Study Guide Musculoskeletal System and Connective Tissue Disorders
STUDY GUIDE
MUSCULOSKELETAL SYSTEMS AND CONNECTIVE TISSUE DISORDERS
FACULTY OF MEDICINE SCHOOL OF MEDICINE UDAYANA UNIVERSITY
Faculty of Medicine Udayana University, MEU 1 Study Guide Musculoskeletal System and Connective Tissue Disorders
Preface
Musculoskeletal system is one of the systems among all system in the body. This system has a major role in human movement and consists of bones, muscles, joints, tendons and ligaments including the neurovascular within the system. The knowledge of musculoskeletal system very useful to determine the normal condition and can be used to explain pathological concept of many disorders as a whole system. There several diseases in this system such as development disorders, infections, metabolism, neoplasm and weakness of muscles. Most of the diseases can be treated as soon as possible through holistic approach related to medical ethics and informed consent due to patient’s satisfaction. Musculoskeletal system is explain the whole body and it's concept as a basic concept for the other block. That,s why this block is put in advance. Some concept will be studied again or will be used for the other block. Musculoskeletal system and disorders will be studied based on case as a trigger. The case is one of examples of musculoskeletal disorders that are commonly finding the real situation. It’s needed comprehensive approach to understand this block base on basic knowledge, clinical and rehabilitation. Hopefully this book will be used as a trigger to study the core of musculoskeletal system and disorders and can be the basic concept to study the others especially in special study and special topics.
Best regards Planners
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Udayana University Faculty of Medicine, MEU 2
Study Guide Musculoskeletal System and Connective Tissue Disorders
Introduction
Movement is very important in human life. Everyone should move as an adaptation to the entire environment even external or internal. Movement is generated by a specific stimulation. Proper stimulus will be processed through central and peripheral nerves system and deliver to muscles by axon and neuromuscular junction. The muscle will contract to pull the bone that is observed as a movement. To get the optimum movement, there are many aspects should be considered such as bones, joints, ligaments, tendons, muscles and nerves. They all work together in a complex coordination to generate a movement according to the stimulus. This guide book will encourage all the students to comprehend all the topics through lecture, small group discussion, individual learning, student project and clinical skill. Student should know about bones and muscles since its developed, location, function and its disorders. Disorder of musculoskeletal system could be as result of several condition such as development, metabolism, trauma, infection, degenerative or neoplasm. Any type of problems will need different approach of treatment such medical, operation, pharmacology and rehabilitation. Understanding of musculoskeletal can be used in phorensic aspect and for many purposes. The student comprehends all disorder as in real situation, so this guide book will provide some cases as a trigger for discussion. So, active participation of student is the most important aspect in learning by doing process, because all the topics should be discussed in small group under supervision of facilitator. Lecturers who give a lecture in the class just give the student the concepts of every topics, and the student should explore and study insight under guidance of learning task and self assessment. The succesfull of this block is depending on your active participation in teching learning process. See you ….
Udayana University Faculty of Medicine, MEU 3
Study Guide Musculoskeletal System and Connective Tissue Disorders
Contents
1. Preface …………………………………………………………………. 2. Contents …………………………………………………………………. 3. Contributors …………………………………………………………… a. Planners ………………………………………………………… b. Lectures ………………………………………………………… c. Facilitators ……………………………………………………… 4. Time Table Regular Class .…………………………………………… 5. Time Table English Class ……………………………………………… 6. Students Meeting Representatives …………………………………… 7. Student Project ...... 8. Assessment ……………………………………………………………..... 9. Learning Programme …………………………………………………… 10. References ……………………………………………………………….
Udayana University Faculty of Medicine, MEU 4
Study Guide Musculoskeletal System and Connective Tissue Disorders
Team of Musculoskeletal System and Disorders
Planners and Resource Persons
No Name Department Phone
1 Prof.Dr. dr. Putu Astawa, Sp.BO, M.Kes Surgery 0811392123 2 Dr. dr. I Putu Gede Adiatmika, M.Kes Physiology 08123811019 3 Prof.Dr.dr. N. Mangku Karmaya, M.Repro Anatomy 0811387105 4 dr. Ida Ayu Ika Wahyuniari, M.Kes Histology 08123614856 5 dr. Ni Made Linawati, MSi Histology 03618617765 6 dr. I Gusti Ayu Sri Mahendra Dewi, Sp.PA Anatomy Phatology 081338736481 7 dr. Ida Bagus Ngurah, M.FOr Pharmacology 08123687288 8 dr. Agung Wiwiek Indrayani, M.Kes Pharmacology 08886855027 9 dr. Gde Kambayana, Sp.PD Interna 08124683416 10 dr. Firman P Sitanggang, Sp.Rad Radiology 081337165566 11 dr. Ni Made Susilawati, Sp.S Neurology 08124690137 12 dr. I.B. Putu Alit, DFM Forensic 081916613459 Medical 13 dr. Tjok Dalem Kurniawan, Sp.RM 08123800149 Rehabilitation 14 Prof.dr. Ketut Siki Kawiyana Sp.B,Sp.OT Surgery 0811392124 15 dr. K.G. Mulyadi Ridia, Sp.OT Surgery 08123972029 16 dr. Wayan Suryanto Dusak, Sp.OT Surgery 08123801878 17 dr. Ketut Suyasa, SpB, Sp.OT Surgery 0811392640 18 dr. I G.N. Wien Aryana, Sp.OT Surgery 0811385263 19 dr. I Gede Eka Wiratnaya, Sp.OT Surgery 081338493832 20 Prof.Dr. dr.Tjok Raka Putra, Sp.PD Interna 08123811354
Udayana University Faculty of Medicine, MEU 5
Study Guide Musculoskeletal System and Connective Tissue Disorders
~ FACILITATORS ~ Regular Class (Class A)
Venue No Name Group Departement Phone rd (2 floor) nd dr. Desak Ketut Indrasari Utami, 2 floor: 1 1 Neurologi Sp.S R.2.09 nd dr. Made Bramantya Karna, 2 floor: 2 2 Ilmu Bedah Sp.OT R.2.10 nd 2 floor: 3 dr. Ni Luh Ariwati 3 Parasitologi R.2.11 nd 2 floor: 4 I B. Putra Dwija, S.Si, M.Biotech 4 Mikrobiologi R.2.12 nd 2 floor: 5 dr. Ni Putu Sriwidyani, Sp.PA 5 Parasitologi R.2.13 nd dr. A A Gde Yuda Asmara, 2 floor: 6 6 IlmuBedah Sp.OT R.2.14 nd 2 floor: 7 7 R.2.15 nd 2 floor: 8 dr. Kadek Mulyantari, Sp.PK 8 Patologi Klinik R.2.16 nd 2 floor: 9 dr. I G.N. Mayun, Sp.HK 9 Histologi R.2.17 nd dr. Made Ratna Saraswati, 2 floor: 10 10 Interna Sp.PD R.2.18
English Class (Class B)
Venue No Name Group Departement Phone rd (2 floor) nd Patologi 2 floor: 1 dr. Ni Wayan Winarti, Sp.PA 1 Anatomi R.2.09 nd Drs. I Gede Made Adioka, Apt, 2 floor: 2 2 Farmasi M.Kes R.2.10 nd 2 floor: 3 dr. Ni Made Linawati, M.Si 3 Histologi R.2.11 nd 2 floor: 4 Dr.dr. I P.G. Adiatmika, M.Kes 4 Fisiologi R.2.12 nd 2 floor: 5 dr. I Kadek Swastika, M.Kes 5 Parasitologi R.2.13 nd Dr.dr. Bagus Komang Satriyasa, 2 floor: 6 6 Farmakologi M.Repro R.2.14 nd 2 floor: 7 dr. I G.N. Pramesemara, S.Ked 7 Andrologi R.2.15 nd dr. I Wayan Sumardika, 2 floor: 8 8 Farmakologi M.Med.Ed R.2.16 nd 2 floor: 9 dr. D.A.A. Sri Laksemi, M.Sc 9 PatologiAnatomi R.2.17 nd 2 floor: 10 dr. I G.N. Wien Aryana, Sp.OT 10 IlmuBedah R.2.18
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Study Guide Musculoskeletal System and Connective Tissue Disorders
Lecture Schedule
DAY / TIME ACTIVITY VENUES CONVEYER DATE Regular Class English Class Intoduction : Human Movement 08.00 – 09.00 09.00 – 10.00 Class room Prof. Mangku Individual learning 09.00 – 10.30 10.00 – 11.30 - - 1 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 17/3 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room Prof. Mangku Lecture : Congenital Bone Disorder 08.00 – 09.00 09.00 – 10.00 Class room Prof. Siki Individual learning 09.00 – 10.30 10.00 – 11.30 - - 2 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 18/3 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room Prof. Siki Lecture : Bone Development And It’s 08.00 – 09.00 09.00 – 10.00 Class room dr. Lina, D r. Adiatmika Microscopic Structure 3 Individual learning 09.00 – 10.30 10.00 – 11.30 - - SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator 19/3 Break 12.00 – 12.30 12.00 – 13.30 - - Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Lina, Dr. Adiatmika Lecture : Bone And Metabolism Disorders 08.00 – 09.00 09.00 – 10.00 Class room Prof. Siki (Osteoporosis) 4 Individual learning 09.00 – 10.30 10.00 – 11.30 - - SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator 20/3 Break 12.00 – 12.30 12.00 – 13.30 - - Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room Prof. Siki Lecture : Pathology Anatomy of 08.00 – 09.00 09.00 – 10.00 Class room Dr. Mahendra Dewi Musculoskeletal Diseases 5 Individual learning 09.00 – 10.30 10.00 – 11.30 - - SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator 21/3 Break 12.00 – 12.30 12.00 – 13.30 - - Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room Dr. Mahendra Dewi Dr. Elysanti , Prof . Lecture : Orthopaedic Problem And Its 08.00 – 09.00 09.00 – 10.00 Class room Astawa Management 6 Individual learning 09.00 – 10.30 10.00 – 11.30 - - SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator 24/3 Break 12.00 – 12.30 12.00 – 13.30 - - Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room Dr. Elysanti, Prof. Astawa Lecture : The Appendicular Skeleton 08.00 – 09.00 09.00 – 10.00 Class room Prof. Mangku Individual learning 09.00 – 10.30 10.00 – 11.30 - - 7 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 25/3 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room Prof. Mangku Lecture : Bone Fracture 08.00 – 09.00 09.00 – 10.00 Class room dr. Wien Aryana Individual learning 09.00 – 10.30 10.00 – 11.30 - - 8 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 26/3 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Wien Aryana Lecture : Bone Joint, Tendons and Ligaments 08.00 – 09.0 0 09.00 – 10.00 Class room Prof. Mangku 9 Individual learning 09.00 – 10.30 10.00 – 11.30 - - SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator 27/3 Break 12.00 – 12.30 12.00 – 13.30 - - Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - -
Udayana University Faculty of Medicine, MEU 7
Study Guide Musculoskeletal System and Connective Tissue Disorders
Plenary 14.00 – 15 .00 15.00 – 16.00 Class room Prof. Mangku 08.00 – 09.00 09.00 – 10.00 Class room Prof. Tjok Raka Lecture : Bone And Immunology Disorder
(Osteoarthritis and Gout Arthtitis)
Individual learning 10 09.00 – 10.30 10.00 – 11.30 - - SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 28/3 12.00 – 12.30 12.00 – 13.30 - - Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room Prof. Tjok Raka Lecture : Skeletal Muscles 08.00 – 09.00 09.00 – 10.00 Class room dr. Ika Wahyuniari Individual learning 09.00 – 10.30 10.00 – 11.30 - - 11 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 2/4 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Ika Wahyuniari Lecture : Muscle Contraction As A Trigger Of 08.00 – 09.00 09.00 – 10.00 Class room Dr. Adiatmika Movement 12 Individual learning 09.00 – 10.30 10.00 – 11.30 - - SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator 3/4 Break 12.00 – 12.30 12.00 – 13.30 - - Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room Dr. Adiatmika dr. Susilawati , dr. 09.00 – 10.00 Lecture : Muscles - Deg Ds and RNA 08.00 – 09.00 Class room Kambayana
Individual learning 09.00 – 10.30 - - 10.00 – 11.30 13 SGD 10.30 – 12.00 Discussion room Facilitator 11.30 – 12.00 Break 12.00 – 12.30 - - 12.00 – 13.30 4/4 Self Assessment and Student Project 12.30 – 14.00 - - 13.30 – 15.00 Plenary 14.00 – 15.00 Class room dr. Susilawati, dr. 15.00 – 16.00 Kambayana dr. Mulyadi Ridia, dr. Degenerative Disorders of Spine 08.00 – 09.00 09.00 – 10.00 Class room Suyasa Individual learning 09.00 – 10.30 10.00 – 11.30 - - 14 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 7/4 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Mulyadi Ridia, dr. Suyasa Anatomy Dept. (1 st fl) Histology Dept. 15 (4 th fl) Basic Clinical Skill 09.00 – 14.00 09.00 – 14.00 Team Physiology Dept. 8/4 (2 nd fl) Joint Laboratory (4 th fl) Anatomy Dept. (1 st fl) Histology Dept. 16 (4 th fl) Basic Clinical Skill 09.00 – 14.00 09.00 – 14.00 Team Physiology Dept. 9/4 (2 nd fl) Joint Laboratory (4 th fl) Anatomy Dept. (1 st fl) Histology Dept. 17 (4 th fl) Basic Clinical Skill 09.00 – 14.00 09.00 – 14.00 Team Physiology Dept. 10/4 (2 nd fl) Joint Laboratory (4 th fl) Anatomy Dept. 18 Basic Clinical Skill 09.00 – 14.00 09.00 – 14.00 (1 st fl) Team Histology Dept.
