Conclution Etiology b. Pathogenesis

systems and disorders Regulation for Strudent Project 1. Each small group discussion must make 2 scientific writing see topic for each group 2. Each small group discussion must ready to present their scientific writing due to the above schedules 3. Each small group must collect their scientific writing after paper presentation. 4. Evaluation of student project will be performed in concordance with final examination in form of multiple choice question. There will be 2 questions to each topics. Report Format I. Introduction II. Content

a. Etiology b. Pathogenesis

c. Clinical feature d. Diagnosis e. Therapy

III. Conclution

IV. References vancouver style min. 8 15- 20 halaman; 1,5 spasi; Times New Romance; jilid warna hijau Cover  Tittle Name Student Registration Number Faculty of Medicine, Udayana University 2014 Student Project Topic No Group Topic 1 A1 - Prurigo - Deafness 2 A2 - Disorders of keratinization Ichtyosis vulgaris Faculty of Medicine Udayana University,MEU 19 systems and disorders - Fistula preauricular 3 A3 - Miliaria - Deafness 4 A4 - Cutaneous discoid lupus - Fistula preauricular 5 A5 - Prurigo - Disorders of keratinization Ichtyosis vulgaris 6 A6 - Miliaria - Cutaneous discoid lupus 7 A7 - Prurigo - Deafness 8 A8 - Disorders of keratinization Ichtyosis vulgaris - Fistula preauricular 9 A9 - Miliaria - Deafness 10 A10 - Cutaneous discoid lupus - Hearing systems 2 11 B1 - Prurigo - Disorders of keratinization Ichtyosis vulgaris 12 B2 - Miliaria - Cutaneous discoid lupus 13 B3 - Prurigo - Fistula preauricular 14 B4 - Disorders of keratinization Ichtyosis vulgaris - Fistula preauricular 15 B5 - Miliaria - Deafness 16 B6 - Cutaneous discoid lupus - Fistula preauricular 17 B7 - Prurigo - Disorders of keratinization Ichtyosis vulgaris 18 B8 - Miliaria - Cutaneous discoid lupus 19 B9 - Disorders of keratinization Ichtyosis vulgaris - Fistula preauricular 20 B10 - Miliaria - Deafness ASSESSMENT METHODES NO TOPIC ASSESSMENT METHOD 1 2 Introductionary to Block Skin and Disorders Functional structure of the skin and it’s appendices and hearing system disorder MCQ MCQ Faculty of Medicine Udayana University,MEU 20 systems and disorders 3 4 5 Common Pathological bases of the skin disorders Rational topical treatment in dermatology and hearing systems Dermatofarmacology and hearing systems MCQ MCQ MCQ 5 Skin manifestation effloresences in common skin disorders OSCE 6 Dermatitis numularis, fotocontact, neurodermatitis, napkin eksema, perioral, urtikaria MCQ 7 8 Papulo-erythrosquamosa Drug eruption of the skin MCQ MCQ 9 Pigmentary and sebaceous gland disorders MCQ 10 Bacterial infection impetigo, scrofuloderma, erisipelas, selulitis, eritrasma, hidradenitis MCQ 11 Eksisi tumor and curetase OSCE 12 Insect bite and infestation Scabies, creeping eruption, pediculosis MCQ 13 Tumor of the skin, vaginitis, servicitis MCQ 15 Abcess incision OSCE 16 Miliaria MCQ 17 Laboratory investigation OSCE 18 Disorders of keratinization MCQ 19 Prurigo MCQ 20 Cutaneous discoid lupus MCQ 21 Pericondritis, wax, foreign bodies, and bulous myringitis MCQ 22 Perforasi membran timpani,OMS,LABIRINITIS,paresis nervus fasialis MCQ 23 Ear trauma othematoma, barotrauma,motion sickness,PGPKT MCQ 24 Hearing loss, noise induced hearing loss MCQ 25 Deafness MCQ 26 Fistula preauricular MCQ 27 Manuver valsalva, pembersihan MAE dengan usapan, pengambilan serumen dengan kaitkuret, pengambilan benda asing di telinga OSCE Faculty of Medicine Udayana University,MEU 21 ~ MEETING ~ Meeting of the student representatives The meeting between block planners and student group representatives will be held on Wednesday, Jan 14 , at 10.00 until 11.00 at Class Room. In this meeting, all of the student group representatives are expected to give suggestions and inputs or complaints to the team planners for improvement. For this purpose, every student group should choose one student as their representative to attend the meeting. Meeting of the facilitators The meeting between block planners and facilitators will take place on Wednesday, Jan 14 at 11.00 until 12.00 at Class Room. In this meeting all the facilitators are expected to give suggestions and inputs as evaluation to improve the study guide and the educational process. Because of the importance of this meeting, all facilitators are expected to attend the meeting. ~ PLENARY SESSION ~ For each learning task, the student is requested to prepare a group report. The report will be presented in plenary session. Lecturer in charge will choose the group randomly. The aim of this presentation is to make similar perception about the topic that has been given. ~ ASSESSMENT METHOD ~ Assessment will be performed on Monday, February 2 th 2015 for both Regular class and English class. There are 100 questions for the examination that consist of Multiple Choice Question MCQ. The borderline to pass exam is 70. The proportion of final results are: Small group discussion : 5 Final exam MCQ : 95 BLOCK RULES: 1. Each student must follow all of the block activity, if they don’t do that, they have to make paper related to the block topic when was they absent lecture, practicumBCS and they have to collect to the lecture supervisor conveyer on that day. 2. Student have to prepare for pre and post test every day during the block. 3. Each student must on time, more than 5 minutes late, they wouln’t permitted to enter the room. 4. Cheating is prohibited, violent of the rules would be considered to decrease 10 of final exam result. Faculty of Medicine UNUD,MEU 22 systems and disorders ~ LEARNING PROGRAMS ~ ABSTRACTS OF LECTURES Day 1 Lecture 1. Introduction to The Block Skin and Disorders Suryawati Lecture 2. Functional Structure of the Skin and Its Appendices Linawati The skin consist of three layers firmly attach to one another. 1 The outer is epidermis, derived from ectoderm; 2 the deeper dermis, derived from mesoderm; and 3 the hypodermis or subcutaneous layer, corresponding to the superfisial fascia in gross anatomy. The epidermis is stratified squamous epithelial layer which consists of four distinct cell types; keratinocyte, melanocytes, langerhans cells and merkel cells. The epidermis consist of in five layer or strata : 1 stratum basale, 2 stratum spinosum, 3 stratum granulosum, 4 stratum lusidum and 5 stratum corneum. Skin appendages consist of hair, nail, sebaseous gland, sweat gland and nails. Skin is generaly classified into two types : 1 thick skin and thin skin. Thick skin more than 5 mm thick covers the palms of the hands and the soles of the feet and has a thick epidermis and dermis. Thin skin 1 to 2 mm in thickness lines the rest of the body; the epidermis is thin. The skin has several functions : 1 Protection mechanical function; 2 as a water barrier; 3 Regulation of body temperature conservation and dissipation of heat; 4 Non spesifik defense barrier to microorganism; 5 Excretion of salts; 6 synthesis of vitamin D; 7 as sensory organ The epidermis and dermis display a tight fit interface at the dermal-epidermal junction, where a basal lamina and hemidesmosomes are located. A primary epidermal ridge interlocks with a subjacent primary dermal ridge. An epidermal interpapilary peg, projecting downward from the primary epidermal ridge, interlocks with the primary dermal ridge, which is subdivided into two secondary dermal ridges. A number of dermal papillae project upward from the surface of each secondary dermal ridge into the epidermal region, interlocking with downward projections of the epidermis. This arrangement is predominant in hairless thick skin. Dermal papillae are numerous and branched. In thin skin, papillae are low and their number is reduced. Day 2 Lecture BCS 1 : Effloresensi Puspa Distribution of the rash, arrangement and morphology of individual rash, distribution of the lesion: symmetrical, asymmetrical, exposed area, sun exposed area, scalp region, hand, extensor aspect, flexor aspect. Arrangement and configuration of the lesion: grouped as in insect bites, dermatitis herpetiformis, herpes simplex, common warts, annular or arciform as in granuloma annulare, mycosis fungoides, tinea circinata, erythema annulare centrifugum, linear pattern as in Koebner phenomenon, Psoriasis, lichen planus, plane wart, molluscum contagiosum; Faculty of Medicine Udayana University,MEU 23 systems and disorders epidermal naevus, sporotrichosis, lichen striatus, lichen simplex, morphoea, lichen sclerosis, phytophotodermatitis. Morphology of lesion: Individual lesion described with the help of magnifying glass. To find out the early primary lesion and to inspect it closely. Note the shapegeometric shape, oval, coloursalmon-pink, erythematous, skin colour, yellow, size, margin sharpness of edge, well-defined, ill-defined, the surface characteristics dome-shaped, umbilicated, spike like, temperature and smell. It is a good practice if affordable to have thorough examination of the whole body especially for new consultation and for the elderly. Sometimes, examination of the back and buttock of the elderly may pick up unexpected lesions, even the patient himself or herself may not notice them e.g. persistent chronic annular erythematous rash in the buttock found in a case of tuberculoid leprosy. The major types of primary lesions are:  Macule. A small, circular, flat spot less than [frac25] in 1 cm in diameter. The color of a macule is not the same as that of nearby skin. Macules come in a variety of shapes and are usually brown, white, or red. Examples of macules include freckles and flat moles. A macule more than [frac25] in 1 cm in diameter is called a patch.  Vesicle. A raised lesion less than [frac15] in 5 mm across and filled with a clear fluid. Vesicles that are more than [frac15] in 5 mm across are called bullae or blisters. These lesions may may be the result of sunburns, insect bites, chemical irritation, or certain viral infections, such as herpes.  Pustule. A raised lesion filled with pus. A pustule is usually the result of an infection, such as acne, imptigeo, or boils .  