Study Guide Special Topic

STUDY GUIDE SPESIAL TOPIK SEMESTER III

1 Udayana University Faculty of Medicine, DME, 2018

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TABLE OF CONTENTS

Page Table of Contents 1 Curriculum 2 The Seven General Core Competencies Planner Team & Lecturers 7 Facilitator 9 Time Table 10 Health Care in Elderly 13 Travel Medicine 23 Andrology and Anti-Aging Medicine 40 Important Informations Student’s Project Meeting of The Students’ Representative Meeting of The Students’ Representative Learning Programs Curriculum Map 48

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SPECIAL TOPIC CURRICULUM

AIMS 1. To introduce the existence of Special Topics in the curriculum of the medical profession. 2. To understand the science and it’s practices of health care in elderly in medical profession. 3. To understand the science and it’s practices of travel medicine in medical profession. 4. To understand the science and it’s practices of andrology and anti-aging medicine in medical profession.

CURRICULUM OF HEALTH CARE IN ELDERLY

AIM OF HEALTH CARE IN ELDERLY TOPIC 1. To know general perspective of health care in elderly 2. To describe the most common health problem in elderly

LEARNING OUTCOMES 1. Know about delirium in elderly 2. Know about frailty in elderly 3. To develop and implement a plan of care for a patient with history of recurrent falls. 4. Know about immobilization in geriatric patient 5. Know about polypharmacy problem in geriatric patient 6. Know and can managed cognitive impairment in elderly 7. Know about psychiatric disorders in elderly 8. Know about principles and rehabilitation in elderly

CURRICULUM CONTENT I. DELIRIUM Aim: 1. Understanding about epidemiology and pathogenesis delirium in elderly. 2. Understanding about the risk factors for the development of delirium. 3. Understanding about the diagnostic workup of delirium. 4. Develop a rational management plan for persons with delirium.

II. FRAILTY IN ELDERLY Aim: 1. To understand the definition and theory of frailty 2. To know the cycle of frailty 3. To understand the treatment and prevention of frailty

III. INSTABILITY AND FALLS Aim: 1. Understanding about balance, postural control, walking cycle and functional mobilization 2. Identify predisposing risk factors for falls among older adults. 3 Udayana University Faculty of Medicine, DME, 2018

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3. Develop and implement a plan of care for a patient with history of recurrent falls.

IV. IMMOBILIZATION Aim: 1. To know about the risk factors of immobilization in geriatric patient. 2. To know about the complication pathogenesis of immobilization in geriatric patient. 3. To know and can provide comprehensive treatment for geriatric patient with immobilization

V. POLYPHARMACY IN ELDERLY Aim: 1. To understand pharmacokinetics changes 2. To understand relevant change in aging and pharmacology 3. To understand pharmacodynamics change with age 4. To understand guidelines for proper medication prescribing and medication reduction 5. To know about inappropriate medication use in older adults and coments about that

VI. COGNITIVE IMPAIRMENT IN ELDERLY Aim: 1. To know cognitive changes associated with normal aging 2. To describe the difference of cognitive function in normal aging, mild cognitive impairment (MCI), dementia 3. To describe factors affecting cognition in elderly, age related nervous system changes, neuropathology in cognitive impairment, diagnosis, cognitive function in elderly

VII. PSYCHIATRIC DISORDERS IN ELDERLY Aim: 1. To know sign and symptom psychiatric disorder in elderly such as: - Depression - Anxiety - Behavioral and Psychological symptom of Dementia - Delirium, etc. 2. Could diagnosed, treatment, or referal cases of psychiatric disorder in elderly 3. Could do psychotherapy in elderly and their family or care giver

VIII. PRINCIPLES OF REHABILITATION IN ELDERLY Aim: 1. Know and understand about the principles of rehabilitation in elderly a. Recognize the definition of rehabilitation in elderly b. Recognize the ICIDH classification of WHO c. Recognize the rehabilitation site d. Recognize process of rehabilitation 2. Know about Rehabilitation Team for the elderly a. Recognize who they are

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b. Recognize what their duties are 3. Know about the physical modalities and adaptive aids for the elderly a. Recognize the physical modalities that are often used with older adults b. Recognize the adaptive aids that allow person with physical limitation to participate in activities 4 Know about rehabilitation for common geriatric problems a. Recognize the common geriatric problems b. Recognize the rehabilitation for common geriatric problems

CURRICULUM OF TRAVEL MEDICINE

AIM OF TRAVEL MEDICINE 1. To introduce the existence of Special Topics in the curriculum of the medical profession. 2. To know general perspective of Travel Medicine 3. To understand the science and it's practices of travelers medicine in the medical profession. 4. To describe etiology, patophysiology, clinical features, diagnosis, and management of travel related illness 5. To describe the 5 most common in travel related illness

LEARNING OUTCOMES 1. Know and can perform immunization and give chemoprophylaxis to prevent travel- related illness 2. Understand the management of primary care practice specific for traveler 3. Diagnose, treat, and prevent traveler`s diarrhea 4. Diagnose, treat, refer, and prevent DVT 5. Diagnose, treat, refer, and prevent ACS 6. Manage traveler with respiratory disease who undergo air travel 7. Diagnose, treat, refer, and prevent traveler with heat exhaustion and heat stroke 8. Diagnose, treat, refer, and prevent traveler with near drowning 9. Diagnose, treat, refer, and prevent traveler with decompression syndrome after dive

CURRICULLUM CONTENT 1. General perspective for travel medicine a. Scope has largely evolved in response to changing of travel trend b. Understand the primary care practice specific for traveler c. Recognize the management of primary care practice specific for traveler

2. Diagnose, treat, and prevent traveler`s diarrhea a. Understand the definition of traveler`s diarrhea b. Understand the etiology of traveler`s diarrhea c. Describe the pathogenesis of traveler`s diarrhea d. Recognize the clinical manifestation of traveler`s diarrhea e. Recognize the management of traveler`s diarrhea f. Understand the prevention of traveler`s diarrhea

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3. Diagnose, treat, refer, and prevent DVT a. Understand the predisposing factor of DVT b. Describe the pathophysiology of DVT c. Recognize the clinical presentation of DVT d. Recognize the management of DVT e. Understand the prevention of DVT

4. Know and can perform immunization and give chemoprophylaxis to prevent travel- related illness a. Recognize the immunizations to prevent travel-related illness b. Recognize the prophylaxis for malaria c. recognize respiratory disorders with potential complication for air travel

5. Diagnose, treat, refer, and prevent traveler heat exhaustion and heat stroke a. Understand the definition of heat exhaustion and heat stroke b. Describe the pathophysiology of heat exhaustion and heat stroke c. Recognize the clinical manifestation of heat exhaustion and heat stroke d. Recognize the complication of heat exhaustion and heat stroke e. recognize the management of heat exhaustion and heat stroke

6. Diagnose, treat, refer, and prevent traveler with near drowning a. Understand the definition of near drowning b. Describe the pathogenesis of near drowning c. Recognize the clinical manifestation of near drowning d. Recognize the complication of near drowning e. recognize the management of near drowning

7. Diagnose, treat, refer, and prevent traveler with decompression syndrome after dive a. Understand the definition decompression syndrome after dive b. Describe the pathogenesis decompression syndrome after dive c. Recognize the clinical manifestation decompression syndrome after dive d. Recognize the complication decompression syndrome after dive e. recognize the management decompression syndrome after dive

8. Animal bite Objectives a. To describe why rabies continues to be a feared zoonotic disease. b. To describe how is rabies spread c. To describe disease that Rabies most commonly mimic d. To understand how Rabies is diagnosed e. To describe the current recommendation for Rabies treatment f. To describe pre and post exposure prophylaxis g. To describe clinical presentation of Rabies h. To describe the clinical management of snake bite envenoming i. To describe the clinical management of scorpion sting envenoming

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CURRICULUM OF ANTI AGING MEDICINE

1. Theories and the principles of Anti-Aging Medicine 2. The paradigm changes of aging proccess 3. The role of hormones in aging process 4. The role of sport in preventing and reversing aging process 5. The role of nutrient in preventing aging process 6. The role of aesthetics in Anti-Aging Medicine 7. The role of sexual function in aging process 8. Diagnose, prevent, manage, or refer all changes related to aging process

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The Seven General Core Competencies

1. Patient Care Demonstrate capability to provide comprehensive patient care that is compassionate, appropriate, and effective for the management of health problems, promotion of health and prevention of disease in the primary health care settings.

2. Medical Knowledge Base Mastery of a core medical knowledge which includes the biomedical sciences, behavioral sciences, epidemiology and statistics, clinical sciences, the social aspect of medicine and the principles of medical ethics

3. Clinical skill Demonstrate capability to effectively apply clinical skills and interpret the findings in the investigation of the patients

4. Communication Demonstrate capability to communicate effectively and interpersonally to establish rapport with the patient, family, community at large, and professional associates, that results in effective information exchange, the creation of a therapeutically and ethically sound relationship

5. Information Management Demonstrate capability to manager information which includes information access, retrieval, interpretation, appraisal, and application to patience’s specific problem, and maintaining records of his or her proactive for analysis and improvement

6. Professionalism Demonstrate a commitment to carrying out professional responsibilities and to personal probity, adherence to ethical principles, sensitivity to a diverse patient population and commitment to carrying out continual self-evaluation of his or her professional standard and competence

7. Community-based and health system-based practice Demonstrate awareness and responsiveness to larger context and system of health care, and ability to effectively use system resource for optimal patient care.

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PLANNERS TEAM

HEALTH CARE IN ELDERLY

No. Name Departement Phone Dr. dr. Tuty Kuswardhani, Sp.PD-KGer, Internal Medicine 1 0811388700 FINASIM, MARS 2 dr. I Nyoman Astika, Sp.PD-KGer, FINASIM Internal Medicine 08123974128 dr. I Gusti Putu Suka Aryana, Sp.PD-KGer, Internal Medicine 3 08164724600 FINASIM 4 dr. IB Putu Putrawan, Sp.PD, FINASIM Internal Medicine 081236194672

5 dr. Ni Ketut Rai Purnami, Sp.PD Internal Medicine 0818350703

6 dr. Dedi Silakarma, Sp.KFR Rehabilitation Medic 08123884896

7 dr. A.A.A. Meidiary, Sp.S Neurology 08123616763

8 dr. Ni Ketut Sri Diniari, Sp.KJ Psychiatry 081338748051 TRAVEL MEDICINE

No. Name Department Phone

1 Prof. Dr. dr. Tuti Parwati Merati, SpPD-KPTI Internal Medicine 08123806626

2 dr. I Made Susila Utama, SpPD-KPTI Internal Medicine 08123815025

3 dr. Made Agus Hendrayana, M.Ked Microbiology 08123921590

4 Dr. dr. Tjok Gde Agung Senapati, SpAn-KAR Anesthesiology 081337711220

5 dr. Wayan Losen Adnyana, SpPD-KHOM Internal Medicine 08123995536

6 dr. I Putu Adiarta Griadi, M.Fis Physiology 081999636899

7 dr. I Made Ady Wirawan, MPH, PhD Public Health 081239394465

8 dr. Anita Devi, M.Si Hyperbaric 081805505911

9 dr. Ketut Agus Somia, SpPD-KPTI Internal Medicine 08123989353

10 dr. Anak Agung Ayu Yuli Gayatri, SpPD Internal Medicine 08123803985

11 dr. Ni Made Dewi Dian Sukmawati, SpPD Internal Medicine 08123320380 ANDROLOGY AND ANTI-AGING MEDICINE dr. Yukhi Kurniawan, Sp.And Andrology and 1 08123473593 Sexology dr. I Dewa Ayu Inten Dwi Primayanti, Andrology and 2 081337761299 M.Biomed. Sexology Andrology and 3 dr Ida Ayu Dewi Wiryanthini, M.Biomed 081239990399 Sexology Andrology and 4 dr. I Gusti Ayu Dewi Ratnayanti, M.Biomed 085104550344 Sexology

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LECTURES

HEALTH CARE IN ELDERLY

No. Name Departement Phone Dr. dr. Tuty Kuswardhani, Sp.PD-KGer, Internal Medicine 1 0811388700 FINASIM, MARS 2 dr. I Nyoman Astika, Sp.PD-KGer, FINASIM Internal Medicine 08123974128 dr. I Gusti Putu Suka Aryana, Sp.PD-KGer, Internal Medicine 3 08164724600 FINASIM 4 dr. IB Putu Putrawan, Sp.PD, FINASIM Internal Medicine 081236194672