Udayana University Faculty of Medicine, MEU 8
Study Guide Musculoskeletal System and Connective Tissue Disorders
(4 th fl) 11 /4 Physiology Dept. (2 nd fl) Joint Laboratory (4 th fl) Anatomy Dept. (1 st fl) Histology Dept. 19 (4 th fl) Basic Clinical Skill 09.00 – 14.00 09.00 – 14.00 Team Physiology Dept. 14/4 (2 nd fl) Joint Laboratory (4 th fl) 09.00 – 10.30 09.00 – 10.30 20 Class Room, Lab, Mid-Test 10.30 – 12.00 10.30 – 12.00 Team SGD 15/4 Lecture : Neoplasm Of Bone and Ulcer 08.00 – 09.00 09.00 – 10.00 Class room dr. Eka W Individual learning 09.00 – 10.30 10.00 – 11.30 - - 21 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 16/4 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Eka W Lecture : Bone Infections 08.00 – 09.00 09.00 – 10.00 Class room dr. Suryanto Dusak Individual learning 09.00 – 10.30 10.00 – 11.30 - - 22 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 17/4 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Suryanto Dusak dr. Tjok Dalem 08.00 – 09.00 09.00 – 10.00 Class room Kurniawan Lecture : Musculoskeletal Rehabilitation
Individual learning 09.00 – 10.30 10.00 – 11.30 - - 23 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 21/4 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Tjok Dalem Kurniawan Lecture : Bone Forensic 08.00 – 09.00 09.00 – 10.00 Class room dr. Alit Individual learning 09.00 – 10.30 10.00 – 11.30 - - 24 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 22/4 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Alit Lecture : NSAID And Muscle relaxant 08.00 – 09.00 09.00 – 10.00 Class room dr. Ngurah, d r. Wiwik Individual learning 09.00 – 10.30 10.00 – 11.30 - - 25 SGD 10.30 – 12.00 11.30 – 12.00 Discussion room Facilitator Break 12.00 – 12.30 12.00 – 13.30 - - 23/4 Self Assessment and Student Project 12.30 – 14.00 13.30 – 15.00 - - Plenary 14.00 – 15.00 15.00 – 16.00 Class room dr. Ngurah, dr. Wiwik
ATT : Pre-Evaluation Break : 24 April 2014 EXAMINATION DAY : 25 April 2014 Class Room : R. 3.02 (3rd Floor)
Udayana University Faculty of Medicine, MEU 9
Study Guide Musculoskeletal System and Connective Tissue Disorders
ENGLISH CLASS
DAY / ACTIVITY TIME VENUES CONVEYER DATE Intoduction : Human Movement 09.00 – 10.00 Class room Prof. Mangku Individual learning 10.00 – 11.30 - - 1 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 17/3 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room Prof. Mangku Lecture : Congenital Bone Disorder 09.00 – 10.00 Class room Prof. Siki Individual learning 10.00 – 11.30 - - 2 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 18/3 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room Prof. Siki Lecture : Bone Development And It’s 09.00 – 10.00 Class room dr. Lina, D r. Adiatmika Microscopic Structure 3 Individual learning 10.00 – 11.30 - - Break 11.30 – 12.00 - Facilitator 19/3 Self Assessment and Student Project 12.00 – 13.30 - - SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room dr. Lina, Dr. Adiatmika Lecture : Bone And Metabolism Disorders 09.00 – 10.00 Class room Prof. Siki (Osteoporosis) 4 Individual learning 10.00 – 11.30 - - Break 11.30 – 12.00 - Facilitator 20/3 Self Assessment and Student Project 12.00 – 13.30 - - SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room Prof. Siki Lecture : Pathology Anatomy of 09.00 – 10.00 Class room Dr. Mahendra Dewi Musculoskeletal Diseases 5 Individual learning 10.00 – 11.30 - - Break 11.30 – 12.00 - Facilitator 21/3 Self Assessment and Student Project 12.00 – 13.30 - - SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room Dr. Mahendra Dewi Lecture : Orthopaedic Problem And Its 09.00 – 10.00 Class room Dr. Elysanti , Prof . Astawa Management 6 Individual learning 10.00 – 11.30 - - Break 11.30 – 12.00 - Facilitator 24/3 Self Assessment and Student Project 12.00 – 13.30 - - SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room Dr. Elysanti, Prof. Astawa Lecture : The Appendicular Skeleton 09.00 – 10.00 Class room Prof. Mangku Individual learning 10.00 – 11.30 - - 7 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 25/3 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room Prof. Mangku Lecture : Bone Fracture 09.00 – 10.00 Class room dr. Wien Aryana Individual learning 10.00 – 11.30 - - 8 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 26/3 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room dr. Wien Aryana 09.00 – 10.00 Class room Prof. Mangku Lecture : Bone Joint, Tendons and Ligaments
Individual learning 10.00 – 11.30 - - 9 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 27/3 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room Prof. Mangku
Udayana University Faculty of Medicine, MEU 10
Study Guide Musculoskeletal System and Connective Tissue Disorders
09.00 – 10.00 Class room Prof. Tjok Raka Lecture : Bone And Immunology Disorder
(Osteoarthritis and Gout Arthritis)
Individual learning 10 10.00 – 11.30 - - Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 28/3 12.00 – 13.30 - - SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room Prof. Tjok Raka Lecture : Skeletal Muscles 09.00 – 10.00 Class room dr. Ika Wahyuniari Individual learning 10.00 – 11.30 - - 11 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 2/4 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room dr. Ika Wahyuniari Lecture : Muscle Contraction As A Trigger Of 09.00 – 10.00 Class room Dr. Adiatmika Movement 12 Individual learning 10.00 – 11.30 - - Break 11.30 – 12.00 - Facilitator 3/4 Self Assessment and Student Project 12.00 – 13.30 - - SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room Dr. Adiatmika 09.00 – 10.00 Class room Lecture : Muscles - Deg Ds and RNA dr. Susilawati, dr. Kambayana
Individual learning - 10.00 – 11.30 - 13 Break Facilitator 11.30 – 12.00 - Self Assessment and Student Project - 12.00 – 13.30 - 4/4 SGD - 13.30 – 15.00 Discussion room Plenary dr. Susilawati, dr. Kambayana 15.00 – 16.00 Class room Degenerative Disorders of Spine 09.00 – 10.00 Class room dr. Mulyadi Ridia, dr. Suyasa Individual learning 10.00 – 11.30 - - 14 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 7/4 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room dr. Mulyadi Ridia, dr. Suyasa Anatomy Dept. (1 st fl) 15 Histology Dept. (4 th fl) Basic Clinical Skill 09.00 – 14.00 Team Physiology Dept. (2 nd fl) 8/4 Joint Laboratory (4 th fl) Anatomy Dept. (1 st fl) 16 Histology Dept. (4 th fl) Basic Clinical Skill 09.00 – 14.00 Team Physiology Dept. (2 nd fl) 9/4 Joint Laboratory (4 th fl) Anatomy Dept. (1 st fl) 17 Histology Dept. (4 th fl) Basic Clinical Skill 09.00 – 14.00 Team Physiology Dept. (2 nd fl) 10/4 Joint Laboratory (4 th fl) Anatomy Dept. (1 st fl) 18 Histology Dept. (4 th fl) Basic Clinical Skill 09.00 – 14.00 Team Physiology Dept. (2 nd fl) 11/4 Joint Laboratory (4 th fl) Anatomy Dept. (1 st fl) 19 Histology Dept. (4 th fl) Basic Clinical Skill 09.00 – 14.00 Team Physiology Dept. (2 nd fl) 14/4 Joint Laboratory (4 th fl) 20 09.00 – 10.30 Mid-Test 10.30 – 12.00 Class Room, Lab, SGD Team 15/4 Lecture : Neoplasm Of Bone and Ulcer 09.00 – 10.00 Class room dr. Eka W Individual learning 10.00 – 11.30 - - 21 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 16/4 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room dr. Eka W
Udayana University Faculty of Medicine, MEU 11
Study Guide Musculoskeletal System and Connective Tissue Disorders
Lecture : Bone Infections 09.00 – 10.00 Class room dr. Suryanto Dusak Individual learning 10.00 – 11.30 - - 22 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 17/4 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room dr. Suryanto Dusak 09.00 – 10.00 Class room dr. Tjok Dalem Kurniawan Lecture : Musculoskeletal Rehabilitation
Individual learning 10.00 – 11.30 - - 23 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 21/4 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room dr. Tjok Dalem Kurniawan Lecture : Bone Forensic 09.00 – 10.00 Class room dr. Alit Individual learning 10.00 – 11.30 - - 24 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 22/4 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room dr. Alit Lecture : NSAID And Muscle relaxant 09.00 – 10.00 Class room dr. Ngurah, d r. Wiwik Individual learning 10.00 – 11.30 - - 25 Break 11.30 – 12.00 - Facilitator Self Assessment and Student Project 12.00 – 13.30 - - 23/4 SGD 13.30 – 15.00 Discussion room - Plenary 15.00 – 16.00 Class room dr. Ngurah, dr. Wiwik
ATT : Pre-Evaluation Break : 24 April 2014 EXAMINATION DAY : 25 April 2014 Class Room : R. 3.02 (3rd Floor)
Udayana University Faculty of Medicine, MEU 12
Study Guide Musculoskeletal System and Connective Tissue Disorders
Schedule Basic Clinical Skill
CLASS ROOM JOINT LAB DAY ANATOMY (PHYSICAL PHYSIOLOGY / DEPT DIAGNOSTIC DEPT PATHOLOGY HISTOLOGY DATE MSD) ANATOMY DEPT 08.00 – 11.00 11.30 – 14.30 15 8/4 A B C D E 16 9/4 B C D E A 17 10/4 C D E A B 18 11/4 D E A B C 19 14/4 E A B C D
Group Distribution Member Basic Clinical Skill
REGULAR CLASS ENGLISH CLASS GROUP (ABSENT NUMBER) (ABSENT NUMBER)
A 1 – 45 B 46 – 90 C 91 – 116 1 – 19 D 20 – 65 E 66 – 120 Total Student 116 120
ATT : Pre-Evaluation Break : 24 April 2014 EXAMINATION DAY : 25 April 2014 Class Room : R. 3.02 (3rd Floor)
Udayana University Faculty of Medicine, MEU 13
Study Guide Musculoskeletal System and Connective Tissue Disorders
Students Meeting Representatives
In the middle of block schedule, a meeting is designed among the student representatives of every small group discussion, facilitators and resource persons. The meeting will discuss the ongoing teaching learning process , quality of lecturers and facilitators as a feedback to improve the next process. The meeting will be held based on schedule from Medical Education Unit.
Student project and Individual Learing
For a more comprehensive achievement in studying the whole topics in this Block, the student must spend the time alocation properly including Individual Learing. At this time, the student must read the references and make a summary or synthesis from the references. The goal is the student could fullfil the learning objectives of each topic and in accordance to SKDI. As a proof of good individual learning process has been done properly, the student must write the summary or synthesis for each topic during the Individual Learning session and must be showed signed by the facilitator after SGD . Please completed the student project by handwriting , not by computer.
Assessment
Type of assessment is multiple choice questions (MCQ) and fill the blank and OSCE. A prerequisite condition to follow the assessment is attendance in at least 75% of all scheduled teaching-learning activities and follows the questionnaire test during lecture. Students’ assessment consists of summative assessment that is given at the end of lecture. Main examination be held at 25 April 2014 and OSCE will be conducted together with other block at semester IV. The score main examination will be calculated from questionnaire during lecture (5 %), Basic Clinical Skill (10 %), MCQ (80 %) and SGD (5 %). Passing level is 69.5 or above. The student who does not pass the passing level should follow remedial. For those student who get score 64.5 – 69.4 must write paper about musculoskeletal in accordance to musculoskeletal from SKDI. The student who get score below than or similar to 64.4 must follow test. Remedial will be held later. Remedial topics are just for the fail topic or not pass. So, the student must follow the topics that are not yet pass to substitute the main examination. The best score will be used for final calculation.
Udayana University Faculty of Medicine, MEU 14
Study Guide Musculoskeletal System and Connective Tissue Disorders
LEARNING PROGRAM
Day 1st
MODULE 1
HUMAN MOVEMENT - THE AXIAL SKELETON
Prof. Dr. dr. Mangku Karmaya, M.Repro
AIMS:
Describe the common functional of musculoskeletal system related to musculoskeletal disorders
LEARNING OUTCOME:
1. Describe the role of musculoskeletal system 2. Describe the element of musculoskeletal system 3. Describe the function of musculoskeletal 4. Describe the development of MSDs
CURRICULUM CONTENTS: 1. Role of musculoskeletal system 2. Element of musculoskeletal system 3. Function of musculoskeletal 4. Development of MSDs
ABSTRACTS:
Musculoskeletal system consists of muscles and bones. Muscles are connected with bones, cartilages, ligaments and skin either directly or through the intervention of fibrous structures called tendons or aponeurosis. Muscles are various in their form, arrangement and size. So there are terms considering the form as long, broad, short, etc., used in the description of a muscle. The terms quadrilateral, fusiform, triangular, oblique, penniform, bipeniform, sphincter are correlate with muscle arrangement. Gastrocnemeus, sartorius and stapedius are terms according to their size. Name of the muscles are derived from: (1) their situation, as the Tibialis, Radialis, Ulnaris, Peroneus; (2) their direction as the Rectus abdominis, Obliqui capitis, Transversalis; (3) their uses, as Flexors, Extensors, abductors etc. (4) their shape as Deltoid, Rhomboid, Trapezius; (5) the number of their division as the Biceps, the Triceps; (6) the points of attachment as the Sternocleidomastoideus, Sternothyroid, Sternothyroid. It is very important to know the exact origin and insertion because it is of great importance in the determination of their action. There is a number of actions: flexion, extention, abduction, adduction, rotation, circumduction, supination, pronation, protrusion (protraction), retrusion (retraction), elevation and depression. Also the relation of the
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Study Guide Musculoskeletal System and Connective Tissue Disorders muscles especially those in immediate apposition with the larger blood vessels and the surface marking they produce should be remembered as they form useful guides in the application of a ligature to those vessels. The fibrous tisssues are in close relation with the muscle. They are tendons and aponeurosis. They are connected, on the one hand, with the muscles and, on the other hand with the movable structures as bones, cartilages and fibrous membranes. The skeleton of the body is composed of bones and cartilages. Bones provide protection for vital structures, support for the body, the mechanical basis for movement, storage for salts (e.g., calcium) and a continuous supply of new blood cells. Cartilage forms parts of the skeleton where more flexibility is necessary as yhe costal cartilage and articular cartilage. There are two types of bones: compact and spongy; its architecture varies according to function. Compact bone provides strength for weightbearing. Bones are classified according to their shape: long, short, flat, irregular and sesamoid bone. The skeleton system has two main parts: the axial skeleton consist of the bones of the head, neck and trunk and appendicular skeleton consist of the bones of the limbs, including those forming the pectoral and pelvic girdles.Thoracic skeleton (bony thorax) dibentuk oleh 12 pasang costae (ribs) dan costal cartilages, 12 thoracic vetebrae dan intervertbral disc dan sternum.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Functions of bones and muscles 2. Name of skeletal muscles according to their location, attachment, form, direction of the fibers and its function 3. Parts of bones and muscles 4. Clinical aspects of musculoskeletal system and its implications
SCENARIO
Case 1 A 65-year-old man and a14-year-old boy were involveed in severe automobile accident. In both patients the thorax had been badly crushed. X-ray examination revealed that the man had five fractured ribs but the boy had no fractures.
Learning task 1. What is the most likely explanation for this difference in medical findings? 2. Explain why the last two ribs are prone to fracture? 3. Describe the type of the ribs and how they joint with other bones.
