Study Guide Block Skin and Hearing Systems and Disorders

Nyoman Suryawati Putu Gede Sudira

Faculty of Medicine UNUD,MEU 4 Study Guide Block Skin and Hearing Systems and Disorders

STUDY GUIDE THE SKIN AND HEARING SYSTEMS AND DISORDERS

FIRST EDITION

Editor Nyoman Suryawati Putu Gede Sudira

Publisher:

Eka Print

In collaboration with

Department of Medical Education Medicine Programme, Faculty of Medicine, Udayana University

Denpasar 2017

Department of Medical Education - Faculty of Medicine - Udayana University 2

Study Guide Block Skin and Hearing Systems and Disorders

STUDY GUIDE THE SKIN AND HEARING SYSTEMS AND DISORDERS

Planners Nyoman Suryawati Yuliana Ni Made Linawati I Made Krisna Dinata Andi Dwi Saputra Putu Gede Sudira IA Alit Widhiartini

Contributors Nyoman Suryawati Prima Sanjiwani Sudarsa Ni Made Linawati Herman Saputra Made Swastika Adiguna Andi Dwi Saputra AA Gede Putra Wiraguna Eka Putra Setiawan IGAA Praharsini I Made Wiranadha Luh Mas Rusyati IA Alit Widhiartini IGAA Elis Indira Sucindra Dewi IGAA Dwi Karmila IG Kamasan Arijana NLP Ratih V. Karna I Made Krisna Dinata Ni Made Dwi Puspawati Yuliana

Editors Nyoman Suryawati Putu Gede Sudira

Layout Yuliwaty I Gde Nengah Adhilaksman S. W

21,6 cm X 27,9 cm xi, 75 pages ISBN : 9 786022 942849 First Edition: November 2017 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without prior written permission of the publisher. Published by Eka Print in collaboration with Department of Medical Education Medicine Programme, Faculty of Medicine, Universitas Udayana. Department of Medical Education - Faculty of Medicine - Udayana University 3

Study Guide Block Skin and Hearing Systems and Disorders

CONTENT

CONTENT ...... 4 PREFACE ...... 6 CURRICULUM MAP ...... 7 GENERAL CURRICULUM OF THE SKIN AND HEARING SYSTEMS AND DISORDERS ...... 8 LIST OF COMPETENCY CLINICAL DIAGNOSIS OF INTEGUMENT SYSTEMS AND DISORDERS ...... 9 LIST OF COMPETENCY CLINICAL SKILLS OF INTEGUMENT SYSTEMS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012) ...... 12 LIST OF COMPETENCY CLINICAL DIAGNOSIS OF HEARING SYSTEMS AND DISORDERS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012) ...... 13 LIST OF COMPETENCY CLINICAL SKILLS OF HEARING SYSTEMS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012) ...... 14 GENERAL CORE COMPETENCY ...... 15 BLOCKS OUTCOMES...... 16 PLANNERS TEAM ...... 17 FACILITATORS ...... 18 TIMETABLEBLOCK SKIN AND HEARING SYSTEMS AND DISORDERS ...... 19 STUDENT PROJECT ...... 24 STUDENT PROJECT TOPIC ...... 26 PAPER ASSESSMENT FORM ...... 27 STUDENT MEETING...... 29 PLENARY SESSION ...... 29 ASSESSMENT METHOD ...... 29 BLOCK RULES ...... 29 Lecture 1: Highlight of Skin Systems and Disorders ...... 30 Lecture 2: Functional Structure of the Skin and Its Appendices ...... 32 Lecture 3: Common Pathological Bases of Skin Disorders and HearingSystems ...... 34 Lecture 4: Infection of () ...... 35 Lecture 5: Viral Infection (Verucca, Morbili) ...... 37 Lecture 6: Papuloerythrosquamous Skin Disease ...... 39 Lecture 7: Insect Bite and Infestation ...... 42 Lecture 8: Bacterial Infection of the Skin ...... 45 Lecture 9: Pigmentary and Sebaceous Gland Disorders ...... 48 Lecture 10: Dermatophytosis ...... 50 Lecture 11: Drug Eruption (Exanthematous Drug Eruption, Fixed Drug Eruption) ...... 51 Lecture 12: Dermatitis and Urticaria ...... 53

Department of Medical Education - Faculty of Medicine - Udayana University 4

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 13: Rational Therapy of Topical Preparations in Dermatology ...... 58 Lecture 14: Dermatopharmacology ...... 61 Lecture 15: Physiology of Hearing systems ...... 63 Lecture 16: Histology of Hearing Systems ...... 64 Lecture 17: Anatomy of the Ear ...... 66 Lecture 18: Otic Drug ...... 69 Lecture 19: Hearing loss in Children, Meniere, Sudden Hearing loss, Presbycusis ...... 72 Lecture 20: Perichondritis, Myringitis, Otitis Media, Labyrinthitis ...... 73 Lecture 21: Ear trauma/ othematoma, Barotrauma, Motion Sickness, PGPKT ...... 74 REFERENCES...... 75

Department of Medical Education - Faculty of Medicine - Udayana University 5

Study Guide Block Skin and Hearing Systems and Disorders

PREFACE

The medical curriculum has become increasingly vertically integrated, with stronger basic concept and support by clinical examples and cases to help in the understanding of the relevance of the underlying basic science. Basic science concepts may help in the understanding of the pathophysiology and treatment of diseases. Skin and hearing systems and disorders block has been written to take account of this trend and to integrate core aspects of basic science, pathophysiology, and treatment into a single, easy to use revision aid. The skin and hearing systems and disorders block will refresh the basic anatomy, histology, physiology of skin and hearing systems, varies dermatology cases (papulo-erythrosquamosa, Morbus Hansen, viral infection, insect bite and infestation, dermatophytosis, drug eruption, pigmentary, and sebaceous gland disorders, bacterial infection, dermatitis), rational topical treatment in dermatology, dermatopharmacology, an example of the otic drug, and varies cases in hearing systems including hearing loss. This study guide is developed by the academic staffs from various departments: Anatomy, Physiology, Histology, Pharmacology, Pharmacy, Anatomy Pathology, Dermato-venereology, Ear Nose and Throat Department. The learning process will be carried out for 3 weeks (16 working days) and 1 week for Basic Clinical Skills starts from December 12th, 2017 as shown in the timetable. The final examination will be conducted on January 17th, 2018 in the form of Multiple Choice Questions (MCQ). Assessment methods are a final exam (MCQ), small group discussion, and a student project. The learning situations include lectures, individual learning, small group discussion, student project, plenary session, practice, and clinical skills. Most of the learning material should be learned independently and discuss in Small Group Discussion by the students with the help of a facilitator. Lectures are given to emphasize the most important thing of the material. In a small group discussion, the students gave learning task to lead their discussion. This study guide needs more revision in the future so that the planners kindly invite readers to give any comments and critics for its completion. Thank you.

Planners

Department of Medical Education - Faculty of Medicine - Udayana University 6

Study Guide Block Skin and Hearing Systems and Disorders

CURRICULUM MAP

10 Senior Clerkship 9 Senior Clerkship 8 Senior Clerkship Health System-based Community-based Evidence-based Elective StudyIV Comprehensive 19 7 Practice practice Medical Practice (evaluation) Clinic Orientation weeks (3 weeks) (4 weeks) (2 weeks) (3 weeks) (Clerkship) BCS (1 weeks) Special topics : + medical ethic Health Ergonomy & (4 weeks) Health Environment (2 weeks) The Cardiovascular Medical Emergency The Urinary System The Elective StudyIII 19 6 System and Disorders (2 weeks) and Disorders Reproductive weeks (3 weeks) BCS (1 weeks) (3 weeks) System and (3 weeks) BCS (1 weeks) BCS (1 weeks) Disorders (4 weeks) BCS (1 weeks) Neuroscience and The Respiratory The skin &hearing Special Topic : Elective Study II 18 5 neurological System and system - Palliative Med (2 weeks) weeks disorders Disorders & disorders - Complement& (3 weeks) (4 weeks) (3 weeks) Alternative Med. BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) - Forensic (3 weeks) Musculoskeletal Alimentary The Endocrine Clinical Nutrition The Visual 19 4 system & & hepatobiliary System, Metabolism and Disorders system & weeks connective tissue systems & and Disorders (2 weeks) disorders disorders disorders (4 weeks) BCS (1 weeks) (2 weeks) (3 weeks) (3 Weeks) BCS (1 weeks) BCS (1weeks) BCS (1 weeks) BCS (1 weeks) Basic microbiology Immune system Hematologic Special Topic Basic 19 3 &Parasitology &disorders system & disorder & - Andro & aging Pharmaceutical weeks (3 weeks) (2 weeks) clinical oncology - - Geriatric medicine & drug Basic Infection BCS (1 weeks) (3 weeks) -Travel medicine ethics & infectious BCS (1 weeks) - (4 weeks) (1 weeks) Diseases(3 weeks) BCS (1 weeks) Medical Medical Behavior Change Elective Study I 19 2 communication Professionalism and disorders (2 weeks) weeks (3 weeks) (2 weeks) + medical (3 weeks) Basic Pharmacology ethic (1 weeks) (2 weeks) Basic Anatomy BCS (1 weeks) BCS (1 weeks) Pathology & Clinical Pathology (3 weeks) BCS (1 weeks) Studium Generale and The cell Growth & 19 1 Humaniora as biochemical development weeks (2 weeks) machinery (2 weeks) Basic Anatomy (2 weeks) Basic Biochemistry ( 4 weeks) Basic Histology (2 weeks) Practicum Anatomy (2 weeks) & Basic BCS (1 weeks) (1 Weeks) Physiology (2 weeks) BCS (1 weeks) Pendidikan Pancasila & Kewarganegaraan ( 3 weeks )

Department of Medical Education - Faculty of Medicine - Udayana University 7

Study Guide Block Skin and Hearing Systems and Disorders

GENERAL CURRICULUM OF THE SKIN AND HEARING SYSTEMS AND DISORDERS

Aims:  Manage common skin disorders knowledge in the context of primary health care settings.  Identify skin disorders which may require a referral.

Learning outcomes:  Describe the functional structure of the skin and its appendices and hearing systems.  Identify typical skin manifestation related to skin disorders.  Identify the risks and compatibility of topical treatment in dermatology.  Diagnose and manage common skin and hearing systems disorders.  Refer patient to life/disability threatening, refractory, and unidentified skin and hearing systems disorders.  Educate the patient and their family about skin health.

Curriculum contents:  The functional structure of the skin and its appendices and hearing systems.  Common pathological bases of skin disorders.  Primary skin manifestation in common skin disorders.  Risks and compatibility of topical treatment in dermatology.  Secondary skin manifestations.  Symptoms and sign of common skin disorders, clinical diagnose of common skin disorders, management of common skin disorders: papulo-erythrosquamosa, Morbus Hansen, viral infection, insect bite and infestation, dermatophytosis, drug eruption, pigmentary and sebaceous gland disorders, bacterial infection, dermatitis  Symptoms and sign, clinical diagnosis, and management of common hearing systems disorders: hearing loss in children, Meniere, sudden hearing loss, presbycusis, perichondritis, myringitis, otitis media, labyrinthitis, ear trauma/othematoma, barotrauma, motion sickness, PGPKT.  Referal of a patient with life/ disability threatening, refractory, or unidentified skin and hearing systems disorders.  General principles of skin and hearing systems health.  Education and prevention of common and contagious skin and hearing systems diseases.

Department of Medical Education - Faculty of Medicine - Udayana University 8

Study Guide Block Skin and Hearing Systems and Disorders

LIST OF COMPETENCY CLINICAL DIAGNOSIS OF INTEGUMENT SYSTEMS AND DISORDERS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012)

Kulit Infeksi Virus 1 Veruka vulgaris 4A 2 Kondiloma akuminata 3A 3 Moluskum kontagiosum 4A 4 Varisela, herpes zoster, herpes simpleks 4A 5 Campak 4A Infeksi Bakteri 6 4A 7 Impetigo ulseratif (ektima) 4A 8 Folikulitis superfisialis 4A 9 Furunkel, karbunkel 4A 10 Eritrasma 4A 11 Erisipelas 4A 12 Skrofuloderma 4A 13 Leprosi 4A 14 Reaksi lepra 3A 15 Sifilis 4A 16 Aktinomikosis 1 17 In growing toe nail 4A 18 Paronikia 4A Infeksi Fungal Superfisialis 19 Tinea, Tinea versikolor 4A 20 Kandidiasis mukokutaneous 4A Penyakit jamur sistemik 2 Gigitan Serangga dan Infestasi 21 Pedikulosis capitis, pubis 4A 22 Reaksi gigitan serangga 4A 23 Skabies 4A 24 Cutaneus larva migran 4A 25 Filariasis tanpa komplikasi 4A Dermatitis Eksim 26 Dermatitis kontak iritan 4A 27 Dermatitis kontak alergika 3A 28 Dermatitis atopik 4A 29 Dermatitis numularis 4A 30 Liken simpleks kronik/ neurodermatitis 3A 31 Napkin eczema 4A

Department of Medical Education - Faculty of Medicine - Udayana University 9

Study Guide Block Skin and Hearing Systems and Disorders

Lesi Eritro-Squamosa 32 Psoriasis vulgaris 3A 33 Dermatitis seboroik 4A 34 Pitiriasis rosea 4A Kelainan Kelenjar Sebasea dan Ekrin 35 Akne vulgaris 4A 36 Hidradenitis supuratif 4A 37 Dermatitis perioral 4A 38 Rosasea 3A 39 Miliaria 4A 40 Hiperhidrosis 2 Penyakit Vesikobulosa 41 Pemphigus vulgaris 2 42 Pemphigoid 2 43 Dermatitis herpetiformis 2 44 Toxic epidermal necrolysis 3B 45 Sindroma Stevens-Johnson 3B Penyakit Kulit Alergi 46 Urtikaria 4A 47 Angioedema 3B 48 Dishidrosis 4A Penyakit Autoimun 49 Dermatomiositis 1 50 Skleroderma/morfea 3A Gangguan Keratinisasi 51 Ichthyosis vulgaris 3A Klavus 3A Inflamasi Non Infeksi 52 Liken planus 3A 53 Granuloma annulare 3A Reaksi Obat 54 Exanthematous drug eruption, fixed drug eruption 4A Kelainan pigmentasi 55 Vitiligo 3A 56 Melasma 3A 57 Albino 2 58 Hiperpigmentasi dan hipopigmentasi paska inflamasi 3A Neoplasma 59 Tumor epitel jinak 1 60 Keratosis seboroik 2 61 Kista epitel 3A Tumor Epitel Premaligna dan Maligna 62 Squamous cell carcinoma 2