5 dr. Ni Ketut Rai Purnami, Sp.PD Internal Medicine 0818350703

6 dr. Dedi Silakarma, Sp.KFR Rehabilitation Medic 08123884896

7 dr. A.A.A. Meidiary, Sp.S Neurology 08123616763

8 dr. Ni Ketut Sri Diniari, Sp.KJ Psychiatry 081338748051 TRAVEL MEDICINE

No. Name Department Phone

1 Prof. Dr. dr. Tuti Parwati Merati, SpPD-KPTI Internal Medicine 08123806626

2 dr. I Made Susila Utama, SpPD-KPTI Internal Medicine 08123815025

3 dr. Made Agus Hendrayana, M.Ked Microbiology 08123921590

4 Dr. dr. Tjok Gde Agung Senapati, SpAn-KAR Anesthesiology 081337711220

5 dr. Wayan Losen Adnyana, SpPD-KHOM Internal Medicine 08123995536

6 dr. I Putu Adiarta Griadi, M.Fis Physiology 081999636899

7 dr. I Made Ady Wirawan, MPH, PhD Public Health 081239394465

8 dr. Anita Devi, M.Si Hyperbaric 081805505911

9 dr. Ketut Agus Somia, SpPD-KPTI Internal Medicine 08123989353

10 dr. Anak Agung Ayu Yuli Gayatri, SpPD Internal Medicine 08123803985

11 dr. Ni Made Dewi Dian Sukmawati, SpPD Internal Medicine 08123320380 ANDROLOGY AND ANTI-AGING MEDICINE dr. Yukhi Kurniawan, Sp.And Andrology and 1 08123473593 Sexology dr. I Dewa Ayu Inten Dwi Primayanti, Andrology and 2 081337761299 M.Biomed. Sexology Andrology and 3 dr Ida Ayu Dewi Wiryanthini, M.Biomed 081239990399 Sexology Andrology and 4 dr. I Gusti Ayu Dewi Ratnayanti, M.Biomed 085104550344 Sexology

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FACILITATORS Regular Class (Class A)

Venue No Name Group Departement Phone (3rd floor) dr. Dewa Ayu Mas Shintya Dewi 3rd floor: 1 A1 Anesthesy 085238514999 Sp.An R.3.01 3rd floor: 2 DGP. Dharma Santi, Ssi., Apt., M.Kes A2 Patologi Klinik 0817569021 R.3.02 3rd floor: 3 dr. I Kadek Swastika, M.Kes A3 Parasitology 08124649002 R.3.03 3rd floor: 4 dr. I Wayan Surudarma, Msi A4 Biochemistry 081338486589 R.3.04 dr. Ni Nyoman Metriani Mesa, MSc, 3rd floor: 5 A5 Pediatric 081337072141 Sp.A R.3.05 3rd floor: 6 Dr. dr. Ni Made Linawati, M.Si A6 Histology 081337222567 R.3.06 dr. Ni Wayan Sucindra Dewi, 3rd floor: 7 A7 Pharmacology 08113935700 M.Biomed R.3.07 3rd floor: 8 dr. I Made Winarsa Ruma, Ph.D A8 Biochemistry 081338776244 R.3.08 dr. Ni Nengah Dwi Fatmawati, Sp.MK, 3rd floor: 9 A9 Microbiology 087862200814 Ph.D R.3.21 Prof. Dr.dr. I Putu Gede Adiatmika, 3rd floor: 10 A10 Physiology 08123811019 M.Kes R.3.22

English Class (Class B)

Venue No Name Group Departement Phone (3rd floor) Desak Kt. Ernawati, S.Si, Apt. 3rd floor: 1 B1 Pharmacology 081236753646 M.Pharm, Ph.D R.3.01 3rd floor: 2 Dr.dr. Anna Marita Gelgel, Sp.S(K) B2 Neurology 08113980999 R.3.02 3rd floor: 3 dr. I Wayan Sugiritama, M.Kes B3 Histology 08164732743 R.3.03 3rd floor: 4 Dr. dr. I Made Muliarta, M.Kes B4 Physiology 081338505350 R.3.04 3rd floor: 5 dr. Muliani, M.Biomed B5 Anatomy 085103043575 R.3.05 3rd floor: 6 dr. Putu Cintya D.Y, MPH B6 Public Health 081353380666 R.3.06 dr. Ni Made Ayu Surasmiati, 3rd floor: 7 B7 Opthalmology 081338341860 M.Biomed. Sp.M R.3.07 3rd floor: 8 Dr. Ni Wayan Tianing, S.Si, M.Kes B8 Biokimia 08123982504 R.3.08 3rd floor: 9 Dr. dr. Susy Purnawati, M.KK B9 Physiology 08123989891 R.3.21 3rd floor: 10 Prof. dr. I G M. Aman, Sp.FK B10 Pharmacology 081338770650 R.3.22 11 Udayana University Faculty of Medicine, DME, 2018

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TIME TABLE Day Date Topic Learning Regular Class English Conveyer situation Class 1 Kamis, Lecture 1 Intro. Lect 08.00-09.00 09.00-10.00 Dr.dr. RA Tuty 11 Delirium IL 09.00-10.30 11.30-13.00 Kuswardhani, Januari SGD 10.30-12.00 13.30-15.00 SpPD-KGer, 2018 Break 12.00-12.30 13.00-13.30 FINASIM, SP 12.30-14.00 10.00-11.30 MARS Pleno 14.00-15.00 15.00-16.00 2 Jumat, Lecture 2 Intro. Lect 08.00-09.00 09.00-10.00 12 Frailty in Elderly IL 09.00-10.30 11.30-13.00 dr. I Nyoman Januari SGD 10.30-12.00 13.30-15.00 Astika, Sp.PD- 2018 Break 12.00-12.30 13.00-13.30 KGer, SP 12.30-14.00 10.00-11.30 FINASIM Pleno 14.00-15.00 15.00-16.00 3 Rabu, 17 Lecture 3 Intro. Lect 08.00-09.00 09.00-10.00 dr. Ni Ketut Januari Instability and Falls IL 09.00-10.30 11.30-13.00 Rai Purnami, 2018 SGD 10.30-12.00 13.30-15.00 Sp.PD Break 12.00-12.30 13.00-13.30 SP 12.30-14.00 10.00-11.30 Pleno 14.00-15.00 15.00-16.00 4 Kamis, Lecture 4 Intro. Lect 08.00-09.00 09.00-10.00 dr. IB Putu 18 Imobilisasi IL 09.00-10.30 11.30-13.00 Putrawan Januari SGD 10.30-12.00 13.30-15.00 Sp.PD 2018 Break 12.00-12.30 13.00-13.30 SP 12.30-14.00 10.00-11.30 Pleno 14.00-15.00 15.00-16.00 5 Jumat, Lecture 5 Intro. Lect 08.00-09.00 09.00-10.00 dr. I Gusti 19 Polypharmacy in IL 09.00-10.30 11.30-13.00 Putu Suka Januari Elderly SGD 10.30-12.00 13.30-15.00 Aryana, 2018 Break 12.00-12.30 13.00-13.30 Sp.PD-KGer, SP 12.30-14.00 10.00-11.30 FINASIM Pleno 14.00-15.00 15.00-16.00 6 Senin, Lecture 6 Intro. Lect 08.00-09.00 09.00-10.00 dr. AAA 22 Cognitive IL 09.00-10.30 11.30-13.00 Meidiary Sp.S Januari Impairment in SGD 10.30-12.00 13.30-15.00 dr. Ni Ketut 2018 Elderly Break 12.00-12.30 13.00-13.30 Sri Diniari, Psychiatric SP 12.30-14.00 10.00-11.30 Sp.KJ Disorders in Elderly Pleno 14.00-15.00 15.00-16.00

7 Selasa, Lecture 7 Intro. Lect 08.00-09.00 09.00-10.00 dr. Dedi 23 Principles of IL 09.00-10.30 11.30-13.00 Silakarma Januari Rehabilitation in SGD 10.30-12.00 13.30-15.00 Sp.KFR 2018 Elderly Break 12.00-12.30 13.00-13.30 SP 12.30-14.00 10.00-11.30 Pleno 14.00-15.00 15.00-16.00 8 Rabu, 24 Introduction and Intro. Lect 08.00-09.00 09.00-10.00 Prof.Dr.dr. Januari general perspective IL 09.00-10.30 11.30-13.00 Tuti Parwati, 2018 of Travel Medicine. SGD 10.30-12.00 13.30-15.00 SpPD-KPTI Break 12.00-12.30 13.00-13.30 SP 12.30-14.00 10.00-11.30 Pleno 14.00-15.00 15.00-16.00 9 Kamis, Traveler`s diarrhea Intro. Lect 08.00-09.00 09.00-10.00 dr.Made 25 Emerging Diseases IL 09.00-10.30 11.30-13.00 Susila Januari Related Worldwide SGD 10.30-12.00 13.30-15.00 Utama,Sp.PD 2018 Travelling Break 12.00-12.30 13.00-13.30 dr.Made Agus SP 12.30-14.00 10.00-11.30 Hendrayana, Pleno 14.00-15.00 15.00-16.00 M. Ked

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10 Jumat, Air travel: Intro. Lect 08.00-09.00 09.00-10.00 dr.Losen 26 thromboembolism IL 09.00-10.30 11.30-13.00 Adnyana Januari High altitude SGD 10.30-12.00 13.30-15.00 Sp.PD-KHOM 2018 Break 12.00-12.30 13.00-13.30 dr. I Putu SP 12.30-14.00 10.00-11.30 Adiartha Pleno 14.00-15.00 15.00-16.00 Griadhi,M.Fis 11 Senin, Medical evacuation Intro. Lect 08.00-09.00 09.00-10.00 dr. Tjok 29 Air travel: Fit to IL 09.00-10.30 11.30-13.00 Senapathi,Sp Januari Flight SGD 10.30-12.00 13.30-15.00 .An 2018 Break 12.00-12.30 13.00-13.30 dr.I Md.Ady SP 12.30-14.00 10.00-11.30 Wirawan,MP Pleno 14.00-15.00 15.00-16.00 H,PhD 12 Selasa, Immunization and Intro. Lect 08.00-09.00 09.00-10.00 dr. I K Agus 30 Chemoprophylaxis IL 09.00-10.30 11.30-13.00 Somia, Januari to prevent travel- SGD 10.30-12.00 13.30-15.00 SpPD-KPTI 2018 related illness Break 12.00-12.30 13.00-13.30 dr.Made Heat exhaustion SP 12.30-14.00 10.00-11.30 Susila and heat stroke Pleno 14.00-15.00 15.00-16.00 Utama,Sp.PD 13 Rabu, 31 Near drowning Intro. Lect 08.00-09.00 09.00-10.00 dr. Tjok Januari Diving IL 09.00-10.30 11.30-13.00 Senapathi,Sp 2018 Decompression SGD 10.30-12.00 13.30-15.00 .An Syndrome Break 12.00-12.30 13.00-13.30 dr. Anita Devi SP 12.30-14.00 10.00-11.30 Pleno 14.00-15.00 15.00-16.00 14 Kamis, Animal Bite Intro. Lect 08.00-09.00 09.00-10.00 dr.A.A Yuli 01 IL 09.00-10.30 11.30-13.00 Marine Gayatri,Sp.P Februari SGD 10.30-12.00 13.30-15.00 Envenomation D 2018 Break 12.00-12.30 13.00-13.30 dr.Dewi Dian SP 12.30-14.00 10.00-11.30 Sukmawati, Pleno 14.00-15.00 15.00-16.00 Sp.PD 15 Jumat, Scope and Goals of Intro. Lect 08.00-09.00 09.00-10.00 dr. Yukhi 02 Andrology IL 09.00-10.30 11.30-13.00 Kurniawan, Februari SGD 10.30-12.00 13.30-15.00 Sp.And 2018 Break 12.00-12.30 13.00-13.30 SP 12.30-14.00 10.00-11.30 Pleno 14.00-15.00 15.00-16.00 16 Senin, Male Sexual Intro. Lect 08.00-09.00 09.00-10.00 dr. Yukhi 05 Dysfunction IL 09.00-10.30 11.30-13.00 Kurniawan, Februari SGD 10.30-12.00 13.30-15.00 Sp.And 2018 Break 12.00-12.30 13.00-13.30 SP 12.30-14.00 10.00-11.30 Pleno 14.00-15.00 15.00-16.00 17 Selasa, Female Sexual Intro. Lect 08.00-09.00 09.00-10.00 dr. Yukhi 06 Dysfunction IL 09.00-10.30 11.30-13.00 Kurniawan, Februari SGD 10.30-12.00 13.30-15.00 Sp.And 2018 Break 12.00-12.30 13.00-13.30 SP 12.30-14.00 10.00-11.30 Pleno 14.00-15.00 15.00-16.00 18 Rabu, 07 Anti- aging Intro. Lect 08.00-09.00 09.00-10.00 dr. I Dewa Februari medicine IL 09.00-10.30 11.30-13.00 Ayu Inten Dwi 2018 SGD 10.30-12.00 13.30-15.00 Primayanti, Break 12.00-12.30 13.00-13.30 M.Biomed SP 12.30-14.00 10.00-11.30 Pleno 14.00-15.00 15.00-16.00

19 Kamis, Anti- aging Intro. Lect 08.00-09.00 09.00-10.00 dr Ida Ayu 08 medicine IL 09.00-10.30 11.30-13.00 Dewi 13 Udayana University Faculty of Medicine, DME, 2018

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Februari SGD 10.30-12.00 13.30-15.00 Wiryanthini, 2018 Break 12.00-12.30 13.00-13.30 M.Biomed SP 12.30-14.00 10.00-11.30 Pleno 14.00-15.00 15.00-16.00 20 Jumat, Anti- aging Intro. Lect 08.00-09.00 09.00-10.00 09 medicine IL 09.00-10.30 11.30-13.00 dr. I Gusti Februari SGD 10.30-12.00 13.30-15.00 Ayu Dewi 2018 Break 12.00-12.30 13.00-13.30 Ratnayanti, SP 12.30-14.00 10.00-11.30 M.Biomed Pleno 14.00-15.00 15.00-16.00 21 Senin, Team 12 Evaluation Februari 2018

Lecture and Plennary Room : 3.02, 3rd room

TIME TABLE TIME TOPIC January, 11 – 23 2018 Health Care in Elderly January, 24- February 01 2018 Travel Medicine February 02 – 09 2018 Andrology and Anti-Aging Medicine February 10, 2018 Pre-evaluation Break February 12, 2018 Evaluation February 21, 2018 Remedial Schedule

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Student’s Project

Every student requires finding a scientific journal based on the topic of their groups and create a review paper as a group project. The journal has to be from year 2015 to recent years.