Case 2 A medical student offered to move a grand piano for his landlady. He just finished his final examinations in Anatomy and was in poor physical shape. He strugled with the antique monstrosity and suddenly experienced an acute pain in the back, which extended down the back and outer side of his left leg. On examination in the emergency department, he was found to have a slight scoliosis with the convexity on the right side. The deep muscles of the back in the left lumbar region felt firmly than normal. No evidence of muscle weakness was present, but the left ankle jerk was deminished. The symptoms and signs of the patient strongly suggested a diagnosis of prolapsed intervertebral disc.
Learing task 1. Why the doctor concluded that the patient suffered from prolapsed intervertebral disc? 2. What is the normal position of lumbar vetebrae in erect position?
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3. Compare the lumbar vertebrae with other vertebrae. 4. Describe all muscles that construct the back
Case 3 A 45-year-old man was seen in the emergency department after beeing knock down in a street brawl. He had received a blow on the right head with an empty bootle. On examination the patient was conscious with swelling on his upper right head and right face. The head skin is intact and he could not move his lower jaw.
Learning task 1. What layer of SCALP the hematoma occupied? 2. If the lateral side of cranium was injured, what muscles and bones are suffered? 3. What probably occured to him so he could not move his lower jaw? 4. What structures involve in temporomandibular joint movement?
Self assessment 1. Describe the functions of bones and muscles 2. Describe the name of skeletal muscles according to their location, attachment, form, direction of the fibers and its function 3. Discribe the parts of bones and muscles 4. Describe some clinical aspects of musculoskeletal system and its implications 5. Describe the name of bones that construct the axial skeleton 6. Identify SCALP, facial muscles and mastication muscles 7. Compare the new born-baby and adult cranium
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nd Day 2
MODULE 2
CONGENITAL BONE DISORDER
Prof. Dr. dr, I Ketut Siki Kawiyana,SpB. SpOT(K)
AIMS:
Establish tentative diagnosis, provide initial management and/or refer patient with congenital anomaly of musculoscletal system.
LEARNING OUTCOME: Establish tentative diagnosis, provide initial management and/or refer patient with o CTEV o CDH
CURRICULLUM CONTENTS: 1. Principle management of congenital anomaly of musculoscletal system. 2. Establish tentative diagnosis, provide initial management and/or refer patient with a. CTEV b. CDH
ABSTRACTS
CTEV (Congenital Talipes Equinovarus). Synonym is a Clubfoot. It is a common birth defect, occurring in about one in every 1.000 live birth. Approximately 50% of case of clubfoot is bilateral. In most case it is an isolated dysmelia. Incidence in males is slightly higher than females. Cause: There is different cause for clubfoot. It is not known what the exact cause of clubfoot may be, but it has be found common in individuals with Edwards syndrome, a genetic defect, external influences such as intrauterine compression from oligohydramnion or from amniotic band syndrome. CTEV may be associated with use of medicamentous while pregnant. Clinical sign: The foot is twisted in (inverted) and down. The deformities are Equinus of the ankle, varus of hind foot, supination of midfoot, and adduction of forefoot. Without treatment, person afflicted often appear to walk on their ankles, or on the sides of their feet. Treatment: Clubfoot is treated by non operative or operative. By non operative, clubfoot is treated with manipulation and is followed by serial casting, most often by the Ponseti Method. Foot manipulation is usully done as soon as possible or within two weeks of birth. Even with successful treatment, when only one side is affected. Surgery is indicated in rigid or neglected clubfoot. In the chilled under 5 years old, posteromedial soft tissue release must be done, there are ATL, lengthening of tibialis posterior tendon, flexor digitorum and flexor hallucis tendon, and release, and release all of ligament and joint capsule on the medial foot and ankle. In chilled over then 10 years old, bone procedure must be done.
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DDH (Developmental Dysplasia of Hip) Developmental Dysplasia of Hip is congenital (present at birth) condition of the hip joint. It occurs once in every 1.000 live birth. The hip joint is created as a ball and socket joint. In DDH, the hip socket may be shallow, letting the “ball” also known as the femoral head, slip in and out of the socket. The femoral head may move partially or completely out of the hip socket. Cause: The greatest incidence of DDH occurs in first-born females. Hip dysplasia is considered a “multifactorial trait”. Multifactorial inheritance means that many factors are inveloved in causing a birth defect. The factors are usually both genetic and environmental. The risk factors for DDH are: - Family history of developmental dysplasia of the hip, or very flexible ligament. - Position of the baby in the uterus, especially with breech presentations. - Associations with other orthopaedic problems that include metatarsus adductus, clubfoot, and arthrogryposis multiplex congenital. Diagnosed of DDH: The symptoms and sign may include: - The leg may appear shorter. - The leg turns outward. - The folds in the skin of tight or buttocks may appear uneven. - The space between the legs may look wider than normal. Diagnostic procedure may include: - X-ray of the pelvis. - Ultra sound (Sonography). - CT scan (Computed tomography scan). - MRI (Magnetic resonance imaging). Treatment for DDH: The goal of treatment is to put the femoral head back into the socket of the hip, so that the hip can develop normally. Treatment options vary for babies and may include: - Placement of a Pavlik harness. - Traction and casting. - Surgery and casting.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Concept of congenital abnormalities 2. Type of congenilat abnormalities 3. Management patient with congenital abnormalities
SCENARIO
Case I A lecturer showed one of his medical students, a 4 months old female patient with abnormalities in her left lower limb, shortening in her thigh, adducted and difference in skin fold between her right and left thighs. Lecturers said this patient might be having DDH (Developmental Dysplasia of the Hip) 1. Where is the abnormality occured and why is it called DDH? 2. What are the incidence, etiology and pathogenesis of DDH? 3. How do you diagnosed and treat DDH patient based on age of the patient?
Case II A normal male baby was born in a maternity clinic, with normal body weight, cried spontaneous after examined by midwife. She found both of the baby’s legs bowed inwards. She has a daughter studying in medical faculty. She asked her daughter about the abnormalities in this baby and how to treat this baby appropriately.
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1. What are the congenital abnormalities found in lower limb? 2. What are the causes of bowed legs? 3. In this case, what are the deformities found in leg and ankle? 4. How do you manage this baby and when do you start the treatment?
Case III A newborn baby found born with both of his legs bowed inwards 1. What are the congenital abnormalities found in this baby? 2. What are the radiologic examinations needed to be done for this patient? 3. What are the radiologic imaging are expected in this patient?
Learning Task: 1. Definition of congenital abnormalities in musculoskeletal system 2. Congenital abnormalities that is common found 3. Signs and diagnostic criteria 4. Management procedures 5. Consultation patient with congenital abnormalities
Self Assessment: 1. What is the meaning of congenital abnormalities? 2. When do you refer a newborn baby with congenital abnormalities?
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rd Day 3
MODULE 3 BONE DEVELOPMENT AND ITS MICROSCOPIS STRUCTURE
dr. Ni Made Linawati, M.Si Dr. dr. I Putu Gede Adiatmika, M.Kes
MICROSCOPICS OF BONE
AIMS :
1. Describe normal bones as structure and bone as an organ and apply its concepts and principles in the approach of patient with healing/injury 2. Describe several factors that affect to regulation of calcium and bone remodeling in the patient with healing/injury
LEARNING OUTCOME: 1. Comprehend the concept of microscopic bone structure and it’s development 2. Apply the concept to clinical case such as osteoporosis, bone fracture 3. Comprehend the physiology of calcium and its regulation within the body. 4. Apply the concept calcium balance to bone fracture / injury
CURRICULUM CONTENTS: a. Bone : • Intra membraneous ossification • Endochondral Ossification • Compact / lamellar bone • Woven bone b. Cartilage : • Hyaline cartilage • Elastic cartilage • Fibrocartilage c. Bone development d. Bone deposition, bone absorption
ABSTRACTS
Cartilage and Bones Cartilage is characterized by an extracellular matrix enriched with glycosaminoglycans and proteoglicans, macromolecules that interact with collagen and elastic fibers. Variations in the compositione matrix component produce 3 types of cartilage adapted to local biomechanical needs. Cartilage consists of cells called chondrocytes and an extensive extracellular matrix composed of fibers and ground substance. Condracytes synthesize and secrete the extracellular matrix and the cells themselves are located in
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Study Guide Musculoskeletal System and Connective Tissue Disorders matrix cavities called lacunae. There are three forms of cartilage: hyaline cartilage, elastic cartilage and fibrocartilage. Bone is specialized connective tissue composed of intercellular calcified material, the bone matrix, and 3 cell types: osteocytes, osteoblasts and osteoclast. Microscopic examination of bone shows 2 varieties: primary, immature or woven and secondary, mature or lamellar bone. Bone can be formed in 2 ways: by direct mineralization of matrix secreted by osteoblast ( intramembranous ossification ) or by deposition of matrix on a pre-existing cartilage matrix ( endochondral ossification). Joint regions were bones that are capped and surrounded by connective tissue that hold the bones together and determine the type and degree of movement between them. Joint may be classified as synostosis, synchondrosis and syndesmosis. In synostosis, bone is united by bone tissue and no movement takes place. In children and young adult, are united by dense connective tissue. Synchondroses are articulations in which the bone is joined by hyaline cartilage. Diarthroses are joints that generally unite long bones and have great mobility. In this joint, ligament and a capsule of connective tissue maintain the contact at the end of bone. The articular surfaces of a diarthrosis are covered by hyaline cartilage that is devoid of perichondrium. The capsule of dioarthroses varies in structure according to the joint. Generally, this capsule is composed of 2 layers, the external fibrous layer and the internal synovial layer. The synovial layer is formed by two types of cells. One resembles fibroblast and the other has the aspect and behavior of macrophages. The fibrous layer is made of dense connective tissue.
Bone growth and remodeling Bone growth was affected by several factors such genetics, nutrition, endocrine dan nerve. Bone tissue development consists of primary and secondary process. Osteogenesis is the process of bone growth until 18 years old for female and 21 years old for male. Osteoblasts will secret osteoid, as one kind of collagen fibers which not yet reach for the classification process. Calcificaton process occurred about 1 week. Active substance of vitamin D (1,25-dyhidroxycholecalciferal) was arranged through skin where the 7-dehydrocholesterol was changed to vitamin D3. The vitamin D3 will be changed to be 25-hydroxycholecalciferol within the liver. The 25-hydroxycholecalciferol will be changed to be 1,25-dyhydroxycholecalciferal within the renal cortex. This process supported by parathyroid hormone. Meanwhile, calcium absorption was occurred in the intestine and affected by 1,25 dyhydroxycholecalciferol within intestine epithelial. Bone remodeling was affected by (1) mechanical stress that stimulates the bone harder at the stress point. ; (2) Parathyroid hormone and 1,25-dyhydroxycholecalciferol that stimulates osteoclast activity; and (3) calcitonin that decreasing osteoclast absorption capacity and reducing new osteoclast development. Bone remodeling was a dynamic process for long life and a balance process of osteoblast dan osteoclast function.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Microscopic view of bone cell 2. Composition of bone cell 3. Bone development 4. Calcium balance 5. Bone remodeling
SCENARIO Female 13 years old, had first menstrual cycle. She complained about her height that couldn’t increase again.
Learning Task : 1. Describe the histogenesis of cartilage
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2. Describe the normal structure and function of hyaline, elastic and fibrocartilage 3. Describe the microscopic structure of osteoprogenitor cells, osteoblast, osteocyte, osteoclast and bone matrix 4. Describe the organization of immature and lamellar bones 5. Describe the histogenesis of bones, included : a. Intramembraneous and endochondral ossification b. Growth in length of long bones c. Growth in diameter of long bones d. Surface modeling of bones 6. Describe the histology structure of articular surface of joint.
Self Assesment 1. Chondrogenesis (cartilage growth) takes place by two mechanisms: (1)……….. and (2)……………….. 2. The two major cell components of bone are the …………….. and………………… 3. Explain the process of bone growth and remodeling
SCENARIO A woman, 45 years old, come to hospital for thyroid and parathyroid surgery. For the preparation, the patient must do some assessment and therapy a better result after surgery.
Learning Task : 1. Identify any assessment that must done by this patient. 2. Explain what the effect of parathyroid surgery to the other organ and calcium balance.
Self Assesment 1. What is the effect of parathyroid surgery ? 2. What should be given to patient to avoid hypocalcemia ? 3. What is the mechanism of organ to anticipate loss of parathyroid organ after the surgery ?
Reference: 1. Junquera LC. 2003. Cartilage and Bone in Basic Histology tenth edition. P. 135-156 2. Textbook of Medical Physiology, 10 th ed, A.C. Guyton, Hall, Philadelphia, WB Saunders Co, 2000, pp. 52 – 95
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th Day 4
MODULE 4 BONE AND METABOLISM DISORDERS
Prof. Dr. dr. I Ketut Siki Kawiyana, SpB. SpOT (K) AIMS: Establish tentative diagnosis, provide initial management and/or refer patient with methabolic disorders.
LEARNING OUTCOMES: Establish tentative diagnosis, provide initial management and/or refer patient with : osteoporosis, rickets osteomalacea.
CURRICULUM CONTENTS: 1. Osteoporosis 2. Rickets 3. Osteomalacea.
ABSTRACTS
OSTEOPOROSIS Osteoporosis is a disease that thins and weakens the bones to the point that they become fragile and break easily. Women or men with osteoporosis most often break bones in the hip, spine, and wrist, but any bone can be affected. Osteoporosis is often called “silent” because bone loss occurs without symptoms. People may not know that they have osteoporosis until a sudden strain, bump, or fall causes a bone to break. Bone is living tissue. Throughout our live, the body breaks down old bone and replaces it with new bone (remodeling). But as people age, more bone is broken down than is replaced. The bone will become thin and porous (osteoporosis).
Risk Factor: - Gender. - Age. - Ethnicity. - Family history. - Life style: diet, Calcium, vit D, - Physical activity. - Smoking - Low body weight - Medication
Sign and Diagnosis: Osteoporosis does not have any symptoms until a fracture occurs, most often break bones in the hip, spine, and wrist. If spine fractures, height loss, back pain, back fatigue, curved spine.
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The best screening test is dual energy X-ray absorptiometry (DEXA). This procedure is quick, simple and gives accurate results. It measures the density of bone in spine, hip and wrist. Treatment & drugs: Prescription drugs can help slow bone loss and may even increase bone density over time. It was including: hormonal therapy, bisphosphonates, and calcitonin. Prevention: Getting adequate calcium and vitamine D is an important factor in reducing risk of osteoporosis. Other tips for prevention: exercise, add soy to diet, don’t smoke, avoid excessive alcohol, and limit caffeine.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Clinical aspect of Osteoporosis 2. Differential diagnosis of osteoporosis 3. Management of osteoporosis.