Department of Medical Education - Faculty of Medicine - Udayana University 10

Study Guide Block Skin and Hearing Systems and Disorders

63 Basal cell carcinoma 2 Tumor Dermis 64 Xanthoma 2 65 Hemangioma 2 67 Limfangioma 1 68 Angiosarkoma 1 Tumor Sel Melanosit 69 Lentigo 2 70 Nevus pigmentosus 2 71 Melanoma maligna 1 Rambut 72 Alopesia areata 2 73 Alopesia androgenik 2 74 Telogen eflluvium 2 Trauma 75 Vulnus laseratum, punctum 4A 76 Vulnus perforatum, penetratum 3B 77 Luka bakar derajat 1 dan 2 4A 78 Luka bakar derajat 3 dan 4 3B 79 Luka akibat bahan kimia 3B 80 Luka akibat sengatan listrik 3B

Department of Medical Education - Faculty of Medicine - Udayana University 11

Study Guide Block Skin and Hearing Systems and Disorders

LIST OF COMPETENCY CLINICAL SKILLS OF INTEGUMENT SYSTEMS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012)

PEMERIKSAAN FISIK 1 Kulit, inspeksi dengan kaca pembesar 4A 2 Inspeksi membran mukosa 4A 3 Inspeksi daerah perianal 4A 4 Inspeksi kulit dan kuku ekstremitas 4A 5 Kulit, inspeksi dengan sinar UVA (Wood’s lamp) 4A 6 Dermografisme 4A 7 Palpasi kulit 4A 8 Deskripsi lesi kulit dengan perubahan primer dan sekunder, 4A seperti ukuran, distribusi, penyebaran dan konfigurasi 9 Pemeriksaan rambut (inspeksi, pull test) 4A PEMERIKSAAN TAMBAHAN 10 Pemeriksaan laboratorium: ZN, KOH, Giemsa, Gram 4A 11 Punch biopsy 2 12 Patch test 2 13 Prick test 2 TERAPI 14 Desinfeksi 4A 15 Kulit, insisi/drainase abses, bursa/ ganglion 4A 16 Kulit, eksisi tumor 4A 17 Warts, cryotherapy 1 18 Jerawat, terapi komedo 4A 19 Perawatan luka (pemasangan dressing, bandage) 4A 20 Varicose veins, compressive sclerotherapy 2 21 Varicose veins, compressive bandage therapy 4A 22 Phototherapy 1 23 Ekstraksi kuku 4A 24 Rozerplasty 4A PENCEGAHAN 25 Pencarian kontak 4A

Department of Medical Education - Faculty of Medicine - Udayana University 12

Study Guide Block Skin and Hearing Systems and Disorders

LIST OF COMPETENCY CLINICAL DIAGNOSIS OF HEARING SYSTEMS AND DISORDERS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012)

TELINGA Telinga, Pendengaran, dan Keseimbangan 1 Tuli (kongenital, perseptif, konduktif) 2 2 Inflamasi pada aurikuler 3A 3 Herpes zoster pada telinga 3A 4 Fistula pre-aurikuler 3A 5 Labirintitis 2 6 Otitis eksterna 4A 7 Otitis media akut 4A 8 Otitis media serosa 3A 9 Otitis media kronik 3A 10 Mastoiditis 3A 11 Miringitis bullosa 3A 12 Benda asing 3A 13 Perforasi membran timpani 3A 14 Otosklerosis 3A 15 Timpanosklerosis 2 16 Kolesteatoma 1 17 Presbiakusis 3A 18 Serumen prop 4A 19 Mabuk perjalanan 4A 20 Trauma akustik akut 3A 21 Trauma aurikuler 3B HIDUNG Hidung dan Sinus Hidung 22 Deviasi septum hidung 2 23 Furunkelpada hidung 4A 24 Rhinitis akut 4A 25 Rhinitis vasomotor 4A 26 Rhinitis alergika 4A 27 Rhinitis kronik 3A 28 Rhinitis medikamentosa 3A 29 Sinusitis 3A 30 Sinusitis frontal akut 2 31 Sinusitis maksilaris akut 2 32 Sinusitis kronik 3A 33 Benda asing 4A 34 Epistaksis 4A 35 Etmoiditis akut 1 36 Polip 2 Kepala dan Leher 37 Fistula dan kista brankial lateral dan medial 2 38 Higroma kistik 2 39 Tortikolis 3A 40 Abses Bezold 3A

Department of Medical Education - Faculty of Medicine - Udayana University 13

Study Guide Block Skin and Hearing Systems and Disorders

LIST OF COMPETENCY CLINICAL SKILLS OF HEARING SYSTEMS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012)

Indra Pendengaran dan Keseimbangan 1 Inspeksi aurikula, posisi telinga dan mastoid 4A 2 Pemeriksaan meatus auditorius externus dengan otoskop 4A 3 Pemeriksaan membran timpani dengan otoskop 4A 4 Menggunakan cermin kepala 4A 5 Menggunakan lampu kepala 4A 6 Tes pendengaran, pemeriksaan garpu tala (Weber, Rinne, 4A Schwabach) 7 Tes pendengaran, tes berbisik 4A 8 Intepretasi hasil Audiometri – tone & speech audiometry 3 9 Pemeriksaan pendengaran pada anak-anak 4A 10 Otoscopy pneumatic (Siegle) 2 11 Melakukan dan menginterpretasikan timpanometri 2 12 Pemeriksaan vestibular 2 13 Tes Ewing 2 Indra Pembau 14 Inspeksi bentuk hidung dan lubang hidung 4A 15 Penilaian obstruksi hidung 4A 16 Uji pembauan 4A 17 Rinoskopi anterior 4A 18 Transluminasi sinus frontalis & maksila 4A 19 Nasofaringoskopi 2 20 USG sinus 1 21 Radiologi sinus 2 22 Interpretasi radiologi sinus 3 Indra Pengecap 23 Penilaian pengecapan 4A THT 24 Manuver Politzer 2 25 Manuver Valsalva 4A 26 Pembersihan meatus auditorius eksternus dengan usapan 4A 27 Pengambilan serumen menggunakan kait atau kuret 4A 28 Pengambilan benda asing di telinga 4A 29 Parasentesis 2 30 Insersi grommet tube 1 31 Menyesuaikan alat bantu dengar 2 32 Menghentikan perdarahan hidung 4A 33 Pengambilan benda asing dari hidung 4A 34 Bilas sinus/ sinus lavage /pungsi sinus 2 35 Antroskopi 1 36 Trakeostomi 2 37 Krikotiroidektomi 2

Department of Medical Education - Faculty of Medicine - Udayana University 14

Study Guide Block Skin and Hearing Systems and Disorders

GENERAL CORE COMPETENCY

1. Patient Care Demonstrate capability to provide comprehensive patient care that is compassionate, appropriate, and effective for the management of health problems, promotion of health and prevention of disease in the primary health care settings. 2. Medical knowledge base Mastery of a core medical knowledge which includes the biomedical sciences, behavioral sciences, epidemiology and statistics, clinical sciences, the social aspect of medicine and the principles of medical ethics, and applies them. 3. Clinical skill Demonstrate capability to effectively apply clinical skills and interpret the findings in the investigation of a patient. 4. Communication Demonstrate capability to communicate effectively and interpersonally to establish rapport with patient, family, community at large, and professional associates, that results in effective information exchange, the creation of therapeutically and ethically sound relationship. 5. Information management Demonstrate capability to manage information which includes information access, retrieval, interpretation, appraisal, and application to patient’s specific problem, and maintaining records of his or her practice for analysis and improvement. 6. Professionalism Demonstrate a commitment to carrying out professional responsibilities and to personal probity, adherence to ethical principles, sensitivity to diverse patient population, and commitment to carrying out continual self-evaluation of his or her professional standard and competence. 7. Community-based and health system-based practice Demonstrate awareness and responsiveness to larger context and system of healthcare, and ability to effectively use system resources for optimal patient care.

Department of Medical Education - Faculty of Medicine - Udayana University 15

Study Guide Block Skin and Hearing Systems and Disorders

BLOCKS OUTCOMES

LEARNING OUTCOMES CURRICULUM CONTENT

1. Describe the functional structure of 1.1 Describe the functional structure of the skin and its appendices and the skin and its appendices and hearing systems. hearing systems.

2. Identify typical skin manifestation 2.1 Common pathological bases of skin related to skin and hearing disorders. disorders. 2.2 Skin manifestation (efflorescences) Incommon skin disorders.

3. Identify the risks and compatibility of 3.1 Identify the risks and compatibility of topical treatment in dermatology. topical treatment in dermatology.

4. Diagnose and manage common skin 4.1 Symptoms and sign of common skin and hearing systems disorders. and hearing systems disorders.

4.2 Clinical diagnostic of common skin

and hearing systems disorders. 4.3 Management of common skin and hearing system infection.

5. Refer patient with life/ disability 5.1 Refer patient with life/ disability threatening, refractory and threatening, refractory, and unidentified skin and hearing systems unidentified skin and hearing systems disorders. disorders.

6. Educate the patient and their family 6.1 General principles of skin health. about skin health. 6.2 Education and prevention of common and contagious skin diseases.

Department of Medical Education - Faculty of Medicine - Udayana University 16

Study Guide Block Skin and Hearing Systems and Disorders

PLANNERS TEAM NO NAME DEPARTMENT 1 dr. Nyoman Suryawati, Sp.KK, FINSDV (Head) Dermatovenereology 2 Dr. dr. Ni Made Linawati,M.Si Histology 3 dr. Andi Dwi Saputra, Sp.THT ENT 4 Dra. I A Alit Widhiartini, Apt, M.Si Pharmacy 5 dr. Yuliana, M.Biomed Anatomy 6 dr.I Made Krisna Dinata, M.Erg Physiology 7 dr. Putu Gede Sudira, Sp.S DME LECTURERS NO NAME DEPARTMENT PHONE 1 dr. Nyoman Suryawati, M.Kes, Sp.KK, Dermatovenereology 0817447279 FINSDV 2 Dr. dr. Ni Made Linawati,M.Si Histology 081337222567 3 Prof. dr. Made Swastika Adiguna Sp.KK Dermatovenereology 08123828548 (K), FINSDV, FAADV 4 Dr. dr. AA Gde Putra Dermatovenereology 081338645288 Wiraguna,Sp.KK(K), FINSDV, FAADV 5 Dr. dr. IGAA Praharsini, SpKK, FINSDV, Dermatovenereology 081238888794 FAADV 6 Dr. dr. Luh Mas Rusyati, SpKK (K), Dermatovenereology 081337338738 FINSDV 7 dr. IGAA Elis Indira, Sp.KK, FINSDV Dermatovenereology 081338718384 8 dr.IGAA Dwi Karmila, Sp.KK Dermatovenereology 08123978446 9 dr. Ni Luh Putu Ratih Vibriyanti K, Sp.KK, Dermatovenereology 081337808844 FINSDV 10 dr. Ni Made Dwi Puspawati, Sp.KK Dermatovenereology 08123766268 11 dr. Prima Sanjiwani Saraswati Sudarsa, Dermatovenereology 08123818826 M.Biomed, Sp. KK 12 dr. Herman Saputra, Sp.PA (K) Anatomy Pathology 081558028879 13 dr. Andi Dwi Saputra, Sp.THT ENT 081338701878 14 dr.Eka Putra Setiawan, Sp.THT ENT 087861361255 15 dr. I Made Wiranadha, Sp.THT –KL ENT 08123968294 16 Dra. I A Alit Widhiartini, Apt, M.Si Pharmacy 0816572852 17 dr. Ni Wayan Sucindra Dewi, S.Ked Pharmacy 08113935700 18 dr. IG Kamasan Arijana, Msi Med Histology 085339644145 19 dr.I Made Krisna Dinata, M.Erg Physiology 08174742566 20 dr. Yuliana, M.Biomed Anatomy 0816555671

Department of Medical Education - Faculty of Medicine - Udayana University 17

Study Guide Block Skin and Hearing Systems and Disorders

FACILITATORS

Regular Class

No Name Group Department Phone Room 2nd floor: 1. dr. IGN Sri Wiryawan, M.Repro A1 Histology 082341768888 R.2.01 Dr. rer nat dr. Ni Nyoman Ayu 2nd floor: 2. A2 Biochemistry 081337141506 Dewi M.Kes R.2.02 dr Ni Putu Wardani M.Biomed 2nd floor: 3. A3 DME 08113992784 Sp.An R.2.03 dr. I Wayan Artana Putra, 2nd floor: 4. A4 Obs/Gyn 08123927235 Sp.OG(K) R.2.04 Anatomy 2nd floor: 5. Dr.dr. Sianny Herawati,Sp.PK A5 0818566411 Pathology R.2.05 2nd floor: 6. Prof. dr. I D P Sutjana, M.Erg A6 Physiology 08123924477 R.2.06 Dr. dr. Desak Made Wihandani, 2nd floor: 7. A7 Biochemistry 081338776244 M.Kes R.2.07 2nd floor: 8. Dr. dr. BK. Satriyasa, M.Repro A8 Pharmacology 087777790064 R.2.08 dr. I Nyoman Gede Wardana, 2nd floor: 9. A9 Anatomy 087860405625 S.Ked., M.Biomed R.2.21 Dr. dr. Ni Nyoman Sri Budayanti, 2nd floor: 10. A10 Microbiology 08553711398 Sp.MK (K) R.2.22

English Class No Name Group Department Phone Room 2nd floor: 1. Dr.dr. I Made Jawi, M.Kes B1 Pharmacology 08179787972 R.2.01 2nd floor: 2. dr Putu Gede Sudira Sp.S B2 DME 081805633997 R.2.02 2nd floor: 3. dr. I Gusti Ngurah Mayun, Sp.H.K B3 Histology 081237395050 R.2.03 2nd floor: 4. Dr. dr. I Wayan Weta, MS, SpGK B4 Public Health 081337005360 R.2.04 Prof. Dr. I Nyoman Adiputra, 2nd floor: 5. B5 Physiology 0811397971 M.O.H. PFK R.2.05 Dr.dr. I Gede Ngurah Harry 2nd floor: 6. B6 Obs/Gyn 0811386935 Wijaya Surya, Sp.OG R.2.06 Prof. dr. Ketut Tirtayasa, MS, AIF, 2nd floor: 7. B7 Physiology 08123623422 AIFO, Sp.Erg R.2.07 dr. I Ketut Suardamana, Sp.PD- Internal 2nd floor: 8. B8 08123985811 KAI Medicine R.2.08 2nd floor: 9. Dr. dr. I Made Sudarmaja, M.Kes B9 Parasitology 081239539945 R.2.21 dr. Luh Putu Iin Indrayani Maker, Anatomy 2nd floor: 10. B10 08174761804 Sp.PA(K) Pathology R.2.22