No Topic Group

Geriatri Inkontinensia Urin pada Lansia A1 Anemia pada Usia Lanjut A2 Konstipasi pada Usia Lanjut A3 Insomnia pada Lansia A4 Infeksi pada Usia Lanjut B1 Nyeri pada Usia Lanjut B2 Sarcopenia pada Usia Lanjut B3 Travel Medicine Traveling with Disability A5 Long-Term Travelers and Expatriates A6 Pregnant traveler A7 Elderly traveler B4 Travel to Cold Climates B5 Haji travel B6 Sex tourism B7 Andrology Micropenis A8 Late Onset Hypogonadism A9 Priapismus A10 Patophysiologi of Aging Process B8 Role of Hormon in Reversal of Aging Process B9 Exercise to Reserve Aging Process B10

Report Format

Cover Preface Table of Content a. Introduction b. Content c. Summary d. References (Harvard referencing style)

Space : 1,5 Space Font : Times New Roman 12 Minimum Page: 15

The student’s project is present starting by the 14th day of the meeting on the plenary meeting. The results will be review by the block planning group for final mark.

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Student Project Assessment Form Faculty of Medicine, Udayana University

Blok : Behavior Changes and Disorders Name/NIM : Facilitator : Title :

Time Table of Consultation Point of Discussion Week Date Tutor Sign

Title 1 Translation of 2 Journals Discussion and 3 Summary of Journal Final Report 4

Assessment A. Paper structure : 6 7 8 9 10 B. Content : 6 7 8 9 10 C. Discussion : 6 7 8 9 10 D. References : 6 7 8 9 10

Total Point : (A+B+C+D)/4 = ______

Denpasar,

Facilitator

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Meeting of Student Representatives and Facilitators

Meeting of student representatives and facilitators will be held on the second Friday of the block period if necessary. This meeting will be organized by the planners and attended by lecturers, students group representatives and all facilitators. Meeting with the student representatives will take place at 09.00 until 10.00 am and meeting with the facilitators at 10.00 until 11.00 am. The purpose of the meeting is to evaluate the teaching learning process of the Block. Feedbacks and suggestions are welcome for improvement of the Block educational programs.

~ ASSESSMENT METHOD ~

Assessment will be carried out on the 21st day of the block period. The test will consist of 100 questions with 100 minutes provided for working. The assessment will be held at the same time for both Regular Class and English Class. The passing score requirement is  70. More detailed information or any changes that may be needed will be acknowledged at least two days before the assessment.

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LEARNING CONTENTS

LECTURE 1 DELIRIUM

(Dr. dr. RA Tuty Kuswardhani, SpPD-KGer, FINASIM, MARS)

CASE An 81-yr-old woman presented with delirium 4 days after undergoing laparoscopic colon surgery under general anesthesia. She had a history of major tobacco consumption (2 cigarette packs/day for 45 yr) and still smokes. She also had moderate hypertension and peripheral vascular disease for which she had been treated with bare metal stents in both iliac arteries and the left femoral artery 3 yr ago. Chronic medications consisted of clopidogrel (75 mg/day), simvastatin (20 mg/day), bromazepam (6 mg/day), valsartan (160 mg/day), and bisoprolol (10 mg/day). She was admitted for laparoscopic surgical treatment of sigmoid diverticulitis complicated by sigmoido-vaginal fistula. Several episodes of polymicrobial urinary tract infections had been treated with antibiotics before admission. Preoperative examination revealed satisfactory cardiopulmonary status. Blood electrolytes were normal, troponin Ic was less than 0.04 ng/ml, hemoglobin was 12.9 g/dl, and platelet count was 260 g/l. Electrocardiogram showed regular sinus rhythm, blood pressure was 168/78 mmHg, and stress-echocardiography was negative for ischemia but showed left ventricular diastolic dysfunction with left ventricular hypertrophy. Doppler ultrasound examination of the carotid arteries was normal. Clopidogrel, simvastatin, bromazepam, and bisoprolol were continued until the day of surgery, whereas valsartan was discontinued 2 days before surgery. Anesthesia was induced with propofol, sufentanil, and atracurium, and it was maintained with desflurane in O2/N2O 50:50. After an uneventful 3-h operation that consisted of sigmoidectomy, colorectal anastomosis, and ileostomy, residual neuromuscular blockade was reversed with neostigmine and atropine, the trachea was extubated, and the patient was transferred to the postanesthesia care unit (PACU) and then to the surgical ward. Postoperative analgesia consisted of intravenous propacetamol (500 mg 4 doses per day), nefopam (20 mg 3 doses per day), and morphine titration in the PACU. Patient-controlled analgesia with morphine hydrochloride (bolus = 1 mg, refractory interval = 7 min) was used during the first 48 postoperative hours. Epidural analgesia was not used in this case. On postoperative day 4, the patient experienced several episodes of confusion, logorrhea, and disorientation. Glasgow Coma Scale score was 15. Temperature was 37.2°C but had a transient peak to 38.4°C the day before. Physical examination revealed slight abdominal tenderness, diarrheic stool in the ileosotomy, and normal cardiac and pulmonary auscultation. Blood leukocytes were 10,000/ml, hemoglobin was 12.9 g/dl, blood electrolytes were normal, and computed tomographic scan revealed a 3-cm diameter fluid collection at the colorectal anastomosis. A geriatric consultant was called.

LEARNING TASK 1. How Is Delirium Diagnosed in the Postoperative Period? 2. What Is the Pathophysiology of Postoperative Delirium in the Elderly? 3. What Are the Causes of Postoperative Delirium? 4. What Was the Probable Cause of Delirium in This Case? 5. How Can Postoperative Delirium Be Treated or Prevented in Elderly Patients?

SELF ASSESMENT (STUDENT PROJECT) 1. Explain the epidemiology of delirium in older adults. 2. Describe the screening and diagnostic workup of delirium. 3. Describe a comprehensive management for persons with delirium. 18 Udayana University Faculty of Medicine, DME, 2018

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LECTURE 2 FRAILTY IN ELDERLY (dr. I Nyoman Astika, SpPD-KGer, FINASIM)

Case 1 The first case involves a very robust older man who underwent surgery and did very well. He was 75 years old, had a history of hypertension, mild congestive heart failure, and chronic knee osteoarthritis. He walked daily and lifted some weights, but had experienced increasing knee pain that slowed his activity level. He was admitted for an elective knee replacement and did very well in the postoperative period.He went home after 3 days on anticoagulation and narcotic pain medications, tolerated home physical therapy for 2 weeks, and returned close to his functional baseline within a month.

Case 2 In the second case, a man with a similar clinical history exhibited vulnerabilities to adverse outcomes following surgery that differentiated him from the first patient. This man, also 75 years old and with a history of hypertension, mild congestive heart failure, and chronic knee osteoarthritis, walked several times a week for exercise and volunteered at a hospital gift shop. He had to stop these activities because of increasing knee pain and fatigue about 2 months prior to surgery. He underwent elective knee replacement and did well in the immediate postoperative period. However, after being given narcotic pain medications, he became delirious, pulled out his foley catheter, and fell out of bed. He refused all physical therapy interventions and developed incontinence. He was eventually transferred to a subacute rehabilitation facility, where he gradually recovered over 3 weeks. He was then transferred to home and required 3 more weeks of physical therapy. After 3 months, he approached his previous functional baseline, but still described fatigue and inability to do as much as he did before.

Case 3 An obviously frail, vulnerable older man without known medical illness had a series of adverse events near the end of life. He was 83 years old and had lived alone since his wife died 5 years earlier. He had a history of hypertension, compensated congestive heart failure, and a fall with fracture of left hip 3 years earlier. He did most of his own activities of daily living, but was not able to get out in the community anymore because of fatigue and fear of falling. He had minimal activity and almost no planned exercise. He was found on the floor by a neighbor when it was noticed that he had not been outdoors to get his morning newspaper. The patient reported that he had simply fallen and was too weak to get up. In the emergency room and subsequent hospitalization, the physicians identified diffuse muscular weakness and elicited a history of a 10 pound weight loss over a year, but found no other laboratory or obvious medical etiology for his decline and weakness. The patient was transferred to subacute rehabilitation and gradually improved to the point where he could ambulate 20 feet with a walker. However, he was not able to care for himself as he did previously, and was therefore transferred to an assisted living facility. He died there, of undefined causes, 3 months later.

Case 4 Mr. Nilsson is an 83 years old NHR (Nursing Home Residents ) with late-stage dementia. Because of the cognitive decline he has difficulties with memory, understanding others and expressing himself. He is also diagnosed with COPD and pulmonary cancer. He is on daily medication with sedatives, antidepressants and analgesics (paracetamol) three times a day. He is vaccinated against influenza and pneumonia. He has a severe physical disability and can only manage to eat by himself and tell when he needs the toilet. He often reacts 19 Udayana University Faculty of Medicine, DME, 2018

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aggressively when the nursing assistant (NA) help him with personal hygiene, eating, or toileting. Sometimes he is apathetic, probably due to mild depression. His baseline body temperature is 36.6°C in the ear and 36.9°C rectally. One morning nursing assistants (NA) observed that Mr. Nilsson was behaving differently, e.g. he did not feel well, expressed as “expression in the eyes”, less appetite, lethargy and general signs of illness. They also observed respiratory symptoms. The NA continued to report about his changed condition for the next few days to the registered nurse (RN), who noted that he might have a cold but took no further action as he did not have a fever. His ear temperature was 37.6°C in the morning and 36.8°C in the afternoon the first day, and 37.2°C in the morning and 37.3°C in the evening the second day. Day six Mr. Nilsson’s temperature is 38.1°C and hence the RN informs the general practitioner (GP), who takes no further action. There is no more RN documentation about his condition until day 16, when the RN order paracetamol due to increased body temperature (38.9°C). The next morning the nurse contacts the GP who prescribes antibiotics due to suspected pneumonia. The condition worsens and Mr. Nilsson dies on day 24.

Learning Task 1. What is the biological difeferences between the case no 1-3? 2. What is the symptoms of frailty that were found in case no 3? 3. What is risk factors for infection in case no 4? 4. What is the atypical signs of infection that can delay the diagnosis and treatment in the case no 4?

Self Assesment 1. Describe the definition and theory of frailty! 2. Describe the cycle of frailty! 3. Describe treatment and prevention of frailty!

LECTURE 3 INSTABILITY AND FALLS (dr. Ni Ketut Rai Purnami, Sp.PD)

CASE Mr. K, 76 years old is accompanied by his family to a primary health care unit with a complaint of fall. Mr. K experienced fall around 04.00am. When he wanted to go to toilet to defecate, he slipped because of slippery rug. Mr. K said that his feces’ colour was blackish and watery like asphalt 3-4 times a day in the last 2 days. Mr. K cannot be back to stand up when he fell and felt painful on his right hip. Mr. K had a history of Osteoarthritis on his right and left knee joint in the last 1 year, therefore he felt disturbed when walking. The painful was worse in the last 10 days and he bought a medicine in a drug store to relieve the pain.

LEARNING TASK 1. What is the possible problem which is experienced by Mr. K? 2. Mention the risk factors of Falls on Mr. K 3. How are the management principles of the problem and how are the efforts to prevent the Fall at the later time?

SELF ASSESMENT (STUDENT PROJECT) 1. Describe the prevalence of falls in older adults. 2. Describe predisposing risk factors for falls among older adults. 3. Describe a plan of care for a patient with history of recurrent falls.