SCENARIO A 60 year old woman came to the orthopaedic clinic due to pain on her back since a year ago and already got treatment from general practitioner. She said that her back start to bent since 3 months and severe pain since yesterday because of fall down in sit position. She had gynecological operation when she was 40 year old 1. Please make imaginative anamnesis in this patient to lead to osteoporosis diagnosis. 2. What is the Differential Diagnosis? Please explain other examinations which can distinguish the DD. 3. What is the definition of osteoporosis? 4. What is the pathogenesis? 5. Is osteoporosis happened in female only? 6. How to prevent it? 7. In which bone, can fracture happened if this patient fell down?
Learning Task: 1. Osteoclast and osteoblast function 2. Bone remodeling process 3. Factors that affect bone remodeling
Self Assessment: 1. What is the osteoporosis classification? 2. Why in colles fracture often associate with pathological fracture?
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th Day 5
MODULE
5 PATHOLOGY ANATOMY OF MUSCULOSKELETAL DS
Dr. dr. I G.A.Sri Mahendra Dewi, SpPA
AIM: Describe the etiopathogenesis and morphologic features of musculoskeletal diseases and apply it concept for approach of musculoskeletal problems and its therapy.
LEARNING OUTCOMES : 1. Bone 1.1 describe the effect (etiopathogenesis and morphologic features) of stress/ injury/ disease to bone. 2. Joint 2.1 describe the effect (etiopathogenesis and morphologic features) of stress/ injury/ disease to joint. 3. Muscle 3.1 describe the morphologic features of skeletal muscle tumors. 3.2 describe the morphologic features of smooth muscle tumors. 4. Soft tissue 4.1 describe the morphologic features of adipose tissue tumors. 4.2 describe the morphologic features of fibrous tissue tumors.
CURRICULUM CONTENTS 1. Bone 1.1 Congenital and Hereditary Diseases of Bone : Achondroplasia, Osteogenesis Imperfecta 1.2 Osteoporosis and Acquired Metabolic Diseases (Rickets and Osteomalacia) 1.3 Osteomyelitis and Spondilitis 1.4 Bone Tumors : primary and secondary bone tumors, osteosarcoma, Ewing sarcoma, fibrous dysplasia
2. Joint : arthritis (gout arthritis and infectious arthritis), osteoarthritis, 3. Muscle : rhabdomyosarcoma, leiomyoma, leiomyosarcoma 4.Soft tissue : adipose tissue tumors (lipoma, liposarcoma), fibrous tissue tumors (fibroma, fibrosarcoma)
ABSTRACT
1. BONE Achondroplasia is an inherited disorder characterized by impaired maturationof cartilage in the developing growth plate. The most conspicuous changes are marked, disproportionate shortening of the proximal extremities, bowing of the legs, and a lordotic
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(sway-backed) posture. The cartilaginous growth plates contain hypoplastic or disorganized aggregates of chondrocytes instead of the long, orderly columns normally seen at this site. Osteogenesis Imperfecta (OI) or brittle bone disease, is a group of hereditary conditions characterized by abnormal development of type I collagen. Type I collagen is present in many different tissues, including skin, joints and eyes. OI characterized by the present of multiple bone fractures. Other tissues containing type I collagen are also affected, resulting in abnormal dentition, hearing loss, and blue appearance to the sclera. Osteoporosis is a skeletal disorder characterized by low bone mass and microarchitectural deterioration with a subsequent increase in bone fragility and susceptibility to fracture. It occurs most commonly as primary disorders or secondary. Osteoporosis result when imbalance occurs between bone formation and resorption. The hallmark of osteoporosis is a loss of bone, the bony trabeculae are thinning and widening of haversian canal. Both rickets and osteomalacia are manifestations of vitamin D deficiency. The fundamental change in these diseases is defective mineralization of bone, accompanied by an increase in nonmineralized osteoid. In rickets, the defective mineralization involves the developing bones in children, but osteomalacia involves the bone that has completed its normal development. Osteomyelitis designated as inflammation of the bone and marrow cavity by infectious agents. Osteomyelitis may be an acute or chronic. The most common etiologic agents are pyogenic bacteria and mycobacterium tuberculosis. Morphologically acute pyogenic osteomyelitis characterized by an intense, neutrophilic inflammatory infiltrate. Chronic osteomyelitis show sequestrum, involucrum and Brodie abscess. Tuberculous osteomyelitis causes the granulomatous inflammatory reaction. Bone tumors divided in two categories : bone-forming tumors (osteoma, osteoid osteoma and osteoblastoma, and osteosarcoma) and cartilaginous tumors (osteochondroma, chondroma, and chondrosarcoma). - Osteosarcoma is malignant mesenchymal neoplasm in which the neoplastic cells produce osteoid. Most unknown etiology. The lesion usually in the mataphyseal region of the bone, often elevates the periosteum toproduce the Codman triangle on radiographs. The hallmark of osteosarcoma is the formation of osteoid by malignant mesenchymal cells, that may be spindle shaped, pleomorphic, bizarre, and giant cell often present. - Osteochondroma is benign proliferations composed of mature bone and a cartilaginous cap. Probably represent malformations rather than true neoplasm. - Chondrosarcoma is malignant neoplasm populated by mesenchymal cells that produce a cartilaginous matrix. Microscopically, chondrosarcoma vary great in appearance. There are well, moderately or poorly differentiated malignant cells, multinucleate cells are present with lacunae containing 2 or more chondrocytes. - Ewing sarcoma occurs predominantly in children and adolescents, with a peak incidence in the second decade of life. Ewing sarcoma arises within the medullary cavity of the affected bone to produce a soft, expansile mass. Microscopically it composed of sheets of primitive cells, with small, fairly uniform nuclei and only scant cytoplasm. - Fibrous dysplasia is an uncommon, benign, tumor-like lesion of bone, in which the normal trabecular bone is replaced by proliferating fibrous tissue and disorderly islands of malformed bone.
2. JOINT Osteoarthritis also termed degenerative joint disease. In most cases it arises without obvious predisposing factors (primary). Morphologically, the earliest structural changes are enlargement & disorganization of the chondrocytes in the superficial part of the articular cartilage. These accompanied by fibrillation (splitting) at the articular surface. Portions of the articular cartilage are eventually completely eroded, cyst may form in the underlying bone.
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Additional bone proliferation occurs at the margins of the joints to produce bony excrescences, termed osteophytes. Non specific inflammation can develops. Gout is a disorder caused by the tissue accumulation of excessive amounts of uric acid, an end product of purine metabolism. The major morphologic manifestation of gout are acute arthritis, chronic tophaceous arthritis and soft tissue tophi, and gouty nephropathy. The most common form of infectious arthritis is caused by bacteria. The usual reaction manifested by local pain, fever and an intense neutrophilic inflammatory infiltrate within the joint and periarticular tissues.
3. MUSCLE Rhabdomyosarcoma is predominantly a neoplasm of infancy, childhood and adolescence, with the peak incidence in the first decade of life. Microscopically there are three variants : embryonal, alveolar and pleomorphic. Leiomyoma is common benign smooth muscle tumors, encountered most frequently in the uterus, composed of hyperplasia of smooth muscle cells arrayed in whorled-like without anaplastic appearance. Leiomyosarcoma is malignant smooth muscle tumors, occur most often in the uterus and gastrointestinal tracts, composed of hyperplasia of smooth muscle cells with anaplastic appearance, with infiltrative growth.
4. SOFT TISSUE Soft tissue tumors are generally classified on the basis of tissue type that they recapitulate, including tumors of adipose tissue (lipoma and liposarcoma), tumors of fibrous tissue (fibroma and fibrosarcoma). Lipoma is benign tumor, soft, yellow mass, composed of mature adipose tissue. Liposarcoma is malignant neoplasm, a number of different histologic subtypes are recognized, including well-differentiated, myxoid, round cell, pleomorphic and dedifferentiated liposarcoma. Fibrosarcoma is malignant neoplasm, composed of interlacing fascicles of fibroblast, sometimes arranged in a ‘herringbone’ pattern.
SCENARIO A 72 years old woman came to a general hospital with chief complain pain and swelling in proximal region of her right lower extremity, after she fall in the bathroom. Radiograph examination showed fracture of femoral neck and decreased of bone density.
Learning task : 1.1 What is the possible diagnosis of this patient ? 1.2 What are the role of hormonal factors in this case ? 1.3 Describe the morphologic features of the femoral bone of this patient.
A 22 years old man came to a doctor with chief complain swelling and pain in his knee, enlarge fast since a week ago. Radiograph examination showed lesion in metaphyseal region of distal femur, destroy the cortex, elevate periosteum and extend into the soft tissue. Biopsy was done in this patient.
Learning task : 2.1.What is the possible diagnosis of this patient ? 2.2 Describe the morphologic features of the biopsy specimen.
A 35 years old man came to a general hospital with chief complain subcutaneous masses, enlarge slowly since about 3 years ago, without pain. Biopsy was done in this patient. The result of histopathological examination was lipoma.
Learning task : 3.1 Describe the morphologic features (macroscopic and microscopic) of the biopsy specimen from this patient.
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3.2 Mention some histopatological variant of lipoma.
Self Assessment
1. BONE 1.1 Disorders of the skeletal system can occur in many nutritional and endocrine disorders. Describe the morphologic appearance of osteoporosis. 1.2 The most common etiologic agents of osteomyelitis are pyogenic bacteria and Mycobacterium tuberculosis. Describe the macroscopic and microscopic appearance of acute & chronic osteomyelitis, and tuberculous osteomyelitis. 1.3 Diagnosis of bone tumors require integration of the clinical history, radiologic, macroscopic and microscopic appearance of the tumor. Describe the macroscopic and microscopic appearance of the : 1.4 Bone-forming tumor (osteoma, osteoid osteoma and osteoblastoma, and osteosarcoma). 1.5 Cartilaginous tumors (osteochondroma, chondroma and chondrosarcoma).
2. JOINT 2.1 The most common disorder of the joints is degenerative joint disease. Describe some sequences in morphologic appearance of that disorder. 2.2 Gout arthritis is caused by the tissue accumulation of excessive amounts of uric acid. There are four major morphologic manifestations of gout arthritis. Describe the four manifestation above. 2.3 The most common form of infectious arthritis are caused by bacteria. Describe the macroscopic and microscopic appearance of acute suppurative arthritis.
3. MUSCLE 3.1 Describe the macroscopic and microscopic appearance of rhabdomyosarcoma 3.2 Describe the macroscopic and microscopic appearance of leiomyoma and leiomyosarcoma 4. SOFT TISSUE Describe the macroscopic and microscopic appearance of soft tissue tumor : - adipose tissue : lipoma and liposarcoma - fibrous tissue : fibrosarcoma
Learning Resources :
Robbins Basic Pathology, 7 th ed, Kumar V, Cotran RS, Robbins SL. WB Saunders, Philadelphia, 2003, pp 755-787.
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th Day 6
MODULE
6 ORTHOPAEDIC PROBLEM AND ITS MANAGEMENT
Dr. dr. Elysanti Danun, SpRad Prof. Dr. dr. Putu Astawa, SpOT(K), M.Kes
AIMS: Describe the clinical management of musculoskeletal disorders (Dx, RO”, Lab. Th. medical, operative and rehabilitation)
LEARNING OUTCOMES:
Describe how to: 1. Diagnosis 2. Rontgen 3. Laboratory 4. Therapy (medical, operative and rehabilitation)
CURRCIULUM CONTENS: 1. history taking, (fundamental four and secret seven) of MSD’s 2. physical examination of MSD’s 3. investigation routine and specific of MSD’s 4. modality of treatment of MSD’s
ABSTRACTS (Prof. Dr.dr. Putu Astawa, SpOT(K). M.Kes)
The clinical management of musculoskeletal disorders consists of how to make a proper diagnosis through good anamnesis, physical examination, rontgen, and laboratory and give the patient proper treatment with medical, operative and rehabilitation modality.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. The procedure of musculoskeletal disorders diagnosis 2. Management of musculoskeletal disorders 3. Imaging for musculoskeletal disorders
SCENARIO Ten years old boy came to orthopaedic clinic with main complain swollen in the right knee due to trauma 1 week ago. The swollen has already developed before trauma and pain has already developed several months before. Patient’s bodyweight felt decrease 1 month ago. No fever.
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Learning Task: 1. From the story above, what need to be asking to the patient? (Remember the secret seven and fundamental four). 2. Make the physical examination of this patient with imagination in correlation with the story above. 3. What is the differential diagnosis of this patient? 4. Please explain the pathogenesis from each of the differential diagnosis that has been mentioned above! 5. What is the planning diagnosis that you suggest? 6. If you want to make an X-ray, how to make a good photo? (Remember the rule of two). 7. How to read an X-ray photo of bone in generally? 8. If you doubt in make a diagnosis then need a biopsy and pathological examination. How is the general pathological appearance of chronic infection, TBC and bone malignancy?
Self Assessment: 1. How to do a good anamnesa in musculoskeletal cases 2. How to do a good physical examination in musculoskeletal cases 3. What is the laboratory findings that need to be checked in musculoskeletal cases 4. How to do radiologic imaging and reading in musculoskeletal cases 5. What is the etiology of musculoskeletal cases in general
LEARNING OBJECTIVE
Describe Radiological Imaging in Musculoskeletal System
ABSTRACTS (Dr. dr. Elysanti Danun, Sp Rad.)
Evaluating the radiology imaging, it is important to evaluate the condition of soft tissue, bones and joint. Remember rule of two in making x-rays. So after studying the musculoskeletal topic, the students are expected to diagnose the mormal and abnormal patient, which at least consist of : 1. Traumatic : fracture and joint disclocation 2. Infection, ex. Osteomyelitis 3. Malignancy, ex. Osteosarcoma
Learning Task
Find Radiologic term o Systematicsm of x-ray reading o Radioscleerotic o Radiolucent o Codmann Triangle o Onion Shape. o Gegraphic patern o Mooth eaten o Permeated patern
Self Assessment 1. How to know the fracture in X – Ray 2. How to know the osteomyelitis 3. How to know the osteosarcoma
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th Day 7
MODULE
7
THE APPENDICULAR SKELETON
Prof. Dr. dr. Mangku Karmaya, M.Repro
AIMS: Establish the appendicular skeleton for human movement
LEARNING OUTCOMES: Comprehend the macroscopic aspect of appedicular skeleton
CURRICULUM CONTENTS: 1. Upper 2. Lower limb
ABSTRACTS Both appendicular skeletons that build upper and lower limb have the similar patern. They attach at axial skeleton through girdle. Humeral joint is analog to hip joint, humery analog to femur, elbow joint to knee, radius ulna to tibia fibula, wrist to ankle and hand to foot. Due to work load of both appendicular skeletons, joint and lower limb muscles are stronger than upper limb. The type of joint promotes for upper limb for more free movement, pronation supination and occur inversion eversion on lower limb. The phalanges of hand can do apposition movement compare to foot is not possible. All of the appedicular skeleton were covered by group muscles, and their type are similar.