Papule. A solid, raised lesion less than [frac25] in 1 cm across. A patch of closely grouped papules more than [frac25] in 1 cm across is called a plaque. Papules and plaques can be rough in texture and red, pink, or brown in color. Papules are associated with such conditions as warts, syphilis , psoriasis, seborrheic and actinic keratoses, lichen planus , and skin cancer .  Nodule. A solid lesion that has distinct edges and that is usually more deeply rooted than a papule. Doctors often describe a nodule as palpable, meaning that, when examined by touch, it can be felt as a hard mass distinct from the tissue surrounding it. A nodule more than 2 cm in diameter is called a tumor. Nodules are associated with, among other conditions, keratinous cysts, lipomas, fibromas, and some types of lymphomas.  Wheal -Urtica. A skin elevation caused by swelling that can be itchy and usually disappears soon after erupting. Wheals are generally associated with an allergic reaction, such as to a drug or an insect bite.  Telangiectasia. Small, dilated blood vessels that appear close to the surface of the skin. Telangiectasia is often a symptom of such diseases as rosacea or scleroderma . The major types of secondary skin lesions are:  Ulcer. Lesion that involves loss of the upper portion of the skin epidermis and part of the lower portion dermis. Ulcers can result from acute conditions such as bacterial infection or trauma, or from more chronic conditions, such as scleroderma or disorders involving peripheral veins and arteries. An ulcer that appears as a deep crack that extends to the dermis is called a fissure.  Scale. A dry, horny build-up of dead skin cells that often flakes off the surface of the skin. Diseases that promote scale include fungal infections, psoriasis, and seborrheic dermatitis .  Crust. A dried collection of blood, serum, or pus. Also called a scab, a crust is often part of the normal healing process of many infectious lesions.  Erosion. Lesion that involves loss of the epidermis. Faculty of Medicine Udayana University,MEU 24 systems and disorders  Excoriation. A hollow, crusted area caused by scratching or picking at a primary lesion.  Scar. Discolored, fibrous tissue that permanently replaces normal skin after destruction of the dermis. A very thick and raised scar is called a keloid.  Lichenification. Rough, thick epidermis with exaggerated skin lines. This is often a characteristic of scratch dermatitis and atopic dermatitis .  Atrophy. An area of skin that has become very thin and wrinkled. Normally seen in older individuals and people who are using very strong topical corticosteroid medication. Day 3 Lecture 3: Common Pathological bases of Skin disorders Herman S Little more than 100 years ago, the noted pathologist Rudolph Virchow considered the skin as protective covering for more delicate and functionally sophisticated internal viscera. Then, and for the century that followed, the skin was considered primarily a passive barrier to fluid loss and mechanical injury. During the past three decades, however, of scientific inquiries have demonstrated the skin to be a complex organ in which precisely regulated cellular and molecular interactions govern many crucial responses of the skin to our environment. Accurate description of the clinical appearance of the skin at a macroscopic level is often critical for diagnosis. Correlation between the gross and histologic appearances is often essential in formulating diagnoses and in understanding p athogenesis. Accordingly, efforts are made in the following pages to depict and describe clinical lesions whenever possible and to relate these findings to the microscopic appearance of lesions. Day 4 Lecture 4: Benign skin tumors, V aginitis and C ervicitis Wiraguna Dhana Saputra Benign tumors of the skin is a dermatosis which consists of multiple entities. Examination of skin tumors, not only determine the malignant or benign , but also determine the origin of the tumor cell component of the skin. Tumors can be derived from epidermal keratinocytes or accessory gland cells. Epidermal nevus is a benign skin tumor that is a proliferation of epithelial hamartoma include; verukosa epidermal nevus derived from keratinocytes, sebaceous nevus derived from sebaceous gland, nevus komedonikus derived from pilosebaceous units, eccrine nevus derived from eccrine glands and apocrine nevus that derived from apocrine glands. Expression of epidermal nevus mosaicsm considered to have a genetic mutation occurs not only on the skin but also other networks. Lesions follow Blaschko lines which indicate the presence of mutations postzigotik. In general, large lesions and the wide distribution of lesions in the head and neck have internal organ involvement and is known as the epidermal nevus syndrome. Epidemiology, pathology and clinical course of the disease can vary depending on the clinical variations of tumor cell origin . Infection of Human Papilloma Virus HPV can cause mucosal and skin epithelial proliferation and cause warts. Warts can be classified by anatomic location or its morphology , such as verruca vulgaris , verruca plana and palmo plantar warts . Humans are the only hosts and intermediaries. Warts Treatment based on clinical appearance , location and the patients immune status, common warts are more difficult to treat in patients with immunosuppression. Because warts are linked as a cofactor cancer, it is necessary to be evaluated histologically .Molluscum is caused by poxviruses , MCV 1-4 and its variants. Faculty of Medicine Udayana University,MEU 25 systems and disorders In children, the infection is caused by MCV 1. In patients who have HIV infection, MCV type 2 cause infection in most cases. Molluscum is easily transmitted through skin contact - chiefly on wet skin . Treatment is determined based on the clinical situation, in immunocompetent pediatric patients, sometimes no treatment is required. Sexually transmitted infections STIs can be caused by various etiologies that have various clinical symptoms. Etiologic agent of STIs in women such as Neisseria gonorrhoeae, Trichomonasvaginalis and Candida albicans infections can produce vaginal discharge and cause vaginitis or cervicitis. The diagnosis can be confirmed by laboratory tests such as microscopic examination, culture or the latest diagnostic methods such as nucleic acid amplification test. Besides syndromic approach can be useful in tertiary care centers that do not have a complete diagnostic tool. Early diagnosis and appropriate therapy gives good prognosis accompanied by prevention of sexual transmission through treatment of sexual partners, sex abstinencia and safe sexual behavior. Day 5 L ecture 5 : Drug eruption exantematous drug reaction, fixed drug reaction, erythema nodosum, erythema multiforme Suastika A Ratih Exanthematous drug reaction are the most common form of adverse cutaneous drug eruption. They are characterized by erythema, often with small papules throughout. They tend to occur within the first two weeks of treatment but may appear later, or even within 10 days after the medication has been stopped. Lesions tend to appear first proximally, especially in the groin and axilla, generalizing within 1 or 2 days. Pruritus is usually prominent. The most common cause is an antibiotisc semisynthetic penicillins and trimethoprim-sulfamethoxazole. Fixed drug reaction are common. Fixed drug eruptions are so named because they recur at the same site with each exposure to the medication. In most patients, six or fewer lesions appear, frequently only one. Uncommonly, fixed eruptions may be multifocal with numerous lesions. They may present on the body, but half occur on the oral and genital mucosa. Clinically, a fixed eruption begins as a red patch that soon evolves to an iris or target lesion identical to erythema multiforme, and may eventually blister and erode. Characteristically, prolonged or permanent post inflammatory hyperpigmentation results, althought a nonpigmenting variant of a fixed drug eruption is recognized. Erythema nodosum is the most commonly diagnosed form of inflamatory panniculitis, with most cases occuring in young adult women. The eruption consists of bilateral, symetrical, deep, tender, bruise-like nodules, 1-10 cm in diameter, located pretibially. Initially the skin over the nodules is red, smooth, slightly elevated, and shiny. The onset is generally acute, frequently associated with malaise, leg edema and arthritis or athralgias. Erythema multiforme minor is a self-limited recurrent disease, usually in young adults, occuring seasonally in the spring and fall, with each episode lasting 1-4 weeks. The individual clinical lesions begin as sharply marginated, erythematous macules, which become raised, edematous papules over 24 to 48 h. The lesions may reach several centimeters in diameter. Typically EM minor is usually associated with a preceding orolabial herpes simplex virus infection. Faculty of Medicine Udayana University,MEU 26 systems and disorders Day 6 Lecture 6 : Papuloerytroskuamosa psoriasis, pityriasis rosea and erythrodermi Luh Mas Rusyati Karmila Erythrosquamous skin disease are disease with efflorescence in the form of erythema and squama. These diseases include psoriasis, pityriasis rosea, seborrheic dermatitis and erythrodermi. Psoriasis is a common scaly erythematous disease of unknown cause showing wide variation in severity and distribution of skin lesions. It usually follows an irregular chronic course marked by remissions and exacerbations of unpredictable onset and duration. Factors that may lead to more lesions include drug reactions, respiratory infections, cold weather, emotional stress, surgery, and also viral infections. The goal of therapy in psoriasis is to achieve remission in which all or almost all lesions have disappeared. Topical therapy should be used if possible. Systemic therapy is used if topical therapy has failed. If psoriasis is limited to a few plaques, topical corticosteroids or tar should be used initially. Application of topical corticosteroids under an occlusive or intralesional injection of