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LECTURE 4 IMOBILISASI (dr. Ida Bagus Putu Putrawan, Sp.PD, FINASIM)

CASE Pasien Laki-laki, 85 tahun, datang ke unit gawat darurat Rumah Sakit, dibawa oleh keluarganya karena beberapa hari ini pasien dikeluhkan batuk batuk dan sulit mengeluarkan dahak. Pasien juga dikeluhkan panas badan sejak 2 hari yang lalu. Lima tahun yang lalu pasien mengalami stroke non hemorhagic, dan lumpuh di kaki kanan serta lemah di tangan kanan. Setelah kejadian itu, pasien sama sekali tidak bisa bergerak dari tempat tidur. Pasien makan, minum serta buang air besar dan buang air kecil di tempat tidur. Sejak 3 bulan yang lalu, kondisi pasien semakin lemah, badannya semakin kurus, nafsu makan berkurang, serta otot kakinya mengecil. Kulit di bokong belakang mulai kemerahan sejak 6 bulan lalu, dan 3 bulan lalu mulai ditemukan luka yang semakin membesar di bokong kanan dan kiri, warna kehitaman dan bernanah. Riwayat Penyakit dahulu: Diabetes melitus, hipertensi, dislipidemia. Saat diperiksa di UGD, ditemukan kesan umum sakit berat, status gizi: malnutrisi, serta ditemukan suara nafas Bronkovesikuler pada paru kanan, Rhonchi basah kasar pada paru- paru kanan. Regio pelvis posterior ditemukan luka menganga sampai kelihatan tulang dasar panggul, jaringan nekrotik, serta pus di dasar ulkus. Pada pemeriksaan penunjang ditemukan peningkatan leukosit (dominan segmen neutrofil 80%). Dokter jaga UGD kemudian menghubungi dokter konsultan Geriatri untuk penatalaksanaan kasus ini.

LEARNING TASK 1. Sebutkan komplikasi Imobilisasi yang ditemukan pada pasien ini? 2. Jelaskan pathogenesis kedua komplikasi yang ditemukan pada kasus di atas? 3. Bagaimana penatalaksanaan kasus Imobilisasi pada usia lanjut? 4. Jelaskan tools screening yang bisa digunakan untuk menilai kemungkinan pasien tersebut di atas mengalami komplikasi VTE?

SELF ASSESMENT (STUDENT PROJECT) 1. Explain the Pathogenesis of Immobilization and Its Complication in elderly. 2. Describe a comprehensive managemenT for persons with immobilization

LECTURE 5 POLYPHARMACY IN ELDERLY (dr. I Gusti Putu Suka Aryana, SpPD-KGer, FINASIM)

CASE You are seeing Ms. Clark for the fi rst time. She is an 88-year-old woman who lives alone. She has long-standing hypertension, bipolar disorder, and a seizure disorder, all of which have been well controlled for years with verapamil 80 mg po three times a day, lithium 300 mg po three times a day, and phenytoin 300 mg nightly. Over the past few years she has been eating poorly. Recently she has been feeling drowsy and woozy, a bit confused, with increased urination, nausea, and diffi culty walking. She fell yesterday without loss of consciousness or head trauma. Ms. Clark’s exam is remarkable for a weight of 89 lb (40 kg), blood pressure of 110/60 mmHg lying down and 90/60 mmHg standing, nystagmus,

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an ataxic gait, and fi ne hand tremors. Laboratory results are all within normal limits except for blood urea nitrogen of 6 mg/dL, an albumin of 2.5 g/dL, and a white blood count (WBC) of 11,000. Creatinine is 1.0 mg/dL. Urine reveals no evidence of urinary tract infection (UTI). Lithium level is 1.5 (target 0.6 to 1.2 mEq/L) and phenytoin level is 15 (target 10–20).

LEARNING TASK 1. Is it possible that Ms. Clark’s symptoms are due to her medications, even though she is taking them as prescribed? 2. Does Ms. Clark appear to be clinically phenytoin toxic? Is her blood drug level above normal? How about her free drug level? 3. Which of the medications Ms. Clark is taking has much greater bioavailability in older than younger adults? How would this affect the serum levels of the drug and the patient’s response to the drug? 4. Which of these medications is primarily renally excreted? What is Ms. Clark’s estimated creatinine clearance?

SELF ASSESSMENT 1. Describe of definition of polypharmacy. 2. Describe of change of pharmaco dynamic related to aging process 3. Describe of change of pharmacokinetic related to aging process

LECTURE 6A COGNITIVE IMPAIRMENT IN ELDERLY (dr. AAA Meidiary Sp.S)

CASE Seorang wanita usia 60 tahun suku Bali, agama Hindu mengikuti posyandu lansia di puskesmas. Penderita mengeluh sering lupa.

LEARNING TASK 1. Apa saja yang perlu anda tanyakan pada penderita maupun keluarganya? 2. Pemeriksaan fisik apa saja yang perlu anda lakukan pada penderita ini? 3. Untuk menentukan fungsi kognisi penderita tersebut, apa yang harus dikerjakan? 4. Pemeriksaan penunjang apa yang anda usulkan? 5. Apa dugaan diagnosis Jika ADL dan IADl penderita baik , tetapi hasil MMSE 23? 6. Apa pilihan penatalaksanan non farmakologi?

SELF ASSESSMENT (STUDENT PROJECT) 1. Jelaskan apa yang dimaksud dengan: - Gangguan kognitif pada penuaan normal - Mild kognitf impairment - Demensia 2. Jelaskan perbedaan antara gangguan kogitif pada penuaan normal, mild kognitif impairment dan demensia! 3. Jelaskan tahap-tahap diagnosis gangguan kognitif pada lansia! 4. Jelaskan Penatalaksanaan gangguan kognitif pada lansia!

LECTURE 6B PSYCHIATRIC DISORDERS IN ELDERLY 22 Udayana University Faculty of Medicine, DME, 2018

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(dr. Ni Ketut Sri Diniari, Sp.KJ)

Psychiatric disorders common among the elderly, have consequences that include social deprivation, poor quality of life, cognitive decline, disability, increased risk for somatic disorders, suicide, and increased nonsuicidal mortality. Recent research has shown that depression, anxiety disorders, and psychosis are more common than previously supposed in elderly populations without dementia. Cognitive function is often decreased in people with depression, anxiety disorders, and psychosis, but whether these disorders are risk factors for dementia is unclear. Psychiatric disorders among the elderly include: Cognitive impairment, Depression disorder, Anxiety disorders, Somatization, Psychotic disorders, adjustment disorder, sleep disorders, etc. It is important not only to identify and treat specific psychiatric disorders but also to provide education, support, and preventive interventions to strengthen older people and their families in managing common stresses of aging.

CASE Mr. K is a 78 years old, complained of by the children daydreaming after his wife's death one month ago. He often complained of headaches, body weakness, loss of appetite, and difficulty sleeping. Everyday he lived alone and did not want to burden their children. The results of cognitive examination (MMSE) normal limits, just decrease in the short-term memory. Before the sick he could perform daily activities, but this time look sad and dreamy, and weak to move. He had the personality of a perfectionist. The results of the laboratory there was an mild increase in blood sugar (BS) levels with a value of 215 mg / L. Examination of Geriatric Depression Scale (GDS): 20. Physical examination and other investigations: within normal limits.

LEARNING TASK 1. How interviews are required to get sign and symptom psychiatric disorder? 2. What mental status examination are used to diagnose this case? 3. What deferesial diagnosis of this case? 4. What the possible diagnosis of this case? 5. Describe treatment is given for Mr. K? 6. What kind of psychotherapy for his Care Giver?

SELF ASSESSMENT 1. What is the difference between Depression, Dementia and Delirium? 2. Explain the risk factor for elders with major depression! 3. What a risk factor for suicide in patients with major depression? 4. What cause of anxiety in elderly? 5. Decribe about Bereavement in elderly! 6. What kind of non-pharmacological therapies that can be given to the elderly? 7. Could you explain farmakotherapy for sleep disorder for elderly? 8. Describe about sleep hygiene for elderly!

LECTURE 7 PRINCIPLES OF REHABILITATION IN ELDERLY (dr. Dedi Silakarma, Sp.KFR)

Case A 70 years man came to the rehabilitation clinic with pain on his right knee since five years ago. He felt pain on his right knee when she was walking on the sidewalk or bending his knee more than 90 degrees. He has used a cane for reducing the pain.

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He also complained to the doctor about the weakness on the right side limb. He still able elevate his right limb but not too optimal of its range of motion. He also can walk but with abnormal gait. He cannot speak well.

The Past History  One year ago he hospitalized caused by cardiac disease and hypertension.

Physical Examination  Paretic of VII & XII cranial nerve right side.  Improvement of Motoric Aphasia  Hemiparetic right side (flaccid) Manual Muscle Testing (MMT)

3333 5555 3333 5555

Knee : No swollen, Crepitation on both side, positive Patellar grinding test on both side. Range of motion (ROM) : 0-90 degrees/0-135 degrees. MMT of quadriceps muscles 3/5 ; hamstring muscles 3/5.

Learning Task 1. Can explain about principles and rehabilitation for the elderly 2. Know about disease, impairment, disability, handicap 3. Know about rehabilitation team for the elderly and can explain what are jobs at each. 4. Know about the equipment in rehabilitation should be used appropriately to provide the best benefit & safety 5. Know about rehabilitation for common geriatric problem and treatment 6. Understand about the ultimate goal of rehabilitation in elderly

Self Assessment (Student Project) 1. Based on the case, what are the diagnose and rehabilitation program for that patient? 2. Which one of the equipment in geriatric rehabilitation should be used appropriately with this case?

Right/ Wrong 1. The proper cane using for this patient is on the right hand. 2. The proper modality for reducing the pain for this case is icing therapy. 3. Most of the functional recovery occurs in the first 1 month after a stroke. 4. Most of the speech recovery occurs in the first 6 month after a stroke.

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TOPIC 1 Introduction and general perspective of Travel Medicine

ABSTRACT

Introduction and general perspective of Travel Medicine Travel Medicine is the branch of medicine that deals with the prevention and management of health problems of international travelers. It is concerned with both prevention and management of illness related to travel Why TM ? • Increased trend of travelers : many more people are travel abroad • Scope has largely evolved in response to changing of travel trend, such as : • The reason for travel and types of travel has become much more diverse. • Organized package tour remain popular, but many traveler are becoming more adventurous and choose to backpack out with ‘tourist‘ areas, go on expedition into remote areas sometime in several countries and work as volunteers for prolonged period. • Travel for business take a common place. • In addition, potentially vulnerable groups of people such as the very young, the elderly, pregnant women and those with underlying medical problems or disabilities and immune compromized are traveling more than ever before. As a result of these changes, more people need information, more advise and more prophylactic prior and during travel Important component of TM includes not only vaccination and prophylaxis for malaria, but also advise on accident prevention, sexual health and guidance on contraception, safety food and water, hygiene and other precautions History of TM ? The disciplines of TM evolved initially from infectious disease, tropical and preventive medicine and historically from quarantine and international health regulations, the subject encompasses the whole range of clinical and preventive medicine; this includes care of the travelers with special needs such as, children, the elderly, pregnant women, and person with underlying medical problems: cardiovascular, respiratory, kidney, GIT, metabolic , neurological, malignant, HIV and behavioral dis.

TM concerned with both prevention and management of illness related to travel Illness may result from exposure to infection, accidents, psychological upset, environmental hazards and political unrest The specialty of TM therefore is truly interdisciplinary and international specialty involving numerous disciplines including , tropical medicine, infectious diseases, microbiology, public health and nursing. Continued surveillance of illness and disease both in the host countries and returning travelers is necessary to allow sound risk assessment to be made for intending travelers. This is a crucial area for development within the specialty Dissemination of information regarding real or potential risks can both prevent illness and increase detection of illness in travelers who have returned to their country of origin. This may have important public health implications when considering secondary cases or outbreaks as a results of travelers returning with infections

Risks in Travel Risk in travel can be non communicable and communicable disease 25 Udayana University Faculty of Medicine, DME, 2018

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Non-Communicable disease : • Aircraft travel, reduced O2, pressure and humidity • Motion sickness • Jet Lag • DVT’s and immobility • Altitude • Heat/cold/humidity • Sunburn • Water safety • Accidents and Injuries • Animals and Insects • Accidents, vehicles, marine • Snakes, (vipers, cobras and kraits ) • Marine stings

There are many potential diseases spread via : • Food and water • Insect vectors • Soil and water • Sexual contact, Body-fluid exposures • Animals

LEARNING TASK

Case: A 28 year old woman from Swiss, come to you and ask your advise due to her plan to go to Lovina to join a Yoga training program for 4 weeks

Learning Task : 1. What kind of advise do she need ? 2. What other information do you need to know before giving her advice? 3. Does she need vaccination against rabies? And what other immunization does she need? 4. What does she need to do if 2 weeks post travels she suffering from fever?

Self Assessment : 1. Describe what is the unique of travel medicine, and what kind of specialist do involved in Travel Medicine! 2. Describe why traveler has more risks than non-traveler! 3. Describe type of traveler and their common risks! 4. Describe what Pretravel consultation is! 5. Describe what is the important of post travel consultation!