Department of Medical Education - Faculty of Medicine - Udayana University 18

Study Guide Block Skin and Hearing Systems and Disorders

TIMETABLE BLOCK SKIN AND HEARING SYSTEMS AND DISORDERS 5TH SEMESTER MEDICAL FACULTY UDAYANA UNIVERSITY 2017-2018

Days / Time Time Activity Venue Lecturers Date Class A Class B

Lecture 1: Introduction to Block Skin and 08.00-08.30 (30’) 09.00-09.30 (30’) Class Room Suryawati Hearing and Disorders

Lecture 2: Functional structure of the skin 08.30-09.00 (30’) 09.30-10.00 (30’) Class Room Linawati and its appendices Dec 12, 2017 12.30-14.00 (90’) 10.00-11.30 (90’) Student Project - Tuesday 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator 12.00-12.30 (30’) 13.00-13.30 (30’) Break - 09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning - 14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Linawati Dec 13, 2017 08.00- 15.00 09.00- 16.00 BCS: Efflorescence Class Room Dwi Puspawati Wednesday see BCS see BCS Prac: microscopic structure of the skin Histology lab Linawati / Arijana schedule schedule and appendages and hearing system Lecture 3: Common Pathophysiological 08.00-09.00 (60’) 09.00-10.00 (60’) bases of the skin and hearing system Class Room Herman disorders

12.30-14.00 (90’) 10.00-11.30 (90’) Student Project - Dec 14, 2015 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator Thursday 12.00-12.30 (30’) 13.00-13.30 (30’) Break - 09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning - 14.00-15.00 (60’) 15.00-16.00 (90’) Plenary Session Class Room Herman 08.00-08.30 (30’) 09.00-09.30 (30’) Lecture 4: Morbus Hansen Class Room Luh Mas Rusyati Lecture 5 :Viral infection (Verucca, 08.30-09.00 (30’) 09.30-10.00 (30’) Class Room Wiraguna Morbili) 12.30-14.00 (90’) 10.00-11.30 (90’) Student Project - Dec 15, 2017 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator Friday 12.00-12.30 (30’) 13.00-13.30 (30’) Break - 09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning - Luh Mas 14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Rusyati/ Wiraguna 08.00-09.00 (60’) 09.00-10.00 (60’) Lecture 6 :Papuloerythrosquamosa Class Room Prima 12.30-14.00 (90’) 10.00-11.30 (90’) Student Project - 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator Dec 18, 2017 12.00-12.30 (30’) 13.00-13.30 (30’) Break - Monday 09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning -

14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Prima

Department of Medical Education - Faculty of Medicine - Udayana University 19

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 7: Insect bite and infestation 08.00-09.00 (60’) 09.00-10.00 (60’) Class Room Praharsini (pediculosis, capitis, and pubic, scabies)

12.30-14.00 (90’) 10.00-11.30 (90’) Student Project - Dec 19, 2017 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator Tuesday 12.00-12.30 (30’) 13.00-13.30 (30’) Break - 09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning -

14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Praharsini

Lecture 8: Bacterial Infection (impetigo, 08.00-09.00 (60’) 09.00-10.00 (60’) Class Room Dwi Karmila scrofuloderma, ) 12.30-14.00 (90’) 10.00-11.30 (90’) Student Project -

Dec 20, 2017 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator Wednesday 12.00-12.30 (30’) 13.00-13.30 (30’) Break - 09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning -

14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Dwi Karmila

Lecture 9: Pigmentary and Sebaceous 08.00-09.00 (60’) 09.00-10.00 (60’) gland disorders (hypo/hyperpigmentation, Class Room Elis Indira miliaria, hydradenitis suppurativa)

12.30-14.00 (90’) 10.00-11.30 (90’) Student Project - Dec 21, 2017 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator Thursday 12.00-12.30 (30’) 13.00-13.30 (30’) Break - 09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning - 14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Elis Indira 08.00-08.30 (30’) 09.00-09.30 (30’) Lecture 10: Dermatophytosis Class Room Swastika Lecture 11: Drug eruption (FDE, 08.30-09.00 (30’) 09.30-10.00 (30’) Class Room Ratih maculopapular drug eruption) Dec 22, 2017 12.30-14.00 (90’) 10.00-11.30 (90’) Student Project - Facilitator Friday 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room 12.00-12.30 (30’) 13.00-13.30 (30’) Break - 09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning - 14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Swastika/Ratih Lecture 12: Dermatitis (numularis, neurodermatitis, napkin eczrema, perioral, 08.00-09.00(60’) 09.00-10.00(60’) Suryawati urticaria, photocontact dermatitis, Class Room angioedema) Dec 27, 2017 12.30-14.00 (90’) 10.00-11.30 (90’) Student Project Presentation (Skin I) Class Room Wednesday 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facillitator 12.00-12.30 (30’) 12.00-13.30 (30’) Break - 09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning - 14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Suryawati 08.00-08.30 (30’) 09.00-09.30 (30’) Lecture 13: Rational topical treatment in Class Room Alit Widhiartini Dec 28, 2017 dermatology Thursday 08.30-09.00 (30’) 09.30-10.00 (30’) Lecture 14: Dermatopharmacology Class Room Sucindra Dewi 12.30-14.00 (90’) 10.00-11.30 (90’) Student Project Presentation (Skin II) Class Room

Department of Medical Education - Faculty of Medicine - Udayana University 20

Study Guide Block Skin and Hearing Systems and Disorders

10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator

12.00-12.30 (30’) 13.00-13.30 (30’) Break -

09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning -

Alit W, Sucindra 14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Dewi 08.00-08.30 (30’) 09.00-09.30 (30’) Lecture 15: Physiology of hearing systems Class Room Krisna Dinata 08.30-09.00(30’) 09.30-10.00(30’) Lecture 16: Histology of hearing systems Class Room Arijana

12.30-14.00 (90’) 10.00-11.30 (90’) Student Project Presentation Class Room Facilitator

Dec 29, 2017 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room

Friday 12.00-12.30 (30’) 13.00-13.30 (30’) Break -

09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning -

Krisna Dinata/ 14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Arijana 08.00-08.30 (30’) 09.00-09.30 (30’) Lecture 17: Anatomical of Hearing Class Room Yuliana Systems 08.30-09.00 (30’) 09.30-10.00 (30’) Lecture 18: Otic drug Class Room Alit Widhiartini

12.30-14.00 (90’) 10.00-11.30 (90’) Student Project - Jan 02, 2018 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator Tuesday 12.00-12.30 (30’) 13.00-13.30 (30’) Break -

09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning -

Yuliana, Alit 14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Widhiartini Lecture 19: Hearing loss in Children, 08.00-09.00 (60’) 09.00-10.00 (60’) Meniere, Sudden Hearing loss, Class Room Wiranadha Presbycusis Student Project Presentation 12.30-14.00 (90’) 10.00-11.30 (90’) Class Room Jan 03, 2018 Meniere, Sudden Hearing loss Wednesday 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator

12.00-12.30 (30’) 13.00-13.30 (30’) Break -

09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning -

14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Wiranadha

Lecture 20: Perichondritis, Myringitis, Otitis Andi Dwi 08.00-09.00 (60’) 09.00-10.00 (60’) Class Room media, Labyrinthitis Saputra Student Project Presentation 12.30-14.00 (90’) 10.00-11.30 (90’) Class Room Jan 04, 2018 Effusion otitis media

Thursday 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Facilitator

12.00-12.30 (30’) 13.00-13.30 (30’) Break

09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning

Andi Dwi 14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Saputra

Department of Medical Education - Faculty of Medicine - Udayana University 21

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 21: Ear Trauma/ othematoma, 08.00-09.00 (60’) 09.00-10.00 (60’) Class Room Eka Putra barotrauma, Motion Sickness, PGPKT Student Project Presentation Preauricular 12.30-14.00 (90’) 10.00-11.30 (90’) Class Room Fistula Jan 05, 2018 10.30-12.00 (90’) 11.30-13.00 (90’) SGD Disc. Room Facilitator Friday 12.00-12.30 (30’) 13.00-13.30 (30’) Break -

09.00-10.30 (90’) 13.30-15.00 (90’) Independent Learning -

14.00-15.00 (60’) 15.00-16.00 (60’) Plenary Session Class Room Eka Putra

L. Bersama, Jan 08, 09, 08.00 - 13.00 08.00 - 13.00 BCS 2, 3, 4 dan 5 Pharmacy L, 10,11, 2018 RK.302 Jan 12, 2018 EXAM. PREPARATION Friday Jan 17, 2018 FAS

Wednesday EXAMINATION LEC

Department of Medical Education - Faculty of Medicine - Udayana University 22

Study Guide Block Skin and Hearing Systems and Disorders

LABORATORY AND BASIC CLINICAL SKILLS SCHEDULE

13-12-2017 08-01-2018 09-01-2018 10-01-2018 11-01-2018

Classroom Classroom Classroom Classroom Classroom Skin, Nail, Laboratory Wound Care, Open BCC,SCC, Nevus Valsalva Mucous, Hair Investigation Dressing, pigmentosus, Maneuver, Effloresence, (KOH, Compression Malignant melanoma, Cleaning of Dermographism Giemsa,wood Pressure of Incision, MAE, Foreign lamp) Varicose Vein Enucleation, Nail bodies, and (Praharsini/ Dwi Extraction, Nevus Cerumen Puspawati) (Suryawati, Dwi (Luh Mas Rusyati, Excision Extraction Karmila) Ratih) (Wardhana/ Dharma (Andi S) Putra) 08.00 – 09.00 A, B A, B A, B A, B A, B 09.00 – 10.00 A, B A, B A, B A, B A, B 10.00 – 11.00 C, D C, D C, D C, D C, D 11.00 – 12.00 C, D C, D C, D C, D C, D

Histology lab Histology lab Physiology & Physiology/ Pharmacy Physiology Pharmacy Lab Lab Lab Histology Anatomy Topical Prepa Pharma Physiology Practicum skin PathologyPracti ration in skin and cology practicum practicum and hearing organ cum skin and Otic drug in Skin and hearing hearing systems (Krisna) (Linawati/ Arijana) ( IA Alit W) (Sucindra Dewi) (Herman) 08.00-09.00 C C C C C 09.00-10.00 D D D D D 10.00-11.00 A A A A A 11.00-12.00 A A A A A

Group A: SGD A1, A2, A3, A4, A5.

Group B: SGD A6, A7, A8, A9, A10.

Group C: SGD B1, B2, B3, B4, B5.

Group D: SGD B6, B7, B8, B9, B10.

Department of Medical Education - Faculty of Medicine - Udayana University 23

Study Guide Block Skin and Hearing Systems and Disorders

STUDENT PROJECT

No Topics Supervisors Time of presentation December 27, 2017 Swastika 1 Icthyosis vulgaris B : 10.00 - 10.30 Prima A: 12.30 – 13.00 December 27, 2017 Luh Mas Rusyati 2 Hemangioma B : 10.30 – 11.00 Dwi Karmila A: 13.00 – 13.30 December 27, 2017 Post inflammatory Praharsini 3 B : 11.00 - 11.30 hyperpigmentation Suryawati A: 13.30 – 14.00 December 28, 2017 Post inflammatory 4 Wiraguna B : 10.00 - 10.30 hypopigmentation A: 12.30 – 13.00 December 28, 2017 Wardhana*/ Dharma Putra 5 Seborrheic keratosis B : 10.30 – 11.00 Dwi Puspawati A: 13.00 – 13.30 December 28, 2017 Telogen effluvium and 6 B : 11.00 - 11.30 alopecia areata Ratih VK A: 13.30 – 14.00 January 3, 2018 7 Meniere Wiranadha B: 12.30 – 14.00 A: 10.00 – 11.30 January 3, 2018 8 Sudden Hearingloss Wiranadha B: 12.30 – 14.00 A: 10.00 – 11.30 January 4, 2018 9 Effusion Otitis Media Andi B: 12.30 – 14.00 A: 10.00 – 11.30 January 5, 2018 10 Preauricular Fistula Eka Putra B: 12.30 – 14.00 A: 10.00 – 11.30 *Prof. DR. dr Made Wardhana, SpKK (K) FINSDV, FAADV (Phone No: 081237011853)

Regulation for Student Project 1. Each small group discussion must make 1 scientific writing (see topic for each group) 2. Each small group discussion must ready to present their scientific writing (due to the above schedules) 3. The assessment of student project (SP) for each student would be evaluated by evaluator 4. Report Format 15- 20 pages; 1,5 space; Times New Roman 12; green cover.

Department of Medical Education - Faculty of Medicine - Udayana University 24

Study Guide Block Skin and Hearing Systems and Disorders

TITLE (Subject/ Topic: choose from competency list) Grup Discussion

Members’ Name and Student Registered Number

Faculty of Medicine Udayana University 2017

______I. Introduction II. Content a. Definition b. Epidemiology c. Etiology d. Pathogenesis e. Clinical feature f. Diagnosis g. Therapy/ Prevention III. Conclusion IV. References (Vancouver style) (min. 8) Example: Journal Sheetz MJ, King GL. Molecular understanding of hyperglycemia’s adverse effect on diabetic complications. JAMA. 2002;288:2579-86. Textbook Libby P. The Pathogenesis of atherosclerosis. In: Braunwald E, Fauci A, Kasper D, Hoster S, Longo D, Jamason S (eds). Harrison’s principles of internal medicine. 15thed. New York: McGraw Hill; 2001. p. 1977-82. Internet WHO. Obesity: preventing and managing the global epidemic. Geneva: WHO 1998. [cited 2005 July]. Available from: http://www.who.int/dietphysicalactivity/publications/facts/ obesity/en.

Department of Medical Education - Faculty of Medicine - Udayana University 25

Study Guide Block Skin and Hearing Systems and Disorders

STUDENT PROJECT TOPIC

No Group Topic 1 A1 Ichthyosis Vulgaris 2 A2 Hemangioma 3 A3 Post-inflammatory hyperpigmentation 4 A4 Post-inflammatory hypopigmentation 5 A5 Seborrheic keratosis 6 A6 Telogen effluvium and alopecia areata 7 A7 Meniere 8 A8 Sudden Hearing loss 9 A9 Effusion Otitis Media 10 A10 Preauricular Fistula 11 B1 IchthyosisVulgaris 12 B2 Hemangioma 13 B3 Post-inflammatory hyperpigmentation 14 B4 Post-inflammatory hypopigmentation 15 B5 Seborrheic keratosis 16 B6 Telogen effluvium and alopecia areata 17 B7 Meniere 18 B8 Sudden Hearing loss 19 B9 Effusion Otitis Media 20 B10 Preauricular Fistula

Department of Medical Education - Faculty of Medicine - Udayana University 26

Study Guide Block Skin and Hearing Systems and Disorders

PAPER ASSESSMENT FORM BLOCK THE SKIN AND HEARING SYSTEMS AND DISORDERS

Name : ...... Student Reg. Number : ...... Facilitator : ...... Title : ......