corticosteroid may result in rapid clearing of limited lesions. Seborrheic dermatitis or also known as pityriasis sicca is a very common chronic dermatosis characterized by redness and scaling, occurring in regions where the sebaceous glands are most active such as the face, scalp, presternal area and in the body folds. Mild seborrheic dermatitis causes flaking which is familiar in the term of dandruff. Generalized seborrheic dermatitis, failure to thrive, and diarrhea in infants should bring to mind Leiner’s disease which also accompanied by a variety of immunodeficiency disorders. Pityriasis rosea is a mild inflammatory exanthema characterized by salmon coloured papular and macular lesions that are first discrete but may be confluent. The individual patches are oval or circinate, and are covered with finely crinkled, dry epidermis which often desquamates, leaving a collarate of scalling. When stretched across a long axis, the scales tend to fold across the lines of stretch forming the so called “hanging curtain” sign. The disease most frequently begin with a single herald or mother patch, the efflorescence of new lesions spreads rapidly, and after 3-8 weeks they usually disappear spontaneously. Erythrodermi is characterized by erythema over the whole of the body. It can be triggered by widely sebhorreic dermatitis, widely psoriasis vulgaris, or drug eruptions. Day 7 Lecture 7: Dermatitis numularis, neurodermatitis, napkin eksema, perioral, urtikaria, fotokontak Wardana Suryawati Numular dermatitis Nummular dermatitis is defined as an eruption of round discoid eczematous patches almost exclusively of the extremities often the lower legs in men and the forearms and dorsal aspects of the hands in women. The lesions are well demarcated and measure 1–3 cm, only occasionally being larger. They may be acutely inflamed with vesicles and weeping, but are more often lichenified and hyperkeratotic. The pathogenesis has not been fully elucidated. Pruritus may be intense and excoriations are often prominent. Nummular dermatitis usually takes a very chronic course. Options comprise medium-to high-potency topical corticosteroid ointments, topical tacrolimus or pimecrolimus, and emollients. Tar Faculty of Medicine Udayana University,MEU 27 systems and disorders preparations have also been used successfully. However, a number of patients will require phototherapy to clear the lesions. Lichen simplex chronicus circumscribed neurodermatitis Paroxysmal pruritus is the main symptom. Lichen simplex chronicus is a result of long-continued rubbing and scratching, more vigorously than a normal pain threshold would permit, the skin becomes thickened and leathery. Chronic scratching of a localized area is a response to unknown factors; however, stress and anxiety have long been thought important. It is important to stress the need for the patient to avoid scratching the areas involved if the sensation of itch is ameliorated. High-potency agents should be used initially and the treatment can be shifted to the use of medium-to lower-strength topical steroid creams as the lesions resolve. Topical doxepin, capsaicin, or pimecrolimus cream or tacrolimus ointment provides significant antipruritic effects and is a good adjunctive therapy. Intralesional injections of triamcinolone suspension, using a concentration of 5 or with caution 10 mgmL, may be required. Diaper napkin dermatitis Diaper dermatitis is the cumulative result of several factors, in particular dampness and exposure to urine and feces. Prolonged use of diapers, dampness, and the factors detailed above lead to the breakdown of the horny layer barrier function. An alkaline pH also facilitates the development of secondary C. albicans infection. Diaper dermatitis is strictly confined to the diaper area, presenting with mild to pronounced erythema, erosions and scaling. Refractory diaper dermatitis may require a biopsy to exclude some of the above conditions. In the acute phase, mild corticosteroid preparations are helpful. Topical imidazole creams are added for secondary infection with Candida spp. The major goal of long-term management is avoidance of the causative factors. Frequent changing of highly absorbent disposable diapers is associated with a lower incidence and severity of diaper dermatitis, and it leads to a more physiologic pH. Emollients containing white paraffin or soft zinc pastes provide both protective and soothing effects. Perioral Dermatitis Perioral dermatitis is characterized by small discrete papules and pustules in periorificial distribution. Patients often reveal a history of an acute steroid-responsive eruption around the mouth, nose andor eyes that worsen when the topical corticosteroid is discontinued. If the topical corticosteroid are being used, they should be discontinued. Patients should be educated about the link between application of topical corticosteroid and exacerbation of the dermatitis. In the most cases, treatment includes oral tetracycline, doxycycline or minocycline for a course 8-12 weeks, including a taper over the last 2-4 weeks. Topical antibiotic therapy most commonly with topical metronidazole, should be initiaed concurrently wiyh the systemic antibiotic. Other options include topical clindamycin or erythromycin, topical sulfur-based preparations, and topical azelaic acid. Photoallergic Contact Dermatitis Certain substances are transformed into irritants or sensitizers photosensitizers after irradiation with UV or short-wave visible radiation 280–600 nm. The photoactivated molecules may be transformed into new substances capable of acting as irritants or haptens. Photoallergic reactions are based on immunological mechanisms, and can be provoked by UV radiation only in a small number of individuals who have been sensitized by previous exposure to the photosensitizer. The reaction to a photoallergen is based on the same immunological mechanism as contact allergic reactions. The action spectrum for photoallergy is generally in the UVA range. Many photocontact allergens have been identified with varying degrees of confirmatory evidence, and these are perfumes, topical non-steroidal anti-inflammatory agents, phenothiazines, sulphonamides used for topical treatment, bithionol and hexachlorophene in toilet soaps, shampoos and deodorants, quinines. Photoallergic reactions can resemble sunburn, but usually show the same spectrum of features seen with allergic contact dermatitis. The dermatitis is localized to exposed areas of the skin, usually with well-demarcated margins where the skin is covered by clothing, for Faculty of Medicine Udayana University,MEU 28 systems and disorders example at the collar and ‘V’ of the neck, below the end of the sleeves and trouser leggings. The area below the chin is usually spared. Urticaria Wheals Urticaria is a vascular reaction of the skin characterized by the appearance of wheals, generally surrounded by a red halo or flare and associated with severe itching, stinging, or pricking sensations. These wheals are caused by localized edema. Lesions may be a few millimeters in diameter or as large as a hand, and the number can vary from a few to numerous. The hallmark of wheals is that individual lesions come and go rapidly, by definition, in general within 24 hours. Angioedema swellings occur deeper in the dermis and in the subcutaneous or submucosal tissue. They may also affect the mouth and, rarely, the bowel. The areas of involvement tend to be normal or faint pink in color, painful rather than red and itchy, larger and less well defined than wheals, and often last for 2 to 3 days. Etiologic factors including drug, food, food additives, infections, emotional stress, menthol, neoplasm, inhalant, alcohol, hormonal imbalance, and genetics. A comprehensive history is essential in every patient with urticaria. Patients should be given advice and information on common precipitants, treatments and prognosis. Antipruritic lotions and the avoidance of aggravating factors, including NSAIDs, may be sufficient for some, but many will need additional interventions, including systemic medications. Antihistamines are the mainstay of management for most patients with urticaria, although not all patients will respond and only about 40 of those attending tertiary care clinics will clear or almost clear at licensed doses. For severe reactions, including anaphylaxis, respiratory and cardiovascular support is essential. A 0.3 mL dose of a 1 : 1000 dilution of epinephrine is administered every 10–20 min as needed. In young children, a half-strength dilution is used. Day 8 Lecture 8: Pigmentary and sebaseous gland disorders Sumedha P Elies Praharsini Acne vulgaris is a chronic inflammatory disease of the pilosebaceous follicles, characterized by comedones, papules, pustules, nodules, and often scars. The comedo is the primary lesion of acne. Acne affects primarily the face, neck, upper trunk and upper arms. Acne is primarily a disease of the adolescent, with 85 of all teenagers being affected to some degree.Treatment consist of systemic and topical antimicrobials, systemic and topical retinoids, and systemic hormonal therapy. Melasma is characterized by brown patches, typically on the malar prominences and forehead. There are three clinical patterns : 1 centrofacial, 2 malar, and 3 mandibular. Melasma occurs during pregnancy, using oral contraceptives or with hormone replacement therapy HRT. Treatment: exposure to sunlight should be avoided and a complete sunblock with broad-spectrum UVA coverage should be used daily. Bleaching creams with hydroquinone are the gold standard. The combination of hydroquinone, tretinoin, topical steroid has been called Kligman’s formula and is excellent. Day 9 Lecture 9: Bacterial infection Darma Bacterial infection of the skin and it’s appendages are manifested as folliculitis, furunculosis, carbuncles, pyogenic paronichia, impetigo, staphylococcal scalded skin syndrome SSSS, ecthyma, erysipelas and cellulitis. These bacterial infections above commonly caused by staphylococcal infection S.aureus, S.epidermidis and streptococcal Faculty of Medicine Udayana University,MEU 29 systems and disorders infection S.aureus, S.pyogenes, S.