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TOPIC 2 Traveler’s diarrhea

ABSTRACT Traveler’s diarrhea (TD) is the most common travel-related health problem that affects up to half of travelers during their first 2 weeks abroad. A case of TD is described as the sudden onset of loose, watery stools associated with abdominal pain, fever or tenesmus. Fever occurs commonly and blood is noted in stools rarely. Nausea and vomiting are also common in the first few hours, adding to the discomfort and water loss. TD usually presents as an acute illness, resolving completely in less than a week. Bacteria are the most common cause of TD and ETEC (enterotoxigenic E. coli) is the most common bacterial cause. Salmonella, Shigella and campylobacter make up the majority of remaining bacterial pathogens. Host factors such as age, pre-existing immunity, underlying medical conditions and genetic factors play a role in susceptibility to TD. Effective pre-travel counseling may motivate some travelers to avoid risky food and drink, which may in turn reduce diarrheal incidence. Since most TD is bacterial in origin, traveling with appropriate antibiotics for treatment and prevention is also important.

Learning Task : Traveler group from Netherland come to emergency dept of private hospital with diarrhea for 2 days, diarrhea more than 10 times for half day, stools without blood and slym, water only. Nausea, vomiting and abdominal pain was found. They have history fast food dinner in restaurant. 1. What is the possibility a cause of diarrhea in this ase? 2. How the management and treatment must you done in this case? 3. What is your suggest to travelers for prevention traveler diarrhea ?

Self Assessment 1. Describe etiology of Traveler’s Diarrhea 2. Describe pathogenesis of Traveler’s Diarrhea 3. Describe clinical pattern of Traveler’s Diarrhea 4. Plan for management of of Traveler’s Diarrhea 5. Describe complication 6. t may happen 7. Describe prevention of Traveler’s Diarrhea

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TOPIC 3 Emerging & Re-emerging Diseases Related Worldwide Travelling

ABSTRACT

Emerging Diseases Related Worldwide Travelling It is believed that increased global travel is the reason for the recent resurgence of many infectious diseases in the world. International movement of individuals, populations, and products is one of the major factors associated with the emergence and reemergence of infectious diseases as the pace of global travel and commerce increases rapidly. The number of people traveling internationally is increasing every year, and more people are taking trips to remote parts of the world, which often have unfamiliar health problems as well as underdeveloped health care services. Many travelers are also unaware of potential hazards in different parts of the world and do not take the necessary precautions, such as getting necessary vaccines or taking preventive medicine. Travel can be associated with disease emergence because (1) the disease arises in an area of heavy tourism, (2) tourists may be at heightened risk because of their activities, or (3) because they can act as vectors to transport the agent to new areas. Many of the newly discovered infections have actually been in existence for a long time, but doctors have not seen them in areas where new outbreaks occur. With people's ability today to travel anywhere in the world within 36 hours or less, formerly little-known infections are picked up and rapidly spread to areas where they previously did not exist.

Case : A family from Indonesia has plan a vacation to Hong Kong and China mainland next week. They came to you to get some advices.

Learning Task: 1. Explain any diseases in Hong Kong and China mainland that needs to be alerted by this family! 2. Describe the each way transmission of that diseases! 3. Explain to that family the preventive measures so they can prevent the diseases! 4. How the SARS and AVIAN FLU Disease can spread worldwide? 5. Describe the transmission mode of Legionnaire’s disease! 6. Describe the relationship between the Tourism and Legionnaire’s disease! 7. Explain the mechanism of MERS-Cov spread from animals to infect humans through! 8. Explain how to prevent MERS-Cov infection! 9. Describe the clinical signs and symptoms of Ebola virus infection! 10. Explain the Ebola virus transmission!

Self-assessment: 1. What is the agent of Legionnaire’s disease? 2. What is their habitat? 3. Describe the clinical signs and symptoms of Legionnaire's disease! 4. Describe the clinical signs and symptoms of MERS-Cov infection! 5. What is the characteristic of Ebola virus?

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TOPIC 4

Air travel and thromboembolism

ABSTRACT

Air travel and thromoembolism DVT and thromboembolism have long been proposed as possible complication of air travel. Pulmonary embolism (PE) has been suggested as a culprit in deaths related to air travel, although evidence linking air travel to DVT has been somewhat elusive. Many studies found that 18% of sudden deaths among long distance travelers were attributable to PE.

Case : A 55 years old man, American, fat, smoker, complain his left lower limb is swelling, painful, cramp and pain on pressure. He just arrived in Denpasar after has 10 hours flight from United States.

Learning Task: 1. What other anamnesis should be added to this case? 2. What kind of physical examination should be focused for this patient ? 3. What kind of other supported examinations suggested for the patient ? 4. What is the possible diagnose for this case ?

Self assessment : 1. Describe the predisposition factors for venous thromboembolism related to the air travel 2. Describe the mechanism of venous thromboembolism related to the air travel 3. Describe how to prevent venous thromboembolism during long flight trip

TOPIC 5 High altitude illness

ABSTRACT

High altitude illness High altitude medicine is one of medical science that discuss human adaptation that occur in high altitude environment. It is importance for us to study this topic because some people travelling to high area, expedition to the mountain, and excellent physiology research in high altitude. Understanding human adaptation to high altitude provide us importance information needed for planning the trip and avoid many disease that may occur. Aclimatization is the key point during high altitude travelling. Failure in this process will affect our body condition manifest as several high altitude problems. Acute Mountain Sickness (AMS) is the most common syndrome occur in high altitude, followed by high

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altitude cerebral edema, and hipoxic hipoksia. As a medical doctor it is importance to understand this topic, especially in region that choosen as traveller destination.

Learning Task 1. Explain the basic physiology process that occur in our body system while travelling to high altitude environtment! 2. What is acclimatization? Explain the physiological process that occur in acclimatization? 3. If you want to climb 18000 feet mountain, how can you plan your trip? 4. Mention the altitude illness that may occur in high altitude and explain the prevention and treatment for these illness!

TOPIC 6

Medical Evacuation

ABSTRACT

Medical Evacuation Transport pasien dalam keadaan kritis mempunyai resiko pada pasien sehingga merupakan tantangan yang sangat besar bagi para klinisi. Alasan untukmelakukan transport pada pasien adalah untuk mendapatkan pelayanankesehatan tambahan, diagnostik atau terapiutik yang lebih canggih tidaktersedia. Pasien dalam keadaan kritis memiliki sedikit atau tidak samasekali cadangan fisiologis tubuhnya. Memindahkan pasien seperti tersebut menimbulkan suatu masalah tersendiri dan dapat menimbulkan suatu perubahan fisiologis yang merugikan dan dapat mengancam keselamatan pasien saat transportasi. Sehingga transport pasien kritis harus dilakukan dengan persiapan yang matang dan perhatian yang seksama dan detail pada hal-hal yang harus diperhatikan. Guideline atau pedoman sudah tersedia dan prinsip-prinsip utama dalam melakukan transport pasien kritis meliputi 5P: 1. Planning (perencanaan) 2. Personnel (jumlah yang cukup disertai dengan kemampuan yang sudah terstandarisir dalam evakuasi pasien kritis). 3. Properties (alat yang dipakai dalam transportasi) 4. Procedures (alat yang dipakai mengukur kestabilan keadaan pasien sebelum dan saat diberangkatkan) 5. Passage (pilihan rute dan tehnik transport).

Learning Task :

1. What is the key principle in transporting crititical ill patient ? 2. Transportation of critical ill patient are catagorized as ? 3. What is the outside hospital environment transportation ? 4. Describe the International transportation distance criteria 5. After completing the evacuation duty, each member of medical team should have approximately how many hours rest before on duty again, Please Describe

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TOPIC 7 Air travel and Fit to Fly

ABSTRACT

Air travel and Fit to Fly Each year, approximately 3.3 billion people are estimated to travel by aircraft. Furthermore, the passenger numbers are expected to reach 7.3 billion by 2034, as predicted by the International Air Transport Association (IATA). While many of these people have medical conditions that pose no risk to themselves or to other passengers, there are some medical conditions that should preclude flying or require pre-flight evaluation. Most airlines have medical passenger policies to determine fitness to fly, in order to minimize the risk of disruption to other passengers and crew, the likelihood of the aircraft diversion, and risks to the passenger’s safety. A passenger medical information form is commonly used, which asks details from both patient and doctor, about diagnosis, prognosis, desired supplemental oxygen, food, etc. Reduced oxygen tension, pressure changes and reduced space and mobility are the principal effects on the health of the air-traveler. Modern commercial airliners fly with a cabin altitude of between 4000 and 8000 feet (1200 and 2400 m) when at cruising altitude (30.000-39.000 feet), which means a reduction in ambient pressure of the order of 20% compared with sea level and a consequent reduction in blood oxygen saturation of about 10%. The cabin air is relatively dry, and the limited room available in the non- premium cabin may be a factor to be considered. In determining the passenger’s fitness to fly, a basic knowledge of aviation physiology and physics can be applied to the pathology. Any trapped gas will expand in volume by up to 30% during flight, and consideration must be given to the effects of the relative hypoxia encountered at a cabin altitude of 8000 feet (2400 m) above mean sea level.

Learning Task : 1. A 26-year-old woman at 29 weeks estimated gestational age of her first pregnancy presents for a consultation. She has a history of pain and spotting or light bleeding during the first trimester that resolved. She plans to fly from Denpasar to Amsterdam which takes about 18 hours including 1 transit. A. Explain how air travel affects pregnancy in general! B. Explain general considerations for pregnant women travelling by aircraft? C. On the above case, what are your considerations and advice? Is she fit to fly? 2. A 60-year-old man with type 2 diabetes mellitus plans to travel by aircraft westward. He is taking medication to control the diabetes regularly, under physician supervision. The flight will take approximately 18 hours including transit. A. Explain how long-haul westward air travel will affect this patient! B. What are your considerations and advice? Is he fit to fly? 3. A 40-year-old man with a history of epilepsy presents for a travel consultation. He just recently experienced a short episode of seizure, about 1 week ago, at a hotel where he stays. However, he currently is under control with medication from a local neurologist. He plans to go back to his country and will take an approximately 9-hour flight. A. Explain how air travel affects this patient! B. What are your considerations and advice in this case? When will he be fit to fly?

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TOPIC 8 Immunization and Chemoprophylaxis to prevent travel-related illness

ABSTRACT Immunization to prevent travel-related illness Pre-travel immunization divide into three categories : recommended as part of routine health maintenance irrespective of international travel; may be required into a country; and recommended because of risk during travel.

Chemoprophylaxis for travel related illness (Malaria) Malaria is one of the most severe infectious diseases of travelers. Nearly all cases in travelers are preventable. Prevention and best management of malaria include awareness of risk, avoidance of mosquito bites, compliance with chemoprophylaxis, and prompt diagnosis in the event of a febrile illness either during or on return from travel.

Case 1 : A 30 years old woman, Australian, Laboratory’s employee, came to Sanglah Hospital. She plans to travel to Papua to collect blood sample for Malaria study. She wants to have immunization to prevent infections transmitted by blood or body fluid. Learning Tasks 1. What kind of immunizations needed by this patient ? 2. What examination are required for this patients related with immunization? 3. How about immunization schedule? 4. How to evaluate response related with immunization ?

Case 2 Male - 65 years old , from Bali plans to go to worship Tirta Yatra to the Ganges river in India . The man has a history of diabetes mellitus and chronic obstructive lung disease . Learning Tasks 1. What the vaccinations are prioritized on the case 2. What kind of immunizations needed by this patient ? 3. What examination are required for this patients related with immunization? 4. How about immunization schedule? 5. How to evaluate response related with immunization ?

Case 3. male, bali, 78 yrs, will going to Mecca for pilgrimage. Learning tasks 1. What the Vaccinations required for pilgrims who will perform the pilgrimage 2. What examination are required for this patients related with immunization? 3. How about immunization schedule? 4. How to evaluate response related with immunization ?

Case 4: A 30 years old man, American, plan to go on vacation to Komodo island, West Manggarai, NTT from Denpasar for 2 weeks. He came to Sanglah Hospital to get advice and prophylaxis for malaria while in NTT. Learning Tasks: 1. What kind of chemophrophylaxis given for this case? 32 Udayana University Faculty of Medicine, DME, 2018

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2. How about the schedule of the chemoprophylaxis? 3. What kind of clinical condition should be evaluate related to this chemophrophylaxis?

Self Assessment: 1. Describe type, method, and schedule of routine immunization for travelers 2. Describe type, method, and schedule of required immunization for travelers 3. Describe type, method, and schedule of recomended immunization for travelers 4. Describe Malaria prophlaxis for areas of chloroquin sensitives 5. Describe Malaria prophlaxis for areas of chloroquin resistant 6. Describe Malaria prophlaxis for areas of Mefloquine Resistant

TOPIC 9 Heat exhaustion and heat stroke

ABSTRACT

Heat exhaustion and heat stroke Heatstroke (HS) is the most serious of the syndrome associated with excess body heat. It is defined as condition in which body temperature is elevated to such level that body tissue damage occurs, giving rise to a characteristic multiorgan clinical and pathological syndrome. The severity depends on the degree of hyperthermia and its duration. Heatstroke is a medical emergency that can be fatal if not diagnosed and treated promptly. The literature differentiates between two entities of heatstroke: exertional heatstroke (EHS) and classic heatstroke. The presentation of EHS is usually acute, the prodorme, occurring in 25% of casualties, consists dizziness, weakness, nausea, confusion, disorientation, drowsiness and irrational behavior, this may last from minutes to hour. ES should be the working hypothesis in any cases of collapse during exercise or immediately, apparently healthy individual whose body core temperature is high and who presents with neurological sign (from aggressiveness to coma). Prolonged exertion, warm climate, very high body core temperature and dry skin are typically linked with EHS. Treatment of HS is supportive. Cooling should be initiated vigorously immediately upon collapse. The most practical and efficient method of cooling is the use of large quantities of tap water, which is readily available. No drug is effective in reducing body temperature.