Evaluator’s scoring with qualification :

No Item Assessment Range Score (%) Score

1. Quality of material 0-60

2. Capability of information searching 0-10

3 Critical thinking 0-30

TOTAL 100

Place and date Facilitator/ Evaluator*

(...... )

Department of Medical Education - Faculty of Medicine - Udayana University 27

Study Guide Block Skin and Hearing Systems and Disorders

ASSESSMENT METHODS

NO TOPIC ASSESSMENT (amount) 1 Introductionary to Block Skin and Disorder 2 Functional structure of the skin and its appendices MCQ (5) 3 Common Pathological bases of the skin disorders MCQ (5) 4 Rational topical treatment in dermatology and hearing MCQ (5) systems 5 Dermatopharmacology and hearing systems MCQ (5) 6 Skin manifestation (efflorescences) in common skin MCQ (5) disorders OSCE (coordination with OSCE team) 7 Dermatitis (numularis, fotocontact, neurodermatitis, MCQ (5) napkin eczema, perioral, urticaria) 8 Papulo-erythrosquamosa MCQ (5) 9 Drug eruption of the skin MCQ (5) 10 Pigmentary and sebaceous gland disorders MCQ (5) 11 Bacterial infection (impetigo, scrofuloderma, erythrasma, MCQ (5) hidradenitis) 12 Tumour excision and curettage OSCE (coordination with OSCE team) 13 Insect bite and infestation (Scabies, creeping eruption, MCQ (5) pediculosis) 14 Tumour of the skin, vaginitis, cervicitis MCQ (5) 15 Abscess incision OSCE (coordination with OSCE team) 16 Laboratory investigation OSCE (coordination with OSCE team) 17 Anatomical of Hearing Systems MCQ (5) 18 Histology of Hearing Systems MCQ (5) 19 Physiology of Hearing systems MCQ (5) 20 Otic Drug MCQ (5) 21 Pericondritis, Myringitis, Otitis media, Labyrinthitis MCQ (5) 22 Hearing loss in Children, Meniere, Sudden Hearing loss, MCQ (5) Presbycusis 23 Ear Trauma/ othematoma, barotrauma, Motion MCQ (5) Sickness, PGPKT 24 Valsalva Maneuver, Cleaning of MAE, Foreign bodies, OSCE (coordination with and Cerumen Extraction OSCE team)

Department of Medical Education - Faculty of Medicine - Udayana University 28

Study Guide Block Skin and Hearing Systems and Disorders

STUDENT MEETING

Meeting of the student representatives The meeting between block planners and student group representatives will be held on Wednesday, Dec 27th, at 11.30 until 12.30 at Class Room. In this meeting, all of the student group representatives are expected to give suggestions and inputs or complaints to the team planners for improvement. For this purpose, every student group should choose one student as their representative to attend the meeting.

Meeting of the facilitators The meeting between block planners and facilitators will take place on Wednesday, Dec 27th, at 11.30 until 12.30 at Class Room. In this meeting, all the facilitators are expected to give suggestions and inputs as an evaluation to improve the study guide and the educational process. Because of the importance of this meeting, all facilitators are expected to attend the meeting.

PLENARY SESSION For each learning task, the student is requested to prepare a group report. The report will be presented in the plenary session. Lecturer in charge will choose the group randomly. The aim of this presentation is to make similar perception about the topic that has been given.

ASSESSMENT METHOD Assessment will be performed on Wednesday, January 17th, 2018 for both Regular class and English class. There are 100 questions in Multiple Choice Question (MCQ) form. The borderline to pass the exam is 70. The proportion of final results are: Final exam (MCQ) : 80% Small group discussion : 5% Student project (SP) : 15%

BLOCK RULES Cheating during block activity (paper plagiarism, during block exam, etc) is prohibited, violent of the rules would be considered to decrease 10% of the thefinal result.

Department of Medical Education - Faculty of Medicine - Udayana University 29

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 1: Highlight of Skin Systems and Disorders Suryawati

Basic structure Skin is considered to be the largest organ of the human body with an average surface area of 1.6-2 m2 and accounts for about 15% of the total body weight of an adult human. It is the outer covering of the body and has multiple layers which protect underlying muscles, bones, ligaments and internal organs. The skin is a complex organ system that has many important functions. The skin functions as a protective barrier against external assaults (external physical, chemical, and biologic assailants). Some of the skin's major functions are: 1. Thermoregulation: The skin acts to maintain temperature control by secreting sweat from sudoriferous (sweat glands). The sweat helps to lower body temperature. 2. Protection: the skin is the first layer of protection when it comes to invading organism. It also protects against excessive water loss, chemical and other harmful substances and ultraviolet radiation. 3. Immunologic barrier: the skin both senses and responds to pathogens. 4. Sensation: the skin has many nerve endings that send signals to the brain to convey sensations such as touch, pain, pressure, and temperature. 5. Excretion: the skin helps rid the body of wastes. It does this via perspiration that secrets water, salt and a small amount of organic chemistry. 6. Synthesis vitamin D: when the skin is exposed to sunlight (ultraviolet light), it converts vitamin D precursor to vitamin D via the liver and kidneys. The integumentary system is formed by the skin and its derivative structures. The skin is composed of three layers: the epidermis, the dermis, and subcutaneous tissue. The outer-most layer is called the epidermis, which serves as a barrier and protects the body from any infection. The second layer is called the dermis and consists of the connective tissue which cushions the body from stress and strain. The inner-most layer is the fatty subcutaneous tissue called the hypodermis and contains larger blood vessels and nerves: it insulates the body and absorbs shock.

Fundamental of Skin Disorders Dermatology is a visual specialty and some skin lesions may be diagnosed at a glance. Nonetheless, the history is important. A thorough examination of patients with skin disorders requires comprehensive examination, including anamnesis, physical examination, and

Department of Medical Education - Faculty of Medicine - Udayana University 30

Study Guide Block Skin and Hearing Systems and Disorders

investigation. Skin disorders that occur can reflect the skin disease and systemic disease conditions suffered by patients. Skin diseases often appear in the form of similar skin disorders, so it takes the ability to perform anamnesis and physical examination of the skin. Anamnesis is performed include basic four and seven secrets. Physical examination includes present status, generalist status and dermatology status (description of skin disorder or skin eflorescence). The complete cutaneous examination includes inspection of the entire skin surface, including often overlooked areas such as the scalp, eyelids, ears, genitals, buttocks, perineal area, and interdigital spaces; the hairs; the nails; and the mucous membranes of the mouth, eyes, anus, and genitals. In routine clinical practice, not all of these areas are examined unless there is a specific reason to do so. A complete skin examination is most effective when performed under ideal conditions. It is most important to have excellent lighting, preferably bright, even light that stimulates the solar spectrum. Without a good lighting, subtle but important details may be missed. The patient should be fully undressed, wearing only a gown that is easily moved aside, with a sheet over the legs, if desired. Underwear, socks, and shoes should be removed, as should any makeup or glasses. The examining table should be at a comfortable height, with a head that reclines, an extendable footrest and gynecologic stirrups. It should contain a sink for hand washing and disinfecting hand foam, as patients are reassured by seeing their physician wash hands before the examination. If the patient and physician are of opposite genders, having a chaperone in the room can make the examination more comfortable for both. To remember, all the examination process should provide the patient's privacy. Enforcement of skin disease diagnosis requires good investigation of examination of skin specimens, nails, hair or mucosa. Other examinations such as Wood's lamps can be helpful in cases of pigmentation, as well as infections. Sometimes in diagnosis, we also need skin sampling (skin biopsy) to know the pathology process that occurs on the skin. Another capability that must be possessed is the ability to provide rational treatment of both topical and systemic treatments.

Department of Medical Education - Faculty of Medicine - Udayana University 31

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 2: Functional Structure of the Skin and Its Appendices Linawati

The skin consist of three layers firmly attaches to one another. (1) The outer is epidermis, derived from ectoderm; (2) the deeper dermis, derived from mesoderm; and (3) the hypodermis or subcutaneous layer, corresponding to the superficial fascia in gross anatomy. The epidermis is a stratified squamous epithelial layer which consists of four distinct cell types; keratinocyte, melanocytes, Langerhans cells and Merkel cells. The epidermis consists of in five layer or strata: (1) stratum basale, (2) stratum spinosum, (3) stratum granulosum, (4) stratum lucidum and (5) stratum corneum. Skin appendages consist of hair, nail, sebaceous gland, sweat gland, and nails. Skin is generally classified into two types: (1) thick skin and thin skin. Thick skin (more than 5 mm thick) covers the palms of the hands and the soles of the feet and has a thick epidermis and dermis. Thin skin (1 to 2 mm in thickness) lines the rest of the body; the epidermis is thin. The skin has several functions: (1) Protection (mechanical function); (2) as a water barrier; (3) Regulation of body temperature (conservation and dissipation of heat); (4) Non specific defense (barrier to microorganism); (5) Excretion of salts; (6) synthesis of vitamin D; (7) as sensory organ The epidermis and dermis display a tight fit interface at the dermal-epidermal junction, where a basal lamina and hemidesmosomes are located. A primary epidermal ridge interlocks with a subjacent primary dermal ridge. An epidermal interpapillary peg, projecting downward from the primary epidermal ridge, interlocks with the primary dermal ridge, which is subdivided into two secondary dermal ridges. A number of dermal papillae project upward from the surface of each secondary dermal ridge into the epidermal region, interlocking with downward projections of the epidermis. This arrangement is predominant in the hairless thick skin. Dermal papillae are numerous and branched. In thin skin, papillae are low and their number is reduced.

Department of Medical Education - Faculty of Medicine - Udayana University 32

Study Guide Block Skin and Hearing Systems and Disorders

Functional Structure of the skin and its appendices Vignette 1 A newborn baby has blisters on hands and feet. doctors diagnose with epidermolysis bulosa simplex. 1. What kind of keratins mutation involved in this disorders? 2. In which stratum of epidermis the disorder occurs? Vignette 2 A male 19 years old present with a chief complaint with stubborn dandruff with the scaly scalp, itching, and flushing. The doctor diagnosed with seborrhea capitis. 1. What kind of structure involved? 2. Please describe the microscopic structure involved above! Self assessment 1. Describe the anatomical structure of the thin and thick skin! 2. Describe the differences between eccrine and apocrine sweat gland! 3. Describe the morphology of 4 type cells that located in epidermis! 4. Describe the process of melanin synthesizes!

Department of Medical Education - Faculty of Medicine - Udayana University 33

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 3: Common Pathological Bases of Skin Disorders and HearingSystems (Herman S)

Little more than 100 years ago, the noted pathologist Rudolph Virchow considered the skin as a protective covering for more delicate and functionally sophisticated internal viscera. Then, and for the century that followed, the skin was considered primarily a passive barrier to fluid loss and mechanical injury. During the past three decades, however, of scientific inquiries have demonstrated the skin to be a complex organ in which precisely regulated cellular and molecular interactions govern many crucial responses of the skin to our environment. Accurate description of the clinical appearance of the skin at a macroscopic level is often critical for diagnosis. Correlation between the gross and histologic appearances is often essential in formulating diagnoses and in understanding pathogenesis. Accordingly, efforts are made in the following pages to depict and describe clinical lesions whenever possible and to relate these findings to the microscopic appearance of lesions.

Learning task List and describe the Descriptive term of microscopic features in dermatopathology bellow: 1. Hyperkeratosis 2. Parakeratosis 3. Hypergranulosis 4. Acanthosis 5. Papillomatosis 6. Dyskeratosis 7. Acantholysis 8. Spongiosis 9. Hydropic swelling 10. Exocytosis 11. Erosion 12. Ulceration 13. Vacuolization 14. Lentiginous

Department of Medical Education - Faculty of Medicine - Udayana University 34

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 4: Infection of Mycobacterium (Leprosy) Luh Mas Rusyati

Leprosy or Morbus Hansen is a chronic infectious disease caused by and generally affected the periphery nerve but also can affect the skin and the other organ, and may lead to permanent disability. So far, leprosy is one of a health problem in developing countries, especially the one with leprosy endemic such as Indonesia. Internationally, Indonesia rank as 3rd in the number of new cases of leprosy after Brazil and India. The lack of education and the stigma surrounding the disease made some delay in diagnosing and develop life-changing disabilities. The cardinal signs of Leprosy are 1. Hypopigmented or erythematous macules, 2. Anaesthesia, 3. Enlargement of periphery nerve, 4. Acid Fast Bacilli (AFB) found from slit skin smear. Diagnosis of leprosy is based on finding two from three cardinal sign of leprosy or if only cardinal sign number 4. Readley and Joppling classification are Tuberculoid-Tuberculoid (TT), Borderline Tuberculoid (BT), Borderline-Borderline (BB), Borderline-Lepromatous (BL), and Lepromatous- Lepromatous (LL). Leprosy is usually well controlled with a combination of drugs known as MDT, and the treatment varies according to whether leprosy has been classified by World Health Organization (WHO) as paucibacillary (PB) and multibacillary (MB) leprosy. The therapy for paucity bacillary leprosy (TT, BT with AFB (-) are rifampicin 600 mg a month and dapsone (DDS) 100 mg a day continuous for six months and for multibacillary leprosy are rifampicin 600 mg a month, clofazimine (Lamprene) 300 mg a month continuous with Lamprene 50 mg a day and Dafson (DDS) 100 mg a day continuous therapy for 12 months.

Learning Task Vignette 1 A 30 years old man complaining of redness patches on the left cheek with more redness patches on the back and chest without itchy or painful. From physical examination found multiple erythematous macules, ill-defined margin, symmetrically distributed. There were also found infiltrates on both of the earlobe and madarosis of both eyebrows. 1. What more could be found from anamnesis? 2. What examination should be done? 3. What is the differential diagnosis? 4. What is the working diagnosis? 5. What is the treatment? Vignette 2

Department of Medical Education - Faculty of Medicine - Udayana University 35

Study Guide Block Skin and Hearing Systems and Disorders

A 35 years old woman complaining of whitish patches on right thigh without itchy since 6 months ago. From physical examination found solitary hypopigmented macules, ill-defined margin, without a scale. There were also found hypoesthesia, reduce in thermal sensibility and impaired warm and cold perception. There was no enlargement of a nerve. 1. What is the differential diagnosis? 2. What is the working diagnosis? 3. What examination should be done? 4. What is the treatment?

Self Assessment 1. Explain the etiology of leprosy (Mycobacterium leprae)! 2. Explain the test for detection of M.leprae: Zeihl-Neilsen staining test, histopathological examination, lepromin test, Gunawan test and anesthetic test in supporting the diagnosis of leprosy! 3. Explain the clinical sign and symptom of leprosy! 4. Explain the classification of leprosy! 5. Explain the complications of leprosy! 6. Explain the management of leprosy and the possible complications!

