Curriculum Vitae

Nama Lahir Alamat Istri Anak/Mantu/Cucu Pendidikan : : : : : : I Gede Arinton Singaraja, 1 Januari 1950 Jl. Pramuka 249 Purwokerto 1 5/2/3 1. dr. umum FK. UNUD 1977 2. dr. SpPD FK. UNDIP 1987 3. MKom STIBBi Jkt 1999 4. MMR UNSUD 2005 5. KGEH FK. UI 2007 6. Doktor Ilmu Kedokteran UNDIP 2008 : Bag. Penyakit. Dalam RSUD. Margono Soekarjo/FKIK Unsud Purwokerto Pelatihan Endoscopy di RSU dr. : 1. Hasan Sadikin Bandung. 2. International Endoscopy Workshop 2007, Jakarta 5 7 April 2007. 3. Training Endoscopy Showa University Yokohama 2009

Pekerjaan Pendidikan Tambahan

The Diagnostic Framework

To carefully observe the phenomena of life in all its phases, normal and perverted, to make perfect that most difficult of all arts, the art of observation, to call to aid the science of experimentation, to cultivate the reasoning faculty, so as to be able to know the true from the falsethese are our methods.
Sir William Osler

Don't strain for arrangement. Look and put down and let your sensibility be the sieve.
Theodore Roethke

. . .the framing of hypotheses is the most difficult part of scientific work, and the part where great ability is indispensable. So far, no method has been found which would make it possible to invent hypotheses by rule. Usually some hypothesis is a necessary preliminary to the collection of facts, since the selection of facts demands some way of determining relevance. Without something of this kind, the multiplicity of facts is baffling.
Bertrand Russell

Introduction
Why is Diagnosis Important?
Ax & PE - basis Dx hypothesis generation Accurate Dx. - precedes 3 tasks central to the healing professions:
explanation, prognostication, and therapy.

To answers 3 patient's fundamental questions:

1. What is happening to me and why? 2. What does this mean for my future? 3. What can be done about it and how will that change my future?

Failure Dx -> to progress from curable to incurable.

Introduction
Clinician :
Takes experience, Knowledge of the medical literature, Good judgment, and an understanding of the fundamentals of clinical

epidemiology and decision making.

Introduction
Diagnosis = the process of discovering a patients underlying disease. Step Diagnostic Process:
1. Based on probability 2. Pattern recognition 3. History taking 4. Develop Hypotheses 5. Physical Examination 6. Make a Problem List 7. Generate a Differential Diagnoses 8. Test the Hypotheses 9. Modify Your Differential Diagnosis 10. Repeat Steps 3 to 9 11. Make the Diagnosis

E/

The Illness DERANGEMENT Anatomic Biochemical Physiological Psycological Exhibit Symptom

Sign

DISEASE 4 strategies of Clinical Dx.

Step.1. Base on Probability

Pre test Probability

- Prevalence - Ax - PD
Penunjang - Laboratorium - USG - Ro. - dsb

Gold Standard
Decision Analysis :
Making Prognosis Deciding Best Therapy

Post test Probability/ Clinical Dx.

Dx. pasti

Step.1. Base on Probability

Step.1. Base on Probability

Step 2. pattern recognition

= gestalt method (considering or
treating what a person experiences and believes as a whole and individual thing )
The instaneous realization that patients

Def :
presentation conform to a previously learned picture/pattern of disease

Step 2. pattern recognition

Auditary - the speech of patient
Odor :
Diabetec acidosis Liver failure

Lung abscess

Strategy #2
= the multiple branching method
Algorithm Triage

Strategy #3
= Go do complete hystory & physical

Hystory taking Physical examination

Strategy #4
= Hypothetico-deductive strategy
the earlist clues of the patients Short list of potential Dx/action History & Physical Paraclinic(lab., x-ray etc) From : Colleague Teacher

HYPOTHESIS

Deduction/ Reduce the list

HISTORY TAKING
Dr. I Gede Arinton,SpPd,MKom,MMR The Head of Internal Medicine Margono Soekarjo Hospital Medical Faculty UNSOED PURWOKERTO

PATIENT

seeking help

DOCTOR

to regain or retain health

TACKLING "THE FIVE DS" OF HEALTH: - DISEASE - DISCOMFORT - DISABILITY - DEATH DISSATISFACTION

set the stage for : * making a diagnosis * determining prognosis * carrying out treatment * promoting health * preventing disease
* * * * * * * DESCRIPTION OF PATIENT CHIEF COMPLAINT HISTORY OF THE PRESENT ILLNESS PAST MEDICAL HISTORY SOCIAL AND OCCUPATIONAL HISTORY FAMILY HISTORY REVIEW OF SYSTEMS --->PD