β-hemolyticus group A, S.β-agalactiae, S.pneumoniae. The treatment of these bacterial infections needs local and systemic antibiotics. Day 10 Lecture 10. Insect bite , Infestation scabies, creeping eruption , Pediculosis, Cycticercosis cellulosa, Bedbugs and Mosquito bites Praharsini Dhana Scabies is transmisibble ectoparasite skin infection characterized by superficial burrow, intense pruritus and secondary infection. Scabies is worldwide problem and all ages, races and socioeconomic groups are susceptible. There is variation in prevalence rates in some developing countries ranging from 4 to 100 . The caused is Sarcoptes scabiei varian homonis. The intense pruritus is accentuated at night. Typical sites of involvement include the interdigital webbing of hands, flexural aspect of the wrist, axillae, buttock and genital area. Primary lesions is small erythematuos papules, variable numbers of excoriation, visicles., indurated noduls, excematous dermatitis and secondary bacterial infection. The pathognomonic sign is burrow. Treatment options include either topical or oral medication. Topical option include permetrim cream, lindane, sulfur, crotamiton, benzyl benzoate. Oral option includes ivermectin, but is not avalaible in Indonesia. Creeping eruption is term applied to twisting, winding linier skin lesions produced by the burrowing of larvae of various nematoda parasites . People who go bare footed on the beach, children playing on sandhoxes, carpenter and gardener are often victims. The most common areas involved are the feet, buttock, genital and hands, accompanied by light local itching and the appareance of papules at the site of infection. After few days, the larvae migrate in the skin, creating bizzare erythematous curved lines. Topical treatment include cryotherapy, topical theabendazole compounded as a 10 suspension or 15 cream. The 3 mayor lice that infest humans are Pediculus humanus var. capitis head lice, Pthirus pubis Crab louse, and Pediculus humanus var. Corporis Body Louce. Patient with louse infestation present with scalp pruritus, excoriations, cervical lymphadenopathy, and conjungtivitis. Head louse infestation crossses all social and geographic boundaries, occuring in affluent suburban schools and inner city school alike. Clinical manifestation is immediate urticarial lesion, a small 2-to 3 mm red macula or papul developing hours to days later, or the classic macula cerulae. Pubis infestation often ia acquired as a sexually transmitted disease. Treathment of louse infestation are topical pediculides permethrin, lindane, malathion and envirommental control. Cysticercosis refers to tissue infection after exposure to eggs of Taenia solium, the pork tapeworm. The disease is spread via the fecal-oral route through contaminated food and water, and is primarily a food borne disease. Humans are T. solium reservoirs. They are infected by eating undercooked pork that contains viable cysticerci. The condition known as cysticercosis in humans occurs due to the ingestion of tape worm eggs, either from external sources or from the persons own feces. In some cases the cysts will eventually cause an inflammatory reaction presenting as painful nodules in the muscles and seizures when the cysts are located in the brain. The disease is most prevalent in countries in which pigs feed on human feces. A positive diagnosis is established where the parasite will be found. Albendazole and praziquantel is effective, however the status of CNS, spinal and ocular involvement needs to Faculty of Medicine Udayana University,MEU 30 systems and disorders be thoroughly assessed prior treatment. None of these regimens clears the calcified parasites, however need to be surgically removed. Bedbugs have flat oval bodies and retroverted mouthparts used for taking blood meals. They breed through a process referred to as traumatic insemination, where the male punctures the female and deposits sperm into her body cavity. Bedbugs hide in cracks and crevices then descend to feed while the victim sleeps. It is common for bedbugs to inflict a series of bites in a row breakfast, lunch and dinner, bites may mimic urticaria and patients with popular urticaria commonly have antibodies to bedbug antigens.Bullous and urticarial reactions occur. Bedbugs are suspected vectors for chagas disease and hepatitis B, although data are sparse. Bedbugs often infest in bats and birds and these hosts may be responsible for infestations in houses. Management of the infestations may require elimination in houses. The area treated with an insecticides such as dichlorvos or permethrin. Mosquitoes are vectors of malaria, encephalitis and yellow and dengue fevers. Their bite can also cause allergic reactions in sensitive individuals. Image of a Mosquito Biting a Human Mosquito bites are a common cause of popular urticaria. More severe local reactions are seen in young children, individuals with immunodeficiency and those with new exposure to indigenous mosquitos. Both necrotizing fasciitis and the hemophagocytic syndrome have been reported following mosquito bites and exaggerated hypersensitivity reactions to mosquito bites. Those with mild reactions to a mosquito bite can take antihistamines to reduce itching and swelling. Over time, some individuals develop immunity to the saliva of a mosquito and do not experience any symptoms at all upon being bitten. Day 11 Lecture 11: Rational Topical Treatment in Dermatology Alit Widhiartini Dermatological therapy usually involves the use of topical therapy that was known since ancient times. Many agents are applied to the skin either for cosmetic or therapeutic purposes. However it is important that the basic principles underlying effective therapy should be well-understood. There are many factors to be considered, these include patient’s age, hormonal status, and history. The anatomy and physiology of the skin and its appendages change with age and especially in woman, hormonal status may considerably influence the skin texture. The nature of the lesion, e.g. wet or dry, will determine the choice of the vehicle, the kind of topical preparation exactly, in which the active ingredient drug will be administered. The concepts of “If it’s wet , dry it;if it’s dry, wet it” will be clarified in detail during the small group learning. Faculty of Medicine Udayana University,MEU 31 systems and disorders The basic principles of topical therapy from the view point of pharmacotherapy, will guide the general practitioner to develop confidence in using topical therapy for common skin disorders such as wound dressing, acne, intralesional therapy, etc. Lecture 12 : Dermatofarmacology Wiwiek Indrayani Therapy for cutaneous diseases often introduced by citing the skin’s role as a supportive interface between human’s external and internal milieu and as a barrier to potentially harmful agents in the environment. The fact that most dermatologic disorders are not life threatening should not lessen a physician’s responsibility for having to make as correct a therapeutic decision as is currently possible. The general pharmacokinetic principles governing the use of drugs applied to the skin are the same involved in other routes of drug administration. Quantification of the flux of drugs and drug vehicles through these barriers is the basis of pharmacokinetic analysis of dermatologic therapy, techniques for making such measurements are rapidly increasing in number and sensitivity. Topical medications usually consist of active ingredients incorporated in a vehicle that facilitates cutaneous application. Important consideration in selection of a vehicle include the solubility of the active agent in the vehicle, the rate of release of the agent from the vehicle. The ability of the vehicle to hydrate the stratum corneum, the stability of the therapeutic agent in the vehicle and interactions, chemical and physical of the vehicle, stratum corneum and active agent The risks of less than through evaluation of simple dermatologic problems apply when problems become more complex. The drugs usually used in dermatologic disorders such as antibacterial agents, antifungal agents, topical antiviral agents, ectoparasiticides agents, agents affecting pigmentation, acne preparations, agents for psoriasis, antiinflamatory agents, keratolytic destructive agents, antipruritic agents and trichogenic agents. Day 12 Lecture 13. Anatomy of the Ear Yuliana The Ear The ears are vestibulocochlear organs. Each ear comprises three portions: external, middle and internal. External and middle ear function is for hearing process only. Internal ear function is for hearing and equilibrium. The external ear the external acousticauditory meatus conducts sound toward the middle and internal components of the ear. It protects middle and internal ear from outside damage and acts as pressure amplifier. It is about 25mm in length, extends from the concha to the tympanic membrane. External ear is composed of auricle pinna, which collect sound and external acoustic meatus canal, which conducts sound to the tympanic membrane. The lateral part is largely cartilaginous and slightly concave anteriorly. Skin of auricle continuously lines the meatus tightly. In cartilaginous part of auricle, there are hair follicles, sebaceous and ceruminous glands. The sensory innervations of external ear is derived from the auricular nerve 5 th cranial nerve, the cervical plexus, and 7 th cranial nerve. Glossopharyngeal nerve 9 th cranial nerve and vagus nerve 10 th cranial nerve innervate concha region. The blood supply mainly from the posterior auricular and superficial temporal arteries of the external carotid. Faculty of Medicine Udayana University,MEU 32 systems and disorders The Tympanic MembraneEar Drum is about 1 cm in diameter, faces laterally, forward and downward. It is divided into tense part and flaccid part. Tense part is the larger portion and attached to the tympanic plate of the temporal bone. Flaccid part is thinner in the anteriorsuperior portion and is limited by anterior and posterior mallear fold. Its lateral surface is concave and the center is called the umbo. The tympanic membrane is innervated by 5 th and 10 th cranial nerves for its lateral surface and 9 th cranial nerve for medial surface. The Middle Ear consists of tympanic cavity and auditory ossicles. The tympanic cavity communicates with 1 the mastoid air cells and the mastoid antrum by means of the auditus, and 2 the nasopharynx by means of the auditory tube phrayngotympanic tube. Auditory tube acts as equalizer for both ears. The cavity is divided into 3 portions 1 the affic or epitympanic recess situated above the level of the tympanic membrane. Its contains the head of the malleus and the body and short crus of the incus. This recess communicate with the aditus. 