According to the International Association for the Study of Pain IASP, pain is defined as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in term
of such damage. “IASP 1979. With regard to a more recent classification, pain states maybe characterized as physiologic, inflammatory nociceptive, orneuropathic. Physiologic pain defines rapidly
perceived nontraumaticdiscomfort of very short duration. Physiologic pain alertsthe individual to the presence of a potentially injurious environmentalstimulus, such as a hot object, and initiates
withdrawalreflexes that prevent or minimize tissue injury.Nociceptive pain is defined as noxious perception resultingfrom cellular damage following surgical, traumatic, ordisease-related injuries. Nociceptive pain
has also been termedinflammatory 6 because peripheral inflammation and inflammatorymediators play major roles inits initiation and development.In general, the intensity of nociceptive pain is proportional
tothe magnitude of tissue damage and release of inflammatorymediators.Neuropathic pain is defined by the International Associationfor the Study of Pain as “pain initiated or caused by apathologic lesion or
dysfunction” in peripheral nerves and CNS.Some authorities have suggested that any chronic pain stateassociated with structural remodeling or “plasticity” changesshould be characterized as
neuropathic.Neuropathic painis usually constant and described as burning, electrical, lancinating,and shooting.
Case A 45 years old woman was admitted to emergency unit with broken left lower arm and bruishing in her left
foot due to motorcycle accident. She was fully conscious. She was crying for those pain. It was so painful, she told the physician at the emergency unit. She brought to the OR for close reduction and wound toilette
under general anesthesia. The anesthesiologist gave some opioid analgesic and non steroid anti- inflamation drug post anesthesia. She looks comfortable in post anesthesia care unit and discharge at the
same day.
Learning Task
Describe mechanismpathophysiology of pain in this patient? How should we manage the pain in this patient?
What is the risk of under-treatment in the acute pain patients?
Self Assesment
What is meant by analgesia? What is the difference between analgesia anesthesia?
What is hyperalgesia? What is a dysesthesia?
What is neuroplasticity in pain and explain the mechanism?
DAY 6
th
April 16
th
2015 DEMENTIA ALZHEIMER
dr. I Putu Eka Widyadharma, M.Sc, SpSK
Aims : Provide initial assessment and management, established tentative diagnosis and refer patient with
Alzheimer Dementia AD and vascular dementia VaD
Learning outcome : 1. Describe different types of dementia
2. Describe signs and symptoms of dementia 3. Explain risk factors and prevention of dementia
4. Identify some tools available to assess the presence of dementia
Faculty of Medicine Udayana University, DME 47
Abstracts
Dementia is defined as an acquired syndrome of decline in memory and at least one other cognitive domain such as language, visuo-spatial, or executive function sufficient to interfere with social or
occupational functioning in an alert person. Dementia involve a mental decline that affects more than one of the four core mental functions :
recent memory the ability to learn and recall new information
language the ability to write and speak or to understand written or spoken words
visuspatial function the ability to see and understand spatial relationships among objects, ex : skill
needed to use a map
executive function the ability to plan, reason, solve problems and focus on a task As people age there are normal changes on memory. There are changes in the way our brains
store information and it is often harder to recall information. However, normal memory changes do not interfere with your ability to function on daily living. When this occurs it is not normal aging.
Mild cognitive impairment MCI is a transition phase between normal aging and dementia. People with MCI present with subjective memory loss and have evidence of memory impairment on cognitive
testing. However, general intelligence is preserved and there are no changes in the ability to carry out activities of daily living ADL.
Alzheimer’s disease and cerebrovascular ischemiavascular dementia are the two most common causes of dementia. Between 60 and 70 of individuals with dementia have Alzheimer’s disease; about
20 to 30 have either vascular dementia or a combination of vascular dementia and Alzheimer’s disease.
A definitive diagnosis of dementia alzheimer is possible only through brain autopsy, so completing a thorough assessement encompassing many components lends to the best probable diagnosis.
Assessment for dementia includes history from patients, history from a reliable family member caregiver, physical examination, cognitive assessment and functional assessment. Laboratory and imaging test are
used to rule out reversible causes of dementia.
Scenario 1 : A 60-years-old man, came to the hospital with difficulty in memory. This patient had a 6-months history of
memory impairment. He has been a cerebrovascular diseases stroke since a year ago. He has been a high blood
pressure and diabetes mellitus.
Learning Task :
1. How to diagnose this patients? 2. How to differentiate this patients?
3. Please explain the etio-pathogenesis and pathophysiology 4. What test should be used ?
Self Assessment :
1. Describe taking a good history on the memory impairment 2. Describe the neurologic and neurobehaviour examination
3. Describe the causes of dementia 4. Describe how to manage this dementia
5. Describe the prognosis for this patient
Scenario 2 :
Faculty of Medicine Udayana University, DME 48
A 60 years old woman came with complaint of slowly progressed memory and cognitive impairment approximately since 5 years ago.
He has not been a high blood pressure or head injury.
Learning Task :
1. How to diagnose this patients? 2. How to differentiate this patients?
3. Please explain the etio-pathogenesis and pathophysiology 4. What test should be used ?
Self Assessment :
1. Describe taking a good history on the memory impairment 2. Describe the neurologic and neurobehaviour examination
3. Describe the causes of dementia 4. Describe how to manage this dementia
5. Describe the prognosis for this patient
MOVEMENT DISORDERSNEUROGERIATRIC dr. IA Sri Wijayanti, M.Biomed, Sp.S
Movement disorders are commom in clinical practice. Movement disorders are doe to primary and secondary. But the most populer movement disorders divided , based on movement type. Based on
these movement disorders divided : hyperkinetic movement disorders and hypokinetic movement disorders.
Hypokinetic : Parkinsonism Stiff-man syndrome
Hyperkinetic : Chorea
Myoclonus Dystoniia
Tics Tremor
PARKINSONISM Parkinsonism is a syndrome manifested by a comination following six cardinal features. A
combination of these signs is used to clinically define : definitte, probable and possible.
Parkinson disease PD , first rcognized as a unique clinical entity by James Parkinson in 1817, who in his An Essay on the Shaking Palsy.
Diagnostic criteria of Parkinsonism 1. Tremor at arest
2. Bradykinesia 3. Rigidity
4. Loss of postural reflexes 5. Flexed posture
6. Freezing motor blocks
Definite : At least two of these features must be present, one of them being 1 or 2 Possible : At least two of feture 3 to 6 must be present
Probable: Feature 1 or 2 alone is present
Faculty of Medicine Udayana University, DME 49
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