UPPER LIMB
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. The upper and lower limb. Explain the part of those bone 2. Important parts of upper and lower limb bones 3. The muscles in the regions of shoulder/buttock, fore arm/femur, lower arm/leg, hand/pedis
SCENARIO
Case 1 A15-year-old girl, while demonstrating to her friends her proficiency at standing on her hands, suddenly went off balance and put all her body weight on her left outstretched hand. A distinctive cracking noise was heard, and he felt a suddent pain in her left shoulder region. On examination in the emergency department, the smooth contour of her left shoulder was absent. The clavicle was obviously fractured, and the edge of the bony fragments could be palpated.
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Learning task 1. Which part of clavicle that the fracture commonly occurs. Why? 2. What is the position of lateral and medial fragments according to muscles traction? 3. Describe all bones that joint the clavicle. 4. What is the function of clavicle?
Case 2 A 63-year-old man fell down a flight of stairs and sustained a fracture of the lower end of the left radius. On examination the distal end of the radius was displaced posteriorly. This patient has sustained a Colles’ fracture.
Learning task 1. Why the distal end of the radius was displaced posteriorly? 2. Describe all bones that joint the tradius 3. Describe all muscles attached to the radius
LOWER LIMB
Case 1 After recovery from long hospitalization, a 65-year-old woman try to walk alone. But suddenly she fell down. The doctor noted that the woman had a spontaneous fracture of the neck of the femur . The neck fractures are common and are of two types, subcapital and trochanteric. Subcapital femoral neck fractures are particularly common in women after menopause.
Learning task 1. Why the fractures have gender predisposition? 2. In the neck fractures the leg become shortened and pointed laterally. Why? (Think about the muscles pull action). 3. Describe all mucles attached to the neck and shaft of the femur
Case 2 A motocyclist try his new motorcycle in town mainroad in high speed. But he did not know the truck in front of him suddenly turn to the right. The accident could not be avoided. After striking hard the truck the man was thrown 10 meters and landed first on his right leg. On examination in the emergency department the doctor noted fractures of the right tibia with minimal displacement.
Learning task 1. Why the displacement was minimal? 2. Why the fracture of the shaft of the tibia are more frequent compare to fibula? 3. What muscles are attached to tibia?
Self assessment 1. Compare the upper and lower limb 2. Identify the important parts of upper and lower limb bones 3. Identify the muscles in the regions of shoulder/buttock, fore arm/femur, lower arm/leg, hand/pedis
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th Day 8
MODULE
8 BONE FRACTURE
dr. Wien Aryana, SpOT
AIMS: Establish tentative diagnosis, provide initial management and/or refer patient with: Fracture and dislocation in child and adult.
LEARNING OUTCOMES: Establish tentative diagnosis, provide initial management and/or refer patient with: Fracture and dislocation in child and adult.
CURRICULUM CONTENTS: 1. Bone healing 2. Diagnosis, provide initial management and/or refer patient with: Fracture and dislocation in child and adult.
ABSTRACTS
A tentative diagnosis fracture is a break in the structural continuity of bone. It may be no more than a crack, a crumpling or a splintering of the cortex; more often the break is complete and the bone fragments are displaced. Most fractures are caused by sudden and excessive force, which may be tapping, crushing, bending, twisting or pulling. The process of fracture repair varies according to the type of bone involved and the amount of movement at the fracture site. The specific aims of fracture treatment are: to relieve pain, to obtain and maintain satisfactory position of the fracture fragment, to allow and if necessary to encourage bony union; to restore optimum function not only in the fracture limb or spine but also in the patient as a person. There are three degrees of joint stability: occult joint instability, subluxation in which the joint surfaces have lost their normal relationship but still retain considerable contact; dislocation in which the joint surfaces have completely lost contact. The general principles of treatment for dislocations and subluxations: in order to restore normal congruity to the joint surfaces, perfect reduction of dislocations and subluxations must be achieved, either by closed manipulation or, when necessary, by open reduction.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. The type of fracture and healing process 2. Fracture in adult and children 3. Management of fracture
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SCENARIO Male 30 years old, came to our hospital with painful, swollen on he left thigh and difficulty to move his leg after traffic accident. He was motor cyclist and hit by a car. On physical examination: shortening of his left lower leg and false movement found. 1. What symptom and sign you find? 2. Which one is the probably symptom and sign for fracture? 3. Which one is the significant (full blown) symptom and sign for fracture?
Learning Task 1. How fractures happen? 2. Types of fracture 3. How fractures are displaced? 4. Fracture healing
Self Assessment 1. Describe about normal healing of fracture 2. Describe about abnormal healing of fracture
LEARNING OUTCOME
Establish tentative diagnosis, provide initial management and/or refer patient with: Fracture and dislocation in child and adult. o Fracture in adult
SCENARIO Male 25 years old, came to our hospital with painfull on he left thigh and difficulty to move his leg after traffic accident. He was motor cyclist and hit by a car. On physical examination: shortening of his left lower leg and false movement found. 1. What is your assessment for this patient? 2. How to manage the patient?
Learning Task 1. The special features of fractures and dislocation in adult and children 2. The general principles of fracture treatment 3. How to diagnosis of fracture and associated injuries
Self Assessment 1. Describe the special features of fractures and dislocation in adult 2. Explain the general principles of fracture treatment 3. How to diagnosis of fracture and associated injuries 4. Describe 3 degree of joint histability
LEARNING OBJECTIVE Establish tentative diagnosis, provide initial management and/or refer patient with: Fracture and dislocation in child and adult. o Fracture in children
SCENARIO Male, 3 years old, came to emergency unit with painfull on the right elbow and difficulty to movement his elbow after traffic accident. On physical examination; swelling of right elbow. 1. What is your assessment for this patient? 2. How to manage the patient?
Learning Task
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1. The specific methods of treatment of closed fracture 2. The complication of fractures and complication of fracture treatment 3. Explain about 3 degree of joint instability
Self Assessment 1. Describe the special features of fractures and dislocation in children 2. Explain the specific methods of treatment of closed fracture 3. Describe about the complication of fractures 4. Describe about the complication of fracture treatment
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th Day 9
MODULE 9 BONE JOINT, TENDONS AND LIGAMENTS
Prof. Dr.dr. Mangku Karmaya, M.Repro
AIMS: Describe normal structure and function of Joints and articular cartilage and.
LEARNING OUTCOMES: Apply its concepts and principles in the approach of patient with common arthritis and related inflammation/ infection
CURRICULUM CONTENTS: 1. cartilage of joint 2. sinovium and sinovial fluid 3. function of Joint
ABSTRACTS A joint is an articulation, the place of union or junction between two or more rigid components (bone, cartilages, or even parts of the same bone). Joints show variety of form and function. Some joints have no movement; others allow only slight movement, and some are freely movable. There are three types of joint according to the manner of material by which the articulating bones are united: (1) fibrous joints are united by fibrous tissue. This type are found as syndesmosis where a sheet of fibrous tissue, either a ligament or fibrous membrane, interosseous membrane in the forearm (between radius and ulna) and gomphosis or dentoalveolar syndesmosis between the root of the tooth and the alveolar process. (2) cartilaginous joints are united by cartilage or fibrocartilage and (3) synovial joints, the most common type of joint, that the articulating surfaces are covered with cartilage and united by a fibrous capsule. Distinguishing features of a synovial joint are, a joint cavity, articular cartilage that cover the bone end, and articular or joint capsule (fibrous capsule lined with synovial membrane) that enclose articulating surfaces and joint cavity. There are several types of synovial joint: (1) hinge joint (uniaxial: permit flexion and extension only eg., elbow joint), (2) pivot joint (uniaxial: allow rotation, a round process of bone fits into a bony ligamentous socket e.g., atlantooccipital joint between atlas /C1 and axis/C2), (3) saddle joint (biaxial: are shape like a saddle; i.e., they are concave and convex where bones articulate); (4) condyloid joints (biaxial: permit flexion and extension, abduction and adduction, and circumduction; eg., metacarpophalangeal joints or digits); (5) plane joints permit gliding or sliding movement (e.g., acromioclavicular joint) and (6) ball and socket joints (multiaxial: permit movement in several axes: flexion-extension, abductuction-adduction, medial and lateral rotation and circumduction, where a rounded head fits into a concavity)
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SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Classification of joints and its structures 2. Parts of synovial joint 3. The anatomy of ligament, tendon, aponeurosis, synovial tendon sheaths and bursae and their functions 4. Intra and extra articular ligaments
SCENARIO :
Case 1 A 60 year-old-woman fell down the stairs and was admitted to the emergency department with severe right shoulder pain. On examination, the patient was sitting up with her right arm by her side and her right elbow joint supported by the left hand. Inspection of the right shoulder showed loss of the normal rounded curvature and evidence of slight swelling below the right clavicle. Any atempt at active or passive movement of the shoulder was stop by severe pain in the shoulder. A diagnosis of dislocation of he right shoulder joint was made.
Learning task 1. Why the shoulder joint prone to dislocation? 2. Why the downward dislocation more frequent? 3. Describe the shoulder joint, its movement and the muscles involved.
Case 2 A father seeing his 3-year-old son playing in the garden, ran up and pick him up by both hands and swung him around in a circle. The child’s enjoyment suddenly urned to tearsand he said left elbow hurt. On examination, the child held his left elbow joint hemiflexed and his forearm pronated.
Learning task 1. What was really happen to the child’s elbow? 2. Why the elbow position hemiflexed and the fore arm pronated? 3. Describe the elbow joint (the bone, type, capsule, ligaments, synovial membrane).
Case 3 A medical student, while playing football, collided with another player and fell to the ground. As he fell the right knee, which was taking the weight of his body, was partially flexed, the femur rotatede medially, and the leg abducted on the thigh. A sudden pain was felt in the right knee joint, and he was unable to extend it. The student was diagnosed as having a torn medial meniscus of the kenee joint.
Learning task 1. What is meniscus? What is discus (disc)? What are their differences? 2. What structures involved in forming the knee joint? 3. What kind of movement in the knee joint and what muscles involved in the movement? 4. Compare the knee joint and elbow joint.
Self assessment 1. Describe the classification of joints and its structures 2. Describe the six major types of synovial joints and give examples for each type and their possible movements 3. Identify the parts of synovial joint
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4. Describe the joint of vertebral column 5. Compare the joints of upper and lower limb
AIMS: Describe normal structure and function of Tendons and ligaments.
LEARNING OUTCOMES: Apply its concepts and principles in the approach of patient with musculoskeletal disorders such as tendinitis
CURRICULUM CONTENTS: 1. Tendon 2. Ligament
ABSTRACTS OF LECTURES Structure and Function of Ligaments and Tendons Ligaments and tendons are soft collagenous tissues. Ligaments connect bone to bone and tendons connect muscles to bone. Ligaments and tendons play a significant role in musculoskeletal biomechanics. They represent an important area of orthopaedic treatment for which many challenges for repair remain. A good deal of these challenges has to do with restoring the normal mechanical function of these tissues. Again, as with all biological tissues, ligaments and tendons have a hierarchical structure that affects their mechanical behavior. In addition, ligaments and tendons can adapt to changes in their mechanical environment due to injury, disease or exercise. Thus, ligaments and tendons are another example of the structure-function concept and the mechanically mediated adaptation concept that permeate this biomechanics course. In this section, we will review aspects of ligament and tendon structure, function and adaptation. These notes follow very closely Chapter 6 on Structure and Function of Tendons and Ligaments from your text. We start out again emphasizing those ligaments and tendons have a hierarchical structure. One schematic of this hierarchical structure is taken from your text, and is a very famous schematic from Kasterlic:
The largest structure in the above schematic is the tendon (shown) or the ligament itselt. The ligament or tendon then is split into smaller entities called fascicles. The fascicle contains the basic fibril of the ligament or tendon, and the fibroblasts, which are the biological cells that produce the ligament or tendon. There is a structural characteristic at this level that plays a significant role in the mechanics of ligaments and tendons: the crimp of the fibril. The crimp is the waviness of the fibril; we will see that this contributes
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SCENARIO Case 1 A 54-year-old man was told by his physician to reduce his weight. He was prescribed a diet and was advised to exercise more. One morning while jogging, he heard a sharp snap and felt a sudden pain in his right lower calf. Onaxamination in the emergency department, physician noted that the upper part of the right calf was swollen and a gap was apparent between the swelling and the heel. A diagnosis of rupture of the right Achilles tendon was made.
Learning task 1. Why there was a gap apparent between the swelling and the heel? 2. Describe the anatomical and physiological aspects of Achilles tendon.
Case 2 A 27-year-old woma was running across some rough ground when the stumbled and overinverted her left foot. On examination in the emergency department of the local hospital, the lateral side of the left ankle was tender and swollen. A small area of hgreat tendernes was found below and in front of the lateral m,alleolus. X-ray exmination on the ankle joint was negative. A diagnosis of sprain of the left ankle was made.
Learning task 1. Why overinverted can cause sprain on the lateral side? 2. Describe the ankle joint, the muscles and the movements. 3. What structures as a stabilisator of ankle joint?
Case 3 A worker complained pain on his right elbow after doing painting. There was a swelling on the joint and become more pain after moving the elbow and grasping. On examination the doctor suspect a tendon injured.
Learing task 1. What tendon supposed to be injured? Why? 2. Describe the elbow joint, its movements and its muscles.
Self assessment 1. Describe the differences between ligament, tendon, aponeurosis, synovial tendon sheaths and bursae and their functions 2. Describe the intra and extra articular ligaments 3. Describe some clinical aspects of the ligaments, tendon, aponeurosis, synovial tendon sheath and bursae.
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th Day 10
MODULE
10 BONE AND IMUNOLOGY DISORDERS (OSTEOARTHRITIS AND GOUT ARTHRITIS)
Prof. Dr. dr. Tjok Raka Putra, Sp.PD
AIMS: Establish tentative diagnosis, provide initial management and/or refer patient with imunologis disorder.
LEARNING OUTCOMES: Establish tentative diagnosis, provide initial management and/or refer patient with osteoarthritis
CURRICULUM CONTENTS: 1. Osteoarthritis 2. Gout
ABSTRACTS The new definition Osteoarthritis (OA) is a result from mechanic and biochemistry phenomenon where imbalance between degradation and synthesis from chondrosit cartilage and matrix extracellular and subchondral bone. OA is a form of arthritis that common happened in human. Clinically OA is characterized with joint stiffness, pain and motion disorder, which in late state can develop deformity and immobilization. Osteophyte in cartilage can be found in radiographic findings. Estimation 10-30% of OA patients will become permanent disable; therefore OA is the main cause of chronic dysfunction worldwide. Treatment of OA until now is still unsatisfied, and the goal treatment is to reduce pain and disabilities.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Diagnosis of Osteoarthritis 2. Management of osteoarthritis 3. Diagnosis of gout arthritis 4. Management of gout arthritis
SCENARIO A 57 year old woman government servant, a Balinese pensioner came to hospital with main complaint swelling of right knee since 2 months ago. She also complains pain while moving around. She has the relapse during religious occasion in her village. Her weight is 67kg and height 156cm. At the moment, she is active as a Hindu priest.