2 mesotympanum, the main portion, and 3 the lowest portion, the hypotympanic recess. The tympanic cavity is bounded laterally by tympanic membrane. The roof of the cavity is formed by tegmen tympani, a portion of the petrous temporal. Auditory ossicles are three small bones: malleus hammer, incus anvil, and stapes stirrup. They joint as incudomallear and incudo stapedial joints in type of synovial joint. The chain of the auditory ossicles act as a system of levers. The handle and the lateral process of the malleus are embedded in the fibrous layer of the tympanic membrane. So the motion of the membrane by the sound waves are converted into intensified movements of the stapes. Two important muscles are tensor tympani and stapedius muscles. Tensor tympani muscle arises from cartilaginous part of the auditory tube and inserted on the handle of the malleus. It draws the handle medially, thereby tightening the tympanic membrane. The muscle supplied by the mandibular nerve and tympanic plexus. The stapedius muscle draws the stapes laterally and perhaps rotate the incus. The muscle is supplied by the 7 th cranial nerve. The chief blood supply to the middle ear is from the external carotid stylomastoid artery from posterior auricular artery and the maxillary anterior tympanic artery. The internal ear is located within the petrous part of the temporal bone. It consists of the membranous and bony labyrinth. Membranous labyrinth is located within bonyosseous labyrinth. The bony labyrinth is a series of cavities composed of three parts: cochlea, vestibule and semicircular canals. The membranous labyrinth consists of three parts: 1 utricle and saccule, two small communicating sac in the vestibule; 2 three semicircular ducts in the semicircular canals and 3 cochlear duct in the cochlea that contains the organ of hearing. Its chief divisions are the cochlear labyrinth and the vestibular labyrinth. The utricle and saccule have specialized area of sensory epithelium, the maculae. The macula of the utricle is in the floor of the utricle; the macula of the saccule is vertically placed on the medial wall of the saccule. The hair cells in the macula are innervated by the vestibulocochlear nerve and the cell bodies are in the vestibular ganglion, which is in the internal acoustic meatus. The roof of the cochlear duct is formed by the vestibular membrane and the floor by the basilar membrane plus the outer adge of the osseous spiral lamina. The spiral organ of Corti contain hair cells situated on the basilar membrane. The tips of cells are embedded in the gelatinous tectorial membrane. The vibration of the base of stapes ascend to the apex by one cannel, the scala vestibule; then the pressure waves pass through the helicotrema and descend back to the basal turn by the other channel, the scala tympani. Lecture 14. Histology of Hearing Systems Arijana Ratnayanti Faculty of Medicine Udayana University,MEU 33 systems and disorders The functions of the ear are for hearing and equilibrium. Ears consisted of three major parts, namely external ear which received sound wave, middle ear which transmitted from air to fluid via a set of small bone and internal ear which transform fluid movement to nerve impulses. External ear has auricle, external acoustic meatus, ceruminous glands and tympanic membrane. Middle ear has tympanic cavity, Eustachian tube, oval window, round window, and auditory ossicles malleus, incus and stapes. Internal ear has bony labyrinth and membranous labyrinth. Membranous labyrinth has vestibular labyrinth equilibrium system and cochlear labyrinth hearing system. Vestibular labyrinth has utricle, saccule and semicircular ducts. For equilibrium the receptors are located in 2 maculae utricular macula and saccular macula and 3 cristae ampullaris in each semicircular duct. For hearing the receptors are located in spiral organ of Corti in cochlear duct. The receptors are mechanoreceptors called hair cells which convert sound wave into electrical impulses in nerve. All regions of bony labyrinth are filled with perilymph and membranous labyrinth is filled with endolymph. Day 13 Lecture 15 : Physiology of Hearing systems Krisna Dinata Audition, the sense of hearing, involves the transduction of sound waves into electrical energy, which then can be transmitted in the nervous system. Most sounds are mixtures of pure tones. The human ear is sensitive to tones with frequencies between 20 and 20,000 Hz and is most sensitive between 2000 and 5000 Hz. The usual range of frequencies in human speech is between 300 and 3500 Hz, and the sound intensity is about 65 dB. Sound intensities greater than 100 dB can damage the auditory apparatus, and those greater than 120 dB can cause pain. Sound waves are directed toward the tympanic membrane, and, as the tympanic membrane vibrates, it causes the ossicles to vibrate and the stapes to be pushed into the oval window. This movement displaces fluid in the cochlea and cause vibration of the organ of Corti. Thus, vibration of the organ of Corti causes bending of cilia on the hair cells by a shearing force as the cilia push against the tectorial membrane. Bending of the cilia produces a change in K+ conductance of the hair cell membrane. Thus, oscillating depolarizing and hyperpolarizing receptor potentials in the hair cells cause intermittent release of glutamate, which produces intermittent firing of afferent cochlear nerves. Information is transmitted from the hair cells of the organ of Corti to the afferent cochlear nerves. The cochlear nerves synapse on neurons of the dorsal and ventral cochlear nuclei of the medulla, which send out axons that ascend in the CNS. Lecture 16. Otic Drug Alit Widhiartini Middle and inner ear disorder often requires oral systemic or topical medications. Treatment of external ear however depend on topical otic drugs instilled directly into the external meatus of the ear for local action to prevent or treat disorders. These drugs include antibiotics, antiinfectives, anti-inflammatory, anesthetics, drying and cerumen softener solvents. Many otic drugs are consist of single or combination of 2 or more drugs these are used to treat external ear infections, inflammation, and pain, and removing excessive or impacted cerumen. Day 14 Faculty of Medicine Udayana University,MEU 34 systems and disorders Lecture 17. Pericondritis, Wax, Foreign Bodies, Bulous Myringitis Lely Rahayu Ear is one off indera wich have important function. The ear caught sound and then processed at the hearing cortex area at cerebri. This connect us with others. That’s why we must take good care of our ear. Ear divided into three part wich are outer, middle and inner ear. Outer ear diseases include perichondritis, foreign bodies, bulous myringitis. Wax or cerumen in normal production have protective function Day 15 Lecture 18. Membrane tymphani perforation, OMS, Labirinitis, Paresis N.Facialis Andi Dwi Saputra Infections of the middle ear space and their sequelae have plagued mankind from the beginning of time. First described by Hippocrates in 450 BC, this universally observed process continues to present one of the most perplexing medical problems of infancy and childhood, while being the leading cause of hearing loss in this age group. Complications of acute and chronic otitis media can cause grave morbidity and even mortality. Eventhough the incidence and prevalence of these complications have dramatically declined, their potential gravity requires physicians to have a thorough understanding of the diagnosis and management of each one. Labyrinthitis could be part of otitis media when the infections spread into inner ear. Acute facial palsy is a common diagnostic problem encountered by the otolaryngologist, but its presentation often provokes consternation on the physicians part. This reaction stems from our limited knowledge of facial nerve pathology, from the shortcomings of currently popular electrophysiologic tests in defining nerve injury, and from the controversy surrounding the management of facial palsy. Day 16 Lecture 19. Ear traumaothematoma, Barotrauma, Motion Sickness, PGPKT Eka Putra Trauma of the ear can cause damage to the ear structures such as Othematum, external ear canal, middle ear canal and tympanic membrane rupture as a change inpressure in the middle ear, and dinner ear damage. The journey traveled either by air, sea and land can lead to complaints of motion sickness, with symptoms: nausea, vomiting, pallor, sweating, so it should be anticipated. Broadly speaking the causes of hearing loss and deafness are: wax obsturan, OMSK, Noisy, Presbicus is and Congenital deaf, because the Ministry of Health and its staff enough trouble to his ministry then formed an independent forum that is the National Committee for Prevention Hearing Loss and Deafness PGPKT. Lecture 20. Hearing loss, noise induced hearing loss Wiranadha 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 Faculty of Medicine Udayana University,MEU 35 systems and disorders 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 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. Noise refers to unwanted, undesirable, or excessively loud sound experienced by an individual. The effects of noise depend on various characteristics of the sound: intensity, spectrum, cumulative lifetime exposure, and pattern. NIHL results from trauma to the sensory epithelium of the cochlea. Patients with NIHL frequently complain of a gradual, insidious deterioration in hearing. The most common complaint is difficulty in comprehending speech, especially in the presence of competing background noise. NIHL is frequently accompanied by tinnitus. The diagnosis of NIHL characterized by “4000 Hz notch”. Evoked otoacoustic emissions OAE may be useful in detecting early NIHL in persons with normal audiograms. No medical or surgical treatments are available to reverse the effects of NIHL. In patients with NIHL, hearing generally stabilizes if the patient is removed from the noxious stimulus. NIHL does not progress after the worker is removed from the source of the hazardous noise. Faculty of Medicine Udayana University,MEU 36 systems and disorders LEARNING TASKS Day 1 Functional Structure of the skin and its appendices Vignette 1 A baby boy present with erythroderma and severe blisters blister at his feet. The doctor diagnosed him with epidermolytic hyperkeratosis. 