pain. Clinician should not routinely obtain imaging or other diagnostic tests in patients with non specific low back pain. Clinician should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficit are present or when serious underlying conditions are suspected on the basis of history and physical examination. Many therapeutic options are available for patients low back pain. The primary of treatment shoud be conservative care and operative. Conservative care consist of pharmacologic and non pharmacologic therapies. Clinicians should consider the use of medication with proven benefits in conjuction with back care information. For patients who do not improve with self care options, clinician should consider the addition of non pharmacologic therapy with profen benefit for low back pain. Surgical intervention decision should be made carefully because surgery doesnot tend to lead to huge improvements on average. Self assesment. 1. What is the classification of LBP ? 2. What is the meaning of red flag and yellow flag ? 1. Explain the mechanism herniated disc 2. Explain the diagnostic work-up LBP Scenario : A 45 years old man, farmer complaint low back pain suddenly after worked in this rice field . The pain is sharp pain accompanied by paresthesia that spreading to the left lateral side of thigh untill toe. There were no micturation and defection disturbances. Learning task : 1. What is the differential diagnosis of this patient ? 2. If etiology of LBP in this patient is HNP hernia nukleus pulposus L5-S1, what is the symptoms and signs ? what is diagnostic work-up for this patients ? 3. What is the management of Lumbar HNP ? Learning Resources : 1. Atlas SJ, Deyo RA. Evaluating and Managing Acute Low Back Pain in the Primary Care Setting. J Gen Intern Med 2001 : 16 : 120-131 Faculty of Medicine Udayana University, DME 44

2. Deyo RA. Evaluating and Managing Acute Low Back Pain in the Primary Care Setting.J Gen Intern