Learning task Man, 24 years old, was referred to hospital with collapse and seizure. He have history of expose to high temperature when exercise. His body temperature was 41 degree Celcius and dry skin. 1. What kind of heat related illness in this case? 2. How the management must you done in this case? 3. How we can prevention heat related illness in traveler?

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TOPIC 10 Near drowning

ABSTRACT

Near drowning Traditionally, the terminology used to describe submersion injuries has been confusing and impractical. In the past, drowning referred to death within 24 hours of suffocation from submersion in a liquid, whereas near-drowning described victims who survived at least 24 hours past the initial event regardless of the outcome. In 2005, the World Health Organization (WHO) published a new policy defining drowning in an attempt to clarify documentation and better track submersion injuries worldwide. Drowning was defined as “the process of experiencing respiratory impairment from submersion/immersion in liquid.” Furthermore, the WHO policy states that “drowning outcomes should be classified as: death, morbidity, and no morbidity. … Use of the terms wet, dry, active, passive, silent, and secondary drowning should no longer be used.” As such, the term near-drowning should not be used, and the association of the term drowning with a fatal outcome should be abandoned.

Risk Factors Ethanol consumption in proximity with water is a major risk factor for submersion injury or death. Acute ethanol intoxication may be a contributing factor in 30 to 50% of drownings among adults and adolescents. In one study of boating fatalities, most of which were due to drowning, an association between blood ethanol concentration and risk of death from drowning while using watercraft was established Odds ratios of fatality from drowning followed a trend from 2.8 (95% confidence interval [CI] 1.6, 4.8) for a blood ethanol concentration (BEC) of 1 to 49 mg/dL to 37.4 (95% CI 16.8, 83.0) for a BEC of 150 mg/dL or greater compared with sober case controls.

Pathophysiology Unexpected submersion triggers breath-holding, panic, and a struggle to surface. Air hunger and hypoxia develop, and the victim begins to swallow water. As breath-holding is overcome, involuntary gasps result in aspiration The quantity of fluid aspirated, rather than the composition, determines subsequent pulmonary derangement.

Sign & Symptom Many submersion injuries are witnessed. Toddler drownings are an important exception, however, often occurring because of a lapse in supervision. Occasionally, the history of coughing, choking, or vomiting in a patient found near a body of water suggests the diagnosis. Signs of pulmonary injury may be obvious in a submersion victim who is hypoxic, cyanotic, and in obvious respiratory distress or arrest. More subtle clues, such as increased respiratory rate and audible rhonchi, rales, or wheezes, should alert the clinician to evolving respiratory compromise. Submersion victims swallow a significantly greater volume of water than is aspirated, and gastric distention from positive-pressure ventilation during rescue is common. As a result, 60% of patients vomit after a submersion event. Aspiration of gastric contents greatly compounds the degree of pulmonary injury and increases the likelihood that acute respiratory distress syndrome will ensue. In addition, aspiration of particulate contaminants such as mud, sewage, and bacteria may obstruct the smaller bronchi and bronchioles and greatly increase the risk of infection both bacterial and fungal in nature.

Prognostic

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Many factors may help predict patients who will survive a submersion injury neurologically intact. Submersion victims who arrive in the emergency department alert with normal hemodynamics are unlikely to experience neurologic impairment. Circumstantial variables that portend a poor outcome include victim age younger than 3 years, submersion for longer than 5 minutes, and initiation of cardiopulmonary resuscitation (CPR) more than 10 minutes after rescue. With the exception of victim age, however, such measurements are generally either unknown or inaccurately estimated at the time of a patient's arrival in the emergency department. Objective findings on emergency department arrival that are associated with an unfavorable prognosis include hypothermia, severe acidosis, unreactive pupils, a Glasgow Coma Scale score of 3, and asystole or the need for ongoing CPR. Neurologically intact survival is reported for individual patients even with several of these factors present, and none of several proposed scoring systems using combinations of these variables shows 100% predictive power

Case : A Group of teenagers was sweeming at the lake, when one of the boys failed to surface after diving off a platform. He was quickly found and rescued by another swimmer from the lake bottom. The patient was noted to be apneic and cardiopulmonary resuscitation (CPR) was initiated by one of bystanders. After the paramedics arrived, the patient was noted to have spontaneous shallow breathing, a weak palpable pulse and glasgow coma scale (GCS) score of 7 (eyes 1, verbal 2, motor 4). The paramedics intubated the patient and transported him to emergency department (ED). In the ED, the patient has an initial pulse of 70 beats perminute, blood pressure of 110/70 mmhg, spontaneous respiratory rate of 12 breaths perminute, temperature of 35,6°C, GCS score of 6 (eyes 1, verbal 1, motor 4) and oxygen saturation of 92% on 100% FiO2.

Learning Task 1. What are the complications associated with this condition? 2. What is the best treatment for this patient?

Self Assesment 1. Describe the pathophysiology of drowning injury 2. Describe the risk factor of drowning injury 3. Describe symptom and sign of drowning injury 4. Describe prognostic factor of drowning injury 5. Describe management patient or victim of drowning injury 6. Describe differential studies of drowning injury 7. Describe preventive efforts of drowning injury

TOPIC 11 Diving Decompression Syndrome

ABSTRACT

Diving decompression syndrome Decompression syndrome is the most common consequence of diving activities. Knowledge about this condition very important because of its different approach and management.

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Case : 52 Years old Man, Germany, He did 3 dives yesterday afternoon, maximum depth 23 meters. After rapid ascent he felt chesttightness affecting difusely, mostly on left lung. It gradually worsened since the night. it’s came with concommitant numbness / tingling on shoulders and elbow. His legs felt weak so he cant walk unaided. He also felt dizzy, nausea, vomiting, left ear problem (ringing ears, ear block, ear pain) difficulty to urinate and very tired.

Learning Task : 1. What is the possible diagnosis for this Patient? 2. What is the first aid should recommended for this patient? 3. What is the treatment should recommended for this patient?

Self assessment 1. Describe the pathogenesis of decompression syndromes ! 2. Describe the clinical sign of decompression syndromes ! 3. Describe the treatment of decompression syndromes ! 4. Describe the preventions of decompression syndromes !

TOPIC 12 Animal Bite

ABSTRACT

Animal Bite Rabies, Herpes B and envenoming are the diseases that result from bites by rabid mammals or bites and stings by venomous animals, especially snakes and scorpions. In all cases, appropriate early treatment, including therapeutic anti-sera, can prevent life- threatening systemic spread of the virus or venom toxins. Introduction In recent years, the growth of the adventure travel market in particular eco-tourism, extreme dive and wilderness safari has increased opportunities for travelers to encounter dangerous species. For travelers to remote destinations pre-travel safety education should be extended to include first aid for bite and sting injuries and potentially, provisioning of standby antibiotics for prophylaxis of high-risk wounds Mammals Bite or Scratch Wounds Animal bites present a risk for rabies, herpes B, tetanus and other bacterial infections. Animals’ saliva can be so heavily contaminated. Rabies is present on all continents with the exception of Antartica, but more than 95% of human deaths occur in Asia and Africa. Rabies occurs in more than 150 countries and territories. Worldwide, more than 55 000 people die of rabies every year, and 40 % of people who are bitten by suspect rabid animals are children under 15 years of age.. In travelers, bite wounds are mostly causes by dogs (51%), monkeys (21%) and cats (8%). The wounds inflicted are often a combination of punctures, avulsions, abrasions and crush injuries, the last of which may not be apperent until compartment syndrome develops. Rabies virus, a rhabdovirus present in infected animal’s saliva is inoculated into the bite wound, enter peripheral nerves and spreads to the central nervous system where it causes a lethal encephalomyelitis. Fortunately the availability of efficacious and save vaccines and immunoglobulin has prevented many fatalities and almost 10 million people receive post 36 Udayana University Faculty of Medicine, DME, 2018

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exposure treatment annually after potential rabies exposure, mostly following dogs bites. In Addition, increase public and clinician awareness about the risk associated with an injury from a macaque, improved first aid after exposure, the availability of better diagnostic test, and improved antiviral therapeutics have decreased the case-fatality ratio to 20% in treated people. Before departure, travelers should have a current tetanus vaccination or documentation of having received a booster vaccination within the previous 5-10 years. Travel health provider should assess a traveler’s need for pre-exposure rabies immunization. In order to prevent infection, all wounds should be promptly cleaned with soap and water, and the wound promptly debrided, if necrotic tissue, dirt or other foreigner materials is present. Travelers who might have been expose to rabies or Herpes B should contact a reliable health care provider for advice about rabies or Herpes B post-exposure prophylaxis. Snake bites Snakebite accounts for the majority of severe envenoming in tropical developing countries. Physicians with experience treating snakebite generally agree that while elapids (cobra and kraits) account for the greatest number of deaths, vipers account for the greates number of bites. Viper venoms is rich in enzymes, which cause local pain, swelling, tissue damages, coagulopathy and for some species, damage to the kidneys, adrenals and pituitary gland. Venom from cobras may be myonecrotic, leading to devastating tissue injury; neurotoxic, leading to respiratory failure or possess mixed activity. Poisonuos snakes are hazards in many locations, although deaths from snakebites are rare. If snakebite result in intravenous injection of venom, syncope and death may occur quickly. Deaths occurring within hours usually result from paralysis of respiratory muscles following bites from kraits, mambas, coral snakes and Philippine cobra. Death after 12 hours is likely to be caused by defibrination-related hemorrhage and shock following viper bite. In developing regions, patients may suc-cumb days after the bite, due to complications such as renal failure, secondary wound infection or failure of mechanical ventilation due to power outages. A large percentage of cobra and viper bites, between 25%-40% do not result in envenoming and may be treated conservatively, while continuing to observe for delayed onset of symptoms. For extra precaution, when practical, travelers should wear heavy, ankle-high or higher boots and long pants when walking outdoors in areas possibly inhabited by venomous snakes. Travelers should be advised to seek immediate medical attention any time a bite wound breaks the skin or when snake venom is injected into their eyes or mucous membranes. Immobilization of the infected limb and application of a pressure bandage that does not restrict blood flow are recommended first aid measures while the victim is moved as quickly as possible to a medical facility. Specific anti-venoms are available for some snakes in some areas, so trying to ascertain the species of snakes that bite the victim may be critical. Insect Bites and Scorpion Stings Venom from insects can produce severe allergic reactions and lead to life-threatening anaphylactic shock. More commonly, insect bites and stings are painful and produce local reaction (redness and swelling) at the site. The most medically significant venomous arthropods belong to order Hymenopthera which include; bees, wasps and stinging ansts . Together the members of Hymenopthera account for the greatest number of stings injuries and are responsible for considerable morbidity and in some case death secondary to hypersensitivity reaction. Most Hymenopthera venom contains serotonin, histamine and in some tropical hornet species, acetylcholine. The sting injuries cause immediate pain, which tends to decrease over min 30 in the case of honeybees (Apidae) or hours in the case of large hornets (Vespidae). Honeybees have a barbed stinger. When the bee attempts to fly away, it is eviscerated, leaving the stinger and the contracting venom gland behind. When present, the stinger gland complex should be immediately removed with minimal regard to method, as even minor delays will increase the amount of venom that is delifvered. Additional care; 37 Udayana University Faculty of Medicine, DME, 2018