1. In which stratum of epidermis the disorder occurs? 2. What type of keratins involved in this disorders? Vignette 2 A male 18 years old present with chief complaint with odor secretion in his armpit. 1. Why these situation could be happen ? 2. Please describe the microscopic structure involved Self assesment 1. Describe the differences between ecrine and apocrine sweat gland 2. Describe the hair growth cycles 3. Describe the anatomical structure of the thin and thick skin 4. List and describe the sensory receptor of the skin 5. Describe the hair growth cycles 6. Describe the morphology of 4 type cells that located in epidermis Day 2 : BCS and Practicum 1 see BCS schedule Day 3 Common pathological bases of skin disorders Learning task List and describe the Descriptive term of microscopic features in dermatopathology bellow: 1. Hyperkeratosis 2. Parakeratosis 3. Hypergranulosis 4. Acanthosis 5. Papillomatosis 6. Dyskeratosis 7. Acantholysis 8. Spongiosis 9. Hydropic swelling 10. Exocytosis 11. Erosion 12. Ulceration 13. Vacuolization Faculty of Medicine Udayana University,MEU 37 systems and disorders 14. Lentigenous Self assesment Day 4 Benign skin tumor veruca, moluscum, kista, vaginitis and servicitis Vignette 1 A woman, aged 23 years came out with complaints of vaginal discharge that smells since 5 days ago, the first time a complaint is sustained. History obtained from patients with frequent vaginal douching and taking oral glucocorticoids within the last 3 months because of disease SLE systemic lupus erythematosus who suffered. For discharge complaints the patient was taking amoxicillin itself purchased for 1 month but said the complaint is not reduced. Patients having undergone sexual partners and monogamous relationship for 2 years, found no complaints on sexual partner. In a speculum examination found a white vaginal discharge that is attached to a homogeneous vaginal wall. In the cervical region found no abnormality. a. Give other differential diagnosis that have similar symptom with the case. b. Explain clearly the comparison of candidiasis, trikomoniasis dan bakterial vaginosis based on: sign and symptom, color of the discharge, consistency, smell, pH, microscopy and etiology finding c. Mention the other risk factor of the case d. Mention the laboratory examination to established diagnosis e. What is the diagnosis of the case based on your evaluation f. Mention the risk factor that may cause recurrence cases g. What is the treatment modality may be given in case Vignette 2 A mother dropping her 7-year-old to the clinic with complaints arise warts on her feet since 2 weeks ago. Patients sister also had the same complaint. Known history of these lesions multiplied because the lesions often carded. According to her, her children love to play water with his friends. a. Mention the diagnosis of the case b. Mention other clinical variant of the disease c. Mention the laboratory examination to established diagnosis d. Mention the etiology that might be found based on polymerase chain reaction PCR e. Mention the reason to give invasive treatment in these case, mention what are they ? f. Mention the reason to give non invasive treatment in these case, mention what are they ? Vignette 3 A 70-year-old man presents with raised black spots on his face, is not painful or itchy. Patients observe the complaint and began to arise since 5 years ago and is currently perceived to multiply and grow. Patients worked as a gardener and rarely use sun protection both physically and sunscreen. The spotting never bleed or smell formed wounds. Faculty of Medicine Udayana University,MEU 38 systems and disorders a. mention the diagnosis of the case b. mention the risk factor of the case c. mention the other clinical variant of the case d. how we differentiate between benign and malignant lesion? e. mention the clinical sign that may related with internal organ malignancy e. what is the treatment modality we can give to the patient? Day 5 Drug Eruption Vignette 1 A 14 yo karate athlets, complain abaout rash of his body since 2 days ago. He also had fever since 3 days ago.He denied ever taking drugs because he never sick in this 2 month. He regularly take herb capsul which is given by his coach, for his stamina and decrease muscle pain after exercise. 1. Is there any possibility he had drug eruption 2. If the answer yes, what anamnesis need to be ask to the patient to support diagnosis drug eruption On Physical examination, blood pressure 11080, pulse 90 xmenit, axila temperature 38,5 o C Didnt found konjungtivitis and enlargement of lymphnode. On laboratory examination blood, liver function test and kidney functiont test within normal limit 3. What is differential diagnosis 4. What is management of this patient 5. Counseling, information and education for this patient? 6. In another case, the patient was given medication from general practicioner or midwife. What the explaination should give to the patient or family. Self Assesment 1. List the symptoms of drug eruption 2. What is expected from the laboratory? 3. How is pathogenesis of the disease? 4. How is the prognosis? Vignette 2 A man 45 yo, complained about of the black spot on his lips , penis and also his thigh. Last year he has the same symptom after took antibiotic from dentist. 1. What are the other complaints ? 2. What kind of examination do we need ? 3. What is the diagnosis ? 4. Are there any other possible diseases? 5. How are the management and KIE? 6. How is the prognosis of this patient? Faculty of Medicine Udayana University,MEU 39 systems and disorders Self Assessment 1. List the symptoms of fixed drug eruption 2. What is expected from the laboratory? 3. How is pathogenesis of the disease? 4. How is the prognosis? Vignette 3 A woman 30 yo, consulted from ER. She complaine about blister on her skin, rednes of her eyes and her lips easily bleeding since 2 days ago. Last week she got diarrhea and taken antibiotic from GP. She also applied bokasi oil all over her body 1. What are the other complaints ? 2. What kind of examination do we need ? 3. What is the diagnosis ? 4. Are there any other possible diseases? 5. How are the management and KIE? 6. How is the prognosis of this patient? Self Assessment 1. List the symptoms of Stevens Johnson syndrom 2. What is expected from the laboratory? 3. How is pathogenesis of the disease? 4. How is the prognosis? Day 6 Papulo-erytroskuamosa psoriasis, pityriasis rosea and erythrodermi Vignette 1 A 43 years old man came to the hospitals complaining red patches that felt itchy and scaly on upper back, scrotum, and at the back of the ears. He also complain his hair easily felt oily if he was late washing his hair. He has suffered from this complain for a long time and often recurrent. Learning Task 1. Ask about other questions regarding this complain 2. What is the possible diagnosis for this complain? 3. What is the other differential diagnosis for this complain? 4. How is the management and education for this patient? Self Assessment 1. Mention other clinical manifestation of this disease 2. What should be expected from the laboratory result? 3. How is the pathogenesis? 4. How is the histopathological pictures of this disease? 5. How is the prognosis? Vignette 2 A woman complaining unwell and malaise, with red patches, not so itchy, at her part of body that enclosed by clothes, with varying size diameter 0,5-1 cm, round-oval shape. This is the third time she was suffering from the same complain. Learning Task 1. Ask about other questions regarding this complain 2. What is the other examination that needed to confirm the diagnosis? 3. What is the possible diagnosis for this complain? 4. What is the other differential diagnosis for this complain? 5. How is the management and education for this patient? Faculty of Medicine Udayana University,MEU 40 systems and disorders Self Assessment 1. Mention other clinical manifestation of this disease 2. What should be expected from the laboratory result? 3. How is the pathogenesis? 4. How is the histopathological pictures of this disease? 5. How is the prognosis Day 7 Dermatitis Numularis, neurodermatitis, napkin eksema, perioral, urtikaria, dermatitis fotocontact Vignette Man 35 years old, complained itchy skin rash on almost over the body since 1 weeks ago. He felt the rash come and go in one day. On physical examination there were wheals, generally surrounded by a red halo. Patient come to you, asking for explaination and treatment. Learning Task : Draw and explain the etiology, patophysiology, diagnosis, diff. diagnosis, planning to confirm the diagnosis, and treatment for the case Self Assessment 1. Explain what should we ask in the anamnesis? 2. Explain symptoms, signs and what kind of examinations do we need for the patient? Day 8 Pigmentary and sebaceous gland disorders Vignette 1 A woman, aged 25 years, came to the dermatovenereology clinic with complain having acne since 2 years ago. Physical examination reveal comedo, papul, pustule, nodul and scars. Learning task 1. What we should ask to the patient in the anamnesis? 