Stage one Stage two Stage three Stage four Stage five

Etiologi : Common causes of Parkinsonism : 1. Idiopathic Parkinson Disease primary 2. Drug-induced Parkinsonism secondary Parkinsonism 3. Multiple system atrophy 4. Progressive supranuclear palsy Pathogenesis Parkinson desease and Parkinsonism doe to degeneration of substansia nigra part of basal ganglia, with a resulting deficiency of striatal dopamine. Clinical features begin to emerge when approximately 60 loss dopamine. Another sgn of Parkinsonism are non motor symptom : autonomic dysfunction, cognitive abnormalitas, sleep disorders, depressive disorders, gastrointestinal abnormalit Pathophysiology of Parkinonism : decrease of dopaminergyc neurons at substantia nigra, as a part of basal ganglia. The basal ganglia comprice four structures: The striatum putamen,nucleus caudatus, the pallidum, the subthalamic nucleus and nigral subtstance. The Hoehn Yahr Scale: the common way to rate progression of symptoms in PD 17

1. Stage one

1. Sign and symptoms on one side only 2. Symptoms mild 3. Symptoms inconvenient but not disabling 4. Usually presents with tremor of one limb 5. Friends have noticed changes in posture, locomotion and facial expression.

2. Stage two

1. Symptoms are bilateral 2. Minimal disability 3. Posture and gait affected

3. Stage three

1. Significant slowing of body movements 2. Early impairment of equilibrium on walking or standing 3. Generalized dysfunction that is moderately severe

4. Stage four

1. Severe symptoms 2. Can still walk to a limited extent 3. Rigidity and bradykinesia 4. No longer able to live alone 5. Tremor may be less than earlier stages