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washing with soap and water, verifying tetanus immunization and monitoring for infection. Oral non-steroidal antiinflammatory agent (NSAIDs) such as ibuprofen are effective in reducing pain, and swelling, but are little value after swelling is established. Oral antihistamines are effective at reducing local pruritus which appears minutes to hours after the sting injuriy. Cold pack relieve pain associated with Hymenopthera sting injuries. Treatment of hypersensitivity reactions should be initated as soon as systemic symptoms appear. The most effective therapy is prompt treatment with 1:1000 epinephrine hydrochloride (0.25-0.5 ml, subcutaneous). Patients with severe reactions are likely to need a second injection. Sting injuries that develop pain, erythema and lymphadenopathy should be treated with antibiotics with activity against Gram positive skin flora. Some spider species, such as the hobo spider (Tageneria) and violin spider group (violin or recluse spider; Loxosceles) and several tipes of wolf spider (Lycosa) possess venom capable of causing necrotic skin lesions. In the case of Loxosceles spider, necrosis may be severe. Systemic effect of Loxosceles spiders include renal failure, hepatic insufficiency and hemolysis. No FDA approved polyspecific antivenin is available for the treatment of Loxosceles envenoming and treatment remains unsatisfying and supportive. Widow spiders (Latrodectus) have a worldwide distribution and are responsible for a significant number of neurotoxic envenoming. All widow spiders are a web-dwelling species and it is a female spiders that are responsible for human bites. Widow spiders prefer to build webs near attractant for insects such as trash dump, refuse pile and latrines. Bites by widow spiders may initially be mild, however rapid onset of cramping and muscular spasms cause considerable pain. Small children are at increased risk of envenoming and a bad outcome. Highly effective antivenins against widow spider bites are produced in Australia, South Africa and USA. Scorpion are responsible for a significant number of fatalities in Central America, India, and North Africa. Most fatalities involve small children and debilitated patients. Scorpion venoms which are especially lethal in young children, release autonomic nervous system mediators causing myocardial damage, cardiac arrhythmias, pulmonary edema, shock, paralysis, muscle spasm and pancreatitis. Early administration of anti-venom is highly effective, together with intensive care support in severe cases. In addition, infectious diseases can be spread by insect bites, especially in tropical countries. Travelers are likely to be envenomed when they take a shower and step on scorpions that have fallen in to the tub. Many scorpions seek shelter in footwear or between folded clothing, leading to unfortunate encounters. Antivenin is produced against several of the more toxic species such as the Middle Eastern Leiurius and American Centruroides. In addition to antivenin , neorotoxic bites and stings may be treated with a compression bandage as for neurotoxic snake venoming. Wearing protective clothing, applying insect repellents containing DEET are important preventive measures. The general treatment include; - Ice or cold pack and sting relief swabs (applied topically) will help alleviate local pain and swelling. - Any bite or sting can become infected and should therefore be examined at regular intervals for progressive redness, swelling pain or pus drainage - Oral anti-histamines, such as diphenhydramine 25 to 50 mg every hours are helpful in relieving the itching, rash and swelling associated with many insect bites and stings - If anaphylactic shock occurs it must be treated immediately with epinephrine and antihistamines. - A specifics antidote is available for those suffering severe symptoms

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Learning task:

Case 1. Mr WS, 24 yo, a traveler, come to the emergency ward of Sanglah hospital with multiple stings on his face, neck and all of the extremities since 2 hours prior to admission when he had traveling to Alas Purwo. He complained painfulhot and icthi on the sting injuries. Local status: Face, neck and extremities: Multiple sting injuries with stingers+ redness+ swelling+ Laboratory result: Wbc: 16.67 K/ul, Neut: 8.71, Lymph: 4.43., Mono: 2.2, Eos: 1.38, Baso : 0.01, Hb: 11.9 g/dl, PLT: 165 k/ul, BS: 189 BUN,SC, GOT,GPT within normal limits

Case 2 IWP, Male 67 yo, balinese Pain on left hand since 1 day PTA after got bitten by small green snake when he cut the grass Swelling more worst and the skin become tens and pain. This makes he cant move his hand Bleeding from bite site was continuously event has tamponed Local status: Antebrachii S: black and redness, ulkus skizum ± 2 cm, edema (+), bula multipel diameter ± 2 cm with fluid inside and active bleeding +. Laboratory result: Wbc: 19.3 K/ul, Hb: 11.9 g/dl, PLT: 16.8 k/ul, PTT: 21.6, APTT: 36.9, INR: 1.9 BUN,SC, GOT,GPT, BS: within normal limmits

Questions : 1. Find key words related to this case 2. Describe condition related to key words 3. Define organ system that involved in this condition and find probably cause of the key words 4. Define differential diagnosis and other examinations to support the diagnosis 5. Describe laboratory examination to diagnose snake bite 6. Define management of this case 7. Define complication and prognosis 8. Define prevention based on individual, family, and community

Self assessment: 1. Describe pathogenesis of rabies 2. Describe diagnosis of rabies 3. Define management of animal bite or scratch wounds and how can rabies be prevented 4. To describe Three families of the dangerously venomous snakes in Indonesia 5. To describe clinical presentation spectrum of snake bite 6. Describe the clinical management of snake bite envenoming 7. Describe the clinical management of insect bite envenoming 8. Describe the clinical management of scorpion sting envenoming

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Reference 1. World Health Organisation. Rabies. Geneva: WHO, 2011. URL: http//www.who.int/ith 2. Susan E., Charles E., Daniel Fishbein, Cathleen A. Hanlon, Boonlert Lumlertdacha, Marta Guerra, et al. Human Rabies Prevention --- United States, 2008. MMWR Recommendations of the Advisory Committee on Immunization Practices. May 7, 2008 / 57(Early Release);1-26,28 3. World Health Organization. Rabies. Current strategies for human rabies pre and post- exposure prophylaxis, September 2010 4. Meslin FX, Hemachuda T, Wilde H, Gongal G. WHO Standards for Rabies Control. At The Occasion of the OIE Global Conference on Rabies Control: towards sustainable prevention at the source, Incheon Republic of Korea 7-9 September 2011 5. WHO Guide for Rabies Pre and Post –exposure prophylaxis in Humans. Department of Neglected Tropical Disease-Neglected Zoonotic Disease Team. Revised 15 Juni 2010 6. Weiss EA. A Comprehensive Guide to Wilderness and Travel Medicine. 3 rd ed. Adventure Medical Kits, 2005: 121-133

TOPIC 13

Marine Envenomation

ABSTRACT

Marine injuries and envenomations Poisoning, envenomation, and direct trauma are all possible in the marine environment. Ciguatera poisoning can result from ingestion of predatory fish that have accumulated biotoxins. Symptoms can be gastrointestinal or neurologic, or mixed. Management is mostly symptomatic. Scombroid poisoning results from ingestion of fish in which histamine-like substances have developed because of improper refrigeration. Gastrointestinal and systemic symptoms occur. Treatment is based on antihistamines. Envenomations from jellyfish are painful but rarely deadly. Household vinegar deactivates the nematocysts, and manual removal of tentacles is important. Treatment is symptomatic. Heat immersion may help with the pain. Stingrays cause localized damage and a typically severe envenomation. The venom is deactivated by heat. The stingray spine, including the venom gland, typically is difficult to remove from the victim, and radiographs may be necessary to localize the spine or fragment. Surgical débridement occasionally is needed. Direct trauma can result from contact with marine creatures. Hemorrhage and tissue damage occasionally are severe. Infections with organisms unique to the marine environment are possible; antibiotic choices are based on location and type of injury. Shark attacks, although rare, require immediate attention.

Learning Task :

1. A 45 year old female come to your clinics with complain of nausea, vomiting, and diarrhea, since 6 hours prior to the admission and 30 minutes later complain of muscle aches and hallucinations. 12 hours before she had grilled snapper for supper. What do you think happening to her? How can that happen? How do you manage the case?

2. A 31 year-old male from Canada presented to the emergency room with a hot, swollen foot. He was diving at Tulamben Beach , and got stung by a blue spotted 40 Udayana University Faculty of Medicine, DME, 2018

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stingray the day before. He felt a sharp pain to the top of his foot. He continued to dive most of the day. In the evening, his foot swelling and pain got progressively worse.What is the initial important thing to do for cases with acute stingray stung? At presentation in the ER, how do you manage this case?

3. A 28 year old female come to the emergency room with history of immediate onset of severe pain following a sting by jellyfish. She has been surfing the Tuban outer reef at that time. A friend suggested her using urine to encounter the venom, but the skin around the stung area showed "cross hatched ladder" pattern and the pain get worse. What is the assessment of this patient? How do you manage the case? What kind of complication that can be expected in severe envenomations?

Self Assessment

1. Recognize the signs and symptoms of dangerous envenomations 2. Discuss the importance of proper wound care principles when treating victims of envenomations 3. Understand the indications of antivenom therapy and the complications associated with its use 4. Review the potential pitfalls in the misdiagnosis

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Introduction Scope and Goals of Andrology (dr. Yukhi Kurniawan, Sp.And) Department of Andrology & Sexology

Abstract Andrology is defined as the branches of science and medicine dealing with reproductive functions of the male under physiological and pathological conditions (Statutes of the European Academy of Andrology). Therefore, primarily, its clinical focus is the diagnosis and therapy of male fertility disturbances. Thus, andrology is the male equivalent of gynaecology and deals with the disorders of the male reproductive organs. In some parts of the world, andrology is closely connected or even an integral part of in vitro fertilization centres. According to the definition of the World Health Organization (WHO), andrology is engaged in all aspects of male reproductive health. Following the definitions of the WHO, male reproductive health is the subject of andrology.The central topics of andrology are: (1) Infertility, (2) hypogonadism, (3) male contraception, (4) erectile dysfunction, and (5) male senescence. Most often the individual partners of a barren couple continue to consult physicians of different disciplines in order to be diagnosed and treated. For the woman it is relatively easy to find a competent physician, since gynecology is a traditional field of medicine and amply represented. It is much more difficult for the afflicted male. If he suspects problems of infertility on his part, he does not know immediately to whom he should turn. One third first consults the primary health care physician or family practitioner, one quarter turns to (his wife’s) gynecologist and the remaining patients consult urologists (Bruckert 1991) and perhaps endocrinologists. As a firm discipline of medicine andrology is established in very few countries. It is a recognized field only in Poland and Estonia; in Italy it is a speciality, practiced, however, within the frame of endocrinology. In addition, andrology is a speciality in Egypt and Indonesia. The interdependencies of male and female reproductive functions described above should provide reason enough to examine both partners simultaneously in the event of involuntary childlessness. Both partners should be examined with the same degree of thoroughness. Good medical practice requires a full anamnesis, careful physical examination followed by all necessary technical and laboratory investigations.

Learning task

Mr. Yk 29 years old and mrs. Nn 24 years old are couple. They have married 4 years ago, but never been pregnant. The wife has been examined by an Obstetrician and found no abnormalities in her reproductive system.

Question

1. What is the problem of the couple? 2. Considering that the wife is normal, what you should do to manage the husband? 3. What examination you need?

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Self Assesment 1. What are the syndrome of late onset hypogonadism 2. Explain the management of late onset hypogonadism 3. What are the syndrome of hypogonadothropic hypogonadism 4. What is the chemical castration 5. Explain the kind of Assisted reproductive technology (ART)

References

 Brinsaden, Peter R. TextBook of In Vitro Fertilization and Assisted Reproduction. United Kingdom. Taylor & francis Group, 2005

 Cavallini, Giorgio. Clinical Management of Male Infertility. Switzerland. Springer International Publishing Switzerland, 2015

 Nieschlag, Eberhard. Andrology Male Reproductive Health and Dysfunction 3rd Edition. Germany. Springer-Verlag Berlin Heidelberg, 2010

 Schill, W.-B.. Andrology for the Clinician. Germany. Springer-Verlag Berlin Heidelberg, 2006

Male Sexual Dysfunction (dr. Yukhi Kurniawan, Sp.And) Department of Andrology & Sexology

Abstract

Sexual dysfunction in the male is not merely one kind of sexual disorder. The classification of male sexual dysfunction (MSD) is as follows. 1. Sexual desire disorders: - Hypoactive sexual desire disorder - Sexual aversion disorder 2. Erectile disorders: - Erectile dysfunction - Prolonged erection 3. Ejaculatory disorders: - Rapid ejaculation - Retarded ejaculation 4. Orgasmic disorder

Many factors may cause one or more sexual dysfunction. Basically the etiologies of sexual dysfunction are divided into 2 groups, i.e. physical factors and psychic factors. However, whatever the etiology, finally the patients will also suffer from psychic problems that make the sexual function worse.

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There are 4 groups of physical factors as the causes MSD, i.e. hormonal, vasculogenic, neurogenic, and iatrogenic factors. Hormonal factors may cause reduced or inhibited sexual desire which secondarily disturb other sexual function. Some hormonal abnormalities associated with MSD are hypogonadism, hyperprolactinemia, hyperthyroidism, and hypothyroidism. Hypogonadism may also result in decreased erectile capacity, anatomically and physiologically. Vasculogenic factors as the causes of MSD are hypertension, hyperlipidemia, diabetes, traumatic injury of the arteries due to pelvic fracture, and cardiovascular diseases. The diseases or disorders of arteries may restrict the blood inflow into the genital organs. The most common of the arterial disorder is atherosclerosis. However, the venous factors play an important role mainly in male based on the veno-occlusive mechanism in the erectile process. Failure of the veno-occlusive mechanism causes blood outflow from the penis, and erection does not occur. The neurogenic causes of MSD include any disease or injury affecting the central nervous system, spinal cord, and peripheral nervous system. Damages of nerves may result in sexual dysfunction. Iatrogenic factors include some operation procedures, drugs, and life style as heavy smoking and alcoholism. Some drugs that may cause MSD are psychotropic agents, anti- depressants, anti-hypertensives, hormonal drugs, anti- cholinergic agents, and recreational drugs. The psychic factors can be divided into three groups, i.e. predisposing, precipitating, and maintaining factors. Predisposing factors include restricted upbringing (e.g. guilty feeling), traumatic sexual experience, poor sexual education, disturbed family relationship, lifestyle problems, and personality type. Factors included in precipitating factors are organic disease, ageing, infidelity, unreasonable expectation, depression, anxiety, and loss of partner. In fact, it is not always easy to diagnose the sexual dysfunction. Some obstacles occurred during the visit of the patient, ie. patient is not able to express their sexual problem, patient-physician do not have a same perception about the sexual complaint expressed by the patient, physician does not have proper knowledge and skill. Many patients with sexual dysfunction need sexual counseling, not merely medication. The counseling capability of the physician is needed. .