2. What is the diagnosis of the patient? 3. What should we look for if we considered the patient on hyperandrogenic state? 4. What is the management of non medicamentosa in this patients? 5. What is the management of medicamentosa in this patients? 6. How is the prognosis of the disease 7. How is management of acne scars ? 8. What advice we could give to the patients Vignette 2 A 33 years old woman came to the clinic with complaint brown spots at her face appeared since 2 years ago. First it appeared in both ceek than spread to the forehead. This is not accompanied with pain and itchy. Learning task 1. What kind of anamnesis asked to the patients? 2. What are clinical picture obtained in patients? Faculty of Medicine Udayana University,MEU 41 systems and disorders 3. What is the diagnosis ? 4. What kind of additional examination need to be done? 5. What result that expected from additional examination? 6. What are the principal management of these patients? 7. How is the prognosis? 8. What advice we can give to the patients? Self assessment 1. Describe the definition of melasma 2. Explain the pathogenesis of melasma 3. Describe the clinical forms of melasma 4. Describe predisposing factors of melasma 5. Explain the classification of melasma according from light wood examination 6. Explain prevention of melasma 7. Explain some topical agents for treatment of melasma, the mechanism and side effect 8. Describe the definition of acne vulgaris 9. Explain the pathogenesis of acne 10. Explain predisposing factors of acne 11. What is the general principle to manage acne vulgaris 12. Explain the condition in Neonatal acne 13. Explain about topical acne medication 14. Explain about oral acne medication 15. Explain about hormonal therapy in acne vulgaris Day 9 Bacterial infection Vignette 1. Old woman complained with a pain mass at her back which drained a pus from multiple hole. It’s begin with small pain spot since one week ago. She came to you to ask explanation and treatment. 2. a 60 years old man complained with redness, swelling and pain at his right lower leg since 2 days ago. Before he suffer with this symptoms his right foot was pricked by a needle. He had history of fever after swelling. Then came to you to ask explanation and treatment. 3. a 5 months old baby came to you with his mother with chief complain, thin wall vesicles that rapidly become pustular and then rupture which leaving a thick yellow crust around his nose since 3 days ago. There are no pain, itchy, and fever. They came to you to ask explanation and treatment. 4. a mother complained about the exfoliativa skin at the whole of her’s child skin 3 years old. Before that her’s child got disfagia. She didn’t gave any kind of medicine to her child. We can’t find another disorder at her’s child lip or mouth. Then came to you to ask explanation and treatment. Learning task : Draw and explain the Etiology, pathophysiology, diagnosis, diff diag, treatment of all cases above. Self Assesment “For all case above” 1. Explain what should we ask in the anamnesis? 2. Explain symptoms , signs and what kind of examination do we need for the patient. Faculty of Medicine Udayana University,MEU 42 systems and disorders Day 10 Insect bite , Infestation scabies, creeping eruption and pediculosis Vignette 1 A 19-year-old female patient presented with multiple swellings of 1 year duration all over the body. The lesions started as two small swellings over the right side of the forehead. Since then, it gradually spread to involve the whole body over a period of 4 months. The lesions were asymptomatic. She gave a history of seizures 10 months ago. They were generalised tonic clonic seizures with loss of consciousness in the post ictal period. On examination, multiple nodules approximately 80 were present all over the body. They were skin-colored, well-circumscribed, nontender, firm in consistency, mobile and varying in size from 0.5 - 1.5 cm in diameter. There was no regional or generalised lymphadenopathy. 1. Discuss and explain about the treatment of choice you can give 2. Discuss and explain the prevention you can advice Vignette 2 A 22 year old balinese male who had traveled for several weeks, returned to his apartment in the kuta area. A few days later he observed reddish spots on his body, which were accompanied by intense pruritus. The bites were concentrated on the hands, legs and neck area. He was treated repeatedly with scabicides and systemic corticosteroids but there was little improvement in his clinical symptoms. The patient, who was living alone, noticed new bites on his skin for several weeks, and then discovered on his body some crawling insects. They were sent to our laboratory and identified as adult and nymphal stages of C. lectularius 1. Discuss and explain about the disease 2. Discuss and explain about the treatment 3. Discuss and explain about your advis Vignette 3 An 8-year-old boy8 with symptoms very itchy nodules on the penis. Two weeks ago the patient went to the doctor with complaints of itching at night. On examination was found papules, excoriation in the lower abdomen, axilla and umbilicus. Patients have received the drug but there is no improvement. 1. What is the most likely diagnosis ? 2.What evaluations or lab study must be perform before giving the treatment? 3.What is the treatment options? Vignette 4 A 26-year –old male came with complaints of an itchy eruption on his back and arms of 2 months duration. He was a fisherman by occupation and gave a history of sleeping on the beach for long hours. He was treated with antihistamines, but without any response. Cutaneus examination revelaed multiple erythematous papules, plaques and wavy serpentine tracts on the back and posterior aspect of arms. 1. What is the most likely diagnosis ? 2. What is the treatment options ? Vignette 5 A-20 year old man complaints severe pruritus burning or pain. On examination presented with small blue-black dots macula cerulea and scratch mark on perianal and gluteal. Wood’s lamp examination will reveal bluish, pearl-colored nits. 1 What is the most likely diagnosis ? 2 What is the treatment options Faculty of Medicine Udayana University,MEU 43 systems and disorders Self Assesment for all case above : Explain the etiology, clinical sign and symptoms and the management Day 11 Rational Topical Treatment in Dermatology Vignette A 9 -month-old infant presents with an intensely pruritic generalized atopic dermatitis with multiple areas of excoriation and lichenification on the flexor side of the upper arm. The eruption spares only the diaper area, the palms, and the soles. Most skin regions are dry and fissured. Learning task 1. Should you treat this patient with topical steroid, and if so, what type of topical steroids and what kinds of preparation are available in Indonesia? 2. Should you treat this patient with systemic steroids, and if so. What kind of systemic steroid? 3. Should you apply occlusive dressings in this patient over the affected areas, and if so. what type of occlusive dressings ? 4. Should you treat this patient with an emollient, and if so, why? 5. Is this patient an appropriate candidate for antihistamines, and if so, Why? Self assesment Dermatofarmacology Vignette 1 A women, 18 years old come to public hospitals with chief complain feel itchy in her whole body especially in the night since a week ago. The doctor had found : erythema , papule, vesicle, tunnel and excoriation on the skin of the finger. Learning task 1. What is the best treatment for this patient ? 2. Please explain the pharmacokinetic and pharmacodynamic profile of that medicine? 3. What is the adverse effect of that medicine ? Vignette 2 A women , 25 years old come to policlinic with red spot and feel icthy on the face since 3 days ago. Past history she has been used new cosmetics since two weeks ago. Physical examination: there is some eflorescencia and erythematous papules . In some part of the face there is some erotion and slight edema. Learning task 1. What is the best treatment for this patient ? 2. Please explain the pharmacokinetic and pharmacodynamic profil of that medicine? 3. What is the adverse effect of that medicine ? Self assesment 1. A woman with non inflammatory acne needs topical treatment for her acne. Which is the best treatment for her acne ? 2. A man with eczema on his skin. Which is the best treatment can be used for the inflammatory process for this condition? 3. What kinds of antifungal drugs can be used in onycomycosis ? Please explain Faculty of Medicine Udayana University,MEU 44 systems and disorders Day 12 Anatomy of Hearing systems Vignette 1 A male 35 years old complained of sudden right ear pain after scuba diving this morning. Patient never had the same problem before. There is no fever. He had terrible nose blocked for two days. a. Based on knowledge of anatomy, which part of the ear might be affected? b. Describe the anatomy features of the answer on question a c. What would you suggest to the patient to prevent the same problem? Vignette 2 A female 27 years old complained of motion sickness and got vomited when travelling from Denpasar to Gilimanuk. a. Which part of the ear might be affected in this case? b. Describe the part of the ear on the answer of question a in details SELF ASSESSMENT 1. Describe the anatomy characteristic of external ear, including the innervations and blood supply 2. Describe the role of the tensor tympani and stapedius mucles 3. Describe the anatomy of middle ear in detail Histology of Hearing systems Vignette 1 A man, 40 years old come to Hospital complains vomiting since one hour ago. He felt his body is rotating. Anamnesis and physical examination is performed. The diagnosis is vertigo. Learning Task 1. Vertigo is related to vestibular system, which one? 2. Describe the histological structure Vignette 2 A woman, 35 years old come to ship’s clinic due to motion sickness 10 minutes ago. Learning Task 1. Seasickness is related to vestibular system, which one? 2. Describe the histological structure Vignette 3 A woman, 35 years old come to ship’s clinic due to motion sickness 10 minutes ago. Learning Task 3. Seasickness is related to vestibular system, which one? Describe the histological structure Self Assessment 1. Describe histological structure in vestibular system 2. Describe histological structure in hearing system Faculty of Medicine Udayana University,MEU 45 systems and disorders Day 13 Physiology of Hearing systems Learning task 1. What is the function of pinna, external auditory, tympanic membrane, ossicles, middle ear bones, and oval window? 