Department of Medical Education - Faculty of Medicine - Udayana University 36

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 5: Viral Infection (Verucca, Morbili) AAGP Wiraguna

Verruca vulgaris is the common wart is a benign growth caused by localized infection with one of the many types of human papillomavirus. These small DNA viruses are part of the papovavirus group. Warts are especially common among children and adolescents and may occur on any mucocutaneous surface. The hands are a particularly frequent location. The typical wart is a rough-surfaced nodule that may be either lighter or darker than the surrounding skin. Factors that increase the risk include the use of public showers, working with meat, eczema, and a low immune system. The virus is believed to enter the body through skin that has been damaged slightly.A number of types exist including common warts, plantar warts, filiform warts, and genital warts.Genital warts are often sexually transmitted infection.

Learning task 1. What kind of virus for verruca vulgaris? 2. Describe the pathogenesis of verruca vulgaris! 3. What is the clinical manifestation of verruca vulgaris?

Self assessment 1. How to diagnose the verruca vulgaris? 2. What is the treatment of verruca vulgaris? 3. How to prevent verruca vulgaris?

Morbilli is a viral infection. The transmission spread by respiratory droplet aerosols produced by sneezing and coughing. Infected persons contagious from several days before onset of rash up to 5 days after lesions appear. Asymptomatic infection is uncommon. The pathogenesis of morbilli, when the virus enters cells of the respiratory tract, replicates locally, spread to regional lymph nodes, and disseminates hematogenous located. Persons deficient in cellular immunity are high risk for severe measles. The incubation period is 10-15 days.Clinical manifestations are fever, malaise, upper respiratory symptoms, photophobia, conjunctivitis with lacrimation. Sometimes we found peri-orbital edema. As exanthema progresses, systemic symptoms subside.

Department of Medical Education - Faculty of Medicine - Udayana University 37

Study Guide Block Skin and Hearing Systems and Disorders

Learning task 1. What kind of viral is that the etiology of morbilli? 2. Please explain that how to diagnose patient with morbilli!

Self Assessment 1. What is the difference of clinical manifestation between morbilli and varicella? 2. What is the treatment for morbilli? 3. What is the differential diagnosis of morbilli? Can you explain?

Department of Medical Education - Faculty of Medicine - Udayana University 38

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 6: Papuloerythrosquamous Skin Disease Prima Sudarsa

A Papuloerythrosquamous skin disease is a group of skin disease characterized by lesions of papules and erythematous macules that covered by scales. This group of skin disease consisted of varying entities of disease, but under this chapter will be discussed among others are seborrheic dermatitis, pityriasis rosea, psoriasis, and erythroderma. Seborrheic dermatitis is a common, chronic, superficial, inflammatory disease affecting 2-5% of the population. The disease is characterized by scaling on an erythematous base. The scale often has a yellow, greasy appearance with varying degree of itching. The predilection sites are the scalp, eyebrows, eyelids, nasolabial crease, lips, ears, sternal area, axillae, submammary folds, umbilicus, groins, and gluteal crease. The etiology of this disease is complex but may be related to the presence of Pityrosporum ovale which produces bioactive indoles. Seborrheic dermatitis and seborrheic dermatitis-like eruption also may be associated with several internal diseases such as Parkinson’s Disease, diabetes mellitus, malabsorption, epilepsy, and HIV infection. Varying treatment agents are available, such as corticosteroids, antifungal agents, and calcineurin inhibitors. Pityriasis rosea is a mild inflammatory exanthem characterized by salmon-colored papular and macular lesion that is at first discrete but may be confluent. The disease most frequently begins as a single herald or mother patch that followed by multiple smaller lesion. The individual patches are oval or circinate and are covered with finely crinkled, dry, epidermis, which often desquamates leaving a collarette of scaling. This disease was believed a form of viral exanthem and related with Human Herpesvirus (HHV-6 and 7). The incidence is highest between the age of 15 and 40 y.o, with most prevalent in the spring and autumn season. Most patients require no therapy, and the lesion will heal spontaneously after 3-8 weeks. Psoriasis is a common, chronic, and recurrent inflammatory disease of the skin characterized by circumscribed, erythematous, dry, scaling plaques of varying sizes. The lesion is usually covered by silvery white lamellar scales. The lesion has a predilection for the scalp, nails, extensor surface of the limbs, umbilical region, and sacrum. The eruption is usually symmetrical. Subjective symptoms such as itching and burning may be present and causing discomfort. Psoriasis has a varying type of manifestation, with the classic form of psoriasis vulgaris, psoriasis inversa, psoriasis guttata, psoriasis pustulosa, etc. Psoriasis has specific signs to help diagnoses such as Koebner Phenomenon, Kaarsvlek Phenomenon, and Auspitz Sign. The pathogenesis of psoriasis is complex with multiple factors involved such as inheritance and environmental

Department of Medical Education - Faculty of Medicine - Udayana University 39

Study Guide Block Skin and Hearing Systems and Disorders

influence ranging from stress, bacterial infection, or drugs. Treatment also varied, ranging from topical, systemic, or phototherapy with variable results. Exfoliative dermatitis or also known as erythroderma is a skin disease characterized by extensive erythema and scaling. Ultimately, the entire body surface is dull scarlet and covered by small, laminated scales that exfoliate profusely. Itching of the erythrodermic skin may be severe and the onset is often accompanied by symptoms of general toxicity including fever and chills. Secondary infections by pyogenic organism often complicate the course of the disease in the absents of treatment. Severe complication includes sepsis, cardiac failure, acute respiratory distress syndrome and capillary leak syndrome. The mortality rate approaches 7% in some series. Erythroderma is frequently the results of generalization of a pre-existing chronic dermatosis such as psoriasis or atopic dermatitis. Many other cases are related to medication, internal malignancy, or immune defect.Treatment is according to the underlying disease. Immunosuppressive agents may occasionally be necessary for idiopathic erythroderma not responding to therapy.

Learning Task 1. Describe the etiology and pathogenesis of each disease in papulo-erythrosquamous skin disease group! 2. Describe the characteristic clinical manifestation of seborrheic dermatitis, pityriasis rosea, psoriasis vulgaris, and erythroderma! 3. Mention the treatment modalities of seborrheic dermatitis, pityriasis rosea, psoriasis vulgaris, and erythroderma! 4. Explain the prognosis of each disease in papuloerythrosquamous skin disease group!

Self Assessment A 32-year-old man came with chief complain of redness patches that felt slightly itchy in the back of his ears, eyebrows, and around his nose since one year ago that getting worse and spread to his chest since 3 months ago. The redness was covered by yellowish scales. He also complained of weight loss, prolonged fever, and diarrhea since 3 months ago.

Department of Medical Education - Faculty of Medicine - Udayana University 40

Study Guide Block Skin and Hearing Systems and Disorders

1. Describe what should be asked more to gain information from anamnesis! 2. Describe the dermatological status that might be found in physical examination! 3. Explain what laboratory examination can be proposed! 4. Explain treatment modalities that available! 5. Describe what should be explained to the patient regarding his complain!

Department of Medical Education - Faculty of Medicine - Udayana University 41

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 7: Insect Bite and Infestation Praharsini

Parasite Infestation in Cutaneous Parasite infestation of the skin is a common presentation to a dermatologist as well as to primary care physicians. A parasite organism that lives on or in the host and gets its food from its host. This lecture will focus on scabies, pediculosis, and creeping eruption. Scabies is parasite infection in human-caused by Sarcoptesscabei var.hominis. The patient typically presents with the different eruption of small pink papules with combination burrows in predilection site. Topical Permethrin 5% in the first line dan most effective treatment. Louse infestation in human is caused by 3 type sucking lice: the head lice (Pediculus human capitis), the body lice (Pediculuscorporis)and the crabs (Pthirus pubis). All forms of lice infection regardless of distribution presents with regional pruritus, excoriation, erythematous papules. There are 3 categories of lice treatment: mechanical, topical and systemic therapy. Creeping eruption is the most tropical dermatosis. It is caused by hookworm larvae, which are in the feces of infected dogs and cats.The lesions are characteristically erythematous, raised and vesicular, linear or serpentine and intensely pruritic. The conditions respond to oral and or topical albendazole. Arthropod Bites The phylum Arthropoda includes arachnids (those with eight legs) and insects (those with six legs). Arthropod saliva contains anticoagulants and enzyme that can cause pain, localized irritation, allergic reactions or transmitted diseases. Arthropod venom can affect cellular and nervous function. The two medically important spiders that are: the black widow and the brown recluse. Most spiders are harmless. Widow venom contains the toxin, which caused cramps muscle spasm, pain, nausea, weakness and facial edema. Widow bite responds to a benzodiazepine or when necessary antivenom. The most common type of reaction to an insect sting is a local reaction but can occur systemic reaction.The reaction reflects an allergic and toxic response to proteins in the insect’s saliva. The allergic reaction leads to an immediate allergic reaction (wheal) and delayed reaction (papule).Bites from bedbugs, mosquitoes presents as pruritic, pink papule. History and location insect bite can assist with diagnosis. Mosquitoes bites are on the exposed skin. Most arthropod bites resolve without aggressive therapy and require only wound care and minor debridement. Antihistamine treatment s required for insect bite.

Department of Medical Education - Faculty of Medicine - Udayana University 42

Study Guide Block Skin and Hearing Systems and Disorders

LEARNING TASK Vignette 1 A 37-year-old female presented with a two-day history of multiple blisters over both hands preceded by one-week history of generalized pruritus. He complained of itchy red raised lesions over genital. The itching was more during at night. From examination found multiple erythematous papules, excoriation on the wrist, trunk and lower limbs. Multiple erythematous- papulo-nodular lesions were seen over scrotum and penis. 1. What is the diagnosis this patient? 2. What examination should be done? 3. What is the treatment and counseling, information, education for the patient?

Self Assesment 1. Explain the etiology of scabies, pediculosis, and creeping eruption! 2. Explain the laboratory examination for scabies! 3. Explain the clinical sign and symptom of scabies, pediculosis, and creeping eruption! 4. Explain the clinical variant of scabies! 5. Explain the management of scabies, pediculosis, and creeping eruption! 6. Explain the complication of scabies and pediculosis!

Vignette 2 A 21-year-old man was admitted to the Department of Dermatology presented multiple rashes with itchy. He is a healthy soldier and living in police dorm. From physical examination found erythematous macules, papules, nodules, urticarial wheals, and blisters on arms, shoulders, buttock, and legs.Linear formation and visible punctum of some lesion could be observed.Patient’s roommate presented similar lesions. 1. What is the differential diagnosis? 2. What examination should be done? 3. What is the working diagnosis? 4. What is the treatment and counseling, information, education for the patient?

Vignette 3 A 39-year-old male complaining of erythematous patches and felt burning on his left elbow on day 3 of the trip.They traveled by boat on Ayung river.He did sleep on the top deck of the boat, which opens to air. From physical examination found linear erythematous patch measuring 10 cm in longest dimension with central vesicle and bulla.

Department of Medical Education - Faculty of Medicine - Udayana University 43

Study Guide Block Skin and Hearing Systems and Disorders

1. What is the differential diagnosis? 2. What is the working diagnosis? 3. What is the treatment?

Self Assesment 1. Explain the etiology of arthropod bites! 2. Explain the clinical sign and symptom of Arachnida and insect bite! 3. Explain the management of Arachnida and insect bite!

Department of Medical Education - Faculty of Medicine - Udayana University 44

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 8: Bacterial Infection of the Skin Dwi Karmila

Bacterial infection in the skin often has distinct morphologic characteristics that should alert the clinician to the fact that a potentially treatable and reversible condition exists. These cutaneous signs may be an indication of a generalized systemic process or simply an isolated superficial event. The categorization of this infection will be first those diseases caused by Gram-positive bacteria, than those caused by Gram-negative bacteria. The majority of the primary and secondary (cutaneous bacterial infections) are caused by either S. aureus or group A . These bacteria cause a broad clinical spectrum of infection ranging from superficial pyodermas to invasive soft-tissue infection depending on the organism, the anatomic location of infections, and on host factors.Local manifestations include , furunculosis, , and impetigo. Colonization by S. aureus may be transient or represent a prolonged carrier state.S. aureus produces many cellular Host factors such as immunosuppression, glucocorticoid therapy, and atopy may play a major role in the pathogenesis of staphylococcal infections. Pre-existing tissue injury or inflammation (surgical wound, burn, trauma, dermatitis, retained foreign body ) is of major importance in the pathogenesis of staphylococcal disease. Pyodermas are infections of the epidermis, just below the stratum corneum or in hair follicles. In industrialized nations, S.aureus is the most common cause of superficial pyodermas, but group A streptococcus continues to be a common cause of in developing countries. Untreated, Pyodermas can extend to the dermis, resulting in ecthyma and furuncle formation.

Impetigo Two clinical patterns of impetigo are recognized: bullous and nonbullous. is caused by S. aureus. Currently, in industrialized nations, nonbullous impetigo is most commonly caused by S. aureus and less often by group A streptococcus.

Superficial Folliculitis Superficial folliculitis has also been termed follicular or Bockhart impetigo. A small, fragile, dome- shaped pustule occurs at the infundibulum (ostium or opening) of a hair follicle, often on the scalps of children and in the beard area, axillae, extremities, and buttocks of adults. Isolated staphylococcal folliculitis.

Department of Medical Education - Faculty of Medicine - Udayana University 45

Study Guide Block Skin and Hearing Systems and Disorders

Ecthyma Ecthyma is an ulcerative staphylococcal or streptococcal pyoderma, nearly always of the shins or dorsal feet. The disease begins with a vesicle or vesicopustule, which enlarges and in a few days becomes thickly crusted. When the crust is removed there is a superficial saucer-shaped ulcer with a raw base and elevated edges. Local adenopathy may be present. Uncleanliness, malnutrition, and trauma are predisposing causes.

Infections Caused by Erythrasma Erythrasma is a common superficial bacterial infection of the skin characterized by well-defined but irregular reddish-brown patches, occurring in the intertriginous areas, or by fissuring and white maceration in the toe clefts. The most common site of involvement in the web spaces of the feet, where erythrasma presents as a hyperkeratotic white macerated plaque, especially between the fourth and fifth toes. In the genitocrural, axillary, and inframammary regions, the lesions present as well-demarcated, reddish-brown, superficial, finely scaly, and finely wrinkled patches. In the sites, the patches.

Skin disease caused by Mycobacterium Scrofuloderma Scrofuloderma is subcutaneous tuberculosis leading to cold abscess formation and a secondary breakdown of the overlying skin.Scrofuloderma represents contiguous involvement of the skin overlying another site of infection (e.g., tuberculous lymphadenitis, tuberculosis of bones and joints, or tuberculous epididymitis). Scrofuloderma most often occurs in the parotid, submandibular, and supraclavicular regions and may be bilateral. It first presents as a firm, subcutaneous nodule, usually well defined, freely movable, and asymptomatic. As the lesion enlarges is softens. After months, liquefaction with perforation occurs, causing ulcers and sinuses.