Learning task

A man aged 43 years old visits your GP clinic. His complaint is he can not get erection every time he wants to have sexual intercourse. In the physical examination, there are no abnormalities in blood pressure, pulse pressure, heart beat, and abdomen area.

Questions

1. What do you think the diagnosis of his sexual problem? Based on his complaint, is it absolutely erectile dysfunction? Is there any other sexual dysfunction related to his complaint? 2. What are you going to do to establish your diagnosis? 44 Udayana University Faculty of Medicine, DME, 2018

Study Guide Special Topic

3. Do you need laboratory tests? If yes, what tests do you need? 4. How do you treat the sexual problem of the man?

Self assessment

1. What kind of sexual dysfunctions in the male that result in erectile disturbance? 2. What are the causes of erectile dysfunction? 3. Could you explain the mechanism of erection and pathophysiology of erectile dysfunction? 4. What physical examinations must be performed to manage erectile dysfunction? 5. How do you treat erectile dysfunction?

References

Eardley, I., Sethia, K. Erectile Dysfunction Current Investigation and Management. London, Mosby-Wolfe Medical Communication, 1998.

Jardin, A., Wagner, G., Khoury, S., Giuliano, F., Padma-Nathan, H., Rosen, R. et al. Recommendations of the International Scientific Committee on the evaluation and treatment of erectile dysfunction. In: Jardin, A., Wagner, G., Khoury, S., Giuliano, F., Padma-Nathan, H., Rosen, R. (Editors). Erectile Dysfunction. Health Publication Ltd. 2000.

Pangkahila, W. Evaluation of transurethral application of alsprostadil for erectile dysfunction in Indonesians. Asian J Androl 2 (3): 233-236. 2000.

Pangkahila, W. Male Sexual Dysfunction. Module for Continuing Medical Education. Yayasan Penerbit IDI. Jakarta. 2005.

Pangkahila, W. Erectile Dysfunction. Module for Continuing Medical Education. Yayasan Penerbit IDI. Jakarta. 2006.

Pangkahila, W. Sexual Function in the Concept of Anti-Aging Medicine. Presented at the Intensive Education on Sexology. Denpasar. 5-10 March 2006.

Sommer, F., Klotz, T., Steinritz, D., Bloch, W. Evaluation of tetrahydrobiopterin (BH4) as a potential therapeutic agent to treat erectile dysfunction. Asian J Androl 8 (2): 159-167. 2006.

45 Udayana University Faculty of Medicine, DME, 2018

Study Guide Special Topic

Female Sexual Dysfunction (dr. Yukhi Kurniawan, Sp.And) Department of Andrology & Sexology

Abstract

It is sometimes difficult for the physician to distinguish whether the primary problem is desire or arousal in female sexual dysfunction. These two diagnostically separate disorders, are often used interchangeably by the patients, thus making it difficult for the physician to identify which is the target problem. Sexual dysfunction in female is not merely one kind of sexual disorder. Female sexual dysfunction (FSD) is classified as follows: 1. Sexual desire disorders: - Hypoactive sexual desire disorder - Sexual aversion disorder 2. Sexual arousal disorder 3. Orgasmic disorder 4. Sexual pain disorders: - dyspareunia - vaginismus - non coital sexual pain disorder

There are 4 groups of physical factors as the causes of FSDi.e. hormonal, vasculogenic, neurogenic, and iatrogenic factors. In addition to these physical factors, there are two other important factors that may cause FSD, i.e. sexual function of the male partner and the coital position. Sexual dysfunctions of the male partner that commonly cause FSD are erectile dysfunction and rapid ejaculation. The coital position that is not sexually effective for women may cause FSD. Sexual dysfunctions, either in female or male, may result in psychological effects like disappointment, anger, anxiety, infidelity, low self confidence, and low self esteem. Other effects are psychosomatic symptoms and sexual dysfunctions. Further, these results may disturb the harmony of sexual life and the quality of life of the couple. Therefore it should be managed scientifically. Certain cases of sexual dysfunction need special device to recover their sexual function. Women with vaginismus need a series of dilator to perform sex therapy. Eros CTD is a device to stimulate clitoris and brings to orgasm. In fact, it is not always easy to diagnose the sexual dysfunction. Some obstacles occurred during the visit of the patient, ie. patient is not able to express their sexual problem, patient-physician do not have a same perception about the sexual complaint expressed by the patient, physician does not have proper knowledge and skill

Learning task

A woman visits your GP clinic. She is 32 years old with 1 daughter aged 1 year old. She is complaining of no orgasm every time she has coitus.

46 Udayana University Faculty of Medicine, DME, 2018

Study Guide Special Topic

Questions

1. What is your diagnosis concerning to her complaint? 2. What are your steps to manage her problem?

Self assessment

1. Is there any different between orgasm in the male and female? 2. Is orgasm identical with ejaculation? Please explain 3. What are the causes of orgasmic disorder in the female?

References

Basson, R. , Berman, J.,Burnett, A., Derogatis, L., Ferguson, D., Fourcroy, J., Goldstein, I., Graziottin, A., Herman, J., Laan, E., Leiblum, S., Padma-Nathan, H., Rosen, R., Segraves, K., Segraves, RT., Shabsigh, R., Sipski, M., Wagner, G., Whipple, B. Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and Classifications. J Urol 163: 888-893, 2000.

Pangkahila, W. Psychogenic aspects of female sexual dysfunction. Presented at the 8th Federation of ASEAN Urological Associations and 21st Continuing Urological Education of the Indonesian Urological Association. Denpasar, August 29- September 1, 2001.

Pangkahila, W. Management of Female Sexual Dysfunction. Presented at the 12th National Congress of Obstetrics and Gynecology. Batam. July 11-12, 2005

Pangkahila, W. The role of Sexology in Reproductive Health. In: Social Obstetrics and Gynecology (Editor: Martaadisoebrata, D., Sastrawinata, S., Saifudin, A.B.). Yayasan Bina Pustaka Sarwono Prawirohardjo. Jakarta. 2005

Pangkahila, W. Sexual Function in the Concept of Anti-Aging Medicine. Presented at the Intensive Education on Sexology. Denpasar. 5-10 March 2006. Apabila ada perubahan materi mohon disampaikan ke Sekretariat Divisi Geriatri NB: Untuk Geriatri Materi diambil dari Hazzard’s : Geriatric Medicine and Gerontology Ruang Kuliah 4.02 lt IV

47 Udayana University Faculty of Medicine, DME, 2018

Study Guide Special Topic

ANTI- AGING MEDICINE (Prof. Dr. dr. Wimpie Pangkahila, Sp.And, FAACS) Department of Andrology & Sexology

Abstract Anti-Aging Medicine is a new discipline in medical science. The world’s first Post Graduate Study in Anti-Aging Medicine was established at the Udayana University in 2007. The principles of Anti-Aging Medicine are aging process can be slowed down, delayed, even reversed, and lifespan can be extended. Finally people can live longer in healthy condition with optimal Quality of Life. Therefore aging is considered as a disease that can be prevented, treated, and reversed. Aging is no longer accepted as a destiny with all disability, dysfunction, diseases, debility, or cognitive impairment. Aging process actually does not occur abruptly at the time when people reach old age, but it happens gradually through three phases as follows: 1). Subclinical phase (ages 25-35): In this phase, most hormones begin to decline: testosterone, growth hormone, and estrogen. Free radical formation, which can damage cells and DNA, begins to affect the body. This damage usually is not outwardly detectable. Therefore people in this phase can look and feel “normal” without any signs or symptoms of aging. However, many young women using hormonal contraception experience sexual desire disorder due to hormone imbalance. 2). Transition phase (age 35-45): Hormone levels can fall by as much as 25%. Muscle is lost at the rate of a kilogram every couple of years, which can result in loss of strength and energy, with a higher body fat composition, leading to insulin resistance and increased risk of heart disease and obesity. Clinical symptoms begin to appear: decline in visual acuity and hearing; graying of the hair; loss of elasticity and skin pigmentation, decreased sexual desire and arousal. Aging people start to feel and look older. Free radical damage begins to affect gene expression, which causes many diseases of aging, including cancer, arthritis, memory loss, coronary artery disease, and diabetes. 3). Clinical phase (age 45 and above): Decline of hormones continues, including DHEA, melatonin, growth hormone, testosterone, and estrogen, with increased risk of decline in thyroid hormone. There is also the loss of the ability to fully absorb nutrients, vitamins and minerals. A decrease in bone density, accelerated muscle loss (about a kilogram every three years, resulting in the inability to burn calories), and increased body fat and weight also occur. Chronic disease becomes very apparent, organ systems begin to fail, and chronic disease takes over. Disability becomes a major factor with the inability to perform simpler activities of daily living. Sexual dysfunctions become prominent complaints and disturb many couples. There are many factors causing aging process that are divided into two groups, internal factor and external factors. Some internal factors are decreased hormone, free radicals, glycosylation, methylation, apoptosis, immune system, DNA damage, genes. External factors are unhealthy diet and lifestyle, wrong habits, environmental pollution, stress, and poverty. .Considering that aging process occurs gradually by age, there is a chance for intervention to prevent, delay, and treat it. Without intervention or treatment, many signs and symptoms appear which decrease the quality of life. The application of Anti-Aging Medicine is as follows. 48 Udayana University Faculty of Medicine, DME, 2018

Study Guide Special Topic

1. Early detection of the aging process and age-related disorders or dysfunctions. Diagnosis should be based on signs and symptoms, physical examination and biochemistry tests of biomarkers of aging 2. Practice healthy life style including regular exercise, diet control, enough sleep, avoid toxic substances, manage stress, balance between activities and relaxation 3. Replacement therapy: supplement, hormone, stem cell therapy in the next 4. In case there is age-related disease found in early detection, treatment should follow the treatment procedure of each disease

Aims : 1. To provide the knowledge of Anti-Aging Medicine based on scientific evidence 2. To introduce the concepts and management of Anti-Aging Medicine in an effort to prevent, slow down and reverse the aging proccess 3. To improve the health quality in Indonesia as well as the other nations

Learning Outcome : 1. Understand the theories and the principles of Anti-Aging Medicine 2. Understand the changes of paradigm of aging proccess 3. Understand the role of hormones in aging process 4. Understand the role of sport in preventing and reversing aging process 5. Understand the role of nutrient in preventing aging process 6. Understand the role of aesthetics in Anti-Aging Medicine 7. Understand the role of sexual function in aging process 8. Diagnose, prevent, manage, or refer all changes related to aging process

49 Udayana University Faculty of Medicine, DME, 2018

Study Guide Special Topic

CURRICULUM MAP

Program or curriculum blocks 10 Senior Clerkship 9 Senior Clerkship 8 Senior Clerkship Health System- Community-based Evidence-based Special topics : Elective Study IV Compre 18 7 based Practice practice Medical Health Ergonomy & (evaluation) Clinic (3 weeks) Practice Health Environment Orientation (4 weeks) (2 weeks) (Clerkship) BCS (1 weeks) (2 weeks) (2 weeks) + medical ethic (4 weeks) The Medical The Urinary The Reproductive Elective Study III 19 6 Cardiovascular Emergency System and System and Disorders System and (3 weeks) Disorders (3 weeks) (3 weeks) Disorders (3 weeks) (3 weeks) BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) Neuroscience and The Respiratory The skin & Special Topic : Forensic Medicine Elective 18 5 neurological System and hearing system - Palliative med and Medicolegal Study II disorders Disorders & disorders - Complemnt & (2 weeks) (2 weeks) (3 weeks) (3 weeks) (3 weeks) Alternative Med.

BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) (2 weeks) Musculoskeletal Alimentary The Endocrine Clinical Nutrition The Visual 18 4 system & & hepatobiliary System, and Disorders system & connective tissue systems & Metabolism and (2 weeks) disorders disorders disorders Disorders (2 weeks) (3 weeks) (3 Weeks) (3 weeks) BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) BCS (1weeks) Behavior Change Basic Infection Immune system Hematologic Special Topic 19 3 and disorders & infectious & system & disorder & - Andro & aging (3 weeks) diseases disorders clinical oncology - - Geriatri (3 weeks) (2 weeks) (3 weeks) -Travel medicine BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) - (4 weeks) BIOMEDIK III Growth Medical Medical Basic Elective Study 17 2 (4 weeks) & communication Professionalism Pharmaceutical I development (2 weeks) (2 weeks) medicine & drug (2 weeks) (2 weeks) etics BCS: (1 weeks) BCS (1 weeks) BCS (1 weeks) (2 weeks) Studium BIOMEDIK I The cell BIOMEDIK II 19 1 Generale and (8 weeks) as biochemical (6 weeks) Humaniora machinery (2 weeks) (2 weeks) BCS(1 weeks)

Pendidikan Pancasila & Kewarganegaraan ( 3 weeks )

50 Udayana University Faculty of Medicine, DME, 2018