History Taking

student learn skills

THE PATIENT'S MEDICAL HISTORY

Introduction

HISTORY TAKING

List of Problem

Physical Examination

Hypothesis
Lab Special

Dx

CHIEF COMPLAINT
Definition : statement of the primary reason for the patient seeking medical attention, often stated in the patient's own words. The chief complaint could be :
a pain a symptom of discomfort a loss of usual function troublesome bodily change a psychiatric symptom

CHIEF COMPLAINT
Why do patients seek care at a particular time? :

1. the symptoms of the illness increase to the point that they are unbearable and the patient realizes s/he needs help
2. anxiety 3. the symptom in the chief complaint is sometimes a "ticket of admission" to the physician's office or emergency room;

HISTORY OF PRESENT ILLNESS

an elaborated description of the patient's chief complaint. The goal is : to obtain a coherent, orderly picture of how the patient's chief complaint developed, linking the chronological emergence of symptoms within the overall life circumstances of the patient.

HISTORY OF PRESENT ILLNESS

Most important part of the medical history, providing the essential information for making the diagnosis. Physician works in partnership with the patient to develop an accurate and useful understanding of the illness in the patient's life.

Seven Core Dimensions

1. Location:
Where is the problem located?

Does it radiate?
Can you take one finger and

show me exactly where it

hurts?

Seven Core Dimensions

2. Quality

What is it like? How does it feel? Before we go on further, can

you describe the pain in some more detail? Was it sharp or dull? Did it come and go or just stay there all the time?

Seven Core Dimensions

3. Quantity/Severity:
How bad is it?

On a 1 to 10 scale, where 1

represents no pain and 10

represents the worst pain.

Seven Core dimensions

4. Chronology/Timing:
When did each symptom or problem begin? How did the events unfold? How often does it occur?

Was this your very first episode of chest pain or have you ever had chest pain before? What happened next? How frequently are you having the

Seven Core Dimensions

5. Setting/Context:
What environmental factors, activities, emotional reactions or other circumstances may have contributed to or led up to the problem?

Can you tell me what you are doing when you experience this chest pain? Is there anything else that comes to mind about the situations in which these headaches develop?

Seven Core Dimensions

6. Modifying Factors:

What makes it better? What makes it worse?

Can you tell me what tends to decrease the intensity of the pain? Have you tried any medications to control the diarrhea? Have you noticed anything that makes the pain worse? Is your shortness of breath worse when you lie down?

Seven Core Dimensions

7. Associated Symptoms/ Manifestations:

What other symptoms occur preceding, coincidentally, or following the primary symptom? Pertinent positives and negatives Organ specific review of symptoms
Do you have any other sensations or feelings when you have these headaches? Did you notice any pain or discomfort in your jaw or left arm when you experienced the chest pain?

HISTORY OF PRESENT ILLNESS

Tips for Eliciting the HPI :
1.Types of Questions: Open ended :
Generally used at the beginning of the interview and throughout. " What is the pain like? "Tell me about that".

HISTORY OF PRESENT ILLNESS

Direct :
To the point.
"What day did the pain start?" "How many times have you had diarrhea today?"

Designed :
to get specific information about a
particular point in the history

HISTORY OF PRESENT ILLNESS

Multiple :
To be avoided. Questions like "Do you have any change in bowel or bladder habits, blood in your stool or abdominal pain?" By the time you get to the end of the question, both you and the patient have forgotten exactly what you asked.

HISTORY OF PRESENT ILLNESS

Laundry List:
Somewhat similar to Multiple. Useful in patients who have difficulty in describing a symptom. "Is the pain sharp or dull or burning or throbbing?"

Try the open ended "What is the pain like?" first.

HISTORY OF PRESENT ILLNESS

2. Ways to Enhance Communication
Be sure the patient is comfortable. Be sure you are ready to listen. Introduce yourself Be respectful of the patient (Call the patient by his or her surname unless told otherwise)

HISTORY OF PRESENT ILLNESS

Facilitate (These are phrases and
gestures that encourage the patient to tell the story, such as leaning forward, nodding your head, saying "go on", or "uh huh"

Empathize (Put yourself in the

patient's shoes. How would you feel?