Vignette 1. A 25-year-old male came to the hospital with chief complain redness on the axilla since 3 days ago, not so itchy. From physical examination found well demarcated reddish brown. The KOH preparation has already done, but there is no fungal element found. They came to you to ask explanation and treatment.

Department of Medical Education - Faculty of Medicine - Udayana University 46

Study Guide Block Skin and Hearing Systems and Disorders

a. What is the most likely diagnosis and differential diagnosis? b. What must evaluations or lab study be performed? c. What are the treatment options and prognosis?

2. A 5-month-old baby and his mother came to the primary hospital with chief complain, thin wall vesicles that rapidly become pustular and then rupture which leaving a thick yellow crust around his nose since 3 days ago. There are no pain, itchy, and fever. They came to you to ask explanation and treatment a. What other anamnesis are needed to ask this patient? b. What is the most likely diagnosis and differential diagnosis? c. What is the laboratory examination need to confirm the diagnosis? d. What is the treatment options?

Self assessment 1. Explain the pathogenesis of pyodermas, erythrasma, and scrofuloderma! 2. Describe the clinical sign pyodermas, erythrasma, and scrofuloderma! 3. Describe predisposing factors of pyodermas, erythrasma, and scrofuloderma! 4. Explain what kind examination we need to confirm the diagnosis! 5. Explain the management of pyodermas, erythrasma, and scrofuloderma!

Department of Medical Education - Faculty of Medicine - Udayana University 47

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 9: Pigmentary and Sebaceous Gland Disorders Elis Indira

Acne vulgaris is a chronic inflammatory disease of the pilosebaceous follicles, characterized by comedones, papules, pustules, nodules, and often scars. The comedo is the primary lesion of acne. Acne affects primarily the face, neck, upper trunk and upper arms. Acne is primarily a disease of the adolescent, with 85% of all teenagers being affected to some degree. Treatment consists of systemic and topical antimicrobials, systemic and topical retinoids, and systemic hormonal therapy. Melasma is characterized by brown patches, typically on the malar prominences and forehead. There are three clinical patterns: 1) centro-facial, 2) malar, and 3) mandibular. Melasma occurs during pregnancy, using oral contraceptives or with hormone replacement therapy (HRT).Treatment: exposure to sunlight should be avoided and a complete sunblock with broad- spectrum UVA coverage should be used daily. Bleaching creams with hydroquinone are the gold standard. The combination of hydroquinone, tretinoin, topical steroid has been called Kligman’s formula and is excellent.

Learning objective: 1. Explain the pathogenesis of acne vulgaris! 2. Explain the predisposing factor of acne vulgaris! 3. Describe the efflorescence that found in acne vulgaris and its signature! 4. Explain the degree and classification of acne vulgaris! 5. Explain the differential diagnosis of acne vulgaris! 6. Explain non-medicamentousa andmedicamentosa treatment of acne vulgaris! 7. Explain the prognosis of acne vulgaris! 8. Explain the efflorescence of perioral dermatitis! 9. Explain the therapy of perioral dermatitis! 10. Describe types of miliaria and their clinical features! 11. Describe the clinical picture of suppurative hidradenitis and treatment option! 12. Describe some examples of pigmentation abnormalities, accompanied by clinical features and their management!

Department of Medical Education - Faculty of Medicine - Udayana University 48

Study Guide Block Skin and Hearing Systems and Disorders

Case 1 A 35-year-old woman came to the hospital with complaints of brown-black spots on the face since 1 year ago. The spots are felt became wider without itching, or pain sensation. On physical examination general condition was normal, blood pressure 120/80 mmHg, pulse 88x/minute, the frequency of breath 20x/minute and temperature 36,4°C. Dermatologic examination on facial area (forehead, left and right cheeks, and chin) was found multiple macular hyperpigmentations, brown-black in color, well-defined margin, geographical in shape, size varies between 3 to 5 cm. 1. What is the possible diagnosis of the above case? 2. What investigations can be performed in this case and their usefulness? 3. What are the predisposing factors that can cause this disorder? 4. Mention the various treatment options for this case and the gold standard of topical treatment!

Case 2 A 21-year-old woman came to a dermatologist and genital complaints of multiple on the face. The pimples appeared since 6 months ago and sometimes accompanied by itchy but without pain. Physical examination found open blackheads and closed multiple whiteheads with the number of lesions 20, found no papules, pustules, nodules or cysts on the face. 1. What is the diagnosis of the above case (complete diagnosis)? 2. Whether the investigation is required in the above case, if necessary, specify the type of examination! 3. Explain the management in the above case! 4. What factors should be avoided so that the disorder does not become worse? 5. How is the prognosis in the above case?

Department of Medical Education - Faculty of Medicine - Udayana University 49

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 10: Dermatophytosis Swastika Adiguna

Mycoses are divided among three form; superficial mycoses, subcutaneous mycoses and deep/systemic mycoses. The focus of this chapter is the superficial mycosis which is involving stratum corneum, nail and hair. Superficial mycoses classified into dermatophytes and non- dermatophytes. Dermatophytes including Tinea corporis, tinea cruris, tinea pedis etc. Nondermatophytes including Pityriasis versicolor, Candidiasis, Tinea nigra and Piedra. Until now this fungal diseases still prevalent in society, so it is important to study the clinical manifestations and pathogenesis of the diseases.

LEARNING TASK Vignette 1 Male 35 years old came to Dermatology Clinic with chief complain itching in the sites of the neck, upper, lower extremities, trunk, and inner surfaces of the thigh especially during the hot climate. It began as a small erythematous and scaling or vesicular and crusted patch that spreads peripherally and partly clear in the center. This lesion may be slightly elevated particularly at the border, where they more inflamed and scaly. 1. Please explore another history to complete anamnesis! 2. What kind of clinical examination will you do? 3. What kind of laboratory examination will you do? 4. What was the diagnosis of this patient? 5. Describe your planning therapy for this patient! 6. Describe your planning education for this patient!

Self assessment 1. What the definition of dermatophytosis (tinea or ringworm)? 2. Please describe the fungi of dermatophytes! 3. What is the differential diagnosis of dermatophytosis? 4. Describe anti-fungal therapy, how they work, how long the patient should take the medication until cured!

Department of Medical Education - Faculty of Medicine - Udayana University 50

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 11: Drug Eruption (Exanthematous Drug Eruption, Fixed Drug Eruption) Ratih Karna

Drug eruption is an adverse drug reaction of the skin. Most drug-induced cutaneous reactions are mild and disappear when offending drug is withdrawn, however more serious life-threatening drug eruption may be associated with organ injury as liver and kidney. Some case of drug eruption in society always misleads into malpractice case, as patient misunderstanding drug eruption occurred because of the wrong medication is given by the doctor.The offending drug should be asked in anamnesis. It includes non-prescription drug, pharmaceutical delivered by others (eye drop, suppositories, implant, injection, etc) include herbal medication. Drug eruption needs to be properly diagnosed, treated with appropriate treatment, and CIE to the patient to avoid the offending drug in the future. LEARNING TASK Vignette 1 A man 40-year-old complained of the red spot on his body since 3 days ago. He regularly took anti retroviral pills, anti-TBC pills (Rifampicin, and anti-fungal tablet since is diagnosed as an HIV patient last month).On physical examination we found present status: BP: 120/80, temp: 38,5o C, RR: 20x/minute, pulse: 80x/minute. Dermatology status: Location Trunk and upper femur dextra et sinistra. Eflorescence: Multiple Erythematous macules, round shape diameter 0,5 – 1 cm, well- defined margin, discrete. No lesion found on his mucous membrane.

1. What are the other complaints should be asked to the patient? 2. Describe the efflorescence of this patient! 3. What is the diagnosis? 4. Are there any other possible diseases? 5. How are the management and CIE? 6. How is the prognosis of this patient?

Department of Medical Education - Faculty of Medicine - Udayana University 51

Study Guide Block Skin and Hearing Systems and Disorders

Self Assessment 1. List the symptoms of drug eruption! 2. What is expected from the laboratory? 3. How is pathogenesis of the disease? 4. How is the prognosis?

Vignette 2 A man 45-year-old, complained about of the black spot on his lips, penis and also his thigh. Last year he has the same symptom after took antibiotic from the dentist. 1. What are the other complaints? 2. What kind of examination do we need? 3. What is the typical efflorescence of this case? 4. Is it possible if only found single lesion? 5. What is the diagnosis? 6. Are there any other possible diseases? 7. How are the management and CIE? 8. How is the prognosis of this patient?

SelfAssessment 1. List the symptoms of fixed drug eruption! 2. How is pathogenesis of the disease? 3. How is the prognosis?

Department of Medical Education - Faculty of Medicine - Udayana University 52

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 12: Dermatitis and Urticaria Suryawati

Nummular Dermatitis Nummular dermatitis is defined as an eruption of round (discoid) eczematous patches almost exclusively of the extremities often the lower legs in men and the forearms and dorsal aspects of the hands of women. The lesions are well demarcated and measure 1–3 cm, only occasionally being larger. They may be acutely inflamed with vesicles and weeping, but are more often lichenified and hyperkeratotic. The pathogenesis has not been fully elucidated. Pruritus may be intense and excoriations are often prominent. Nummular dermatitis usually takes a very chronic course. Options comprise medium-to high-potency topical corticosteroid ointments, topical tacrolimus or pimecrolimus, and emollients. Tar preparations have also been used successfully. However, a number of patients will require phototherapy to clear the lesions.

Lichen simplex chronicus (circumscribed neurodermatitis) Paroxysmal pruritus is the main symptom. Lichen simplex chronicus is a result of long-continued rubbing and scratching, more vigorously than a normal pain threshold would permit, the skin becomes thickened and leathery. Chronic scratching of a localized area is a response to unknown factors; however, stress and anxiety have long been thought important. It is important to stress the need for the patient to avoid scratching the areas involved if the sensation of itch is ameliorated. High-potency agents should be used initially and the treatment can be shifted to the use of medium-to lower-strength topical steroid creams as the lesions resolve. Topical doxepin, capsaicin, or pimecrolimus cream or tacrolimus ointment provides significant antipruritic effects and is a good adjunctive therapy. Intralesional injections of triamcinolone suspension, using a concentration of 5 or (with caution) 10 mg/mL, may be required.

Diaper (napkin) dermatitis Diaper dermatitis is the cumulative result of several factors, in particular, dampness and exposure to urine and feces. Prolonged use of diapers, dampness, and the factors detailed above lead to the breakdown of the horny layer barrier function. An alkaline pH also facilitates the development of secondary C. albicans infection. Diaper dermatitis is strictly confined to the diaper area, presenting with mild to pronounced erythema, erosions and scaling. Refractory diaper dermatitis may require a biopsy to exclude some of the above conditions. In the acute phase, mild corticosteroid preparations are helpful. Topical imidazole creams are added for secondary

Department of Medical Education - Faculty of Medicine - Udayana University 53

Study Guide Block Skin and Hearing Systems and Disorders

infection with Candida spp. The major goal of long-term management is avoidance of the causative factors. Frequent changing of highly absorbent disposable diapers is associated with a lower incidence and severity of diaper dermatitis, and it leads to a more physiologic pH. Emollients containing white paraffin or soft zinc pastes provide both protective and soothing effects.

Perioral Dermatitis Perioral dermatitis is characterized by small discrete papules and pustules in periorificial distribution. Patients often reveal a history of an acute steroid-responsive eruption around the mouth, nose and/or eyes that worsen when the topical corticosteroid is discontinued. If the topical corticosteroid is being used, they should be discontinued. Patients should be educated about the link between the application of topical corticosteroid and exacerbation of dermatitis. In the most cases, treatment includes oral tetracycline, doxycycline or minocycline for a course 8-12 weeks, including a taper over the last 2-4 weeks. Topical antibiotic therapy most commonly with topical metronidazole should be initiated concurrently with the systemic antibiotic. Other options include topical clindamycin or erythromycin, topical sulfur-based preparations, and topical azelaic acid.

Photoallergic Contact Dermatitis Certain substances are transformed into irritants or sensitizers (photosensitizers) after irradiation with UV or short-wave visible radiation (280–600 nm). The photoactivated molecules may be transformed into new substances capable of acting as irritants or haptens. Photoallergic reactions are based on immunological mechanisms and can be provoked by UV radiation only in a small number of individuals who have been sensitized by previous exposure to the photosensitizer. The reaction to a photo-allergen is based on the same immunological mechanism as contact allergic reactions. The action spectrum for photoallergy is generally in the UVA range. Many photo contact allergens have been identified with varying degrees of confirmatory evidence, and these are perfumes, topical non-steroidal anti-inflammatory agents, phenothiazines, sulphonamides used for topical treatment, bithionol and hexachlorophene (in toilet soaps, shampoos, and deodorants), quinines. Photoallergic reactions can resemble sunburn, but usually, show the same spectrum of features seen with allergic contact dermatitis. The dermatitis is localized to exposed areas of the skin, usually with well-demarcated margins where the skin is covered by clothing, for example at the collar and ‘V’ of the neck, below the end of the sleeves and trouser leggings. The area below the chin is usually spared.

Department of Medical Education - Faculty of Medicine - Udayana University 54

Study Guide Block Skin and Hearing Systems and Disorders

Urticaria (Wheals) Urticaria is a vascular reaction of the skin characterized by the appearance of wheals, generally surrounded by a red halo or flare and associated with severe itching, stinging, or prickling sensations. These wheals are caused by localized edema. Lesions may be a few millimeters in diameter or as large as a hand, and the number can vary from a few to numerous. The hallmark of wheals is that individual lesions come and go rapidly, by definition, in general within 24 hours. Angioedema swellings occur deeper in the dermis and in the subcutaneous or submucosal tissue. They may also affect the mouth and, rarely, the bowel. The areas of involvement tend to be normal or faint pink in color, painful rather than red and itchy, larger and less well defined than wheals, and often last for 2 to 3 days. Etiologic factors including drug, food, food additives, infections, emotional stress, menthol, neoplasm, inhalant, alcohol, hormonal imbalance, and genetics. A comprehensive history is essential in every patient with urticaria. Patients should be given advice and information on common precipitants, treatments, and prognosis. Antipruritic lotions and the avoidance of aggravating factors, including NSAIDs, may be sufficient for some, but many will need additional interventions, including systemic medications. Antihistamines are the mainstay of management for most patients with urticaria, although not all patients will respond and only about 40% of those attending tertiary care clinics will clear or almost clear at licensed doses. For severe reactions, including anaphylaxis, respiratory and cardiovascular support is essential. A 0.3 mL dose of a 1: 1000 dilution of epinephrine is administered every 10–20 min as needed. In young children, a half-strength dilution is used.