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1. What are other things that have to be asked in patient with swelling and pain in the knee? 2. What associate factors those need to be asked? 3. What other risk factors should be asked in this patient? 1. What other physical examination should be find in this patient? 4. What are the diagnosis criteria in this patient? 5. What is the general management in this patient? 6. What is the medication should be given in this patient? 7. How do you educate this patient? 8. When do we refer this patient to expertise? And what expertise?
Learning Task 1. Joint Anatomy 2. Joint disorder in Osteoarthritis patient 3. Pathogenesis of Osteoarthritis 4. Diagnosis criteria in Osteoarthritis 5. Management of Osteoarthritis
Self Assessment: 1. Please state types and etiology of OA 2. Please state pathogenesis of OA 3. What are the pathology found in OA 4. What are the diagnostic criteria in OA 5. What are the complications in OA
LEARNING OBJECTIVE Establish tentative diagnosis, provide initial management and/or refer patient with : Gouty arthritis/Pseudo Gout
ABSTRACTS Gouty arthritis is a disease of uric acid metabolism disorder, characterized by hyperuricemia and uric acid crystal deposits in joint, predominantly at big toe. Gouty arthritis is a group of heterogenic disease caused by deposition of uric monosodium crystal in tissue or supersaturation of uric acid in extracellular fluid. Gouty is a disease caused by uric acid metabolism, manifested by gouty arthritis, uric acid accumulation in tissue, uric nephropaty, uric acid stone in kidney. Most of gouty arthritis common in men (90%), with peak of acute attack in fifth decade of life, in woman it commonly occured after menopause. Management of gouty arthritis patient should be comprehensive and continuous. Basic principle of the management is normal uric acid serum regulation.
SCENARIO A 45 year old Balinese Male, with height 170 cm, weight 65 kg, complaint pain and swelling in his left big toe since yesterday. Two day ago, he didn´t complaint any thing and he just played football in renon field. He had the same complaint before but never this worst. Patient feels dizzy and malaise. He had history of high uric acid level but 3 months ago the level was 6.5 mg%. He has no take medication.
Learning Task: 1. What should you ask to the patient if the chief complaint is swelling at big toe? 2. What other complaints that you should ask to this patient? 3. What are the risk factors in this patient? 4. What are the physical examination (general and specific) that you should look in this patient? 5. How to make proper diagnosis in this patient?
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6. What is the management in general? 7. What medication should be given to this patient? 8. What other education should be given to this patient? 9. When this patient should be referred to expertise? To what expertise?
Self Assessment: 1. What is hyperuricemia? 2. What is the pathologic manifestation of hyperurecemia? 3. What is the pathogenesis of gouty arthritis? 4. What are the diagnosis criteria of gouty arthritis? 5. What is the gold standard to diagnose gouty arthritis? 6. What are the complications of gouty arthritis? 7. What is the management of gouty arthritis? 8. What medication should be given in acute gouty arthritis? 9. What is the management of intercritical and chronic gouty arthritis? 10. What is the diet in gouty arthritis patient?
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th Day 11
MODULE 11 SKELETAL MUSCLES
dr. I.A. Ika Wahyuniari, M.Kes
AIMS: Describe normal of microscopic structure and function of skeletal muscles.
LEARNING OUTCOMES: Apply its concepts and principles in the approach of patient with musculoskeletal disorders such as degenerative disease of muscle (Duchene, Becker)
CURRICULUM CONTENTS: Microscopic of Skeletal muscle
ABSTRACTS Histology of Muscle The muscle cells are mesodermal origin. Their differentiation occurs mainly by gradual process of lengthening. Muscle tissue is responsible for body movements. Three types of muscle tissue may be distinguished on the basic of morphologic and fungtional characteristic. Smooth muscle consists of collections of fusiform cells with light microscope do not show striation. Striated skeletal muscle is composed of bundles of very long cylindric multinucleated cells that present cross-striation. Cardiac muscle composed of elongated or branched cells that run parallel each other and end to end contact are the intercalated disks and it contraction is voluntary, vigorous and rhythmic.
Organization of striated muscle Dense connective tissue surrounding the entire muscle called the epimysium and extend inward surrounding bundles of muscle are called perimysium and delicate layer of connective tissue surrounding the fiber called endomysium. The blood vessels penetrate into the muscle runs between and parallel to the muscle fibers. As observed with the light microscope, longitudinally sectioned muscle fibers when stained with hematoxylin and eosin show darker bands are called A band and lighter band are called I band. Each I band is bisected by dark tranverse lines, the Z line. The smallest repetitive subunit of the contractile apparatus is called sarcomere extend from Z to Z. The sarcoplasm of each fiber is filled with long cylindric filamentous bundles called myofibrils and composed of end to end chain-like arrangement of sarcomeres. The sarcomere are composed of thick (the myosin) and thin (the actin) filament. The thick filaments occupy the A band the central of sarcomere and the thin filaments run between and parallel to the thick ones and have one end attached to Z line. The striated muscle fibers contain at least four main proteins: actin, tropomyosin, troponin and myosin. Troponin is a complex of 3 subunits: TnT (attached to tropomyosin), TnC ( which binds calsium ions ) and TnI ( which inhibits the actin and myosin interaction ).
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Myosin can be cleaved into two fragments, light meromyosin and heavy meromyosin. Analysis of thin section of striated muscle show the present of crossbridges between thin and thick filament.The head of the myosin, the ATPase head are considered to be directly involved in transduction chemical into mechanical energy for muscle contraction.
Organization of cardiac muscle Mature cardiac cell exhibit a crossstriated banding patern which centrally nucleus identical to that skeletal muscle and distinguish by the present of intercalated disk a junctional complexs between adjacent cardiac muscle. Cells within a chain often bifurcate or branch and bind to cell adjacent chains. Smooth muscle is composed of long spindlelike cells, each cell possesses centrally located nucleus. In bundles of smooth muscle, the fusiform cells overlap one another along their length. The bundles normally arranged into layers with cells in adjacent layers usually lying at right angles to each other.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Microscopic view of muscle cell 2. Typre of muscle cell 3. The component of cell relate to muscle contraction
SCENARIO A 50-year-old man came to the clinic because of the asymetry of his leg: the left leg being much smaller than the right one. Five months earlier, he had an accident with fracture of his left leg (tibial bone) and he refused to get an operation. Until now, he has been using a crutch to support his left leg during walking. The doctor diagnosed him to suffer from disuse atrophy.
Learning Task: 1. What has happened to the structure of his left skeletal muscle? 2. Describe the microscopic structure of skeletal muscle! 3. Differentiate the skeletal muscle from cardiac and smooth muscles! 4. Describe the structural organization of myofibrils and sarcomere!
Self Assessment: 1. Can you tell me all cell structure that involved in contraction? 2. Please differentiate the three kind of muscle cell? 3. Can you tell me the ultrastructure of actin and myosin?
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th Day 12
MODULE
12 MUSCLE CONTRACTION AS MOVEMENT TRIGGER
Dr.dr. I Putu Gede Adiatmika, M.Kes
AIMS: Describe bioelectric of excitation and muscle contraction.
LEARNING OUTCOMES: Apply its concepts and principles in the approach of patient with musculoskeletal disorders
CURRICULUM CONTENTS: 1. Action potential 2. Muscle contraction 3. Excitation contraction process
ABSTRACT Human movement is occur under spesific stimulation. Proper stimulus will excite the nerve to generate an action potential within nerve including axon. Action potential is affected by sodium and potassium exchange between extracelular and intracellular fluid, permeability of membrane and membrane threshold. Every stimulation will drive electrolyte to move pass the membrane and will increase the membrane potential to be action potential. Action potential stage consist of depolarization and repolarization. All the process of action potential refers to all-or-nothing principle. Action potential will deliver along axon to the muscles through neuromuscular junction using neurotransmitter called acetylcholine. Action potential will spread into the muscle through motor end plate, sarcolemma, t-tubule and cisternae. The end result of this process is release of calcium ions to the filaments. Calcium from cisternae will stimulate sliding filamen mechanism where actin and miosin acttach each other. This process need energy that is provided from anaerobic or aerobic metabolism and promote contraction. Mechanism of muscle contraction is similar to both skeletal and smooth muscles. The differences of them are time of contraction, energy consumed, source of calcium ion and excitation-contraction coupling.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Action potential and its components 2. Process of muscle contraction 3. Transfer impus from neuron to cell
SCENARIO
Case 1
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Mr X, 45 years old, brought to emergency unit cause of traffic accident, and the motor cycle hit his back. On physycal examination, he could not move his lower back was with the chief complaint of unable to move his lower leg.
Learning Task: 1. Identify the problem of those patients? 2. What did the cause and source of paralyze? 3. Why stimulus from the brain couldn’t move the lower leg? 4. Explain the process of action potential within the axon!
Case 2 On marathon race, one athlete was falling down during the racing and scream that his left calf was suffer from cramp. He felt very pain on the legs and asked someone to stretch the legs. The therapist sprayed chlorethyl and massaged the calf. The others gave the athlete an isotonic liquid, too.
Learning task: 1. Please explain why the athlete suffers from cramp? 2. What is happen of contraction relaxation process within his calf muscles? 3. Identify any factors that affect to contraction process? 4. What is the important process within muscle cell that cause contraction? 5. What the role of electrolit and energy during racing? 6. What type of contraction that able to move the legs during race?
Case 3 One patient came to emergency department with the chief complaint of open wound on the lower arm and must be stitched. The patient cried and asked for anesthesia from the doctor. During the stichting, the patient looked happy and asked the doctor what happen to his wound and why he didn’t feel pain?
Learning Task: 1. Please explain the role of anesthesia in that case? 2. Which one of the neuromuscular components that was blocked? 3. Explain several substances that affect to neuromuscular junction?
Self Assessment: 1. Describe distribution of ions surrounding the cell membrane and concentration of various ion to tissue electric arrangement, transport ion through Na-K pump and resting potential membrane. 2. Describe the stage of action potentials on the neuromuscular and its response. Identify resting, depolarization and repolarization stage. 3. Describe the propagation of action potential on nerve. Explain the principle of “all or none law” or “All-or-Nothing Principle”. 4. Describe general mechanism of muscle contraction or “sliding filament theory” step by step from excitation to contraction. 5. Describe the source of energy for muscle contraction. 6. Describe the characteristics of whole muscle contraction such as isotonic – isometric, slow – fast fibers, motor unit, multiple fiber – frequency summation which can lead tetanization, muscle fatigue, atrophy – hypertrophy. 7. Describe the transfer impulse process from nerve to muscle 8. Describe the excitation contraction process from nerve to muscles
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th Day 13
MODULE
13 MUSCLE AND DEGENERATIVE DISORDERS
dr. Ni Made Susilawati, SpS
AIMS: Establish tentative diagnosis, provide initial management and/or refer patient with Degenerative disorders.
LEARNING OUTCOMES: Establish tentative diagnosis, provide initial management and/or refer patient with Duchene and Becker Muscular dystrophy
CURRICULUM CONTENTS: Duchene and Becker Muscular dystrophy
ABSTRACTS OF LECTURES Dystrophy Muscular Progressive (DMP) is a neuromuscular disease which attacks the muscle organs. This disease is caused by x-linked recessive. The first symptoms that occurred is when the patient is 2 year old. The patient shows Gower Sign and waddling gait sign. The muscle weakness usually can be seen in the proximal muscles. In the laboratory findings, there will be slight increase in CPK enzyme. The progressivity of this disease occurs fast, and the patient died at the age of 15 or 40, depends on the type of DMP.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Diagnosis of Duchene and Becker Muscular dystrophy 2. Management of Duchene and Becker Muscular dystrophy
SCENARIO The surveillance team AFP health department of Bali Province in Bangli found 2 boys at the age of 6 and 12, suffering from paralisi in 4 extremities which started from lower extremities to the upper extremities. This started gradually when they were 3 year old. Their sister doesn’t suffer from this condition. When the patients lie down and want to get up, they showed as if they were climbing and can’t stand spontaneously. This complain doesn’t followed by sensibility disorder such as numbness or tingling sensation. Their calf muscle looks bigger; they walked like duck, cognitive function impaired. No history of fever or neck injury was found in these patients before having this complain.
Learning Task: 1. What’s the problem found in the scenario above?
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2. What’s the differential diagnosis and what’s the most probable diagnosis? 3. Could you explain the pathogenesis of this disease? 4. Could you explain in detail, the clinical diagnostic of this patient? 5. What do you expect from the physical examination in this patient? 6. What other laboratory would like to perform in this patient? 7. How do you manage this patient? 8. When do you refer this patient?
Self Assessment: 1. What is the genetic characteristic and how it can be passed in their kids? 2. Please explain the clinical signs and symptoms in DMP patient and types of DMP? 3. What other test needed to help the diagnosis? 4. What is the early stage management in this patient and how to suppress the progressivity of this disease? 5. How is the prognosis in DMP patients based on the type?
RHEMATIC NON ARTHRICULAR (dr. Kambayana, Sp.PD)
Will be delivered later – on scheduled)
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th Day 14
MODULE
14
DEGENERATIVE DISORDERS OF SPINE
dr. K.G. Mulyadi Ridia, SpOT (K) / dr. K. Suyasa, Sp.B, Sp.OT (K)
LEARNING OBJECTIVE Establish tentative diagnosis, provide initial management and/or refer patient with Degenerative disorders of spine.
CURICULIM CONTENT 1. Low Back Pain (LBP) 2. Neck Pain
ABSTRACTS (Dr. K.G. Mulyadi Ridia, SpOT (K))
Degenerative disorders in the spine, includes two interrelated condition: intervertebral disc joint (Degenerative disc disorders) and posterior facet joint (degenerative joint disorders). Both condition represent an exaggeration of normal aging process, and may be aggravated by injury, deformity, and pre – existing disorders of the spine. The resultant LBP is the most common of symptoms The interrelated degenerative process in the spine is best considered under the heading of disc degenerative, segmental instability, segmental hyperextension, segmental narrowing, and herniation of the disc. The treatment of patients with degeneration disorders in the spine is base in the following aims: 1. To alleviate pain 2. To help the patient understand the nature of the disorders 3. To provide psychological support 4. To strengthen weak trunk muscles 5. To improve function 6. To rehabilitate the individual patient The methods of treatment are: Psychological consideration, therapeutic drug, bed rest, orthopaedic apparatus, appliances, physical therapy, spinal manipulation, chemo nucleolysis, surgical apparatus, and rehabilitation.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Diagnosis of Low Back Pain and Neck Pain 2. Management of Low Back Pain and neck Pain
SCENARIO 55 year old male, automobile mechanic, ex weight lifter, complained back pain since 5 years ago, especially after working, and sitting for long time. Patient also felt morning
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Study Guide Musculoskeletal System and Connective Tissue Disorders stiffness of her back. At 25 year old, patient had back pain referred to his buttocks and right leg.