HISTORY OF PRESENT ILLNESS

Compassion
Silence Confront and clarify (If something doesn't make sense or is contradictory, ask the patient to make it clear

Reflect or repeat what you have heard or understand back to the patient

HISTORY OF PRESENT ILLNESS

Use summary statements
occasionally Use transition statements Use a concluding question or statement :
"Is there anything else you can think of?
"Is there anything else that might be important?"

PAST MEDICAL HISTORY

= is a record of the patient's past experiences with illnesses and medical treatments-- information : adds to the physician' s understanding of the presenting problem or that leads to diagnostic possibilities to explain the current illness PMH often has a great impact on eventual patient management.

FAMILY HISTORY
a systematic exploration of the

presence or absence of illness

in the patient's family-

information may be helpful in

diagnosing the patient's present illness or suggest possible risks for future disease.

PAST MEDICAL HISTORY

Core Elements of the PMH : 1. Childhood Illnesses:
Inquire about serious or chronic illnesses

2. Adult Illnesses:
illnesses in general inquire specifically about common conditions

3. Obstetric/Gynecologic History:
Female patients pregnancies and outcomes
miscarriages or abortions

PAST MEDICAL HISTORY

4. Psychiatric Illnesses:
hospitalizations, suicide attempts, treatments (include dates)

5. Surgeries:
dates, indications, outcomes and complications.
serious accidents or injuries (include dates and complications) Hospitalizations:

6. Injuries/Trauma:

PAST MEDICAL HISTORY

7. Medications:
hormone replacement and birth
control pils (include dosage and dosing regimen)

8. Allergies/Drug intolerance:
medication, environmental and

food allergies.
medication side effects

PAST MEDICAL HISTORY

9. Transfusions:
transfusions of blood and blood products (include dates, units and reactions).

10. Hazardous Exposures:

occupational and home exposures e.g. any chemicals,

dust or fumes at work or at home that might be dangerous?

FAMILY HISTORY
Core Element of the FH : 1. Parents, siblings, and children:
health status, major illnesses, age at and causes of death

2. Other family members:

genetic factors : diabetes, CAD, hypertension, cancers, lipid disorders, psychiatric illnesses including alcoholism Illnesses similar to the patient's

PHYSICAL EXAMINATION (PE)

INTRODUCTION
ERA OF HIGH TECHNOLOGY

PHYSICAL EXAMINATION ???

INTRODUCTION
Proper performance of PE :
Routine ordering lab. Test & X-ray -guided by History Taking & PE interpretation of result lab.test, imaging, even biopsy -need PE Patients trust -- PE doctor

DEFINITION
The

process of examining the patients body to determine the presence or absence of physical problems.
It

includes :
(looking) (feeling) (listening)

inspection palpation

auscultation percussion

(producing sounds )

Inspection :
Method of observation used during

physical examinations. Inspection, or

"looking at the patient," is the first

step in examining a patient or body

part

Palpation is the method of "feeling" with the hands during a physical examination

Percussion is a method of "tapping" on body parts with fingers, hands, or small instruments

Auscultation is a method used to "listen" to the sounds of the body by using a stethoscope.

HISTORY
Hippocrates (c.460-377BC) :
the 'Father of Medicine' by refusing to use gods to explain illnesses and disease-a science rather than a religion. stressed the importance of observation

HISTORY
Leopold Auenbrugger:
An Austrian physician the inventor of percussion -by tapping on the chest with the finger the lungs wheel percussed, give a sound like a drum consolidated, as in pneumonia-= the thigh is taped. the heart -dull sound injected fluid into the pleural cavity, -- by percussion to tell exactly the limits of the fluid present He pointed out how to detect cavities of the lungs, and how their location and size might be determined by percussion

HISTORY
Jean-Nicholas Corvisart:
Napoleon's personal physician popularized percussion as diagnostic tool With a picture -Cause of death a

Laenec:

The inventor of stethoscope-a perforated wooden cylinder one foot long one end of a wooden listening to the transmitted sound at the other end.

Laennec stethoscope

Piorry Stethoscope

Flexible Stethoscopes Binaural Stethoscopes

Electronic Stethoscopes

INTRODUCTION

VITAL SIGN
SYSTEMIC REVIEW

VITAL SIGN (VS)

INTRODUCTION
VS include the measurement of: Temperature Respiratory rate Pulse Blood pressure

provide critical information ("vital")

about a patient's state of health.

INTRODUCTION
In particular, they: Can identify the existence of an acute medical problem. rapidly quantifying the magnitude of an illness

how well the body is coping with the

resultant physiologic stress.