2. Explain the mechanism of transduction in hearing 3. Could listen the music with an earphone makes deafness? Explain about that Self Assesment 1. What is the function of eustachius tube? 2. The sound energy is amplified by two effects. Explain about this statement Otic Drug Scenario 1 A two years old boy brings by his mother to a primary health care clinics with fever and he cried and told his mother that his ear was pain since two days ago. His mother told that he got sore throat since 3 days ago. His father is an active smoker. Clinical examination found his axial temperature was 38 °C and found mucus in middle ear. His body weight is 16 kg. Questions 1. Do you think that he need painkiller? What kind of analgesic will you prescribe for him? Discussion must include groups of analgesic antipyretic, the pharmacokinetic and pharmacodynamic, the rute of administration, analgesic choice, the dose, the duration of treatment. 2. Will you prescribe another drugs for treatment. What kinds of drugs? Discussion must include mapping of the drug, drug of choice, rute of administration, the dose, the duration of treatment. Scenario 2 Mrs Anna middle age woman comes to you and ask your advise. Over the two weeks ago she feels that his hearing particularly in his right ear has become progressively deaf and she feel “full up”. She did not take any medication but she instilled ear drops for one weeks and she stopped as she confused to her self therapy. Questions 1.How do the products generally use to treat the condition work? Discussion must include group of otic drugs and their characteristics. 2. How can product formulation affect the outcome of treatment for the condition? Discussion must include drug dosage form for oral and topical, the positive and negative of them. 3. What advice can you give to help the patient to manage this condition? Discussion must be include the effectivity, safety, suitability and cost of rational therapy. Day 14 Pericondritis, wax, foreign bodies, bulous myringitis A girl 25 years old come to ENT clinic with chief complain pain and sweeling at right ear since 2 days ago after scratching because of its itchy. The girl already take paracetamol but the sweeling and pain didn’t subside. At physical examination, there’s hyperemic and Faculty of Medicine Udayana University,MEU 46 systems and disorders swelling at the right auricle without affecting lobule area Learning task 1 Describe other question needed to complete the anamnesis 2 Describe diagnosis, etiology, pathogenesis, sign and symptom, plan of treatment and complication Self assessment 1. What is pericondritis? 2. Explain pathogenesis of pericondritis 3. What bacteria caused pericondritis 4. How to managed pericondritis 5. What is bulous myringitis? 6. Explain pathogenesis bulous myringitis 7. Explain how to treat bulous myringitis 8. Describe tipe of cerumen 9. Explain how to treat cerumen obturans 10. Explain how to manage foreign bodies in the ear Day 15 Membrane typmphani perforation, OMS, labirinitis, paresis N. Facialis Vignette 1 A man, 30 y.o, feel dizzy since 3 days ago. He did not dare open his eyes and just lie in bed. He feels like the world spins and increasingly serious when he moves his head. His right ear often produce odorless liquid since last 1 year. Learning task 1. What happened to this man? Explain the pathophysiology. 2. Indicate the types of labyrinthitis and describe the symptoms of each. 3. Can you explain, why labyrinthitis can cause deafness? 4. Can you explain, why labyrinthitis can cause vertigo? Vignette 2 A boy, 10 y.o complained of buzzing in the ears since last 3 months. He also frequently complain of runny nose and sneezing. Parents also told that while sleeping, he is snoring. Learning task 1. Explain, what are the causes of serous otitis media in children. 2. Explain the pathophysiology of serous otitis media. 3. Can you explain, why deafness can occur in serous otitis media. 4. Specify and explain the necessary examinations on this case. Day 16 Ear traumaothematome, barotrauma, motion sickness, PGPKT Vignette 1 A New student is currently facing a college event Orientation Introduction universities facing seniors. Due to an in advertent, senior supset then slapped, hit exactly. The student felt his ear sringing and reduced hearing one side. 1. The question of whether that is necessary to complete towards the diagnosis? 2.What kind of examination is needed to diagnose? 3. What is the therapy? Faculty of Medicine Udayana University,MEU 47 systems and disorders Vignette 2 A family consisting of father, mother and daughters aged 12 years old and 9 year old boy driving a sedan traveled to Bedugul. Moments before arriving, the girls experienced nausea, vomiting, pallor, sweating. Other family members feel a buzzing ears. 1. The question of whether the diagnose is needed to drive the girl to the family? 2. What kind of examination is needed to diagnose? 3. What is the therapy? 4. What happened to the other family members? Self Assesment 1. Mention division ear barotrauma? 2. Is flying with a diving barotraumas difference? 3. Why do people get drunk trip to the place of high? 4. Mention 5 diseases causes of hearing loss and deafness? 5. Mention the target group of PGPKT Team? 6. What is the target to be achieved? Hearing loss, noise induced hearing loss Vignette 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? Vignette 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? Vignette 3 A 37-year male workers were complaints difficult to catch the conversation of his friends, especially in a crowded place. There were no previous complaints of hearing loss, do not use ear protective devices. Patient work as gamelan maker, with exposure to noise at work 95 db, has been working for 17 years. Learning task 1. What question is needed to complete anamnesis? 2. Describe what is obtained from the examination of the tuning fork? 3. What investigations are needed? 4. What education we can give to the patient? 5. Treatment plan for patients Faculty of Medicine Udayana University,MEU 48 systems and disorders BSC 1 : Effloresensi 16-1-2014 dr. Puspawati, Sp.KK at class room Please describe the efflorescence below Laboratory Guideline for Histology Topic “ Skin and Hearing Structure “ Thick Skin, Thin Skin and skin appendages Aim : To increase understanding about thick, thin skin, and skin appendages structure Date and place : - January 16, 2014 - Lab. Bersama Conveyer : dr. Ni made Linawati, M.Si; dr. IGK. Arijana, M.Si Med Material : Microscope, Histological preparat about thick, thin skin and skin appendages a. Thick Skin : - Epidermis, dermis b. Thin Skin eyelid, lip,scalp etc - Epidermis, dermis c. Skin appendages in thick and thin skin: - Hair,sweat gland, sebaseous gland Faculty of Medicine Udayana University,MEU 49 systems and disorders Farmacology Practicum dr. AA Wiwiek Indrayani, M.Kes Aim : To understand the principles of rationale drug therapies for topical preparations in dermatology diseases The process of the rationale drug therapies : Step 1 : What is the problem Step 2 : What is the aim of the therapy Step 3 : Is the Personalized therapy P therapy suitable for your patient efficacy, safety, suitability, cost Step 4 : Start treatment Step 5 : Giving the information about the therapy, how to apply and adverse effect Step 6 : Monitoring and stop the treatment Physiology Practicum dr. I Made Krisna Dinata, M.Erg TUJUAN : Untuk mempelajari pemeriksaan pendengaran dengan garpu tala dan tajam dengar. ALAT DAN BAHAN : 1. Garpu tala ukuran 256, 512 dan 100 Hz 2. Arloji TATA KERJA : TES PENDENGARAN : 1. Cara Rhine : 1.1. Getarkan garpu tala 256 Hz dengan cara memukulkan salah satu ujungnya pada teli telapak tangan jangan sekali-kali pada benda keras 1.2. Tekanlah gagang garu tala yang bergetar itu pada prosesus mastoideus salah satu telinga orang coba, dimana orang coba akan mendengar garu tala mendengung di telinga yang diperiksa. 1.3. Tepat pada saat dengung menghilang orang coba saat itu mengangkat telunjuknya, garpu tala dipindahkan oleh pemeriksa ke depan liang telinga yang diperiksa sedekat-dekatnya. 1.4. Bila orang coba sekarang mendengar kembali dengung garpu tala tersebut untuk beberapa waktu, maka hasil pemeriksaan disebut Rhine negatif, bila tidak mendengar lagi maka disebut Rhine positif. 1.5. Ulangi percobaan dengan telinga yang lain. 2. Cara Weber : 2.1. Getarkan garu tala 512 Hz dengan cara di atas, dan tekanlah gagang garpu tala tadi pada dahi orang coba di garis median. 2.2. Tanyakan apakah orang coba mendengar dengung sama kuatnya di antara kedua telinganya. Bila demikian disebut tidak ada lateralisasi. Bila dengungan didengar lebib kuat di salah satu telinga, maka disebut terdapat lateralisasi ke arah telinga yang mendengar dengungan lebih kuat. Faculty of Medicine Udayana University,MEU 50 systems and disorders 2.3. Bila tidak dapat lateralisasi, dalam percobaan untuk mendapatkan lateralisasi secara buatan, maka tutuplah salah satu telinga dengan kapas, dan ulangilah percobaan di atas. 3. Cara Schwabach : 3.1. Getarkan garpu tala 100 Hz dengan cara di atas, dan tekankan gagangnya pada prosesus mastoideus salah satu telinga orang coba. 3.2. Suruh orang coba mengacungkan tangannya pada saat dengungan menghilang, dan pada saat itu pemeriksa memindahkan garpu tala pada prosesus mastoideusnya sendiri.

3.3. Bila masih terdengar dengungan oleh pemeriksa, maka disebut schwabach memendek.