Case 1 A 5-months old baby, came to dermatology polyclinic with her mother with redness rash on his diapers area since 2 days ago. Anamnesis from his mother there was a history of diarrhea and used baby diapers since 7 days ago. Physical examination of diaper area reveals erythematous macule ill define margins, some part with erosion and brown crust. Learning Task : 1. Please do further anamnesis in this case! 2. What is the differential diagnosis of this case? 3. What is the possible diagnostic of this case? 4. What is the other examination we must do to confirm the diagnostic of this case? 5. What is the complication of this case?

Department of Medical Education - Faculty of Medicine - Udayana University 55

Study Guide Block Skin and Hearing Systems and Disorders

6. How is the management of this case?

Self Assessment 1. What is the definition of diaper dermatitis? 2. What are the symptom and sign of diaper dermatitis? 3. What is the pathogenesis of diaper dermatitis? 4. What is the management of diaper dermatitis?

Case 2 Woman 17 years old, complained itchy skin rash on her face especially after sun exposed since 1 weeks ago. From anamnesis, there was a history of used sunblock cream since 3 weeks before. Physical examination on her face there is a multiple erythematous macules ill-defined margin with erythematous papule, some part with excoriation.

Learning Task 1. Please do further anamnesis in this case! 2. What is the differential diagnosis of this case? 3. What is the possible diagnostic of this case? 4. What is the other examination we must do to confirm the diagnostic of this case? 5. What is the complication of this case? 6. How is the management of this case?

Self Assessment 1. What is the definition of photoallergic contact dermatitis? 2. What are the symptom and sign of photoallergic contact dermatitis? 3. What is the pathogenesis of photoallergic contact dermatitis? 4. What is the management of photoallergic contact dermatitis?

Case 3 Man 35 years old, complained itchy skin rash on almost over the body since 1 weeks ago. He felt the rash come and go in one day. On physical examination there were wheals, generally surrounded by a red halo. Learning Task : 1. Please do further anamnesis in this case

Department of Medical Education - Faculty of Medicine - Udayana University 56

Study Guide Block Skin and Hearing Systems and Disorders

2. What is the differential diagnosis of this case? 3. What is the possible diagnostic of this case? 4. What is the other examination we must do to confirm the diagnostic of this case? 5. What is the complication of this case? 6. How is the management of this case?

Self Assessment 1. What is the definition of urticaria? 2. What are the symptom and sign of urticaria? 3. What is the pathogenesis of urticaria? 4. What is the management of urticaria?

Department of Medical Education - Faculty of Medicine - Udayana University 57

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 13: Rational Therapy of Topical Preparations in Dermatology Alit Widhiartini

Dermatological treatment usually involves the use of topical preparations which has known since ancient times. Many topical dermatologic treatments include: cleansing agents, absorbents, anti- infective agents, anti-inflammatory agents, astringents, emollient, and keratolytic are applied to the skin either for cosmetic and or therapeutic purposes. Dispensing multiple or different pharmaceutically active compounds to be a new formula may change the former purposes. Several active compounds do physical even chemical interaction which may enhance percutaneous absorption or permeability, physically unstable which influence their dermatological activities to be less active or contrary to be more potent. Optimizing absorption could be performed by altering the formulation vehicle. Some vehicles enhance the penetration and biological activity of therapeutic agents. Some vehicles in used are powders, creams, ointments, gel, aerosol, and lotions formulation and their uses must be considered based on their properties such as (1) solubility of the therapeutic agent in the vehicle; (2) rate of release of the agent from the vehicle; (3) ability of the vehicle to hydrate the Stratum Corneum; (4) stability of the therapeutic agent in the vehicle; (5) interactions, chemical and physical, of the vehicle, Stratum Corneum, and therapeutic agent. Further, the basic principles of optimal and effective topical preparation for dermatological therapy should be well-understood. There are many factors should be put into consideration when prescribing topical preparations. These include patient’s age, hormonal status, and history. The anatomy and physiology of the skin and changes with age and woman hormonal status may considerably influence the skin texture. The nature of the lesion (e.g. wet or dry) will determine the choice of vehicle, the type appropriate topical preparation, in which the active compound (drug) will be administered.

Learning Task Case 1. A female young adult, 22 years old, married, comes to your private practice. She complains of itch and redness in the groin area, since 3 days ago. The itch becomes more severe when she is sweating. She has not treated her conditions yet. She denies any history of drug allergy. Physical examination reveals erythematous polycyclic lesions, clearly demarcated, with central healing.

Department of Medical Education - Faculty of Medicine - Udayana University 58

Study Guide Block Skin and Hearing Systems and Disorders

Exercise: 1. Please make a list of possible effective and safe treatments for the patient problem! What is the first line drug for this disorder? Second line? 2. After making the list, please choose your p-drug and explain the rationale for choosing your p-drug! 3. Please explain schematically about the pharmacodynamics of your p-drug! (We encourage you to use table or any other kind of picture manually made by yourself). 4. Write your P-drugs in detailed prescription according to her needs on the prescription sheet that has been provided. 5. Please describe what will you say to inform and educate the patient about your prescribed p-drug, regarding the use, possible side effects, cost, and possible drug-drug interactions (if the patient receives more than one p-drug)! Note: Please avoid medical terminologies.

Case 2. A female, 32 years old, a housemaid comes to a private practice with the complaints of intense itching and redness on his left wrist after detergent contact. The problems appeared to worsen at night. He denies any history of medication to treat his condition. Exercise: 1. Please make a list of possible effective and safe topical treatments for the patient problem! What is the first line drug for this disorder? Second line? 2. After making the list, please choose your p-drug and explain the rationale for choosing your p-drug! 3. Please explain schematically about the pharmacodynamics of your p-drug! (We encourage you to use table or any other kind of picture manually made by yourself) 4. Write your P-drugs in detailed prescription according to her needs on the prescription sheet that has been provided. 5. Please describe what will you say to inform and educate the patient about your prescribed p-drug, regarding the use, possible side effects, cost, and possible drug-drug interactions (if the patient receives more than one p-drug)! Note: Please avoid medical terminologies.

Department of Medical Education - Faculty of Medicine - Udayana University 59

Study Guide Block Skin and Hearing Systems and Disorders

Prescription Sheet dr ..... SIP:IDI ……………………. Jl Praktikum Farmakoterapi, 2, Denpasar (0361)234567

Denpasar,......

R/

Nama pasien :…...... ……………. Alamat :…………....……………. Umur/BB : ......

Department of Medical Education - Faculty of Medicine - Udayana University 60

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 14: Dermatopharmacology Sucindra Dewi

Dermatopharmacology is focused on topical and systemic drug which is used to treat skin diseases. Most skin diseases are not life-threatening, but nevertheless, proper diagnosis and therapy are needed to obtain a cure. Pharmacological responses to drugs applied to the skin (topical drugs) are determined by some of the major variables including regional variation in drug penetration, concentration gradient, delivery schedule, vehicles, and occlusion. More complex skin problems require systemic treatment. The selection of treatment to be used is determined by the type, severity of the disease and the condition of the patient.The drugs usually used in dermatologic disorders are antibacterial agents, antifungal agents, topical antiviral agents, ectoparasiticides agents, agents affecting pigmentation, acne preparations, agents for psoriasis, anti-inflammatory agents, keratolytic & destructive agents, antipruritic agents and trichogenic agents.

Vignette 1 A thirty-year-old man comes to the clinic with chief complain itching in almost all over the body since 2 weeks ago. Itching is especially felt in the area around the armpits, chest, neck, groin, and back. Itching is felt worse when sweating. On physical examination, the rash was found on the skin with slightly raised edges and in the middle rash, there is a healthy skin. Learning task 1. What is the best treatment for this patient? 2. Please explain the pharmacokinetic and pharmacodynamic profile of that medicine! 3. What is the adverse effect of that medicine? 4. What is (are) the contraindication(s) of that drug? 5. What point should be informed the patient regarding the proper use of this drug?

Vignette 2 A child, 6-year-old comes to the GP with his parent, with chief complain itching on whole of his body especially complaining of itching all over his body especially in the armpit area, groin and between fingers. Itching is felt worse at night. On the physical examination was found erythema, papule, vesicle, tunnel, and excoriation on the skin of the finger.

Department of Medical Education - Faculty of Medicine - Udayana University 61

Study Guide Block Skin and Hearing Systems and Disorders

Learning task 1. What is the best treatment for this patient? 2. Please explain the pharmacokinetic and pharmacodynamic profile of that medicine! 3. What is the adverse effect of that medicine? 4. What is (are) the contraindication(s) of that drug? 5. What point should be informed the patient regarding the proper use of this drug?

Self assessment Explain what is (are) the best drug(s) used for a treat this problem, mechanism of action and the adverse effect of this drug! 1. Drug for Eczema! 2. Drug for Onychomycosis! 3. Drug for Cutaneous larva migrans!

Department of Medical Education - Faculty of Medicine - Udayana University 62

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 15: Physiology of Hearing systems Krisna Dinata

Audition, the sense of hearing, involves the transduction of sound waves into electrical energy, which then can be transmitted in the nervous system. Most sounds are mixtures of pure tones. The human ear is sensitive to tones with frequencies between 20 and 20,000 Hz and is most sensitive between 2000 and 5000 Hz. The usual range of frequencies in human speech is between 300 and 3500 Hz, and the sound intensity is about 65 dB. Sound intensities greater than 100 dB can damage the auditory apparatus, and those greater than 120 dB cause pain. Sound waves are directed toward the tympanic membrane, and, as the tympanic membrane vibrates, it causes the ossicles to vibrate and the stapes to be pushed into the oval window. This movement displaces fluid in the cochlea and causes vibration of the organ of Corti.Thus, the vibration of the organ of Corti causes bending of cilia on the hair cells by a shearing force as the cilia push against the tectorial membrane. Bending of the cilia produces a change in K+ conductance of the hair cell membrane. Thus, oscillating depolarizing and hyperpolarizing receptor potentials in the hair cells cause the intermittent release of glutamate, which produces intermittent firing of afferent cochlear nerves. Information is transmitted from the hair cells of the organ of Corti to the afferent cochlear nerves. The cochlear nerves synapse on neurons of the dorsal and ventral cochlear nuclei of the medulla, which send out axons that ascend in the CNS.

LEARNING TASK A male 20 years old worker came to a physician with a complaint that his hearing doesn’t work properly. Thiscomplaintoccurs temporarily especially when he goes to a cold and high place. Every day he works for 8 hours at a factory with a noise level of 75dB. 1. In your opinion as a physician, Why doesn't his hearing work properly? 2. Explainthefunctionofeustachius tube! 3. The sound energy is amplified by two effects. Explain this statement! 4. Could listen to the music with an earphone makes deafness? Explain your answer!

SELF ASSESSMENT 1. What is the function of the pinna, auditory canal, tympanic membrane, middle ear bones, and oval window? 2. Explain the mechanism of transduction in hearing!

Department of Medical Education - Faculty of Medicine - Udayana University 63

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 16: Histology of Hearing Systems Arijana

The functions of the ear are for hearing and equilibrium. Ears consisted of three major parts, namely external ear which received sound wave, the middle ear which transmitted from air to fluid via a set of small bone and internal ear which transform fluid movement to nerve impulses. The external ear has auricle, external acoustic meatus, ceruminous glands and tympanic membrane. Middle ear has tympanic cavity, Eustachian tube, oval window, round window, and auditory ossicles (malleus, incus, and stapes). The internal ear has bony labyrinth and membranous labyrinth. Membranous labyrinth has vestibular labyrinth (equilibrium system) and cochlear labyrinth (hearing system). Vestibular labyrinth has utricle, saccule, and semicircular ducts. For equilibrium, the receptors are located in 2 maculae (utricular macula and saccular macula) and 3 cristae ampullaris (in each semicircular duct). For hearing the receptors are located in spiral organ of Corti in cochlear duct. The receptors are mechanoreceptors called hair cells which convert sound wave into electrical impulses in nerve. All regions of bony labyrinth are filled with perilymph and the membranous labyrinth is filled with endolymph.

Learning Task Vignette 1 A 10-years old child complains his right ear feel pain especially after touched. The child comes with his mother to Primary Health Care. After anamnesis and physical examination, the diagnosis is otitis externa and accompanied by cerumen obturan.

Learning Task 1 1. Describe histology structure of ear which is related to the diagnosis! 2. Cerumen wax is produced by ….. gland and ….gland. 3. Ceruminous gland is modification of ….gland.

Vignette 2 A 45-years old man complains his head feels spinning around (dizziness) accompanied by hearing loss and ringing in his ears. The man comes with his wife to Emergency Room. After anamnesis and physical examination, the diagnosis is Meniere disease.

Department of Medical Education - Faculty of Medicine - Udayana University 64

Study Guide Block Skin and Hearing Systems and Disorders

Learning Task 2 1. Describe histology structure of ear which is related to the diagnosis! 2. Perilymph is located in …. 3. Endolymph is located in ….

Vignette 3 A 22-year-old woman aboard in cruise ship feels nausea. The woman comes to the clinic on the cruise ship. After anamnesis and physical examination, the diagnosis is motion sickness.

Learning Task 3 Describe histology structure of ear which is related to the diagnosis!

Self Assessment 1. Describe histology structure of external ear! 2. Describe histology structure of middle ear! 3. Describe histology structure of inner ear! 4. Describe the differences between endolymph and perilymph!

Department of Medical Education - Faculty of Medicine - Udayana University 65

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 17: Anatomy of the Ear Yuliana

The Ear The ears are vestibulocochlear organs. Each ear comprises three portions: external, middle and internal. External and middle ear function is for hearing process only. Internal ear function is for hearing and equilibrium. The external ear (the external acoustic/auditory meatus) conducts sound toward the middle and internal components of the ear. It protects the middle and internal ear from outside damage and acts as pressure amplifier. It is about 25mm in length, extends from the concha to the tympanic membrane. The external ear is composed of the auricle (pinna), which collect sound and external acoustic meatus (canal), which conducts sound to the tympanic membrane. The lateral part is largely cartilaginous and slightly concave anteriorly. Skin of auricle continuously lines the meatus tightly. In cartilaginous part of the auricle, there are hair follicles, sebaceous and ceruminous glands.The sensory innervations of the external ear are derived from the auricular nerve (5th cranial nerve), the cervical plexus, and 7thcranial nerve. Glossopharyngeal nerve (9th cranial nerve) and vagus nerve (10th cranial nerve) innervate concha region. The blood supply mainly from the posterior auricular and superficial temporal arteries (of the external carotid). The Tympanic Membrane/ Ear Drum is about 1 cm in diameter, faces laterally, forward and downward. It is divided into the tense part and flaccid part. Tense part is the larger portion and attached to the tympanic plate of the temporal bone. Flaccid part is thinner in the anterosuperior portion and is limited by anterior and posterior mallear fold. Its lateral surface is concave and the center is called the umbo. The tympanic membrane is innervated by 5th and 10thcranial nerves for its lateral surface and 9th cranial nerve for the medial surface.