Learning Task: 1. How do you do complete anamnesis of the patient with back pain and neck pain? 2. How do you do physical examination in back pain patient and neck pain ? 3. What is the predisposing factor in back pain amd meck pain patient? 4. What is the management of back pain and neck painpatient? 5. What is your advice for those patient?
Self Assessment: 1. Please draw the anatomical structure of spine 2. What are the structures in the lumbal area that might cause back pain? 3. What are the structures in the lumbal area that might cause neck pain?
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Day 15 th - 19 th CLINICAL SKILL
MODULE 15
ANATOMY OF MUSCULOSKELETAL DS T e a m
AIMS:
LEARNING OUTCOMES:
CURRICULUM CONTENTS:
PROCEDURAL OF CLINICAL SKILL:
MODULE 16
HISTOLOGY OF BONE, CARTILAGE, MUSCLE
Team
AIMS:
To increase understanding about bone, cartilage and muscle
PROCEDURAL OF CLINICAL SKILL: Material : 1. Microscope 2. Histological preparat about bone, cartilage and muscle a. Bone : - Intra membraneous ossification - Endochondral Ossification - Compact / lamellar bone - Woven bone b. Cartilage : - Hyaline cartilage - Elastic cartilage - Fibrocartilage c. Muscle :
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- Cardiac muscle - Smooth muscle - Skeletal muscle
MODULE 17
PHYSIOLOGY OF MUSCLE CONTRACTION MUSCLE STRENGTH CONTRACTION
Team
AIMS:
1. To compare steady state work and fatigue related work 2. To comprehend the effect of blood supply disturbation, rest and massage to the fingers muscles work
MATERIAL:
1. Kimograf SET 2. Manset spigmomanometer. 3. Ergograf 4. Metronom
PROCEDURAL OF CLINICAL SKILL :
Steady state work
1. Set all the equipment as shown at the picture on the left. 2. While recorded, do one contraction every 4 second according to Metronom’s sound (120 second minutes) about 1/2 round of tromol. 3. After each contraction, put off your fingers from the trigger, so the trigger will back to the initial position.
Fatigue related work
1. Blood supply disturbance: 1.1 Apply the sphigmomanometer’s manset on the same student’s upper arm. 1.2 Before test, do several exercises of blood occlusion by pump the manset immediately until the tester can’t feel the pulse of artery radialis. 1.3 On the same position, please do 12 contractions without occlusion every 4 second. 1.4 While continue tromol rotation, on the 13 th contraction occlusion is started by pump the manset. The student continues his contraction.
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1.5 Put the sign on the curve when the pulse rate disappeared. 1.6 After complete fatigue, decrease the blood pressure, so the blood circulation returns to normal. The student still continues his contraction. 1.7 In the same frequention, please continue the contraction and recording until the effect of blood occlusion is gone. 2 Effect of rest and massage: 2.1 Please use another student for the next test. 2.2 Set load of ergograf at the maximal position. 2.3 Do the contraction every 1 second and stop when get on complete fatigue and stop tromol rotation. 2.4 Take a rest for 2 minutes dan put the hand on the table. 2.5 Slide the tromol manually about 2 cm and stard the rotation. Continue the contraction as previously until complete fatigue. 2.6 Take a rest for 2 minutes and do a massage on the arm of sample. 2.7 Slide the tromol, and do the similar contraction as on 2.5. 2.8 Compare both recorded of contraction only and contraction with massage.
3. Pain, color and temperature: 3.1 Do the test with new student. 3.2 Put the manset on right upper arm and give maximal load. The result will show little deviation on the tromol. 3.3 While contraction, please observe the temperature and colour of lower arm’s skin of sample. 3.4 Do the contraction every 1 second and blood occlusion until complete fatigue or painful. 3.5 Stop the occlusion when the sample feels painful. Observe the colour and temperature of lower arm’s skin.
MODULE 18
PATHOLOGY ANATOMY OF MUSCULOSKELETAL DS
Team
AIMS:
LEARNING OUTCOMES:
CURRICULUM CONTENTS:
PROCEDURAL OF CLINICAL SKILL:
MODULE 19
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PHYSICAL DIAGNOSTICS OF MUSCULOSKELETAL DS
Team
AIMS:
LEARNING OUTCOMES:
CURRICULUM CONTENTS:
PROCEDURAL OF CLINICAL SKILL:
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th Day 20
MODULE 20
MID – TERM TEST
Topics : Anatomy of Bone and Muscle
Student will be assessed using pcture of bone and muscle. The picture are provided and the student must give the name of bones or muscles acoording to the pointer on the picture
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st Day 21
MODULE 21
NEOPLASM OF SOFT TISSUE & BONE (BENIGN)
Dr. Eka W, Sp.OT
AIMS: Establish tentative diagnosis, provide initial management and/or refer patient with various soft tissues tumors and tumor-like lesion and benign neoplasm
LEARNING OUTCOMES: Establish tentative diagnosis, provide initial management and/or refer patient with various soft tissues tumors and tumor-like lesion and benign neoplasm
CURRICULUM CONTENTS: 1. soft tissues tumors and tumor-like lesion and 2. Benign neoplasm a. Osteochondrome b. Gct c. Osteoma d. Osteoid osteoma
ABSTRACT Bone tumor or tumor from bone is rare case that only 0.2 % from all tumors. Bone tumors are benign and malignant. Cancers of bone can be primarily from bone itself, or secunderly from another site. Benign neoplasm of bone usually found unpredictable, because no specific symtoms before it give complication like compression to the surrounding tissues or a fracture. Conversely bone cancers always give similar signs as another diseases like osteomyelitis or fracture of bone, and bone cancers always be found with bad condition. The management of bone tumors particularly for malignant tumors, early diagnosis is very imfortant for further treatment. The modality of management is defending on the gradation. To know about the stadium, cooperation between orthopaedi, radiology and pathology anatomy are necessary. Vigilance for the bone tumors should be increase because sign of malignant bone tumor always mistakable with another case. Malignant bone tumor usually (75%) attack childrents and need radical surgery, extensive, and chemotherapy which uncomfortable, and that are challenge to be an orthopaedic for treating bone tumors. Because of that to be general practitioner to impeach bone tumor will increase early diagnosis and good result in the management.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Diagnosis od soft tissue tumor
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2. Management of soft toissue tumor
SCENARIO
Case 1 A boy come with lump at the bone of the right thigh close with knee, and below of the left knee. His family doesn’t suffering disease like him, but his farent has lump like him.
Learning Task: 1. What the problem with him? 2. What kind of anamnesis which necessary for the patient? 3. What kind of physical examination and pem. Tambahan which necessary for the patient? 4. If the the lump is benign, can you make the classification of bone tumor by Aegerter? 5. Explain, what the meaning with reactive bone lesion, hamartoma ? 6. What are the clinical feature, radiologic, and histopathology of the benign bone tumors (Osteoma, Osteochondroma, GCT) 7. How the principely of the management of benign bone tumors?
Case 2 Seventeen year old boy, two weeks ago his right knee hited a table, and now his knee swollen, redness, warm, and painfull.
Learning Task: 1. What x-ray should be performed? 2. What are yourdifferential diagnoses regarding on location where the patient complaint? 3. May the patient suffer of malignant bone tumor? 4. What are the radiologically if true malignant bone tumor? 5. What is the prognosis base on the radiology imaging? 6. Can you explain the tumors which have radiology feature patognomonic?
Self Assessment: 1. Learn about the definition of benign and malignant bone tumors 2. Learn the classification of bone tumors 3. Learn about the relation between the location and kind of bone tumors? 4. Learn about the management of benign bone tumors 5. What the classification of bone tumor by Aegerter? 6. Can be the GCT classify into malignant bone tumor? 7. What kind of radiology appearance for the bone tumor generally?
NEOPLASM OF SOFT TISSUE & BONE (MALIGN)
AIMS :
Establish tentative diagnosis, provide initial management and/or refer patient with malign neoplasm of the bone & soft tissue
LEARNING OUTCOME: Establish tentative diagnosis, provide initial management and/or refer patient with malign neoplasm of the bone soft tissue
CURRICULUM CONTENTS: Malign neoplasm of the bone soft tissue
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1. osteosarcoma 2. chondrosarcoma 3. ewing tumor
ABSTRACTS Bone tumor or tumor from bone is rare case that only 0.2 % from all tumors. Bone tumors are benign and malignant. Cancers of bone can be primarily from bone itself, or secunderly from another site (metastasis). Benign neoplasm of bone usually found unpredictable, because no specific symtoms before it give complication like compression to the surrounding tissues or a fracture. Conversely bone cancers always give similar signs as another diseases like osteomyelitis or fracture of bone, and bone cancers always be found with bad condition. The management of bone tumors particularly for malignant tumors, early diagnosis is very imfortant for further treatment. The modality of management is defending on the gradation. To know about the stadium, cooperation between orthopaedi, radiology and pathology anatomy are necessary. Vigilance for the bone tumors should be increase because sign of malignant bone tumor always mistakable with another case. Malignant bone tumor usually (75%) attack childrents and need radical surgery, extensive, and chemotherapy which uncomfortable, and that are challenge to be an orthopaedic for treating bone tumors. Because of that to be general practitioner to impeach bone tumor will increase early diagnosis and good result in the management.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Diagnosis of malign tissue tumors 2. Management of malign tissue tumors
SCENARIO A 10 year old boy complaint about lump around his right knee accompanied with erythema and pain. The lump and pain were beginning 4 months ago. He looks pale and skinny. One week ago, he got slipped and fall, the pain is getting worst. After that, this patient comes to you.
Learning task: 1. Make a complete history of this patient! 2. In physical examination what would you expect to find in this patient? After that, what other you should do? 3. Please explain the radiograph of bone cancer? 4. Please explain about hysthopathologic of bone cancer ( osteosarcoma, chondrosarcoma, ewing tumor etc) 5. What is metastase? How is the pathway of bone cancer metastase? 6. What is the principal of bone cancer treatment?
Self assessment: 1. Learn about primary and secondary bone cancer. 2. Learn about management of bone cancer, especially: a. History taking b. Radiographic c. Biopsy d. Treatment: Surgical and adjuvant 3. What is the commonest bone cancer you can find? 4. What is the differences of primary osteosarcoma and secondary osteosarcoma?
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ULCER AND MANAGEMENTS dr. Eka W, Sp.OT
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nd Day 22
MODULE 22 BONE INFECTIONS
dr. Wayan Suryanto Dusak, SpOT
AIMS: Establish tentative diagnosis, provide initial management and/or refer patient with infection of musculoscletal system
LEARNING OUTCOMES: Establish tentative diagnosis, provide initial management and/or refer patient with: Osteomyelitis and Septic arthritis
CURRICULUM CONTENTS: 1. Osteomyelitis and 2. Septic arthritis
ABSTRACTS
One of the most serious inflammatory disorders of the musculoskeletal system is acute hematogenous osteomyelitis, a rapidly developing blood – borne bacterial infection of bone and its marrow in children The first and most significant symptom afflicted child experiences is severe and constant pain near the end of the involved long bone. It’s extremely important to appreciate that the early diagnosis of acute hematogenous osteomyelitis must be made on clinical ground alone, because during at least the first week of illness, there is absolutely no concrete radiographic evidence of bone infection Acute hematogenous osteomyelitis represents an extremely serious infection that demands urgents and vigorous treatment. As soon as the clinical diagnosis strongly suspected, the child should be admitted to hospital for intensive treatment. In general, the most effective treatment is bed rest and analgetics, supportive measures immobilization, and antibacterial therapy When pyogenic bacteria are invide a synovial joint, the result is acute septic (pyogenic) arthritis. The most common source of septic arthritis in children is spreading of pyogenic bacteria from hematogenous osteomyelitis. The general features and general principles treatment of septic arthritis is similar to acute hematogenous osteomyelitis
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Diagnosis of osteomyelitis 2. Management of osteomyelitis
SCENARIO
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Five years old boy, came to the hospital with pain and swelling on his right hip after fell down when he played 3 days ago. The child un willingness to use his limb and within 24 hours appears acutely ill: 1. What you assessment for this patient? 2. What is your diagnosis? 3. How to manage the patient?
Learning task: 1. General features of inflammatory process of the musculoskeletal tissue 2. Etiology of AHO and septic arthritis 3. Pathogenesis and clinical features of AHO and SA 4. Treatment AHO and SA 5. Complication of AHO and SA
Self Assessment I : 1. Please explain the definition and sign and symptoms of bone infection 2. Please explain the infection route in bone and cartilage 3. Please explain the osteomyelitis classification
Self Assessment II: 1. Please explain the radiologic findings of osteomyelitis
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Day 23rd
MODULE 23 MUSCULOSKELETAL REHABILITATION
dr. Tjok Dalem Kurniawan, SpRM
AIMS: Describe the Rehabilitation of musculoskeletal
LEARNING OUTCOMES: Describe the Rehabilitation of musculoskeletal after injury degenerative disorders
CURRICULUM CONTENTS: a. Execerise Therapy b. Deconditioning c. Physical modality d. Prosthesis
ABSTRACTS
Musculoskeletal disorders are the most frequent type of disabilities, and pain is the most common cause musculoskeletal disability. Musculoskeletal complaint include non specific symptoms such as pain in the neck, back, and extremities, chronic inflammatory or degenerative disorders, and a wide range of sports injuries, traffic and occupation accident. These disorder cause disability, suffering and reduce a person quality of life. Early mobilization in musculoskeletal disorder is needed for preventing immobilization syndrome. Management of rehabilitation for musculoskeletal disorders consist of giving some medicine, physical modality, exercise therapy and sometime need walking aid
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Rehabilitation for musculosceletal disorders
SCENARIO Old men, 40 year, have a traffic accident. In emergency room, is got right thighbone fracture and left forearm, then planned to do operation. After operation, right thigh muscle minimizes and stiff in the knee and patient cannot walk.
Learning Task 1. Mention kind of exercise therapy 2. Mention complication of long immobilization! 3. Explain the way of prevention of that complication long immobilization! 4. Mention what physical modalities able to be used! 5. Mention kind of walking aid!
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Self Assessment: What is the role of rehabilitation for the musculoskeletal disorders treatment?