INTRODUCTION
Are a marker of chronic disease
states (e.g. Hypertension)

To use these values as the basis for

management decisions.

VITAL SIGN :
Body temperature
Blood Pressure Pulse Rate

Respiration Rate

Equipment Needed
A A A A stethoscope blood pressure cuff watch displaying seconds thermometer

General Considerations
The patient should not have had :
Alcohol Tobacco Caffeine Performed vigorous exercise
within 30 minutes of the exam.

General Considerations
Ideally the patient should be:
sitting with feet on the floor

their back supported.

The examination room should be quiet and the patient comfortable.

General Considerations
History of :
hypertension;

slow, rapid or irregular pulse

and current medications

should always be obtained.

General Considerations
In addition :
peak expiratory flow,

oxygen saturation or
blood glucose level.

etc

Temperature
can be measured is several different ways:
Oral

Glass, paper, or electronic

Normal 98.6 F/37 C Axillary Glass or electronic Normal 97.6 F/36.3 C

Temperature
Rectal (or "core") Glass or electronic Normal 99.6 F/37.7 C Aural (in the ear)
Electronic Normal 99.6 F/37.7 C

axillary < acurrate rectal Fever oral 100.5 F/38.5 C or above.

 Duration Pattern:
Intermitten Remitten continue

Pulse
1. Sit or stand facing your

patient.
2. Grasp the patient's wrist with your free

(non-watch bearing)
hand (patient's right with your right or

patient's left with your

left).

Pulse
3. Compress the radial artery with your index and middle fingers. Note :
the rate,
the regularity,

and amplitude
of the pulse you are measuring.

Pulse
Count the pulse for 15 seconds - multiply by 4. Count for a full minute if the pulse is irregular. A normal adult heart rate is between 60-100 beats per minute.

Pulse

Contour

Pulse
The pulse may be palpated of the accessible arteries : - a. radialis ------> very common - a. brachialis - a. temporalis ---> anesthesiologist - a. dorsalis pedis----> DM - a. carotis -----> aortic pulse wave

- Start with a swift upstroke ----> the pe ak sys. pre ss.--> followe d by a more gradual de cline --->- approximate ly at the e nd of v e nt.sys. ---> se c. & normal upstroke ( dicrotic wav e ) by the close d aortic v alv e
Normally impapable ( only by sphygmograph) wher palpable

One wav e in sys. and one in dia.

Volume

Pulsus Bisfe rie ns: - 2 wav e in sys. In : - AI + : *AS mode rate * HSS * Hype rthyroidism Bounding or Collapsing Pulsus ( Corrigan, Wate r-Hamme r pulse ): - upstroke -->v e ry sharp - downstroke -> pre cipitously - pistol-shot sound In : - HT Ess.+ rigid aorta - Hype rthyroidism - Emotional state - AI - PDA - AV-fistule Plate au pulse (Pulsus Tardus) - upstroke -->gradual - downstroke -> de laye d - be st appre ciate d in a. carotis In : - AS

Rate

Rhytm

Volume
Pulsus Alte nans: - Rythm Normal - Inte rv al - Pulse wav e --->v olume >>> & <<< In : - myocardial we akne ss

The pulse may be palpated of the accessible arteries : - a. radialis ------> very common - a. brachialis - a. temporalis ---> anesthesiologist - a. dorsalis pedis----> DM - a. carotis -----> aortic pulse wave

Pulsus Bige mini(Couple d Rythm): - Rythm Normal - Inte rv al be twe e n me mbe r-->shorte r Pulsus Paradoxus: - Normal: Inspiration--->Sys.fall <10mmHg - Sys.fall >10 mmHg. - Cardiac tamponade Ine quality of Contralate ral Pulsus : - Ane urysm - Partial Obstruction

Rate
Sinus Rythm : 60-100 Sinus Bradycardia : < 60 - AV Block - Athle te Sinus Tachycardia : >100: -

Contour

Rhytm
- Sinus Rythm : 60-100 - Dysrythmia : - Atrial fibrilation - Atrial Flutte r - Extra systole

Respiration
Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations.

Respiration
Without letting go of the

patient's wrist begin to observe

the patient's breathing.

Count breaths for 15 seconds

multiply by 4

In adults, N: 14-20 X/minute

Respiration
Tachypnea- Rapid

Hyperpnea-->Deep : Kussmaul
Bradypnea-->Slow Apnea ---- Absent

Cheyne-Stokes-apneahyperpnea

Blood Pressure
The room should be quiet and the patient comfortable. Position the patient's arm so the antecubital fold is level with the heart. (It is best that the

arm be support by
an armrest or your arm.)