5. Stage five

1. Cachetic stage 2. Invalidism complete 3. Cannot stand or walk 4. Requires constant nursing care Faculty of Medicine Udayana University, DME 50 Treatment Treatment of Parkinsonism : 1. Medical treatment 2. Surgical treatment invasive treatment Medical treatment : 1. Increase dopamine level : l-dopa levodopa, carbidopa, benzerazide, ,COMT inhibitor catechol-O methyltransferase inhibitor : entacapone, type B MAO inhibitor selegiline. 2. Dopamine agonist : pramifeksole 3. Anti cholenergic : trihexyphenidyl Surgical treatment : 1. DBS : deep brain stimulation 2. Tranplantation Rehabilitation: Physical, accupational. References : 1. Parkinson Disease and Movement Disorders by : T.N Mehrotra, Kalyan B.Bhattachharyya. 2. Principles and Practice of Moveement Disorders by : Stanley Fahn, Joseph Jankovic, Mark Hallet DAY 7 th April 17 th 2015 NEUROPATHIC PAIN AND NEUROPATHY dr. I Putu Eka Widyadharma, M.Sc, SpSK Aims : Know the current definition of neuropathic pain, the epidemiology, classification and etiological, anatomical or mechanism based of neuropathic pain. Clinical characteristic ,diagnostic work-up including history, clinical examination and treatment of neuropathic pain. Learning outcome 1. Definition Recognize that neuropathic pain is a consequence of injury or disease affeting the somatosensory system. 2. Epidemiology - Know that painful peripheral neuropathy is common complication in HIVAIDS, diabetes, alcoholism and vasculitis. - Know that 4 out of 5 patients with idiopathic polyneuropathy and 1 in 3 patients with Guillain Barré syndrome have neuropathic pain - Know that peripheral neuropathic is common after surgical procedure, as well as during treatment with chemotherapeutic agents. 3. Etiology. - Know the common causes for neural damaged and subsequent pain i.e.: metabolic disease, infection, ischemia, injury, entrapment, connective tissue disease, AIDS, malignancy, drugs and toxins. - Know that neuropathic pain may develop without any identifiable cause e.g., intercostal neuralgia, idiopathic polyneuropathy. - Know that painful neuropathy may be the first manifestation of a systemic disease. 4. Clinical characteristic of neuropathic pain Faculty of Medicine Udayana University, DME 51 - Know the common symptoms associated with neuropathic pain e.g., burning pain, electric shock-like pain, pain paroxysm, dysesthesia and paresthesia. - Know the common signs associated with neuropathic pain including positive mechanical and thermal allodynia and hyperalgesia, temporal and spatial summation, negative sensory loss, weakness and muscle atrophy and other signs neuroma signs, referred sensation, swelling, skin flare and discoloration, hyperhidrosis and trophic changes. - Know that the patient with neuropathic pain may have concomitant non-neuropathic pain. - Know that questionnaires have been developed to differentiate neuropathic pain from non- neuropathic pain, e.g., the LANSS Pain Scale and the Neuropathic Pain Questionnaire or to measure various characteristics, e.g., the Neuropathic Pain Scale and the Neuropathic Pain Inventory . 5. Pathological changes in nervous system - Know the pathological changes that occur the affected nerves e.g. Wallerian degeneration, sprouting and neuroma formation. 6. Know pathophysiological mechanisms in peripheral and central nervous system. 7. Know diagnostic work-up including history, clinical examination and treatment of neuropathic pain. Abstract . The new definition ofneuropathic painaccording International Association for Study of Pain IASP is a consequence of injury or disease affeting the somatosensory system. For the vast majority of neuropathic pain diagnostic entities, there is no precise information about percentage of subjects reporting neuropathic pain. However it has been estimated that about 5 of patient with traumatic injury suffer from pain. Further about 8 of stroke patients suffer from central neuropathic pain as do about 28 of patients with multiple sclerosis and about 75 of patients with syringomyelia. Neuropathic pains are classified according either to the etiological diagnosis of the neuropathy e.g., painful diabetic neuropathy, postherpetic neuralgia or post traumatic neuralgia, or to the anatomical site of the lesion e.g., central or peripheral pain. Basic research in animal models of neuropathic pain indicates that multiple pathophysiological mechanism may be at play in neuropathic pain condition. Clinical characteristic of neuropathic pain were varied. The common symptoms associated with neuropathic pain e.g., burning pain, electric shock-like pain, pain paroxysm, dysesthesia and paresthesia. The symptoms of neuropathic pain including positive mechanical and thermal allodynia and hyperalgesia, temporal and spatial summation, negative sensory loss, weakness and muscle atrophy and other signs neuroma signs, referred sensation, swelling, skin flare and discoloration, hyperhidrosis and trophic changes. Diagnostic work-up including collection of medical history, focused at exploring the onset of pain and posssible association with current diseases, trauma, surgery etc. Therapeutic intervention applied in neuropathic pain consist of pharmacological and non pharmacological approach. Common pharmacological approaches used for neuropathic pain including : sodium and calcium channel blocker, NMDA receptor blocker, anti depressant, anti convulsant and opioid. NSAID is not responsive for treatment neuropathic pain. Scenario A 55 years old man complaint parasthesia in both his legs accompanied by electric shock like pain especially in bed time. Patient refused use blanked when he sleeps although the weather is very cool , the reasons were he felt pain on his legs when contact with contact with blanked. Past history : he has been suffering diabetes since 6 years ago, with un controlled blood glucose. Learning task : 1. What is the type of the pain in this patient ? Faculty of Medicine Udayana University, DME 52 2. Describe the pathophysiology of the pain in this patient. 3. What is the management of this patient ? Self assesment. 1. What is the classification of neuropathic pain ? 2. Explain the mechanism of neuropathic pain 3. Explain the clinical manifestation of neuropathic pain 4. Explain the management of neuropathic pain Learning Resource : 1. Justins DM. Pain an Update Review. IASP Press, Seattle, 2005 2. Bonica Management of Pain, 2001 3. Loeser JD. The Kyoto protocol of IASP Basic Pain Terminology Pain 137 2008, 473-7 4. Mogil J. Pain 2010 an Updated Review. IASP Press, seattle, 2010. CARPAL TUNNEL SYNDROME CTS, TARSAL TUNNEL SYNDROME AND PERONEAL PALSY dr. I Putu Eka Widyadharma, M.Sc, SpSK Aims: Describe pathophysiology, diagnosis, early management and referral patient with CTS Learning outcome: 1. To Describe the definition of CTS, TTS AND PERONEAL PALSY 2. To describe patophysiology of CTS, TTS AND PERONEAL PALSY 3. To describe diagnosis and differential diagnosis of CTS, TTS AND PERONEAL PALSY 4. To describe how to manage CTS, TTS AND PERONEAL PALSY Curiculum contens: 1. Epidemiology of CTS, TTS AND PERONEAL PALSY 2. Clinical presentation of CTS, TTS AND PERONEAL PALSY 3. Risk factor of CTS, TTS AND PERONEAL PALSY 4. Pathophysiology of CTS, TTS AND PERONEAL PALSY 5. Diagnosis and Differential diagnosis of CTS, TTS AND PERONEAL PALSY 6. Treatment of CTS, TTS AND PERONEAL PALSY Abstract of lecture Carpal Tunnel Syndrome CTS remains a puzzling and disabling condition present in 3.8 of the general population. CTS is the most well-known and frequent form of median nerve entrapment, and accounts for 90 of all entrapment neuropathies. The pathophysiology of CTS involves a combination of mechanical trauma, increased pressure and ischemic injury to the median nerve within the carpal tunnelThe various methods of diagnosis are explored; including nerve conduction studies, ultrasound, and magnetic resonance imaging. The treatment of CTS falls under two categories: conservative and surgical. The treatment of CTS falls under two categories: conservative and surgical Triggerscenario A woman25years old present withparasthesiain the fingers ofthe right handaccompanied bypain.Complaintsbecome worsenedat night. Faculty of Medicine Udayana University, DME 53 Learning Task. 1. What other symptom we should know to diagnose this case? 2. What could be the possible diagnosis? 3. What is the management of this patient? Self assesment. 1. What is the definition of CTS 2. Explain patophysiology of CTS 3. Explain the diagnosis and differential diagnosis of CTS 4. Explain the management of CTS Learning Resource : 1. Ibrahim., Khan W.S., Goddard N.,and P. Smitham, 2012. Carpal Tunnel Syndrome: A Review of the Recent Literature. The Open Orthopaedics Journal, 2012, 6, Suppl 1: M8 69-76. DAY 8 th May 26 th 2014 CENTRAL NERVOUS SYSTEM TUMOR dr. Made Susilawathi, Sp.S Abstract Tumor of the nervous system comprise a diverse, heterogeneous group of neoplastic lesions that affect every age group and every element of the central nervous and peripheral nervous system. Most CNS tumors are thought to be sporadic in origin, tumors arise as a result of combined somatic mutation that active oncogenes such as platelet-derived growth factor and inactivate tumor suppressor genes as p53. The role of environmental factors –physical,chemical, or infectious- in causing such mutations or otherwise acting as risk factor is as yet unclear. There are two types of tumor, 80 of all tumors are primary tumors and 20 are metastatic . Typical presenting signs are headache, seizure, focal neurologic deficit and non specific cognitive and personality changes that follow a subacute course. Detailed neurologic examination can localize lesions within the CNS. Imaging tests are essential to direct further diagnostic and management strategies. Surgical biopsy is almost always required for conclusive diagnosis. A female, 30 years old, government employee, came to the neurologic ward who has been suffering from blur and double vision for about two weeks and getting worst. She has also severe headache, nausea and vomiting since eight months ago. Learning task 1. What is the differential diagnose of this case ? 2. What is the most signs and symptoms appearance in the brain’s tumour ? 3. Mention of signs and symptoms the brain tumour depend on the location such as: a. Lobus frontales b. Lobus temporales Faculty of Medicine Udayana University, DME 54 c. Lobus parietales d. Lobus occipitals e. Suprasellar 4. Explain the classification of the brain tumour according to original cell of the tumour 5. If the patient suffering from metastase tumour where is the primary source ? 6. If the patient is man,where is the primary source ? 7. What kind the diagnostic tool to examine the process of space occupying lesion ? 8. How to manage of the brain tumour ? 9. How is the prognose of the brain tumour ? Self assessment 1. Student be able to explain the classification brain and spine tumour 2. Student be able to explain the insidence of brain tumour in adult and children 3. Student be able to explain sign and symptom of brain tumour according to part of the brain involved 4. Student be able to explain diagnostic tool to assess brain and spine tumour 5. Student be able to explain how to manage the basic treatment of brain and spine tumour 6. Student be able to explain when to refer patient with headache which is suspected brain tumour TRAUMATIC BRAIN INJURY, EDH, SAH Prof. Dr. dr. Sri Maliawan, SpBSK Aims: To understand traumatic brain injury Learning Outcome 1. Comprehend the specific principles of anatomy and physiology related to brain injury. 2. Identify and discuss the principles of general management of unconscious patient. 3. Outline the method of evaluating head injury using a minineurologic examination 4. Identify and discuss the management techniques of head injury. Curriculum contents: 1. Scalp hematoma 2. Skull fracture 3. Monroe kelli doctrine. 4. Glasgow coma scale 5. Intracranial hematoma 6. Cushing response 7. Minineurologc examination 8. Brain death 9. Ct scan 10. External and internal decompression . Abtract of lectures Incidence Neurotrauma is responsible for 70 of all road fatalities and 50 of trauma deaths. Road crashes cause 50- 60 of all head injuries. Accidental injury is the third highest cause of death in motorised countries. The highest incidence for hospital admission in persons under 45 years of age is form trauma. Faculty of Medicine Udayana University, DME 55 Factor in the Rural Environment The following factors are significant in rural trauma : asolation and distance, medical facilities, level of neurosurgical competence, delay in definitive care, administrative organisation, rural crash profiles, e.g., incidence of 40 fatality on admission, more severe injuries, multiple injuries, higher incidence of single vehicle crashes, road and environmental conditions, driver competence and fatigue and compliance with preventive measures such as alcohol, seatbelts, helmets and speed. Neurotrauma Clinical factors adversely influencing outcome [death and disability] - Severity of Primary Injury - Intracranial Complications - Hypoxaemia - Hypercarbia - Hypotension - Anaemia - Multiple Injuries - Age - Prolonged Prehospital Time - Admission To Inappropriate Hospital - Delayed Or Inappropriate Interhospital Transfer Retrieval - Delay In Definitive Surgical Treatment Learning Task Head Injury Female 40 years old a pedestrian was hit by motor bike , upon arrival to emergency department, she able to open her eye and say painfull while she withdrawn her hand , there are brill hematoma, rinorhea, and bloody discharge from her nose and mouth, respiratory rate 26xmnt gurgling, Blood pressure 8060 mmHG, and Heart rate 120xmnt. 1. What is the clinical diagnosis base on GCS. 2. Initial management 3. Sign of skull base fracture 4. Sign and symptom of intracranial hematoma

5. Mention and explain about EDH,SDH,ICH,SAH, IVH.