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th Day 24
MODULE 24 BONE FORENSIC
dr. Ida Bagus Putu Alit, Sp.F, DFM
AIMS:
Describe personal identity and pathological changes from skeleton
LEARNING OUTCOMES:
Describe personal identity and pathological changes from skeleton
CURRICULUM CONTENTS: a. Animal bone b. Human bone c. Age of human bone
ABSTRACTS
Examination of Human Skeletal can provide important information to determine the identity of decease. The necessity for the identification of a decreased individual not only fulfill a legal obligation which may be down in law, but recognize the fundamental right of all individual to have an identity both in life and after death. The doctor must collect information that will established the identity, the time of death, the cause of death and the manner or mode of death (homicide, suicide, accidental or natural). In identification process, the doctor have task to establish: 1). The Human or non human skeletal, 2). the number of deceased, 3). General identification of the skeletal (gender, race, age, stature etc) and specific traits of the bone. Human or non human skeletal can be established by gross anatomy, histology appearances and x-ray examination. The gender and race can be determined by examination of many bones especially skull, pelvic bone and long bones. The age can be estimated by the changes pattern of ectocranial sutures, pubic symphysis and pre auricular surfaces. The cause of death (COD) and the manner of death (MOD) can be established only if the trauma implicated the bone or related poison can be detected on bone.
SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. The role of bone forensic 2. International protocol analysis 3. Medicolegal aspect of violence
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SCENARIO
Case 1 Skeletal was found by a farmer in the field and reported to police immediately. After that, police came to secure the skeletal and did an investigation. From the investigation, police found that the skeletal was 35 year old Indonesian female, Type A Blood, height 149cm. The victim had already given birth twice with history of normal labor. Police asked for medical examination afterwards. The doctor, who examined, found that the skeletal was complete human skeletal. 1. What’s the purpose of this investigation? 2. a. To do bone sexing, the most accurate criteria can be seen from pelvic and cranium bone. Please mention the characteristic of the cranium and pelvic bone based on their gender. b. Beside cranium and pelvic bone, gender can also be determined from the other long bones. What are the differences of the long bones at each gender? 3. Race can be determined based on the characteristic of the skeleton and race indexes a. Please mention the race characteristics seen on their skeleton b. Please explain about cephalic indexes and pos-cranial indexes in determining race 4. Bone aging based on skeletal appearance can be evaluated from its ossification center, teeth eruption, suture closure, symphisis appearance and preauricular surface. Please mention and explain about bone aging. 5. Besides determining sex and age, pelvic bone can also be used to determine parturitas. What’s the characteristic of parturitas on the pelvic bone? How’s the process happened? 6. How to determine blood type from the skeleton?
Case 2: A 40 year old male was hit with a block wood at the right thigh during a fight. Examination revealed wound and closed fracture femur at middle 1/3th 1. The fracture can be seen with 2 aspects, medical and judicial. What are those terms means ? 2. Please explain in medicolegal aspect of the fracture. 3. Please define the qualification of the fracture and the reason for the qualification 4. What are the purpose of fracture qualification in the conclusion of visum et repertum
Learning Task: 1. Student know about international protocol analysis 2. Student know about bone and bone change according to age 3. Student know about medicolegal aspect of violence
Self Assessment I: 1. Can we determine bone age? 2. Can we differentiate between human bone and animal bone?
Self Assessment II: 1. What’s the meaning of visum et repertum?
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th Day 25
MODULE 25 NSAID AND MUSCLE RELAXANT
dr. I.B. Ngurah, M.Kes dr. Agung Wiwiek Indrayani, M.Kes
AIMS: Describe the pharmacologic of NSAID and muscle relaxant
LEARNING OUTCOMES: 1. Describe the classification of NSAID, toxicity and interaction 2. Describe the classification of muscle relaxants, toxicity and interaction
CURRICULUM CONTENTS: 1. Classification the anti-inflammatory drugs, drugs used in Gout 2. Mechanism of actions of the NSAIDs, acetaminophen and drugs used in Gout 3. Pharmacokinetics of the NSAIDs and drugs used in Gout 4. Clinical used of the NSAIDs and drugs used in Gout 5. Toxicities of the NSAIDs and drugs used in Gout 6. Drug drug interactions of the NSAIDs 7. Pharmacologic aspects of Celecoxib, Rofecoxib, Meloxicam, Diclofenac, Diflunizal, Etodolac, Ibuprofen, Indomethacine, Mefenamic acid, Naproxen, Piroxicam 8. Classification the Disesase-Modifying, Slow-Acting Antirheumatic Drugs (DMARDS, SAARDS)
ABSTRACT
The treatment of patients with inflammation involves two primary goals : first, the relief of pain, which is often the presenting symptom and the major continuing complaint of the patient; and second, the slowing or- in theory- arrest of the tissue-damaging process. Reduction of inflammation with nonsteroidal antiinflamatory drugs (NSAIDs) often results in relief of pain for significant periods. Furthermore, most of the nonopioid analgesics (aspirin, etc) also have anti-inflammatory effects, so they are appropriate for the treatment of both acute and chronic inflammatory conditions. The glucocorticoids also have powerful anti-inflammatory effects and when first introduced were considered to be the ultimate answer to the treatment of inflammatory arthritis. Unfortunately, the toxicity associated with chronic corticosteroid therapy inhibits their use except in the control of acute flare ups of joint disease. Therefore, the nonsteroidal antiinflamatory drugs have assumed a major role in the treatment of arthritis. Another important group of agents are characterized as slow-acting antirheumatic drugs (SAARDs) or disesase-modifying antirheumatic drugs (DMARDs). They may slow the bone damage associated with rheumatoid arthritis and are tought to affect more basic inflammatory mechanism than do the NSAIDs. Unfortunately, they may also be more toxic than the nonsteroidal anti-inflammatory agents.
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SELF DIRECTING LEARNING
Basic knowledge that must be known: 1. Type of NSAID 2. Pharmacology of NSAID 3. Type of muscle relaxant 4. Pharmakologic of muscle relaxant
SCENARIO : A 60-year-old woman complains with intense painful, warmth, redness and great swollen in the first toe her right foot. Examination of fluid from the inflammed joint revealed crystals of uric acid. The physician diagnosed the patient as acute attack of Gout. 1. Classify the treatment strategies in Gout arthritis 2. Explain the choice treatment for acute attack of Gout 3. List the toxicities drugs for acute attack of Gout
Learning Task: 1. Classify the anti-inflammatory drugs and drug used in Gout (Trevor, page 307) 2. Describe the mechanism of actions NSAIDs, Acetaminophen and drugs used in Gout (Trevor, page 307, 311) 3. Explain the pharmacokinetics of theNSAIDs (Trevor, page 308) 4. List the toxicities of the NSAIDs (Trevor, page 309) 5. Describe the clinical used of the NSAIDs (Trevor, page 308) 6. Describe the advantages of the COX 2 inhibitor compare with non selective NSAIDs (Trevor, page 309) 7. List the toxicities of the COX 2 selective inhibitor (coxibs), why? (Lecture, Katzung, page 583) 8. Explain the interaction of the NSAIDs and drugs used in Gout with other drugs ollowing drugs (Trevor, page 313) 9. Describe the pharmacologic aspects of the Celecoxib, Rofecoxib, Meloxicam, Diclofenac, Diflunizal, Etodolac, Ibuprofen, Indomethacine, Mefenamic acid, Naproxen, Piroxicam (Katzung, page 582-587) 10. Classify of the Disease-Modifying, Slow-Acting Antirheumatic Drugs (DMARDS, SAARDS) (Trevor, page 309) 11. List the toxicities of the glucocorticoid (Katzung, page 594-595) 12. How to use the glucocorticoid in rheumatoid arthritis (Lecture, Katzung, page 594)
Self Assessment: 1. Which of the drugs do not have anti-inflammatory effect A. Ibuprofen B. Mefenamic acid C. Acetaminophen D. Aspirin E. Naproxen 2. What’s the toxicity of phenylbutazone ? A. Vertigo B. Reye’s syndrome C. Miosis D. Aplastic anemia E. Hypotention 3. Which of the drugs do not have gastric irritation A. Aspirin B. Phenylbutazone C. Diclofenac
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D. Celecoxib E. Mefenamic acid 4. Aspirin overdose is characterized by a syndrome of A. Fulminant hepatic failure B. Acute renal failure C. Bone marrow suppression D. Metabolic acidosis E. Encephalopathy 5. Which of the drugs do not have Disease-Modifying Antirheumatic Drugs A. Chlorambucil B. Cyclosporine C. Methotrexate D. Flurbiprofen E. Chloroquine
SKELETAL MUSCLE RELAXANTS
CURRICULUM CONTENT - definition - classification and prototypes - pharmacokinetics - pharmacodynamics - antidote - toxicity - interactions
ABSTRACT Contraction of skeletal muscles is voluntarily controlled by impulses that originate in the central nervous system (CNS). Impulses from the brain are conducted through the spinal cord to the somatic motor neurons. Somatic motor neurons eventually connect with skeletal muscle fibers forming a neuromuscular junction. The neuronal endings of the somatic motor fibers contain the neurotransmitter acetylcholine (ACH). When ACH is released into the neuromuscular synapses, it has interaction with cholinergic receptors known as nicotinic –II (NII) receptors. Depolarization of the muscle fibers occurs when ACH has interaction with the NII receptors. Following depolarization, the contractile elements of the muscle fibers (actin and myosin) produce muscle contraction. Muscle relaxation occurs after ACH is hydrolyzed by acetylcholinesterase, this terminates the action of ACH. A variety of neuromuscular blocking agents with varying mechanism of blockade and pharmacokinetic properties are used to produce muscle relaxation during anesthesia. Centrally acting muscle relaxants (Baclofen, Carisoprodol, Chordiazepoxide, Chlorphenesin Carbamate, Diazepam, and Tizanidine) are drugs that relax skeletal muscle by a central mechanism depress reflex impulse conduction within the spinal cord. Peripherally acting skeletal muscle relaxants are drugs that inhibit skeletal muscle contraction by interfering with NII receptors. There are two types of neuromuscular blockers: nondepolarizing (curare, gallamine and pancuronium) and depolarizing (succinylcholine). Direct acting muscle relaxants (dantrolene) are drugs that inhibits the skeletal muscle fiber by prevents actin and myosin contraction.
Standard References
1. Trevor A.J., Katzung B.G.,and Masters S.B., : Katzung & Trevor’s Pharmacology, 7 th Ed. New York, Mc Graw-Hill/Lange., 2005, pp. 244-251
Additional Reading
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1. Katzung, B.G.Basic & Clinical Pharmacology, 9 th ed, New York, McGraw- Hill/Lange, 2004 pp.446-462 2. Taylor, P. Agents Acting at Neuromuscular Junction and Autonomic Ganglia in Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 10 th Ed. Editor: Hardman, J.G., Limbird L.E., and Gilman, A.G. New York, Mc Graw- Hill/Lange., 2001, pp.193-214 3. Hitner, H., and Nagle, B. Basic Pharmacology, 4 th Ed. Singapura, Mc Graw- Hill/Glencoe. 2002,pp.103-115
SCENARIO : Mrs. Anita , 45 years old, come to Sanglah Hospital because she had traffic accident. Doctor in hospital told her that she will have knee surgery. A note on her chart indicates that she will be given succinylcholine during the operation to relax the muscles in her leg. Her chart also indicates that she takes digitalis for a heart problem.
Learning task: 1. Assume that you work in a surgical unit where you coordinate patient medications, identify a potential drug problem in case above and how it might be avoided 2. Explain mechanism action of succinylcholine as peripherally acting skeletal muscle relaxants 3. Describe at least two ways in which skeletal muscles may be relaxed 4. Describes drugs that reduce the contraction of skeletal muscles affecting posture and motor function 5. Compare the mechanism of action between depolarizing and non depolarizing skeletal muscle relaxants 6. List three potential adverse effect associated with muscle relaxants
Self assessment: 1. What are the physiological events that precede skeletal muscle contraction? 2. What adverse effects are produced by the skeletal muscle relaxants as a result of histamine release? 3. How does dantrolene differ from neuromuscular blockers? 4. What is the mechanism action of centrally acting skeletal muscle relaxants? 5. When are centrally acting skeletal muscle relaxants used?
Udayana University Faculty of Medicine, MEU 70
Study Guide Musculoskeletal System and Connective Tissue Disorders
REFERENCES
1. Essential Clinical Anatomy, 2 nd ed, Keith L. Moore and Anne M.R.Agur, Lippincott William & Willems, Philadhelpia, 2002, pp. 10 - 26 2. Bloom & Fawcett’s Concise Histology, 2 nd ed, Fawcett D.N., Jensh, R.P, London, 2002, pp. 79 - 115 3. Textbook of Medical Physiology, 10 th ed, A.C. Guyton, Hall, Philadelphia, WB Saunders Co, 2000, pp. 52 – 95 4. Medical Biochemistry, Baynes J and Dominiczak, London, 1999, pp 497 - 509 5. Katzung & Trevor’s Pharmacology, Examination & Board Review, 6 th ed. A.J. Trevor, B.G. Katzung, Susan B Masters, pp. 322 – 330, 244 – 251. 6. Robbins Basic Pathology, 7 th ed, Kumar V, Cotran RS, Robbins SL. WB Saunders, Philadelphia, 2003, pp. 3 – 31; 756 – 787 7. Textbook of disorder and injuries of the musculoskeletal system, Robert B. Salter MD Apley’s system Orthopaedics and Fractures. Apley, Solomon, pp 25, 44, 52, 75, 101, 349, 427, 477. 8. Harrison’s, 16 th ed. 2005. pp 2029 – 2036
ADDITIONAL TEXTBOOK
9. Review of Medical Physiology , 10 th ed, W.F. Ganong, California : LANGE Medical Publications. 10. Human Physiology – An Integrated Approach . 2 nd ed. Silverthorn, 2001New Jersey : Prentice-Hall Inc. 11. Pocket Companion to Textbook of Medical Physiology , 10 th ed, A.C. Guyton, Hall, Philadelphia, WB Saunders Co, 2000, pp. 52 – 95
Udayana University Faculty of Medicine, MEU 71
Study Guide Musculoskeletal System and Connective Tissue Disorders
STUDENT PROJECT MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS 2015 ______
Modul No : ...... Topics : ...... Lecturer : ......
Competencies related to SKDI : ______Level 1 2 3A 3B 4 (Choose one)
Synthesis :
Facilitator
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Udayana University Faculty of Medicine, MEU 72
Study Guide Musculoskeletal System and Connective Tissue Disorders
SCORE OF STUDENT PROJECTMUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS 2015 ______
Group : ...... Class : ...... Facilitator : ......
Dear Facilitators,
Please observe, appraise and give score to student project of the student in this groups foolowing the criteria as belows.
No NIM Name Complete Writing Time
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Att : - Complete : content of synthesis related to SKDI and learning task - Writing : handwriting and easy to read (clear) - Time : complete and show the task to facilitator according to lecture's schedule
Score range : 1 - 10
Facilitator
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Udayana University Faculty of Medicine, MEU 73