The Middle Ear consists of tympanic cavity and auditory ossicles. The tympanic cavity communicates with (1) the mastoid air cells and the mastoid antrum by means of the auditus, and (2) the nasopharynx by means of the auditory tube(pharyngotympanic tube). The auditory tube acts as an equalizer for both ears. The cavity is divided into 3 portions (1) the affic or epitympanic recess situated above the level of the tympanic membrane. It contains the head of the malleus and the body and short crus of the incus. This recess communicates with the aditus. (2) mesotympanum, the main portion, and (3) the lowest portion, the hypotympanic recess. The tympanic cavity is bounded laterally by tympanic membrane. The roof of the cavity is formed by tegmen tympani, a portion of the petrous temporal.

Department of Medical Education - Faculty of Medicine - Udayana University 66

Study Guide Block Skin and Hearing Systems and Disorders

Auditory ossicles are three small bones: malleus (hammer), incus (anvil), and stapes (stirrup). They joint as incudomallear and incudo stapedial joints in the type of synovial joint. The chain of the auditory ossicles acts as a system of levers. The handle and the lateral process of the malleus are embedded in the fibrous layer of the tympanic membrane. So the motion of the membrane by the sound waves are converted into intensified movements of the stapes. Two important muscles are tensor tympani and stapedius muscles. Tensor tympani muscle arises from acartilaginous part of the auditory tube and inserted on the handle of the malleus. It draws the handle medially, thereby tightening the tympanic membrane. The muscle supplied by the mandibular nerve and tympanic plexus. The stapedius muscle draws the stapes laterally and perhaps rotate the incus. The muscle is supplied by the 7th cranial nerve.The chief blood supply to the middle ear is from the external carotid (stylomastoid artery from a posterior auricular artery) and the maxillary (anterior tympanic artery).

The internal ear is located within the petrous part of the temporal bone. It consists of the membranous and bony labyrinth. The membranous labyrinth is located within the bony/osseous labyrinth. The bony labyrinth is a series of cavities composed of three parts: cochlea, vestibule, and semicircular canals. The membranous labyrinth consists of three parts: (1) utricle and saccule, two small communicating sac in the vestibule; (2) three semicircular ducts in the semicircular canals and (3) cochlear duct in the cochlea that contains the organ of hearing. Its chief divisions are the cochlear labyrinth and the vestibular labyrinth. The utricle and saccule have a specialized area of sensory epithelium, the maculae. The macula of the utricle is in the floor of the utricle; the macula of the saccule is vertically placed on the medial wall of the saccule. The hair cells in the macula are innervated by the vestibulocochlear nerve and the cell bodies are in the vestibular ganglion, which is in the internal acoustic meatus. The roof of the cochlear duct is formed by the vestibular membrane and the floor by the basilar membrane plus the outer edge of the osseous spiral lamina. The spiral organ (of Corti) contain hair cells situated on the basilar membrane. The tips of cells are embedded in the gelatinous tectorial membrane. The vibration of the base of stapes ascend to the apex by one channel, the scale vestibule; then the pressure waves pass through the helicotrema and descend back to the basal turn by the other channel, the scala tympani.

Department of Medical Education - Faculty of Medicine - Udayana University 67

Study Guide Block Skin and Hearing Systems and Disorders

LEARNING TASK 1. A child (8 years old) complained of sudden right ear pain after having cold symptoms about one week. The patient never had the same problem before. There is a fever. He had terrible nose blocked for two days. a. Based on knowledge of anatomy, which part of the ear might be affected? b. Describe the anatomy features of the answer on the question above! c. What would you suggest to the patient to prevent the same problem? 2. A male (27 years old) complained of bad ear pain after having hearing loud music for 2 hours. a. Please draw the anatomy of the ear! b. Based on the case, which part of the ear might be affected? c. What is the meaning of hyperacusis?

SELF ASSESSMENT 1. Describe the anatomy characteristic of the external ear, including its innervations and blood supply! 2. Describe the role of the tensor tympani and stapedius muscles! 3. Describe the anatomy of the middle ear in detail!

Department of Medical Education - Faculty of Medicine - Udayana University 68

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 18: Otic Drug Alit Widhiartini

Abstract Middle and inner ear disorders often require oral systemic or topical medications. Many drugs can be used to treat that disorder. Treatment of external ear, however, depends on topical otic drugs instilled directly into the external meatus of the ear for local action to prevent or treat disorders. Itchy, pain, and infections which may occur due to a cold, throat infection, or allergy attack caused ear infections and pain can usually clear by the immune system. But, sometimes the defense mechanism does not run well so it might need proper medicines to overcome the problem. The varieties drugs include antibiotics, anti-infectives, anti-inflammatory, anesthetics, drying and cerumen softener solvents. Many otic drugs are consist of single or combination of 2 or more drugs these are used to treat external ear infections, inflammation, and pain, and removing excessive or impacted cerumen. Treatment for suspect infection might begin with managing pain systemically by prescribing analgesic even topically local anesthetic and physician have to monitor while evaluating the therapeutic progress. Although prescribing antibiotic is not advised in most cases, it is very useful when the child is under 2 years old to prevent the risk of complications in babies, or when severe bacterial infection as the infection is not settling within 2-3 days or complications develop. Then, long-term therapy related to ear infections to overcome persistent fluids in the middle ear, persistent infections or frequent infections have to be well managed because they can cause hearing problems and other serious complications and several drugs also cause hearing disorders. We need to develop any drug of choice which is suitable for the patient’s diagnose and drug of choices was depending on the therapeutic objective also patient’s characteristics such as age and body weight as well as drug’s history and pathophysiology.

Learning Task Please make a summary of P drugs (drug of choice) of ear problem with oral even topical recommended treatment. Use the table below. You can use textbook or journal as references and compared to Buku Panduan Praktek Klinis bagi Dokter di Fasilitas Pelayanan (Permenkes no 5 Tahun 2014)

Department of Medical Education - Faculty of Medicine - Udayana University 69

Study Guide Block Skin and Hearing Systems and Disorders

Diagnosis Recommended Treatment Drug Dosage form Frequency per day, duration

Cases A five years old boy brings is accompanied by his parents come to a hospital ear pain since two days ago after getting a sore throat. His father is active smoking. Clinical examination found his body temperature is 38°C and found mucus in the middle ear. His body weight is 35 kg. Discussion and exercise: 1. What are the p-drugs of painkiller to this child? Why can’t aspirin give in this case? Please give your reason! 2. Please explain the profile pharmacokinetic and pharmacodynamics of the painkiller which can use in ear problems! 3. What kinds of antibiotics can be used in this case, please explain your answer? 4. Please explain the pharmacokinetic and pharmacodynamic profile of ofloxacin as ear drops antibiotic! 5. Please explain the rational drug therapy in ear infections! Why is the rational drug therapy very important to prevent complications in ear infections? 6. Write your P-drugs in detailed prescription according to her needs on the prescription sheet that has been provided! 7. Please describe what will you say to inform and educate the patient about your prescribed p-drug, regarding the use, possible side effects, cost, and possible drug-drug interactions (if the patient receives more than one p-drug)! Note: Please avoid medical terminologies.

Department of Medical Education - Faculty of Medicine - Udayana University 70

Study Guide Block Skin and Hearing Systems and Disorders

Prescription Sheet dr ..... SIP:IDI ……………………. Jl Praktikum Farmakoterapi, 2, Denpasar (0361)234567

Denpasar,......

R/

Nama pasien :…...... ……………. Alamat :…………....……………. Umur/BB :......

Department of Medical Education - Faculty of Medicine - Udayana University 71

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 19: Hearing loss in Children, Meniere, Sudden Hearing loss, Presbycusis (Wiranadha)

Hearing loss is one of the health problems commonly caused by age factor or because of exposure to loud noise. Hearing can be disturbed if the voice signal fails to reach the brain. Hearing process occurs when the eardrum vibrates due to sound waves entering the ear canal. The vibrations proceed to the middle ear through three auditory bones known as ossicles (consisting of malleus, incus, stapes). The ossicles will amplify the vibration to proceed towards the fine hairs inside the cochlea, where the cochlea ends up sending signals through the auditory nerve to the brain. There are two types of hearing loss: sensorineural hearing loss and conductive hearing loss. The sensorineural hearing loss is caused by damage to sensitive hair cells present in the inner ear or damage of the auditory nerve. Some of the causes of sensorineural hearing loss are Meniere disease, acoustic neuroma, meningitis, encephalitis, or multiple sclerosis. Conductive hearing loss usually occurs when sound waves cannot enter the inner ear. The following are the causes of conductive hearing loss: ruptured or perforated eardrums, otosclerosis, and hearing loss due to trauma.Anamnesis, physical examination, and a good investigation is the key to diagnose hearing loss.

Questions The 45 years old man comes with full ear complaints, ringing in the ear and dizzy He also complaints nausea and vomiting. He complains these problems since 2 months ago. 1. What is the name of the illness suffered by the patient? 2. What is the management of these problems? 3. What is the differential diagnosis?

Self-Assessment 1. How are newborn's hearing screening and handling if there are abnormalities? 2. What are the diagnostic criteria for Meniere disease? 3. What are the diagnostic criteria for sudden deafness? 4. What are the diagnostic criteria and management for presbycusis?

Department of Medical Education - Faculty of Medicine - Udayana University 72

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 20: Perichondritis, Myringitis, Otitis Media, Labyrinthitis (Andi Dwi Saputra)

The ear has a function as hearing and balance organ. Anatomically divide into outer ear, middle ear, and inner ear. Any disorder and abnormality on each part will cause impaired ear function. A preauricular fistula is a congenital abnormality of the outer ear. While perichondritis is often caused by infection.The management in both cases above is intended for cosmetic purposes. Otitis media with effusion is an inflammation of the middle ear which often expanding to the mastoid region. This disease is very influential in hearing function. A good management should be done to prevent complication and disability that can interfere with daily activities. Labyrinthitis may be part of otitis media with effusion or another disease such as meningitis and encephalitis. The sign and symptoms of labyrinthitis are very specific so particular examination is necessary to make a definitive diagnosis.

Learning Task A 20-year-old male came to Emergency Department complaining of dizziness since morning that is worsened when the patient moves his head. The patient can only lie down. The patient also complained tinnitus. History of discharge from right ear since childhood, sometimes smelly. 1. What is the differential diagnosis of this case? 2. How is the pathophysiology of vertigo in this case? 3. What should supporting examination be done in this patient? 4. What is the definitive diagnosis of this case? 5. What is the management of this case?

Self Assesment 1. Please describe and identify anatomy and function of the outer ear. 2. Please describe and identify anatomy and function of the middle ear. 3. Please explain the pathophysiology of otitis media with effusion and labyrinthitis. 4. How to diagnose perichondritis and preauricular fistula? 5. How to diagnose otitis media with effusion and labyrinthitis? 6. What is the management of perichondritis, preauricular fistula, otitis media with effusion and labyrinthitis?

Department of Medical Education - Faculty of Medicine - Udayana University 73

Study Guide Block Skin and Hearing Systems and Disorders

Lecture 21: Ear trauma/ othematoma, Barotrauma, Motion Sickness, PGPKT (Eka Putra)

The trauma of the ear can cause damage to the ear structures such as Othematum, external ear canal, middle ear canal and tympanic membrane rupture as a change in pressure in the middle ear, and inner ear damage. The journey traveled either by air, sea, and land can lead to complaints of motion sickness, with symptoms: nausea, vomiting, pallor, sweating, so it should be anticipated. Broadly speaking the causes of hearing loss and deafness are wax obsturan, OMSK, Noisy, Presbyacusis and Congenital deafness, because the Ministry of Health and its staff enough trouble to his ministry then formed an independent forum that is the National Committee for Prevention Hearing Loss and Deafness (PGPKT).

Vignette 1 A new student is currently facing a college event Orientation Introduction universities facing seniors. Due to an inadvertent, seniors upset then slapped, hit exactly. The student felt his ears ringing and reduced hearing one side. 1. The question of whether that is necessary to complete towards the diagnosis? 2. What kind of examination is needed to diagnose? 3. What is the therapy? Vignette 2 A family consisting of father, mother, and daughters aged 12 years old and the 9-year-old boy driving a sedan traveled to Bedugul. Moments before arriving, the girls experienced nausea, vomiting, pallor, sweating. Other family members feel buzzing ears. 1. The question of whether the diagnosis is needed to drive the girl to the family? 2. What kind of examinations needed to diagnose this patient? 3. What is the therapy? 4. What happened to the other family members? Self Assesment 1. Mention division ear barotrauma! 2. Is flying with a diving barotraumas difference? 3. Why do people get the drunk-like sensation when they trip to the higher place? 4. Mention 5 diseases causes of hearing loss and deafness? 5. Mention the target group of PGPKT Team? 6. What is the target to be achieved?

Department of Medical Education - Faculty of Medicine - Udayana University 74

Study Guide Block Skin and Hearing Systems and Disorders

REFERENCES

1. James WD, Berger TG, Elston DM, editors. Andrews' diseases of the skin: Clinical dermatology. 11th ed. Elsevier; 2011. 2. Buku Panduan Praktik Klinis bagi Dokter di Fasilitas Pelayanan Primer (Permenkes No 5 Tahun 2014) 3. Katzung BG, Dirk B Robertson, Howard I Maibach. Basic & Clinical Pharmacology. In Dermatologic Pharmacology.12rd 4. Leprosy. Third edition. Antony Bryceson 5. Medical Physiology eleventh edition, Guyton & Hall. 6. Milan C, Richir, Jelle Tichelaar, Eric CT Geijteman, Vries TPGM, 2008, Teaching Clinical Pharmacology and Therapeutics with an Emphasis on the Therapeutic Reasoning of Undergraduate Medical Students, J Clin Pharmacol 64, 217-224. 7. Moore KL, Dalley AF, Agur AMR. 2014. Moore clinically oriented anatomy. 7th edition. Baltimore: Lippincott Williams & Wilkins. 8. Physiology fifth edition, Linda S. Costanzo. 9. Rook’s Textbook of Dermatology 8th edition 2010 10. Trozak, D, J., Tennenhouse, D.J., Russell, J.J., 2006. Dermatological Skills for Primary care, Humana Press. Totowa. 11. Vries TPGM, Henning RH, Hogerzeil HV, Fresle DA, 1995, Guide to Good Prescribing, World Health Organization Action Programme on Essential Drugs, Geneva.

Department of Medical Education - Faculty of Medicine - Udayana University 75

Study Guide Block Skin and Hearing Systems and Disorders

Department of Medical Education - Faculty of Medicine - Udayana University 76