Blood Pressure
Center the bladder of the cuff over

the brachial artery approximately 2

cm above the antecubital fold.

Position the patient's arm so it is

slightly flexed at the elbow.

Blood Pressure
Palpate the radial pulse and

inflate the cuff until the pulse

disappears. This is a rough estimate of the systolic pressure. Place the stethoscope over the brachial artery.

Blood Pressure
Inflate the cuff 20 to 30 mmHg

above the estimated systolic

pressure.

Release the pressure slowly, no

greater than 5 mmHg per

second.

Blood Pressure
The level at which you begin to

hear Korotkoff sounds is the

systolic pressure. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure.

Blood Pressure
Blood pressure should be taken in

both arms on the first encounter.

If there is more than 10 mmHg difference between the two arms, make a note to always use the reading from the arm with the higher

pressure.

Interpretation
BP should be taken in both arms -- < 10 mmHg difference
retake the BP ----"white coat" effect. In situations auscultation is not possible-SP by palpation alone.

Interpretation
Classification :
Normal Mild HT Moderate HT : < 140/< 90 : 140-159/90-99 : 160-179/100-109 Isolated Sys.HT : >140/<90

Severe HT
Crisis HT

: 180-209/110-119
: > 209/> 119

PROBLEM BASED LEARNING

Introduction
learning is a strategy for
learning basic science concepts using problems from clinical practice

Objective
introduce the student in a practical setting to the thought processes required for solving clinical problems. Specifically, we propose :
1. to promote active learning 2. to encourage students to think creatively about medical problems 3. to integrate learning across the basic science curriculum.

Organization
Internal Department :
Small Group 7-8 student + Tutor Monday -decided cases Wednesday --tutorial Saturday -case report :
1. 2. 3. 4. patient presentation physical examination laboratory findings treatment and follow-up

Case Report Form

LAPORAN KASUS
Nama Pasien : Nama Mahasiswa NIRM Nama Tutor : Tanggal : : : :

Kelamin/Umur : Alamat Ruang Dirawat sejak : : :

Case Report Form

I. a. Keluhan Utama : b. Masalah :

Case Report Form

II. Riwayat Penyakit sekarang, Riwayat Penyakit Dahulu dan Riwayat Penyakit keluarga yang sesuai dengan keluhan utama a. RPS ( Ingat 7 dimensi)

b. RPD :

Melanjutkan penyakit sekarang Hubungannya dengan tindakan.

c. RPK

Penularan Keturunan

Case Report Form

III. BUAT HIPOTESIS BERDASARKAN 1 DAN 2 SERTA TERANGKAN PEMBENARANNYA (LITERATUR)
1.

2.

3.

Case Report Form

IV. TENTUKAN PEMERIKSAAN DIBUTUHKAN(LITERATUR) FISIK YANG

Case Report Form

V. HALUSKAN HIPOTESIS DIATAS BERDASARKAN DUKUNGAN DARI PEMERIKSAAN FISIK. JELASKAN BERDASARKAN LITERATUR
1.

2.

3.

Case Report Form

VI. TENTUKAN KEBUTUHAN YANG SESUAI(LITERATUR) LABORATORIUM/PENUNJANG

VII. BILA HASIL TELAH HIPOTESIS(LITERATUR) 1.

ADA

HALUSKAN

LAGI

2.

3.

Case Report Form

VIII. TENTUKAN TERAPI DAN FOLLOW-UP (TERANGKAN PEMBENARANNYA) 1.
2. 3. 4. 5. IX. TENTUKAN PROGNOSIS BERDASARKAN KRITERIA

Evaluation
Student Activities

Yes

No

Arrived on time for session.

Prepared assigned learning issue.

Integrated their contributions into session events rather than simply reading from notes.

Evaluation
Provided rationale/explanations for contributions; avoids unsubstantiated opinion.

Admitted the limits of their knowledge (Is not afraid to say I dont know.) Asked for clarification/explanation of topics that are unclear to them. Was receptive to ideas and contributions of other group members.

Evaluation
As part of their participation, connected/integrated the basic science of the case with previously acquired knowledge. Synthesized or summarized information for the group. Extended discussion beyond case objectives (e.g., brought in new research findings.) Demonstrated leadership (e.g., acted to keep the group on task, monitored time, kept comments focussed on discussion topic.)

Evaluation

Actively encouraged the input of other group members Additional Facilitator Comments: