tag:blogger.com,1999:blog-25017254450381816872024-02-20T08:06:33.017+07:00Belajar Sepanjang HayatSaudaraku! Kamu tidak akan mendapatkan ilmu, kecuali dengan enam perkara; Kecerdasan, Kethoma’an (terhadap ilmu),Kesungguhan, Harta benda (bekal), Mempergauli guru dan Waktu yang panjang ^_^arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.comBlogger46125tag:blogger.com,1999:blog-2501725445038181687.post-53674878856535901232013-11-10T01:23:00.003+07:002013-11-10T01:23:29.140+07:00Farmakokinetik dan Farmakodinamik Obat<div style="text-align: justify;">
Pengantar farmakologi </div>
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<br /><b>I.FARMAKOKINETIK</b><br />Farmakokinetik merupakan ilmu yang mempelajari kinetika absorpsi, distribusi dan eliminasi ( yakni ekskresi dan metabolisme ) obat pada manusia atau hewan dan menggunakan informasi ini untuk meramalkan efek perubahan-perubahan dalam takaran,rejimen takaran, rute pemberian, dan keadaan fisiologi pada penimbunan dan disposisi obat. (1)<br />Absorpsi, distribusi, biotransformasi ( metabolisme ) dan eliminasi suatu obat dari tubuh merupakan proses dinamis yang kontinu dari saat suatu obat dimakan sampai semua obat tersebut hilang dari tubuh. Laju terjadinya proses-proses ini mempengaruhi onset, intensitas, dan lamanya kerja obat di dalam tubuh. (1)</div>
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<b><br />A.Absorpsi</b><br />Absorpsi merupakan proses masuknya obat dari tempat pemberian ke dalam darah. Bergantunng pada cara pemberiannya, tempat pemberian obat adalah saluran cerna ( mulut sampai dengan rectum ), kulit, paru, otot, dan lain-lain. Yang terpenting adalah cara pemberian obat per oral, dengan cara ini tempat absopsi utama adalah usus halus karena memiliki permukaan absorpsi yanng sangat luas, yakni 200 m2 ( panjang 280 cm, diameter 4 cm, disertai dengan villi dan mikrovilli ).(2)<br />Absorpsi obat melalui saluran cerna pada umumnya terjadi secara difusi pasif, karena itu absorpsi mudah terjadi bila obatdalam bentuk non-ion dan mudah larut dalam lemak. Absorpsi secara transpor aktif terjadi teutama di dalam usus halus untuk zat-zat makanan : glokusa dan gula lain, asam amino, basa purin, dan pirimidin, mineral, dan beberapa vitamin. Cara ini juga terjadi untuk obat-obat yang struktur kimianya mirip struktur zat makanan tersebut. Misalnya levodopa, metildopa, 6-merkaptopurin, dan 5-flourourasil.(2)<br />Kebanyakan obat merupakan electrolit lemah, yakni asam lemah atau basa lemah. Dalam air, elektrolit lemah ini akan terionisasi menjadi bentuk ionnya. Untuk asam lemah, pH yang tinggi (suasana basa ) akan meningkatkan ionisasinya dan mengurangi bentuk nonionnya. Sebaliknya untuk basa lemah, pH yang rendah (suasana asam ) yang akan meningkatkan ionisasinya dan mengurangi nonionnya. Hanya bentuk nonion yang mempunyai kelarutan lemak, sehingga hanya bentuk nonion dan bentuk ion berada dalam kesetimbangan, maka setelah bentuk nonion diabsopsi, kesetimbangan akan bergeser kearah bentuk nonion sehingga absorpsi akan berjalan terus sampai habis.Zat-zat makanan dan oabt0obat yanng strukturnya mirip makanan, yang tidak dapat / sukar berdifusi pasif memerlikan membran agar dapat dapat diabsorpsi dari saluran cerna maupun direabsopsi dari lumen tubulus ginjal.(2)<br /><br />Faktor-faktor yang mempengaruhi absorpsi:<br />• Derajat ionisasi<br />• Dosis dan waktu pemberian obat<br />• pH dan pK<br />• pelarut obat dan bentuk obat<br />• luas permukaan absorpsi<br />• aliran darah<br />• kondisi usus dan kecepatan pengosongan lambung<br />• interaksi dengan obat lain</div>
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<a name='more'></a><br /><b>B.Distribusi</b><br />Setelah diabsorpsi, obat akan didistribusikan ke seluruh tubuh melalui sirkulasi darah. Selain tergantung dari aliran darah, distribusi obat juga ditentukan oleh sifat fisikokimianya. Obat yang mudah larut dalam lemak akan melintasi membran sel dan terdistribusi ke dalam sel, sedangkan obat yang tidak larut dalam lemak akan sulit menembus membran sel sehingga distribusinya terbatas terutama di cairan ekstrasel. Distribusi juga dibatasi oleh ikatan obat pada protein plasma, hanya obat bebas yang dapat berdifusi dan mencapai keseimbangan. Derajat ikatan obat dengan protein plasma ditentukan oleh afinitas obat terhadap protein, kadar obat, dan kadar proteinnya sendiri. (2)<br />Untuk mencapai sel target, suatu obat harus dapat menembus sawar biologic, dapat berupa membrane yang terdiri atas satu atau beberapa sel. Pada sawar darah otak, obat-obatan yang larut dalam air sulit melewatinya dan pada sawar plasenta hanya obat-obatan dengan BM besar (seperti heparin, plasma sekunder) sukar masuk fetus (3).<br />Oleh karena molekul protein plasma cukup besar, maka hanya fraksi obat bebas saja yang mempunyai arti klinis, karena bagian tersebut yang dapat mencapai reseptor pada organ sasaran (termasuk bakteri). Protein plasma yang berikatan dengan molekul obat terutama adalah albumin(A), disamping itu protein lain juga berperan, misalnya alfa amino globulin (AAG) dan lipoprotein (LP) pada keadaan tertentu.(1)<br />
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<br /><b>C.Eliminasi</b><br />Proses eliminasi bertanggung jawab atas durasi atau lamanya obat berefek dengan cara mengusahakan agar obat dapat segera dikeluarkan dari tubuh, temasuk ke dalam alat eksresi seperti ginjal, hati dan paru. Agar obat mudah dieksresi, kadang-kadang obat harus diubah lebih dahulu menjadi senyawa lain yang bersifat tidak mudah larut dalam lemak baru dieksresi. Proses metabolisme dan eksresi secara merupakan proses eliminasi. [3]<br />D.Metabolisme<br />Metabolisme atau biotransformasi obat adalah proses perubahan struktur perubahan kimia yang tejadi dalam tubuh dan dikatalisis oleh enzim. Pada poses ini molekul obat diubah menjadi lebih polar (lebih mudah larut dalam air) dan kurang larut dalam lemak sehingga mudah dieksresi melalui ginjal [2].<br />Kebanyakan obat diubah di hati dalam hati, kadang-kadang dalam ginjal dan lain-lain. Kalau fungsi hati tidak baik maka obat yang biasanya diubah dalam hati tidak mengalami peubahan atau hanya sebagian yang diubah. Hal tesebut menyebabkan efek obat berlangsung lebih lama dan obat menjadi lebih toxic [4].<br />Metabolisme obat di hepar terganggu oleh adanya zat hepatotoksik atau pada sirosis hepatis kaena pada keadaan-keadaan tesebut terjadi kerusakan sel parenim hati serta enzim-enzim metabolismenya. Dalam hal ini dosis obat yang eliminasinya terutama melalui metabolism di hati harus disesuaikan atau dikurangi. Demikian juga penurunan alir darah hepar, baik oleh obat maupun gangguan kardiovaskular, akan mengurangi metabolisme obat di hati [2].</div>
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<br /><b>E.Ekskresi</b><br />Obat dikeluarkan dari tubuh melalui berbagai organ ekskresi dalam bentuk metabolit hasil biotransformasi atau dalam bentuk asalnya. Obat atau metabolit yang polar diekskresi lebih cepat daripada obat yang larut baik dalam lemak, kecuali pada eksresi melaui paru-paru.[2]<br />Ginjal merupakan organ eksresi yang terpenting [2]. Metabolit yang larut dalam air sukar direabsorpsi oleh tubuli ginjal, sehingga akan dikeluarkan bersama-sama urine. Sebaliknya, obat yang mudah laut dalam lemak jika sudah berada dalam tubuli ginjal sebagian besar direabsorpsi oleh tubuli ginjal. Obat yang tidak dapat difiltasi oleh glomerulus bisa disekresi oleh ginjal melalui sekresi tubulus. Jadi proses eliminasi oleh ginjal (ekskresi) meupakan hasil dari proses-proses filtrasi glomerulus, reabsorbsi, dan sekresi tubulus [4]. Bila fungsi ginjal rusak sedangkan obat harus dikeluarkan melalui ginjal maka eksresinya tidak sempurna dan memudahkan terjadinya keracunan [1]. Hasil ekskresi dapat berupa urine, air ludah, air susu, air mata, keringat dan lain-lain [1].</div>
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<br /><b>II.FARMAKODINAMIK</b><br />Farmakodinamik ialah cabang ilmu yang mempelajari efek biokimiawi dan fisiologi obat serta mekanisme kerjanya. (2) Sifat kerja obat tersebut menentukan kelompok tempat obat tersebut digolongkan dan sering kali mempunyai peran penting untuk memutuskan apakah kelompok tersebut adalah terapi yang tepat untuk gejala atau penyakit tertentu, (1)<br />Mekanisme Kerja Obat<br /><br />Efek obat umumnya timbul karena interaksi obat dengan reseptor pada sel suatu organisme. Interaksi obat dengan reseptornya ini mencetuskan perubahan biokimiawi dan fisiologi yang merupakan respons khas untuk obat tersebut. Reseptor obat merupakan komponen makromolekul fungsional yang kencakup dua fungsi penting. Pertama, bahwa obat dapat mengubah kecepatan kegiatan faal tubuh. Kedua, bahwa obat tidak menimbulkan suatu fungsi baru, tetapi hanya memodulasi fungsi yang sudah ada. Setiap komponen makromolekul fungsional dapat berperan sebagai reseptor obat tertentu, juga berperan sebagai reseptor untuk ligand endogen (hormon, neurotransmitor). Substansi yang efeknya menyerupai senyawa endogen disebut agonis. Sebaliknya, senyawa yang tidak mempunyai aktivitas intrinsic tetapi menghambat secara kompetitif efek suatu agonis di tempat ikatan agonis (agonit binding site ) disebut antagonis.(2)<br />Teori Reseptor<br />Efek terapeutik obat dan efek toksik obat adalah hasil dari interaksi obat tersebut dengan molekul di dalam tubuh pasien. Sebagian besar obat bekerja melalui penggabungan dengan makromolekul khusus dengan cara mengubah aktivitas biokimia dan biofisika makromolekul, hal ini dikenal dengan istilah reseptor. (1)<br />Sebagian besar reseptor adalah protein karena struktur polipeptida memberikan perbedaan corak dan kekhususan yang diperlukan dari bentuk dan muatan listrik.<br />Reseptor obat yang paling baik adalah protein regulator, yang menjembatani kerja dan sinyal-sinyal bahan kimia endogen, seperti: neurotransmitter, autacoids, dan hormone. Kelompok reseptor ini menjembatani efek dari sebagian besar agen terapeutik yang paling bermanfaat. Struktur molekuler dan mekanisme biokimia reseptor regular ini menggunakan lima mekanisme dasar sinyalisasi transmembran yang masing-masing menggunakan strategi/ pendekatan yang berbeda untuk menghindari halangan yang disebabkan oleh dua lapisan lemak (bilayer lipid) membran plasma. Strategi pendekatan ini menggunakan:<br /><br />1.Ligan larut lemak yang melintasi membrane dan bekerja pada reseptor intraseluler.<br />Sinyal kimia larut lemak melintasi membran plasma dan bekerja pada reseptor intraseluler (yang mungkin adalah enzim atau pengatur transkripsi gen)<br /><br />2.Protein reseptor transmembran yang aktivitas enzimatik intraselulernya diatur secara allosterical oleh ligan yang terikat pada tempat di domain ekstraseluler protein.<br />Sinyal tersebut terikat pada domain ekstraseluler protein transmembran, sehingga mengaktifkan aktivitas enzimatis domain sitoplasmiknya.<br /><br />3.Reseptor transmembran yang mengikat dan menstimulasi protein tyrosine kinase.<br />Sinyal tersebut terikat pada domain ekstraseluler reseptor transmembran yang terikat pada protein kinase tyrosine, yang diaktifkannya.<br /><br />4.Kanal ion transmembran yang ligand-gated, yaitu kanal ion yang pembukaan/ penutupannya dapat diinduksi oleh ligan yang terikat pada reseptor kanal ion tersebut.<br />Sinyal tersebut terikat dan langsung mengatur pembukaan saluran ion.<br /><br />5.Protein reseptor transmembran yang menstimulasi transduktor yang memberi sinyal setelah berikatan dengan GTP (protein G) yang kemudian menimbulkan pembawa pesan kedua.<br />Sinyal tersebut terikat pada reseptor permukaan sel yang dihubungkan pada enzim efektor oleh protein G.<br />Kelompok protein lainnya yang telah dikenal jelas sebagai reseptor obat juga termaasuk enzim, yang mungkin dihambat (atau, yang kurang umum, diaktifkan) dengan mengikat obat (misalnya dihydrofolate reductase, reseptor untuk obat antikanker methotrexate), protein pembawa (transport protein) (misalnya, Na+/ K+ ATPase, reseptor membran untuk digitalis, glycoside yang aktif pada jantung) dan protein structural (misalnya, tubulin, reseptor untuk colchicine, agen antiinflamasi).(3)<br /><br />Ikatan obat reseptor dapat berupa ikatan ion, hydrogen hidrofobik, van der walls, atau kovalen , tetapi umumnya merupakan campuran dari berbagai ikatan di atas.(2)<br />Konsep reseptor ini mempunyai konsekuensi-konsekuensi yang penting untuk perkembangan obat dan pengambilan keputusan terapeutik dalam praktek klinik.<br /><br />1.Pada dasarnya reseptor menentukan hubungan kuantitatif antara dosis atau konsentrasi obat dan efek farmakologi: afinitas reseptor untuk mengikat obat menentukan konsentrasi obat yang diperlukan untuk membentuk kompleks obat- reseptor (drug-receptor complexes) dalam jumlah yang berarti, dan jumlah reseptor secara keseluruhan dapat membatasi efek maksimal yang ditimbulkan oleh obat.<br /><br />2.Reseptor bertanggung jawab pada selektivitas tindakan obat : ukuran, bentuk dan muatan ion elektrik molekul obat menentukan apakh-dan dengan kecocokan/kesesuaian yang bagaimana- molekul itu akan terikat pada reseptor tertentu diantara bermacam-macam tempat ikatan yang secara berbeda. Oleh karena itu, perubahan struktur kimia obat secara dramatis/ mencolok dapatmenaikan atau menurunkan afinitas obat-obat baru terhadap gollongan-golongan reseptor yang berbeda, yang mengakibatkan perubahan-perubahan dalam efek terapi dan toksiknya.<br /><br />3. Reseptor- reseptor menjembatani kerja antagonis farmakologi: efek antagonis di dalam tubuh pasien bergantung pada pencegahan pengikatan molekul agonis dan penghambatan kerja biologisnya. Beberapa obat bermanfaat sebagai antagonis farmakologis dalam pengibatan klinik.(1)<br />Spesifisitas dan Selektivitas<br />Suatu obat dikatakan spesifik bila kerjabya terbatas pada satu jenis reseptor, dan dikatakan selektif bila menghasilkan satu efek pada dosis rendah dan efek lain baru timbul pada dosis yang lebih besar. Obat yang spesifik belum tentu selektif tetapi obat yang tidak spesifik dangan sendirinya tidak selektif.(2)</div>
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<br /><b>KERJA OBAT YANG TIDAK DIPERANTARAI RESEPTOR</b><br />• Efek Nonspesifik Dan Gangguan Pada Membran<br />• Perubahan sifat osmotic<br />• Diuretic osmotic (urea, manitol), misalnya, meningkatkan osmolaritas filtrate glomerulus sehingga mengurangi reabsorpsi air di tubuli ginjal dengan akibat terjadi efek diuretic.<br />• Perubahan sifat asam/basa<br />Kerja ini diperlihatkan oleh oleh antacid dalam menetralkan asam lambung.<br />• Kerusakan nonspesifik<br />Zat perusak nonspesifik digunakan sebagai antiseptik dan disinfektan, dan kontrasepsi.contohnya, detergen merusak intregitas membrane lipoprotein.<br />• Gangguan fungsi membrane<br />Anestetik umum yang mudah menguap misalnya eter,, halotan, enfluran, dan metoksifluran bekerja dengan melarut dalam lemak membrane sel di SSP sehingga eksitabilitasnya menurun.<br />• Interaksi Dengan Molekul Kecil Atau Ion<br />Kerja ini diperlihatkan oleh kelator (chelating agents) misalnya CaNa2 EDTA yang mengikat Pb2+ bebas menjadi kelat yang inaktif pada keracunan Pb.<br />• Masuk ke dalam komponen sel<br />Obat yang merupakan analog puri atau pirimidin dapat berinkoporasi ke dalam asam nukleat sehingga mengganggu fungsinya. Obat yang bekerja seperti ini disebut antimetabolit misalnya 6-merkaptopurin atau anti mikroba lain. (2)</div>
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<br /><b>KONSENTRASI DAN RESPON OBAT</b><br />Hubungan antara konsentrasi obat dan respon obat<br />Respons terhadap dosis obat yang rendah biasanya meningkat sebanding langsung dengan dosis. Namun, dengan meningkatnya dosis penigkatan respon menurun. Pada akhirnya, tercapailah dosis yang tidak dapat meningkatkan respon lagi. Pada system ideal atau system in vitro hubungan antara konsentrasi obat dan efek oabat digambarkan dengan kurva hiperbolik menurut persamaan sebagi berikut:<br />E=<br />di mana E adalah efek yang diamati pada konsentrasi C, Emaks adalah respons maksimal yang dapat dihasilkan oleh obat. EC50 adalah konsentrasi obat yang menghasilkan 50% efek maksimal.<br />Hubungan antara konsentrasi dan efek obat (panel A) atau obat yang terikat reseptor (panel B). Konsentrasi obat yang efeknya separuh maksimum disebut EC50 dan konsentrasi obat yang okupansi reseptornya separuh maksimum disebut KD.(2)<br /><br />Hubungan dosis dan respons bertingkat<br />1. Efikasi (efficacy). Efikasi adalah respon maksimal yang dihasilkan suatu obat. Efikasi tergantung pada jumlah kompleks obat-reseptor yang terbentuk dan efisiensi reseptor yang diaktifkan dalam menghasilkan suatu kerja seluler<br />2. Potensi.Potensi yang disebut juga kosentrasi dosis efektif, adalah suatu ukuran berapa bannyak obat dibutuhkan untuk menghasilkan suatu respon tertentu. Makin rendah dosis yang dibutuhkan untuk suatu respon yang diberikan, makin poten obat tersebut.Potensi paling sering dinyatakan sebagai dosis obat yang memberikan 50% dari respon maksimal (ED50). Obat dengan ED50 yang rendah lebih poten daripada obat dengan ED50 yang lebih besar.<br />3. Slope kurva dosis-respons. Slope kurva dosis-respons bervariasi sari suatu obat ke obat lainnya. Suatu slope yang curam menunjukkan bahwa suatu peningkatan dosis yang kecil menghasilkan suatu perubahan yang besar (1)<br />Pada gambar diatas diperlihatkan suatu kurva dari tiga obat yang berbeda yang menunjukkan potensi farmakologis yang berbeda dan efikasi maksimal yang berbeda: (1)<br />Obat A lebih poten disbanding obat B, tetapi keduanya memiliki efikasi yang yang sama, sedangkan obat C memperlihatkan potensi dan efikasi yang lebih rendah daripada obat A dan B(1)<br />Dosis yang menimbulkan efek terapi pada 50% individu (ED50) disebut juga dosis terapi median. Dosis letal median adalah dosis yang emnimbulkan kematian pada 50% individu , sedangkan TD50 adalah dosis toksik 50%.(2)<br /><br />Indeks terapeutik<br />Indeks terapeutik suatu obat adalah rasio dari dosis yang menghasilkan toksisitas dengan dosis yang menghasilkan suatu respon yang efektif dan diinginkan secara klinik dalam suatu populasi individu(1)<br />Indeks terapeutik = dosis toksik/dosis efektif(1)<br /><br />Jadi indeks terapeutik merupakan suatu ukuran keamanan obat, karena nilai yang besar menunjukkan bahwa terdapat suatu batas yang luas/lebar diantara dosis-dosis yang efektif dan dosis-dosis yang toksik(1)<br />Indeks terapeutik ditentukan dengan mengukur frekuensi respons yang diinginkan dan respons toksik pada berbagai dosis obat.Pada gambar berikut diperlihatkan indeks terapeutik yang berbeda dari dua jenis obat (1)<br />Warafarin, suatu obat dengan indeks terapeutik yang kecil. Pada saat dosis warfarin ditingkatkan , terjadi suatu respon toksik, yaitu kadar anti koagulan yang tinggi yang menyebabkan perdarahan. Variasi respon penderita mudah terjadi dengan obat yang mempunyai indeks terapeutik yang sempit, karena konsentrasi efektif hamper sama dengan konsentrasi toksik(1)<br />Suatu obat dengan indeks terapeutik yang besar. Penisilin aman diberikan dalam dosis tinggi jauh melebihi dosis minimal yang dibutuhkan untuk mendapatkan respon yang diinginkan(1)<br />Obat ideal menimbulkan efek terapi pada semua pasien tanpa menimbulkan efek toksik pada seorang pasienpun, oleh karena itu, (2)<br /><br />Indeks terapi = adalah lebih tepat<br /><br />Dan untuk obat ideal : ≥ 1(2)<br />ASPIRIN<br />Aspirin/asam asetilsalisilat (asetosal adalah suatu jenis obat dari keluarga salisilat yang sering digunakan sebagai analgesik (terhadap rasa sakit/nyeri minor), antipiretik (terhadap demam), dan anti inflamasi. Aspirin juga memiliki efek antikoagulan dan digunakan dalam dosis rendah dalam tempo lama untuk mencegah serangan jantung. Asperin obat pertama yang dipasarkan dalam bentuk tablet.</div>
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<br />DAFTAR PUSTAKA<br />1.Staf pengajar Farmakologi. Absorpsi dan Eksresi. Bagian Farmakologi FK UNLAM: Banjarbaru<br />2.Ganiswara, S.G., Setiabudi, R., Suyatna, F.D., Purwantyastuti, Nafrialdi (Editor).1995. Farmakologi dan Terapi. Edisi 4.. Bagian Farmakologi FK UI: Jakarta<br />3.Katzung.1989.Farmakologi Dasar dan Klinik Edisi 3.EGC: Jakarta<br />4.Lamid, Sofyan. Farmakologi Umum I. EGC: Jakarta<br />5.Mycek.2001.Farmakologi Ulasan Bergambar.Widya Medika : Jakarta<br /></div>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com3tag:blogger.com,1999:blog-2501725445038181687.post-45851266139416737142013-11-10T01:13:00.000+07:002013-11-10T01:16:36.547+07:00Interaksi Obat Mempengaruhi ADME Obat<div style="text-align: justify;">
Farmakokinetika Klinik<br />
Di dalam tubuh obat mengalami berbagai macam proses hingga akhirnya obat di keluarkan lagi dari tubuh. Proses-proses tersebut meliputi, absorpsi, distribusi, metabolisme (biotransformasi), dan eliminasi. Dalam proses tersebut, bila berbagai macam obat diberikan secara bersamaan dapat menimbulkan suatu interaksi. Selain itu, obat juga dapat berinteraksi dengan zat makanan yang dikonsumsi bersamaan dengan obat.<br />
Interaksi yang terjadi di dalam tubuh dapat dibedakan menjadi dua, yaitu interaksi farmakodinamik dan interaksi farmakokinetik. Interaksi farmakodinamik adalah interaksi antar obat (yang diberikan berasamaan) yang bekerja pada reseptor yang sama sehingga menimbulkan efek sinergis atau antagonis. Interaksi farmakokinetik adalah interaksi antar 2 atau lebih obat yang diberikan bersamaan dan saling mempengaruhi dalam proses ADME (absorpsi, distribusi, metabolisme, dan eliminasi) sehingga dapat meningkatkan atau menurunkan salah satu kadar obat dalam darah. Selanjutnya akan dibahas lebih lanjut tentang interaksi farmakokinetik.</div>
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Interaksi Famakokinetik<br />
1. Interaksi pada proses absorpsi<br />
Interaksi dala absorbs di saluran cerna dapat disebabkan karena<br />
a. Interaksi langsung yaitu terjadi reaksi/pembentukan senyawa kompleks antar senyawa obat yang mengakibatkan salah satu atau semuanya dari macam obat mengalami penurunan kecepatan absorpsi.<br />
Contoh: interaksi tetrasiklin dengan ion Ca2+, Mg2+, Al2+ dalam antasid yang menyebabkan jumlah absorpsi keduanya turun.<br />
b. Perubahan pH<br />
Interaksi dapat terjadi akibat perubahan harga pH oleh obat pertama, sehingga menaikkan atau menurukan absorpsi obat kedua.<br />
Contoh: pemberian antasid bersama penisilin G dapat meningkatkan jumlah absorpsi penisilin G<br />
c. Motilitas saluran cerna<br />
Pemberian obat-obat yang dapat mempengaruhi motilitas saluan cerna dapat mempegaruhi absorpsi obat lain yang diminum bersamaan.<br />
Contoh: antikolinergik yang diberikan bersamaan dengan parasetamol dapat memperlambat parasetamol.</div>
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2. Interaksi pada proses distribusi<br />
Di dalam darah senyawa obat berinteraksi dengan protein plasma. Seyawa yang asam akan berikatan dengan albumin dan yang basa akan berikatan dengan α1-glikoprotein. Jika 2 obat atau lebih diberikan maka dalam darah akan bersaing untuk berikatan dengan protein plasma,sehingga proses distribusi terganggu (terjadi peingkatan salah satu distribusi obat kejaringan).<br />
Contoh: pemberian klorpropamid dengan fenilbutazon, akan meningkatkan distribusi klorpropamid.<br />
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3. Interaksi pada proses metabolisme<br />
a. Hambatan metabolisme<br />
Pemberian suatu obat bersamaan dengan obat lain yang enzim pemetabolismenya sama dapat terjadi gangguan metabolisme yang dapat menaikkan kadar salah satu obat dalam plasma, sehingga meningkatkan efeknya atau toksisitasnya.<br />
Cotoh: pemberian S-warfarin bersamaan dengan fenilbutazon dapat menyebabkan mengkitnya kadar Swarfarin dan terjadi pendarahan.<br />
b. Inductor enzim<br />
Pemberian suatu obat bersamaan dengan obat lain yang enzim pemetabolismenya sama dapat terjadi gangguan metabolisme yang dapat menurunkan kadar obat dalam plasma, sehingga menurunkan efeknya atau toksisitasnya.<br />
Contoh: pemberian estradiol bersamaan denagn rifampisin akan menyebabkan kadar estradiol menurun dan efektifitas kontrasepsi oral estradiol menurun.</div>
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4. Interaksi pada proses eliminasi<br />
a. Gangguan ekskresi ginjal akibat kerusakan ginjal oleh obat<br />
jika suatu obat yang ekskresinya melalui ginjal diberikan bersamaan obat-obat yang dapat merusak ginjal, maka akan terjadi akumulasi obat tersebut yang dapat menimbulkan efek toksik.<br />
Contoh: digoksin diberikan bersamaan dengan obat yang dapat merusak ginjal (aminoglikosida, siklosporin) mengakibatkan kadar digoksin naik sehingga timbul efek toksik.<br />
b. Kompetisi untuk sekresi aktif di tubulus ginjal<br />
Jika di tubulus ginjal terjadi kompetisi antara obat dan metabolit obat untuk sistem trasport aktif yangsama dapat menyebabkan hambatan sekresi.<br />
Contoh: jika penisilin diberikan bersamaan probenesid maka akan menyebabkan klirens penisilin turun, sehingga kerja penisilin lebih panjang.<br />
c. Perubahan pH urin<br />
Bila terjadi perubahan pH urin maka akan menyebabkan perubahan klirens ginjal. Jika harga pH urin naik akan meningkatkan eliminasi obat-obat yang bersifat asam lemah, sedangkan jika harga pH turun akan meningkatkan eliminasi obat-obat yang bersifat basa lemah.<br />
Contoh: pemberian pseudoefedrin (obat basa lemah) diberikan bersamaan ammonium klorida maka akan meningkatkan ekskersi pseudoefedrin. Terjadi ammonium klorida akan mengasamkan urin sehingga terjadi peningkatan ionisasi pseudorfedrin dan eliminasi dari pseudoefedrin juga meningkat.</div>
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Daftar Pustaka<br />
Mutschler, E., 1985, Dinamika Obat Farmakologi dan Toksikologi, 88-93, Penerbit ITB, Bandung<br />
Sulistia, dkk, 2007, Famakologi dan Terapi, 862-872, UI Press, Jakarta</div>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-64917649678158682022013-11-10T01:05:00.003+07:002013-11-10T01:08:19.389+07:00Interaksi Obat<div style="text-align: justify;">
Tipe interaksi<br />
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Macam Interaksi Obat<br />
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1.Interaksi farmasetis<br />
Adalah interaksi fisiko-kimia yang terjadi pada saat obat diformulasikan/disiapkan sebelum obat di gunakan oleh penderita.<br />
Misalnya interaksi antara obat dan larutan infus IV yang dicampur bersamaan dapat menyebabkan pecahnya emulsi atau terjadi pengendapan.<br />
Contoh lain : dua obat yang dicampur pada larutan yang sama dapat terjadi reaksi kimia atau terjadi pengendapan salah satu senyawa, atau terjadi pengkristalan salah satu senyawa dll.<br />
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Bentuk interaksi:<br />
a. Interaksi secara fisik<br />
Misalnya :<br />
- Terjadi perubahan kelarutan<br />
- Terjadinya turun titik beku<br />
b. Interaksi secara khemis<br />
Misalnya :<br />
Terjadinya reaksi satu dengan yang lain atau terhidrolisisnya suatu obat selama dalam proses pembuatan ataupun selama dalam penyimpanan.<br />
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2. Interaksi Farmakokinetika<br />
Pada interaksi ini obat mengalami perubahan pada :<br />
-Absorbsi<br />
-Distribusi<br />
-Metabolisme<br />
-Ekskresi<br />
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Yang disebabkan karena obat/senyawa lain<br />
Hal ini umumnya diukur dari perubahan pada satu atau lebih parameter farmakokinetika, seperti konsentrasi serum maksimum, luas area dibawah kurva, waktu, waktu paruh, jumlah total obat yang diekskresi melalui urine, dsb.<br />
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3. Interaksi Farmakodinamika<br />
Adalah obat yang menyebabkan perubahan pada respon pasien disebabkan karena berubahnya farmakokinetika dari obat tersebut karena obat lain yang terlihat sebagai perubahan aksi obat tanpa menglami perubahan konsentrasi plasma. <br />
Misalnya naiknya toksisitas dari digoksin yang disebabkan karena pemberian secara bersamaan dengan diuretic boros kalium misalnya furosemid.</div>
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Kombinasi Obat</div>
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Pemilihan penggunaan kombinasi obat untuk terapi merupakan hal yang controversial</div>
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Harapan : </div>
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Terjadi peningkatan efek terapi obat </div>
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Misalnya pada Cotrimoksazol, amoxiclave.</div>
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Berkurangnya efek merugikan, misalnya pada kombinasi INH – Vit B6</div>
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Turunnya biaya kesehatan disebabkan karena potensi obat tinggi akibatnya lama sakit berkurang.</div>
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Kelemahan :</div>
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Rasio dosis tidak terkendali</div>
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Kemungkinan terjadi interaksi obat</div>
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Tugas farmasis adalah : Segera mendeteksi dan mengkoreksi adanya interaksi obat </div>
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Secara matematis bila ada 2 atau lebih obat dikombinasi maka kemungkinan terjadi interaksi adalah :</div>
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[ ½ n (n-1)] kali</div>
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dengan n = jumlah Obat</div>
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Obat-obat yang cenderung menyebabkan Interaksi Obat </div>
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1. Obat yang memiliki ikatan obat- protein yang tinggi.</div>
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Obat yang memiliki ikatan obat-protein tinggi cenderung dominan, akibatnya obat tersebut dapat mendesak obat lain yang terikat protein sehingga terbebaskan, akibatnya kadar obat bebas dalam darah meningkat dengan tajam, secara matematis dapat digambarkan pada table berikut :</div>
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Contoh obat : Aspirin, Fenilbutazon, Sulfanilamid, walfarin dll</div>
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2.Obat-obat yang menstimulasi atau menginhibisi metabolisme obat lain</div>
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Interaksi ini merugikan atau menguntungkan tergantung dari sifat obatnya masing-masing</div>
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-Obat aktif adalah metabolitnya </div>
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Misalnya :</div>
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Prednison Prednisolon</div>
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Procainamid N-Asetil Procainamid</div>
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Maka obat yang menstimulasi metabolisme akan menyebabkan meningkatnya kadar obat aktif dalam darah</div>
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-Obat aktif adalah obat aslinya</div>
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Misalnya :</div>
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Captoril, furosemid, methyldopa dll</div>
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Maka obat yang menstimulasi metabolisme akan menyebabkan menurunnya kadar obat aktif dalam darah. </div>
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Obat yg menstimulasi Contoh</div>
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Antikonvulsan(fenitoin, karbamazepin, fenobarbital); Rifampisin; griseofulvin</div>
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Obat yg menginhibisi contoh :</div>
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Allopurinol; kloramfenikol; cimetidine; metronidazol; INH; ciprofloksasin</div>
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3. Obat-obat yang mempengaruhi fungsi Renal</div>
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Obat-obat golongan ini dapat mengubah kliren ginjal obat lain, misalnya obat-obat diuretic.</div>
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Obat-obat yang cenderung menjadi objek interaksi obat</div>
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a.Obat-obat yang memiliki kurve dosis respon curam.</div>
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b.Obat-obat yang memiliki </div>
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rasio efek toksik : terapetik rendah</div>
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Interaksi Farmakokinetika</div>
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Interaksi ini terjadi ketika proses absorbsi, distribusi, metabolisme atau ekskresi suatu obat terpengaruh oleh adanya obat(senyawa)lain.</div>
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1.Interaksi absorbsi</div>
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Mekanisme yang dapat mengubah kecepatan absorbsi obat dalam GI tract dipengaruhi banyak factor antara lain, berubahnya: kecepatan aliran darah GI, motilitas GI, pH GI, kelarutan obat, Metabolisme GI, Flora GI, atau Mucosa GI, terbentuknya komplek yang tidak larut. </div>
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Contoh :</div>
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Penurunan motilitas Gastrointestinal, disebabkan karena obat-obat golongan morfin, dan obat-obat dengan efek antikolinergik misalnya antidepresan trisiklik.</div>
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Terbentuk chelat dari Ca, Al, Mg, garam besi oleh tetrasiklin.</div>
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Obat terjebak dalam makanan, contoh Ampisilin</div>
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Obat diabsorbsi obat lain : Lincomycin dan kaolin-pektin, obat dgn karboadsorben.</div>
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Perubahan ion : cholestyramin-walfarin.</div>
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Peningkatan absorbsi digoksin atau penurunan absorbsi estrogen dalam kontrasepsi oral yang digunakan secara bersamaan dengan antibiotika </div>
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Efek interaksi ini jarang dimanfaatkan secara klinis</div>
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Ada 2 contoh penting dari pemanfaatan interaksi absorbsi, yaitu :</div>
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1. Metoclopamide dapat meningkatkan kecepatan pengosongan lambung, dan hal ini menyebabkan meningkatnya penyerapan analgesik pada pengobatan migrain akut, </div>
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. Adanya charcoal yang mengikat beberapa obat di usus, hal ini dapat mencegah penyerapan dan obat tersebut di reabsorbsi setelah ekskresi bilier atau sekresi intestinal.</div>
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Prinsip ini dipergunakan dalam perawatan keracunan yang disebabkan bahan-bahan golongan phenobarbiton dan antidepresan trisiklik. </div>
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Interaksi pendesakan ikatan obat-protein</div>
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Pendesakan ikatan obat-protein oleh obat lain dapat meningkatkan kadar obat bebas dalam darah, dan hal ini sangat potensial dalam peningkatan efek bahkan efek toksik dari suatu obat, terutama obat yang memiliki rasio </div>
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efek terapi dan efek toksik rendah.</div>
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Interaksi Distribusi Seluler</div>
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Rifampisin dapat mereduksi efek walfarin dengan cara menginhibisi up take dari hepatocytes, hal ini menyebabkan peningkatan metabolisme sehingga efek walfarin menurun.</div>
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Transport aktif dari beberapa obat anti hipertensi (bethanidine, Guenethidine, debricoquine) ke pangkal syaraf simpatik yang merupakan tempat terjadinya efek terapeutik, di inhibisi oleh antidepresan trisiklik (dan mungkin juga oleh beberapa phenothiazine) sehingga terjadi penurunan kontrol terhadap tekanan darah.</div>
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-metildopa.Mekanisme tersebut juga menjadi dasar dari interaksi antara antidepresan trisiklik dengan clonidine dan </div>
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Interaksi Metabolisme</div>
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Interaksi obat pada saat terjadi metabolisme dapat terjadi ketika metabolisme sebuah obat dihambat atau ditingkatkan oleh obat lain.</div>
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Biasanya reaksi ini berpengaruh pada cytocrom P450 </div>
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Induksi Metabolisme obat</div>
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Obat-obat yang meningkatkan (menginduksi) metabolisme obat melalui peningkatan reticulum endoplasma di hepatocyte dan karena peningkatan kandungan Cyt P450 dan cyt c- reduktase.</div>
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Hal ini dapat meningkatkan ataupun menurunkan efek dari object drug</div>
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Contohnya :</div>
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Interaksi Digoksin-Furosemid</div>
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Efek terapeutik glikosida jantung pada fungsi mekanis adalah untuk meningkatkan intensitas filamen actin dan myosin dari sarkomer jantung</div>
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Peningkatan intensitas disebabkan oleh peningkatan konsentrasi kalsium bebas di dalam daerah sekitar protein kontraktil selama systole.</div>
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Peningkatan konsentrasi Natrium intraseluler :</div>
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Karena penghambatan Na/K ATP-ase (1)</div>
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Karena suatu penurunan relatif ekspulsi kalsium dari sel oleh exchanger natrium-kalsium (2) disebabkan oleh peningkatan natrium intraseluler.</div>
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Kalium dan digitalis berinteraksi dalam 2 cara :</div>
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1.Mereka saling menghambat pada pengikatan Na/K ATP-ase.</div>
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2.automatisitas jantung yg tidak normal dihambat oleh hiperkalemia. Karenanya peningkatan kalium ekstraseluler yang sedang dapat menurunkan efek digitalis, utamanya efek toksik.</div>
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Interaksi Ekskresi</div>
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Kompetisi pada sekresi tubulus ginjal adalah mekanisme yang penting dalam interaksi ini.</div>
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Contoh :</div>
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Probenecid menginhibisi sekresi tubular penisilin, sehingga dapat meningkatkan dan memperlama efek,</div>
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Sehingga interaksi ini relatif menguntungkan</div>
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Efek yang sama dapat meningkatkan toksisitas kloroquin pada mata pada penderita yg menggunaka probenecid.</div>
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Qiunidine menginhibisi sekresi tubular dari digoksin dan konsekuensinya konsentrasi plasma digoksin meningkat dan mungkin menyebabkan toksik, hal yang sama juga terjadi pada verapamil dan digoksin</div>
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Interaksi Farmakodinamika</div>
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Pada interaksi farmakodinamika precipitant drug mempengaruhi efek dari object drug pada tempat aksi, </div>
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baik secara langsung maupun tak langsung.</div>
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1.Interaksi farmakodinamika secara langsung</div>
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Terjadi jika dua obat yang memiliki aksi ditempat yg sama (antagonis atau sinergis) atau memiliki aksi pada dua tempat yang berbeda yang hasil akhirnya sama.</div>
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Antagonis pada tempat yg sama terjadi misalnya:</div>
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penurunan efek opiat dengan naloxon</div>
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penurunan aksi walfarin oleh vit. K</div>
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penurunan aksi obat-obat hipnotik oleh caffeine.</div>
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Penurunan aksi obat-obat hipoglikemik oleh glucocorticoids. </div>
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Sinergis pada tempat yg sama :</div>
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* adrenoseptor antagonis menyebabkan frekuensi yg sangatVerapamil dan tinggi dari aritmia jantung dibanding pada pemberian sendiri-sendiri, hal ini mungkin disebabkan oleh adanya interaksi dgn jaringan khusus cardiac.</div>
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* Anti hipertensi dan obat-obat yang menyebabkan hipotensi misalnya anti angina, vasodilator.</div>
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Interaksi farmakodinamika secara tak langsung</div>
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Pada interaksi ini, farmakologik, therapeutic, atau efek toksik dari precipitant drug dalam beberapa kesempatan dapat mengubah efekterapi atau efek toksik dari object drug, tetapi terdapat 2 efek yang tidak berkaitan dan tidak berinteraksi secara mandiri (langsung)</div>
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Walfarin dan antikoagulan lain mungkin terlibat interaksi tidak langsung dengan 3 cara :</div>
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a.Agregasi platelet</div>
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Beberapa obat dapat menurunkan daya agregasi dari platelet, misalnya salisilat, dipiridamol, asam mefenamat, fenilbutazon, dan obat-obat NSAID.</div>
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b.Ulcerasi GI</div>
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Jika sebuah obat menyebabkan ulcerasi GI, maka akan menyebabkan kemungkinan terjadi pendarahan pada penderita karena pemberian antikoagulan, misalnya aspirin, fenilbutazon, indometasin, dan NSAID lain</div>
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c.Fibrinolisis</div>
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Obat-obat fibrinolitik misalnya biguanid mungkin meningkatkan efek walfarin.</div>
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Ada 4 sasaran interaksi :</div>
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1. Interaksi obat – obat</div>
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2. Interaksi Obat – makanan</div>
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3. Interaksi Obat – penyakit</div>
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4. Interaksi Obat – Hasil lab</div>
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1. Interaksi Obat-obat</div>
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Tipe interaksi obat dengan obat merupakan interaksi yang paling penting dibandingkan dengan ketiga interaksi lainnya (Walker dan Edward, 1999).</div>
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Semua pengobatan termasuk pengobatan tanpa resep atau obat bebas harus diteliti terhadap terjadinya interaksi obat, terutama bila berarti secara klinik karena dapat membahayakan pasien</div>
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2. Interaksi Obat – makanan</div>
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Tipe interaksi ini kemungkinan besar dapat mengubah parameter farmakokinetik dari obat terutama pada proses absorpsi dan eliminasi, ataupun efikasi dari obat. </div>
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Contoh: MAO inhibitor dengan makanan yang mengandung tiramin (keju, daging, anggur merah) akan menyebabkan krisis hipertensif karena tiramin memacu pelepasan norepinefrin sehingga terjadi tekanan darah yang tidak normal (Grahame-Smith dan Arronson, 1992), </div>
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makanan berlemak meningkatkan daya serap griseofulvin, (Shim dan Mason, 1993).</div>
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3. Interaksi Obat – penyakit</div>
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Acuan medis seringkali mengacu pada interaksi obat dan penyakit sebagai kontraindikasi relatif terhadap pengobatan. </div>
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Kontraindikasi mutlak merupakan resiko, pengobatan penyakit tertentu kurang secara jelas mempertimbangkan manfaat terhadap pasiennya (Shimp dan Mason, 1993). </div>
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Pada tipe interaksi ini, ada obat-obat yang dikontraindikasikan pada penyakit tertentu yang diderita oleh pasien. Misalnya pada kelainan fungsi hati dan ginjal, pada wanita hamil ataupun ibu yang sedang menyusui</div>
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Contohnya pada wanita hamil terutama pada trimester pertama jangan diberikan obat golongan benzodiazepin dan barbiturat karena akan menyebabkan teratogenik yang berupa phocomelia</div>
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Juga pada pemberian NSAID pada Px riwayat tukak lambung</div>
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4. Interaksi Obat – Hasil lab</div>
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Interaksi obat dengan tes laboratorium dapat mengubah akurasi diagnostik tes sehingga dapat terjadi positif palsu atau negatif palsu.</div>
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Hal ini dapat terjadi karena interferensi kimiawi. Misalnya pada pemakaian laksativ golongan antraquinon dapat menyebabkan tes urin pada uribilinogen tidak akurat (Stockley, 1999), atau dengan perubahan zat yang dapat diukur contohnya perubahan tes tiroid yang disesuaikan dengan terapi estrogen (Shimp dan Mason, 1993).</div>
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obat setelah dikonsumsi, dan di absorbsi maka akan tersebar keseluruh tubuh melalui darah. dalam darah atau jaringan biasanya mengandung protein. nah obat-obat tertentu akan berikatan tengan protein ini, obat yg berikatan dgn protein tidak aktif alias tidak berkhasiat, obat yg aktif adalah obat bebas. Obat yg berikatan dgan protein ada yg kuat ada yang lemah, yang lemah gampang lepas, menjadi obat bebas trus jadi berkhasiat, lepasnya obat dari protein dapat disebabkan karena hadirnya senyawa baru yang berkeinginan menempati tempat yg diduduki obat di protein, tgt mana yg dominan, kalo obat tsb lebih lemah maka akan terlepas. jika banyak obat yg terikat dengan protein ( berikatan protein tinggi baca banyak )dan diganggu senyawa lain menjadi terlepas semua atau sebagian, maka kondisi ini sangat berbahaya, karena obat aktif akan meningkat tajam, kondisi ini bisa menyebabkan toksik/keracunan obat. </div>
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pada kondisi malnutrisi, protein sedikit, yg berikatan sedikit, jadi obat bebas banyak, yg aktif banyak dari biasanya maka dapat menyebabkan keracunan obat</div>
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arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-68216568289395632502013-11-10T00:43:00.001+07:002013-11-10T01:01:07.374+07:00Dosis Obat<div style="text-align: justify;">
Macam-macam dosis obat:</div>
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- Dosis toksik, yaitu dosis yang menimbulkan gejala keracunan.</div>
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- Dosis minimal, yaitu dosis yang paling kecil yang masih mempunyai efek terapeutik.</div>
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- Dosis maksimal,yaitu dosis terbesar yang mempunyai efek terapeutik, tanpa gejala/ efek toksik.</div>
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- Dosis terapeutik, yaitu dosis diantara dosis minimal dan maksimal yang dapat memberikan efek menyembuhkan/terapeutik. Dosis ini dipengaruhi oleh Umur, Berat badan, jenis kelamin, waktu pemberian obat, cara pemberian obat.(Dewi, 2010)</div>
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Ada pula beberapa istilah yang berhubungan dengan dosis:</div>
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(Mutschler, 1991)</div>
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KONSENTRASI DAN RESPON OBAT</div>
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Respons terhadap dosis obat yang rendah biasanya meningkat sebanding langsung dengan dosis. Namun, dengan meningkatnya dosis peningkatan respon menurun. Pada akhirnya, tercapailah dosis yang tidak dapat meningkatkan respon lagi. Pada system ideal atau system in vitro hubungan antara konsentrasi obat dan efek obat digambarkan dengan kurva hiperbolik pada EC50, di mana E adalah efek yang diamati pada konsentrasi C, Emaks adalah respons maksimal yang dapat dihasilkan oleh obat. EC50 adalah konsentrasi obat yang menghasilkan 50% efek maksimal.</div>
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Hubungan dosis dan respons bertingkat</div>
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1. Efikasi (efficacy)</div>
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Efikasi adalah respon maksimal yang dihasilkan suatu obat. Efikasi tergantung pada jumlah kompleks obat-reseptor yang terbentuk dan efisiensi reseptor yang diaktifkan dalam menghasilkan suatu kerja seluler.</div>
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2. Potensi</div>
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Potensi yang disebut juga kosentrasi dosis efektif, adalah suatu ukuran berapa bannyak obat dibutuhkan untuk menghasilkan suatu respon tertentu. Makin rendah dosis yang dibutuhkan untuk suatu respon yang diberikan, makin poten obat tersebut.Potensi paling sering dinyatakan sebagai dosis obat yang memberikan 50% dari respon maksimal (ED50). Obat dengan ED50 yang rendah lebih poten daripada obat dengan ED50 yang lebih besar.</div>
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3. Slope kurva dosis-respons</div>
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Slope kurva dosis-respons bervariasi sari suatu obat ke obat lainnya. Suatu slope yang curam menunjukkan bahwa suatu peningkatan dosis yang kecil menghasilkan suatu perubahan yang besar.</div>
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(Katzung, 1989)</div>
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Dosis yang menimbulkan efek terapi pada 50% individu (ED50) disebut juga dosis terapi median. Dosis letal median adalah dosis yang emnimbulkan kematian pada 50% individu , sedangkan TD50 adalah dosis toksik 50% (Ganiswara, 1995).</div>
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Gambar 1. Kurva Dosis Terapi (ED50) dan Dosis Lethal (LD50)</div>
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Variabel Hubungan dosis-intensitas efek obat</div>
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Kurva sederhana yang menunjukkan hubungan dosis-intensitas efek obat selallu mempunyai 4 variabel karakteristik, yaitu: potensi, kecuraman (Slope), efek maksimal, dan variasi individual</div>
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a. Potensi: menunjukkan kisaran dosis obat yang menimbulkan efek. Besarnya ditentukan oleh kadar obat yang mencapai reseptor.</div>
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b. Efek maksimal/efektivitas: respon maksimal yang dapat ditimbulkan oleh obat jika diberikan pada dosis yang tinggi</div>
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c. Slope: menunjukkan batasan keamanan obat.</div>
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d. Variasi biologic: variasi antar individu dalam besarnya respons terhadap dosis obat yang sama pada populasi yang sama.</div>
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(Farmakologi dan Terapi, 2007)</div>
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INDEKS TERAPI</div>
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Obat mempunyai respon farmasetik sepanjang masih adanya dosis obat yang terkandung dalam obat dan berada dalam margin/ batas keamanan obat. Beberapa obat mempunyai batas terapi yang luas. Ini menunjukkan bahwa pasien dapat diberikan dengan range tingkat dosis yang lebar tanpa terjadi efek toksik. Obat lainnya mempunyai batas terapi yang sempit dimana perubahan sejumlah kecil dosis obat dapat menyebabkan efek samping yang tidak diinginkan atau bahkan efek toksik ( Yesi, 2009 ).</div>
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Dosis yang memberikan efek terapi pada 50% individu disebut dosis terapi median atau dosis efektif median ( ED 50 ). Dosis letal median ( LD 50 ) adalah dosis yang menimbulkan kematian pada 50% individu, sedangkan TD 50 adalah dosis toksik pada 50% individu ( Departemen Farmakologik dan Terapeutik, 2007 ).</div>
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Indeks terapeutik suatu obat adalah rasio dari dosis yang menghasilkan racun dengan dosis yang menghasilkan respon klinis yang diinginkan atau efektif dalam populasi individu.</div>
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Dimana: TD50 adalah dosis obat yang menyebabkan respon beracun di 50% dari populasi dan ED50 adalah dosis terapi obat yang efektif dalam 50% dari populasi.</div>
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Baik ED50 dan TD50 dihitung dari kurva dosis respon quantal, yang merupakan frekuensi yang masing-masing dosis obat memunculkan efek respon atau beracun yang diinginkan dalam populasi</div>
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Ada beberapa karakteristik penting dari kurva dosis-respons quantal (lihat gambar di atas) yang patut dicatat:</div>
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• Dosis obat dalam plasma diplot dalam sumbu horisontal sedangkan persentase individu (hewan atau manusia) yang menanggapi atau menunjukkan efek toksik direpresentasikan dalam sumbu vertikal.</div>
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• Beberapa contoh respon positif meliputi: bantuan, sakit kepala untuk obat antimigraine, peningkatan denyut jantung minimal 20 bpm untuk stimulan jantung, atau 10 jatuh mmHg pada tekanan darah diastolik untuk antihipertensi.</div>
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• Data diperoleh dari suatu populasi. Tidak seperti grafik dosis-respons dinilai, data untuk kurva dosis-respons quantal diperoleh dari banyak individu.</div>
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( Guzman, 2011 )</div>
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Grafik di bawah menunjukkan bagaimana ED50 dihitung.</div>
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Dosis yang diperlukan untuk menimbulkan efek terapi (respon positif) dalam 50% dari populasi adalah ED50 tersebut</div>
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Dosis yang dibutuhkan untuk menghasilkan efek toksik di 50% dari populasi dikaji adalah TD50 tersebut. Untuk studi hewan, LD50 adalah dosis yang dapat menyebabkan kematian 50% dari populasi ( Guzman, 2011 ).</div>
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arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com1tag:blogger.com,1999:blog-2501725445038181687.post-61004126890469745432013-06-06T22:14:00.003+07:002013-06-06T22:14:43.900+07:00LIMFADENITIS<!--[if !mso]>
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<br />
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">BAB 1</span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">PENDAHULUAN</span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kelenjar
getah bening termasuk dalam susunan retikuloendotel, yang tersebar di seluruh
tubuh. Kelenjar inimempunyai fungsi penting berupa barier atau filter terhadap
kuman-kuman/bakteri-bakteri yang termasuk ke dalam badan dan barier pula untuk
sel-sel tumor ganas (kanker). Disamping itu bertugas pula untuk membentuk
sel-sel limfosit darah tepi. Limfadenitis adalah peradangan kelenjar getah
bening (kelenjar limfe) regional dari lesi primer akibat adanya infeksi dari
bagian tubuh yang lain.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Streptokokus dan bakteri
staphylococcal adalah penyebab paling umum dari limfadenitis, meskipun virus,
protozoa, rickettsiae, jamur, dan basil TB juga dapat menginfeksi kelenjar
getah bening. Streptokokus dan bakteri penyebab adalah pagar staphylococcal limfadenitis
Umum, meskipun virus, protozoa, rickettsiae, jamur, dan TBC juga dapat
menginfeksi kelenjar getah bening.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 42.55pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penyakit yang melibatkan kelenjar
getah bening di seluruh tubuh termasuk mononucleosis, infeksi sitomegalovirus,
toksoplasmosis, dan brucellosis. Gejala awal limfadenitis adalah pembengkakan
kelenjar yang disebabkan oleh penumpukan cairan jaringan dan peningkatan jumlah
sel darah putih akibat respon tubuh terhadap infeksi. Pembesaran kelenjar
terjadi karena adanya hiperplasia limfoid dan terbentuknya tuberkel, kemudian
terjadi granulasi kronis, di kelenjar terjadi nekrosis dan perkejuan. Kelenjar
dapat membesar dan melekat satu dengan yang lainnya serta melekat dengan
jaringan sekitarnya, kemudian terjadi perkejuan selanjutnya terbentuk abses.</span></div>
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><br clear="all" style="page-break-before: always;" />
</span>
<div align="center" class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">BAB 2</span></b></div>
<div align="center" class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: center;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">PEMBAHASAN</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; letter-spacing: -.7pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">2.1 DEFINISI </span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">LIMFADENITIS</span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Limfadenitis adalah peradangan pada satu atau beberapa
kelenjar getah bening. Peradangan tersebut akan menimbulkan hiperplasia
kelenjar getah bening hingga terasa membesar secara klinik. Kemunculan
penyakit iniditandai dengan gejala munculnya benjolan pada saluran getah bening
misalnya ketiak, leher dan sebagainya. Kelenjar getah bening yang terinfeksi
akan membesar dan biasanya teraba lunak dan nyeri. Kadang-kadang kulit
diatasnya tampak merah dan teraba hangat.</span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 18.0pt; text-align: justify;">
<span class="a"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2.2 ETIOLOGI </span></b></span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">LIMFADENITIS</span></b><span class="a"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></b></span></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 18.0pt; text-align: justify;">
<span class="a"><span style="background: white; border: none windowtext 1.0pt; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-border-alt: none windowtext 0cm; padding: 0cm;"><span style="mso-tab-count: 1;"> </span>Limfadenitis bisa
disebabkan oleh infeksi dari berbagai organisme yaitu bakteri,virus, protozoa,
riketsia atau jamur. </span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Streptokokus dan bakteri
staphylococcal adalah penyebab paling umum dari limfadenitis, meskipun virus,
protozoa, rickettsiae, jamur, dan basil TB juga dapat menginfeksi kelenjar
getah bening. Ciri khasnya, infeksi tersebut menyebar menuju kelenjar getah
bening dari infeksi kulit, telinga, hidung, atau mata atau dari beberapa
infeksi seperti infectious mononucleosis, infeksi cytomegalovirus, infeksi
streptococcal, tuberculosis, atau sifilis. Infeksi tersebut bisa mempengaruhi
kelenjar getah bening atau hanya pada salah satu daerah pada tubuh.</span></div>
<a name='more'></a><br />
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;">2.3
EPIDEMIOLOGI </b></span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">LIMFADENITIS</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Dari
studi di belanda terdapat 2.556 kasus limfadenitis, 10% dirujuk kepada
subspesialis, 3.2% membutuhkan biopsy dan 1.1% mwngalami keganasan. Studi
kedokteran keluarga di Amerika Serikat tiga dari 238 pasien limfadenitis yang
mengalami komplikasi yang berat.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Penderita
limfadenitis di RSUP H.Adam Malik Sumatera Utara pada tahun 2011 dengan rentang
20 – 50 tahun, yaitu 74 dengan jenis kelamin terbanyak adalah wanita. Dari
hasil penelitian ini juga diperoleh bahwa sebagian besar limfadenitis ada
mengalami gejala sistemik. Berdasarkan hasil pemeriksaan didapatkan 13 orang
memiliki pembesaran kelenjar berdiameter ≥ 2cm, 12 orang memiliki pembesaran
kelenjar yang multiple, 17 orang memiliki pembesaran kelenjar dengan
konsistensi kenyal, 16 orang memiliki pembesaran kelenjar tanpa disertai adanya
ulkus, dan 12 orang memiliki pembesaran kelenjar tanpa disertai adanya nyeri.</span></div>
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-bidi-language: AR-SA; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US;"><br clear="all" style="page-break-before: always;" />
</span></b>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">2.4 PATOFISIOLOGI </span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">LIMFADENITIS</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"></span></b></div>
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<a href="http://arijal-ridz-arti.blogspot.com/" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhf-KiIIGw6-B0kTTBnN5W88B1geJac2LA3zDE7KxtDjh0Xc4SJ1D-QgDFqKn6GfmUG9mox-rmoBqN7felLSTvakrjKYtm-JOSorGhXpghLhh_Qz3LySl4mxbBdAm8YihrWhZdTEVS17IsO/s640/patofisiologi+Limfadenitis.jpg" width="520" /></a>
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<span lang="EN-US"><span style="mso-spacerun: yes;"> </span></span><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">Gambar</span><span lang="EN-US"> 1</span></b><b style="mso-bidi-font-weight: normal;"><span style="mso-ansi-language: IN;">: P</span><span lang="EN-US">atofisiologi
Limfadenitis</span></b></div>
<div class="Default" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US">Kelenjar getah bening (KGB) adalah bagian dari sistem pertahanan
tubuh. Tubuh kita memiliki kurang lebih sekitar 600 kelenjar getah bening,
namun hanya di daerah sub mandibular, ketiak atau lipat paha yang teraba normal
pada orang sehat. Terbungkus kapsul fibrosa yang berisi kumpulan sel-sel
pembentuk pertahanan tubuh dan merupakan tempat penyaringan antigen (protein
asing) dari pembuluh-pembuluh getah bening yang melewatinya. Pembuluh-pembuluh
limfe akan mengalir ke kelenjar getah bening sehingga dari lokasi kelenjar
getah bening akan diketahui aliran pembuluh limfe yang melewatinya. Oleh karena
dilewati oleh aliran pembuluh getah bening yang dapat membawa antigen dan
memiliki sel pertahanan tubuh maka apabila ada antigen yang menginfeksi maka
kelenjar getah bening dapat menghasilkan sel-sel pertahanan tubuh yang lebih
banyak untuk mengatasi antigen tersebut sehingga kelenjar getah bening
membesar. </span></div>
<div class="Default" style="line-height: 150%; text-align: justify;">
<br /></div>
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<span style="mso-ansi-language: IN;"></span></div>
<br /><div class="Default" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US">Pembesaran kelenjar getah bening dapat berasal dari penambahan
sel-sel pertahanan tubuh yang berasal dari kelenjar getah bening itu sendiri
seperti limfosit, sel plasma, monosit dan histiosit atau karena datangnya
sel-sel peradangan (neutrofil) untuk mengatasi infeksi di kelenjar getah bening
(limfadenitis), infiltrasi sel-sel ganas atau timbunan dari penyakit metabolite
macrophage (gaucher disease). Dengan mengetahui lokasi pembesaran kelenjar
getah bening maka kita dapat mengarahkan kepada lokasi kemungkinan terjadinya
infeksi atau penyebab pembesaran kelenjar getah bening. Benjolan, bisa berupa
tumor baik jinak atau ganas, bisa juga berupa pembesaran kelenjar getah bening.
Kelenjar ini ada banyak sekali di tubuh kita, antara lain di ujudaerah leher,
ketiak, dalam rongga dada dan perut, di sepanjang tulang belakang kiri dan kanan
sampai mata kaki. Kelenjar getah bening berfungsi sebagai penyaring bila ada
infeksi lokal yang disebabkan bakteri atau virus. Jadi, fungsinya justru
sebagai benteng pertahanan tubuh.</span></div>
<div class="Default" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US">Jika tidak terjadi infeksi, kemungkinan adalah tumor. Apalagi bila
pembesaran kelenjar didaerah-daerah tersebut di atas, pertumbuhannya cepat dan
mudah membesar. Bila sudah sebesar biji nangka, misalnya, bila ditekan tidak
sakit, maka perlu diwaspadai. Jalan terbaik, adalah dilakukan biopsy di
kelenjar tersebut. Diperiksa jenis sel-nya untuk memastikan apakah sekedar
infeksi atau keganasan. Jika tumor dan ternyata ganas, pembesaran kelenjar akan
cepat terjadi. Dalam sebulan, misalnya sudah membesar dan tak terasa sakit saat
ditekan. Beda dengan yang disebabkan infeksi, umumnya tidak bertambah besar dan
jika daerah di sekitar benjolan ditekan,terasa sakit. </span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><span style="mso-tab-count: 1;"> </span></span></div>
<div class="Default" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";">Peningkatan ukuran kelenjar getah bening
disebabkan</span></div>
<div class="Default" style="line-height: 150%; margin-left: 36.0pt; mso-list: l3 level1 lfo13; text-align: justify; text-indent: -18.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";">Multiplikasi sel-sel di dalam node, termasuk
limfosit, sel plasma, monosit, histiosit</span></div>
<div class="Default" style="line-height: 150%; margin-left: 36.0pt; mso-list: l3 level1 lfo13; text-align: justify; text-indent: -18.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";">Infiltrasi sel dari luar nodus seperti sel
ganas atau neutrofil</span></div>
<div class="Default" style="line-height: 150%; margin-left: 36.0pt; mso-list: l3 level1 lfo13; text-align: justify; text-indent: -18.0pt;">
<span lang="NO-BOK" style="mso-ansi-language: NO-BOK; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="NO-BOK" style="mso-ansi-language: NO-BOK; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";">Pengeringan infeksi (misalnya abses) ke
kelenjar getah bening lokal.</span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">2.5
</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">PATOGENESIS
LIMFADENITIS</span></b></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Kelenjar
getah bening </span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Kelenjar getah bening (KGB) adalah
agregat nodular jaringan limfoid yang terletak sepanjang jalur limfe di seluruh
tubuh. Sel dendritik membawa antigen mikroba dari epitel dan mengantarkannya ke
kelenjar getah bening yang akhirnya dikonsentrasikan di KGB. Dalam KGB
ditemukan peningkatan limfosit berupa nodus tempat proliferasi limfosit sebagai
respons terhadap antigen.</span></div>
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<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l4 level1 lfo1; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">System
limfatik-resirkulasi limfosit</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Sirkulasi darah ada dibawah tekanan dan
komponennya (plasma) masuk<span style="mso-spacerun: yes;"> </span>dinding
kapiler yang<span style="mso-spacerun: yes;"> </span>tipis ke jaringan sekitar.
Cairan ini disebut cairan interstisial yang membasahi semua jaringan dan sel.
Bila cairan ini tidak dikembalikan ke sirkulasi dapat terjadi edema,
pembengkakan progresif yang dapat mengancam nyawa. Hal itu tidak terjadi<span style="mso-spacerun: yes;"> </span>oleh karena cairan dikembalikan ke darah
melalui dinding venul. Jadi system tersebut menampung cairan yang dari pembuluh
darah dan masuk ke dalam jaringan dan mengembalikannya ke pembuluh darah.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>Sel limfosit, SD, makrofag dan sel
lainnya juga dapat masuk melalui dinding tipis sel endotel yang longgar dari
pembuluh limfe primer dan masuk ke dalam arus limfe. Antigen asing yang masuk
ke dalam jaringan akan ditangkap oleh sel system imun dan dibawa ke berbagai
jaringan limfoid regional yang teroganisasi seperti KGB. Jadi system limfatik
juga berperan sebagai alat transport limfosit dan antigen dari jaringan ikat ke
jaringan limfoid yang teroganisasi, tempat limfosit diaktifkan.<sup>1</sup></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>Keuntungan dari resirkulasi limfosit
ialah bahwa sewaktu terjadi infeksi non-spesifik, banyak limfosit akan terpajan
dengan antigen/kuman. Keuntungan lain dari resirkulasi limfosit ialah bahwa
bila ada organ limfoid misalnya limfa yang deficit limfosit karena infeksi,
radiasi atau trauma. Limfosit dari jaringan limfoid lainnya melalui sirkulasi
akan dapat dikerahkan kedalam organ limfoid tersebut dengan mudah.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>Sel T naïf (Sel matang yang belum
terpajan dengan antigen dan belum berdiferensiasi) cenderung meninggalkan
sirkulasi darah dan menuju kelenjar getah bening dalam daerah sel T. SD/APC
dari berbagai bagian tubuh yang membawa antigen juga berimigrasi dan masuk ke
dalam kelenjar getah bening dan mempresentasikan antigen ke sel T. sel T yang
diaktifkan SD/APC tersebut keluar dari kelenjar limfoid dan melalui aliran
darah bergerak ke tempat infeksi dan bekerja sebagai sel efektor. Tidak seperti
leukosit, limfosit terus menerus di resirkulasikan melalui darah dan limfe ke
berbagai organ limfoid.</span></div>
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<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l2 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">HEV-tempat
ekstravasasi limfosit</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Beberapa
tempat di endotel<span style="mso-spacerun: yes;"> </span>vascular dalam venul
poskapilar berbagai organ limfoid terdiri<span style="mso-spacerun: yes;">
</span>atas sel khusus, gemuk dan tinggi yang disebut HEV. Sel-selnya berlainan
sekali dengan sel endotel yang gepeng yang membatasi kapiler lainnya. Setiap
organ limfoid sekunder, kecuali limpa mengandung HEV.<sup>1</sup></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>HEV mengekspresikan sejumlah besar molekul
adhesi. Seperti sel endotel vascular lainnya, HEV mengekspresikan CAM family
selektin (selektin E dan P), family musin (GlyCAM-1 dan CD34) dan superfamily
immunoglobulin (ICAM-1, ICAM-2. ICAM-3, VCAM-1 dan MAdCAM-1) beberapa molekul
adhesi disebut adresin vascular, oleh karena berperan dalam mengarahkan
ekstravasasi berbagai populasi limfosit dalam resirkulasi ke organ limfoid
khusus.<sup>1</sup></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l2 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></i></b><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Homing
atau trafficking</span></i></b></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Pada
keadaan normal terjadi lintas arus limfosit aktif terus menerus melalui
kelenjar getah bening, tetapi bila ada antigen masuk, arus limfosit dalam
kelenjar getah bening akan berhenti sementara. Sel yang antigen spesifik akan
ditahan dalam kelenjar getah bening. Dalam menghadapi antigen tersebut,
kelenjar dapat membengkak seperti yang sering ditemukan pada infeksi. Hal
tersebut merupakan hal yang esensial untuk respons imun yang efektif terhadap antigen
asing.</span></div>
<div class="MsoNormal" style="line-height: 150%; tab-stops: 18.0pt; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"> </span>Limfosit
cenderung berimigrasi ke tempat-tempat yang selektif. Homing mukosa adalah
kembalinya sel limfoid reaktif imunologis ke asalnya di folikel mukosa. Hal
tersebut terjadi<span style="mso-spacerun: yes;"> </span>melalui ikatan antara
molekul adhesi dan kemokin, reseptor<span style="mso-spacerun: yes;"> </span>yang
mengarahkan berbagai populasi limfosit ke jaringan limfoid khusus atau
inflamasi yang disebut dengan reseptor <i style="mso-bidi-font-style: normal;">homing</i>.
L-selektin atau CD62L adalah molekul pada permukaan limfosit yang berperan pada
homing limfosit. Adresin mukosa adalah salah satu adresin yang mengikat
integrin pada sel T yang memilih<i style="mso-bidi-font-style: normal;"> homing</i>
di saluran cerna. Reseptor pada permukaan limfosit tersebut akan memberikan
arah dan tujuan kembali ke plak peyer. Limfosit yang awalnya disensitasi oleh
antigen di plak peyer akan diaktifkan dan memproduksi sel memori yang akan
berimigrasi kembali ke tempat yang semula mensensitasinya.</span></div>
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2.6 </span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">KLASIFIKASI
LIMFADENITIS</span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Sebagian
besar kasus merupakan respon jinak terhadap infeksi lokal atau sistemik.
Sebagian besar anak dengan limfadenitis menunjukkan<span style="mso-spacerun: yes;"> </span>kecil, teraba serviks, ketiak, dan kelenjar
getah bening inguinal. Kurang umum adalah pembesaran suboksipital atau
postaurikular node. Supraklavikula, epitrochlear, dan poplitea kelenjar getah
bening teraba jarang terjadi, seperti yang diperbesar node mediastinum dan
perut.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Limfadenitis
dapat mempengaruhi node tunggal atau sekelompok node (adenopati daerah) dan
dapat unilateral atau bilateral. Onset dan perjalanan limfadenitis mungkin
akut, subakut, atau kronis.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">jenis
lymphadenitis:</span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Lymphadenitis disebabkan oleh virus:</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"></span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Arial Unicode MS";">Infectious mononucleosis
lymphadenitis</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Arial Unicode MS";">Cytomegalovirus (CMV) lymphadenitis</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Arial Unicode MS";">Herpes simplex virus lymphadenitis</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Arial Unicode MS";">Varicella-herpes zoster
lymphadenitis</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Arial Unicode MS";">Vaccinia lymphadenitis</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Arial Unicode MS";">Measles lymphadenitis</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Arial Unicode MS";">Human immunodeficiency virus (HIV)
lymphadnitis, with and without salivary gland invovlvement</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Arial Unicode MS";">Human immunodeficiency virus (HIV)
lymphadnitis of salivary gland invovlvement</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Lymphadenitis disebabkan oleh
bakteri:</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Non-specific acterial lymphadenitis
(common, non-specific species)</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Cat-scratch lymphadenitis (<i>Afipia
felis</i>)</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Bacillary angiomatosis of lymph
nodes (<i>Bartonella henselae</i> and <i>B. quintana</i>)</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Lymphogranuloma venereum
lymphadenitis (<i>Chlamydia trachomatis</i>)</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Syphilitic lymphadenitis (<i>Trapenosoma
pallidum</i>)</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Lymphadenitis of Whipple disease</span></div>
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<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 35.45pt; margin-right: 0cm; margin-top: 3.75pt; mso-add-space: auto; mso-list: l9 level1 lfo3; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Lymphadenitis disebabkan oleh
mycobacteria:</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 36.0pt; margin-right: 0cm; margin-top: 3.75pt; text-align: justify;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Mycobacterium tuberculosis</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"> lymphadenitis (TB)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 36.0pt; margin-right: 0cm; margin-top: 3.75pt; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Atypical mycobacterial
lymphadenitis</span></div>
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<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Mycobacterium avium-intracellulare</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"> lymphadenitis</span></div>
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<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Mycobacterium leprae</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"> lymphadenitis</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Miscellaneous mycobacterial
lymphadenitis</span></div>
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<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 35.45pt; margin-right: 0cm; margin-top: 3.75pt; mso-add-space: auto; mso-list: l9 level1 lfo3; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Lymphadenitis disebabkan oleh jamur</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 36.0pt; margin-right: 0cm; margin-top: 3.75pt; text-align: justify;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Cryptococcus</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"> lymphadenitis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 36.0pt; margin-right: 0cm; margin-top: 3.75pt; text-align: justify;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Histoplasma</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"> lymphadenitis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 36.0pt; margin-right: 0cm; margin-top: 3.75pt; text-align: justify;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Coccidioidomycosis</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"> lymphadenitis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 36.0pt; margin-right: 0cm; margin-top: 3.75pt; text-align: justify;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Pneumocystis</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"> lymphadenitis</span></div>
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<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 35.45pt; margin-right: 0cm; margin-top: 3.75pt; mso-add-space: auto; mso-list: l9 level1 lfo3; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Lymphadenitis
disebabkan oleh protozoa</span></b></div>
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<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Toxoplasma</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"> lymphadenitis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 36.0pt; margin-right: 0cm; margin-top: 3.75pt; text-align: justify;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Leishmania </span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">lymphadenitis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 36.0pt; margin-right: 0cm; margin-top: 3.75pt; text-align: justify;">
<i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Filaria </span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">lymphadenitis</span></div>
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<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 35.45pt; margin-right: 0cm; margin-top: 3.75pt; mso-add-space: auto; mso-list: l9 level1 lfo3; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Others</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: 3.75pt; margin-left: 36.0pt; margin-right: 0cm; margin-top: 3.75pt; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Arial Unicode MS";">Malaioplakia (most common in the
mesenteric lymph nodes)</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2.7
MANIFESTASI KLINIS LIMFADENITIS</span></b></div>
<div class="MsoNormal" style="background: white; line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Kelenjar getah bening yang
terserang biasanya akan membesar dan jika diraba terasa lunak dan nyeri,
selain itu gejala klinis yang timbul adalah demam, nyeri tekan, dan tanda radang.
Kulit di atasnya terlihat merah dan terasa hangat, pembengkakan ini akan
menyerupai daging tumbuh atau biasa disebut dengan tumor. Dan untuk memastikan
apakah gejala-gejala tersebut merujuk pada penyakit limfadenitis maka perlu
adanya pengangkatan jaringan untuk pemeriksaan di bawah mikroskop.</span></div>
<div class="MsoNormal" style="background: white; line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Limfadenitis pada taraf parah
disebut limfadenitis kronis. Limfadenitis ini terjadi ketika penderita
mengalami infeksi kronis, misal pada kondisi ketika seseorang dengan faringitis
kronis akan ditemukan pembesaran kelenjar getah bening leher (limfadenitis).
Pembesaran di sini ditandai oleh tanda radang yang sangat minimal dan tidak
nyeri. Pembesaran kronis yang spesifik dan masih banyak di Indonesia adalah
akibat tuberkulosa. Limfadenitis tuberkulosa ini ditandai oleh pembesaran
kelenjar getah bening, padat/keras, multiple dan dapat berhubungan satu sama
lain. </span></div>
<div class="MsoNormal" style="background: white; line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Limfadenitis tuberculosa pada
kelenjar getah bening dapat menjadi besar dan berhubungan sehingga leher
penderita itu bias disebut seperti bull neck. Pada keadaan seperti ini
kadang-kadang sulit dibedakan dengan limfoma malignum.
Limfadenitis tuberkulosa diagnosis ditegakkan dengan
pemeriksaan histopatologi, terutama yang tidak disertai oleh tuberkulosa paru.</span></div>
<div class="MsoNormal" style="background: white; line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2.8 ANAMNESIS LIMFADENITIS</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">a. Keluhan Utama</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">
: </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Pembengkakan Kelenjer di bagian bawah
Regio Supra Clavicula Dekstra. Bengkaknya sebesar telur puyuh , lunak serta
nyeri bila di tekan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">b. Keluhan penyerta</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">
dari limfadenitis ialah :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Adanya
luka perih berdenyut biasanya muncul pada daerah sellulitis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Anoreksia</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Malaise</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Menggigil
dan demam 37,8° - 40°C.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Takikardia</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Terdapat
garis merah pada kulit mulai dari luka sampai ke limfonodi regional, biasanya
meluas dan lunak akibat keterlibatan limfatik.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l1 level1 lfo4; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Adakah
batuk, nyeri tenggorokan dan ruam.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: -14.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Penurunan berat badan, demam, keringat
malam adalah gejala dari limfoma.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">c. Riwayat penyakit </span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Adanya peradangan tonsil (amandel)
sebelumnya mengarahkan kepada infeksi oleh streptokokus. Adanya infeksi gigi
dan gusi dapat mengarahkan kepada infeksi bakteri anaerob. Transfusi darah
sebelumnya dapat mengarahkan kepada Citomegalovirus, Epstein Barr Virus atau
HIV.</span></div>
<pre style="line-height: 150%; margin-left: 21.3pt; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">d. </span></b><b style="mso-bidi-font-weight: normal;"><span lang="X-NONE" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Riwayat Obat- Obatan </span></b></pre>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; text-align: justify; text-indent: 36.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Riwayat
obat-obatan: </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">fenitoin
dan isoniazid.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">e. </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Riwayat
pekerjaan dan perjalanan</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Paparan terhadap infeksi / kontak
sebelumnya kepada orang dengan infeksi saluran nafas atas, faringitis oleh
Streptococcus, atau tuberculosis turut membantu mengarahkan penyebab
limfadenitis. Riwayat perjalanan atau pekerjaan, misalnya perjalanan ke
daerah-daerah di Afrika dapat mengakibatkan penyakit Tripanosomiasis, orang
yang bekerja dalam hutan dapat terkena Tularemia.</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2.9
PEMERIKSAAN FISIK LIMFADENITIS</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Pada
pemeriksaan fisik limfadenitis harus dicatat ada tidaknya nyeri tekan,
kemerahan, hangat pada perabaan, dapat bebas digerakkan atau tidak dapat
digerakkan, Apakah ada fluktuasi, konsistensi apakah keras atau kenyal. Pasien
tampak sakit ringan atau berat , demam, dan pada kulit adakah lesi misalnya
selulitis, abses, melanoma.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Periksa
dimana kelenjer getah bening yang membesar : Misalnya di bagian bawah Regio Supra
Clavicula Dekstra, KGB di servikal, aksilaris, inguinal, dll.</span></div>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="line-height: 150%; mso-list: l8 level1 lfo6; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Ukuran:
Normal bila diameter 0,5 cm (pada lipat paha >1,5cm dikatakan
abnormal).</span></li>
</ul>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="line-height: 150%; mso-list: l5 level1 lfo5; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Nyeri
tekan: Umumnya diakibatkan peradangan atau proses perdarahan.</span></li>
<li class="MsoNormal" style="line-height: 150%; mso-list: l5 level1 lfo5; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Konsistensi:
Keras seperti batu mengarahkan kepada keganasan, padat seperti karet
mengarahkan kepada limfoma; lunak mengarahkan kepada proses infeksi;
fluktuatif mengarahkan telah terjadinya abses/pernanahan.</span></li>
<li class="MsoNormal" style="line-height: 150%; mso-list: l5 level1 lfo5; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Penempelan:
Beberapa Kelenjar Getah Bening yang menempel dan bergerak bersamaan bila
digerakkan. Dapat akibat tuberkulosis, sarkoidosis keganasan.</span></li>
</ul>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Pembesaran
KGB leher bagian posterior terdapat pada infeksi rubela dan mononukleosis. Pada
pembesaran KGB oleh infeksi virus, KGB umumnya bilateral (dua sisi-kiri/kiri
dan kanan), lunak dan dapat digerakkan. Bila ada infeksi oleh bakteri, kelenjar
biasanya nyeri pada penekanan, baik satu sisi atau dua sisi dan dapat
fluktuatif dan dapat digerakkan. Adanya kemerahan dan suhu lebih panas dari
sekitarnya mengarahkan infeksi bakteri dan adanya fluktuatif menandakan
terjadinya abses. </span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Bila
limfadenitis disebabkan keganasan, tanda-tanda peradangan tidak ada, KGB keras
dan tidak dapat digerakkan (terikat dengan jaringan di bawahnya). Pada infeksi
oleh mikobakterium pembesaran kelenjar berjalan mingguan-bulanan, walaupun
dapat mendadak, KGB menjadi fluktuatif dan kulit diatasnya menjadi tipis, dan
dapat pecah. </span></div>
<pre style="line-height: 150%; text-align: justify;"><span lang="X-NONE" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>Adanya tenggorokan yang merah, bercak-bercak putih pada tonsil, bintik-bintik merah pada langit-langit mengarahkan infeksi oleh bakteri streptokokus.<span style="mso-spacerun: yes;"> </span>Pembengkakan pada jaringan lunak leher (bull neck) mengarahkan kepada infeksi oleh bakteri difteri. Faringitis, ruam-ruam dan pembesaran limpa mengarahkan kepada infeksi epstein barr virus. Adanya radang pada selaput mata dan bercak koplik mengarahkan kepada campak.</span></pre>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2.10 PEMERIKSAAN PENUNJANG
LIMFADENITIS</span></b></div>
<ol start="1" style="margin-top: 0cm;" type="1">
<li class="MsoNormal" style="line-height: 150%; mso-list: l11 level1 lfo7; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Hasil Laboratorium
pada limfadenitis :</span></b></li>
</ol>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Lekositosis biasanya tanpa perubahan.
Pada akhirnya, kultur darah menjadi positif, umumnya spesies stafilokokus atau
streptokokus. Pemeriksaan kultur dan sensitivitas pada eksudat luka atau pus
dapat membantu pengobatan infeksi.</span></div>
<ol start="2" style="margin-top: 0cm;" type="1">
<li class="MsoNormal" style="line-height: 150%; mso-list: l11 level1 lfo7; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Pemeriksaan
Mikrobiologi</span></b></li>
</ol>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Pemeriksaan mikrobiologi yang meliputi
pemeriksaan mikroskopis dan kultur. Spesimen untuk mikrobiologi dapat diperoleh
dari sinus atau biopsi aspirasi. Dengan pemeriksaan ini kita dapat memastikan
adanya mikroorganisme pada spesimen.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Kultur (contoh dikirim ke laboratorium
dan diletakkan pada kultur medium yang membiarkan mikroorganisme untuk
berkembang) kemungkinan diperlukan untuk memastikan diagnosa dan untuk mengidentifikasikan
organisme penyebab infeksi.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l11 level1 lfo7; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Ultrasonografi
(USG) </span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">USG merupakan salah satu teknik yang
dapat dipakai untuk mengetahui ukuran, bentuk, dan gambaran mikronodular. USG
juga dapat dilakukan untuk membedakan penyebab pembesaran kelenjar (infeksi,
metastatik, lymphoma, atau reaktif hiperplasia).</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l11 level1 lfo7; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Biopsi
</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: 36.0pt;">
<span class="a"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Biopsi adalah
pengambilan sejumlah kecil jaringan dari tubuh manusia
untuk pemeriksaan patologis mikroskopik.</span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; letter-spacing: 2.25pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Biopsi Aspirasi Jarum Halus (<em>Fine
Needle Aspiration Biopsy</em>/ FNAB), adalah prosedur biopsi yang
menggunakan jarum sangat tipis yang melekat pada jarum suntik
untuk menarik (aspirasi) sejumlah kecil jaringan dari lesi
abnormal. Sampel jaringan ini kemudian dilihat di bawah mikroskop.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-indent: 36.0pt;">
<span class="a"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Biopsi kebanyakan dlakukan untuk mengetahui adanya
kanker. Bagian apapun dari tubuh, seperti kulit, organ tubuh maupun benjolan
dapat diperiksa</span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">. </span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 17.45pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; letter-spacing: .75pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Indikasi Fine
Needle Aspiration Biopsy :</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; mso-list: l6 level1 lfo8; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pasien yang menjalani FNAB umumnya dideteksi memiliki
massa jaringan lunak di bawah permukaan kulit atau mukosa selama pemeriksaan
klinis. Massa leher dapat dideteksi dengan teknik ini. Karena massa yang dalam <span style="letter-spacing: -.75pt;">sulit dibiopsi, FNAB<span style="mso-spacerun: yes;"> </span>dapat sangat membantu.</span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; mso-list: l6 level1 lfo8; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-language: IN;">Kegagalan untuk
mengecil setelah 4-6 minggu dapat menjadi indikasi</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-language: IN;">untuk dilaksanakan biopsi KGB.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; mso-list: l6 level1 lfo8; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-language: IN;">Biopsi dilakukan
terutama bila terdapat tanda dan gejala yang mengarahkan kepada keganasan.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; mso-list: l6 level1 lfo8; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol; mso-fareast-language: IN;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-language: IN;">KGB yang menetap
atau bertambah besar walau dengan pengobatan yang adekuat mengindikasikan
diagnosis yang belum tepat.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; mso-list: l11 level1 lfo7; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">CT
Scan </span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">CT Scan adalah mesin x-ray yang
menggunakan komputer untuk mengambil gambar tubuh untuk mengetahui apa yang
mungkin menyebabkan limfadenitis. CT scan dapat digunakan untuk membantu
pelaksanaan biopsi aspirasi kelenjar limfe intratoraks dan intraabdominal. CT
Scan dapat mendeteksi pembesaran KGB servikalis dengan diameter 5 mm atau
lebih.</span></div>
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<br /></div>
<div class="NoSpacing2" style="line-height: 150%; margin-left: 7.1pt; text-indent: -7.1pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2.11 </span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">PENATALAKSANAAN LIMFADENITIS</span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Penatalaksanaan
yang spesifik pada Limfadenitis Tidak ada. Limfadenitis dapat terjadi setelah
terjadinya infeksi melalui kulit atau infeksi lainnya yang disebabkan oleh
bakteri seperti streptococcus atau staphylococcus. Terkadang juga dapat
disebabkan oleh infeksi seperti tuberculosis atau <i style="mso-bidi-font-style: normal;">cat scratch disease</i> (Bartonella). Oleh karena itu, untuk mengatasi
Limfadenitis adalah dengan mengeliminasi penyebab utama infeksi yang
menyebabkan Limfadenitis.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Limfadenitis
biasanya ditangani dengan mengistirahatkan ekstremitas yang bersangkutan dan
pemberitan antibiotic, penderita limdafenitis mungkin mengalami pernanahan
sehingga memerlukan insisi dan penyaliran. Limfadenitis spesifik, misalnya oleh
jamur atau tuberculosis, biasanya memerlukan biopsi atau biakan untuk
menetapkan diagnosis.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Pengobatan
sesuai gejala harus dilakukan untuk mencegah terjadinya komplikasi. Pengobatan
gejala harus dimulai segera seperti pemberian:</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Analgesik (penghilang rasa sakit) untuk
mengontrol nyeri</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Antipiretik dapat diberikan untuk
menurunkan demam</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Antibiotik untuk mengobati setiap
infeksi sedang sampai berat</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Obat anti inflamasi untuk mengurangi
peradangan</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Kompres dingin untuk mengurangi
peradangan dan nyeri</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Operasi mungkin diperlukan untuk
mengeringkan abses.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Hindari
pemberian aspirin pada anak karena dapat meningkatkan risiko sindrom Reye pada
anak. Kasus limfadenitis mesenterika ringan, tanpa komplikasi dan disebabkan
oleh virus biasanya hilang dalam beberapa hari atau minggu.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-language: IN;">Tata laksana pembesaran kelenjar getah bening leher
didasarkan kepada penyebabnya. Banyak kasus dari pembesaran kelenjar getah
bening leher sembuh dengan sendirinya dan tidak membutuhkan pengobatan apa pun
selain dari observasi. Kegagalan untuk mengecil setelah 4-6 minggu dapat
menjadi indikasi untuk dilaksanakan biopsy kelenjar getah bening. Biopsy
dilakukan bila terdapat tanda dan gejala yang mengarahkan kepada keganasan,
kelenjar getah bening yang menetap atau bertambah besar dengan pengobatan yang
tepat, atau diagnosis belum dapat ditegakkan.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-language: IN;"><span style="mso-spacerun: yes;"> </span>Secara
umum pengobatan Limfadenitis yaitu :</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 49.5pt; mso-add-space: auto; mso-list: l0 level1 lfo10; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">A.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Pengobatan
dilakukan dengan tuberkulositik.bila terjadi abses,perlu dilakukan aspirasi dan
bila tidak berhasil, sebaiknya dilakukan insisi serta pengangkatan dinding
abses dan kelenjar getah bening yang bersangkutan.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 49.5pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo10; tab-stops: 1.0cm 35.45pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">B.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pembesaran kelenjar getah bening
biasanya disebabkan oleh virus dan sembuh sendiri, walaupun pembesaran kelenjar
getah bening dapat berlangsung mingguan. Pengobatan pada infeksi kelenjar getah
bening oleh bakteri (limfadenitis) adalah </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-language: IN;">anti-biotic oral 10 hari dengan pemantauan dalam 2
hari pertama</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> <b style="mso-bidi-font-weight: normal;">flucloxacillin</b>
dosis : 25 mg/kgBB 4 kali sehari. Bila ada reaksi alergi terhadap antibiotic
golongan penicillin dapat diberikan <b style="mso-bidi-font-weight: normal;">cephalexin</b>
dengan dosis : 25 mg/kgBB(dosis maksimal 500 mg) 3 kali sehari atau <b style="mso-bidi-font-weight: normal;">erythromycin</b> 15 mg/kgBB (dosis maksimal
: 500 mg) 3 kali sehari.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 49.5pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo10; tab-stops: 1.0cm 35.45pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><span style="mso-list: Ignore;">C.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Bila
penyebab limfadenopati adalah mycobacterium tuberculosis maka diberikan obat
anti tuberculosis selama 9-12 bulan.</span><span lang="EN-US" style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Perhimpunan Dokter Paru Indonesia (PDPI) mengklasifikasikan
limfadenitis TB ke<span style="letter-spacing: -.75pt;">dalam TB di luar paru
dengan paduan obat 2RHZE/10RH.</span> British Thoracic Society Research
Committee and Compbell (BTSRCC) merekomendasikan pengobatan selama 9 bulan
dalam <span style="letter-spacing: -.75pt;">regimen 2RHE/7RH.</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></div>
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<br /></div>
<div class="NoSpacing2" style="line-height: 150%; margin-left: 7.1pt; text-indent: -7.1pt;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">2.12 PENCEGAHAN LIMFADENITIS</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 7.1pt; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 21.25pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Limfadenitis dapat terjadi setelah terjadinya
infeksi melalui kulit atau infeksi lainnya yang disebabkan oleh bakteri seperti
streptococcus atau staphylococcus. Terkadang juga dapat disebabkan oleh infeksi
seperti tuberculosis atau <i style="mso-bidi-font-style: normal;">cat scratch
disease</i> (Bartonella). Kesehatan umum yang baik dan kebersihan sangat
membantu dalam pencegahan infeksi yang mendasari limfadenitis.</span></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2.13
KOMPLIKASI LIMFADENITIS</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">1. Pembentukan abses</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; text-align: justify; text-indent: 22.35pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Abses adalah suatu penimbunan nanah,
biasanya terjadi akibat suatu infeksi bakteri. Jika bakteri menyusup ke dalam
jaringan yang sehat, maka akan terjadi infeksi. Sebagian sel mati dan hancur,
meninggalkan rongga yang berisi jaringan dan sel-sel yang terinfeksi. Sel-sel
darah putih yang merupakan pertahanan tubuh dalam melawan infeksi, bergerak ke
dalam rongga tersebut dan setelah menelan bakteri, sel darah putih akan mati.
Sel darah putih yang mati inilah yang membentuk nanah,yang mengisi rongga
tersebut. Akibat penimbunan nanah ini, maka jaringan di sekitarnya akan
terdorong. Jaringan pada akhirnya tumbuh di sekeliling abses dan menjadi
dinding pembatas abses; hal ini merupakan mekanisme tubuh untuk mencegah
penyebaran infeksi lebih lanjut. Jika suatu abses pecah di dalam, maka infeksi
bisa menyebar di dalam tubuh maupun dibawah permukaan kulit, tergantung kepada
lokasi abses.<sup>1</sup></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><br />
<b style="mso-bidi-font-weight: normal;">2. Sepsis (septikemia atau keracunan
darah)</b></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; text-align: justify; text-indent: 22.35pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Sepsis adalah kondisi medis yang
berpotensi berbahaya atau mengancam nyawa, yang ditemukan berhubungan dengan
infeksi yang diketahui atau dicurigai.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><br />
<b style="mso-bidi-font-weight: normal;">3. Fistula (terlihat dalam limfadenitis
yang disebabkan oleh TBC)</b></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; text-align: justify; text-indent: 22.35pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Limfadenitis tuberkulosa ini ditandai
oleh pembesaran kelenjar getah bening, padat/keras, multiple dan dapat
berkonglomerasi satu sama lain. Dapat pula sudah terjadi perkijuan seluruh
kelenjar, sehingga kelenjar itu melunak seperti abses tetapi tidak nyeri.
Apabila abses ini pecah ke kulit, lukanya sulit sembuh oleh karena keluar
secara terus menerus sehingga seperti fistula. Fistula merupakan penyakit yang
erat hubungannya dengan immune system / daya tahan tubuh setiap individual.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2.14 PROGNOSIS LIMFADENITIS</span></b></div>
<div class="MsoNormal" style="line-height: 150%; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Prognosis
untuk pemulihan adalah baik jika segera diobati dengan pengobatan yang tepat.
Dalam kebanyakan kasus, infeksi dapat dikendalikan dalam tiga atau empat hari.
Namun, dalam beberapa kasus mungkin diperlukan waktu beberapa minggu atau bulan
untuk pembengkakan menghilang, panjang pemulihan tergantung pada penyebab
infeksi. Pengobatan yang tidak tuntas dapat menyebabkan resistensi dan
septikemia.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2.15 DIAGNOSIS BANDING LIMFADENITIS</span></b></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">berdasarkan
penyebab timbulnya peradangan pada kelenjar getah bening ada pada tabel di
bawah ini ;</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; margin-left: 7.1pt; text-align: center; text-indent: -7.1pt;">
<span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Gambar 3 :
Diagnosa banding berdasarkan penyebab timbul limfadenitis</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 7.1pt; text-align: justify; text-indent: -7.1pt;">
<span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Diagnosis banding
berdasarkan adanya benjolan :</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 7.1pt; text-align: justify; text-indent: -7.1pt;">
<span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">1. Gondongan :
pembesaran kelenjar parotitis akibat infeksi virus, sudut rahang bawah dapat
menghilang karena bengkak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 7.1pt; text-align: justify; text-indent: -7.1pt;">
<span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2. Kista duktus
tiroglosus : berada di garis tengah dan bergerak dengan menelan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 7.1pt; text-align: justify; text-indent: -7.1pt;">
<span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">3. Kista dermoid :
benjolan di garis tengah dapat padat atau berisi cairan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
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<span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">4. Hemangioma :
kelainan pembuluh darah sehingga timbul benjolan berisi jalinan pembuluh darah,
berwarna merah atau kebiruan.</span></div>
<span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-language: AR-SA; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US;"><br clear="all" style="page-break-before: always;" />
</span>
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<b style="mso-bidi-font-weight: normal;"><span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">BAB 3</span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">KESIMPULAN</span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-font-weight: bold;">Seorang wanita 24 tahun
mengeluh </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">adanya pembengkakan kelenjar di leher</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> bagian bawah regio supra clavicula dekstra. </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Bengkaknya
sebesar telur puyuh</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">,</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">
lunak serta nyeri bila di</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">tekan</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">,
badanya sering</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">terasa
hangat dan merasa lemah, selera makan </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">berkurang.
<span style="mso-bidi-font-weight: bold;">Dari data yang diperoleh, diduga wanita
tersebut menderita limfadenitis yaitu suatu peradangan pada kalenjar getah
bening yang disebabakan oleh adanya infeksi mikroorganisme.</span></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Pengobatan
sesuai gejala harus dilakukan untuk mencegah terjadinya komplikasi, Pengobatan
gejala harus dimulai segera seperti pemberian:</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Analgesik (penghilang rasa sakit) untuk
mengontrol nyeri</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Antipiretik dapat diberikan untuk
menurunkan demam</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Antibiotik untuk mengobati setiap
infeksi sedang sampai berat</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Obat anti inflamasi untuk mengurangi
peradangan</span></div>
<div class="MsoNormalCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l10 level1 lfo9; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 14.15pt;">
<span style="font-family: "Cambria","serif"; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria;"><span style="mso-list: Ignore;">-<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Kompres dingin untuk mengurangi
peradangan dan nyeri</span></div>
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<br /></div>
<div class="NoSpacing2" style="line-height: 150%; margin-left: 7.1pt; text-indent: 28.9pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-font-weight: bold;">Untuk mengidentifikasi
mikroorganisme penyebab limfadenitis tersebut maka perlu dilakukan beberapa
pemeriksaan penunjang seperti biopsi dan kultur.</span></div>
<div class="NoSpacing2" style="line-height: 150%; margin-left: 7.1pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-font-weight: bold;">Penetalaksanaan yang sesuai
untuk wanita tersebut adalah :</span></div>
<div class="NoSpacing2" style="line-height: 150%; margin-left: 24.25pt; mso-list: l7 level1 lfo12; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-font-weight: bold;">Jika disebabkan oleh infeksi bakteri maka dengan pemberian atibiotik</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-language: IN;">-biotic oral 10 hari dengan pemantauan dalam 2 hari
pertama</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> <b style="mso-bidi-font-weight: normal;">flucloxacillin</b>
dosis : 25 mg/kgBB 4 kali sehari. Bila ada reaksi alergi terhadap antibiotic
golongan penicillin dapat diberikan <b style="mso-bidi-font-weight: normal;">cephalexin</b>
dengan dosis : 25 mg/kgBB(dosis maksimal 500 mg) 3 kali sehari atau <b style="mso-bidi-font-weight: normal;">erythromycin</b> 15 mg/kgBB (dosis maksimal
: 500 mg) 3 kali sehari.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-font-weight: bold;"></span></div>
<div class="NoSpacing2" style="line-height: 150%; margin-left: 24.25pt; mso-list: l7 level1 lfo12; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-font-weight: bold;">Bila disebabkan oleh virus maka cukup dengan istirahat dan diberikan
vitamin untuk meningkatakan imunitas tubuh.</span></div>
<div class="NoSpacing2" style="line-height: 150%; margin-left: 24.25pt; mso-list: l7 level1 lfo12; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Bila
penyebab limfadenopati adalah mycobacterium tuberculosis maka diberikan obat
anti tuberculosis selama 9-12 bulan</span><span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">. </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">limfadenitis TB ke<span style="letter-spacing: -.75pt;">dalam
TB di luar paru dengan paduan obat 2RHZE/10RH</span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; letter-spacing: -.75pt; line-height: 150%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";">.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-bidi-font-weight: bold;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 7.1pt; text-indent: -7.1pt;">
<br /></div>
<span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%; mso-ansi-language: IN; mso-bidi-language: AR-SA; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US;"><br clear="all" style="page-break-before: always;" />
</span>
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<b style="mso-bidi-font-weight: normal;"><span style="background: white; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">DAFTAR PUSTAKA</span></b></div>
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<br /></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Anonim.
2011. Swollen Lymph Nodes.
(http://www.mayoclinic.com/print/swollen-lymph-nodes/DS00880/METHOD=print&DSECTION=all
</span><cite><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Accessed on Mei </span></cite><cite><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">26</span></cite><cite><sup><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">th</span></sup></cite><cite><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">, 2013</span></cite><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">.)</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l12 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></i><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Baratawidjaja.
G. K, Rengganis Iris. 2012. Imunologi Dasar, Jakarta, Balai Penerbit FKUI</span></i></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; mso-list: l12 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Gleadle,
Jonathan. At a Glance Anamnesis dan Pemeriksaan Fisik (2007). Penerbit
Erlangga, Jakarta, Hal: 86</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l12 level1 lfo11; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">L</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">imfadenitis</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Available</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">at<span style="background: white;">:
http://repository.usu.ac.id/bitstream/123456789/16862/4/Chapter%20II.pdf. </span></span><cite><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Accessed on
Mei </span></cite><cite><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">26</span></cite><cite><sup><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">th</span></sup></cite><cite><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">, 2013</span></cite><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; mso-list: l12 level1 lfo11; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Ioachim HL, Ratech H.(2002).<span style="background: #F2F2F2;"> </span>Ioachim's Lymph Node Pathology.
3rd edition, Lippincott Williams & Wilkins, from,
http://moon.ouhsc.edu/kfung/JTY1/HemeLearn/CapsuleSumary/Lymphadenopathy-M.htm,26
mei 2013</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l12 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">L</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">imfadenitis</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Available</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">at</span><cite><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">:</span></i></cite><span style="background: white; border: none windowtext 1.0pt; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-border-alt: none windowtext 0cm; padding: 0cm;"> <span class="a"><span lang="EN-US">PDPI. Tuberkulosis</span></span></span><span class="a"><span lang="EN-US" style="background: white; border: none windowtext 1.0pt; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-border-alt: none windowtext 0cm; padding: 0cm;"> </span></span><span class="a"><span lang="EN-US" style="background: white; border: none windowtext 1.0pt; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-border-alt: none windowtext 0cm; padding: 0cm;">Pedoman Diagnosis dan Penatalaksanaan di
Indonesia 2006.</span></span><span class="a"><span lang="EN-US" style="background: white; border: none windowtext 1.0pt; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-border-alt: none windowtext 0cm; padding: 0cm;"> </span></span><span class="a"><span lang="EN-US" style="background: white; border: none windowtext 1.0pt; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-border-alt: none windowtext 0cm; padding: 0cm;">Indah Offset
Citra Grafika,</span></span><span class="apple-converted-space"><span lang="EN-US" style="background: white; border: none windowtext 1.0pt; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-border-alt: none windowtext 0cm; padding: 0cm;"> </span></span><span class="a"><span lang="EN-US" style="background: white; border: none windowtext 1.0pt; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-border-alt: none windowtext 0cm; padding: 0cm;">2006.</span></span><cite><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> In site </span></i></cite><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">http://www.scribd.com/doc/81071297/Limfadenitis-Tuberkulosis</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">.</span><cite><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> Accessed on Mei </span></cite><cite><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">26</span></cite><cite><sup><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">th</span></sup></cite><cite><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">, 2013</span></cite><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; mso-list: l12 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">M.
Tierney, Jr., MD , Lawrence, McPhee, MD, Strphen, Papadakis, MD, Maxine. Buku 2
Penyakit Dalam Diagnosis & Terapi Kedokteran. Penerbit Salemba Medika ,
Jakarta.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; mso-list: l12 level1 lfo11; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Partridge E.(2012).Lymphadenitis. from
http://emedicine.medscape.com/article/960858-overview,26 mei 2013</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l12 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">R.Sjamsuhidajat,</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">dkk.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">2010.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Buku Ajar Ilmu
Bedah-Edisi 3.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Jak</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">a</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">rta:</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">EGC.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Hal.465</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; mso-list: l12 level1 lfo11; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">10.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Sambandan et al. <i style="mso-bidi-font-style: normal;">Cervical Lymphadenopathy- A Review. </i>Department of Medicine, India.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 21.3pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l12 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">11.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Tierney,
Lawrence M., et al. Diagnosis dan Terapi Kedokteran Penyakit Dalam Buku 2.
Jakarta: Salemba Medika. 2003</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<br /></div>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com8tag:blogger.com,1999:blog-2501725445038181687.post-20662550229446702422013-05-22T15:37:00.004+07:002013-05-22T15:38:36.130+07:00Bentuk-bentuk Sediaan Obat<div style="text-align: justify;">
<span style="font-size: small;">Berikut Bentuk-bentuk sedian obat berdasarkan dari Farmakope Indonesia Edisi IV, bentuk sedian umum tersebut sebagai berikut : </span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmXq6nh2DX9GhiGn6umJNK2gP0DX0cpIz59tjnnna3PCGPGFGiwydCth7SKCL4R1s6W5na0z0g5EAhmh87XuOs3MZepz3Oipkas1fO00lXOCWozqrBCgY1VzjKLfZhwaEequp1YRNPq98v/s1600/sediaan.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="258" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmXq6nh2DX9GhiGn6umJNK2gP0DX0cpIz59tjnnna3PCGPGFGiwydCth7SKCL4R1s6W5na0z0g5EAhmh87XuOs3MZepz3Oipkas1fO00lXOCWozqrBCgY1VzjKLfZhwaEequp1YRNPq98v/s320/sediaan.jpg" width="320" /></a></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-size: small;">1. Aerosol <br />Sediaan yang dikemas di bawah tekanan, mengandung zat aktif terapeutik yang dilepas pada saat system katup yang sesuai di tekan. Sedian ini digunakan untuk pemakaian topical pada kulit dan juga untuk pemakaian lokal pada hidung.<br /><br />2. Kapsul<br />Sediaan padat yang tediri dari obat dalam cangkang keras atau lunak yang dapat larut.<br /><br />3. Tablet<br />Sedian padat mengandung bahan obat dengan atau tanpa bahan pengisi.<br /><br />4. Krim<br />Sediaan setengah padat mengandung satu atau lebih bahan obat terlarut atau terdispersi dalam bahan dasar yang sesuai.<br /><br />5. Emulsi<br />Sistem dua fase, yang salah satu cairannya terdispersi dalam cairan yang lain, dalam bentuk tetesan kecil.</span><br />
<a name='more'></a><span style="font-size: small;"><br />6. Ekstrak<br />Sediaan pekat yang di peroleh dengan mengekstraksi zat aktif dari simpliisia nabati atau simplisia hewani menggunakan pelarut yang sesuai kemudian semua atau hamper semua pelarut di uapkan dan massa atau serbuk yang tersisa diperlukan sedemikian rupa sehingga memenuhi syarat yang ditetapkan.<br /><br />7. Gel (geli)<br />Sistem semi padat terdiri dari suspense yang di buat partikel anorganik yang kecil ayau molekul organic yang besar, terpenetrsai oleh suatu cairan.<br /><br />8. Imunoserum<br />Adalah sediaan yang mengandung immunoglobulin khas yang di perlukan dari serum hewan dengan pemurnian.<br /><br />9. Implan atau Pelet<br />Sedian dengan massa padat berukuran kecil, berisi obat dengan kemurnian tinggi (dengan atau tanpa eksipien), dibuat dengan cara pengempaan atau pencetakan.<br /><br />10. Infusa<br />Sediaan cair yang dibuat dengan mengekstraksi simplisia nabati dengan air pada suhu 90’ selama 15 menit.<br /><br />11. Inhalasi <br />Sediaan obat atau larutan atau suspensi terdiri dari satu atau lebih bahan obat yang diberikan melalui saluran nafas hidung atau mulut untuk memperoleh efek local atau sistemik.<br /><br /> 12. Injeksi <br />Sediaan steril untuk kegunaan parenteral, yaitu dibawah atau menembus kulit atau selaput lender.<br /><br />13. Irigasi <br />Larutan steril yang digunakan untuk mencuci atau membersihkan luka terbuka atau ronggga rongga tubuh, penggunaan adalah secara topical.<br /><br />14. Lozenges atau tablet hisap<br />Sediian padat yang mengandung satu atau lebih bahan obat, umumnya dengan bahan dasar beraroma manis, yang dapat membuat tablet melarut atau hancur perlahan dalam mulut.<br /><br />15. Sediaan Obat mata<br />• Salep mata <br />Salep steril yang digunakan pada mata.<br />• Larutan Obat mata<br />Larutan steril bebas partikel asing merupakan sediaan yang dibuat dan dikemas sedimikian rupa hingga sesuai di gunakan untuk mata.<br /><br />16. Pasta<br />Sediaan semi padata yang mengandung satu atau lebih bahan yang di tujukan untuk pemakaiaan topical.<br /><br />17. Plester<br />Bahan yang digunakan untuk pemakaian luar terbuat dari bahan yang dapat melekat pada kulit dan menempel pada pembalut.<br /><br />18. Serbuk<br />Campuran kering bahan obat atau zat kimia yang dihaluskan, berupa serbuk yang dibagi bagi (pulveres) atau serbuk yang tak terbagi. (pulvis).<br /><br />19. Solutio atau larutan<br />Sediaan cair yang mengandung satu atau lebih zat kimia yang terlarut. Taerbagi atas :<br />@ Larutan Oral<br />Sediaan cair yang dimasukan untuk pemberian oral.<br /><br />§ Larutan tipikal<br />Sediaan cair yang dimasukan untuk penggunaan topical paad atau mukosa.<br /><br />§ Larutan Otik<br />Sediaan cair yang dimasukan untuk penggunaan dalam telinga.<br /><br />§ Larutan Optalmik<br />Sediaan cair yang digunakan pada mata.<br /><br />§ Spirit<br />Larutan mengandung etanol atau hidroalkohol dari zat yang mudah menguap.<br /><br />§ Tingtur<br />Larutan mengandung etanol atau hidro alcohol di buat dari bahan tumbuhan atau senyawa kimia.<br /><br />20. Suppositoria<br />Sediaan padat dalam bergabai bobot dan bentuk yang diberikan melalui rectal, vagina atau eretra, umunya meleleh, melunak atau melarut pada suhu tubuh.</span></div>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com4tag:blogger.com,1999:blog-2501725445038181687.post-77311395911941300482013-05-18T07:43:00.000+07:002013-05-18T07:44:43.600+07:00FISIOLOGI DARAH<!--[if !mso]>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
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<br />
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 0cm; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">3.1 </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Definisi
darah</span></b></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-left: 7.1pt; text-align: justify; text-indent: 0cm;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>Darah
merupakan </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">suatu suspensi partikel dalam
suatu larutan koloid cair yang mengandung elektrolit, sebagai transpor masal
berbagai bahan antara sel dan lingkungan eksternal atau antara sel-sel itu
sendiri, transpor semacam ini </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">esensial </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">untuk mempertahankan homeostasis</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">.
Memiliki karakteristik</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">yakni:
temperature rata-rata 38° C, viskositas lima kali lebih besar dari viskositas
air. PH alkali, 7.35 - 7.45 volume : 5,5 L (pria), 5 L (wanita)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">, memiliki berat 8% dari berat badan.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">
</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">D</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">alam keadaan
fisiologik, darah selalu berada dalam pembuluh darah sehingga dapat menjalankan
fungsinya</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">.</span></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-left: 7.1pt; text-align: justify; text-indent: 0cm;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 7.1pt; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">3.2 F</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">ungsi
darah</span></b></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 7.1pt; text-align: justify; text-indent: 0cm;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 7.1pt; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">a. </span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"></span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;"><span style="font: 7.0pt "Times New Roman";"></span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Transportasi
dari gas yang terlarut, nutrisi, hormone dan zat sisa metabolic</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">, s</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">ebagai alat pengangkut
yaitu:</span>
</div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; mso-list: l11 level1 lfo12; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 10.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Mengambil oksigen/ zat
pembakaran dari paru-paru untuk diedarkan keseluruh jaringan tubuh.</span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; mso-list: l11 level1 lfo12; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 10.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Mengangkut karbon
dioksida dari jaringan untuk dikeluarkan melalui paru-paru.</span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; mso-list: l11 level1 lfo12; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 10.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Mengambil zat-zat
makanan dari usus halus untuk diedarkan dan dibagikan ke seluruh jaringan/ alat
tubuh.</span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; mso-list: l11 level1 lfo12; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 10.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Mengangkat /
mengeluarkan zat-zat yang tidak berguna bagi tubuh untuk dikeluarkan melalui
ginjal dan kulit.</span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; mso-list: l11 level1 lfo12; tab-stops: list 42.55pt; text-align: justify; text-indent: -14.7pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 10.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Mengedarkan hormon yang dikeluarkan oleh kelenjar endokrin
yang dilakukan oleh plasma darah.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
<span class="apple-style-span"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Regulasi dari pH dan
komposisi dari cairan intersisial.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"> </span><span class="apple-style-span"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">S</span></span><span class="apple-style-span"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">ebagai pengatur regulasi yaitu</span></span><span class="apple-style-span"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"> :</span></span><span class="apple-style-span"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"></span></span><span class="apple-style-span"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span></span></span><span class="apple-style-span"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Mempertahankan PH dan konsentrasi
elektrolit pada cairan interstitial melalui pertukaran ion-ion dan molekul pada
cairan interstitial</span></span><span class="apple-style-span"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">.</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;"> </span></span><br />
<br />
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Restriksi</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">dari kehilangan cairan
pada daerah yang luka</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">. </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"> </span><br />
<br />
<br />
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">d. </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Pertahanan
melawan toxin dan patogen.</span>
<br />
<div class="MsoNormal" style="line-height: 115%; tab-stops: 18.0pt; text-align: justify;">
<span class="apple-style-span"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"></span>Darah
</span></span><span class="apple-style-span"><span lang="EN-US" style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Sebagai
pertahanan tubuh terhadap serangan penyakit dan racun dalam tubuh dengan perantaraan
leukosit dan antibod</span></span><span class="apple-style-span"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">i</span></span><span class="apple-style-span"><span lang="EN-US" style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"> untuk mempertahankan tubuh terhadap invasi mikroorganisme dan
benda asing (leukosit) dan proses homeostatis (trombosit)</span></span><span class="apple-style-span"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">.</span></span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"></span></div>
<br />
<span lang="EN-US" style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">e.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Termoregulasi
(pengatur suhu tubuh)</span>
<br />
<div class="MsoNormal" style="line-height: 115%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; tab-stops: 36.0pt; text-align: justify;">
<span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"><span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"></span></span><span lang="EN-US" style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Menyebarkan panas keseluruh tubuh</span><span class="MsoPageNumber"><span style="color: black; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">, </span></span><span class="apple-style-span"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">d</span></span><span class="apple-style-span"><span lang="EN-US" style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">arah mengatur suhu
tubuh melalui transport panas menuju kulit dan paru-paru</span></span><span class="apple-style-span"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">.</span></span></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhb2ju3LNMKKfPGeFCqkcfKjZOkWn62my_Vu7VxQmI7g1DxQxgzt94ricY-LbJGdMbY0Oiab4vqRvXd2Ss2ARGOUlLsDEeGMDUekJzy33X3NHhHjO7jTvf-5GsigIQx3LfK00sx6j0-ow5c/s1600/dsd.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhb2ju3LNMKKfPGeFCqkcfKjZOkWn62my_Vu7VxQmI7g1DxQxgzt94ricY-LbJGdMbY0Oiab4vqRvXd2Ss2ARGOUlLsDEeGMDUekJzy33X3NHhHjO7jTvf-5GsigIQx3LfK00sx6j0-ow5c/s400/dsd.jpg" width="400" /></a></div>
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<span class="apple-style-span"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"> </span></span><span class="apple-style-span"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"></span></span><span class="apple-style-span"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"> </span></span>
</div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">3.3 </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Komposisi
darah</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"></span></b></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-left: 1.0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">3.3.1 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Darah
terdiri atas 2 </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">k</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">omponen
utama :</span></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-left: 54.0pt; mso-list: l13 level1 lfo2; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;"></span></span></div>
<a name='more'></a>a.<span style="font: 7.0pt "Times New Roman";"> </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Plasma
darah : bagian cair darah yang sebagian besar terdiri atas air, elektroit, dan
protein darah.</span><br />
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 90.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l1 level1 lfo13; tab-stops: 18.0pt; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">Ø<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Plasma
protein terdiri dari albumin (</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">58</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">%),
globulin α, β, γ (3</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">8</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">%),
fibrinogen (</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">4</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">%)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">, other solutes 2%.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
<div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 1.0cm; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; tab-stops: 18.0pt; text-align: center;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-left: 54.0pt; mso-list: l13 level1 lfo2; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">Formed elements</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">, yang terdiri
atas :</span></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-left: 90.0pt; mso-list: l2 level1 lfo3; text-align: justify;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">Ø<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Eritrosit
: sel darah merah (SDM)-<i style="mso-bidi-font-style: normal;">red blood cell (RBC)</i></span></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-left: 90.0pt; mso-list: l2 level1 lfo3; text-align: justify;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">Ø<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Leukosit
: sel darah putih (SDP)-</span><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%; mso-ansi-language: IN;">white</span></i><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">
blood cell (WBC)</span></i><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"></span></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-left: 90.0pt; mso-list: l2 level1 lfo3; text-align: justify;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">Ø<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Trombosit
: butir pembeku-<i style="mso-bidi-font-style: normal;">platelet</i></span></div>
<div align="center" class="MsoNoSpacing" style="line-height: 115%; text-align: center;">
<span style="font-family: Courier; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-fareast-language: IN; mso-no-proof: yes;"></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoListParagraph" style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 1.0cm; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; tab-stops: 18.0pt; text-align: center;">
<span style="font-family: "Times New Roman","serif"; mso-ansi-language: IN;">Gambar 1<span style="mso-spacerun: yes;"> </span>:
Komponen plasma darah, Komponen Formed elements</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 0cm; text-align: justify; text-indent: 0cm;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"><span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;">Tabel
1 : Konstituen darah dan fungsinya</b></span></div>
<div align="center">
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; mso-border-alt: solid black .5pt; mso-border-insideh: .5pt solid black; mso-border-insidev: .5pt solid black; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="height: 41.7pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid black 1.0pt; height: 41.7pt; mso-border-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" width="267"><div class="MsoNormalCxSpFirst" style="line-height: 115%; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><span style="mso-spacerun: yes;"> </span>KONSTITUEN</span></b></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; height: 41.7pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><span style="mso-spacerun: yes;"> </span>FUNGSI</span></b></div>
</td>
</tr>
<tr style="height: 19.9pt; mso-yfti-irow: 1;">
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 426.2pt;" valign="top" width="568"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Plasma </span></b></div>
</td>
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<tr style="height: 20.8pt; mso-yfti-irow: 2;">
<td style="border-top: none; border: solid black 1.0pt; height: 20.8pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">1. </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Air</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 20.8pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Medium
transportasi; mangangkut panas</span></div>
</td>
</tr>
<tr style="height: 60.7pt; mso-yfti-irow: 3;">
<td style="border-top: none; border: solid black 1.0pt; height: 60.7pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">2. </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Elektrolit</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 60.7pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Eksitabilitas
membran; distribusi osmotik cairan intrasel dan ekstrasel; manyangga
perubahan pH</span></div>
</td>
</tr>
<tr style="height: 40.7pt; mso-yfti-irow: 4;">
<td style="border-top: none; border: solid black 1.0pt; height: 40.7pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">3. </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Nutrien,
zat sisa, gas, hormon</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 40.7pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Diangkut
dalam darah; gas CO2<span style="mso-spacerun: yes;"> </span>darah berperan
dalam keseimbangan asam-basa </span></div>
</td>
</tr>
<tr style="height: 80.55pt; mso-yfti-irow: 5;">
<td style="border-top: none; border: solid black 1.0pt; height: 80.55pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">4. </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Protein
plasma</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 80.55pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Secara
umum, menimbulkan efek osmotic yang penting dalam distribusi cairan ekstrasel
antara kompartemen vaskuler dan intestisium; menyangga perubahan pH</span></div>
</td>
</tr>
<tr style="height: 40.7pt; mso-yfti-irow: 6;">
<td style="border-top: none; border: solid black 1.0pt; height: 40.7pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify; text-indent: -20.15pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">4.1 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Albumin</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 40.7pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Mengangkut
banyak zat; memberi kontribusi terbesar bagi tekanan osmotik koloid</span></div>
</td>
</tr>
<tr style="height: 19.9pt; mso-yfti-irow: 7;">
<td style="border-top: none; border: solid black 1.0pt; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 15.85pt; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">4.2 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Globulin </span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<br /></div>
</td>
</tr>
<tr style="height: 40.7pt; mso-yfti-irow: 8;">
<td style="border-top: none; border: solid black 1.0pt; height: 40.7pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify; text-indent: 1.1pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">4.2.1 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Alfa
dan Beta</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 40.7pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Mengangkut
banyak zat; factor pembekuan; molekul precursor inaktif</span></div>
</td>
</tr>
<tr style="height: 19.9pt; mso-yfti-irow: 9;">
<td style="border-top: none; border: solid black 1.0pt; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify; text-indent: 1.1pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">4.2.2 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Gama
</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Antibodi
</span></div>
</td>
</tr>
<tr style="height: 40.7pt; mso-yfti-irow: 10;">
<td style="border-top: none; border: solid black 1.0pt; height: 40.7pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">4.3 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Fibrinogen</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 40.7pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Prekursor
inaktif untuk jaringan fibrin pada bekuan darah</span></div>
</td>
</tr>
<tr style="height: 19.9pt; mso-yfti-irow: 11;">
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 426.2pt;" valign="top" width="568"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">Elemen</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">
Sel</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">ular</span></b></div>
</td>
</tr>
<tr style="height: 19.9pt; mso-yfti-irow: 12;">
<td style="border-top: none; border: solid black 1.0pt; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">1. </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Eritrosit</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Mengangkut
O2 dan CO2 (terutama O2)</span></div>
</td>
</tr>
<tr style="height: 20.8pt; mso-yfti-irow: 13;">
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: 20.8pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 426.2pt;" valign="top" width="568"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">2. </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Leukosit</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"></span></div>
</td>
</tr>
<tr style="height: 19.9pt; mso-yfti-irow: 14;">
<td style="border-top: none; border: solid black 1.0pt; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">2.1 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Neutrofil </span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Fagosit
yang memakan bakteri dan debris</span></div>
</td>
</tr>
<tr style="height: 40.7pt; mso-yfti-irow: 15;">
<td style="border-top: none; border: solid black 1.0pt; height: 40.7pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">2.2 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Eosinofil </span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 40.7pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Menyerang
cacing parasit; penting dalam reaksi alergi</span></div>
</td>
</tr>
<tr style="height: 80.55pt; mso-yfti-irow: 16;">
<td style="border-top: none; border: solid black 1.0pt; height: 80.55pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">2.3 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Basofil </span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 80.55pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Mengeluarkan
histamin, yang penting dalam reaksi alergi, dan heparin yang membantu
membersihkan lemak dari darah dan mungkin berfungsi sebagai antikoagulan</span></div>
</td>
</tr>
<tr style="height: 20.8pt; mso-yfti-irow: 17;">
<td style="border-top: none; border: solid black 1.0pt; height: 20.8pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">2.4 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Monosit </span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 20.8pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Dalam
transit untuk menjadi makrofag jaringan</span></div>
</td>
</tr>
<tr style="height: 19.9pt; mso-yfti-irow: 18;">
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 426.2pt;" valign="top" width="568"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">2.5 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Limfosit </span></div>
</td>
</tr>
<tr style="height: 19.9pt; mso-yfti-irow: 19;">
<td style="border-top: none; border: solid black 1.0pt; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify; text-indent: 1.1pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">2.5.1 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Limfosit
B</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Pembentukan
antibodi</span></div>
</td>
</tr>
<tr style="height: 19.9pt; mso-yfti-irow: 20;">
<td style="border-top: none; border: solid black 1.0pt; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; text-align: justify; text-indent: 1.1pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">2.5.2 </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Limfosit
T</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 19.9pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Respons
imun seluler</span></div>
</td>
</tr>
<tr style="height: 20.8pt; mso-yfti-irow: 21; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid black 1.0pt; height: 20.8pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 200.25pt;" valign="top" width="267"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 0cm;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">3. </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Trombosit
</span></b></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 20.8pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 225.9pt;" valign="top" width="301"><div class="MsoNormalCxSpMiddle" style="line-height: 115%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 8.7pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Hemostasis
</span></div>
</td>
</tr>
</tbody></table>
</div>
<div class="MsoNoSpacing" style="line-height: 115%; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 115%; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 115%; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 115%; text-align: justify; text-indent: -28.9pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">3.4
</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Hemopoesis
(hematopoesis)</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"></span></b></div>
<div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"> Tabel 2 : </span><span lang="EN-US" style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Tempat hemopoesis</span><span style="color: black; font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";"></span></div>
<div align="center">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-table-layout-alt: fixed; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="height: 21.8pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid black 1.0pt; height: 21.8pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 79.0pt;" valign="top" width="105"><br /></td>
<td style="border-left: none; border: solid windowtext 1.0pt; height: 21.8pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 156.85pt;" valign="top" width="209"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";">Umur</span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; height: 21.8pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.05pt;" valign="top" width="169"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";">Tempat
hemopoesis</span></div>
</td>
</tr>
<tr style="height: 21.8pt; mso-yfti-irow: 1;">
<td rowspan="3" style="border-top: none; border: solid black 1.0pt; height: 21.8pt; mso-border-top-alt: solid black 1.0pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 79.0pt;" valign="top" width="105"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Janin</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 21.8pt; mso-border-top-alt: solid windowtext 1.0pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 156.85pt;" valign="top" width="209"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">0-</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";">3</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"> bulan</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 21.8pt; mso-border-top-alt: solid windowtext 1.0pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.05pt;" valign="top" width="169"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Yolk sac</span></div>
</td>
</tr>
<tr style="height: 21.95pt; mso-yfti-irow: 2;">
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 21.95pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 156.85pt;" valign="top" width="209"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";">3</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">-</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";">6</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"> bulan</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 21.95pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.05pt;" valign="top" width="169"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Hati dan limpa</span></div>
</td>
</tr>
<tr style="height: 17.7pt; mso-yfti-irow: 3;">
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 17.7pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 156.85pt;" valign="top" width="209"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-fareast-font-family: "Times New Roman";">4</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">-9 bulan</span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 17.7pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.05pt;" valign="top" width="169"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Sumsum tulang</span></div>
</td>
</tr>
<tr style="height: 21.35pt; mso-yfti-irow: 4;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 21.35pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 79.0pt;" valign="top" width="105"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Bayi</span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 21.35pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 283.95pt;" valign="top" width="379"><div align="center" class="MsoNormal" style="line-height: 115%; text-align: center;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Sumsum tulang (semua bagian
tulang)</span></div>
</td>
</tr>
<tr style="height: 55.45pt; mso-yfti-irow: 5; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 55.45pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 79.0pt;" valign="top" width="105"><div class="MsoNormal" style="line-height: 115%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Dewasa</span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 55.45pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 283.95pt;" valign="top" width="379"><div align="center" class="MsoNormal" style="line-height: 115%; text-align: center;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Os.Vertebrae,Costae,Sternum,Cranium,Sacrum,Pelvis</span></div>
<div align="center" class="MsoNormal" style="line-height: 115%; text-align: center;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Ujung proksimal os.femur</span></div>
</td>
</tr>
</tbody></table>
</div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 0cm; text-align: justify; text-indent: 0cm;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 18.0pt; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Pada orang dewasa dalam keadaan
fisiologik sema hemopoesis terjadi pada sumsum tulang. Dalam keadaan patologik,
seperti pada mielofibrosis, hemopoesis terjadi di luar sumsum tulang, terutama
di lien, disebut sebagai hemopoesis ekstramoduler. Untuk kelangsungan
hemopoesis diperlukan</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">:</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; mso-list: l10 level1 lfo4; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Sel
induk hematopoietic (hematopoietic stem cell)</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Sel induk hemopoetik ialah sel-sel
yang akan berkembang menjadi sel-sel darah, termasuk sel darah merah
(eritrosit), sel darah putih (leukosit), butir pembeku (trombosit), dan juga
beberapa sel dalam sumsum tulang seperti fibroblast. Sel induk yang paling
primitive disebut sebagai <i style="mso-bidi-font-style: normal;">pluripoten
(totipoten) stem cell.</i></span><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"></span></i></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; mso-list: l10 level1 lfo4; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Lingkungan
mikro (microenviromentment) sumsum tulang</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Lingkungan mikro sumsum tulang
adalah substansi yang memungkinkan sel induk tumbuh secara kondusif. Lingkungan
mikro sangat penting dalam hemopoesis karena berfungsi untuk berikut :</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 90.0pt; mso-list: l7 level1 lfo5; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Menyediakan
nutrisi dan bahan hemopoesis yang dibawa oleh peredaran darah mikro dalam sumsum
tulang.</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 90.0pt; mso-list: l7 level1 lfo5; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Komunikasi
antar sel (cell to cell communication), terutama ditentukan oleh adanya <i style="mso-bidi-font-style: normal;">adhesion molecule.</i></span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 90.0pt; mso-list: l7 level1 lfo5; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Menghasilkan
zat yang mengatur hemopoesis : <i style="mso-bidi-font-style: normal;">hematopoetic
growth factor, cytokine</i>, dan lain-lain.</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; mso-list: l10 level1 lfo4; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Bahan-bahan
pembentuk darah</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">, </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Bahan-bahan
yang diperlukan untuk pembentukan darah adalah</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"> :</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"></span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 90.0pt; mso-list: l3 level1 lfo6; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Asam
folat dan vitamin B12 : merupakan bahan pokok pembentukan inti sel.</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 90.0pt; mso-list: l3 level1 lfo6; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Besi
: sangat diperlukan dalam pembentukan hemoglobin</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 90.0pt; mso-list: l3 level1 lfo6; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">c.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Cobalt,
magnesium, cu, zn</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 90.0pt; mso-list: l3 level1 lfo6; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">d.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Vitamin
lain : vitamin C, B kompleks, dan lain-lain.</span></div>
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<br /></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; mso-list: l10 level1 lfo4; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Mekanisme
regulasi</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Mekanisme regulasi sangat penting
untuk mengatur arah dan kuantitas pertumbuhan sel dan pelepasan sel darah yang
matang dari sumsum tulang ke darah tepi sehingga sumsum tulang dapat merespon
kebutuhan tubuh dengan tepat. Produksi komponen darah yang berlebihan ataupun
kekurangan (defisiensi) sama-sama menimbulkan penyakit. </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"></span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"> </span></b></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; text-align: justify; text-indent: 18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">3.5
</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">S</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">i</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">stem Eritroid</span></b>
</div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 18.0pt; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Eritrosit hidup dan beredar dalam
darah tepi (life) span rata-rata selama 120 hari. Setelah 120 hari eritrosit
mengalami proses penuaan (<i style="mso-bidi-font-style: normal;">senescence</i>)
kemudian dikeluarkan dari sirkulasi oleh system RES. Apabila destruksi
eritrosit sebelum waktunya(<120 hari) maka proses ini disebut sebagai
hemolisis.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiaNTJ_mum6QKDZAbWlbx6a0c5PQvJ3PMUCiDZZ0zoU95Jv9_C412aCpmxq6Unwx61yyYKV4QOOnXSmnJFlfySji7BrP_1tIi_DSzT5oEcAeqfc8MwANZnPoUed6nxw4IftgRBcX6-Nd5dT/s1600/sdsd.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiaNTJ_mum6QKDZAbWlbx6a0c5PQvJ3PMUCiDZZ0zoU95Jv9_C412aCpmxq6Unwx61yyYKV4QOOnXSmnJFlfySji7BrP_1tIi_DSzT5oEcAeqfc8MwANZnPoUed6nxw4IftgRBcX6-Nd5dT/s400/sdsd.jpg" width="400" /></a></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-fareast-language: IN; mso-no-proof: yes;"></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"></span></div>
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<span style="font-family: "Times New Roman","serif"; mso-ansi-language: IN;">Gambar 2: </span><span lang="EN-US" style="font-family: "Times New Roman","serif";">Hemopoiesis (pembentukan darah)</span><span style="font-family: "Times New Roman","serif"; mso-ansi-language: IN;"></span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; mso-list: l12 level1 lfo7; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Struktur
Eritrosit</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Eritrosit matang merupakan suatu
cakram bikonkaf dengan diameter sekitar 7 mikron. Eritrosit merupakan sel
dengan struktur yang tidak lengkap. Sel ini hanya terdiri atas membrane dan
sitoplasma tanpa inti sel.</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 54.0pt; text-align: justify; text-indent: 0cm;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Komponen eritrosit terdiri atas :</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 90.0pt; mso-list: l4 level1 lfo8; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Membran
eritrosit</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 90.0pt; mso-list: l4 level1 lfo8; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Sistem
enzim yang terpenting dalam Embden Meyerhoff pathway : pyruvate kinase, dalam
pentose pathway : enzim G6PD (glucose 6-phospate dehidrogenase)</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-left: 90.0pt; text-align: justify; text-indent: 0cm;">
<br /></div>
<div class="MsoNoSpacing" style="margin-left: 90.0pt; mso-list: l4 level1 lfo8; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Hemoglobin : berfungsi sebagai alat
angkut oksigen. Komponennya terdirir atas :</span></div>
<div class="MsoNoSpacing" style="margin-left: 126.0pt; mso-list: l0 level1 lfo9; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">a)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Heme : yang merupakan gabungan
protoporfirin dengan besi</span></div>
<div class="MsoNoSpacing" style="margin-left: 126.0pt; mso-list: l0 level1 lfo9; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Globin : bagian protein yang terdiri
atas 2 rantai alfa dan 2 rantai beta.</span></div>
<div class="MsoNoSpacing" style="margin-left: 2.0cm; text-align: justify; text-indent: 14.2pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Perubahan
struktur eritrosit akan menimbulkan kelainan. Kelainan yang timbul karena
kelainan membran disebut sebagai membranopati, kelainan akibat gangguan sistem
enzim eritrosit disebut ensimopati, sedangkan kelainan akibat gangguan struktur
hemoglobin disebut sebagai hemoglobinopati.</span></div>
<div class="MsoNoSpacing" style="margin-left: 54.0pt; mso-list: l12 level1 lfo7; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">b.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Destruksi Eritrosit</span></div>
<div class="MsoNoSpacing" style="margin-left: 54.0pt; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Destruksi
yang terjadi karena proses penuaan disebut proses <i style="mso-bidi-font-style: normal;">senescene</i>, sedangkan destruksi patologik disebut hemolisis. Hemo</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: IN;">l</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">isis
dapat terjadi intravaskuler, dapat juga ekstravaskuler, terutama pada sistem RE</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: IN;">S</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">,
yaitu lien dan hati.</span></div>
<div class="MsoNoSpacing" style="margin-left: 54.0pt; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Hemolisis
yang terjadi pada eritrosit akan mengakibatkan terurainya komponen-komponen
hemoglobin menjadi berikut:</span></div>
<div class="MsoNoSpacing" style="margin-left: 90.0pt; mso-list: l5 level1 lfo10; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Komponen protein yaitu globin yang akan
dikembalikan ke pool protein dan dapat dipakai kembali.</span></div>
<div class="MsoNoSpacing" style="margin-left: 90.0pt; mso-list: l5 level1 lfo10; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2)<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Komponen heme akan pecah menjadi dua,
yaitu :</span></div>
<div class="MsoNoSpacing" style="margin-left: 126.0pt; mso-list: l6 level1 lfo11; text-align: justify;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 12.0pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">Ø<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Besi : yang akan dikembalikan ke pool
besi dan dipakai ulang.</span></div>
<div class="MsoNoSpacing" style="margin-left: 126.0pt; mso-list: l6 level1 lfo11; text-align: justify;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 12.0pt; mso-bidi-font-family: Wingdings; mso-fareast-font-family: Wingdings;"><span style="mso-list: Ignore;">Ø<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Bilirubin : yang akan disekresikan
melalui hati dan empedu.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglFUEtwg3m95GBQBayzAciC0QA-TUDZGlV38Dpc9gJiS4bvUjnFIfN-JlNQmHYSLl7dGh-WrusJ5gjUuXTOnSDnNzh66RYogfjMK4TcuK6RYkTO-FGJi6zmqvaWKqNFHH4BmFhYXluIWNi/s1600/dsds.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="258" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglFUEtwg3m95GBQBayzAciC0QA-TUDZGlV38Dpc9gJiS4bvUjnFIfN-JlNQmHYSLl7dGh-WrusJ5gjUuXTOnSDnNzh66RYogfjMK4TcuK6RYkTO-FGJi6zmqvaWKqNFHH4BmFhYXluIWNi/s400/dsds.jpg" width="400" /></a></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN; mso-fareast-language: IN; mso-no-proof: yes;"></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;"></span></div>
<div align="center" class="MsoNoSpacing" style="line-height: 115%; text-align: center;">
<span style="font-family: "Times New Roman","serif"; mso-ansi-language: IN;">Gambar 3:
Skema destruksi eritrosit</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">Referensi:</span></div>
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</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">Sherwood, lauralee.
<i style="mso-bidi-font-style: normal;">Fisiologi manusia dari sel ke sistem</i>.
Edisi 6. 2012. jakarta: EGC.</span></div>
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</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">Bakta, I made. <i style="mso-bidi-font-style: normal;">Hematologi Klinik ringkas</i>. 2012.
Jakarta: EGC.</span></div>
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</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: IN;">www.scribd.com/-fisiologi-hematologi/direct/48376519.</span></div>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com1tag:blogger.com,1999:blog-2501725445038181687.post-56649702427770835172013-05-17T07:08:00.003+07:002013-05-17T07:17:23.553+07:00Diabetes mellitus<div style="text-align: justify;">
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<![endif]--><span style="font-size: small;">Diabetes mellitus adalah suatu penyakit dimana kadar glukosa (gula sederhana) di dalam darah tinggi karena tubuh tidak dapat melepaskan atau menggunakan insulin secara cukup. Menurut kriteria diagnostik PERKENI (Perkumpulan Endokrinologi Indonesia) 2006, seseorang dikatakan menderita diabetes jika memiliki kadar gula darah puasa >126 mg/dL dan pada tes sewaktu >200 mg/dL. Kadar gula darah sepanjang hari bervariasi dimana akan meningkat setelah makan dan kembali normal dalam waktu 2 jam. Kadar gula darah yang normal pada pagi hari setelah malam sebelumnya berpuasa adalah 70-110 mg/dL darah. Kadar gula darah biasanya kurang dari 120-140 mg/dL pada 2 jam setelah makan atau minum cairan yang mengandung gula maupun karbohidrat lainnya.<br /><br />Kadar gula darah yang normal cenderung meningkat secara ringan tetapi progresif (bertahap) setelah usia 50 tahun, terutama pada orang-orang yang tidak aktif bergerak. Peningkatan kadar gula darah setelah makan atau minum merangsang pankreas untuk menghasilkan insulin sehingga mencegah kenaikan kadar gula darah yang lebih lanjut dan menyebabkan kadar gula darah menurun secara perlahan. Ada cara lain untuk menurunkan kadar gula darah yaitu dengan melakukan aktivitas fisik seperti berolahraga karena otot menggunakan glukosa dalam darah untuk dijadikan energi.<br /><br />Kondisi ini dapat pula terjadi apabila sel otot, lemak dan liver kurang merespon hormon insulin. Pada orang yang mengidap diabetes, kadar glukosa menumpuk dalam darah dan urin, menyebabkan kencing yang berlebihan, rasa haus dan lapar, dan masalah dengan lemak dan metabolisme protein. Diabetes melitus berbeda dari diabetes insipidus, yang disebabkan karena kekurangan hormon vasopressin yang mengatur jumlah urine yang dikeluarkan.<br /><br />Diabetes umumnya diderita oleh orang dewasa berusia diatas 45 tahun; terutama pada orang yang memiliki kelebihan berat badan dan tidak memiliki cukup aktivitas, pada individu yang memiliki keluarga yang mengidap diabetes; dan diidap pula oleh orang Afrika, Hispanic dan keturunan orang Amerika. Tingkat tertinggi penderita diabetes terjadi di Amerika. Diabetes lebih banyak ditemukan pada wanita daripada pada pria.</span></div>
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<span style="font-size: small;">II. PANCREAS<br /><br />Pancreas merupakan organ yang berperan penting pada kelainan Diabetes Melitus. Pada Diabetes Melitus, insulin yang dihasilkan oleh pancreas tidak cukup untuk mengolah glukosa yang ada dalam darah. Hal ini dapat disebabkan karena kelainan sistem kekebalan tubuh sejak kecil, yang dikenal sebagai Diabetes Tipe 1. Dapat pula terjadi karena ketidakmampuan tubuh dalam menyelaraskan produksi insulin dengan kebutuhan untuk mengolah glukosa dalam darah. Diabetes tipe ini dinamakan Diabetes Tipe 2. Untuk mengenal penyakit ini, ada baiknya kita kenali dulu organ yang bernama Pancreas.</span></div>
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<a name='more'></a><span style="font-size: small;">Pankreas merupakan kumpulan kelenjar yang melepaskan enzim pencernaan kedalam usus dan mengeluarkan hormon insulin dan glucagon kedalam aliran darah. Dua hormon ini berperan penting dalam metabolisme karbohidrat (gula). Pankreas menempel pada duodenum (usus 12 jari), bagian atas dari usus halus. Pembuluh besar utama, disebut pembuluh Wirsung (dalam gambar diatas pancreatic duct), mengumpulkan cairan pankreas dan mengalirkannya kedalam usus 12 jari. Pada banyak individu pembuluh yang lebih kecil (pembuluh Santorini) juga mengalir ke usus 12 jari. Aktif enzim dalam pencernaan karbohidrat, lemak, dan protein terus menerus mengalir dari pankreas melalui pembuluh ini. Aliran ini dikendalikan oleh syaraf vagus dan oleh hormon secretin dan pancreozymin. Dua hormon ini diproduksi dalam mucosa usus. Ketika makanan masuk ke usus 12 jari, secretin dan pancreozymin dilepaskan kedalam aliran darah oleh sel-sel usus 12 jari. Ketika hormon ini sampai di Pankreas, sel-sel pankreas terstimulasi untuk memproduksi dan melepaskan air, bikarbonat, dan enzim pencernaan dalam jumlah yang besar, yang kemudian mengalir ke usus.</span><br />
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<span style="font-size: small;">Hormon insulin dan glucagon dihasilkan oleh suatu jenis sel yang dinamakan sel-sel Beta, yang tersebar dalam pancreas, dalam bagian yang disebut pulau Langerhans. Langerhans adalah nama seorang dokter berkebangsaan Jerman bernama Paul Langerhans. Ialah yang pertama kali pada tahun 1869 menjelaskan fungsi dan keberadaan bagian ini. Dalam pankreas manusia normal terdapat 1.000.000 pulau Langerhans.</span><br />
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<span style="font-size: small;">Ada lima jenis sel yang berbeda dalam pulau Langerhans, dimana tiga diantaranya (sel alpha, sel beta dan sel delta) menghasilkan hormon penting. Sel A(lpha) menghasilkan glucagon, Sel B(eta) menghasilkan insulin; Sel D(elta) yang membuat somatostatin. Jenis sel keempat dan kelima yaitu sel D1 dan sel PP belum diketahui secara pasti fungsinya. Rusaknya sel beta sebagai penghasil insulin merupakan penyebab diabetes mellitus tipe 1 (tergantung insulin).</span></div>
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<span style="font-size: small;">Pulau-pulau Langerhans dalam pankreas mensekresi hormon insulin dan glucagon, untuk mengendalikan kadar gula dalam darah. Insulin merangsang sel untuk membuang gula dari aliran darah dan memanfaatkannya. Insulin merupakan protein sederhana dimana rantai dari dua polipeptid asam amino terhubung dengan ikatan disulfida. Insulin membantu pemindahan glukosa kedalam sel sehingga sel-sel itu dapat mengoksidasi glukosa untuk menghasilkan energi bagi tubuh. Insulin dikeluarkan ketika kadar gula dalam darah meningkat-terutama setelah makan.</span><br />
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<span style="font-size: small;">Pada jaringan lemak, insulin memfasilitasi penyimpanan glukosa dan konversinya menjadi asam lemak. insulin juga memperlambat penguraian asam lemak. Pada otot, Insulin membantu penyerapan asam amino untuk membentuk protein. Insulin juga membantuk merubah glukosa menjadi glikogen dalam liver dan mengurangi gluconeogenesis (pembentukan glukosa dari sumber nonkarbohidrat).</span><br />
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<span style="font-size: small;">Glucagon memiliki efek yang berlawanan; dimana hormon ini merangsang liver untuk melepaskan gula yang disimpannya (Glycogen) kedalam aliran darah. Hal ini dilakukan jika kadar gula dalam darah terlalu rendah atau terlalu banyak insulin dihasilkan oleh tubuh sehingga kadar gula dalam darah menurun. Mekanisme inilah yang mengatur kadar gula dalam darah pada manusia. Pulau Langerhans juga mensekresi, dalam jumlah yang jauh lebih sedikit, somastostatin, yang menghambat dihasilkannya hormon insulin dan glucagon. Selain itu adapula hormon yang disebut pancreatic polypeptide (polipetid pankreas), yang belum diketahui secara pasti guna dan manfaatnya.</span><br />
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<span style="font-size: small;">Produksi hormon insulin yang tidak memadai adalah penyebab diabetes melitus. Diabetes yang parah memerlukan injeksi insulin secara periodik, yang diambil dari pankreas babi, domba, dan banteng. Insulin pertamakali diisolasi sebagai extrak pankreas pada tahun 1921 oleh Sir Frederick G. Banting dan Charles H. Best dari Kanada. Pada awal 1980-an, suatu jenis bakteri tertentu dimodifikasi secara genetik untuk memproduksi insulin manusia.</span><br />
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<span style="font-size: small;">II. SEBAB TIMBULNYA DAN JENIS DIABETES MELITUS</span><br />
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<span style="font-size: small;">Diabetes terjadi jika tubuh menghasilkan insulin yang cukup untuk mempertahankan kadar gula darah yang normal atau jika sel tidak memberikan respon yang terpat terhadap insulin. Pada diabetes melitus, kadar insulin yang rendah membuat sel tidak mampu menyerap glukosa. Sebagai akibatnya, glukosa menumpuk dalam darah. Ketika darah yang banyak mengandung glukosa ini melewati ginjal, organ yang membuang zat-zat yang tidak berguna dalam darah, ginjal tidak sanggup menyerap semua glukosa yang ada dalam darah. Kelebihan glukosa ini keluar bersama dengan urin dan air serta elektrolit–ion yang diperlukan oleh sel untuk mengatur lompatan listrik dan aliran molekul air antar membran sel. Hal ini menyebabkan seringnya buang air kecil untuk membuang kelebihan air (Poliuri). Rasa lapar yang luar biasa juga timbul (Polifagi) disertai dengan rasa haus yang tidak biasa (polidipsi) karena banyak kalori dan cairan yang terbuang bersama air seni, sehingga tubuh menimbulkan rasa lapar dan haus untuk menggantikan kalori dan cairan yang hilang karena urinisasi . Gejala tambahan yang mungkin ada termasuk penglihatan yang buram, turunnya berat badan secara drastis, mudah marah, rasa lemas dan kelelahan, dan mual serta muntah-muntah.</span></div>
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<span style="font-size: small;">Hormon insulin yang dibuat di pankreas, membantu mengendalikan kadar gula dalam darah, yang diperlukan untuk membantu banyak proses kimia tubuh. Pada orang yang sehat, ketika makanan dicerna<br /><br />(1), kadar glukosa di dalam darah naik<br /><br />(2). Pankreas mengeluarkan insulin<br /><br />(3), yang membantu sel tubuh untuk menangkap glukosa. Insulin juga membantu merubah glukosa menjadi glikogen, yang disimpan dalam liver.<br /><br />(4) dan otot yang nantinya akan dibakar kalau dibutuhkan. Hormon-hormon mengatur pelepasan insulin yang dapat menyebabkan kadar gula menjadi drop<br /><br />(5). Hormon ini membuat pankreas mengurangi produksi insulinnya<br /><br />(6). Pada orang yang menderita diabetes melitus, pankreas memproduksi insulin dalam jumlah yang tidak mencukupi atau tubuh tidak dapat menggunakan insulin yang dibuatnya. Setelah menyantap makanan (A), pankreas tidak memproduksi cukup insulin (B), tubuh terpaksa membakar lemak untuk menggantikan glukosa sebagai sumber energi. Zat kimia beracun yang disebut ketone; yang timbul dari proses pembakaran lemak; dikeluarkan melalui urin (D) dan ada pula yang beredar dalam aliran darah(E), menyebabkan ketoacidosis, suatu kondisi yang dapat menyebabkan kematian. Jika tubuh tidak dapat menggunakan insulin dengan baik, glukosa tidak diserap oleh sel dan beredar dalam darah tanpa diserap tubuh. Kadar gula yang tinggi dalam darah (C) dan urin (D) melumpuhkan kemampuan tubuh untuk memerangi infeksi dan dapat menyebabkan ketoasidosis.<br /><br />1. DIABETES TIPE I<br /><br />Diabetes dikelompokan menjadi dua. Pada diabetes tipe I; sering disebut diabetes tergantung insulin dan diabetes–mulai kecil; tubuh tidak dapat memproduksi insulin atau memproduksi insulin hanya dengan jumlah yang sedikit. Gejala yang timbul biasanya datang secara tiba-tiba, terutama pada individu yang berumur dibawah 20 tahun. Kebanyakan kasus terjadi pada masa puber—pada usia 10 sampai 12 tahun untuk wanita dan 12 sampai 14 tahun pada laki-laki.<br /><br />Diabetes tipe 1 digolongkan sebagai penyakit kekebelan tubuh karena sistem kekebalan tubuh (sistem yang terdiri dari organ, jaringan dan sel yang membunuh organisme dan membuang zat-zat yang menimbulkan penyakit) menyerang dan menghancurkan sel yang menghasilkan insulin, yang dikenal sebagai sel beta dalam pulau Langerhans di pankreas. Para ahli meyakini bahwa kombinasi dari faktor genetik dan lingkungan dapat dengan cara tertentu memicu sistem kekebalan tubuh untuk menghancurkan sel-sel ini. Para ahli juga sejauh ini telah menemukan 20 gen yang memainkan peranan pada diabetes tipe 1, walaupun fungsi dari gen ini masih dalam penyelidikan. Faktor lingkungan, seperti virus tertentu, dapat ikut pula membuat penyakit ini berkembang, khususnya pada orang yang telah memiliki faktor genetik dimana penyakit ini dapat berkembang.<br /><br />Tubuh membentuk energi dari beberapa sumber. Sumber pertama yang diolah tubuh menjadi energi adalah glukosa yang berasal dari karbohidrat. Apabila tidak tersedia, maka tubuh mengambil alternatif yang kedua yaitu lemak dan terakhir protein dalam otot. Pada diabetes jenis ini, terjadi suatu keadaan dimana sebagian besar sel tidak dapat mengolah glukosa karena ketiadaan insulin. Akibatnya, sel-sel ini mengambil energi dari sumber lain. Tubuh mengambil alternatif sumber yang kedua, yaitu lemak. Tubuh membakar lemak yang disimpan sebagai bahan bakar penghasil energi. Proses ini mengakibatkan meningkatnya jumlah zat pembentuk asam dalam darah yang disebut ketone, yang merupakan zat kimia beracun yang bisa menyebabkan darah menjadi asam. Keadaan tersebut dinamakan Ketoasdosis Diabetikum.<br /><br />Gejala awal dari ketoasidosis diabetikum adalah rasa haus dan berkemih yang berlebihan, mual, muntah, lelah dan nyeri perut (terutama pada anak-anak). Pernafasan menjadi dalam dan cepat karena tubuh berusaha untuk memperbaiki keasaman darah. Bau nafas penderita tercium seperti bau aseton. Tanpa pengobatan, Ketoasidosis diabetikum bisa berkembang menjadi koma, kadang dalam waktu hanya beberapa jam. Bahkan setelah mulai menjalani terapi insulin, penderita diabetes tipe I bisa mengalami ketoasidosis jika mereka melewatkan satu kali penyuntikan insulin atau mengalami stres akibat infeksi, kecelakaan atau penyakit serius.<br /><br />2. DIABETES TIPE II<br /><br />Pada diabetes tipe ini, yang sebelumnya disebut dibetes tidak–tergantung insulin dan diabetes umur dewasa, kemampuan tubuh untuk menyelaraskan antara insulin yang dihasilkan dengan kemampuan sel untuk menggunakan insulin menjadi buruk. Karakteristik gejala yang ditimbulkan pada tipe 2 sama seperti gejala yang terjadi pada tipe 1, termasuk infeksi yang berulang atau luka di kulit yang lama sembuh atau tidak sama sekali, kelelahan dalam arti umum, dan kesemutan atau rasa kebal di tangan dan kaki.<br /><br />Diabetes tipe II ini biasanya berawal di usia sekitar 45 tahun. Meski demikian, kejadian dimana penyakit ini dimulai di usia yang lebih muda makin sering terjadi. Karena gejala yang timbul berkembang secara perlahan, seseorang yang mengidap penyakit ini sering tidak mengetahui secara dini bahwa penyakit ini telah ada dalam dirinya. Beberapa gen secara bersama-sama dapat menyebabkan diabetes tipe II. Selain itu, para ilmuwan percaya bahwa kegemukan memiliki peran yang besar dalam menyebabkan penyakit diabetes. Hampir 80% dari pengidap penyakit diabetes tipe II mengalami kelebihan berat badan.<br /><br />Pada dasarnya, diabetes tipe II ini merupakan suatu keadaan yang diakibatkan pola hidup dan pola makan yang kurang baik dalam jangka panjang. Pola hidup dan pola makan yang salah ini membuat organ tubuh bekerja berat dan akhirnya terjadi kelainan yang berujung pada diabetes melitus tipe II ini. Namun demikian, secara alami, tubuh memang mengalami kenaikan kadar gula dalam darah seiring dengan bertambahnya usia. Perlu perhatian khusus bagi penderita yang berusia 65 tahun. Sebaiknya pemeriksaan dilakukan secara rutin dan setelah berpuasa. Jangan setelah makan, karena usia lanjut memiliki peningkatan gula darah yang lebih tinggi. Penyebab diabetes lainnya adalah :<br /><br />· kadar kortikosteroid yang tinggi,<br /><br />· kehamilan (diabetes gestasional), akan hilang setelah melahirkan.<br /><br />· obat-obatan yang dapat merusak pankreas<br /><br />· racun yang mempengaruhi pembentukan atau efek dari insulin </span></div>
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<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:10.0pt;
mso-para-margin-left:0cm;
line-height:115%;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;
mso-ansi-language:EN-US;
mso-fareast-language:EN-US;}
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<![endif]-->
<table border="1" cellpadding="0" class="MsoNormalTable" style="height: 710px; margin-left: 3.75pt; width: 483px;">
<tbody>
<tr style="height: 23.45pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="height: 23.45pt; padding: 1.5pt; width: 225.3pt;" valign="top" width="300"><div align="center" class="MsoNormal" style="line-height: 150%; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: center;">
<span style="font-size: small;"><b><span lang="EN-US" style="color: black; font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Diabetes Mellitus tipe
1</span></b></span></div>
</td>
<td style="height: 23.45pt; padding: 1.5pt; width: 228.25pt;" valign="top" width="304"><div align="center" class="MsoNormal" style="line-height: 150%; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: center;">
<span style="font-size: small;"><b><span lang="EN-US" style="color: black; font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Diabetes Mellitus tipe
2</span></b></span></div>
</td>
</tr>
<tr style="height: 115.75pt; mso-yfti-irow: 1;">
<td style="height: 115.75pt; padding: 1.5pt; text-align: justify; width: 225.3pt;" valign="top" width="300"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="color: black; font-family: "Arial","sans-serif"; font-size: small; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Penderita
menghasilkan sedikit insulin atau sama sekali tidak menghasilkan insulin</span></div>
</td>
<td style="height: 115.75pt; padding: 1.5pt; text-align: justify; width: 228.25pt;" valign="top" width="304"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="color: black; font-family: "Arial","sans-serif"; font-size: small; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Pankreas
tetap menghasilkan insulin, kadang kadarnya lebih tinggi dari normal. Tetapi
tubuh membentuk kekebalan terhadap efeknya, sehingga terjadi kekurangan
insulin relatif</span></div>
</td>
</tr>
<tr style="height: 69.6pt; mso-yfti-irow: 2;">
<td style="height: 69.6pt; padding: 1.5pt; text-align: justify; width: 225.3pt;" valign="top" width="300"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="color: black; font-family: "Arial","sans-serif"; font-size: small; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Umumnya
terjadi sebelum usia 30 tahun, yaitu anak-anak dan remaja.</span></div>
</td>
<td style="height: 69.6pt; padding: 1.5pt; text-align: justify; width: 228.25pt;" valign="top" width="304"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="color: black; font-family: "Arial","sans-serif"; font-size: small; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Bisa
terjadi pada anak-anak dan dewasa, tetapi biasanya terjadi setelah usia 30
tahun</span></div>
</td>
</tr>
<tr style="height: 184.5pt; mso-yfti-irow: 3;">
<td style="height: 184.5pt; padding: 1.5pt; text-align: justify; width: 225.3pt;" valign="top" width="300"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="color: black; font-family: "Arial","sans-serif"; font-size: small; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Para
ilmuwan percaya bahwa faktor lingkungan (berupa infeksi virus atau faktor
gizi pada masa kanak-kanak atau dewasa awal) menyebabkan sistem kekebalan
menghancurkan sel penghasil insulin di pankreas. Untuk terjadinya hal ini
diperlukan kecenderungan genetik.</span></div>
</td>
<td style="height: 184.5pt; padding: 1.5pt; text-align: justify; width: 228.25pt;" valign="top" width="304"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="color: black; font-family: "Arial","sans-serif"; font-size: small; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Faktor
resiko untuk diabetes tipe 2 adalah <b><i>obesitas</i></b> dimana sekitar
80-90% penderita mengalami obesitas. Tipe 2 merupakan suatu proses jangka
panjang dalam tubuh dimana pola hidup dan pola makan yang salah membuat organ
tubuh menjadi rusak, dan tidak mampu berfungsi baik lagi.</span></div>
</td>
</tr>
<tr style="height: 115.75pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="height: 115.75pt; padding: 1.5pt; text-align: justify; width: 225.3pt;" valign="top" width="300"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="color: black; font-family: "Arial","sans-serif"; font-size: small; line-height: 150%; mso-fareast-font-family: "Times New Roman";">90%
sel penghasil insulin (<i>sel beta</i>) mengalami kerusakan permanen. Terjadi
kekurangan insulin yang berat dan penderita harus mendapatkan suntikan
insulin secara teratur</span></div>
</td>
<td style="height: 115.75pt; padding: 1.5pt; text-align: justify; width: 228.25pt;" valign="top" width="304"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US" style="color: black; font-family: "Arial","sans-serif"; font-size: small; line-height: 150%; mso-fareast-font-family: "Times New Roman";">Diabetes
Mellitus tipe 2 juga cenderung diturunkan secara genetik dalam keluarga</span></div>
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</tr>
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<td style="padding: 1.5pt 1.5pt 1.5pt 1.5pt; width: 295.6pt;" valign="top" width="394"><br /></td>
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<td style="padding: 1.5pt 1.5pt 1.5pt 1.5pt; width: 295.6pt;" valign="top" width="394"><br /></td>
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<td style="padding: 1.5pt 1.5pt 1.5pt 1.5pt; width: 295.6pt;" valign="top" width="394"><br /></td>
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</tbody></table>
<div style="text-align: justify;">
<span style="font-size: small;">IV. KOMPLIKASI<br /><br />Apabila dibiarkan tidak diobati, diabetis melitus dapat menyebabkan komplikasi yang mengancam jiwa. Diabetes tipe I dapat menyebabkan kondisi koma diabetes (kondisi tidak sadarkan diri karena kadar gula yang sangat tinggi dalam darah) atau kematian. Pada kedua jenis diabetes, komplikasi yang timbul dapat mengakibatkan kebutaan, gagal ginjal, dan penyakit jantung. Diabetes dapat menyebabkan tertutupnya pembuluh darah yang berukuran kecil. Apabila hal ini terjadi pada pembuluh darah mata, dapat menyebabkan retinopathy (pecahnya selaput yang ada di belakang mata), menyebabkan kebutaan. Diabetes melitus adalah penyebab utama dari kasus-kasus baru kebutaan pada orang berusia 20-74.<br /><br />Kadar gula darah yang tidak terkontrol juga cenderung menyebabkan kadar zat berlemak dalam darah meningkat, sehingga mempercepat terjadinya aterosklerosis (penimbunan plak lemak di dalam pembuluh darah). Aterosklerosis ini 2-6 kali lebih sering terjadi pada penderita diabetes.<br /><br />Zat kompleks yang terdiri dari gula di dalam dinding pembuluh darah menyebabkan pembuluh darah menebal dan mengalami kebocoran. Akibat penebalan ini maka aliran darah akan berkurang, terutama yang menuju ke kulit dan saraf. Sirkulasi darah yang buruk karena penebalan pembuluh darah besar (makro) bisa melukai otak, jantung, dan pembuluh darah kaki (makroangiopati), sedangkan pembuluh darah kecil (mikro) bisa melukai mata, ginjal, saraf dan kulit serta memperlambat penyembuhan luka.<br /><br />Kerusakan pada pembuluh darah mata bisa menyebabkan gangguan penglihatan akibat kerusakan pada retina mata (retinopati diabetikum). Gangguan pada saraf dapat bermanifestasi dalam beberapa bentuk. Jika satu saraf mengalami kelainan fungsi (mononeuropati), maka sebuah lengan atau tungkai biasa secara tiba-tiba menjadi lemah. Jika saraf yang menuju ke tangan, tungkai dan kaki mengalami kerusakan (polineuropati diabetikum), maka pada lengan dan tungkai bisa dirasakan kesemutan atau nyeri seperti terbakar dan kelemahan. Kerusakan pada saraf menyebabkan kulit lebih sering mengalami cedera karena penderita tidak dapat meradakan perubahan tekanan maupun suhu. Berkurangnya aliran darah ke kulit juga bisa menyebabkan ulkus (borok) dan semua penyembuhan luka berjalan lambat. Ulkus di kaki bisa sangat dalam dan mengalami infeksi serta masa penyembuhannya lama sehingga sebagian tungkai harus diamputasi.<br /><br />Penderita diabetes bisa mengalami berbagai komplikasi jangka panjang jika diabetesnya tidak dikelola dengan baik. Komplikasi yang lebih sering terjadi dan mematikan adalah serangan jantung dan stroke. Penderita diabetes yang mengalami batuk-batuk yang cukup parah dalam jangka waktu lama dan tidak jelas sebabnya (karena flu atau tersedak), harus mewaspadai adanya penyempitan pembuluh darah jantung dan penurunan fungsi jantungnya. Batuk itu dapat disebabkan karena serangan jantung yang oleh penderita diabetes tidak merasakan sakit di sekitar dada seperti serangan jantung pada umumnya. Ketiadaan rasa sakit ini disebabkan karena sudah rusaknya saraf-saraf di sekitar pembuluh jantung.<br /><br />Jika diabetes mempengaruhi ginjal, disebut nephropathy (ketidakmampuan ginjal untuk menyaring racun dengan baik). Sekitar 40% dari kasus-kasus terbaru penyakit ginjal parah (gagal ginjal) diakibatkan oleh diabetes. Tertutupnya pembuluh darah besar karena diabetes dapat menyebabkan berbagai masalah kardiovaskular, termasuk tekanan darah tinggi, serangan jantung, dan stroke. Walaupun kondisi ini juga terjadi pada orang yang tidak mengidap diabetes, orang dengan diabetes, memiliki kemungkinan dua sampai empat kali lebih besar untuk adanya kerusakan kardiovaskular.<br /><br />Diabetes melitus dapat mengakibatkan mati rasa, terutama pada kaki bagian bawah. Keadaan mati rasa ini dapat membuat penderita tidak merasakan sakit atau iritasi karena kulit yang sobek atau infeksi pada kaki sampai pada terjadinya komplikasi, sehingga dapat mengakibatkan amputasi. Luka bakar, Dapat pula terjadi rasa sensitif bila disentuh, dan kedinginan pada kaki, yang merupakan gejala penyakit neuropathy. Komplikasi lainnya termasuk resiko yang lebih tinggi pada kehamilan ibu yang mengidap diabetes dan sering timbulnya penyakit gigi.<br /><br />V. DIAGNOSA DAN PERAWATAN<br /><br />Diabetes dideteksi dengan mengukur kadar glukosa dalam darah setelah seseorang berpuasa (tidak makan) selama delapan jam. Pada kasus tertentu, dokter mendiagnosa diabetes dengan melakukan tes oral glukosa toleransi, yang mengukur kadar glukosa sebelum dan sesudah mencerna sejumlah tertentu gula. Tes lain dikembangkan untuk diabetes tipe I mencari antibodi tertentu (protein dalam sistem kekebalan yang menyerang zat-zat dari luar) yang hanya ada pada orang yang menderita diabetes. Tes ini dapat mendeteksi diabetes tipe I pada tahap awal sehingga dapat mengurangi resiko komplikasi dari penyakit ini.<br /><br />Ketika diabetes telah didiagnosa, pengobatan terdiri dari pengendalian kadar glukosa dalam darah dan mencegah komplikasi. Berdasarkan tipe diabetes yang diderita, pengobatan dapat dilakukan melalui olah raga teratur, pola makan yang terkontrol dan hati-hati, dan pengobatan.<br /><br />Orang dengan diabetes tipe I memerlukan suntikan insulin, dua sampai empat kali sehari, Untuk menyediakan insulin bagi tubuh yang tidak dapat dihasilkannya. Jumlah insulin yang diberikan berbeda antara individu yang satu dengan yang lain, tergantung pada faktor-faktor seperti tingkat aktivitas fisik individu, pola makan, dan adanya kelainan lain. Biasanya, orang dengan diabetes tipe I melakukan pengukuran kadar glukosa beberapa kali sehari pada tetes darah dengan cara melukai jarinya. Berdasarkan tes tersebut kemudian ditentukan jumlah insulin yang disuntikkan, olah raga, atau makanan yang dikonsumsi untuk menjaga kadar gula pada level normal. Orang dengan diabetes tipe I harus hati-hati mengontrol pola makannya dengan cara mengkonsumsi makanan dalam jumlah sedikit tetapi lebih sering. Dan harus deselingi dengan makanan kecil, sehingga tidak terlalu membebani kemampuan suplai insulin dalam membantu sel menyerap glukosa. Mereka juga perlu mengkonsumsi “gula kompleks”, yang dicerna tubuh secara lebih perlahan dan memperlambat kenaikan kadar gula darah.<br /><br />Walaupun sebagian besar orang dengan diabetes tipe I berusaha untuk menurunkan kadar gula dalam darah, kadar gula yang terlalu rendah dapat menyebabkan masalah kesehatan. Sebagai contoh, jika seseorang dengan diabetes tipe I menyuntikkan terlalu banyak insulin, hal itu dapat menyebabkan kadar gula yang terlalu rendah. Selanjutnya, kadar gula terlalu rendah dapat menimbulkan hipoglicemia.<br /><br />Seseorang yang mengalami hipoglicemia, ditandai dengan rasa lemas, gemetar, kebingungan dan kegundahan, mual dan muntah. Organ pertama yang terkena pengaruh dari keadaan ini adalah otak. Penderita dapat mengalami suatu gejala dimana terjadi perubahan personal, atau terlihat seperti mabuk. Hipoglicemia adalah akibat dari hiperinsulinisme atau kelebihan insulin, yang diakibatkan baik karena overdosis obat insulin atau tubuh memproduksi insulin secara berlebihan. Pada saat hiperinsulin terjadi, glukosa secara tajam menurun dalam proses perubahan bentuk menjadi glikogen dalam liver dan otot, dan menjadi lemak pada jaringan lemak.<br /><br />Hipoglicemia yang reaktif dapat terjadi pada orang-orang yang mengalami stress. Dapat pula terjadi karena kelebihan insulin; umumnya tiga atau empat jam setelah makan. Gejalanya lebih lambat daripada mereka yang mengalami diabet tergantung insulin. Hipoglikemia harus segera diatasi karena dalam beberapa menit bisa menjadi berat, menyebabkan koma dan kadang cedera otak menetap. Penderita hipoglicemia dapat menghilangkan gejala dengan mengkonsumsi gula, seperti tablet glukosa, jus buah, atau permen.<br /><br />Untuk mengendalikan tingkat insulin, orang dengan diabetes tipe I harus memonitor kadar gula beberapa kali sehari. Pada tahun 1983, 1.441 orang pengidap diabetes tipe I yang berusia 13 sampai 39 mulai mengikuti Diabetes Control and Complication Trial (DCCT), studi ilmiah terbesar tentang pengobatan diabetes yang pernah dilakukan. DCCT mempelajari potensi untuk mengurangi komplikasi diabetes, seperti penyakit syaraf atau ginjal atau kelainan pada mata, dengan cara pasien melakukan pemeriksaan kadar gula darah empat sampai enam kali sehari, menjaga kadar gula supaya sedekat mungkin pada kadar normal. Hasil dari studi ini, dilaporkan pada tahun 1993, memperlihatkan 50 sampai 75 persen pengurangan pada komplikasi akibat diabetes pada orang yang sering memeriksa kadar gula darah dan mengendalikan kadar glukosa dalam darah mereka. Walaupun studi ini dillakukan pada orang yang mengidap diabetes tipe I, para ahli percaya bahwa pengawasan ketat terhadap kadar gula darah juga menguntungkan untuk orang yang mengidap diabetes tipe II.<br /><br />Beberapa penderita mengalami resistensi terhadap insulin. Insulin suntikan tidak sepenuhnya sama dengan insulin yang dihasilkan oleh tubuh, karena itu tubuh bisa membentuk antibodi terhadap insulin pengganti. Antibodi ini mempengaruhi aktivitas insulin sehingga penderita dengan resistansi terhadap insulin harus meningkatkan dosisnya.<br /><br />Penyuntikan insulin dapat mempengaruhi kulit dan jaringan dibawahnya pada tempat suntikan. Kadang terjadi reaksi alergi yang menyebabkan nyeri dan rasa terbakar, diikuti kemerahan, gatal dan pembengkakan di sekitar tempat penyuntikan selama beberapa jam. Suntikan sering menyebabkan terbentuknya endapan lemak (sehingga kulit tampak berbenjol-benjol) atau merusak lemak (sehingga kulit berlekuk-lekuk). Komplikasi tersebut bisa dicegah dengan cara mengganti tempat penyuntikan dan mengganti jenis insulin. Pada pemakaian insulin manusia sintetis jarang terjadi resistensi dan alergi.<br /><br />Pada pengidap diabetes tipe II, perawatan dimulai dengan pengendalian pola makan, olah raga, dan pengurangan berat badan, meskipun seiring dengan berjalannya waktu pengobatan ini tidak cukup berhasil. Orang dengan diabetes tipe II sering bekerja sama dengan ahli gizi untuk menyusun rencana diet yang mengatur kadar gula darah sehingga kadar gula tidak naik terlalu cepat setelah makan. Makanan yang dianjurkan biasanya makanan dengan kadar lemak rendah (30 persen atau kurang dari total kalori), memberikan cukup protein (10 sampai 20 persen dari total kalori), dan mengandung berbagai macam karbohidrat seperti kacang, sayuran dan padi-padian. Olah raga teratur membantu sel tubuh untuk menyerap glukosa–bahkan 10 menit olah raga akan efektif. Pengendalian pola makan dan olah raga dapat memainkan peranan penting dalam penurunan berat badan, yang dapat mengurangi ketidakmampuan tubuh menggunakan insulin.<br /><br />Lemak yang berlebih akan menyebabkan resistensi terhadap insulin. Ini menjelaskan mengapa diet dan olahraga merupakan metode penatalaksanaan untuk diabetes tipe II. Dengan menurunkan berat badan dan meningkatkan massa otot, akan mengurangi jumlah lemak sehingga membantu tubuh memanfaatkan insulin dengan lebih baik. Ternyata ada hubungan antara diabetes tipe 2 dengan letak tumpukan lemak terbanyak. Bila timbunan lemak terbanyak terdapat di perut maka risiko terkena diabetes lebih tinggi. Cara mengurangi dan mencegah menumpuknya lemak:<br /><br />1. Membiasakan untuk hidup sehat, teratur dan disiplin<br /><br />2. Berolahraga teratur dan terukur sesuai dengan usia dan kondisi<br /><br />3. Hindari menonton TV atau main komputer terlalu lama.<br /><br />4. Jangan mengkonsumsi permen, coklat atau snack dengan kandungan garam tinggi.<br /><br />5. Hindari makanan siap saji dengan kandungan kalori, karbohidrat dan lemak<br /><br />6. Banyak mengkonsumsi sayur dan buah.<br /><br />Pada orang dengan diabetes tipe II, hanya dengan diet, olah raga dan pengurangan berat badan saja mungkin dapat berguna, namun pada akhirnya program ini tidak dapat mengendalikan kadar gula dalam darah. Pada kasus ini, pengobatan oral dapat diresepkan. Apabila pengobatan oral tidak efektif, seseorang yang mengidap diabetes tipe II harus disuntik insulin atau kombinasi antara pengobatan oral dengan suntik insulin. Sekitar 49 persen individu dengan diabetes tipe II memerlukan pengobatan oral, 40 persen memerlukan suntik insulin atau kombinasi keduanya, dan 10 persen diet dan olah raga saja. Pengobatan diabetes dasar dan utama adalah pengendalian berat badan, olah raga dan diet. Seseorang yang obesitas dan menderita diabetes tipe 2 tidak akan memerlukan pengobatan jika mereka menurunkan berat badannya dan berolah raga secara teratur.<br /><br />VI. PEMANTAUAN YANG BERKELANJUTAN DAN BERJANGKA PANJANG<br /><br />Penderita diabetes harus mampu mengenal, menerima dan memanajemen diri dan keadaan yang dialaminya. Untuk bisa mengenal betul-betul, ia harus melakukan riset jangka panjang terhadap dirinya. Perlu diketahui, kecenderungan naik turunnya kadar gula darah pada tiap individu berbeda meski secara umum dapat diidentifikasi. Makanan atau minuman apa yang secara signifikan menaikkan gula darahnya, atau dalam kondisi pikiran bagaimana gula darah dalam tubuhnya naik.<br /><br />Penderita diabetes harus secara teratur melakukan tes darah untuk mengetahui kadar gula darahnya. Tes gula darah dapat secara efektif menentukan jumlah insulin yang dibutuhkan setiap harinya. Tes sebaiknya dilakukan saat pagi hari sebelum sarapan, dua jam setelah makan, dan malam hari sebelum tidur. Selain itu, diperlukan pula pengukuran pada saat tertentu, misalnya pengukuran yang lebih ketat jika terjadi hipoglikemi, saat sebelum olah raga, dan pada kehamilan. Pengobatan diabetes bisa dikatakan berhasil jika glukosa darah puasa adalah 80 sampai 109 mg/dl, kadar glukosa darah dua jam adalah 80 sampai 144 mg/dl, dan kadar A1c kurang dari tujuh persen. Pengukuran hemoglobin (Hb) terglikosilasi HBA1c (A1c) adalah cara yang paling akurat untuk menentukan tingkat ketinggian gula darah selama dua sampai tiga bulan terakhir. Hal itu disebabkan karena sel darah merah hidup selama 8-12 minggu sebelum digantikan. Dengan mengukur kadar HbA1C, maka dapat diketahui berapa kadar gula rata-rata selama 8-12 minggu. Pada non-diabetisi angka berkisar antara 3,5-5,5%. Untuk diabetisi, 6,5 sudah baik.<br /><br />Hemoglobin adalah bagian dari sel darah merah yang mengangkut oksigen. Salah satu jenis dari Hb adalah HbA dan HbA1c merupakan subtipe spesifik dari HbA. Glukosa melekat pada haemoglobin untum membentuk Glycosylated haemoglobin yang disebut A1C atau HbA1C. Semakin tinggi kadar glukosa darah, akan semakin cepat HbA1c terbentuk, yang mengakibatkan tingginya kadar HbA1c. HbA1c ini juga merupakan pemeriksaan tunggal terbaik untuk menilai risiko terhadap kerusakan jaringan yang disebabkan oleh tingginya kadar glukosa darah. Contohnya, pada saraf dan pembuluh darah kecil di mata dan ginjal. Selain itu, juga bisa menilai risiko terhadap komplikasi penyakit diabetes. Sudah ada penelitian klinis mengenai hal ini, seperti Diabetes Control and Complications Trial (DCCT) dan United Kingdom Prospective Diabetes Study (UKPDS. Penelitian ini membuktikan bahwa dengan memperbaiki nilai HbA1c maka dapat menurunkan perkembangan dan perjalanan komplikasi diabetes pada mata, ginjal, dan saraf, baik pada DM I maupun DM II.<br /><br />VII. HASIL RISET TERBARU<br /><br />Saat ini tidak ada pengobatan untuk penyakit diabetes, dan para ilmuwan tidak yakin atas penyebab yang pasti, walaupun penyelidikan telah meneliti kombinasi dari faktor genetik dan lingkungan. Sampai saat ini para peneliti telah mengidentifikasi 20 gen yang berperan dalam timbulnya diabetes tipe I dan mereka bekerja untuk menentukan peranan setiap gen dalam menimbulkan penyakit gula ini. Pola keturunan pada diabetes tipe I sangat rumit, dengan berbagai gen yang mempengaruhi resiko seseorang. Contohnya, gen yang diketahui sebagai DR memainkan peran dalam menimbulkan penyakit diabetes. Dua bentuk gen yang disebut DR3 dan DR4, ada pada 95 persen orang dengan diabetes tipe I. Orang yang mewarisi DR3 saja dapat terjangkit diabetes pada usia yang lebih tua dan memiliki antibodi yang menghancurkan sel beta penghasil insulin. Orang yang mewarisi DR4 cenderung untuk mengidap diabetes pada usia yang lebih muda dan memiliki antibodi yang menghancurkan insulin. Seseorang dengan DR3 dan DR4 biasanya mengidap diabetes pada usia yang sangat muda dan memiliki kadar antibodi penghancur insulin paling tinggi.<br /><br />Pada tahun 2000 para peneliti terkejut ketika menemukan bahwa variasi gen yang disebut Caplain-10, yang tidak terlibat dalam metabolisme glukosa, justru terlibat dalam berkembangnya diabetes tipe II. Satu bentuk gen memproduksi sejumlah kecil protein, dan peneliti mempelajari bagaimana penurunan protein dapat menyebabkan naiknya resiko seseorang untuk mengidap diabetes. Studi genetik lainnya mengindikasikan bahwa gen-gen tertentu menyebabkan variasi dari diabetes tipe II yang disebut “maturity onset diabetes of the young” (MODY), yang berkembang pada umur dibawah 25 tahun. Walaupun para ilmuwan belum dapat mengerti bagaimana gen ini menyebabkan MODY, gen ini diketahui aktif dalam liver, usus, ginjal dan pankreas.<br /><br />Ilmuwan lain mengidentifikasi faktor lingkungan yang memicu diabetes tipe I pada orang yang cenderung mengidap diabetes. Jika mereka dapat menentukan apa sebab sistem kekebalan menyerang sel yang memproduksi insulin, mereka mungkin akan menemukan bagaimana mencegah kondisi berkembangnya kecenderungan ini. Contohnya, studi mengatakan bahwa virus tertentu seperti coxsackie B, rubella, dan mumps, dapat memicu reaksi kekebalan dengan menghancurkan sel beta.<br /><br />Para peneliti menghubungkan kasus pada diabetes tipe II dengan kegemukan. Penelitian memperlihatkan bahwa resiko untuk mengidap diabetes tipe II meningkat 4 persen untuk setiap pound kelebihan berat pada seseorang. Para ilmuwan sedang mencari peranan yang dimainkan oleh kelebihan berat badan dalam menghambat utilisasi insulin dan mengapa beberapa orang yang memiliki kelebihan berat mengembangkan penyakit itu dalam tubuhnya sedang yang lain tidak.<br /><br />Cara-cara baru untuk mengukur kadar gula dalam darah dapat meningkatkan kualitas hidup untuk banyak pengidap diabetes. Teknik baru termasuk penggunaan sinar laser dan teknologi infra merah. Contohnya, komputer mini dengan menggunakan sinar infra merah dapat digunakan untuk mengukur kadar gula darah seseorang. Komputer secara otomatis mengirimkan hasil analisanya kepada pompa insulin yang terpasang pada tubuh diabetisi yang kemudian menginjeksikan insulin dengan jumlah yang sesuai.<br /><br />Penelitian juga difokuskan untuk mentransplantasikan pankreas sehat atau sel beta penghasil insulin pada seseorang yang mengidap diabetes tipe I untuk menyediakan sumber alami insulin. Beberapa pasien yang telah menerima transplantasi pankreas telah mengalami perkembangan yang cukup baik pada kesehatannya. Namun demikian hasil positif, jangka panjang pada transplantasi sel-beta belum terjadi. Pada kedua tipe transplantasi penerima harus meminum obat-obatan yang menekan sistem kekebalan mereka sehingga tubuh tidak akan menolak pankreas baru mereka atau sel-beta baru mereka. Obat-obatan ini dapat menyebabkan efek yang membahayakan jiwa karena tubuh pasien tidak lagi dapat melindungi dirinya dari zat-zat berbahaya lainnya. Pada sebagian besar orang yang mengidap diabetes, obat-obatan ini mendatangkan resiko yang lebih besar pada kesehatan dari pada hidup dengan diabetes. Para ahli juga mempelajari perkembangan pankreas tiruan dan jalan untuk memanipulasi secara genetik sel-sel yang tidak memproduksi insulin menjadi memproduksi insulin.<br /><br />Perkembangan lain termasuk obat-obatan baru yang mengendalikan gula darah. Pada April 2000 FDA (Food and Drugs Administration) menyetujui glargine, sebuah obat insulin yang hanya perlu diinjeksikan sekali sehari. Dijual dengan merk dagang Lantus, obat ini dapat digunakan oleh penderita diabetes tipe I seperti halnya penderita diabetes tipe II yang memerlukan suntikan insulin. Sejumlah obat-obatan telah dikembangkan untuk menolong orang yang mengidap diabetes tipe II. Contohnya termasuk acarbose, (dijual dengan merk dagang Precose), yang mengendalikan kadar gula dalam darah dengan memperlambat pencernaan karbohidrat, dan metformin (dijual dengan merk dagang Glucophage), yang mengendalikan produksi gula oleh liver, menyebabkan berkurangnya berat badan, dan mengurangi kolesterol total. Pada tahun 2000 FDA menarik obat troglitazone (dijual dengan merk dagang Rezulin) dari pasar. Walaupun obat ini dapat mengembangkan kemampuan tubuh untuk menggunakan glukosa, obat ini juga menimbulkan keracunan pada liver.<br /><br />Pada tahun 2006, FDA menyetujui suatu bentuk insulin yang dapat dihirup. Para dokter telah memahami bahwa beberapa penderita diabetes tergantung insulin tidak dapat mengkonsumsi obat sesering yang dibutuhkan karena kerepotan dari cara menyuntik. Para dokter berharap bentuk insulin hirup dapat lebih memenuhi kebutuhan pasien.</span></div>
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<w:LsdException Locked="false" Priority="9" SemiHidden="true"
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<w:LsdException Locked="false" Priority="9" SemiHidden="true"
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<w:LsdException Locked="false" Priority="9" SemiHidden="true"
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<w:LsdException Locked="false" Priority="9" SemiHidden="true"
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<w:LsdException Locked="false" Priority="9" SemiHidden="true"
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<w:LsdException Locked="false" Priority="9" SemiHidden="true"
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<w:LsdException Locked="false" Priority="9" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="35" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="1" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
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<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
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<w:LsdException Locked="false" Priority="30" QFormat="true"
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<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
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<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
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<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
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<w:LsdException Locked="false" Priority="21" QFormat="true"
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<w:LsdException Locked="false" Priority="31" QFormat="true"
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<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
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<![endif]-->arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-69006092932001387962013-05-17T06:36:00.000+07:002013-05-17T06:38:55.314+07:00FISIOLOGI METABOLISME <!--[if !mso]>
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v\:* {behavior:url(#default#VML);}
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<![endif]--><span style="font-family: inherit;"><br /></span>
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<br />
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Metabolisme
adalah suatu proses komplek perubahan makanan menjadi energi dan panas
melalui proses fisika dan kimia, berupa proses pembentukan dan penguraian
zat didalam tubuh organisme untuk kelangsungan hidupnya.</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Macam
Metabolisme</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Metabolisme
dibedakan 2 macam :</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l31 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Katabolisme
: proses penguraian makanan menjadi energi, yang terjadi pada proses
respirasi sel.</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l31 level1 lfo2; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Anabolisme
: proses pembentukan (sintesa) zat organik komplek yang berasal dari zat yang
lebih sederhana</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Contoh
Metabolisme</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Contoh
Katabolisme :</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l25 level1 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Glikogenolisis
: proses pemecahan glikogen menjadi glukose</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l25 level1 lfo3; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Glikolisis
: proses pemecahan glukose menjadi asam piruvat</span></span></li>
</ul>
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<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Contoh
Anabolisme :</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l3 level1 lfo4; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Glikogenesis
: proses pembentukan glikogen dari glukose</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l3 level1 lfo4; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Glikoneogenesis
: proses pembentukan glukose dari prtein atau lemak</span></span></li>
</ul>
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<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Alur
Metabolisme</span></span></div>
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<span style="font-family: inherit;"><br /></span></div>
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<span style="font-family: inherit;"></span></div>
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<span style="font-family: inherit;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: inherit;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh5xsgyDE9t5iBWV5M_SxW4oyhgUSbZmW9Nyjjx79lEsh3KYCLZ8pV-dVAekcDccf8p_5GXGVfX9IGrxt2SZ2qUJnBDLCVj27tMDA5j_I4WODy8515vn7hitdFC1r12QqkEXgNbPUbvOH-s/s1600/s.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="172" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh5xsgyDE9t5iBWV5M_SxW4oyhgUSbZmW9Nyjjx79lEsh3KYCLZ8pV-dVAekcDccf8p_5GXGVfX9IGrxt2SZ2qUJnBDLCVj27tMDA5j_I4WODy8515vn7hitdFC1r12QqkEXgNbPUbvOH-s/s400/s.jpg" width="400" /></a></span></div>
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"></span></span><br />
<a name='more'></a><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hasil
Metabolisme</span><br />
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l17 level1 lfo5; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hasil
metabolisme berupa energi dan panas → energi tersebut belum dapat
digunakan langsung oleh sel → berikatan adenin, fosfat dan ribose → ATP
(Adenosin Tri Fosfat).</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l17 level1 lfo5; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ATP
tersebut merupakan simpanan energi → siap digunakan oleh sel untuk :
transport membran, sintesis senyawa kimia, kerja mekanik.</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l17 level1 lfo5; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jika
sel memerlukan energi, maka energi diambil dari ATP dengan cara melepas
satu gugus fosfat menjadi ADP (Adenosin Di Phosfat) dengan melepas 8.000
kalori.</span></span></li>
</ul>
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<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penggunaan
ATP</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l16 level1 lfo6; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ATP →
ADP + PO4 + 8.000 kalori </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l16 level1 lfo6; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ADP →
AMP + PO4 + 8.000 kalori</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l16 level1 lfo6; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">AMP sudah
tidak dapat mengeluarkan energi lagi → harus diisi lagi dengan energi baru
yang berasal dari metabolisme makanan → menjadi ATP.</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l16 level1 lfo6; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Metabolisme
→ proses merubah makanan → ATP</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l18 level1 lfo7; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kreatin
+ ATP → Fosforil kreatin + ADP</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l18 level1 lfo7; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kreatin
di otot dalam keadaan istirahat mampu mengikat ATP menjadi Fosforil
kreatin (simpanan energi) </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l18 level1 lfo7; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jika
otot perlu energi untuk gerak maka fosforil kreatin dipecah →Kreatin +
ATP. </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l18 level1 lfo7; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ATP
inilah yang digunakan untuk gerak</span></span></li>
</ul>
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<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fase
Metabolisme Karbohidrat</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l15 level1 lfo8; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Glikolisis
→ proses merubah glukose → asetil Co-A</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l15 level1 lfo8; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Siklus
Kreb → proses merubah asetil Co-A → H</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l15 level1 lfo8; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fosforilasi
Oksidatif → proses mereaksikan H + O → H2O + ATP</span></span></li>
</ul>
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<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Glikolisis</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l2 level1 lfo9; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Glikolisis:
glukose → asam piruvat/ asetil co-A</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l2 level1 lfo9; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">R/
Glukose + 2 ADP + 2 PO4 → 2 Asam Piruvat + 2 ATP + 4 H</span></span></li>
</ul>
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<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hasil akhir
glikolisis:</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l1 level1 lfo10; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Asam
piruvat / Acetil co-A</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l1 level1 lfo10; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2 ATP</span></span></li>
</ul>
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<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Siklus Asam
Sitrat</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l27 level1 lfo11; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Siklus
Kreb: asetil co-A → H</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l27 level1 lfo11; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">R/ 2
Asetil Ko-A + 6 H2O + 2 ADP → 4 CO2 + 16 H + 2 Ko-A + 2 ATP</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l27 level1 lfo11; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hasil
utama: H (hidrogen) dan 2ATP</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fosforilasi
Oksidatif</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l12 level1 lfo12; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Rantai
Respirasi → transfer H dari satu karier ke karier lainya dengan enzim
dehidrogenase </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l12 level1 lfo12; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">H + O2
→ H2O + ATP</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l12 level1 lfo12; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">R/ 2 H
+ ½ O2 + 2e + ADP → H2O + ATP</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l12 level1 lfo12; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ATP
hasil fosforilasi oksidatif = 34 ATP</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Metabolisme
Lemak</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ada 3 fase:</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l8 level1 lfo13; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">β
oksidasi → proses merubah asam lemak → asetil Co-A</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l8 level1 lfo13; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Siklus
Kreb → proses merubah asetil Co-A →H</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l8 level1 lfo13; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fosforilasi
Oksidatif → proses mereaksikan H + O → H2O + ATP</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Metabolisme
Protein</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ada 3 tahap</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l24 level1 lfo14; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Deaminasi
→ proses merubah asam amino → asetil Co-A</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l24 level1 lfo14; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Siklus
Kreb → proses merubah asetil Co-A → H</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l24 level1 lfo14; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fosforilasi
Oksidatif →proses mereaksikan H + O → H2O + ATP</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Keseimbangan
Energi</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l22 level1 lfo15; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Energi
didalam tubuh kita dikatakan seimbang, jika jumlah energi yang masuk
melalui makanan sama besar dengan jumlah energi yang dikeluarkan untuk
kelangsungan hidup</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Basal
Metabolisme Rate (BMR)</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l30 level1 lfo16; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Basal
Metabolisme Rate ( BMR ) : adalah keadaan metabolisme tubuh dalam keadaan
istirahat fisik maupun mental</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l30 level1 lfo16; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jadi
dalam keadaan BMR, diperlukan jumlah tenaga minimal untuk kelangsungan
hidup yang terpenting : gerak nafas, suhu tubuh, sirkulasi darah.</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l14 level1 lfo17; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">BMR
rata rata: 2.000 kalori / hari, </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l14 level1 lfo17; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kebutuhan
energi manusia > 2.000 kalori / hari yang dipergunakan untuk: BMR,
kegiatan fisik dan SDA </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l14 level1 lfo17; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">SDA(
Specifik Dinamic Action ) yaitu energi yang dibutuhkan untuk metabolisme
makanan </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l14 level1 lfo17; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Laju
metabolik → jumlah tenaga yang dibebaskan per satuan waktu</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cara
Pengukuran BMR</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l4 level1 lfo18; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak
makan minimal 12 jam</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l4 level1 lfo18; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidur
nyenyak semalam</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l4 level1 lfo18; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tanpa
gerak badan setelah tidur</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l4 level1 lfo18; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menghilangkan
faktor psikis dan fisik yang merangsang metabolisme</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l4 level1 lfo18; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Suhu
harus nyaman ( 25 – 300 C )</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Faktor BMR</span></span></div>
<ol start="1" type="1">
<li class="MsoNormal" style="line-height: normal; mso-list: l5 level1 lfo19; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Gerak badan </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l5 level1 lfo19; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Makan / minum </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l5 level1 lfo19; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Suhu lingkungan </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l5 level1 lfo19; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tinggi badan, Berat badan</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l5 level1 lfo19; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jenis kelamin </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l5 level1 lfo19; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Suhu tubuh </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l5 level1 lfo19; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kehamilan, menstruasi </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l5 level1 lfo19; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hormon tiroid </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l5 level1 lfo19; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Hormon epineprin dan
nonepineprin </span></span></li>
</ol>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Cara
Menghitung Kebutuhan Energi</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l19 level1 lfo20; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Untuk
menghitung kebutuhan energi seseorang, maka harus diketahui BMR nya dan
kegiatan fisiknya, dan untuk memperkirakan jumlah energi yang diperlukan
dapat dihitung dengan menggunakan rumus berikut</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Rumus BMR</span></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: inherit;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKoFdRrzPdZlI8SLc_gDMdvsOtXvlMLnVuKEmxd3q_eR5Pe71cklyosuzjnY8Mcnx0ISk44DbY63s5dlxupB7TtviWpkflipR_hyphenhyphen-H6OFDVOkgF4OizM585-4pj9cVr6QQVMvyqTyti-KW/s1600/defs.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKoFdRrzPdZlI8SLc_gDMdvsOtXvlMLnVuKEmxd3q_eR5Pe71cklyosuzjnY8Mcnx0ISk44DbY63s5dlxupB7TtviWpkflipR_hyphenhyphen-H6OFDVOkgF4OizM585-4pj9cVr6QQVMvyqTyti-KW/s1600/defs.jpg" /></a></span></div>
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<span style="font-family: inherit;"></span></div>
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<span style="font-family: inherit;"><br /></span></div>
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<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Energi
Aktivitas Fisik</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: inherit;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHMXA6cF_rYr7fSqaQ76MV9pU4CYLl3e4JR7K1XrYJz-nkHIvP8rM1J0hIizOMmtIeZbkWqkHH7eVXTNBerVegY-Xe_pU_zpZR3XsZ3UiHhjjNltRT3TK1QCF7ikvAvlgxoDVouSpUBwBR/s1600/wre.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHMXA6cF_rYr7fSqaQ76MV9pU4CYLl3e4JR7K1XrYJz-nkHIvP8rM1J0hIizOMmtIeZbkWqkHH7eVXTNBerVegY-Xe_pU_zpZR3XsZ3UiHhjjNltRT3TK1QCF7ikvAvlgxoDVouSpUBwBR/s1600/wre.jpg" /></a></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Suhu Tubuh</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l23 level1 lfo21; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Suhu
tubuh normal rata rata per oral = 37oC (36,40C - 37,2OC).</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kehilangan
panas tubuh melalui cara:</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l29 level1 lfo22; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Radiasi
: 60 %</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l29 level1 lfo22; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Konduksi
ke tempat lain : 3 %</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l29 level1 lfo22; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Konveksi
ke udara: 15 %</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l29 level1 lfo22; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Evaporasi:
22 %</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perpindahan
Panas</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l26 level1 lfo23; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Konduksi
→ perpindahan kalor melalui suatu medium, tanpa disertai perpindahan
partikel medium tersebut</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l26 level1 lfo23; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Misal:
perpindahan panas tubuh ke kursi</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l26 level1 lfo23; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Konveksi:
perpindahan kalor melalui suatu medium, yang disertai perpindahan partikel
medium tersebut</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l26 level1 lfo23; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Misal:
perpindahan panas tubuh ke udara</span></span></li>
</ul>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l9 level1 lfo24; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Radiasi
→ perpindahan panas tanpa melalui medium, dalam bentuk gelombang
elektromagnetik</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l9 level1 lfo24; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Misal:
sinar, sinar gama, sinar X, sinar infra merah</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l9 level1 lfo24; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Evaporasi
→ perpindahan panas melalui penguapan</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l9 level1 lfo24; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Misal:
penguapan keringat memerlukan kalori</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Keseimbangan
Panas</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l20 level1 lfo25; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Panas
secara terus menerus dihasilkan oleh tubuh sebagai hasil sampingan
metabolisme, dan panas juga dibuang ke lingkungan sekitar. </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l20 level1 lfo25; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bila
kecepatan pembentukan panas tepat sama dengan kehilangan panas maka tubuh
dalam keadaan keseimbangan panas. </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l20 level1 lfo25; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tetapi
bila keduanya diluar keseimbangan, maka suhu tubuh akan meningkat atau
menurun.</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l20 level1 lfo25; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jika
suhu tubuh > suhu lingkungan → panas akan hilang dengan cara radiasi
dan konduksi</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l20 level1 lfo25; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jika
suhu tubuh < suhu lingkungan → tubuh dapat panas dari radiasi dan
konduksi lingkungan → membuang panas dengan Evaporasi.</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pengaturan
Suhu Tubuh</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l11 level1 lfo26; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pusat
pengatur suhu tubuh →Termostat Hipotalamus</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l11 level1 lfo26; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Reseptor
suhu tubuh :</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l11 level1 lfo26; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Neuron
di area Preoptika Hipotalamus</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l11 level1 lfo26; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Reseptor
suhu kulit </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l11 level1 lfo26; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Reseptor
suhu didalam Medulla spinalis, Abdomen.</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mekanisme
Pembuangan Panas</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l6 level1 lfo27; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perangsangan
kelenjar keringat → pembuangan panas secara penguapan.</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l6 level1 lfo27; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menghambat
pusat simpatis di Hipotalamus posterior, sehingga menghilangkan tonus
vasokonstriksi normal pada pembuluh kulit →terjadi vasodilatasi dan kehilangan
banyak panas dari tubuh</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mekanisme
Pembentukan Panas</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l28 level1 lfo28; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Vasokonstriksi
pada kulit → mencegah konduksi panas dari dalam tubuh ke kulit.</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l28 level1 lfo28; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Piloereksi
“rambut berdiri“ → membentuk isolator pada kulit, efek ini tidak begitu
penting pada manusia.</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l28 level1 lfo28; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Peniadaan
keringat → penguapan terhenti.</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Peningkatan
pembentukan panas :</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo29; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Menggigil
(Pusat motorik efek menggigil terletak pada bagian Dorsomedial Hipotalamus
Posterior)</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo29; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Peningkatan
rangsangan simpatis pembentukan panas → Hormon epinefrin dan norepinefrin
meningkatkan metabolisme.</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo29; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Peningkatan
pengeluaran Hormon Tiroksin → meningkatkan metabolisme.</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fisiologi
Demam</span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l7 level1 lfo30; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Demam →
adalah suhu tubuh diatas batas normal biasa, yang disebabkan oleh zat
toksik (Pirogen), penyakit bakteri, tumor otak, atau dehidrasi yang
mempengaruhi pusat pengaturan suhu (termostat hipotalamus).</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l7 level1 lfo30; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pirogen
tsb merangsang termostat hipotalamus, untuk di set pada suhu yang lebih
tinggi</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l13 level1 lfo31; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Karena
suhu tubuh lebih rendah dari pada setelan ( set ) termostat hipotalamus →
maka terjadi peningkatan suhu tubuh dan terjadilah demam (diatas normal)
sampai mencapai suhu kritis (38,6OC) </span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l13 level1 lfo31; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Pada
suhu kritis tsb (38,6OC) → maka tubuh berusaha men-set termostat
hipotalamus pada suhu normal (37OC) → maka terjadi vasodilatasi, dan
berkeringat.</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l13 level1 lfo31; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Perubahan
peristiwa yang mendadak pada demam dari suhu kritis menuju normal disebut
Kritis atau FLUSH</span></span></li>
</ul>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l10 level1 lfo32; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bila
suhu tubuh meningkat sampai melebihi 40,5OC → terjadi sengatan panas (HEAD
STROKE) dengan gejala : dizziness, distress abdomen, delirium, kehilangan
kesadaran.</span></span></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l10 level1 lfo32; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: inherit;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Obat
anti Piretik (Aspirin) → mempunyai kasiat menurunkan panas, dengan jalan
menurunkan penyetelan termostat hipotalamus (kebalikan efek Pirogen).</span></span></li>
</ul>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-63706822822304257852013-05-16T12:17:00.003+07:002013-05-16T12:17:41.287+07:00Cara Masuk Ke Safe Mode Di Windows 8<div style="text-align: justify;">
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footer"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index heading"/>
<w:LsdException Locked="false" Priority="35" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="caption"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of figures"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope return"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
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<w:LsdException Locked="false" Priority="52"
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<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
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<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
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<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
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<w:LsdException Locked="false" Priority="46"
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<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
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<w:LsdException Locked="false" Priority="52"
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<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
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<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
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</w:LatentStyles>
</xml><![endif]--><!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-parent:"";
mso-padding-alt:0cm 5.4pt 0cm 5.4pt;
mso-para-margin-top:0cm;
mso-para-margin-right:0cm;
mso-para-margin-bottom:10.0pt;
mso-para-margin-left:0cm;
line-height:115%;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]-->
</div>
<div class="MsoNormal" style="line-height: normal; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Untuk pengguna baru windows 8
mungkin akan kebingungan bagaimana cara masuk ke safe mode, karena di windows 8
anda tidak akan sempat menekan tombol f8 untuk masuk ke safe mode.</span></div>
<div class="MsoNormal" style="line-height: normal; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Lansung Saja Ikuti langkah-langkah
mudah di bawah ini :</span></div>
<div class="MsoNormal" style="line-height: normal; text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1. Arahkan mouse ke bagian Kiri bawah pada layar windows 8
anda, Kemudian klik kanan dan cari “Run” atau tekan Tombol Kombinasi
Windows + R</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
<div style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2. Masukkan “Msconfig” dan tekan Oke, maka akan tampil
sbb:</span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgS6vSlw4ZcASBIVBpVaJK1jU-pqwhznfeaQiNr0c7HyjRSFKQhp9G-Xq2mWw3iCYm_nF5asnUhySkhCapszyKgOzxE_Rgkcbvvv1XIVZkjBJDjwi6dJfDaKBf1T9uRfBKo_ICFMluwMWTi/s1600/dfgdg.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="265" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgS6vSlw4ZcASBIVBpVaJK1jU-pqwhznfeaQiNr0c7HyjRSFKQhp9G-Xq2mWw3iCYm_nF5asnUhySkhCapszyKgOzxE_Rgkcbvvv1XIVZkjBJDjwi6dJfDaKBf1T9uRfBKo_ICFMluwMWTi/s400/dfgdg.jpg" width="400" /></a></div>
<div style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"></span>
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<w:WordDocument>
<w:View>Normal</w:View>
<w:Zoom>0</w:Zoom>
<w:TrackMoves/>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:DoNotPromoteQF/>
<w:LidThemeOther>IN</w:LidThemeOther>
<w:LidThemeAsian>X-NONE</w:LidThemeAsian>
<w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:SnapToGridInCell/>
<w:WrapTextWithPunct/>
<w:UseAsianBreakRules/>
<w:DontGrowAutofit/>
<w:SplitPgBreakAndParaMark/>
<w:EnableOpenTypeKerning/>
<w:DontFlipMirrorIndents/>
<w:OverrideTableStyleHps/>
<w:UseFELayout/>
</w:Compatibility>
<m:mathPr>
<m:mathFont m:val="Cambria Math"/>
<m:brkBin m:val="before"/>
<m:brkBinSub m:val="--"/>
<m:smallFrac m:val="off"/>
<m:dispDef/>
<m:lMargin m:val="0"/>
<m:rMargin m:val="0"/>
<m:defJc m:val="centerGroup"/>
<m:wrapIndent m:val="1440"/>
<m:intLim m:val="subSup"/>
<m:naryLim m:val="undOvr"/>
</m:mathPr></w:WordDocument>
</xml><![endif]--></div>
<div style="text-align: justify;">
</div>
<div style="text-align: justify;">
<!--[if gte mso 9]><xml>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<![endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3. Pindah ke Tab “Boot” dan centang pilhan Safe boot</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Tekan Apply, dan Ok</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span></div>
<div style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">4. Restart Computer anda maka akan langsung masuk ke
Safe Mode.Catatan : Jika ingin masuk Kembali ke Normal Mode, Hilangkan
Centang pada “Safe Boot”.</span></div>
<div style="text-align: justify;">
</div>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-85004181948549023992013-05-16T07:12:00.001+07:002013-05-16T07:12:46.054+07:00Nilai Normal Laboratorium<!--[if gte mso 9]><xml>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Setiap laboratorium menentukan nilai
‘normal’, yang ditunjukkan pada kolom ‘Nilai Rujukan’ atau ‘Nilai Normal’ pada
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<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Determination</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
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</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Blood, Plasma or Serum</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Ammonia
(NH3) – diffusion</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">20-120
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">12-70
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Ammonia
Nitrogen</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">15-45
µg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">11-32
µmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Amylase</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">35-118
IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.58-1.97
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Anion gap (Na<sup><span style="border: 1pt none windowtext; padding: 0cm;">+</span></sup>-[Cl <sup><span style="border: 1pt none windowtext; padding: 0cm;">-</span></sup> + HCO3<sup><span style="border: 1pt none windowtext; padding: 0cm;">-</span></sup> ]) (P)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">7-16 mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">7-16
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Antithrombin
III (AT III)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">80–120
U/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">800–1200
U/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Bicarbonate</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Arterial</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">21–28
mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">21–28
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Venous</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">22–29
mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">22–29 mmol/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Bilirubin</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Conjugated
(direct) Total</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 0.2
mg/dl<br />
&<br />
0.1–1 mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 4
mcmol/L<br />
&<br />
2–18 mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Calcitonin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 100
pg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 100
ng/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Calcium</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Total</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8.6–10.3
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2.2–2.74
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Ionized</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.4–5.1
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1–1.3
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><a name='more'></a><br /></span></td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Carbon
dioxide content (plasma)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">21–32 mmol/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">21–32
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Carcinoembryonic
antigen</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 3
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 3
mcg/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Chloride</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">95–110
mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">95–110
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Coagulation screen</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Bleeding
time</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3–9.5 min</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">180–570
sec</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Prothrombin
time</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–13 sec</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–13 sec</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Partial
thromboplastin time (activated)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">22–37 sec</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">22–37 sec</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Protein C</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.7–1.4
µ/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">700–1400
U/ml</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Protein S</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.7–1.4
µ/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">700–1400
U/ml</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Copper,
total</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">70–160
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">11–25
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Corticotropin
(ACTH adrenocorticotropic hormone) – 0800 hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 60
pg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 13.2
pmol/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Cortisol</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0800 hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5–30
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">138–810
nmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1800 hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2–15
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">50–410
nmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2000 hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 50% of
0800 hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 50% of
0800 hr</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Creatine kinase</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Female</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">20–170
IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.33–2.83
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Male</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">30–220
IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5–3.67
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Creatinine
kinase isoenzymes, MB fraction</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0–12 IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0–0.2
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Creatinine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5–1.7
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">44–150
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fibrinogen
(coagulation factor I)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">150–360
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.5–3.6
g/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Follicle-stimulating hormone (FSH)</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Female</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2–13
mlU/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2–13 IU/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Midcycle</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5–22
mlU/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5–22 IU/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Male</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1–8 mlU/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1–8 IU/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Glucose,
fasting</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">65–115
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.6–6.3
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<br /><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Glucose Tolerance Test (Oral)</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 100%px;">
<tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt; width: 40%;" valign="bottom" width="40%"><span style="font-size: small;"><br /></span></td>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(mg/dl)</span></span></div>
</td>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(mmol/L)</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Normal</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Diabetic</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Normal</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Diabetic</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fasting</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">70–105</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 140</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.9–5.8</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 7.8</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">60 min</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">120–170</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 200</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">6.7–9.4</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 11.1</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">90 min</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">100–140</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 200</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5.6–7.8</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 11.1</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">120 min</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">70–120</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 140</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.9–6.7</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 7.8</span></span></div>
</td>
</tr>
</tbody></table>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">(g) – Glutamyltransferase (GGT)</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Male</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">9–50
units/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">9–50
units/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Female</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8–40
units/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8–40
units/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Haptoglobin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">44–303
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.44–3.03
g/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Hematologic Tests</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fibrinogen</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">200–400
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2–4 g/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Hematocrit (Hct)</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">female</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">36%-44.6%</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.36–0.446
fraction of 1</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">male</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">40.7%-50.3%</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.4–0.503
fraction of 1</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Hemoglobin A <sub><span style="border: 1pt none windowtext; padding: 0cm;">1C</span></sub></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5.3%-7.5%
of total Hgb</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.053–0.075</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Hemoglobin (Hb)</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">female</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">12.1–15.3
g/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">121–153
g/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">male</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">13.8–17.5
g/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">138–175
g/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Leukocyte
count (WBC)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3800–9800/mcl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.8–9.8 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">9</span></sup>/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Erythrocyte count (RBC)</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">female</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.5–5 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">6</span></sup>/mcl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.5–5 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">12</span></sup>/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">male</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.3–5.9 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">6</span></sup>/mcl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.3–5.9 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">12</span></sup>/L</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Mean
corpuscular volume (MCV)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">80–97.6 mcm<sup><span style="border: 1pt none windowtext; padding: 0cm;">3</span></sup></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">80–97.6 fl</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Mean
corpuscular hemoglobin (MCH)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">27–33
pg/cell</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.66–2.09
fmol/cell</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Mean
corpuscular hemoglobin concentrate (MCHC)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">33–36 g/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">20.3–22
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Erythrocyte
sedimentation rate (sedrate, ESR)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£30 mm/hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£30 mm/hr</span></span></div>
</td>
</tr>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Erythrocyte enzymes</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Glucose-6
– Pphosphate dehydrognase (G-6-PD)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">250–5000 units/10<sup><span style="border: 1pt none windowtext; padding: 0cm;">6</span></sup>cells</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">250–5000
mcunits/cell</span></span></div>
</td>
</tr>
</tbody></table>
</div>
<span style="font-size: small;">
</span><div align="center" class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<br /></div>
<span style="font-size: small;">
</span><div align="center">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 100%px;">
<tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Determination</span></span></div>
</td>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Reference Value</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(<i>Conventional units</i>)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(<i>SI units</i>)</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Blood, Plasma or Serum:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Ammonia (NH<sub><span style="border: 1pt none windowtext; padding: 0cm;">3</span></sub>) – diffusion</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">20–120
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">12–70
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Ammonia
Nitrogen</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">15–45
µg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">11–32
µmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Amylase</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">35–118
IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.58–1.97
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Anion gap (Na<sup><span style="border: 1pt none windowtext; padding: 0cm;">+</span></sup>-[Cl <sup><span style="border: 1pt none windowtext; padding: 0cm;">-</span></sup> + HCO<sub><span style="border: 1pt none windowtext; padding: 0cm;">3</span></sub><sup><span style="border: 1pt none windowtext; padding: 0cm;">-</span></sup>]) (P)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">7–16 mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">7–16
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Antithrombin
III (AT III)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">80–120
U/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">800–1200
U/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 100%px;">
<tbody>
<tr>
<td rowspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Bicarbonate:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Arterial</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Venous</span></span></div>
</td>
</tr>
</tbody></table>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">21–28
mEq/L<br />
22–29 mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">21–28
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">22–29
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Bilirubin:
Conjugated (direct) Total</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 0.2
mg/dl<br />
(0.1–1 mg/dl)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 4
mcmol/L<br />
(2–18 mcmol/L)</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Calcitonin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 100
pg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 100
ng/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 95%px;">
<tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Calcium:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Total</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Ionized</span></span></div>
</td>
</tr>
</tbody></table>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8.6–10.3
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.4–5.1
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2.2–2.74
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1–1.3
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Carbon
dioxide content (plasma)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">21–32
mmol/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">21–32
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Carcinoembryonic
antigen</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 3
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 3
mcg/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Chloride</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">95–110
mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">95–110
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Coagulation screen:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Bleeding
time<br />
Prothrombin time</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Partial
thromboplastin time (activated)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Protein C</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Protein S</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3–9.5 min</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–13 sec</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">22–37 sec</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.7–1.4
µ/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.7–1.4
µ/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">180–570
sec</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–13 sec</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">22–37 sec</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">700–1400
U/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">700–1400
U/ml</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Copper,
total</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">70–160
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">11–25
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Corticotropin<br />
(ACTH adrenocorticotropic hormone) – 0800 hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 60
pg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 13.2
pmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 100%px;">
<tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Cortisol:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0800 hr</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1800 hr</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2000 hr</span></span></div>
</td>
</tr>
</tbody></table>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5–30
mcg/dl<br />
2–15 mcg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 50% of
0800 hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">138–810
nmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">50–410
nmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 50% of
0800 hr</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 95%px;">
<tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Creatine kinase:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Female</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Male</span></span></div>
</td>
</tr>
</tbody></table>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">20–170
IU/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">30–220
IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.33–2.83
mckat/L<br />
0.5–3.67 mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Creatinine
kinase isoenzymes, MB fraction</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0–12 IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0–0.2
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Creatinine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5–1.7
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">44–150
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fibrinogen
(coagulation factor I)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">150–360
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.5–3.6
g/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Follicle-stimulating hormone (FSH):</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Female</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Midcycle</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Male</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2–13
mlU/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5–22
mlU/ml<br />
1–8 mlU/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2–13 IU/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5–22 IU/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1–8 IU/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Glucose,
fasting</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">65–115
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.6–6.3
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Glucose Tolerance Test (Oral)</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fasting</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">60 min<br />
90 min</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">120 min</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 95%px;">
<tbody>
<tr>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(mg/dl)</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><i><u><span style="font-family: "Times New Roman","serif";">Normal</span></u></i><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><i><u><span style="font-family: "Times New Roman","serif";">Diabetic</span></u></i><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">70–105</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 140</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">120–170</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 200</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">100–140</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 200</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">70–120</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 140</span></span></div>
</td>
</tr>
</tbody></table>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 95%px;">
<tbody>
<tr>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(mmol/L)</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><i><u><span style="font-family: "Times New Roman","serif";">Normal</span></u></i><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><i><u><span style="font-family: "Times New Roman","serif";">Diabetic</span></u></i><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.9–5.8</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 7.8</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">6.7–9.4</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 11.1</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5.6–7.8</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 11.1</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.9–6.7</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 7.8</span></span></div>
</td>
</tr>
</tbody></table>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(g)
-Glutamyltransferase (GGT):</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Male</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Female</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">9–50
units/L<br />
8–40 units/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">9–50
units/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8–40
units/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Haptoglobin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">44–303
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.44–3.03
g/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
</tr>
<tr>
<td rowspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Determination</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Reference Value</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Conventional units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">SI units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Hematologic tests:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fibrinogen</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Hematocrit (Hct)</span></u><span style="font-family: "Times New Roman","serif";">,<br />
female</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">male</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Hemoglobin A <sub><span style="border: 1pt none windowtext; padding: 0cm;">1C</span></sub></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Hemoglobin (Hb)</span></u><span style="font-family: "Times New Roman","serif";">,<br />
female</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">male</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Leukocyte count (WBC)<br />
<u><span style="border: 1pt none windowtext; padding: 0cm;">Erythrocyte count (RBC):</span></u><br />
female</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">male</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Mean
corpuscular volume (MCV)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Mean
corpuscular hemoglobin<br />
(MCH)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Mean
corpuscular hemoglobin</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">concentrate
(MCHC)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Erythrocyte
sedimentation rate</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(sedrate,
ESR)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">200–400
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">36%-44.6%</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">40.7%-50.3%</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5.3%-7.5%
of total Hgb</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">12.1–15.3
g/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">13.8–17.5
g/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3800–9800/mcl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.5–5 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">6</span></sup>/mcl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.3–5.9 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">6</span></sup>/mcl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">80–97.6 mcm<sup><span style="border: 1pt none windowtext; padding: 0cm;">3</span></sup></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">27–33
pg/cell</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">33–36 g/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£30 mm/hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2–4 g/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.36–0.446
fraction of 1</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.4–0.503
fraction of 1</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.053–0.075</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">121–153
g/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">138–175
g/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.8–9.8 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">9</span></sup>/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.5–5 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">12</span></sup>/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.3–5.9 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">12</span></sup>/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">80–97.6 fl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.66–2.09
fmol/cell</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">20.3–22
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 30 mm/hr</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Erythrocyte enzymes:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Glucose-6
-<br />
Pphosphate dehydrognase</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(G-6-PD)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Ferritin</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Folic acid:</span></u><span style="font-family: "Times New Roman","serif";"> normal</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Platelet
count</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Reticulocytes</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Vitamin B<sub><span style="border: 1pt none windowtext; padding: 0cm;">12</span></sub></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">250–5000 units/10<sup><span style="border: 1pt none windowtext; padding: 0cm;">6</span></sup>cells</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–383
ng/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">>3.1–12.4
ng/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">150–450 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">3</span></sup>/mcl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5%-1.5%
of erythrocytes</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">223–1132
pg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">250–5000
mcunits/cell</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">23–862
pmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">7–28.1
nmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">150–450 x 10<sup><span style="border: 1pt none windowtext; padding: 0cm;">9</span></sup>/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.005–0.015</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">165–835
pmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 95%px;">
<tbody>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Iron:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Female</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Male</span></span></div>
</td>
</tr>
</tbody></table>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">30–160
mcg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">45–160
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5.4–31.3
mcmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8.1–31.3
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Iron
binding capacity</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">220–420
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">39.4–75.2
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Isocitrate
dehydrogenase</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.2–7
units/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.2–7
units/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Isoenzymes</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fraction 1</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fraction 2</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fraction 3</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fraction 4</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fraction 5</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">14%-26% of
total</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">29%-39% of
total</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">20%-26% of
total</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8%-16% of
total</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">6%-16% of
total</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.14–0.26
fraction of total</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.29–0.39
fraction of total<br />
0.20–0.26 fraction of total</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.08–0.16
fraction of total</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.06–0.16
fraction of total</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Lactate
dehydrogenase</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">100–250
IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.67–4.17
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Lactic
acid (lactate)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">6–19 mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.7–2.1
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Lead</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 50
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">£ 2.41
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Lipase</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–150
units/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–150
units/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Lipids:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Total
Cholesterol</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Desirable</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Borderline-high</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">High</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">LDL</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Desirable</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Borderline-high</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">High</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">HDL (low)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Triglycerides</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Desirable</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Borderline-high</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">High</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Very high</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 200
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">200–239
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 239
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 130
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">130–159
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 159
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 35
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 200
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">200–400
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">400–1000
mg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 1000
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 5.2
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";"><
5.2–6.2 mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 6.2
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 3.36
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.36–4.11
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 4.11
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 0.91
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 2.26
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2.26–4.52
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.52–11.3
mmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 11.3
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Magnesium</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.3–2.2
mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.65–1.1
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Osmolality</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">280–300
mOsm/kg</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">280–300
mmol/kg</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Oxygen
saturation (arterial)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">94%-100%</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.94 –
fraction of 1</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">PCO<sub><span style="border: 1pt none windowtext; padding: 0cm;">2</span></sub>, arterial</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">35–45 mm
Hg</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.7–6 kPa</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">pH,
arterial</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">7.35–7.45</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">7.35–7.45</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
</tr>
<tr>
<td rowspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Determination</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Reference Value</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Conventional units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">SI units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">PO,
arterial: Breathing room air</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">On 100% O</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">80–105 mm
Hg</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">> 500
mm Hg</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10.6–14
kPa</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Phosphatase
(acid), total at 37°C</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.13–0.63
IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2.2–10.5
IU/L or</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2.2–10.5
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Phosphatase
alkaline</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">20–130
IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">20–130
IU/L or</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.33–2.17
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Phosphorus,
inorganic, (phosphate)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2.5–5
mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.8–1.6
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Potassium</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.5–5
mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.5–5
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Progesterone</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Female</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Follicular
phase</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Luteal
phase</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Male</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.1–1.5
ng/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.1–1.5
ng/ml<br />
2.5–28 ng/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 0.5
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.32–4.8
nmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.32–4.8
nmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8–89
nmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 1.6
nmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Prolactin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.4–24.2
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.4–24.2
mcg/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><i><span style="font-family: "Times New Roman","serif";">Prostate specific antigen</span></i><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Protein:</span></u><span style="font-family: "Times New Roman","serif";"> Total<br />
Albumin</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Globulin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0–4 ng/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">6–8 g/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.6–5 g/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2.3–3.5
g/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0–4 ng/ml<br />
60–80 g/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">36–50 g/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">23–35 g/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Rheumatoid
factor</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 60
IU/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 60
kIU/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Sodium</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">135–147
mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">135–147
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Testosterone:</span></u><span style="font-family: "Times New Roman","serif";"><br />
Female</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Male</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">6–86 ng/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">270–1070
ng/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.21–3
nmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">9.3–37
nmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Thyroid Hormone Function Tests:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Thyroid-stimulating
hormone (TSH)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Thyroxine-binding
globulin capacity</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Total triiodothyronine (T<sub><span style="border: 1pt none windowtext; padding: 0cm;">3</span></sub>)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Total thyroxine by RIA (T<sub><span style="border: 1pt none windowtext; padding: 0cm;">4</span></sub>)<br />
T<sub><span style="border: 1pt none windowtext; padding: 0cm;">3</span></sub> resin uptake</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.35–6.2
mcU/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–26
mcg/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">75–220
ng/dl</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4–11
mcg/dl<br />
25%-38%</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.35–6.2
mU/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">100–260
mcg/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.2–3.4
nmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">51–142
nmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.25–0.38
fraction of 1</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Transaminase,
AST (aspartate aminotransferase, SGOT)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">11–47 IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.18–0.78
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Transaminase,
ALT (alanine aminotransferase, SGPT)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">7–53 IU/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.12–0.88
mckat/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Transferrin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">220–400
mg/dL</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2.20–4.00
g/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Urea
nitrogen (BUN)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8–25 mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2.9–8.9
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Uric acid</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3–8 mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">179–476
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Vitamin A
(retinol)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">15–60
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.52–2.09
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Zinc</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">50–150
mcg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">7.7–23
mcmol/L</span></span></div>
</td>
</tr>
</tbody></table>
</div>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><sup><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">1</span></sup><span style="font-family: "Times New Roman","serif";"> Tergantung pada usia</span></span></div>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><sup><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">2</span></sup><span style="font-family: "Times New Roman","serif";"> Bayi dan anak sampai 104 U/L</span></span></div>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><sup><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">3</span></sup><span style="font-family: "Times New Roman","serif";"> Bayi usia 1 tahun sampai 6 mg/dl</span></span></div>
<span style="font-size: small;">
</span><table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 100%px;">
<tbody>
<tr>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Urine</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td rowspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Determination</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Reference Value</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Conventional units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">SI units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Calcium</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">50–250
mcg/day</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.25–6.25
mmol/day</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Catecholamines:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Epinephrine</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Norepinephrine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 20
mcg/day</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 100
mcg/day</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 109
nmol/day</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 590
nmol/day</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Catecholamines,
24-hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 110
µg</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 650
nmol</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Copper</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">15–60
mcg/day</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.24–0.95
mcmol/day</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Creatinine:</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Child</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Adolescent</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Female<br />
Male</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8–22 mg/kg</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">8–30 mg/kg</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.6–1.5
g/day</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.8–1.8
g/day</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">71–195
µmol/kg<br />
71–265 µmol/kg</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5.3–13.3
mmol/day</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">7.1–15.9
mmol/day</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">pH</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.5–8</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.5–8</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Phosphate</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.9–1.3
g/day</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">29–42
mmol/day</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Potassium</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">25–100
mEq/day</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">25–100
mmol/day</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Protein</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Total</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">At rest</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1–14 mg/dL</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">50–80
mg/day</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–140
mg/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">50–80
mg/day</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Protein,
quantitative</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 150
mg/day</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 0.15
g/day</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Sodium</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">100–250
mEq/day</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">100–250
mmol/day</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Specific
gravity, random</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.002–1.030</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.002–1.030</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Uric acid,
24-hr</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">250–750 mg</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.48–4.43
mmol</span></span></div>
</td>
</tr>
</tbody></table>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><sup><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">1</span></sup><span style="font-family: "Times New Roman","serif";"> Tergantung pada diet.</span></span></div>
<span style="font-size: small;">
</span><table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 100%px;">
<tbody>
<tr>
<td colspan="4" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Drug Levels<a href="http://www.drarief.com/nilai-normal-laboratorium/normal.htm#FN05">*</a></span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td colspan="2" rowspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Drug Determination</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Reference Value</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Conventional units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">SI units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td rowspan="6" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><i><span style="font-family: "Times New Roman","serif";">Aminoglycosides</span></i><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Amikacin</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(trough)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(peak)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1–8 mcg/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.7–13.7
mcmol/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">20–30
mcg/ml<br />
34–51 mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Gentamicin</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(trough)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(peak)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5–2
mcg/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">6–10
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1–4.2
mcmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">12.5–20.9
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Kanamycin</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(trough)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(peak)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5–10
mcg/ml<br />
20–25 mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Netilimicin</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(trough)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(peak)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5–2
mcg/ml<br />
6–10 mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Streptomycin</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(trough)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(peak)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 5
mcg/ml<br />
5–20 mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Tobramycin</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(trough)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(peak)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5–2
mcg/ml<br />
5–20 mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.1–4.3
mcmol/L</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">12.8–21.8
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
</tr>
<tr>
<td colspan="2" rowspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Drug Determination</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Reference Value</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Conventional units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">SI units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td rowspan="13" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Antiarrhythmics</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Amiodarone</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5–2.5
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.5–4
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Bretylium</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5–1.5
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Digitoxin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">9–25 mcg/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">11.8–32.8
nmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Digoxin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.8–2
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.9–2.5
nmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Disopyramide</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2–8 mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">6–18
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Flecainide</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.2–1
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Lidocaine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">1.5–6
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.5–21.5
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Mexiletine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5–2
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Procainamide</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4–8 mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">17–34
mcmol/ml</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Propranolol</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">50–200
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">190–770
nmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Quinidine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2–6 mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4.6–9.2
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Tocainide</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4–10
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Verapamil</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.08–0.3
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td rowspan="5" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Anticonvulsants</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Carbamazepine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4–12
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">17–51
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Phenobarbital</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–40
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">43–172
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Phenytoin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–20
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">40–80
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Primidone</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">4–12
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">18–55
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Valproic
Acid</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">40–100
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">280–700
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td rowspan="11" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Antidepressants</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Amitriptyline</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">110–250
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">500–900
nmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Amoxapine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">200–500
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Bupropion</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">25–100
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Clomipramine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">80–100
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Desipramine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">115–300
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Doxepin</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">110–250
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Imipramine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">225–350
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Maprotiline</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">200–300
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Nortriptyline</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">50–150
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Protriptyline</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">70–250
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Trazodone</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">800–1600
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td rowspan="5" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Antipsychotics</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Chlorpromazine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">50–300
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">150–950
nmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Fluphenazine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.13–2.8
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Haloperidol</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5–20 ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Perphenazine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.8–1.2
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Thiothixene</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">2–57 ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom"><span style="font-size: small;"><br /></span></td>
</tr>
<tr>
<td colspan="2" rowspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Drug Determination</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Reference Value</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Conventional units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">SI units</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td rowspan="11" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Miscellaneous</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Amantadine</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Amrinone</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">300 ng/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">3.7 mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Chloramphenicol</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–20
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">31–62
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Cyclosporine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">250–800
ng/ml</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(whole
blood, RIA)<br />
50–300 ng/ml (plasma, RIA)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Ethanol</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0 mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0 mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Hydralazine</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">100 ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Lithium</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.6–1.2 mEq/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.6–1.2
mmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Salicylate</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">100–300
mg/L</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">724–2172
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Sulfonamide</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5–15 mg/dl</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Terbutaline</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">0.5–4.1
ng/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Theophylline</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">10–20
mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">55–110
mcmol/L</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Vancomycin</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(trough)</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">(peak)</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">5–15 ng/ml<br />
20–40 mcg/ml</span></span></div>
</td>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">nd</span></span></div>
</td>
</tr>
</tbody></table>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">* Nilai yang diberikan secara umum dapat digunakan untuk terapi tanpa
terjadi efek toksik pada kebanyakan pasien, Namun pengecualian juga tidak
jarang terjadi.</span></span></div>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><sup><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">1</span></sup><span style="font-family: "Times New Roman","serif";"> nd = data tidak tersedia.</span></span></div>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><sup><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">2</span></sup><span style="font-family: "Times New Roman","serif";"> Metabolit N-desmethyl beserta
turunannya.</span></span></div>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><sup><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">3</span></sup><span style="font-family: "Times New Roman","serif";"> Nilai 24 jam.</span></span></div>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><sup><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">4</span></sup><span style="font-family: "Times New Roman","serif";"> Toksik: 50–100 mg/dl (10.9–21.7
mmol/L).</span></span></div>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><i><span style="font-family: "Times New Roman","serif";">Diambil dari The Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure,
National Institutes of Health</span></i><span style="font-family: "Times New Roman","serif";">.</span></span></div>
<span style="font-size: small;">
</span><table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: none repeat scroll 0% 0% rgb(239, 239, 239); width: 100%px;">
<tbody>
<tr>
<td colspan="4" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><b><span style="font-family: "Times New Roman","serif";">Classification of Blood Pressure *</span></b><span style="font-family: "Times New Roman","serif";"></span></span></div>
</td>
</tr>
<tr>
<td rowspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Category</span></span></div>
</td>
<td colspan="3" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Reference value</span></span></div>
</td>
</tr>
<tr>
<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; text-align: center; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Systolic (mm Hg)</span></span></div>
</td>
<td colspan="2" style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Diastolic (mm Hg)</span></span></div>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Optimal</span></span></div>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 120</span></span></div>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">and</span></span></div>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 80</span></span></div>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Normal</span></span></div>
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<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">< 130</span></span></div>
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<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
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<span style="font-size: small;"><u><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">Hypertension</span></u><span style="font-family: "Times New Roman","serif";"></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Stage 1</span></span></div>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Stage 2</span></span></div>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">Stage 3</span></span></div>
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<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">140–159<br />
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<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 180</span></span></div>
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<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">or</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">or</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">or</span></span></div>
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<td style="background: none repeat scroll 0% 0% rgb(255, 248, 239); border: 1pt solid rgb(223, 190, 139); padding: 3pt 4.5pt;" valign="bottom">
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">90–99<br />
100–109</span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">³ 110</span></span></div>
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<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 18pt; vertical-align: baseline;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif";">* Untuk dewasa berusia 18 atau lebih yang tidak dalam pengobatan anti
hipertensi dan tidak dalam kondisi akut. Ketika tekanan sistole dan diastole
masuk ke dalam kategori lain, maka kategori di atasnya harus dipilih untuk
menentukan klasifikasi status tekanan darah penderita. Sebagai tambahan dalam
menentukan stadium hipertensi, seorang praktisi medis harus menentukan ada atau
tidaknya penyakit pada target organ serta faktor resiko lainnya.</span></span></div>
<span style="font-size: small;">
</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><sup><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">1</span></sup><span style="font-family: "Times New Roman","serif";"> Tekanan darah yang optimal
terhadap resiko kardiovaskular adalah dibawah 120/88 m Hg. Namun demikian,
nilai rendah yang tidak wajar harus dievaluasi untuk menemukan kelainan klinis
yang signifikan.</span></span></div>
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</span><div class="MsoNormal" style="line-height: 15.75pt; margin-bottom: 0.0001pt; vertical-align: baseline;">
<span style="font-size: small;"><sup><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; padding: 0cm;">2</span></sup><span style="font-family: "Times New Roman","serif";"> Berdasarkan atas pembacaan
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<![endif]-->arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-67779043773499649812013-05-14T07:36:00.002+07:002013-05-16T08:28:30.852+07:00TRIK TES AMPUH DAN TIDAKNYA ANTIVIRUS KOMPUTER KITA <div style="text-align: justify;">
Nih bro, Ridz akan kasih trik bagus dimana dapat membantu kita untuk mengecek seberapa ampuhkah antivirus yang terpasang di komputer kita. adapun caranya adalah sebagai berikut :<br /><br />1. Klik tombol START di kiri bawah komputer anda<br />2. Pilih ALL programs cari folder accessories dan buka folder tersebut dan pilih NOTEPAD, Anda akan menemukan NOTEPAD yang masih kosong<br /><br />3. Isi NOTEPAD tersebut dengan kode dibawah ini : <br /><br />X5O!P%@AP[4\PZX54(P^)7CC)7}$EICAR-STANDARD-ANTIVIRUS-TEST-FILE!$H+H*<br /><br />4. Lalu save as dengan dengan format ( exe ) contohnya : checkantivirus.exe.<br /><br /><br />Antivirus anda akan mendeteksi file ini dan berusaha untuk menghapusnya, jadi definisinya setelah Anda menyimpan file ini jika file tersebut terhapus oleh antivirus yang terpasang di komputer atau laptop kalian Itu membuktikan antivirus kalian bekerja dengan benar, jika tidak, coba ganti antivirus anda dengan yang lain.<br /></div>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-86620214101857557242013-02-23T12:33:00.003+07:002013-05-16T12:02:10.622+07:005 Imunisasi yang harus diberikan pada Bayi<div style="text-align: justify;">
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</xml><![endif]--><span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Inilah 5 jenis imunisasi yang wajib diperoleh bayi sebelum usia setahun.
Penyakit-penyakit yang hendak ditangkalnya memiliki angka kesakitan dan
kematian yang tinggi, selain bisa menimbulkan kecacatan.</span></i></span></span></div>
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<tr><td style="text-align: center;"><span style="font-family: inherit;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhblEaRJ9ypWMq-jATIiEJ0kwKdSTPl-1ufUsyKBbpt46BMNjLLVvZxPL8RrzCt1GK809DwQl3YbnvMaaDPJu_-xgw6mlg4avVKvkRHezXVG64yf5DU2fcjjxq7MQ0K63O9ip0yWoMVctER/s1600/Untitled.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="262" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhblEaRJ9ypWMq-jATIiEJ0kwKdSTPl-1ufUsyKBbpt46BMNjLLVvZxPL8RrzCt1GK809DwQl3YbnvMaaDPJu_-xgw6mlg4avVKvkRHezXVG64yf5DU2fcjjxq7MQ0K63O9ip0yWoMVctER/s320/Untitled.jpg" width="320" /></a></span></span></td></tr>
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<span style="font-family: inherit;"><span style="font-size: small;"><i><b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1. IMUNISASI BCG</span></b></i><br /><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">
Ketahanan terhadap penyakit TB (Tuberkulosis) berkaitan dengan keberadaan virus
tubercle bacili yang hidup di dalam darah. Itulah mengapa, agar memiliki
kekebalan aktif, dimasukkanlah jenis basil tak berbahaya ini ke dalam tubuh,
alias vaksinasi BCG (Bacillus Calmette-Guerin).</span></i></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Seperti diketahui, Indonesia termasuk negara endemis TB (penyakit TB
terus-menerus ada sepanjang tahun) dan merupakan salah satu negara dengan
penderita TB tertinggi di dunia. TB disebabkan kuman Mycrobacterium
tuberculosis, dan mudah sekali menular melalui droplet, yaitu butiran air di
udara yang terbawa keluar saat penderita batuk, bernapas ataupun bersin.
Gejalanya antara lain: berat badan anak susah bertambah, sulit makan, mudah
sakit, batuk berulang, demam dan berkeringat di malam hari, juga diare
persisten. Masa inkubasi TB rata-rata berlangsung antara 8-12 minggu.</span></i></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><i><a href="http://www.blogger.com/blogger.g?blogID=2501725445038181687" name="more"></a><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><br />
Untuk mendiagnosis anak terkena TB atau tidak, perlu dilakukan tes rontgen
untuk mengetahui adanya vlek, tes Mantoux untuk mendeteksi peningkatan kadar
sel darah putih, dan tes darah untuk mengetahui ada-tidak gangguan laju endap
darah. Bahkan, dokter pun perlu melakukan wawancara untuk mengetahui, apakah si
kecil pernah atau tidak, berkontak dengan penderita TB.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jika anak positif terkena TB, dokter akan memberikan obat antibiotik khusus
TB yang harus diminum dalam jangka panjang, minimal 6 bulan. Lama pengobatan
tak bisa diperpendek karena bakteri TB tergolong sulit mati dan sebagian ada
yang “tidur”. Karenanya, mencegah lebih baik daripada mengobati. Selain
menghindari anak berkontak dengan penderita TB, juga meningkatkan daya tahan
tubuhnya yang salah satunya melalui pemberian imunisasi BCG.</span></i></span></span><br />
<a name='more'></a></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Jumlah Pemberian:<br />
Cukup 1 kali saja, tak perlu diulang (booster). Sebab, vaksin BCG berisi kuman
hidup sehingga antibodi yang dihasilkannya tinggi terus. Berbeda dengan vaksin
berisi kuman mati, hingga memerlukan pengulangan.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Usia Pemberian:<br />
Di bawah 2 bulan. Jika baru diberikan setelah usia 2 bulan, disarankan tes
Mantoux (tuberkulin) dahulu untuk mengetahui apakah si bayi sudah kemasukan
kuman Mycobacterium tuberculosis atau belum. Vaksinasi dilakukan bila hasil
tesnya negatif. Jika ada penderita TB yang tinggal serumah atau sering
bertandang ke rumah, segera setelah lahir si kecil diimunisasi BCG</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Lokasi Penyuntikan:<br />
Lengan kanan atas, sesuai anjuran WHO. Meski ada juga petugas medis yang
melakukan penyuntikan di paha.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Efek Samping:<br />
Umumnya tidak ada. Namun pada beberapa anak timbul pembengkakan kelenjar getah
bening di ketiak atau leher bagian bawah (atau di selangkangan bila penyuntikan
dilakukan di paha). Biasanya akan sembuh sendiri.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Tanda Keberhasilan:<br />
Muncul bisul kecil dan bernanah di daerah bekas suntikan setelah 4-6 minggu.
Tidak menimbulkan nyeri dan tak diiringi panas. Bisul akan sembuh sendiri dan
meninggalkan luka parut.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jikapun bisul tak muncul, tak usah cemas. Bisa saja dikarenakan cara
penyuntikan yang salah, mengingat cara menyuntikkannya perlu keahlian khusus
karena vaksin harus masuk ke dalam kulit. Apalagi bila dilakukan di paha,
proses menyuntikkannya lebih sulit karena lapisan lemak di bawah kulit paha
umumnya lebih tebal.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jadi, meski bisul tak muncul, antibodi tetap terbentuk, hanya saja dalam
kadar rendah. Imunisasi pun tak perlu diulang, karena di daerah endemis TB,
infeksi alamiah akan selalu ada. Dengan kata lain, anak akan mendapat vaksinasi
alamiah.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Indikasi Kontra:<br />
Tak dapat diberikan pada anak yang berpenyakit TB atau menunjukkan Mantoux
positif.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2. Imunisasi Hepatitis B</span></b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><br />
Lebih dari 100 negara memasukkan vaksinasi ini dalam program nasionalnya.
Apalagi Indonesia yang termasuk negara endemis tinggi penyakit hepatitis. Jika
menyerang anak, penyakit yang disebabkan virus ini sulit disembuhkan. Bila
sejak lahir telah terinfeksi virus hepatitis B (VHB), dapat menyebabkan
kelainan-kelainan yang dibawanya terus hingga dewasa. Sangat mungkin terjadi
sirosis atau pengerutan hati (kerusakan sel hati yang berat). Bahkan yang lebih
buruk bisa mengakibatkan kanker hati.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Banyak jalan masuknya VHB ke tubuh si kecil. Yang potensial melalui jalan
lahir. Bisa sejak dalam kandungan sudah tertular dari ibu yang mengidap
hepatitis B atau saat proses kelahiran. Cara lain melalui kontak dengan darah
penderita, semisal transfusi darah.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bisa juga melalui alat-alat medis yang sebelumnya telah terkontaminasi
darah dari penderita hepatitis B, seperti jarum suntik yang tidak steril atau
peralatan yang ada di klinik gigi. Bahkan juga lewat sikat gigi atau sisir
rambut yang digunakan antaranggota keluarga.<br />
Malangnya, tak ada gejala khas yang tampak secara kasat mata. Bahkan oleh
dokter sekalipun. Fungsi hati kadang tak terganggu meski sudah mengalami
sirosis.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Tidak cuma itu. Anak juga terlihat sehat, nafsu makannya baik, berat
tubuhnya pun naik dengan bagus pula. Penyakitnya baru ketahuan setelah
dilakukan pemeriksaan darah. Gejala baru tampak begitu hati si penderita tak
mampu lagi mempertahankan metabolisme tubuhnya.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Upaya pencegahan adalah langkah terbaik. Jika ada salah satu anggota
keluarga dicurigai kena VHB, biasanya dilakukan screening terhadap anak-anaknya
untuk mengetahui apakah membawa virus atau tidak. Pemeriksaan harus dilakukan
kendati anak tak menunjukkan gejala sakit apa pun. Selain itu, imunisasi
merupakan langkah efektif untuk mencegah masuknya VHB.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Jumlah Pemberian:<br />
Sebanyak 3 kali, dengan interval 1 bulan antara suntikan pertama dan kedua,
kemudian 5 bulan antara suntikan kedua dan ketiga.</span></i></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Usia Pemberian:<br />
Sekurang-kurangnya 12 jam setelah lahir. Dengan syarat, kondisi bayi stabil,
tak ada gangguan pada paru-paru dan jantung. Dilanjutkan pada usia 1 bulan, dan
usia antara 3-6 bulan. Khusus bayi yang lahir dari ibu pengidap VHB, selain
imunisasi yang dilakukan kurang dari 12 jam setelah lahir, juga diberikan
imunisasi tambahan dengan imunoglobulin antihepatitis B dalam waktu sebelum
berusia 24 jam.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Lokasi Penyuntikan:<br />
Pada anak di lengan dengan cara intramuskuler. Sedangkan pada bayi di paha
lewat anterolateral (antero = otot-otot di bagian depan; lateral = otot bagian
luar). Penyuntikan di bokong tak dianjurkan karena bisa mengurangi efektivitas
vaksin.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Efek Samping:<br />
Umumnya tak terjadi. Jikapun ada (kasusnya sangat jarang), berupa keluhan nyeri
pada bekas suntikan, yang disusul demam ringan dan pembengkakan. Namun reaksi
ini akan menghilang dalam waktu dua hari.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Tanda Keberhasilan:<br />
Tak ada tanda klinis yang dapat dijadikan patokan. Namun dapat dilakukan
pengukuran keberhasilan melalui pemeriksaan darah dengan mengecek kadar hepatitis
B-nya setelah anak berusia setahun. Bila kadarnya di atas 1000, berarti daya
tahannya 8 tahun; di atas 500, tahan 5 tahun; di atas 200, tahan 3 tahun.
Tetapi kalau angkanya cuma 100, maka dalam setahun akan hilang. Sementara bila
angkanya nol berarti si bayi harus disuntik ulang 3 kali lagi.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Tingkat Kekebalan:<br />
Cukup tinggi, antara 94-96%. Umumnya, setelah 3 kali suntikan, lebih dari 95%
bayi mengalami respons imun yang cukup.</span></i></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Indikasi Kontra:<br />
Tak dapat diberikan pada anak yang menderita sakit berat.<b><br />
</b><br />
<b>3. Imunisasi Polio</b><br />
Belum ada pengobatan efektif untuk membasmi polio. Penyakit yang dapat
menyebabkan kelumpuhan ini, disebabkan virus poliomyelitis yang sangat menular.
Penularannya bisa lewat makanan/minuman yang tercemar virus polio.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bisa juga lewat percikan ludah/air liur penderita polio yang masuk ke mulut
orang sehat.<br />
Virus polio berkembang biak dalam tenggorokan dan saluran pencernaan atau usus,
lalu masuk ke aliran darah dan akhirnya ke sumsum tulang belakang hingga bisa
menyebabkan kelumpuhan otot tangan dan kaki. Bila mengenai otot pernapasan,
penderita akan kesulitan bernapas dan bisa meninggal.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Masa inkubasi virus antara 6-10 hari. Setelah demam 2-5 hari, umumnya akan
mengalami kelumpuhan mendadak pada salah satu anggota gerak. Namun tak semua
orang yang terkena virus polio akan mengalami kelumpuhan, tergantung keganasan
virus polio yang menyerang dan daya tahan tubuh si anak. Nah, imunisasi polio
akan memberikan kekebalan terhadap serangan virus polio.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Jumlah Pemberian:<br />
Bisa lebih dari jadwal yang telah ditentukan, mengingat adanya imunisasi polio
massal. Namun jumlah yang berlebihan ini tak akan berdampak buruk. Ingat, tak
ada istilah overdosis dalam imunisasi!</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Usia Pemberian:<br />
Saat lahir (0 bulan), dan berikutnya di usia 2, 4, 6 bulan. Dilanjutkan pada
usia 18 bulan dan 5 tahun. Kecuali saat lahir, pemberian vaksin polio selalu
dibarengi dengan vaksin DTP.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Cara Pemberian:<br />
Bisa lewat suntikan (Inactivated Poliomyelitis Vaccine/IPV), atau lewat mulut
(Oral Poliomyelitis Vaccine/OPV). Di tanah air, yang digunakan adalah OPV.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Efek Samping:<br />
Hampir tak ada. Hanya sebagian kecil saja yang mengalami pusing, diare ringan,
dan sakit otot. Kasusnya pun sangat jarang.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Tingkat Kekebalan:<br />
Dapat mencekal hingga 90%.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Indikasi Kontra:<br />
Tak dapat diberikan pada anak yang menderita penyakit akut atau demam tinggi
(di atas 380C); muntah atau diare; penyakit kanker atau keganasan; HIV/AIDS;
sedang menjalani pengobatan steroid dan pengobatan radiasi umum; serta anak
dengan mekanisme kekebalan terganggu.<br />
<b><br />
</b><br />
<b>4. Imunisasi DTP</b><br />
Dengan pemberian imunisasi DTP, diharapkan penyakit difteri, tetanus, dan
pertusis, menyingkir jauh dari tubuh si kecil. Kekebalan segera muncul seusai
diimunisasi.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Usia & Jumlah Pemberian:<br />
Sebanyak 5 kali; 3 kali di usia bayi (2, 4, 6 bulan), 1 kali di usia 18 bulan,
dan 1 kali di usia 5 tahun. Selanjutnya di usia 12 tahun, diberikan imunisasi
TT</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Efek Samping:<br />
Umumnya muncul demam yang dapat diatasi dengan obat penurun panas. Jika
demamnya tinggi dan tak kunjung reda setelah 2 hari, segera bawa si kecil ke
dokter. Namun jika demam tak muncul, bukan berarti imunisasinya gagal, bisa
saja karena kualitas vaksinnya jelek, misal.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Untuk anak yang memiliki riwayat kejang demam, imunisasi DTP tetap aman.
Kejang demam tak membahayakan, karena si kecil mengalami kejang hanya ketika
demam dan tak akan mengalami kejang lagi setelah demamnya hilang. Jikapun
orangtua tetap khawatir, si kecil dapat diberikan vaksin DTP asesular yang tak
menimbulkan demam. Kalaupun terjadi demam, umumnya sangat ringan, hanya sekadar
sumeng.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">* Indikasi Kontra:<br />
Tak dapat diberikan kepada mereka yang kejangnya disebabkan suatu penyakit
seperti epilepsi, menderita kelainan saraf yang betul-betul berat atau habis
dirawat karena infeksi otak, dan yang alergi terhadap DTP. Mereka hanya boleh
menerima vaksin DT tanpa P karena antigen P inilah yang menyebabkan panas.<br />
Penyakit DTP yang BERBAHAYA</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1. Difteri</span></b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><br />
Penyakit yang disebabkan kuman Corynebacterium diphtheriae ini, gejalanya mirip
radang tenggorokan, yaitu batuk, suara serak, dan tenggorokan sakit. Namun,
difteri tak disertai panas sebagaimana yang terjadi pada radang tenggorokan.
Gejala lain difteri adalah kesulitan bernapas (leher seperti tercekik dan napas
berbunyi), sehingga wajah dan tubuh membiru, serta adanya lapisan putih pada
lidah dan bibir.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bakteri penyebab difteri ditularkan saat batuk, bersin, atau kala
berbicara. Masa inkubasinya 1-6 hari. Penderita harus mendapatkan perawatan di
rumah sakit dalam waktu cukup lama, sekitar 2-3 minggu, dan baru boleh pulang
setelah penyakitnya benar-benar hilang 100%. Soalnya, difteri bisa kambuh lagi
kalau belum betul-betul sembuh.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2. Tetanus</span></b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><br />
Disebabkan oleh bakteri Clostridium Tetani, penyakit ini berisiko menyebabkan
kematian. Infeksi tetanus bisa terjadi karena luka, sekecil apa pun luka itu.
Tetanus rawan menyerang bayi baru lahir, biasanya karena tindakan atau
perawatan yang tidak steril.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Gejala-gejala yang tampak antara lain kejang otot rahang, rasa sakit dan
kaku di leher, bahu atau punggung. Kejang-kejang secara cepat merambat ke otot
perut, lengan atas dan paha. Pengobatan dilakukan dengan pemberian antibiotik
untuk mematikan kuman, antikejang untuk merilekskan otot-otot, dan antitetanus
untuk menetralisir toksinnya.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3. Pertusis</span></b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><br />
Disebut juga kinghoest, batuk rejan, atau batuk 100 hari lantaran batuknya
memang berlangsung lama, bisa sampai 3 bulan. Penyakit ini mudah sekali menular
melalui udara yang mengandung bakteri Bordetella pertussis. Masa inkubasinya
6-20 hari.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Gejala awalnya seperti flu biasa, yaitu demam ringan, batuk, dan pilek,
yang berlangsung selama 1-2 minggu. Kemudian, gejala batuknya mulai nyata dan
kuat, batuk panjang secara terus-menerus yang berbeda dengan batuk biasa. Tak
jarang, karena kuatnya batuk ini, anak bisa sampai menungging-nungging,
muntah-muntah, mata merah, berair, dan napasnya susah. Gejalanya sangat berat.
Bahkan beberapa penderita bisa mengalami perdarahan. Setelah 2-4 minggu
berlalu, batuk mulai berkurang dan kondisi anak mulai pulih.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penderita akan diberi obat antibiotik untuk mematikan kuman, dan obat untuk
mengurangi/menghentikan batuknya. Istirahat yang cukup, banyak minum, dan
konsumsi makanan bergizi akan membantu mempercepat kesembuhan.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">5. Imunisasi Campak</span></b><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><br />
Sebenarnya, bayi sudah mendapat kekebalan campak dari ibunya. Namun seiring
bertambahnya usia, antibodi dari ibunya semakin menurun sehingga butuh antibodi
tambahan lewat pemberian vaksin campak. Apalagi penyakit campak mudah menular,
dan mereka yang daya tahan tubuhnya lemah gampang sekali terserang penyakit
yang disebabkan virus Morbili ini. Untungnya, campak hanya diderita sekali
seumur hidup. Jadi, sekali terkena campak, setelah itu biasanya tak akan
terkena lagi.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penularan campak terjadi lewat udara atau butiran halus air ludah (droplet)
penderita yang terhirup melalui hidung atau mulut. Pada masa inkubasi yang
berlangsung sekitar 10-12 hari, gejalanya sulit dideteksi. Setelah itu barulah
muncul gejala flu (batuk, pilek, demam), mata kemerah-merahan dan berair, si
kecil pun merasa silau saat melihat cahaya. Kemudian, di sebelah dalam mulut
muncul bintik-bintik putih yang akan bertahan 3-4 hari. Beberapa anak juga
mengalami diare.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Satu-dua hari kemudian timbul demam tinggi yang turun naik, berkisar
38-40,5°C. Seiring dengan itu, barulah keluar bercak-bercak merah yang
merupakan ciri khas penyakit ini. Ukurannya tidak terlalu besar, tapi juga tak
terlalu kecil. Awalnya hanya muncul di beberapa bagian tubuh saja seperti
kuping, leher, dada, muka, tangan dan kaki. Dalam waktu 1 minggu, bercak-bercak
merah ini akan memenuhi seluruh tubuh. Namun bila daya tahan tubuhnya baik,
bercak-bercak merah ini hanya di beberapa bagian tubuh saja dan tidak banyak.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jika bercak merah sudah keluar, umumnya demam akan turun dengan sendirinya.
Bercak merah pun akan berubah jadi kehitaman dan bersisik, disebut hiperpigmentasi.
Pada akhirnya bercak akan mengelupas atau rontok atau sembuh dengan sendirinya.
Umumnya, dibutuhkan waktu hingga 2 minggu sampai anak sembuh benar dari
sisa-sisa campak. Dalam kondisi ini, tetaplah meminum obat yang sudah diberikan
dokter. Jaga stamina dan konsumsi makanan bergizi. Pengobatannya bersifat
simptomatis, yaitu mengobati berdasarkan gejala yang muncul. Hingga saat ini,
belum ditemukan obat yang efektif mengatasi virus campak.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jika tak ditangani dengan baik campak bisa sangat berbahaya. Bisa terjadi
komplikasi, terutama pada campak yang berat. Ciri-ciri campak berat, selain
bercaknya di sekujur tubuh, gejalanya tidak membaik setelah diobati 1-2 hari.
Komplikasi yang terjadi biasanya berupa radang paru-paru (broncho pneumonia)
dan radang otak (ensefalitis). Komplikasi inilah yang umumnya paling sering
menimbulkan kematian pada anak.</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Usia & Jumlah Pemberian:<br />
Sebanyak 2 kali; 1 kali di usia 9 bulan, 1 kali di usia 6 tahun. Dianjurkan,
pemberian campak ke-1 sesuai jadwal. Selain karena antibodi dari ibu sudah
menurun di usia 9 bulan, penyakit campak umumnya menyerang anak usia balita.
Jika sampai 12 bulan belum mendapatkan imunisasi campak, maka pada usia 12
bulan harus diimunisasi MMR (Measles Mumps Rubella).</span></i></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;"><i><span style="font-family: "Arial","sans-serif"; font-size: 12.0pt; line-height: 150%; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Efek Samping:<br />
Umumnya tidak ada. Pada beberapa anak, bisa menyebabkan demam dan diare, namun
kasusnya sangat kecil. Biasanya demam berlangsung seminggu. Kadang juga
terdapat efek kemerahan mirip campak selama 3 hari.</span></i></span></span></div>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com2tag:blogger.com,1999:blog-2501725445038181687.post-38970393949847289562012-12-23T07:10:00.000+07:002013-05-16T08:20:57.184+07:00PJR (Penyakit jantung Reumatik)<!--[if !mso]>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 12pt; line-height: 150%;">PEMBAHASAN</span></b></span></div>
<span style="font-family: inherit;">
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</span><div class="MsoListParagraph" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">2.1 </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">DEFINISI DEMAM REUMATIK
DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 115%;">Defenisi
jantung rematik</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 115%;"><span style="mso-tab-count: 1;"> </span>Penyakit jantung rematik adalah sebuah kondisi dimana
terjadi kerusakan permanen dari katup – katup jantung yang disebabkan oleh
demam rematik.penyakit jantung rematik (PJR) merupakan komplikasi yang
membahayakan dari demam rematik. Katup – katup jantung tersebut rusak karena
proses perjalanan penyakit yang dimulai dengan infeksi tenggorokan yang
disebabkan oleh bakteri <i style="mso-bidi-font-style: normal;">Streptococcus β</i>
hemoliticus tipe A (contoh:<i style="mso-bidi-font-style: normal;">Streptococcus
pygenes). </i>Yang bisa menyebabkan demam rematik. kurang lebih 39 % pasien dengan
demam rematik akut bisa terjadi kelainan pada jantung mulai dari insufisiensi
katup, gagal jantung, perikarditis bahkan kematian. Dengan penyakit jantung
rematik yang kronik, pada pasien bisa terjadi stenosis katup dengan derajat
regurgitasi yang berbeda – beda, dilatasi atrium, aritmia dan disfungsi
ventrikel. Penyakit jantung rematik masih terjadi penyebab stenosis katup
mitral dan penggantian katup pda orang dewasa di Amerika serikat.</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 115%;">Demam
rematik </span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 115%;">Demam rematik adalah
peradangan penyakit yang terjadi setelah Streptococcus pyogenes infeksi,
seperti faringitis streptokokus atau demam berdarah. Diyakini disebabkan oleh
antibodi lintas-reaktivitas yang dapat melibatkan jantung, sendi, kulit dan
otot, penyakit biasanya berkembang dua sampai tiga minggu setelah infeksi
streptokokus. Demam rematik akut sering muncul pada anak – anak usia 6 -15,
dengan hanya 20% dari pertama kali serangan yang terjadi pada orang dewasa. </span></span></div>
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</span><div class="MsoListParagraph" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">2.2
</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">EPIDEMIOLOGI</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"> DEMAM REUMATIK DAN
JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">2.2.1
Epidemiologi</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"> jantung rematik</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Demam rematik (demam reumatik) masih sering didapati pada anak di negara
berkembang dan sering mengenai anak usia antara 5 – 15 tahun. Pada tahun 1944
diperkirakan diseluruh dunia terdapat 12 juta penderita demam reumatik dan
penyakit jantung reumatik dan sekitar 3 juta mengalami gagal jantung dan
memerlukan rawat inap berulang di rumah sakit. Prevalensinya dinegara sedang
berkembang berkisar antara 7,9 sampai 12,6 per 1000 anak sekolah dan relatif
stabil.</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Data terakhir mengenai prevalensi demam rematik di Indonesia untuk tahun
1981 – 1990 didapati 0,3-0,8 diantara 1000 anak sekolah dan jauh lebih rendah
dibanding negara berkembang lainnya 5,13. Statistik rumah sakit di negara
sedang berkembang menunjukkan sekitar 10 – 35 persen dari penderita penyakit jantung
yang masuk kerumah sakit adalah penderita demam reumatik dan penyakit jantung
reumatik. Data yang berasal dari negara berkembang memperlihatkan mortalitas
karena demam reumatik dan penyakit jantung reumatik masih merupakan problem dan
kematian karena demam reumatik akut terdapat pada anak dan dewasa muda. Di
negara maju insiden demam reumatik dan prevalensi penyakit jantung reumatik
sudah jauh berkurang dan bahkan sudah tidak dijumpai lagi, tetapi akhir-akhir
ini dilaporkan memperlihatkan peningkatan dibeberapa negara maju 13. Dilaporkan
dibeberapa tempat di Amerika Serikat pada pertengahan dan akhir tahun 1980an
telah terjadi peningkatan insidens demam reumatik, demikian juga pada populasi
aborigin di Australia dan New Zealand dilaporkan peningkatan penyakit ini.</span></span></div>
<a name='more'></a><br />
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</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Tidak semua penderita infeksi saluran nafas yang disebabkan infeksi
Streptokokus β hemolitik grup A menderita demam reumatik. Sekitar 3 persen dari
penderita infeksi saluran nafas atas terhadap Streptokokus β hemolitik grup A
di barak militer pada masa epidemi yang menderita demam reumatik dan hanya 0,4
persen didapati pada anak yang tidak diobati setelah epidemi infeksi
Streptokokus β hemolitik grup A pada populasi masyarakat sipil. Dalam laporan
WHO Expert consultation Geneva, 29 October–1 November 2001 yang diterbitkan
tahun 2004 angka mortalitas untuk penyakit jantung reumatik 0,5 per 100.000
penduduk di negara maju hingga 8,2 per 100.000 penduduk dinegara berkembang dan
didaerah Asia Tenggara diperkirakan 7,6 per <span style="mso-bidi-font-style: italic;">Demam Rematik dan Penyakit Jantung Rematik Permasalahan Indonesia </span>100.000.
Diperkirakan sekitar 2000 – 332.000 yang meninggal diseluruh dunia karena
penyakit tersebut. Angka disabilitas pertahun (<i>The disability-adjusted life
years (DALYs)1 lost</i>) akibat penyakit jantung reumatik diperkirakan sekitar
27,4 per 100.000 dinegara maju hingga 173,4 per 100.000 dinegara berkembang
yang secara ekonomis sangat merugikan.</span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<br /></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">2.2.2
</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Epidemiologi</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"> Deman Rematik</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Meskipun
individu individu segala umur dapat diserang oleh Dr akut, tetapi DR ini banyak
terdapat pada anak anak dan oaring usia ( 1-15 tahun) (Rosenthal,1968). Ada dua
keadaan terpenting dari segi epidemiologic pada DR akut ini yaitu kemiskinan
dan kepadatan penduduk. </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Tetapi
pada saat wabah DR tahun 1980 di amerika pasien pasien anak yang terserang juga
pada pada kelompok ekonomi<span style="mso-spacerun: yes;"> </span>menengah dan
atas. Setelah perang dunia ke dua dilaporkan bahwa di amerika dan eropa<span style="mso-spacerun: yes;"> </span>insiden DR menuruna, tetapi DR masih
merupakan masalah kesehatan masyarakat di Negara Negara berkembang.</span></span></div>
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</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Pada
penelitian di bawah ini terlihat insiden DR dan PJR di eropa dan amerika
menurun<span style="mso-spacerun: yes;"> </span>sedangkan di Negara tropis dan
sub tropis masih terlihat peningkatan yang agresip, seperti kegawatan karditis
dan payah jantung yang meningkat.</span><span style="font-size: 12pt; line-height: 150%;">
</span><span style="font-size: 12pt; line-height: 150%;">Majed</span><span style="font-size: 12pt; line-height: 150%;"> </span><span style="font-size: 12pt; line-height: 150%;">melaporkan insiden DR di beberapa
Negara ternyata insiden yang tinggi dari karditis adalah anak muda dan
teerjadinya<span style="mso-spacerun: yes;"> </span>kelainan katup jantung<span style="mso-spacerun: yes;"> </span>adalah sebagai akibat kekurangan kemampuan
untuk melakukan pencegahan sekunder DR dan PJR. Taranta A DAN Markowictz M,
1998 melaporkan bahwa DR adalah peneyebab utama terjadinya penyakit jantung
untukn usia 5-30 tahun. DR dan PJR adalah penyebab utama kematian penyakit
jantung untuk usia dibawah<span style="mso-spacerun: yes;"> </span>45
tahun,<span style="mso-spacerun: yes;"> </span>juga dilaporkan 25-40% penyakit
jantung disebabkan oleh PJR untuk semua umur.</span></span></div>
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<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraph" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">2.3 ETIOLOGI
DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Streptococcus
Beta Hemolyticus Group A merupakan agen pencetus yang menyebabkan terjadinya
demam reumatik akut,walaupun mekanisme patogenetik yang tetap tidak
terjelaskan.tidak semua serotip Streptococcus Beta Hemolyticsus Group A<span style="mso-spacerun: yes;"> </span>dapat menimbulkan demam reumatik.Bila
beberapa strain (missal,M tipe 4) ada pada populasi yang amat rentan
reumatik,tidak terjadi reumatik ulang.sebaliknya serotip lain yang lazim pada
populasi yang sama menyebabkan angka serangan berulang 20-50% dari mereka yang
dengan faringitis.konsep Reumatogenesitas lebih lanjut didukung oleh penelitian
yang member kesan bahwa serotip-serotip Streptococcus Beta Hemolyticus Group A
yang sering dihubungkan dengan infeksi kulit,biasanya serotip yang lebih
tinggi,sering diisolasi dari saluran pernapasan atas tetapi jarang menyebabkan
kumat demam reumatik pada individu yang sebelumnya dengan riwayat demam
reumatik.selanjutnya,serotip tertentu <b style="mso-bidi-font-weight: normal;"><span style="color: red;"><span style="mso-tab-count: 1;"> </span></span></b>Streptococcus
Beta Hemolyticus Group A (Misal : M tipe 1,3,5,6,18,24) lebih sering diisolasi
dari penderita dengan demam reumatik akut daripada serotip
lain.namun,karena<span style="mso-spacerun: yes;"> </span>serotip tidak
diketahui pada saat diagnosis klinis faringitis streptokokus,klinis harus
menganggap bahwa semua streptokokus group A mempunyai kemampuan menyebabkan demam
Reumatik dan karenanya dari semua episode faringitis streptokokus harus
diobati.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraph" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">2.4 KLASIFIKASI
DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">2.4.1.Klasifikasi
Demam Rematik</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span></b><span style="font-size: 12pt; line-height: 150%;">Demam rematik adalah suatu penyakit
immunitas sistematik di klasifikasikan dalam demam rematik akut dan demam
rematik kronik yang dapat sembuh sendiri. Sesuai dengan adanya bukti
sterptokokus beta Hemolitikus grup A, diagnosa demam rematik dapat
diklasifikasikan menjadi Karditis, Poliartritis migrans, Khorea, Nodul
subkutan, Eritema marginatum, Demam.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">2.4.2<span style="mso-spacerun: yes;"> </span>Klasifikasi PJR</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">PJR lebih sering terjadi pada
penderita yang menderita keterlibatan jantungyang berat padaserangan DR akut.
PJR kronik dapat ditemukan tanpa adanyariwayat DR akut. Hal ini
terutamadidapatkan pada penderita dewasa denganditemukannya kelainan katup.
Kemungkinan sebelumnyapenderita tersebutmengalami serangan karditis rematik
subklinis, sehingga tidak berobat dantidak didiagnosis pada stadium akut.
Kelainan katup yang paling sering ditemukan adalah pada katupmitral, kira-kira tiga
kali lebih banyak daripada katup aorta. Klasifikasi PJR memiliki 4 (empat)
bagian,di antaranya insufisiensi mitral,stenosis mitral, insufisiensi aorta,
dan stenosis aorta.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><i style="mso-bidi-font-style: normal;"><span style="font-size: 12pt; line-height: 150%;">a.
Insufisiensi Mitral (Regurgitasi Mitral)</span></i></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Insufisiensi mitral merupakan lesi yang
paling sering ditemukan pada masaanak-anak dan remajadengan PJR kronik. Pada
keadaan ini bisa juga terjadi pemendekan katup, sehingga daun katup tidakdapat
tertutup dengan sempurna. Penutupan katup mitral yang tidak sempurna
menyebabkanterjadinya regurgitasidarah dari ventrikel kiri ke atrium kiri
selama fase sistol. Pada kelainan ringantidak terdapat kardiomegali, karena
beban volume maupun kerja jantung kiri tidak bertambahsecara bermakna. Hal ini
bisa dikatakan bahwa insufisiensi mitralmerupakan klasifikasi ringan,karena
tidak terdapat kardiomegali yang merupakansalah satu gejala gagal
jantung.Tanda-tanda fisik insufisiensi mitral utama tergantung pada
keparahannya.Pada penyakit ringan,tanda-tanda gagal jantung tidak akan ada.
Pada insufisiensi berat, terdapat tanda-tanda gagal jantung kongestif
kronis, meliputi kelelahan, lemah, berat badan turun, pucat.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">b. Stenosis Mitral</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Stenosis mitral merupakan kelainan katup yang paling
sering diakibatkan olehPJR. Perlekatan antardaun-daun katup, selain dapat menimbulkan
insufisiensi mitral(tidak dapat menutup sempurna) jugadapat menyebabkan
stenosis mitral (tidak dapatmembuka sempurna). Ini akan menyebabkan
beban jantung kanan akan bertambah,sehingga terjadi hipertrofi ventrikel
kanan yangdapat menyebabkan gagal jantungkanan. Dengan terjadinya gagal jantung
kanan, stenosis mitraltermasuk ke dalamkondisi yang berat</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><i style="mso-bidi-font-style: normal;"><span style="font-size: 12pt; line-height: 150%;">c.
Insufisiensi Aorta (Regurgitasi Aorta)</span></i></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">PJR menyebabkan sekitar 50% kasus regurgitasi aorta.
Pada sebagian besar kasus ini terdapatpenyakit katup mitralis serta stenosis
aorta. Regurgitasi aortadapat disebabkan oleh dilatasi aorta,yaitu penyakit
pangkal aorta. Kelainan inidapat terjadi sejak awal perjalanan penyakit
akibatperubahan-perubahan yang terjadisetelah proses radang rematik pada katup
aorta. Insufisiensi aorta ringan bersifatasimtomatik. Oleh karena itu,
insufisiensi aorta juga bisa dikatakansebagaiklasifikasi PJR yang ringan.
Tetapi apabila penderita PJR memiliki insufisiensi mitraldaninsufisiensi aorta,
maka klasifikasi tersebut dapat dikatakan sebagai klasifikasiPJR yang sedang.
Halini dapat dikaitkan bahwa insufisiensi mitral dan insufisiensi aorta
memiliki peluang untuk menjadiklasifikasi berat, karena dapat menyebabkangagal
jantung.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><i style="mso-bidi-font-style: normal;"><span style="font-size: 12pt; line-height: 150%;">d. Stenosis
aorta</span></i></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Stenosis aorta adalah obstruksi aliran
darah dari ventrikel kiri ke aorta dimana lokasi obstruksi dapatterjadi di
valvuler, supravalvuler, dan subvalvuler.Gejala-gejala stenosis aorta akan
dirasakanpenderita setelah penyakit berjalan lanjuttermasuk gagal jantung dan
kematian mendadak.Pemeriksaan fisik pada stenosisaorta yang berat didapatkan
tekanan nadi menyempit dan lonjakandenyut arterimelambat.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">2.5 </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">PATOFISIOLOGI
DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">2.5.1 <span style="color: black;">Patofisiologi
Penyakit Jantung rematik</span></span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Demam reumatik yang
mengakibatkan PJR terjadi akibat sensitasi dari antigenSGA setelah 1-4 minggu
infeksi Streptococcus Grup A beta hemolitikus di faring. Terdapat dua mekanisme
yang diajukan sebagai pathogenesis dari demam reumatik :</span></span></div>
<span style="font-family: inherit;">
</span><ol start="1" style="margin-top: 0cm;" type="1">
<li class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l11 level1 lfo1; text-align: justify;"><span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Respons
hiperimun yang bersifat autoimun maupun alergi,</span></span></li>
<li class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l11 level1 lfo1; text-align: justify;"><span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Efek langsung
organisme streptococcus atau toksinnya.</span></span></li>
</ol>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;"> </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Yang paling dapat
diterima adalah mekanisme pertama yaitu dari sudut imunologi, dimana reaksi
autoimun terhadap infeksi streptococcus akan menyebabkan kerusakan jaringan
atau manifestasi demam reumatik, dengan cara :</span></span></div>
<span style="font-family: inherit;">
</span><ol start="1" style="margin-top: 0cm;" type="1">
<li class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l6 level1 lfo2; text-align: justify;"><span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Streptococcus
grup A akan menyebabkan infeksi faring,</span></span></li>
<li class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l6 level1 lfo2; text-align: justify;"><span style="font-family: inherit;"><span style="font-size: 12pt; letter-spacing: -0.6pt; line-height: 150%;">Antigen Streptococcus akan menyebabkan pembentukan antibody pada
pejamu </span><span style="font-size: 12pt; line-height: 150%;">yang hiperimun,</span></span></li>
<li class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l6 level1 lfo2; text-align: justify;"><span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Antibodi
akan bereaksi dengan antigen streptococcus, dan dengan jaringan pejamu
yang secara antigenic sama seperti streptococcus,</span></span></li>
<li class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l6 level1 lfo2; text-align: justify;"><span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Autoantibodi
tersebut bereaksi dengan jaringan pejamu sehingga mengakibatkan kerusakan
jaringan.</span></span></li>
</ol>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; letter-spacing: -0.6pt; line-height: 150%;">Kerusakan
jaringan yang disebabkan tersebut berupa peradangan difus<span style="mso-spacerun: yes;"> </span>yang </span><span style="font-size: 12pt; line-height: 150%;">menyerang jaringan ikat
berbagai organ, terutama jantung, sendi dan kulit. Terserangnya jantung
merupakan keadaan yang sangat penting, karena :</span></span></div>
<span style="font-family: inherit;">
</span><ol start="1" style="margin-top: 0cm;" type="1">
<li class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l12 level1 lfo3; text-align: justify;"><span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Kematian
pada fase akut, yang sebagian besar karena gagal jantung.</span></span></li>
<li class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-list: l12 level1 lfo3; text-align: justify;"><span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Kecacatan
jantung, yang sebagian besar oleh adanya deformitas katup.</span></span></li>
</ol>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Keterlibatan jantung
pada penyakit demam rematik dapat mengenai setiap komponen jaringannya. Proses
radang selama karditis akut paling sering terbatas pada endokardium dan
miokardium, namun pada pasien dengan miokaditis berat, pericardium dapat juga
terlibat. <b style="mso-bidi-font-weight: normal;">Peradangan di endokardium</b>
biasanya mengenai endotel katup, sekitar 50%kasus adalah katup mitral, yang
mengakibatkan pembengkakan daun katup dan erosi pinggir katup yang ditunjukkan
dengan adanya vegetasi seperti manik-manik (verruceae) di sepanjang
pinggir daun katup. Proses ini mengganggu penutupan katup yang efektif,
mengakibatkan regurgitasi katup. Jika tidak ada pembalikan <span style="letter-spacing: -.6pt;">proses dan penyembuhan, proses ini akhirnya akan
menyebabkan stenosis dan perubahan pengapuran yang kasar, yang terjadi beberapa
tahun pasca serangan. </span></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Peradangan
di miokardium</span></b><span style="font-size: 12pt; line-height: 150%;">, terdapat pembentukan lesi nodular yang
khas pada dinding jantung berupa sel Aschoff yang terdiri dari infiltrat
perivaskuler sel besar dengan inti polimorf dan sitoplasma basofil tersusun
dalam roset sekeliling pusat fibrinoid yang avaskular. Peradangan Perikardium,
adanya penumpukan cairan (eksudasi) di dalam rongga perikard yang disebut
sebagai efusi perikard. Dan hal ini mengganggu pengisian ventrikel sehingga
volume sekuncup berkurang.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 12pt; line-height: 150%;">Bila terjadi karditis</span></b><span style="color: black; font-size: 12pt; line-height: 150%;"> seluruh
lapisan jantung akan dikenai. Perikarditis paling sering terjadi dan
perikarditis fibrinosa kadang-kadang didapati. Pada keadaan fatal, keterlibatan
miokard menyebabkan pembesaran semua ruang jantung. Pada miokardium mula-mula
didapati fragmentasi serabut kolagen, infiltrasi limfosit, dan degenerasi
fibrinoid dan diikuti didapatinya nodul aschoff di miokard yang merupakan
patognomonik DR.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">2.5.1.1
Patofisiologi insufisiensi mitra</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>Insufisiensi ini merupakan akibat
perubahan struktur yang biasanya meliputi kehilangan bahan valvuler dan
pemendekan serta penebalan kordae tendinea. Selama demam rematik akut dengan
keterlibatan jantung berat, gagal jantung kongestif paling sering disebabkan
oleh gabungan pengaruh mekanik insufisiensi mitral berat bersama dengan
penyakit radang yang dapat melibatkan perikardium, miokardium, endokardium dan
epikardium. Karena beban volume yang besar dan proses radang, ventrikel kiri
menjadi besar dan tidak efisien. Atrium kiri dilatasi ketika darah
beregugirtasi kedalam ruangan ini. Kenaikan tekanan atrium kiri mengakibatkan
kongesti pulmonal dan gejala-gejala gagal jantung sisi kiri. Pada kebanyakan
kasus insufisiensi mitral ada dalam kisaran ringan sampai sedang. Bahkan, pada
penderita-penderita yang pada permulaannya insufisiensi berat, biasanya kemudian
ada perbaikan spontan. Hasilnya lesi kronis paling sering ringan atau sedang,
dan penderita akan tidak bergejala. Lebih separuh penderita dengan insufisiensi
mitral selama serangan akut akan tidak lagi mempunyai bising akibat mitral
setahun kemudian. Namun, pada penderita dengan insufisiensi mitral kronis,
berat, tekanan ateria pulmonalis menjadi naik, pembesaran ventrikel dan atrium
kanan dan yang selanjutnya akan terjadi gagal jantung sisi kanan.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">2.5.1.2
Patofisiologi stenosis mitral reumatik</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>Stenosis mitral reumatik adalah
akibat fibrosis cincin mitral, perlekatan komisura, dan kontraktur daun katup,
korda, dan muskulus papilare selama periode waktu yang lama. Stenosis ini
biasanya 10 tahun atau lebih agar lesi menjadi betul-betul tegak, walaupun prosesnya
kadang-kadang dapat dipercepat. Stenosis mitral reumatik jarang ditemukan
sebelum remaja dan biasanya tidak dikenali sampai umur dewasa. Stenosis mitral
secara klinis diketahui jika lubang katup mengurang sampai 25% atau kurang dari
lubang katup yang diharapkan normal. Pengurangan demikian berakibat kenaikan
tekanan pada pembesaran serta hifertrofi atrium kiri. Kenaikan menyebabkan
hifertensi vena pulmonalis, kenaikan tahanan vaskuler pulmonal dan hipertensi
pulmonal. Dilatasi ventrikel dan atrium kanan, dan terjadi hipertrofi dengan
disertai gagal jantung sisi kanan.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; mso-list: l12 level3 lfo3; text-align: justify; text-indent: -36.0pt;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.5.2<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Patofisiologi
Demam Rematik</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Streptococcus
beta-hemolyticus grup A dikenali oleh karena morfologi koloninya dan
kemampuannya untuk menimbulkan hemolisis. Sel ini terdiri dari sitoplasma yang
dikelilingi oleh tiga lapisan membrane, yang disusun terutama dari tiga
komponen. </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">(1) Komponen bagian dalam
adalahpeptidoglikan, yang memberi kekakuan dinding sel, menimbulkan arthritis,
sertareaksi nodular pada kulit binatang percobaan. </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">(2) Komponen kedua adalahpolisakarida
dinding sel, atau karbohidrat spesifik grup. Struktur imunokimia komponen ini
menetukan serogrupnya.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;"> </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Karbohidrat grup A merupakan polimer
polisakarida, yang terdiri dari pendukung utama Ramnose dengan rantai samping
yang diakhiri ujung terminalN-asetilgluktosamin. Karbohidrat ini terbukti
memiliki determinan antigenicbersama dengan glikoprotein pada katup jantung
manusia. </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">(3) Komponenketiga terdiri dari mosaic
protein yang dilabel sebagai protein M, R dan T. Dariketiga protein ini yang
terpenting adalah protein M, yakni antigen spesifik tipe <span style="letter-spacing: -.6pt;">dari</span> streptococcus group A.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adanya protein M pada
permukaan streptokokus menghambat fagositosis; hambatan tersebut dinetralkan
oleh antibody terhadap protein M,yaitu antibody spesifik tipe. Dari permukaan
keluar bentuk menyerupai rambut merupakan lapisan fimbriae yang tersusun oleh
asam lipoteikoat. Komponen ini penting dalam perlekatan (adherence)
streptokokus terhadap sel epitel. Beberapa strain streptokokus grup A, terutama
yang ditemukan dari demam reumatik, mempunyai kapsul mukoid yang terdiri dari
asam hialuronat. Kapsultersebut hanya kadang-kadang ada, kemungkinan karena
hidrolisis olehhialuronidase yang dihasilkan selama masa pertumbuhan
mikroorganisme.Disamping hialuronidase, streptokokus grup A juga
menghasilkansejumlah enzim ekstraselular, termasuk dua hemolisin atau
streptolisin (tipe Syang stabil pada oksigen dan O yang labil pada oksigen).
Hemolisin bekerjapada sel darah merah dan menyebabkan hemolisis di sekitar
kolonistreptokokus. Kebanyakan streptokokus grup A menghasilkan toksin
eritrogenik yang menyebabkan ruam pada kulit dan skarlatina; streptokinase
yang berfungsi sebagai activator sistem fibrinolitik nikotianmid adenine
dinikleotidase;proteinase; amylase dan esterase Empat isoenzim DNAse (A, B, C,
D) dihasilkandalam jumlah yang berbeda-beda oleh strain yang berbeda. Isoenzim
DNAse Bdihasilkan oleh streptokokus grup A yang tersebar dimana-mana.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Pengelepasan enzim
streptokokus ke dalam pejamu pada waktu terjadiinfeksi merangsang pembentukan
antibodi, kecuali streptolisin S, yang pada manusia tidak imunogenik. Uji
antibodi streptokokus didasarkan padaimunogenitas produk. Dalam uji ini, serum
diuji untuk mendeteksi antibodyneutralisasi terhadap satu atau lebih enzim.
Kenaikan titer antibody lebih darinormal atau kenaikan titer yang bermakna
antara serum akut dan konvalesensbukti infeksi sebelumnya.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Kerentanan Pejamu Penelitian
epidemiologis menunjukan bahwa hanya sebagian kecil (2 sampai 3%) yang
menderita faringitis streptokokus menderita demam reumatik, tetapiangka
kejadian penderita demam reumatik adalah 50%. Hal ini memberi kesanadanya
kerentanan pejamu terhadap demam reumatik akut.Penelitian mutakhir memberikan
tambahan bukti. Pemeriksaan fenotip Human Leucocyt Antigen (HLA) terhadap demam
reumatik menunjukanhubungan alloantigen sel B spesifik, dikenal dengan antibodi
monoclonal,dengan status reumatikus. Penelitian lain menunjukan insiden petanda
HLAtinggi pada pasien demam reumatik. Antigen HLA-DR4 dan HLA-DR2 masing-masing
lebih sering terdapat pada pasien demam reumatik ras kaukasoid dan kulit hitam
dibandingkan pada populasi sehat; hal ini mendukung konsep predisposisi genetik
pada demam reumatik.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Nodul aschoff terdiri dari
area nekrosis sentral yang dikelilingi limfosit, sel plasma, sel mononukleus
yang besar dan sel giant multinukleus. Beberapa sel mempunyai inti yang
memanjang dengan area yang jernih dalam membran inti yang disebut <i>Anitschkow
myocytes.</i> Nodul Aschoff bisa didapati pada spesimen biopsi endomiokard
penderita DR. Keterlibatan endokard menyebabkan valvulitis rematik kronis.
Fibrin kecil, vegetasi verrukous, berdiameter 1-2 mm bisa dilihat pada
permukaan atrium pada tempat koaptasi katup dan korda tendinea. Meskipun
vegetasi tidak didapati, bisa didapati peradangan dan edema dari daun katup.
Penebalan dan fibrotik pada dinding posterior atrium kiri bisa didapati dan
dipercaya akibat efek jet regurgitasi mitral yang mengenai dinding atrium kiri.
Proses penyembuhan valvulitis memulai pembentukan granulasi dan fibrosis daun
katup dan fusi korda tendinea yang mengakibatkan stenosis atau insuffisiensi
katup. Katup mitral paling sering dikenai diikuti katup aorta. Katup trikuspid
dan pulmonal biasanya jarang dikenai.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Dasar kelainan<span style="mso-spacerun: yes;"> </span>patologi demam rematik ialah reaksi inflamasi
eksudatif dan proliferatif jaringan mesenkim. Kelainan yang menetap hanya
terjadi pada jantung, organ lain seperti ; sendi, kulit, paru, pembuluh darah,
jaringan otak dan lain-lain dapat terkena tetapi reversibel.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 12pt; line-height: 150%;">Yang terjadi di Jantung</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Baik perikardium,
miokardium, dan endokardium dapat terkena. Miokarditis dapat ringan berupa
infiltrasi sel-sel radang, tetapi dapat berat sehingga terjadi dilatasi jantung
yang dapat berakibat fatal.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Bila peradangan berlanjut,
timbullah badan-badan Aschoff yang kelak dapat meninggalkan jaringan parut
diantara otot jantung. Perikarditis dapat mengenai lapisan viseral maupun
parietal perikardium dengan eksudasi fibrinosa. Jumlah efusi perikard dapat
bervariasi tetapi biasanya tidak banyak, bisa keruh tetapi tidak pernah
purulen.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Bila berlangsung lama dapat
berakibat terjadinya adesi perikardium viseral dan parietal. Endokarditis
merupakan kelainan terpenting, terutama peradangan pada katup-katup jantung.
Semua katup dapat terkena, tetapi katup jantung kiri (mitral dan aorta) yang
paling sering menderita, sedangkan katup trikuspidalis dan pulmonal jarang
terkena. Mula-mula terjadi edema dan reaksi seluler seluler akut yang mengenai
katup dan korda tendinae. Kemudian terjadi vegetasi mirip veruka di tepi
daun-daun katup. Secara mikroskopis vegetasi ini masa hialin. Bila menyembuh
akan terjadi penebalan dan kerusakan daun katup yang dapat menetap dan dapat
mengakibatkan kebocoran katup. </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 12pt; line-height: 150%;">Yang terjadi di organ-organ lain</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Sendi-sendi paling sering terkena.
Terjadi peradangan eksudatif dengan degenerasi fibrinoid sinovium.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Nodul subkutan secara histologis terdiri
dari jaringan nekrotik fibrinoid dikelilingi oleh sel-sel jaringan ikat, mirip
badan aschoff.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 12pt; line-height: 150%;">Di jaringan otak</span></b><span style="color: black; font-size: 12pt; line-height: 150%;"> dapat
terjadi infiltrasi sel bulat di sekitar pembuluh darah kecil. Kelainan tersebut
letaknya tersebar di korteks, serebellum dan ganglia basal. Kelainan-kelainan
pada susunan saraf pusat ini tidak dapat menerangkan terjadinya korea; kelainan
tersebut dapat ditemukan pada penderita demam rematik yang meninggal dan
diautopsi tetapi sebelumnya tidak pernah menunjukkan gejala korea.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 12pt; line-height: 150%;">Pada paru</span></b><span style="color: black; font-size: 12pt; line-height: 150%;"> dapat terjadi
pneumonia dengan tanda-tanda perdarahan. Kelainan pembuluh darah dapat terjadi
dimana-mana, terutama pembuluh darah kecil yang menunjukkan pembengkakan dan
proliferasi endotel.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Glomerulonefritis ringan dapat terjadi
akibat reuma.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: justify; text-autospace: none;">
<br /></div>
<span style="font-family: inherit;">
</span><div align="center" class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: center; text-autospace: none;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;"><img alt="capture1.jpg" height="640" src="file:///C:\Users\DR29EB~1.ARI\AppData\Local\Temp\msohtmlclip1\01\clip_image002.jpg" width="575" /></span></span></div>
<span style="font-family: inherit;">
</span><div align="center" class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; mso-pagination: none; text-align: center; text-autospace: none;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Gambar:
Pathofisiology demam rematik</span><span style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><img alt="jantung rematik.jpg" height="413" src="file:///C:\Users\DR29EB~1.ARI\AppData\Local\Temp\msohtmlclip1\01\clip_image004.jpg" width="621" /><img alt="RHD2.jpg" height="408" src="file:///C:\Users\DR29EB~1.ARI\AppData\Local\Temp\msohtmlclip1\01\clip_image006.jpg" width="676" /></span><span style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
<span style="font-family: inherit;">
</span><div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="font-family: inherit;"><span style="color: black;">Gambar:
Skema Patofisiologi Penyakit jantung Rematik</span></span></div>
<span style="font-family: inherit;">
</span><div align="center" class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l12 level2 lfo3; text-indent: -30.0pt;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.6<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">PATOGENESIS
DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 27.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Meskipun
pengetahuan tentang penyakit ini<span style="mso-spacerun: yes;"> </span>serta
penelitian terhadap kuman beta-streptococcus hemolyticus grup A sudah
berkembang pesat, namun mekanisme terjadinya demam reumatik yang pasti belum
diketahui.</span><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 27.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Pada
umumnya, para ahli sependapat bahwa demam reumatik yang mengakibatkan penyakit
jantung reumatik yang terjadi akibat sensitasi dari antigen streptococcus
sesudah 1-4 minggu infeksi streptococcus difaring.lebih kurang 95% pasien
menunjukkan peninggian titer<span style="mso-spacerun: yes;">
</span>antistreptoksi-O (ASTO),antideoksiribonukleat B (anti DNA –ase B) yang
merupakan 2 macam tes yang biasa dilakukan untuk infeksi kuman streptococcus.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 27.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Penelitian-penelitian
lain kebanyakan menyokong mekanisme autoimunitas atas dasar reaksi antigen
antibody terhadap antigen streptococcus.salah satu antigen tersebut adalah
protein-M streptococcus .pada serum pasien demam reumatik akut ditemukan
antibody dan antigen. Antibodi yang terbentuk bukan bersifat kekebalan. Dan
reaksi ini dapat ditemukan pada miokard, otot skelet dan sel otot polos. Dengan
imunoflorensi dapat ditemukan immunoglobulinnya dan komplemen pada sarkolema
miokard.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-left: 1.0cm; mso-list: l12 level2 lfo3; text-align: justify; text-indent: -30.0pt;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.7<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">GAMBARAN
KLINIS DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Gambaran Klinis</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Perjalanan
klinis penyakit demam reumatik/penyakit jantung reumatik dapat di bagi dalam 4
stadium.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;">Stadium
I</b></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Stadium
ini berupa infeksi saluran atas bagian atas oleh kuman Beta-Streptococcus
hemolyticus grup A. Seperti infeksi saluran nafas pada umumnya, keluhan
biasanya berupa demam,batuk,rasa sakit<span style="mso-spacerun: yes;">
</span>waktu menelan,tidak jarang di sertai muntah bahkan pada anak kecil dapat
terjadi diare. Pada pemeriksaan fisis sering di dapatkan eksudatdi tonsil yang
menyertai tanda-tanda peradangan lainnya. Kelenjar getah bening submandibular
sering kali membesar. Infeksi ini biasanya berlangsung 2-4 hari dan dapat
sembuh sendiri tanpa pengobatan. Para peneliti mencatat 50-90% riwayat infeksi
saluran nafas bagian atas pada penderita demam reumatik/penyakit jantung
reumatik, yang biasanya terjadi 10-14 hari sebelum manifestasi pertama demam
reumatik/penyakit jantung reumatik.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Stadium II</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Stadium
ini disebut juga periode laten,ialah masa antara infeksi Streptococcus dengan
permulaan gejala demam reumatik; biasanya periode ini berlangsung 1-3 minggu,
kecuali korea yang dapat timbul 6 minggu atau bahkan berbulan-bulan kemudian.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Stadium III</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Yang
dimaksud dengan stadium III ini ialah<span style="mso-spacerun: yes;">
</span>fase akut demam reumatik, saat timbulnya berbagai manifestasi klinis
demam reumatik/penyakit jantung reumatik. Manifestasi klinis tersebut dapat
digolongkan dalam gejala peradangan umum dan manifestasi spesifik demam
reumatik/penyakit jan tung reumatik.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Gejala peradangan umum</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Biasanya
penderita mengalami demam yang tidak tinggi tanpa pola tertentu. Anak menjadi
lesu,anoreksia,lekas tersinggung dan berat badan tampak menurun. Anak kelihatan
pucat karena anemia akibat tertekannya eritropoesis. Bertambahnya volume plasma
serta memendeknya umur eritrosi. Dapat pula terjadi epitaksis dan bila banyak
dapat menambah berat derajat anemia.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Artralgia
, rasa sakit disekitar sendi<span style="mso-spacerun: yes;"> </span>selama
beberapa hari /minggu juga sering didapatkan; rasa sakit akan bertambah bila
anak melakukan latihan fisis. Gejala klinis lain yang dapat timbul ialah sakit
perut, yang kadang-kadang bisa sangat hebat sehingga menyerupai apendisitis
akut. Sakit perut ini akan member respons cepat dengan pemberian salisilat.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Pada
pemeriksaan laboratorium akan didapatkan tanda-tanda reaksi peradangan akut
berupa terdapatnhya C-reactive protein dan leukositosis serta meningginya laju
endap darah. Titer ASTO meninggi pada kira-kira 80% kasus. Pada pemeriksaan EKG
dapat jumpai pemanjangan interval P-R (blok AV derajat I).</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 1.0cm;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Sebagai
gejala-gejala peradangan umum ini penting untuk diagnosis dan dikelompokan
sebagai gejala minor.<span style="mso-spacerun: yes;"> </span></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraph" style="line-height: 150%; margin-left: 1.0cm; mso-add-space: auto; mso-list: l12 level2 lfo3; text-indent: -30.0pt;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.8<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">ANAMNESIS
DEMAM REUMATIK DAN</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"> </span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-spacerun: yes;"> </span>JANTUNG REUMATIK</span></b><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"> </span><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; letter-spacing: 0.6pt; line-height: 150%;">Diagnosis pada
demam rematik memerlukan anamnesis dan pemeriksaan fisikyang teliti. Biasanya
pasien datang dengan tanda-tanda Karditis, disebabkan</span><span style="font-size: 12pt; line-height: 150%;">karena
gejala-gejala poliartritis akan sembuh dengan sempurna dalam beberapaminggu.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l10 level1 lfo12; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Tanyakan identitas pasien</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l10 level1 lfo12; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">tanyakan keluhan utama<br />
dan telusuri keluhan utama</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">• Infeksi tenggorokan</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">apakah ada keluhan nyeri menelan sebelumnya?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Apakah disertai gejala batuk dan mata merah?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adakah keluhan demam?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adakah nyeri tekan pada kelenjar leher?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">• Polartritis</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; letter-spacing: 1.2pt; line-height: 150%;">Apakah ada bengkak yang terjadi
tiba-tiba pada sendi-sendi besar(lutut, pergelangan kaki atau tangan,
paha,lengan, siku dan bahu)</span><span style="font-size: 12pt; line-height: 150%;">sebelumnya?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Apakah bengkak pada sendi simetris dan berpindah?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Apakah bengkak tersebut disertai nyeri?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">• Karditis</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; letter-spacing: 0.6pt; line-height: 150%;">Adakah sesak? Apakah sesak
dipengaruhi aktivitas?</span><span style="font-size: 12pt; line-height: 150%;">---<span style="letter-spacing: 1.2pt;">dipsnoe ---on</span>effort</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adakah sesak pada malam hari? (Paroxysmal Nocturnal
Dyspnea)</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; letter-spacing: 1.2pt; line-height: 150%;">Adakah sesak yang terjadi pada
posisi berbaring dan hilang pada</span><span style="font-size: 12pt; line-height: 150%;">posisi duduk? (orthopnea)</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adakah nyeri dada? Bagaimanakah sifat nyeri?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adakah pembengkakan (udem)?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">• Korea</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adakah gerakan-gerakan yang tidak disadari?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adakah kelemahan otot?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adakah ketidakstabilan emosi?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">• Eritema
marginatum</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adakah
bercak kemerahan yang tidak gatal?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Apakah
bercaknya seakan-akan menjauhi pusat lingkaran?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Apakah
bercak berpindah-pindah?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">• Nodul
Subkutan</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adakah
teraba massa padat?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Apakah massa
tersebut tidak terasa nyeri, mudah digerakkan dari kulitdi atasnya?</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Riwayat
medis dimasa lalu</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 21.8pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Kondisi
sebelumnya (termasuk masa kanak-kanak) dan terkait, seperti infark miokard,
hipertensi, diabetes, demam reumatik. Informasi resep dan obat lainnya, serta
kepatuhan pasien. Tinjauan kembali tekanan darah, kadar lipid, rontgen toraks,
dan EKG sebelumnya.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; mso-list: l2 level1 lfo13; text-align: justify; text-indent: 0cm;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Riwayat keluarga,
pekerjaan,dan sosial</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; mso-list: l2 level1 lfo13; text-align: justify; text-indent: 0cm;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Riwayat keluarga </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; mso-list: l2 level1 lfo13; text-align: justify; text-indent: 0cm;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">5.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Hal-hal yang
memperberat dan memperingan</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; mso-list: l2 level1 lfo13; text-align: justify; text-indent: 0cm;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">6.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Aktivitas, iklim,
makanan, kebiasaan dan Obat-obatan</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.9<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">PEMERIKSAAN
FISIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"> DAN DIAGNOSIS</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">
DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">2.9.1
</span><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">PEMERIKSAAN FISIK DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">1. </span><span style="color: black; font-size: 12pt; line-height: 150%;">Pemeriksaan tanda vita</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">l</span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span><span style="color: black; font-size: 12pt; line-height: 150%;">Pemeriksaan tanda vital seperti tekanan darah,frekuensi pernapasan,denyut
nadi,berat badan,tinggi badan. Pemeriksaan tanda vital pada pasien ini
berfungsi untuk mengetahui kondisi umum dari pasien. Pada penderita demam
jantung rematik dengan komplikasi yang parah seperti insufisiensi mitral akan
didapatkan tanda-tanda gagal jantung yaitu dispne</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">a</span><span style="color: black; font-size: 12pt; line-height: 150%;"> dan mungkin juga terjadi denyut nadi yang
cepat untuk mengkompesasi kekurangan aliran darah yang masuk ke aorta. Beberapa
kelainan dari tanda vital juga akan diketemukan pada penyakit jantung rematik
dengan komplikasi yang lain. Berat badan dan tinggi badan juga merupakan suatu
pertanda penting untuk membedakan suatu penyakit jantung bawaan maupun didapat.
Sebagian besar penyakit jantung bawaan akan menunjukkan keterlambatan tumbuh
kembang dari anak terserbut.</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">2. </span><span style="color: black; font-size: 12pt; line-height: 150%;">inspeksi</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">-<span style="letter-spacing: .85pt;"> </span></span><span style="color: black; font-size: 12pt; letter-spacing: 0.85pt; line-height: 150%;">Memperhatikan gerakan-gerakan lain pada dinding</span><span style="color: black; font-size: 12pt; line-height: 150%;">dada</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
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</span><div class="MsoNormal" style="line-height: 150%; tab-stops: 53.2pt; text-align: justify;">
<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span><span style="color: black; font-size: 12pt; line-height: 150%;">Pada pemeriksaan inspeksi perlu diperhatikan adanya sesak napas,pernapasan
cuping</span><span style="color: black; font-size: 12pt; line-height: 150%;"> </span><span style="color: black; font-size: 12pt; line-height: 150%;">hidung,sianosis,pembengkakan pada
sendi,melihat apakah denyut jantung terlihat di permukaan kulit atau tidak.
Adanya pernapasan cuping hidung,sianosis merupakan pertanada adanya gejala dari
gagal jantung ataupun kelainan dari pada jantung. Pembengkakan sendi merupakan
salah satu kriteria major jones sehingga patut menjadi perhatian utama untuk
mendiagnosis pen</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">y</span><span style="color: black; font-size: 12pt; line-height: 150%;">akit jantung rematik. Denyut jantung yang terlihat juga dapat terjadi
karena beberapa sebab, mungkin terjadi karena terjadi kardiomegali yang cukup
besar atau anak tersebut sangat kurus</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">.</span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">3. </span><span style="color: black; font-size: 12pt; line-height: 150%;">Palpasi</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">-</span><span style="color: black; font-size: 12pt; line-height: 150%;">Meraba denyut jantung</span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span><span style="color: black; font-size: 12pt; line-height: 150%;">Palpasi berguna untuk menekan sendi, dimana pada arthritis yang disebabkan
oleh demam rematik akan terjadi sakit. Palpasi juga penting untuk
memeriksa nodul subkutan, nodul subkutan pada demam jantung remat</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">i</span><span style="color: black; font-size: 12pt; line-height: 150%;">k dapat digerakan dan tidak sakit.
Pemeriksaan palpasi yang tidak kalah penting adalah menentukan ukuran dari
hati. Ukuran dari hati akan membesar apabila terjadi gagal jantung kanan yang
merupakan salah satu komplikasi lanjut dari penyakit</span><span style="color: black; font-size: 12pt; line-height: 150%;"> </span><span style="color: black; font-size: 12pt; line-height: 150%;">jantung rematik</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">.</span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">4. </span><span style="color: black; font-size: 12pt; line-height: 150%;">Perkusi</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">- </span><span style="color: black; font-size: 12pt; line-height: 150%;">Mengetahui batas-batas jantung</span><span lang="EN-US" style="background: none repeat scroll 0% 0% white; color: black; font-size: 12pt; letter-spacing: -0.85pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span><span style="color: black; font-size: 12pt; line-height: 150%;">Perkusi berguna untuk memeriksa apaka</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">h</span><span style="color: black; font-size: 12pt; line-height: 150%;"> adanya perbesaran dari jantung. Pada
penderita kronis akan terjadi perbesaran jantung karena efek kompensasi</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">.</span><span style="background: none repeat scroll 0% 0% white; color: black; font-size: 12pt; letter-spacing: -0.85pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">5. </span><span style="color: black; font-size: 12pt; line-height: 150%;">auskultasi</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span></span></div>
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</span><div class="MsoNormal" style="background: white; line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">-</span><span style="color: black; font-size: 12pt; line-height: 150%;">Mendengarkan bunyi-bunyi jantung</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
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</span><div class="MsoNormal" style="background: white; line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: inherit;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span><span style="color: black; font-size: 12pt; line-height: 150%;">Pada pemerikssaan auskultasi berguna untuk mencari suara patologis dari
jantung. Pada penderita jantung rematik biasanya ditemukan murmur holosistolik
yang merupakan akibat dari insufisiensi katup mitral dan mungkin pada penderita
yang lebih lanjut disebabkan oleh insufisiensi katup trikuspidalis. Pada
pemeriksaan auskultasi juga mungkin ditemukan suara jantung ketiga yang
disebabkan keterlambatan penutupan atau percepatan penutupan dari katup-katup
jantung. Yang paling sering adalah kecepatan penutupan dari katup aorta yang
disebabkan oleh insufisiensi dari katup mitral</span><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">.</span><span style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">2.9.2 </span><b><span style="background: none repeat scroll 0% 0% white; color: black; font-size: 12pt; letter-spacing: -0.6pt; line-height: 150%;">DIAGNOSIS DEMAM REMATIK DAN PENYAKIT
JANTUNG REMATIK</span></b><span style="color: #363636; font-size: 12pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 0.6pt; line-height: 150%;">Diagnosis demam rematik lazim didasarkan pada suatu
kriteria yang untuk pertama kali diajukan oleh T. Duchett
Jones dan, oleh karena itu kemudian dikenal</span><span style="color: black; font-size: 12pt; line-height: 150%;">sebagai kriteria Jones. </span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 1.8pt; line-height: 150%;">Kriteria Jones memuat kelompok kriteria mayor dan minor yang pada</span><span style="color: black; font-size: 12pt; letter-spacing: 1.2pt; line-height: 150%;">dasarnya merupakan manifestasi klinik dan laboratorik demam rematik. </span><span style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 1.2pt; line-height: 150%;">Pada</span><span style="color: black; font-size: 12pt; letter-spacing: 0.6pt; line-height: 150%;"> perkembangan selanjutnya, kriteria ini kemudian diperbaiki oleh</span><span style="color: black; font-size: 12pt; line-height: 150%;"> <i><span style="letter-spacing: .6pt;">American Heart </span> Association</i>
<span style="letter-spacing: .6pt;">dengan menambahkan bukti adanya infeksi
streptokokus sebelumnya. <b style="mso-bidi-font-weight: normal;">Apabila
ditemukan 2 kriteria mayor, atau 1 kriteria mayor dan 2 kriteria minor, </b></span><b style="mso-bidi-font-weight: normal;">ditambah dengan bukti adanya infeksi
streptokokus sebelumnya, kemungkinan besar <span style="letter-spacing: 1.2pt;">menandakan adanya demam rematik.</span></b><span style="letter-spacing: 1.2pt;"> Tanpa didukung bukti adanya infeksi </span><span style="letter-spacing: .6pt;">streptokokus, maka diagnosis demam rematik harus selalu diragukan,
kecuali pada kasus demam rematik dengan manifestasi mayor tunggal berupa korea
Syndenham atau karditis derajat ringan, yang biasanya terjadi jika demam
rernatik baru muncul </span>setelah masa laten yang lama dan infeksi
strepthkokus. Perlu diingat bahwa kriteria Jones tidak bersifat mutlak, tetapi
hanya sebagaisuatu pedoman dalam menentukan diagnosis demam rematik. <span style="letter-spacing: 1.8pt;"></span></span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Kriteria ini bermanfaat <span style="letter-spacing: 1.2pt;">untuk memperkecil kemungkinan
terjadinya kesalahan diagnosis,baik berupa </span>overdiagnosis<span style="mso-spacerun: yes;"> </span>maupun<span style="mso-spacerun: yes;">
</span><i>underdiagnosis.</i></span></span></div>
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<span style="font-family: inherit;"><i style="mso-bidi-font-style: normal;"><span style="color: black; font-size: 12pt; line-height: 150%;"><img alt="dsc.jpg" height="252" src="file:///C:\Users\DR29EB~1.ARI\AppData\Local\Temp\msohtmlclip1\01\clip_image008.gif" width="525" /></span></i><span style="color: black; font-size: 12pt; letter-spacing: 1.2pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;"><img alt="1.jpg" height="122" src="file:///C:\Users\DR29EB~1.ARI\AppData\Local\Temp\msohtmlclip1\01\clip_image010.gif" width="464" /><img alt="2.jpg" height="133" src="file:///C:\Users\DR29EB~1.ARI\AppData\Local\Temp\msohtmlclip1\01\clip_image012.gif" width="466" /></span><span style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><b><span style="color: black; font-size: 12pt; letter-spacing: -0.6pt; line-height: 150%;">Kriteria
Mayor</span></b><span style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">1)<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><i><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">Karditis</span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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</span><div class="MsoNormal" style="background: white; line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 0.6pt; line-height: 150%;">merupakan manifestasi klinik demam rematik yang paling
berat karenamerupakan satu-satunya manifestasi yang dapat mengakibatkan
kematian penderita</span><span style="color: black; font-size: 12pt; letter-spacing: 1.2pt; line-height: 150%;"> pada fase akut
dan dapat menyebabkan kelainan katup sehingga terjadipenyakit</span><span style="color: black; font-size: 12pt; letter-spacing: 1.8pt; line-height: 150%;"> jantung rematik. </span></span></div>
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</span><div class="MsoNormal" style="background: white; line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 1.8pt; line-height: 150%;">Diagnosis karditis rematik dapat ditegakkan secara klinik </span><span style="color: black; font-size: 12pt; letter-spacing: 0.6pt; line-height: 150%;"> berdasarkan adanya salah satu tanda berikut: </span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 0.6pt; line-height: 150%;">(a) bising baru atau perubahan sifat</span><span style="color: black; font-size: 12pt; line-height: 150%;"> bising organik, </span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">(b) kardiomegali,</span></span></div>
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</span><div class="MsoNormal" style="background: white; line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 35.45pt; margin-right: 0cm; margin-top: 0cm; text-align: justify; text-indent: -17.45pt;">
<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">(c) perikarditis, dan gagal jantung
kongestif. Bising jantung merupakan manifestasi karditis rematik yang
seringkali muncul pertama kali,</span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">sementara tanda dan gejala perikarditis serta gagal
jantung kongestif biasanya baru </span><span style="color: black; font-size: 12pt; letter-spacing: 1.6pt; line-height: 150%;">timbul
pada keadaan yang lebih berat. Bising pada karditis rematik dapat berupa</span><span style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;"> bising pansistol di daerah apeks (regurgitasi
mitral), bising awal diastol di daerah basal (regurgitasi aorta), dan
bising mid-diastol pada apeks (bising Carey-Coombs)</span><span style="color: black; font-size: 12pt; line-height: 150%;">yang timbul akibat adanya dilatasi ventrikel kiri.</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2)<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><i><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">Poliartritis</span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">ditandai oleh
adanya nyeri, pembengkakan, kemerahan, teraba panas, </span><span style="color: black; font-size: 12pt; line-height: 150%;">dan keterbatasan gerak aktif pada dua sendi atau lebih. Artritis pada demam
rematik <span style="letter-spacing: .8pt;"> paling sering mengenai
sendi-sendi besar anggota gerak bawah. Kelainan ini hanya</span><span style="letter-spacing: 2.35pt;"> berlangsung beberapa hari sampai seminggu pada satu sendi dan kemudian</span><span style="letter-spacing: 1.6pt;"> berpindah, sehingga dapat ditemukan artritis yang
saling tumpang tindih pada</span><span style="letter-spacing: .8pt;"> beberapa sendi pada waktu yang sama; sementara tanda-tanda radang
mereda pada satu sendi, sendi yang lain mulai terlibat. Perlu diingat bahwa
artritis yang hanya mengenai satu sendi (monoartritis)
tidak dapat dijadikan sebagai suatu kriteria mayor. Selain itu,
agar dapat digunakan sebagai suatu kriterium mayor, poliartritisharus disertai
sekurang-kurangnya dua kriteria minor, seperti demam dan kenaikan </span><span style="letter-spacing: 2.35pt;">laju endap darah, serta harus didukung oleh adanya titer ASTO atau antibodi</span>antistreptokokus
lainnya yang tinggi.</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">3)<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><i><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;">Korea</span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">secara khas ditandai oleh adanya gerakan tidak disadari dan tidak bertujuan<span style="letter-spacing: .8pt;">yang berlangsung cepat
dan umumnya bersifat bilateral, meskipun dapat
juga hanya mengenai satu sisi tubuh. Manifestasi demam rematik ini lazim
disertai kelemahan </span>otot dan ketidak-stabilan emosi. Korea jarang
dijumpai pada penderita di bawah usia<span style="letter-spacing: 2.35pt;">3 tahun atau setelah masa pubertas dan lazim terjadi pada perempuan. </span></span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 2.35pt; line-height: 150%;">Korea</span><span style="color: black; font-size: 12pt; line-height: 150%;">Syndenham merupakan satu-satunya tanda
mayor yang sedemikian penting sehingga<span style="letter-spacing: .8pt;">dapat
dianggap sebagai pertanda adanya demam rematik meskipun tidak ditemukan</span>kriteria
yang lain. Korea merupakan manifestasi demam rematik yang muncul secaralambat,
sehingga tanda dan gej ala lain kemungkinan sudah tidak ditemukan lagi padasaat
korea mulai timbul.</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">4)<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><i><span lang="EN-US" style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">Eritema marginatum</span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 1.6pt; line-height: 150%;">merupakan
wujud kelainan kulit yang khas pada demam</span><span style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">rematik
dan tampak sebagai makula yang berwarna merah, pucat di bagian tengah,</span><span style="color: black; font-size: 12pt; line-height: 150%;"> <span style="letter-spacing: .8pt;">tidak terasa gatal, berbentuk bulat atau
dengan tepi yang bergelombang dan meluas</span><span style="letter-spacing: 2.35pt;">secara sentrifugal. Eritema marginatum juga dikenal sebagai eritema anulare</span><span style="letter-spacing: 1.6pt;">rematikum dan terutama timbul di daerah badan, pantat, anggota gerak bagian</span> proksimal,
tetapi tidak pernah ditemukan di daerah wajah. Kelainan ini dapat bersifat <span style="letter-spacing: .8pt;">sementara atau menetap, berpindah-pindah dari satu
bagian tubuh ke bagian tubuh yang lain, dapat dicetuskan oleh pemberian
panas, dan memucat jika ditekan. Tanda </span>mayor demam
rematik ini hanya ditemukan pada kasus yang berat.</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">5)<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><i><span lang="EN-US" style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;"> Nodulus subkutan</span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 1.6pt; line-height: 150%;">pada umumnya hanya dijumpai pada kasus yang berat dan </span><span style="color: black; font-size: 12pt; line-height: 150%;">terdapat di daerah ekstensor persendian, pada kulit kepala serta kolumna
vertebralis. Nodul ini berupa massa yang padat, tidak terasa nyeri, mudah
digerakkan dari kulit di<span style="letter-spacing: .8pt;">atasnya, dengan
diameter dan beberapa milimeter sampai sekitar 2 cm. Tanda ini</span> pada
umumnya tidak akan ditemukan jika tidak terdapat karditis.</span></span></div>
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<span style="font-family: inherit;"><b><span style="color: black; font-size: 12pt; letter-spacing: -0.8pt; line-height: 150%;">Kriteria
Minor</span></b><span style="color: black; font-size: 12pt; line-height: 150%;"></span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">1)<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><i><span lang="EN-US" style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">Riwayar demam rematik sebelumnya</span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">dapat digunakan sebagai salah satu kriteriaminor
apabila tercatat dengan baik sebagai suatu diagnosis yang didasarkan pada</span><span style="color: black; font-size: 12pt; letter-spacing: 1.6pt; line-height: 150%;">kriteria obyektif yang sama.</span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 1.6pt; line-height: 150%;">Akan tetapi, riwayat demam rematik atau penyakit</span><span style="color: black; font-size: 12pt; line-height: 150%;"> jantung rematik inaktif yang pernah diidap seorang penderita
seringkali tidak tercatatsecara baik sehingga sulit dipastikan kebenarannya,
atau bahkan tidak terdiagnosis</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2)<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><i><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"> Artralgia</span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><i><span style="color: black; font-size: 12pt; line-height: 150%;">Artralgia</span></i><span style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;"> adalah rasa nyeri pada satu sendi atau lebih tanpa
disertai peradanganatau keterbatasan gerak sendi. Gejala minor ini harus
dibedakan dengan nyeri padaotot atau jaringan periartikular lainnya, atau
dengan nyeri sendi malam hari yang</span><span style="color: black; font-size: 12pt; line-height: 150%;">lazim terjadi pada
anak-anak normal. Artralgia tidak dapat digunakan sebagai kriteriaminor apabila
poliartritis sudah dipakai sebagai kriteria mayor.</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">3)<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><i><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"> Demam</span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">pada demam
rematik biasanya ringan,meskipun adakalanya mencapai</span><span style="color: black; font-size: 12pt; line-height: 150%;">39°C, terutama jika terdapat karditis. Manifestasi ini lazim berlangsung
sebagai suatudemam derajat ringan selama beberapa minggu. Demam merupakan
pertanda infeksi<span style="letter-spacing: .8pt;">yang tidak spesifik, dan
karena dapat dijumpai pada begitu banyak penyakit lain,</span>kriteria minor
ini tidak memiliki arti diagnosis banding yang bermakna.</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">4)<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><i><span lang="EN-US" style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">Peningkatan kadar reaktan fase akut </span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">berupa kenaikan laju endap darah, kadar </span><span style="color: black; font-size: 12pt; line-height: 150%;"> protein C reaktif, serta leukositosis merupakan indikator nonspesifik
dan peradangan<span style="letter-spacing: .8pt;">atau infeksi. Ketiga tanda
reaksi fase akut ini hampir selalu ditemukan pada demam </span><span style="letter-spacing: 2.35pt;">rematik, kecuali jika
korea merupakan satu-satunya manifestasi mayor yang</span>ditemukan.
<span style="letter-spacing: .8pt;"></span></span></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; line-height: 150%;">Perlu diingat bahwa laju endap darah juga meningkat pada kasus anemiadan
gagal jantung kongestif. Adapun protein C reaktif tidak meningkat pada anemia,<span style="letter-spacing: .8pt;">akan tetapi mengalami kenaikan pada gagal
jantung kongestif. Laju endap darah dankadar protein C reaktif dapat
meningkat pada semua kasus infeksi, namun apabila protein C reaktif tidak
bertambah, maka kemungkinan adanya infeksi streptokokus</span>akut dapat
dipertanyakan.</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">5)<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><i><span lang="EN-US" style="color: black; font-size: 12pt; letter-spacing: 1.6pt; line-height: 150%;">Interval P-R yang memanjang </span></i></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="color: black; font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">biasanya menunjukkan adanya keterlambatanabnormal
sistem konduksi pada nodus atrioventrikel dan meskipun sering dijumpai</span><span style="color: black; font-size: 12pt; letter-spacing: 1.6pt; line-height: 150%;"> pada demam rematik, perubahan gambaran EKG ini
tidak spesifik untuk demam</span><span style="color: black; font-size: 12pt; letter-spacing: 0.8pt; line-height: 150%;">rematik. Selain itu,
interval P-R yang memanjang juga bukan merupakan pertanda</span><span style="color: black; font-size: 12pt; line-height: 150%;">yang memadai akan adanya karditis rematik.</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.10<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">PEMERIKSAAN
PENUNJANG DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Penyakit
Demam Reumatik akibat kumam <i style="mso-bidi-font-style: normal;">Streptococcus
β hemolyticus Lancefield grup A</i> pada tonsilofaringitis dengan masa laten
1-3 minggu (Morehead,1965).Sedangkan yang dimaksud dengan Penyakit Jantung
Reumatik (PJR) adalah kelainan jantung yang terjadi akibat Demam Reumatik,atau
kelainan karditis reumatik (Taranta A dan Markowitz,1981).</span></span></div>
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<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Pemeriksaan
penunjang Demam Reumatik dan Jantung Reumatik :</span></span></div>
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<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">A.Pemeriksaan
darah :</span></span></div>
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<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">LED
tinggi sekali</span></span></div>
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</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l3 level1 lfo6; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Lekositosis</span></span></div>
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</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l3 level1 lfo6; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Nilai
hemoglobin dapat rendah</span></span></div>
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</span><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l3 level1 lfo6; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">4.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">PCR
meningkat</span></span></div>
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<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">B.Pemeriksaan
bakteriologi</span></span></div>
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<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>Biakan hapus tenggorokan untuk
membuktikan adanya kuman streptococcus</span></span></div>
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</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">C.Pemeriksaan
serologi</span></span></div>
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</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-spacerun: yes;"> </span>Titer ASTO, Antistreptokinase,
Antihyaluronidase</span></span></div>
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</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">D.Elektrokardiogram</span></span></div>
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<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Pada
demam reumatik/penyakit jantung reumatik dapat menunjukkan pelbagai kelainan
sesuai dengan kelainan jantungnya.Yang paling sering ditemukan ialah
pemanjangan interval PR,yang dianggap sebagai salah satu gejala minor.</span></span></div>
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</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">E.Bentuk
pemeriksaan paling akurat adalah dengan dilakukannya echocardiografi</span></span></div>
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</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">untuk
melihat kondisi katup-katup jantung dan otot jantung.</span></span></div>
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<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Demam
Reumatik dan Jantung Reumatik ditandai oleh pelbagai manifestasi klinis dan
laboratorium.Sampai saat ini tidak ada satu jenis pemeriksaan laboratorium yang
spesifik.Oleh karena itu diagnosis demam reumatik/jantung reumatik didasarkan
pada gabungan gejala dan tanda klinis serta kelainan laboratorium.</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.11<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">PENATALAKSANAAN
DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
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<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Penatalaksanaan
demam reumatik/PJR meliputi: (1) tirah baring di rumah sakit, (2) eradikasi
kuman streptokokus, (3) pemberian obat-obat anti inflamasi, (4) pengobatan
korea, (5) pemberian diet</span></span></div>
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Tirah baring</span></b></span></div>
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<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Tabel
1 : Pedoman istirahat dan mobilisasi penderita demam reumatik/penyakit jantung
reumatik<span style="mso-tab-count: 1;"> </span></span></span></div>
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<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; mso-border-alt: solid black .5pt; mso-border-insideh: .5pt solid black; mso-border-insidev: .5pt solid black; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184; width: 622px;">
<tbody>
<tr style="height: 76.2pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid black 1.0pt; height: 76.2pt; mso-border-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 105.6pt;" valign="top" width="141">
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<br /></div>
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<td style="border-left: none; border: solid black 1.0pt; height: 76.2pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 80.9pt;" valign="top" width="108">
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Artritis</span></b></span></div>
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<td style="border-left: none; border: solid black 1.0pt; height: 76.2pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.25pt;" valign="top" width="124">
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Karditis
minimal</span></b></span></div>
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<td style="border-left: none; border: solid black 1.0pt; height: 76.2pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.3pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Karditis
tanpa kardiomegali</span></b></span></div>
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<td style="border-left: none; border: solid black 1.0pt; height: 76.2pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.3pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Karditis
dengan kardiomegali</span></b></span></div>
</td>
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<tr style="height: 32.65pt; mso-yfti-irow: 1;">
<td style="border-top: none; border: solid black 1.0pt; height: 32.65pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 105.6pt;" valign="top" width="141">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Tirah baring</span></span></div>
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<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 32.65pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 80.9pt;" valign="top" width="108">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">2 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 32.65pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.25pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">3 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 32.65pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.3pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">6 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 32.65pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.3pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">3-6 bulan</span></span></div>
</td>
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<tr style="height: 76.2pt; mso-yfti-irow: 2;">
<td style="border-top: none; border: solid black 1.0pt; height: 76.2pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 105.6pt;" valign="top" width="141">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Mobilisasi bertahap di ruangan</span></span></div>
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<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 76.2pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 80.9pt;" valign="top" width="108">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">2 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 76.2pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.25pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">3 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 76.2pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.3pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">6 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 76.2pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.3pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">3 bulan</span></span></div>
</td>
</tr>
<tr style="height: 86.5pt; mso-yfti-irow: 3;">
<td style="border-top: none; border: solid black 1.0pt; height: 86.5pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 105.6pt;" valign="top" width="141">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Mobilisasi bertahap diluar ruangan</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 86.5pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 80.9pt;" valign="top" width="108">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">3 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 86.5pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.25pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">4 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 86.5pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.3pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">3 bulan</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 86.5pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.3pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<br /></div>
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">3 bulan atau lebih</span></span></div>
</td>
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<tr style="height: 54.45pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid black 1.0pt; height: 54.45pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 105.6pt;" valign="top" width="141">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Semua kegiatan</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 54.45pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 80.9pt;" valign="top" width="108">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Sesudah 6-8 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 54.45pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.25pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Sesudah 10 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 54.45pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.3pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Sesudah 6 bulan</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 54.45pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 93.3pt;" valign="top" width="124">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">bervariasi</span></span></div>
</td>
</tr>
</tbody></table>
</div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Eradikasi kuman Streptococcus</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span></b><span style="font-size: 12pt; line-height: 150%;">Pengobatan
yang adekuat terhadap infeksi Streptococcus harus segera dilakukan setelah
diagnosis ditegakkan. Dianjurkan menggunakan penisilin dosis biasa selama 10
hari; pada penderita yang peka terhadap penisilin dapat diganti dengan
eritromisin. Pengobatan terhadap Streptococcus ini harus tetap diberikan
meskipun biakan usap tenggorok negative</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Tabel
2 : Pengobatan Infeksi<span style="mso-spacerun: yes;">
</span>Beta-Streptococcus Hemolyticus Grup A</span></span></div>
<span style="font-family: inherit;">
</span><table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; mso-border-alt: solid black .5pt; mso-border-insideh: .5pt solid black; mso-border-insidev: .5pt solid black; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184; width: 623px;">
<tbody>
<tr style="height: 28.55pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid black 1.0pt; height: 28.55pt; mso-border-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 116.85pt;" valign="top" width="156">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Jenis</span></b></span></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; height: 28.55pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 116.85pt;" valign="top" width="156">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Cara
Pemberian</span></b></span></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; height: 28.55pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 80.15pt;" valign="top" width="107">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Dosis</span></b></span></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; height: 28.55pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 153.7pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Frekuensi/lama
pemberian</span></b></span></div>
</td>
</tr>
<tr style="height: 28.55pt; mso-yfti-irow: 1;">
<td style="border-top: none; border: solid black 1.0pt; height: 28.55pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 116.85pt;" valign="top" width="156">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Penisilin benzatin G</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 28.55pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 116.85pt;" valign="top" width="156">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">IM</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 28.55pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 80.15pt;" valign="top" width="107">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">1,2 juta S</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 28.55pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 153.7pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">1 kali</span></span></div>
</td>
</tr>
<tr style="height: 47.0pt; mso-yfti-irow: 2;">
<td style="border-top: none; border: solid black 1.0pt; height: 47.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 116.85pt;" valign="top" width="156">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Penisilin prokain</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 47.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 116.85pt;" valign="top" width="156">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">IM</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 47.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 80.15pt;" valign="top" width="107">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">600.000 S</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 47.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 153.7pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">1-2 kali sehari selama 10 hari</span></span></div>
</td>
</tr>
<tr style="height: 28.0pt; mso-yfti-irow: 3;">
<td style="border-top: none; border: solid black 1.0pt; height: 28.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 116.85pt;" valign="top" width="156">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Penisilin V</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 28.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 116.85pt;" valign="top" width="156">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">oral</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 28.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 80.15pt;" valign="top" width="107">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">250.000 S</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 28.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 153.7pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">3 kali sehari selama 10 hari</span></span></div>
</td>
</tr>
<tr style="height: 29.1pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid black 1.0pt; height: 29.1pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 116.85pt;" valign="top" width="156">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Eritromisin </span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 29.1pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 116.85pt;" valign="top" width="156">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Oral </span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 29.1pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 80.15pt;" valign="top" width="107">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">125-250 mg</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 29.1pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 153.7pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 150%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">4 kali sehari selama 10 hari</span></span></div>
</td>
</tr>
</tbody></table>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Obat anti Inflamasi</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Yang
dipakai secara luas ialah salisilat dan steroid. Keduanya efektif untuk
memngurangi demam, kelainan sendi serta fase reaksi akut. Dosis dan lamanya
pengobatan disesuaikan dengan beratnya penyakit dan responsnya terhadap
pengobatan. </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Tabel
3: Terapi AntiInflamasi pada penyakit DR/PJR</span></span></div>
<span style="font-family: inherit;">
</span><div align="center">
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; mso-border-alt: solid black .5pt; mso-border-insideh: .5pt solid black; mso-border-insidev: .5pt solid black; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="border: solid black 1.0pt; mso-border-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.0pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 115%;">Artritis</span></b></span></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.05pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 115%;">Karditis
ringan tanpa kardiomegali</span></b></span></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.05pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 115%;">Kardiomegali
karditis berat, gagal jantung</span></b></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.0pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 115%;">1.Salisilat 100 mg/kgbb/hari</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.05pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 115%;">1.Salisilat 100 mg/kgbb/hari</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.05pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 115%;">1.Prednison 2 mg/kgbb/hari (rata-rata 4x10
mg/hari)</span></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.0pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 115%;">2.Setelah 1 minggu turunkan menjadi 75
mg/kgbb/hari</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.05pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 115%;">2.Setelah 1-2 minggu turunkan menjadi 75
mg/kgbb/hari</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.05pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 115%;">2.Setelah 2 minggu turunkan menjadi 3x10 mg/hari</span></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.0pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 115%;">3.Bila hasil laboratotium normal turunkan menjadi
50 mg/kgbb/hari,teruskan minimal 6 minggu</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.05pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 115%;">3. teruskan sampai 6-8 minggu (terapi total 12
minggu)</span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 154.05pt;" valign="top" width="205">
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;">3.
setelah 2 minggu turunkan menjadi 4x5 mg/hari</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;">4.
setelah 2 minggu turunkan menjadi 3x5 mg/hari. Mulai berikan salisilat</span></div>
<div class="MsoNoSpacing" style="line-height: 115%; margin-bottom: 10.0pt; text-align: justify;">
<span style="font-family: inherit;">5.
dosis prednisone terus diturunkan setiap minggu; salisilat berikan sampai
6-12 minggu<span style="font-size: 12pt; line-height: 115%;"></span></span></div>
</td>
</tr>
</tbody></table>
</div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Pengobatan Korea</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>Korea pada umunya akan sembuh
sendiri, meskipun dapat berlangsung selama beberapa minggu sampai 3 bulan.
Obat-obat sedative, seperti klorpromazin, diazepam, fenobarbital atau
haloperidol dilaporkan memberikan hasil yang memuaskan . haloperidol sebaiknya
tidak diberikan pada anak dibawah 12 tahun.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Diet</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span></b><span style="font-size: 12pt; line-height: 150%;">Bentuk
dan jenis makanan dengan keadaan penderita,. Pada sebagian besar kasus cukup
diberikan makanan biasa, cukup kalori dan protein. Tambahan vitamin dapat
dibenarkan.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">Penanganan gagal jantung</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span>Gagal jantung pada DR/PJR dapat
ditangani seperti kasus gagal jantung pada umumnya. Komplikasi ini biasanya
dapat diatasi dengan tirah baring dan pemberian kortikosteroid, meskipun
seringkali perlu diberikan digitalis dan diuretic. </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Penatalaksanaan
penyakit jantung reumatik kronik :</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; mso-list: l8 level1 lfo7; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Penatalaksanaan
medik </span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l9 level1 lfo8; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">a.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Kemoprofilaksis
sekunder untuk mencegah serangan ulang demam reumatik</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l9 level1 lfo8; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">b.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Pengobatan
gagal jantung</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l9 level1 lfo8; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">c.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Pencegahan
endokarditis bakterialis</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l9 level1 lfo8; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">d.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Pengaturan
aktivitas</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l8 level1 lfo7; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Penatalaksanaan
bedah</span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"> </span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Pada
anak, indikasi bedah pada umumnya ialah:</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level1 lfo9; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">a.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Kardiomegali
berat yang menetap yamg menghalangi kehidupan normal</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level1 lfo9; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">b.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Kardiomegali
progresif</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 54.0pt; mso-add-space: auto; mso-list: l1 level1 lfo9; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">c.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Gagal
jantung yang tidak dapat diatasi dengan terapi medis</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l8 level2 lfo7; text-indent: -23.25pt;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.12<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">REHABILITASI
DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Penyakit
demam reumatik dapat mengakibatkan gejala sisa (sequele) yang amat penting pada
jantung sebagai akibat berat ringannya karditis selama serangan akut demam
reumatik. Dari beberapa penelitian tentang insidens karditis dan PJR yang
menetap adalah akibat kekambuhan DR tanpa PJR sebelumnya adalah 6-14%.
Kekambuhan yang terbanyak dan terpenting adalah akibat perjalanan penyakit
demam reumatik itu sendiri. Cukup banyak dilaporkan insidens dari kekambuhan
demam reumatik yang berlanjut dan mengakibatkan PJR.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">DR
dapat diatasi dengan antibiotika <i style="mso-bidi-font-style: normal;">penisilin-V</i>
atau <i style="mso-bidi-font-style: normal;">benzatin penisilin</i> <i style="mso-bidi-font-style: normal;">parentral </i>yang adekuat terhadap kuman
SGA hemolitikus. Pasien DR berisiko tinggi untuk terjadi kekambuhan kembali,
sehingga diperlukan pencegahan yang berkelanjutan dengan antibiotika sebagai
pencegahan sekunder terhadap kekambuhan tersebut. Tetapi yang sulit adalah
menetapkan berapa lama pencegahan sekunder ini dilakukan. Walaupun risiko kekambuhan
berkurang dengan bertambahnya umur dan juga interval kekambuhan makin panjang
tetapi kekambuhan ini bisa terjadi selama 5-10 tahun. Hanya akan berkurang atau
menghilang bila dilakukan pengobatan pencegahan sekunder secara teratur untuk
waktu yang cukup lama.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Program
<u>pencegahan sekunder</u> yang dapat mengurangi atau menghilangkan perjalanan
penyakit DR dan PJR, yang dapat dilakukan adalah :</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; mso-list: l7 level1 lfo10; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Untuk
pasien <20 tahun, berikan suntikan <i style="mso-bidi-font-style: normal;">Benzatin
Penisilin G</i> 1,2 juta unit tiap 4 minggu sampai umur 25 tahun</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l7 level1 lfo10; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Bila
umur pasien >20 tahun, berikan suntikan <i style="mso-bidi-font-style: normal;">Benzatin
Penisilin G (long-acting)</i> selama 5 tahun.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l7 level1 lfo10; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Bila
pasien telah selesai dengan protocol 1 dan 2 sedangkan terjadi kekambuhan lagi
maka aka mendapatkan kembali suntikan <i style="mso-bidi-font-style: normal;">Benzatin
Penisilin G</i> dengan dosis 1,2 juta unit tiap 4 minggu untuk selama 5 tahun
berikutnya. Bila kasus berat tiap 3 minggu.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 21.3pt; mso-add-space: auto; mso-list: l8 level2 lfo7; text-indent: -23.25pt;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.13<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">PROGNOSIS
DEMAM REUMATIK DAN JANTUNG REUMATIK</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"></span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Demam
reumatik tidak akan kambuh bila infeksi Streptokokus diatasi. Prognosis sangat
baik bila karditis sembuh pada saat permulaan serangan akut demam reumatik.
Selama 5 tahun pertama perjalanan penyakit demam reumatik dan penyakit jantung
reumatik tidak membaik bila bising organik katup tidak menghilang, (Feinstein
AR dkk, 1964). Prognosis memburuk bila gejala karditisnya lebih berat dan
ternyata demam reumatik akut dengan payah jantung akan sembuh 30% pada 5 tahun
pertama dan 40% setelah 10 tahun. Dari data penyembuhan ini akan bertambah bila
pengobatan pencegahan sekunder dilakukan secara baik. Ada penelitian melaporkan
bahwa stenosis mitralis sangat tergantung pada beratnya karditis, sehingga
kerusakkan katup mitral selama 5 tahun pertama sangat mempengaruhi angka
kematian demam reumatik ini. (Irvington House Group & U.K and U.S 1965).
Penelitian selama 10 tahun yang mereka lakukan menemukan adanya kelompok lain
terutama kelompok perempuan dengan kelainan mitral ringan yang menimbulkan
payah jantung yang berat tanpa diketahui adanya kekambuhan demam reumatik atau
infeksi streptokokus. (Stresser, 1978).<span style="mso-spacerun: yes;">
</span></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt; line-height: 150%;">Adanya
atau tidak adanya kerusakan jantung permanen menentukan prognosis jantung
reumatik. Perkembangan dari penyakit jantung residual dipengaruhi oleh 3
faktor, yaitu :</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; mso-list: l0 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">1.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Keadaan
jantung pada awal terapi. Semakin berat keterlibatan jantung pada saat pertama
kali pasien diperiksa, semakin besar resiko timbulnya kelainan jantung
residual.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l0 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">2.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Kekambuhan
demam reumatik. Semakin berat keterlibatan katup, maka angka kekambuhannya
semakin tinggi.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; mso-list: l0 level1 lfo11; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;"><span style="mso-list: Ignore;">3.<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Regresi
dari gangguan jantung. Bukti adanya keterlibatan jantung pada serangan awal
mungkin tidak terlihat pada 10 – 25 % pasien, dan baru nampak kurang lebih 10
tahun setelah serangan awal.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: justify;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt; line-height: 150%;">Prognosis demam rematik juga
tergantung pada stadium saat diagnosis ditegakkan, umur, ada tidaknya dan
luasnya kelainan jantung, pengobatan yang diberikan, serta jumlah serangan
sebelumnya. Prognosis pada umumnya buruk pada penderita dengan karditis pada
masa kanak-kanak. Serangan ulang dalam waktu 5 tahun pertama dapat dialami oleh
sekitar 20% penderita dan kekambuhan semakin jarang terjadi setelah usia 21
tahun. </span><span style="font-size: 12pt; line-height: 150%;"></span></span></div>
<span style="font-family: inherit;">
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<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">KESIMPULAN</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;"><span style="mso-tab-count: 2;"> </span></span></b><span style="font-size: 12pt; line-height: 150%;">Joko
mengalami penyakit jantung rematik, cara Pengobatannya yaitu tidur istirahat
selama 3 minggu, pemberantasan bakteri streptokokus dengan benzatin<span style="mso-spacerun: yes;"> </span>1,2 juta unit penisilin intramuskular jika
berat> 30 kg dan 600.000-900.000 unit jika berat badan <30kg atau
penisilin 2 x 500.000 unit / kg / bb / hari selama 10 hari. Jika alergi
terhadap penisilin, eritromisin diberikan secara oral 125-250 mg 4 kali sehari
selama 10 hari. Dengan pemberian anti-inflamasi Salisilat 100 mg / kg / hari,
setelah 1-2 minggu turunkan menjadi 75 mg / kg / hari, naik ke 6-8 minggu
(total 12 minggu terapi). Mengingat makanan bergizi tinggi dan vitamin.</span></span></div>
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<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div align="center" class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 0cm; mso-add-space: auto; text-align: center;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 150%;">DAFTAR PUSTAKA</span></b></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">A.price, sylvia.
<i style="mso-bidi-font-style: normal;">Patofisiologi konsep klinis proses-proses
penyakit</i>.2006.EGC</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Arif
mansoer,dkk,<i style="mso-bidi-font-style: normal;">kapita selekta kedokteran,</i><span style="mso-no-proof: yes;"> FKUI</span>,2003 hal 451</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Bermen
dkk.nelson <i style="mso-bidi-font-style: normal;">ilmu kesehatan anak edisi</i>
5, vol 2, 2000.jakarta: EGC</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt;">
<span style="font-family: inherit;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="font-size: 12pt;">Bickley lynn
s.buku saku pemeriksaan fisik & riwayat kesehatan bates.2006.egc:jakarta</span></i></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Buku kuliah 2 <i style="mso-bidi-font-style: normal;">ilmu kesehatan anak</i>, fkui 1985</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt;">
<span style="font-family: inherit;"><i style="mso-bidi-font-style: normal;"><span style="font-size: 12pt;">Buku kuliah ilmu kesehatan anak</span></i><span style="font-size: 12pt;"> , jilid 2,1997, FKUI</span><span style="font-size: 12pt;"></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="margin-top: 12.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Buku kuliah ilmu kesehatan anak fk ui; “<i style="mso-bidi-font-style: normal;">demam reumatik dan penyakit jantung reumatik</i>”</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt;">
<span style="font-family: inherit;"><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="font-size: 12pt;">Buku panduan
blok sistem kardiovaskuler</span></i><i style="mso-bidi-font-style: normal;"><span style="font-size: 12pt;">. FK UNPRI</span></i></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraph" style="line-height: normal; margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt;">Demam
rematik “di Dorland s Dictionary Medis</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt;"><a href="http://id.scribd.com/doc/40545168/DEMAM-REMATIK"><i style="mso-bidi-font-style: normal;">http://id.scribd.com/doc/40545168/demam-rematik</i></a></span><i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="font-size: 12pt;"></span></i></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt; mso-add-space: auto;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt;"><a href="http://www.bemfkunud.com/2009/06/20/demam-reumatik-dan-penyakit-jantung-reumatik/">http://www.bemfkunud.com/2009/06/20/demam-reumatik-dan-penyakit-jantung-reumatik/</a></span><span style="font-size: 12pt;"></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpLast" style="line-height: normal; margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt;"><a href="http://www.infopenyakit.com/2008/08/penyakit-jntung-rematik-pjr.html"><span style="color: black;">http://www.infopenyakit.com/2008/08/penyakit-jntung-rematik-pjr.html</span></a></span><span style="font-size: 12pt;"></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Http://www.scribd.com/doc/54393059/demam-reumatik</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Ilmu penyakit
dalam jilid II edisi V</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraph" style="line-height: normal; margin-bottom: 10.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt; mso-add-space: auto;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt;">Isjd.pdii.go.id/jurnal/116972528.pdf</span><span style="font-size: 12pt;"></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Ismudati
lili, dkk,<i style="mso-bidi-font-style: normal;">buku ajar kardiologi,</i><span style="mso-no-proof: yes;"> FKUI</span>,2002 hal 249</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNoSpacing" style="margin-top: 12.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Kapita selekta fakultas kedokteran
ui,edisi iii, jilid 1,2001,media aesculapius.Jakarta</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt;">Kumar,
Vinay, Abbas, Abul K., Fausto, Nelson,. &Mitchell, Richard N. (2007)
Robbins </span><span style="font-size: 12pt;"></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-left: 0cm; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-left: 0cm; mso-add-space: auto;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt;">Basic
Patologi (8 ed.). Saunders Elsevier.hlm 403-406 ISBN 978-1-4160-2973-1</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 10.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt; mso-add-space: auto;">
<br /></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 10.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt; mso-add-space: auto;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt;">Leman,
saharman; <i style="mso-bidi-font-style: normal;">demam reumatik dan penyakit
jantung rematik</i>; buku ajar lmu penyakit dalam; jilid ii edisi v; interna
publishing; jakarta</span><span style="font-size: 12pt;"></span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Prof.dr.dr.a.samik
wahab,sp.a(k).<i style="mso-bidi-font-style: normal;">ilmu kesehatan anak edisi
15</i>.jakarta : balai penerbit buku kedokteran;2000.hal.930.</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Sudoyo,et al.
(2009).<i style="mso-bidi-font-style: normal;">ilmu penyakit dalam</i>.jakarta :
interna publishing</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoNormal" style="line-height: normal; margin-top: 12.0pt; text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: 12pt;">Wahab
samik, <i style="mso-bidi-font-style: normal;">penyakit jantung anak</i>,EGC,2003
hal 166,179</span></span></div>
<span style="font-family: inherit;">
</span><div class="MsoListParagraph" style="line-height: normal; margin-bottom: 10.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt; mso-add-space: auto;">
<span style="font-family: inherit;"><span lang="EN-US" style="font-size: 12pt;"><a href="http://www.usu.ac.id/id/files/pidato/ppgb/.../ppgb_2008_afif_siregar.pdf"><span style="background: white;">www.usu.ac.id/id/files/pidato/ppgb/.../ppgb_2008_afif_siregar.pdf</span></a></span><span style="font-size: 12pt;"></span></span></div>
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="35" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="1" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
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<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
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<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
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<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
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<w:LsdException Locked="false" Priority="19" QFormat="true"
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<w:LsdException Locked="false" Priority="31" QFormat="true"
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<w:LsdException Locked="false" Priority="32" QFormat="true"
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<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
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<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
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<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
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<w:LsdException Locked="false" Priority="52"
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<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
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<![endif]-->arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com2tag:blogger.com,1999:blog-2501725445038181687.post-34859449589565043242012-05-14T14:14:00.002+07:002013-05-16T07:05:35.621+07:00Nasehat Untuk Remaja<h2 class="title" style="text-align: justify;">
<span style="font-size: small;">
Nasehat Untuk Remaja </span></h2>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHodNaP5zsPtuo6LOZkeZ98hXpLAy2F1me3NeWfYjrxYiNH-whcMdbE4yczmCbwAxUea6GZTk9Mo44eFXqCg1mn5FLMPNfcNYF70alsAyhR1_yeNWvcPJ9aq9O2P5ks7FZG3D6wGCZkyL8/s1600/merah-jambu.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHodNaP5zsPtuo6LOZkeZ98hXpLAy2F1me3NeWfYjrxYiNH-whcMdbE4yczmCbwAxUea6GZTk9Mo44eFXqCg1mn5FLMPNfcNYF70alsAyhR1_yeNWvcPJ9aq9O2P5ks7FZG3D6wGCZkyL8/s1600/merah-jambu.jpg" /></a></span></div>
<div style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Wahai para pemuda muslim, tidakkah kalian menginginkan kehidupan yang
bahagia selamanya? Tidakkah kalian menginginkan jannah (surga) Allah
subhanahu wata’ala yang luasnya seluas langit dan bumi?</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Ketahuilah, jannah Allah subhanahu wata’ala itu diraih dengan usaha
yang sungguh-sungguh dalam beramal. Jannah itu disediakan untuk
orang-orang yang bertaqwa yang mereka tahu bahwa hidup di dunia ini
hanyalah sementara, mereka merasa bahwa gemerlapnya kehidupan dunia ini
akan menipu umat manusia dan menyeret mereka kepada kehidupan yang
sengsara di negeri akhirat selamanya. Allah subhanahu wata’ala
berfirman:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">وَمَا الْحَيَاةُ الدُّنْيَا إِلَّا مَتَاعُ الْغُرُورِ</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Kehidupan dunia itu tidak lain hanyalah kesenangan yang menipu.” (Ali ‘Imran: 185)</span><br />
<a name='more'></a></div>
<div style="text-align: justify;">
<span style="font-size: small;">Untuk Apa Kita Hidup di Dunia?</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Wahai para pemuda, ketahuilah, sungguh Allah subhanahu wata’ala telah
menciptakan kita bukan tanpa adanya tujuan. Bukan pula memberikan kita
kesempatan untuk bersenang-senang saja, tetapi untuk meraih sebuah
tujuan mulia. Allah subhanahu wata’ala berfirman:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">وَمَا خَلَقْتُ الْجِنَّ وَالْإِنْسَ إِلَّا لِيَعْبُدُونِ</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Dan tidaklah Aku ciptakan jin dan manusia melainkan agar mereka beribadah kepada-Ku.” (Adz Dzariyat: 56)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Beribadah kepada Allah subhanahu wata’ala dengan menjalankan segala
perintah-Nya dan menjauhi semua larangan-Nya. Itulah tugas utama yang
harus dijalankan oleh setiap hamba Allah.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Dalam beribadah, kita dituntut untuk ikhlas dalam menjalankannya.
Yaitu dengan beribadah semata-mata hanya mengharapkan ridha dan pahala
dari Allah subhanahu wata’ala. Jangan beribadah karena terpaksa, atau
karena gengsi terhadap orang-orang di sekitar kita. Apalagi beribadah
dalam rangka agar dikatakan bahwa kita adalah orang-orang yang alim,
kita adalah orang-orang shalih atau bentuk pujian dan sanjungan yang
lain.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Umurmu Tidak Akan Lama Lagi</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Wahai para pemuda, jangan sekali-kali terlintas di benak kalian:
beribadah nanti saja kalau sudah tua, atau mumpung masih muda, gunakan
untuk foya-foya. Ketahuilah, itu semua merupakan rayuan setan yang
mengajak kita untuk menjadi teman mereka di An Nar (neraka).</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Tahukah kalian, kapan kalian akan dipanggil oleh Allah subhanahu
wata’ala, berapa lama lagi kalian akan hidup di dunia ini? Jawabannya
adalah sebagaimana firman Allah subhanahu wata’ala:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">وَمَا تَدْرِي نَفْسٌ مَاذَا تَكْسِبُ غَدًا وَمَا تَدْرِي نَفْسٌ بِأَيِّ أَرْضٍ تَمُوتُ إِنَّ اللَّهَ عَلِيمٌ خَبِيرٌ</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Dan tiada seorangpun yang dapat mengetahui apa yang akan
dilakukannya besok. Dan tiada seorangpun yang dapat mengetahui di bumi
mana dia akan mati. Sesungguhnya Allah Maha mengetahui lagi Maha
Mengenal.” (Luqman: 34)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Wahai para pemuda, bertaqwalah kalian kepada Allah subhanahu
wata’ala. Mungkin hari ini kalian sedang berada di tengah-tengah
orang-orang yang sedang tertawa, berpesta, dan hura-hura menyambut tahun
baru dengan berbagai bentuk maksiat kepada Allah subhanahu wata’ala,
tetapi keesokan harinya kalian sudah berada di tengah-tengah orang-orang
yang sedang menangis menyaksikan jasad-jasad kalian dimasukkan ke liang
lahad (kubur) yang sempit dan menyesakkan.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Betapa celaka dan ruginya kita, apabila kita belum sempat beramal
shalih. Padahal, pada saat itu amalan diri kita sajalah yang akan
menjadi pendamping kita ketika menghadap Allah subhanahu wata’ala. Nabi
shallallahu ‘alaihi wasallam bersabda:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">يَتْبَعُ الْمَيِّتَ ثَلاَثَةٌ: أَهْلُهُ وَمَالُهُ وَعَمَلُهُ,
فَيَرْجِعُ اثْنَانِ وَيَبْقَى وَاحِدٌ, يَرْجِعُ أَهْلُهُ وَمَالُهُ
وَيَبْقَى عَمَلُهُ.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Yang mengiringi jenazah itu ada tiga: keluarganya, hartanya, dan
amalannya. Dua dari tiga hal tersebut akan kembali dan tinggal satu saja
(yang mengiringinya), keluarga dan hartanya akan kembali, dan tinggal
amalannya (yang akan mengiringinya).” (Muttafaqun ‘Alaihi)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Wahai para pemuda, takutlah kalian kepada adzab Allah subhanahu
wata’ala. Sudah siapkah kalian dengan timbangan amal yang pasti akan
kalian hadapi nanti. Sudah cukupkah amal yang kalian lakukan selama ini
untuk menambah berat timbangan amal kebaikan.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Betapa sengsaranya kita, ketika ternyata bobot timbangan kebaikan
kita lebih ringan daripada timbangan kejelekan. Ingatlah akan firman
Allah subhanahu wata’ala:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">فَأَمَّا مَنْ ثَقُلَتْ مَوَازِينُهُ فَهُوَ فِي عِيشَةٍ رَاضِيَةٍ
وَأَمَّا مَنْ خَفَّتْ مَوَازِينُهُ فَأُمُّهُ هَاوِيَةٌ وَمَا أَدْرَاكَ
مَا هِيَهْ نَارٌ حَامِيَةٌ</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Dan adapun orang-orang yang berat timbangan (kebaikan)nya, maka dia
berada dalam kehidupan yang memuaskan. Dan adapun orang-orang yang
ringan timbangan (kebaikan)nya, maka tempat kembalinya adalah neraka
Hawiyah. Tahukah kamu apakah neraka Hawiyah itu? (Yaitu) api yang sangat
panas.” (Al Qari’ah: 6-11)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Bersegeralah dalam Beramal</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Wahai para pemuda, bersegeralah untuk beramal kebajikan, dirikanlah
shalat dengan sungguh-sungguh, ikhlas dan sesuai tuntunan Rasulullah
shallallahu ‘alaihi wasallam. Karena shalat adalah yang pertama kali
akan dihisab nanti pada hari kiamat, sebagaimana sabdanya:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">إِنَّ أَوَّلَ مَا يُحَاسَبُ النَّاسُ بِهِ يَوْمَ الْقِيَامَةِ مِنْ أَعْمَالِهِمْ الصَّلاَةُ</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Sesungguhnya amalan yang pertama kali manusia dihisab dengannya di
hari kiamat adalah shalat.” (HR. At Tirmidzi, An Nasa`i, Abu Dawud, Ibnu
Majah dan Ahmad. Lafazh hadits riwayat Abu Dawud no.733)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Bagi laki-laki, hendaknya dengan berjama’ah di masjid. Banyaklah
berdzikir dan mengingat Allah subhanahu wata’ala. Bacalah Al Qur’an,
karena sesungguhnya ia akan memberikan syafaat bagi pembacanya pada hari
kiamat nanti.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Banyaklah bertaubat kepada Allah subhanahu wata’ala. Betapa banyak
dosa dan kemaksiatan yang telah kalian lakukan selama ini. Mudah-mudahan
dengan bertaubat, Allah subhanahu wata’ala akan mengampuni dosa-dosa
kalian dan memberi pahala yang dengannya kalian akan memperoleh
kebahagiaan dunia dan akhirat.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Wahai para pemuda, banyak-banyaklah beramal shalih, pasti Allah
subhanahu wata’ala akan memberi kalian kehidupan yang bahagia, dunia dan
akhirat. Allah subhanahu wata’ala berfirman:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">مَنْ عَمِلَ صَالِحًا مِنْ ذَكَرٍ أَوْ أُنْثَى وَهُوَ مُؤْمِنٌ
فَلَنُحْيِيَنَّهُ حَيَاةً طَيِّبَةً وَلَنَجْزِيَنَّهُمْ أَجْرَهُمْ
بِأَحْسَنِ مَا كَانُوا يَعْمَلُونَ</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Barangsiapa yang mengerjakan amal shalih, baik laki-laki maupun
perempuan dalam keadaan beriman, maka sesungguhnya akan Kami berikan
kepadanya kehidupan yang baik.” (An Nahl: 97)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Engkau Habiskan untuk Apa Masa Mudamu?</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Pertanyaan inilah yang akan diajukan kepada setiap hamba Allah
subhanahu wata’ala pada hari kiamat nanti. Sebagaimana yang diberitakan
oleh Rasulullah shallallahu ‘alaihi wasallam dalam salah satu haditsnya:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">لاَ تَزُوْلُ قَدَمُ ابْنِ آدَمَ يَوْمَ الْقِيَامَةِ مِنْ عِنْدِ
رَبِّهِ حَتَّى يُسْأَلَ عَنْ خَمْسٍ : عَنْ عُمْرِهِ فِيْمَا أَفْنَاهُ
وَعَنْ شَبَابِهِ فِيْمَا أَبْلاَهُ وَمَالِهِ مِنْ أَيْنَ اكْتَسَبَهُ
وَفِيْمَا أَنْفَقَهُ وَمَاذَا عَمِلَ فِيْمَا عَلِمَ.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Tidak akan bergeser kaki anak Adam (manusia) pada hari kiamat nanti
di hadapan Rabbnya sampai ditanya tentang lima perkara: umurnya untuk
apa dihabiskan, masa mudanya untuk apa dihabiskan, hartanya dari mana
dia dapatkan dan dibelanjakan untuk apa harta tersebut, dan sudahkah
beramal terhadap ilmu yang telah ia ketahui.” (HR. At Tirmidzi no. 2340)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Sekarang cobalah mengoreksi diri kalian sendiri, sudahkah kalian
mengisi masa muda kalian untuk hal-hal yang bermanfaat yang mendatangkan
keridhaan Allah subhanahu wata’ala? Ataukah kalian isi masa muda kalian
dengan perbuatan maksiat yang mendatangkan kemurkaan-Nya?</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Kalau kalian masih saja mengisi waktu muda kalian untuk
bersenang-senang dan lupa kepada Allah subhanahu wata’ala, maka jawaban
apa yang bisa kalian ucapkan di hadapan Allah subhanahu wata’ala Sang
Penguasa Hari Pembalasan? Tidakkah kalian takut akan ancaman Allah
subhanahu wata’ala terhadap orang yang banyak berbuat dosa dan maksiat?
Padahal Allah subhanahu wata’ala telah mengancam pelaku kejahatan dalam
firman-Nya:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">مَنْ يَعْمَلْ سُوءًا يُجْزَ بِهِ وَلَا يَجِدْ لَهُ مِنْ دُونِ اللَّهِ وَلِيًّا وَلَا نَصِيرًا</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Barangsiapa yang mengerjakan kejahatan, niscaya akan diberi
pembalasan dengan kejahatan itu dan ia tidak mendapat pelindung dan
tidak (pula) penolong baginya selain dari Allah.” (An Nisa’: 123)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Bukanlah masa tua yang akan ditanyakan oleh Allah subhanahu wata’ala.
Oleh karena itu, pergunakanlah kesempatan di masa muda kalian ini untuk
kebaikan.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Ingat-ingatlah selalu bahwa setiap amal yang kalian lakukan akan
dipertanggungjawabkan kelak di hadapan Allah subhanahu wata’ala.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Jauhi Perbuatan Maksiat</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Apa yang menyebabkan Adam dan Hawwa dikeluarkan dari Al Jannah
(surga)? Tidak lain adalah kemaksiatan mereka berdua kepada Allah
subhanahu wata’ala. Mereka melanggar larangan Allah subhanahu wata’ala
karena mendekati sebuah pohon di Al Jannah, mereka terbujuk oleh rayuan
iblis yang mengajak mereka untuk bermaksiat kepada Allah subhanahu
wata’ala.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Wahai para pemuda, senantiasa iblis, setan, dan bala tentaranya
berupaya untuk mengajak umat manusia seluruhnya agar mereka bermaksiat
kepada Allah subhanahu wata’ala, mereka mengajak umat manusia seluruhnya
untuk menjadi temannya di neraka. Sebagaimana yang Allah subhanahu
wata’ala jelaskan dalam firman-Nya (yang artinya):</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">إِنَّ الشَّيْطَانَ لَكُمْ عَدُوٌّ فَاتَّخِذُوهُ عَدُوًّا إِنَّمَا يَدْعُو حِزْبَهُ لِيَكُونُوا مِنْ أَصْحَابِ السَّعِيرِ</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Sesungguhnya setan itu adalah musuh bagimu, maka jadikanlah ia
musuh(mu), karena sesungguhnya setan-setan itu mengajak golongannya
supaya mereka menjadi penghuni neraka yang menyala-nyala.” (Fathir: 6)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Setiap amalan kejelekan dan maksiat yang engkau lakukan, walaupun
kecil pasti akan dicatat dan diperhitungkan di sisi Allah subhanahu
wata’ala. Pasti engkau akan melihat akibat buruk dari apa yang telah
engkau lakukan itu. Allah subhanahu wata’ala berfirman (yang artinya):</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">وَمَنْ يَعْمَلْ مِثْقَالَ ذَرَّةٍ شَرًّا يَرَهُ</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Dan barangsiapa yang mengerjakan kejahatan sekecil apapun, niscaya dia akan melihat (balasan)nya.” (Az Zalzalah: 8)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Setan juga menghendaki dengan kemaksiatan ini, umat manusia menjadi
terpecah belah dan saling bermusuhan. Jangan dikira bahwa ketika engkau
bersama teman-temanmu melakukan kemaksiatan kepada Allah subhanahu
wata’ala, itu merupakan wujud solidaritas dan kekompakan di antara
kalian. Sekali-kali tidak, justru cepat atau lambat, teman yang engkau
cintai menjadi musuh yang paling engkau benci. Allah subhanahu wata’ala
berfirman:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">إِنَّمَا يُرِيدُ الشَّيْطَانُ أَنْ يُوقِعَ بَيْنَكُمُ الْعَدَاوَةَ
وَالْبَغْضَاءَ فِي الْخَمْرِ وَالْمَيْسِرِ وَيَصُدَّكُمْ عَنْ ذِكْرِ
اللَّهِ وَعَنِ الصَّلَاةِ فَهَلْ أَنْتُمْ مُنْتَهُونَ</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Sesungguhnya setan itu bermaksud hendak menimbulkan permusuhan dan
kebencian di antara kamu karena (meminum) khamr dan berjudi itu, dan
menghalangi kamu dari mengingat Allah dan shalat, maka berhentilah kamu
(dari mengerjakan perbuatan itu).” (Al Maidah: 91)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Demikianlah setan menjadikan perbuatan maksiat yang dilakukan manusia
sebagai sarana untuk memecah belah dan menimbulkan permusuhan di antara
mereka.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Ibadah yang Benar Dibangun di atas Ilmu</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Wahai para pemuda, setelah kalian mengetahui bahwa tugas utama kalian
hidup di dunia ini adalah untuk beribadah kepada Allah subhanahu
wata’ala semata, maka sekarang ketahuilah bahwa Allah subhanahu wata’ala
hanya menerima amalan ibadah yang dikerjakan dengan benar. Untuk itulah
wajib atas kalian untuk belajar dan menuntut ilmu agama, mengenal Allah
subhanahu wata’ala, mengenal Rasul-Nya shallallahu ‘alaihi wasallam,
dan mengenal agama Islam ini, mengenal mana yang halal dan mana yang
haram, mana yang haq (benar) dan mana yang bathil (salah), serta mana
yang sunnah dan mana yang bid’ah.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Dengan ilmu agama, kalian akan terbimbing dalam beribadah kepada
Allah subhanahu wata’ala, sehingga ibadah yang kalian lakukan
benar-benar diterima di sisi Allah subhanahu wata’ala. Betapa banyak
orang yang beramal kebajikan tetapi ternyata amalannya tidak diterima di
sisi Allah subhanahu wata’ala, karena amalannya tidak dibangun di atas
ilmu agama yang benar.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Oleh karena itu, wahai para pemuda muslim, pada kesempatan ini, kami
juga menasehatkan kepada kalian untuk banyak mempelajari ilmu agama,
duduk di majelis-majelis ilmu, mendengarkan Al Qur’an dan hadits serta
nasehat dan penjelasan para ulama. Jangan sibukkan diri kalian dengan
hal-hal yang kurang bermanfaat bagi diri kalian, terlebih lagi hal-hal
yang mendatangkan murka Allah subhanahu wata’ala.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Ketahuilah, menuntut ilmu agama merupakan kewajiban bagi setiap
muslim, maka barangsiapa yang meninggalkannya dia akan mendapatkan dosa,
dan setiap dosa pasti akan menyebabkan kecelakaan bagi pelakunya.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">طَلَبُ الْعِلْمِ فَرِيْضَةٌ عَلَى كُلِّ مُسْلِمٍ.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Menuntut ilmu agama itu merupakan kewajiban bagi setiap muslim.” (HR. Ibnu Majah no.224)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Akhir Kata</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Semoga nasehat yang sedikit ini bisa memberikan manfaat yang banyak
kepada kita semua. Sesungguhnya nasehat itu merupakan perkara yang
sangat penting dalam agama ini, bahkan saling memberikan nasehat
merupakan salah satu sifat orang-orang yang dijauhkan dari kerugian,
sebagaimana yang Allah subhanahu wata’ala firmankan dalam surat Al
‘Ashr:</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">وَالْعَصْرِ (1) إِنَّ الْإِنْسَانَ لَفِي خُسْرٍ (2) إِلَّا الَّذِينَ
آَمَنُوا وَعَمِلُوا الصَّالِحَاتِ وَتَوَاصَوْا بِالْحَقِّ وَتَوَاصَوْا
بِالصَّبْرِ</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">“Demi masa. Sesungguhnya manusia itu benar-benar dalam kerugian,
kecuali orang-orang yang beriman dan mengerjakan amal shalih dan
nasehat- menasehati dalam kebenaran dan nasehat-menasehati supaya
menetapi kesabaran.” (Al ‘Ashr: 1-3)</span></div>
<div style="text-align: justify;">
<span style="font-size: small;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Kami persembahkan nasehat ini untuk saudara-saudara kami terkhusus
para pemuda dan remaja muslim. Mudah-mudahan nasehat ini dapat membuka
mata hati mereka sehingga mereka lebih tahu tentang siapa dirinya
sebenarnya, apa kewajiban yang harus mereka tunaikan sebagai seorang
muslim, agar mereka merasa bahwa masa muda ini tidak sepantasnya untuk
diisi dengan perkara yang bisa melalaikan mereka dari mengingat Allah
subhanahu wata’ala sebagai penciptanya, agar mereka tidak terus-menerus
bergelimang ke dalam kehidupan dunia yang fana dan lupa akan negeri
akhirat yang kekal abadi. </span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Wallahu ta‘ala a’lam bishshowab.</span></div>
<div style="text-align: justify;">
<span style="font-size: small;">Sumber: Buletin Al-Ilmu, Penerbit Yayasan As-Salafy Jember</span></div>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-3413721371707645262012-05-14T13:30:00.000+07:002012-05-14T13:31:12.569+07:00METABOLISME<div class="separator" style="clear: both; text-align: justify;">
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BAB 2<br />
PEMBAHASAN<br />
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2.1 DEFENISI METABOLISME<br />
Metabolism adalah proses pemecahan zat-zat gizi di dalam tubuh untuk menghasilkan energi atau untuk pembentukkan struktur tubuh. Suatu rentetan reaksi kimia dari awal hingga akhir yang terjadi dalam metabolism di namakan jalur metabolisme. Jalur metabolism terdiri atas reaksi-reaksi anabolisme dan katabolisme.reaksi anabolisme adalah reaksi membangun dari ikatan sederhana ke ikatan yang lebih besar dan komleks. Misalnya glukosa di ubah menjadi glikogen, asam lemak dan gliserolmenjadi trigliserida, serta asam amino menjadi protein. Proses anabolisme memerlukan energi.</div>
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Reaksi gambar anabolismepada pembentukan glikogen, trigliserida,dan protein. Reaksi-reaksi ini membutuhkan energi<br />
Reaksi katabolisme adalah reaksi yang memecah ikatan kompleks menjadi ikatan lebih sederhana. Reaksi katabolisme biasanya melepaskan energy. Contoh :katbolisme adalah pemecahan glikogen menjadi glukosa, trigliserida menjadi gliserol dan asam lemak sertaq protein menjadi asam amino.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqfvStrG7RWyfs0aRG8pMq3vUq7izCOGr2EAsVrJH3fJ7bEpZYSiVoScqh0OkdnTjBzbWCOkXTbGYzGdVjsGbymaL_C0MN_U8ea2UIs-45HBOqRkSwz-U7tngR3E225WtczTSJ4SHQY1MC/s1600/gbf.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="301" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqfvStrG7RWyfs0aRG8pMq3vUq7izCOGr2EAsVrJH3fJ7bEpZYSiVoScqh0OkdnTjBzbWCOkXTbGYzGdVjsGbymaL_C0MN_U8ea2UIs-45HBOqRkSwz-U7tngR3E225WtczTSJ4SHQY1MC/s400/gbf.jpg" width="400" /></a></div>
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Reaksi katabolisme menjadi antara lain pada pemecahan glikogen, trigliserida, dan protein . katabolisme glukosa, gliserol, asam lemak, dan asam amino selanjutnya menghasilkan energi.<br />
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2.1.1 PINDAH ENERGI DALAM METABOLISME<br />
Energi dalam tubuh berasal dari fotosintesis tumbuh-tumbuhan. Energi ditangkap dalam ikatan kimia molekul-molekul kabohidrat,protein lemak dan alkoholo.dalam proses katabolisme tubuh kemudian mengubah energi ini kedalam berbagai bentuk eneergi lain: energi kimia untuk membentuk ikatan kimia baru,energi mekanis untuk menggerakan otot-otot, energi elektris untuk untuk mengalirkan transmisi saraf dan energi osmotis untuk mempertahankan keseimbangan isi antar sel energi kimia ini di peroleh dari makanan pada akhirnya akan di keluarkan oleh tubuh sebagai panas.<br />
<br />
2.1.2 Adenosin trifosfat<br />
Energi yang di gunakan sel pada umumnya adalah dalam bentukadenosin trifosfat (ATP). Setiap sel membuat ATP untuk keperluan energinya. Energi yang di keluarkan melalui proses katabolisme sering di gunakan lagi dalam reaksi berantai untuk membentuk ikatan berenergi tinggi ATP. ATP terutamadi peroleh melalui fotosintesis oksidatif. ATP yang mengandung tiga gugus fosfat kemudian dapat dengan mudah memindahkan energi yang di kandungnya yang ada dalam ikatan kimia lain.<br />
Demikianlah pemecahan zat gizi sumber energi di ikuti oleh pembentukan molekul-molekul ATP yang menangkap energi yang di lepas kedalam ikatannya. Bila kemudian energi di butuhkan , ikatan berenergi tinggi dalam gugus fosfat akan dilepas melalui hidrolisis. <br />
ADP dapat dihidrolisis lagi menjadi AMP+Pi. pemecahan ikatan di antara ikatan fosfat pertama dan kedua atau diantara fosfat kedua dan ketiga menghasilkan energi. Energi yang dilepas ini digunakan lagi untuk reaksi kimia lain. Hanya energi berupa ATP dapat digunakan sebagai energi oleh sel. Dengan demikian koma ATP di gunakan untuk memindahkan energi yang dihasilkan oleh reaksi katabolisme untuk keperluan reaksi anabolisme. Kurang lebih 40% dari energi potensial yang berasal dari zat-zat gizi di simpan alam bentuk ATP dan selebihnya di lepas sebagai panas. Sebagian dari panas digunakan untuk mempertahankan suhu tubuh, selebihnya dikeluarkan dari tubuh melalui penguapan dari kulit atau berupa pengeluaran panas secara langsung.<br />
Sebagian besar metabolism terjadi didalam sel-sel tubuh. Jenis dan tingkat metabolism terjadi yang tergantung pada jenis sel. Sel-sel hati merupakan sel-sel yang paling aktif dalam metabolism <br />
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2.1.3 PERANAN ENZIMDAN KOENZIM DALAM METABOLISME<br />
Metabolisme selalu membutuhkan enzim untuk membantu reaksi- reaksi yang terjadi.kadang- kadang enzim membutuhkan pembantu berupa koenzim.<br />
Enzim adalah protein khusus yang berperan sebagai katalisator dalam reaksi kimia,tetapi tidak mengalami perubahan selama proses berlangsung.koenzim adalah zat organikbukan protein yang membantu aktivitas enzim.Banyak koenzim yang bagian strukturnya terdiri dari vitamin B.<br />
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2.1.4 PEMECAHAN ZAT- ZAT GIZI SUMBER ENERGI<br />
Glukosa,gliserol,asam lemak,asam amino, dan alkohol merupakan bahan dasar yang diperoleh dari makanan sebagai sumber energi.<br />
<br />
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2.2 FAKTOR-FAKTOR YANG MEMPENGARUHI METABOLISME<br />
Factor-faktor yang meningkatkan aktifitas kimia dalam sel juga meningkatkan kecepatan metabolisme. Beberapa diantaranya adalah sebagai berikut:<br />
1. Gerak badan<br />
Factor yang menyebabkan efek yang paling dramatis pada kecepatan metabolisme sejauh ini adalah gerak berat badan. Kontraksi otot maksimum yang berlangsung singkat pada salah satu otot, melepaskan panas sebanyak 100 kali panas yang dikeluarkan pada waktu istirahat selama beberapa detik untuk satu waktu. Akan tetapi, dalam keseluruhan tubuh, gerak otot maksimum dapat meningkatkan seluruh pembentukan panas tubuh selama beberapa detik sampai sekitar 50 kali normal atau dipertahankan selama berapa menit sampai sekitar 20 kali normal pada atlit yang terlatih baik, yang merupakan peningkatan kecepatan metabolisme sampai 2000% dari normal.<br />
<br />
2. Kebutuhan energy untuk aktivitas sehari-hari<br />
Bila pria rata-rata 70 kg berbaring di tempat tidur sepanjang hari, ia menggunakan sekitar 1650 kalori energy. Proses makan meeningkatkan jumlah energy yang digunakan setiap hari dengan tambahan 200 kalori atau lebih sehingga pria yang sama yang berbaring pada tempat tidur dan juga makan diet yang layak membutuhkan masukan sehari-hari sekitar 1850 kalori perharikecepatan penggunakan energy sementara seseorang melakukan berbagai jenis aktivitas. Perhatikan bahwa naik tangga memerlukan hamper 17 kali sebanyak energy yang diperlukan sewqaktu tidur ditempat tidur. Pada umumnya dalam masa 24 jam seseorang pekerja dapat mencapai kecepatan penggunaan energy yang maksimum sebesar 6000 sampai 7000 kalori dengan perkataan lain sebanyak 3,5 x kecepatan metabolism basal.<br />
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3. Hormone tiroid<br />
Bila kelenjar tiroid menyekresi tiroksin dalam jumlah maksimum, laju metabolism kadang-kadang meningkat sampai setinggi 100% diatas normal. Sebaliknya, kehilangan total sekresi tiroid menurunkan laju metabolism serendah 50-60% normal. Efek ini dengan mudah dapat dijelaskan dengan fungsi dasar tiroksin untuk meningkatkan laju aktivitas pada hampir semua reaksi kimia dalam semua sel tubuh. Hubungan antara tiroksin dan laju metabolisme akan dibicarakan jauh lebih luas dalam hubungannya dengan fungsi tiroid, karrna salah satu metode yang paling bermanfaat untuk mendiaknosis kecepatan sekresi tiroid abnormal adalah menentukan laju metabolism basal penderita.<br />
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Tabel 1. Energy Yang Digunakan Per jam Selama Berbagai Jenis Aktivitas Bagi Pria 70 Kg</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuhcQ8Ou7HrYuGSLXK3Vjfs0JekpMKJ7OTWRZsuBGxqnlbD-eY5Tgh-P31fYEmWbqP1T8L7l1i5T0sDWkFQm8__Jw0R4wN2QK4-S2_ivxPAJcAkvIv_SEvbY1PZLjSVxClK48Iqp6HuNEx/s1600/rfr.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="420" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuhcQ8Ou7HrYuGSLXK3Vjfs0JekpMKJ7OTWRZsuBGxqnlbD-eY5Tgh-P31fYEmWbqP1T8L7l1i5T0sDWkFQm8__Jw0R4wN2QK4-S2_ivxPAJcAkvIv_SEvbY1PZLjSVxClK48Iqp6HuNEx/s640/rfr.jpg" width="640" /></a></div>
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4. Perangsangan Simpatis<br />
Perangsangan sistem saraf simpatis disertai dengan pengeluaran norepinefrin dan epinefrin meningkatkan laju metabolism pada hakekatnya pada semua jaringan tubuh. Hormone ini mempunyai efek langsung pada sel untuk menyebabkan glikogenolisis, dan hal ini, mungkin bersam dengan efek intra sel lain hormone tersebut meningkatkan aktifitas sel.<br />
Perangsangan maksimum susunan saraf simpatis dapat meningkatkan laju metabolism pada beberapa binatang tingkat rendah sebanyak beberapa ratus persen, tetapi besar efek ini pada manusia masih dalam pertanyaan. Mungkin 15% atau kurang pada orang dewasa, tetapi sebanyak 900% pada Neonatus.<br />
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2.3 METABOLISME KARBOHIDRAT<br />
Karbohidrat yang ada dalam makanan sebagian besar berupa polimer heksosa,di antaranya yang paling penting adalah glukosa,galaktosa,dan fruktosa (Gambar 1) . Kebanyakan monosakarida yang terdapat di dalam tubuh adalah isomer D.produk utama pencernaan karbohidrat dan gula sirkulasi utama adalah glukosa.Dalam darah vena perifer,kadar normal glukosa plasma saat puasa adalah 70-110 mg/dL (3,9-6,1 mmol/L).Dalama darah arteri,kadar glukosa plasma adalah 15-30 mg/dL lebih tinggi di banding kadar glukosa darah vena.<br />
Begitu masuk ke dalam sel,dalam keadaan normal glukosa difosforilasi menjadi glukosa-6-fosfat.Enzim yang mengatalisis reaksi ini adalah heksokinase.selain enzim tersebut,di dalam hati terdapat juga juga enzin yang di sebut glukokinase,yang memiliki spesifisitas yang lebih tinggi untuk glukosa dan,tidak seperti heksokinase,kadarnya meningkat oleh insulin dan menurun pada keadaan kelaparan dan diabetes.Glukosa 6-fosfat kemudian di polimerisasi menjadi glikogen atau di katabolisasi. Langkah-langkah yang berperan di jelaskan secara garis besar dalam gambar 2. proses pembentukan glikogen di sebut glikogenesis,dan pemecahan glikogen di sebut glikogenolisis.Glikogen,bentuk simpanan glukosa,terdapat di dalam kebanyakan jaringan tubuh,tetapi pasokan Utamanya terdapat dalam hati dan otot rangka.Pemecahan glukosa menjadi piruvat atau laktat (atau keduanya) di sebut glikolisis ,katabolisme glukosa berjalan melalui pemecahan fruktosa menjadi triosa atau melalui oksidasi dan dekarboksilasi menjadi pentosa.jalur menjadi piruvat melalui triosa adalah jalur Embden-Meyerhof,dan yang melalui 6-fosfog-lukonat dan pentosa adalah jalur oksidatif langsung (pirau heksosa monofosfat) (Gambar 2).</div>
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D-Gal aktosa 1<br />
Gambar 1. Struktur heksosa utama dalam makanan. Ditampilkan isomer-isomer D yang terdapat di Alam.<br />
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Gambar 2 . Bagan metabolisme karbohidrat dalam sel <br />
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piruvat diubah menjadi asetil-KoA.interkonversi antara karbohidrat,lemak,dan protein mencakup konversi (perubahan) gliserol dari lemak menjadi dihidroksiaseton fosfat dan konversi sejumlah asam amino,yang mempunyai kerangka karbon yang menyerupai zat-antara dalam jalur Embden-Meyerhof dan siklus asam sitrat ,menjadi zat-zat antara ini dengan deaminasi.Dengan cara ini,dan dengan konversi laktat menjadi glukosa,molekul nonglukosa dapat di ubah menjadi glukosa (glukoneogenesis). <br />
Glukosa dapat di ubah menjadi lemak melalui asetil KoA,tetapi karena konversi piruvat menjadi asetil KoA,reaksi ini menjadi ireversibel tidak seperti kebanyakan reaksi dalam glikolisis (Gambar 3); karena itu, lemak tidak dapat di ubah menjadi glukosa melalui jalur ini.Maka, sangat sedikit konversi akhir lemak menjadi karbohidrat di dalam tubuh karena tidak ada jalur untuk konversi kecuali produksi dari gliserol yang secara kuantitatif tidak berarti.<br />
Siklus Asam Sitrat<br />
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Gambar 3. Siklus asam sitrat. Perubahan piruvat menjadi asetil-KoA dan setiap perputaran siklus menghasilkan 4 NADH dan 1 FADH2 untuk oksidasi melalui rantai flovoprotein-sitokrom plus pembentukan 1 GTP yang cepat diubah menjadi ATP<br />
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Siklus asam sitrat (siklus krebs,siklus asam trikarboksilat) adalah serangkaian reaksi untuk memetabolisasi asetil KoA menjadi CO2 dan atom H.Asetil KoA pertama kali di kondensasi dengan anion asam 4-karbon.oksaloasetat,untuk membentuk sitrat dan HS-KoA.Dalam sebuah rangkaian yang terdiri dari tujuh reaksi berurutan,2 molekul CO2 di keluarkan,sehingga terbentuk lagi oksaloasetat (Gambar 3).<br />
Empat pasang atom H di pindahkan ke rantai flavoprotein-sitokrom,menghasilkan 12 ATP dan 4 H2O,2H2O di antaranya di pakai dalam siklus ini.siklus asam sitrat merupakan jalur umum untuk oksidasi karbohidrat ,lemak,dan beberapa asam amino menjadi CO2 dan H2O.jalur masuk utama menuju siklus ini adalah melalui asetil-KoA,tetapi sejumlah asam amino dapat di ubah menjadi zat-zat antara siklus asam sitrat melalui proses deaminasi.siklus asam sitrat memerlukan O2 dan tidak berfungsi pada kondisi anaerobik.<br />
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2.3.1 Produksi Energi<br />
Produk bersih senyawa fosfat kaya-energi selama metabolisme glukosa dan glikogen menjadi piruvat bergantung pada apakah metabolisme tersebit terjadi melalui jalur Embdenmeyerhof atau melalui pirau heksosa monofosfat.Dengan oksidasi pada tingkat substrat,perubahan 1 mol fosfogliseraldehida menjadi fosfogliserat menghasilkan 1 mol ATP,dan perubahan 1 mol fosfoenolpiruvat menjadi piruvat menghasilkan 1 mol lagi.karena 1 mol glukosa 6-Fosfat menghasilkan 2 mol fosfogliseraldehida melalui jalur EmbdenMeyerhof,akan di hasilkan 4 mol ATP per mol glukosa yang di metabolisasi menjadi piruvat.semua reaksi ini terjadi tanpa adanya O2 dan karena itu merupakan produksi energi anaerob.Namun,1 mol ATP di gunakan dalam membentuk fruktosa1,6-difosfat dari fruktosa 6-fosfat dan 1 mol dalam memfosforilasi glukosa ketika memasuki sel.Akibatnya,kalau piruvat di bentuk secara anaerob dari glikogen,terdapat produksi bersih 3 mol ATP per mol glukosa 6-fosfat;tetapi,kalau piruvat di bentuk dari 1 mol glukosa darah ,akhirnya hanya 2 mol ATP.<br />
Pasokan NAD+ diperlukan untuk mengubah fosfogliseraldehida menjadi fosfogliserat.dibawah kondisi anaerob(glikolisis anaerob),satu hambatan glikolisis pada tahap konversi fosfogliseraldehida dapat di harapkan segera terjadi begitu NAD+ yang tersedia diubah menjadi NADH.Namun piruvat menerima hidrogen dari NADH,membentuk NAD+ dan laktat.<br />
Piruvat + NADH _ laktat + NAD<br />
Dengan cara ini,metabolisme glukosa dan produksi energi dapat berlanjut terus tanpa O2 untuk sementara.laktat yang menumpuk diubah kembali menjadi piruvat asalkan pasokan O2 pulih kembali,NADH mentransfer hidrogennya ke rantai flavoprotein-sitokrom.<br />
Selama glikolisis aerob,produksi aerob produksi bersih ATP 19 kali lebih besar dari pada dua mol ATP yang di hasilkan di bawah kondisi anaerob.Enam ATP di bentuk dengan oksidasi melalui rantai flavoprotein-sitokrom dari dua NADH yang di produksi ketika 2 mol fosfogliseraldehida di ubah menjadi fosfogliserat (Gambar 17-9);enam ATP dibentuk dari dua NADH yang dihasilkan <br />
ketika 2 mol piruvat di ubah menjadi asetil-KoA;dan 24 ATP dibentuk pada 2 putaran siklus asam sitrat berikutnya.Dari yang di hasilkan ini,18 dibentuk dengan oksidasi enam NADH,empat dengan oksidasi dua FADH2,dan dua dengan oksidasi pada tingkat substrat ketika suksinil-KoA diubah menjadi suksinat.Reaksi ini sebenernya menghasilkan GTP,tetapi GTP tersebut di ubah menjadi ATP.jadi,produksi bersih ATP per mol glukosa darah yang dimetabolisasi secara aerob melalui jalur Embden-Meyerhof dan siklus asam sitrat adalah 2 + (2*3) + (2*3) + (2*12) = 38<br />
Oksidasi glukosa melalui pirau heksosamanofosfat menghasilkan banyak NADPH.Pasokan koenzim tereduksi ini penting untuk banyak proses metabolik.Pentosa yang terbentuk dalam proses ini merupakan rangka bangun untuk nukleotida (lihat bawah).jumlah ATP yang di hasilkan bergantung pada jumlah NADPH yang di ubah menjadi NADH dan kemudian dioksida.<br />
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”Katup Pengarah Aliran”<br />
Metabolisme diatur oleh berbagai macam hormon dan faktor lain.Untuk menghasilkan perubahan bersih apapun di dalam suatu proses metabolisme tertentu,faktor pengatur jelas harus menggerakkan suatu reaksi kimia ke satu arah. Kebanyakan reaksi di dalam metabolisme-antara bersifat reversibel bebas,tetapi ada sejumlah ”katup pengarah aliran” (directional-flow valves), yakni reaksi yang berjalan satu arah di bawah pengaruh satu enzim atau mekanisme transpor dan dengan arah yang berlawanan di bawah pengarh enzim yang lain.lima contoh di dalam metabolisme-antara karbohidrat diperlihatkan di Gambar 4. jalur yang berbeda untuk sintesis dan katabolisme asam lemak (lihat bawah) adalah contoh yang lain.faktor pengatur memengaruhi metabolisme dengan bekerja langsung atau tak langsung pada ”katup pengarah aliran” ini.<br />
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Gambar 4. Lima contoh katub pengarah aliran dalam metabolisme karbohidrat; reaksi-reaksi yang berlangsung satu arah dengan satu mekanisme dan dengan arah yang berlawanan dengan mekanisme yang berbeda. Garis ganda dalam contoh 5 menggambarkan membran mitokondria. Piruvat diubah menjadi malat di dalam mitokondria dan malat berdifusi ke luar mitokondria masuk ke sitosol, untuk diubah menjadi fosfoenolpiruvat<br />
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2.3.2 Sintesis & Penguraian Glikogen<br />
Glikogen adalah suatu polimer glukosa bercabang dengan dua jenis ikatan glikosida: 1:4 dan 1:6 (Gambar 5). Glikogen di sintesis pada glikogenin,suatu protein primer,dari glukosa 1-fosfat melalui uridin difosfoglukosa (UDPG).Enzim glikogen sintase mengatalisis reaksi sintetik terakhir.ketersediaan glikogenin adalah salah satu faktor yang menentukan jumlah glikogen yang di bentuk.penguraian glikogen di ikatan 1:4 di katalisis oleh fosforilase,sementara pemecahan glikogen di ikatan 1:6 di katalisis oleh enzim lain.<br />
Fosforilase sebagian di aktifkan oleh kerja epinefrin pada reseptor adrenergik- di hati.sebaliknya,aktifnya fosforilase ini mengawali suatu rangkaian reaksi yang menjadi satu contoh klasik kerja hormon melalui cAMP (Gambar 6). Protein kinase A diaktifkan oleh cAMP dan mengatalisis pemindahan satu gugus fosfat ke fosforilase kinase,yang mengubahnya menjadi bentuk aktif.fosforilase kinase kemudian mengatalisis fosforilasi dan aktivasi fosforilase.fosforilase inaktif dikenal sebagai fosforilase b (defosfofosforilase),dan fosforilase aktif di sebut fosforilase a (fosfofosforilase).<br />
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Gambar 5. Pembentukan dan pemecahan glikogen. Pengaktifan fosforilase a diringkas pada gambar 6.<br />
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Gambar 6. Jenjang reaksi epinefrin Untuk mengaktifkan fosforilase. Glukagon mempunyai kerja yang sama di hati tetapi tidak di otot rangka .<br />
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Pengaktifan protein kinase A oleh cAMP tidak hanya meningkatkan pemecahan glikogen melainkan juga menghambat sintesis glikogen.Glikogen sintase aktif dalam bentuk terdefosforilasi dan tidak aktif kalau mengalami fosforilasi,dan enzim ini terfosforilasi bersama dengan fosforilase kinase ketika protein kinase A diaktifkan<br />
Glikogen juga di pecah oleh kerja katekolamin pada reseptor adrenergik- di hati.pemecahan ini di perantarai oleh Ca intrasel dan melibatkan aktivasi fosforilase kinase yang tidak bergantung pada cAMP.<br />
Karena hati mengandung enzim glukosa 6-fosfatase ,banyak glukosa glukosa 6-fosfat yang terbentuk di dalam organ ini dapat di ubah menjadi glukosa dan memasuki aliran darah, meningkatkan kadar glukosa plasma.Ginjal juga ikut andil pada peningkatan kadar glukosa ini.jaringan lain tidak mengandung enzim ini,sehingga di dalam organ-organ itu sebagian besar glukosa 6-fosfat di katabolisasi melalui jalur Embden-meyerhof dan jalur pirau heksosamono fosfat.katabolisme glukosa yang meningkat di otot rangka menyebabkan peningkatan kadar laktat di dalam darah. Dengan merangsang adenilsiklase,epinefrin menyebabkan pengaktifan fosforilase di hati dan otot rangka.Akibat Aktivasi ini adalah nainya kadar glukosa plasma dan laktat dalam darah.Glukagon mempunyai kerja yang serupa,tetapi efeknya hanya pada fosforilase di hati.Akibatnya,glukagon menyebabkan peningkatan glukosa plasma tanpa perubahan pada laktat darah .<br />
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2.3.3 Sindrom McArdle<br />
Pada keadaan klinis yang di kenal sebagai sindrom McArdle atau glikogenosis defisiensi miofosforilase,glikogen menumpuk di dalam otot rangka karena defisisensi fosforilase otot.pasien penyakit ini mengalami nyeri dan kekakuan otot saat berolaraga sehingga toleransi pasien dalam berorahraga sangat menurun;mereka tidak dapat memecah glikogen otot mereka untuk menyediakan energi untuk kontraksi otot.dan glukosa yang mencapai otot mereka dari aliran darah hanya cukup untuk keperluan kerja yang sangat ringan saja.mereka memberi respons dengan peningkatan normal glukosa plasma kalau di beri glukagon atau epinefrin,yang menunjukkan bahwa fosforilase hati mereka normal.<br />
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2.3.4 Glukostat Hati<br />
Akan terjadi penyerapan glukosa netto oleh hati kalu glukosa plasma tinggi dan pembebasan netto kalu kadarnya rendah.Karena itu,hati berfungsi sebagai semacam ”Glukostat”,yang mempertahankan kadar glukosa sirkulasi agar tetap konstan.fungsi ini tidak otomatis;penyerapan dan pengeluaran glukosa di pengaruhi oleh kerja banyak hormon.<br />
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2.3.5 Penanganan Glukosa oleh Ginjal<br />
Di ginjal,glukosa di filtrasi secara bebas;tetapi pada kadar glukosa plasma yang normal,semua glukosa dapat diabsorpsi kembali di tubulus proksimal tetapi dalam jumlah yang sangat sedikit.<br />
Kalau jumlah yang difiltrasi bertambah banyak,reabsorpsinya meningkat,tetapi ada batas jumlah glukosa yang dapat direabsorpsi oleh tubulus proksimal.kalau kadar maksimum tubulu untuk glukosa (tubular maximum for glucose,TmG) di lewati,akan terdeteksi glukosa yang cukup banyak di dalam urine (glikosuria).Ambang ginjal untuk glukosa,yaitu kadar darah arteri yang dapat menimbulkan glikosuria,dicapai kalau konsentrasi glukosa plasma vena sekitar 180 mg/dL,tetapi dapat lebih tinggi kalau laju filtrasi glomerulusnya rendah.<br />
2.3.6 Glikosuria<br />
Glikosuria terjadi jika kadar glukosa plasma meningkat karena defisiensi insulin relatif (diabetes melitus) atau karena glikogenolisis yang berlebihan setelah terjadi trauma fisik atau emosi.pada beberapa orang,mekanisme transpor glukosa di tubulus ginjal sudah cacat sejak lahir,sehingga glikosuria terjadi pada kadar glukosa plasma yang normal.<br />
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2.3.7 Faktor yang Menentukan kadar Glukosa plasma<br />
Kadar glukosa plasma saat di tentukan oleh keseimbangan antara jumlah glukosa yang masuk kedalam aliran darah dan jumlah yang meninggalkannya.oleh karena itu penentu utamanya adalah asupan makanan; kecepatan pemasukan ke dalam sel otot,jaringan adiposa,dan organ-organ lain; dan aktivitas glukostatik hati (Gambar 7).lima persen glukosa yang di konsumsi langsung diubah menjadi glikogen di dalam hati,dan 30-40% di ubah menjadi lemak.Sisanya di metabolisasi di dalam otot dan jaringan lain.pada waktu puasa,glikogen hati di pecah dan hati melepaskan glukosa ke dalam aliran darah. <br />
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Gambar 7. Homeostasis glukosa plasma, perhatikan fungsi glukostatik hati, serta keluarnya glukosa dalam urine apabila ambang ginjal terlampaui (tanda panah terputus-putus)<br />
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kalau puasanya lebih lama lagi,glikogen habis dan terjadi peningkatan glukoneogenesis dari asam amino dan gliserol di dalam hati. pada orang normal,glukosa plasma turun sedang menjadi sekitar 60 mg/dL selama kelaparan berkepanjangan,tetapi tidak timbul gejala hipoglikemia karena glukoneogenesis mencegah terjadinya penurunan lebih lanjut.<br />
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2.3.8 Homeostasis Karbohidrat Selama Olahraga<br />
Pada seorang laki-laki 70 kg,simpanan karbohidrat total adalah 2500 kkal,di simpan dalam 400 g glikogen otot,100 g glikogen hati,dan 20 g glukosa di dalam cairan ekstrasel.sebaliknya,112.000 kkal (sekitar 80 % pasokan bahan bakar tubuh) di simpan dalam lemak dan sisanya dalam protein.Otot yang beristirahat menggunakan asam lemak untuk metabolismenya,demikian pula yang di kerjakan otot setelah berolahraga,dan sel darah meranh menggunakan sebagian besar persetanse sisanya.<br />
Pada waktu olahraga,keperluan kalori otot mula-mula dipenuhi oleh glikogenolisis di otot dan peningkatan ambilan glukosa.Glukosa plasma mula-mula naik karena meningkatnya glikogenolisis hiti tetapi dapat turun pada olahraga yang berat dan lama.glukoneogenesis meningkat (Gambar 8). Insulin plasma turun,dan glukagon serta epinefrin plasma meningkat.Setelah Olahraga,glikogen hati diisi lagi oleh glukoneogenesis tambahan dan terjadi penurunan pengeluaran glukosa oleh hati.<br />
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2.3.9 Regulasi Glukoneogenesis<br />
Bukti-bukti terakhir mengisyaratkan bahwa PGC-1,suatukoaktivator transkripsi,berperan sentral dalam pengaturan glukoneogenesis hati;koaktivator transkripsi adalah suatu molekul yang tidak mengikat DNA dengan sendirinya,tetapi berfungsi sebagai penghubung fungsional antara regulator gen dan sintesis mRNA.PGC-1 sangat meningkat pada keadaan puasa dan pada diabetes yang di picu oleh streptozosin.mencit ob/ob,dan knockout reseptor insulin hati;glukoneogenesis yang di induksi oleh PGC-1,dan aktivitas penuhnya,mmemerlukan pengaktivan reseptor glukokortikoid,yang juga meningkatkan glukoneogenesis.<br />
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2.3.10 Metabolisme Heksosa Selain Glukosa<br />
Heksosa-heksosa lain yang diabsorpsi dari usus antara lain adalah galaktosa,yang dilepaskan dari pencernaan laktosa dan diubah menjadi glukosa di dalam tubuh;dan fruktosa,yang sebagian berasal dari makanan dan sebagian diproduksi dengan hidrolisis sukrosa.Setelah fosforilasi,galaktosa bereaksi dengan uridin difosfoglukosa (UDPG) untuk membentuk uridin difosfogalaktosa.Uridin difosfogalaktosa di ubah kembali menjadi UDPG,dan UDPG berfungsi dalam sintesis glikogen (Gambar 5).Reaksi ini bersifat reversibel,dan perubahan UDPG menjadi uridin difosfogalatosa menghasilkan galaktosa yang deperlukan untuk membentuk glikolipid dan mukoprotein jika asupan galaktosa dari makanan kurang.Penggunaan galaktosa,seperti halnya penggunaan glukosa,bergantung pada insulin.pada kelainan metabolisme bawaan yang di kenal sebagai galaktosemia,terdapat defisiensi kongenital galaktosa 1-fosfat uridin transferase,suatu enzim yang bertanggung jawab atas reaksi antara galaktosa 1-fosfat dan UDPG,sehingga galaktosa yang dimakan menumpuk di dalam sirkulasi.Hasilnya adalah gangguan serius pada pertumbuhan dan perkembangan.tetapi dengan diet bebas galaktosa memperbaiki kondisi ini tanpa menimbulkan defisiensi galaktosa,karena enzim yang di perlukan untuk membentuk uridin difosfogalaktosa dari UDPG tersedia. Fruktosa sebagian diubah menjadi fruktosa 6-fosfat dan kemudian di metabolisasi melalui fruktosa 1,6 difosfat (Gambar 2). Enzim yang mengatalisis pembentukan fruktosa 6-fosfat adalah heksokinase,enzim yang sama dengan yang mengatalisis perubahan glukosa menjadi glukosa 6-fosfat.Namun,jauh lebih banyak fruktosa yang di ubah mmenjadi fruktosa 1-fosfat dalam suatu reaksi yang dikatalisis oleh fruktokinase.<br />
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Gambar 8. Keluaran glukosa splanknik (hepatik), yang memperlihatkan keluaran yang diakibatkan oleh glikogenolisis (balok yang tidak berwarna) dan keluaran yang diperkirakan akibat glukoneogenesis (dalam tanda kurung kurawal). Angka-angka untuk glukoneogenesis adalah nilai-nilai terukur untuk ambilan berbagai prekursor glukoneogenesis oleh splanknik.<br />
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Kebanyakan fruktosa 1-fosfat kemudian di pecah menjadi dihidroksiaseton fosfat dan gliseraldehid.Gliseraldehid mengalami fosforilasi,danhasilnya beserta dihidroksiaseton fosfat memasuki jalur-jalur untuk metabolisme glukosa.Karena reaksi yang berjalan melalui fosforilasi fruktosa di posisi 1 dapat terjadi dengan kecepatan normal tanpa perlu insulin,dianjurkan bahwa fruktosa di berikan pada penderita diabetes untuk mengisi kembali simpanan karbohidrat mereka.Namun,kebanyakan fruktosa dimetabolisasi di usus dan hati,sehingga manfaatnya dalam mengisi kembali karbohidrat di bagian tubuh lain terbatas.<br />
Fruktosa 6-fosfat dapat juga difosforilasi di posisi 2,membentuk fruktosa 2,6-difosfat.Senyawa ini merupakan pengaturan yang penting pada glukoneogenesis hati.jika kadar fruktosa 2,6-difosfat tinggi,perubahan fruktosa 6-fosfat menjadi fruktosa 1,6-difosfat di permudah,sehingga pemecahan glukosa menjadi piruvat meningkat.Turunnya kadar fruktosa 2,6-difosfat mempermudah reaksi balik dan dengan demikian membantu glukoneogenesis.Salah satu kerja protein kinase yang di hasilkan oleh kerja glukagon adalah menurunkan fruktosa 2,6-difosfat hati.<br />
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2.4 METABOLISME LIPID<br />
Istilah lipida meliputi senyawa-senyawa heterogen, termasuk lemak dan minyak yang umum dikenal di sedalam makanan, malam, fosfolipida, sterol dan ikatan lain sejenis yang terdapat di dalam makanan dan tubuh manusia. Lipida mempunyai sifat meliputi senyawa-senyawa heterogen, termasuk lemak dan minyak yang umum dikenal di sedalam makanan, malam, fosfolipida, sterol dan ikatan lain sejenis yang terdapat di dalam makanan dan tubuh manusia. Lipida mempunyai sifat yang sama, yaitu larut dalam pelarut nonpolar, seperti etanol, eter, kloroform dan benzena.<br />
2.4.1 KLASIFIKASI LIPIDA<br />
Klasifikasi lipida yang penting dalam ilmu gizi menurut komposisi kimia dapat dilakukan sebagai berikut:<br />
A. Lipida Sederhana<br />
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1) Lemak netral<br />
Monogliserida, digliserida dan trigliserida (ester asam lemak dan gliserol). Sebagian besar lemak dan minyak dalam alam tediri atas 98-99 % trigliserida. Trigliserida adalah ester gliserol, suatu alkohol trihidrat dan asam lemak yang tepatnya disebut triasilgliserol. Bila ketiga asam lemak di dalam trigliserida adalah asam lemak yang sama dinamakan trigliserida sederhana; bila berbeda dinamakan trigliserida campuran. Bila hanya satu asam lemak bergabung dengan gliserol, maka lemak tersebut dinamakan monogliserida dan bila dua, digliserida. Fungsinya sebagai sumber energi,sumber asam lemak esensial alat angkut vitamin larut lemak, menghemat protein, memberi rasa kenyang dan kelezatan, sebagai pelumas, memelihara suhu tubuh, pelindung organ tubuh <br />
2) Ester asam lemak dengan alkohol berberat molekul tinggi<br />
a. Malam<br />
b. Ester sterol<br />
c. Ester nonsterol<br />
d. Ester vitamin A dan ester vitamin D<br />
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B. Lipida Majemuk<br />
1. Fosfolipida<br />
Fosfolipida terdapat dalam tiap sel hidup,dibentuk di dalam hati dan menempati urutan ke-2 kandungan lipida dalam tubuh. Fosfolipida merupakan trigliserida di mana asam lemak pada posisi karbon ketiga ditempati oleh gugus fosfat dan gugs basa mengandung nitrogen.<br />
2. Lipoprotein<br />
Lipoprotein merupakan gabungan molekul lipida dan protein yag disintesis di dalam hati. Seperempat sampai sepertiga bagian dari lipoprotein adalah protein dan selebihnya lipida. Lipoprotein mempunyai fungsi mengangkut lipida di dalam plasma ke jaringan-jaringan yang membutuhkannya sebagai sumber energi, sebagai komponen membran sel atau sebagai prekursor metabolik aktif.<br />
C. Lipida Turunan<br />
1. Asam lemak<br />
2. Sterol:<br />
a. Kolestrol dan ergosterol<br />
b. Hormon steroida<br />
c. Vitamin D<br />
d. Garam empedu<br />
3. Lain-lain:<br />
a. Karotenoid vitamin A<br />
b. Vitamin E<br />
c. Vitamin K<br />
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2.4.2 ABSORPSI DAN TRANSPORTASI<br />
Absorpsi lipida terutama, terjadi dalam jejunum. Hasil pencernaan lipda di absorpsi ke dalam membran mukosa usus halus dengan cara difusi pasif. Perbedaan konsetrasi diperoleh dengan cara: (1). Kehadiran protein pengikat asam lemak yang segera mengikat asam lemak yang memasuki sel (2). esterifikasi kembali asam lemak menjadi monogliserida,yaitu produk utama pencernaan yang melintasi mukosa usus halus.Sebelum diabsorpsi kolestrol mengalami esterifikasi kembali yang dikatalisis oleh asetil –Koenzim A dan kolestrol asetil transferase. Pembentukan enzim-enzim ini dipengaruhi oleh konsentrasi tinggi kolestrol makanan. Sebagian besar hasil pencernaan lemak berupa monogliserida dan asam lemak rantai panjang (C12 atau lebih) di dalam membrane mukosa usus diubah kembali menjadi trigliserida.<br />
Asam lemak rantai pendek (C4-C6) dan rantai sedang (C8-C10) diabsorpsi langsung ke dalam vena porta dan dibawa ke hati untuk segera di oksidasi. Oleh karena itu, asam-asam lemak ini tidak mempengaruhi kadar lipida plasma dan tidak disimpan di dalam jaringan adipose dalam jumlah berarti.<br />
Trigliserida dan lipida besar lainnya (kolestrol dan fosfolida) yang terbentuk di dalam usus halus dikemas untuk diabsorpsi secara aktif dan ditransporasi oleh darah. Bahan-bahan ini bergabung dengan protein-protein khusus dan membentuk alat angkut lipida yang dinamakan lipoprotein. Tubuh membentuk 4 jenis lipoprotein, yaitu kilomikron, Low Density Lipoprotein (LDL),Very Low Density Lipoprotein (VLDL) dan High Density Lipoprotein (HDL).Tiap jenis lipoprotein berbeda dalam ukuran dan densitas dan mengangkut berbagai jenis lipida dalam jumlah yang berbeda.<br />
Lipoprotein yang mengangkut lipida dari saluran cerna ke dalam tubuh dinamakan kilomikron.Kilomikron diabsorpsi melalui dinding usus halus ke dalam sistem limfe untuk kemudian melalui ductus thoracicus di sepanjang tulang belakang masuk ke dalam vena besar di tengkuk dan seterusnya masuk ke dalam aliran darah. <br />
Kilomikron adalah lipoprotein paling besar dan mempunyai densitas paling rendah. Kilomikron mengangkut lipida berasal makanan dari saluran cerna ke seluruh tubuh.Lipida yang diangkut terutama trigliserida. Kilomikron merupakan tetesan bear lipida berupa trigliserida, kolestrol dan fosfolipida dengan sedikit protein (terutama berupa apolipoprotein A dan B) yang membentuk selaput pada permukaannya. Selaput disekeliling kilomikron ini memungkinkan lipida di dalamnya mengambang secara bebas di dalam aliran darah yang sebagian besar terdiri atas air.<br />
Kilomikron pada dasarnya mengemulsi lemak sebelum masuk ke dalam aliran darah. Proses ini menyerupai kegiatan lesitin dan asam lemak dalam usus halus dalam upaya mengemulsi lemak makanan selama pencernaan. Perbedaannya adalah bahwa dalam pencernaan yang mengelilingi tetesan lemak adalah air, sedangkan pada kilomikron, lemak dikelilingi oleh protein, kolesterol, dan fosfolipida. Dalam aliran darah trigliserida yang ada pada kilomikron dipecah menjadi gliserol dan asam lemak bebas oleh enzim lipoprotein lipase yang berada pada sel-sel endotel kapiler.<br />
Sebagian besar asam lemak yang terbentuk di dalam tubuh diabsorpsi oleh sel-sel otot, lemak, dan sel-sel lain. Asam lemak ini dapat langsung digunakan sebagai zat energi atau diubah kembali menjadi trigliserida. Sel-sel otot cenderung menggunakannya sebagai zat energi, sedangkan lemak menyimpannya sebagai trigliserida. Bila sebagian besar trigliserida telah dipisahkan dari kilomikron,sisanya yang sebagian besarnya terdiri atas kolesterol dan protein dibawa ke hati dan mengalami metabolisme. Sementara itu hati mensintetis trigliserida dan kolesterol dari kelebihan protein dan karbohidrat yang ada. Hati merupakan alat memproduksi lipida (lipogenik) utama di dalam tubuh. Sel-sel lemak tidak membuat lemak tetapi hanya menyimpan lemak.<br />
Very Low Density Lipoprotein (VLDL). Di dalam hati lipida dipersiapkan menjadi lipoprotein sehingga dapat diangkut melalui aliran darah. Lipoprotein yang dibentuk dalam hati ini adalah VLDL, yaitu lipoprotein dengan densitas sangat rendah yang terutama terdiri atas trigliserida.<br />
Bila VLDL meninggalkan hati, lipoprotein lipase kembali bekerja dengan memecah trigliserida yang ada pada VLDL. VLDL kemudian mengikat kolesterol yang ada pada lipoprotein lain dalam sirkulasi darah. Dengan berkurangnya trigliserida, VLDL bertambah berat dan menjadi LDL ( Low Density Lipoprotein), yaitu lipoprotein dengan densitas rendah.<br />
LDL yang terutama terdiri atas kolesterol bersirkulasi dalam tubuh dan dibawa ke sel-sel otot, lemak, dan sel-sel lain. Trigliserida akan diperlakukan sama dengan yang terjadi pada kilomikron dan VLDL. Kolesterol dan fosfolipida akan digunakan untuk membuat membran sel, hormon-hormon atau ikatan lain, atau disimpan. Reseptor LDL yang ada di dalam hati akan mengeluarkan LDL dari sirkulasi.<br />
Pembentukan LDL oleh reseptor LDL ini penting dalam pengontrolan kolesterol darah. Di samping itu dalam pembuluh darah terdapat sel-sel perusak yang dapat merusak LDL. Melalui jalur sel-sel perusak ini ( scavenger pathway) molekul LDL dioksidasi, sehingga dapat masuk kembali ke dalam aliran darah. Kolesterol yang banyak terdapat dalam LDL akan menumpuk dalam sel-sel perusak. Bila hal ini terjadi selama bertahun-tahun , kolesterol akan menupuk pada dinding pembuluh darah dan membentuk plak. Plak akan bercampur dengan protein dan ditutupi oleh sel-sel otot dan kalsium. Hal inilah yang kemudian dapat berkembang menjadi aterosklerosis. Pengatur utama kadar kolesterol darah adalah hati, karena sebagia besar (50-75%) reseptor LDL terdapat di dalam hati. <br />
High Density Lipoprotein (HDL). Bila sel-sel lemak membebaskan gliserol dan asam lemak, kemungkinan kolesterol dan fosfolipida akan dikembalikan pula ke dalam aliran darah. Hati dan usus halus akan memproduksi HDL (lipoprotein dengan densitas tinggi) yang masuk ke aliran darah. HDL menyerahkan kolesterol dan fosfolipida yang ada di dalam aliran darah. HDL menyerahkan kolesterol ke lipoprotein lain untuk diangkut kembali ke hati guna diedarkan kembali atau dikeluarkan dari tubuh.<br />
Nilai LDL dan HDL mempunyai implikasi terhadap kesehatan jantung dan pembuluh darah. Nilai LDL yang tinggi dikaitkan dengan resiko tinggi terhadap serangan jantung. Sebaliknya HDL tinggi dikaitkan dengan resiko rendah. Oleh sebab itu, LDL dikatakan juga sebagai “kolesterol jahat”, sedangkan HDL “kolesterol baik”.<br />
Bagian dalam lipoprotein terdiri atas trigliserida dan kolesterol yang diselubungi fosfolipida. Protein berada di dekat ujung luar fosfolipida menutupi struktur lipoprotein. Penyusunan molekul yang bersifat hidrofobik di bagian dalam dan molekul hidrofilik di bagian luar luar memungkinkan lipida diangkut melalui cairan darah.<br />
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2.4.3 Metabolisme Lipida<br />
Lipid yang diperoleh sebagai sumber energi utamanya adalah dari lipid netral, yaitu trigliserida (ester antara gliserol dengan 3 asam lemak). Secara ringkas, hasil dari pencernaan lipid adalah asam lemak dan gliserol, Selain itu ada juga yang masih berupa monogliserida. Karena larut dalam air, gliserol masuk sirkulasi portal (vena porta) menuju hati. Asam-asam lemak rantai pendek juga dapat melalui jalur ini.<br />
Sebagian besar asam lemak dan monogliserida karena tidak larut dalam air, maka diangkut oleh miselus (dalam bentuk besar disebut emulsi) dan dilepaskan ke dalam sel epitel usus (enterosit). Di dalam sel ini asam lemak dan monogliserida segera dibentuk menjadi trigliserida (lipid) dan berkumpul berbentuk gelembung yang disebut kilomikron. Selanjutnya kilomikron ditransportasikan melalui pembuluh limfe dan bermuara pada vena kava, sehingga bersatu dengan sirkulasi darah. Kilomikron ini kemudian ditransportasikan menuju hati dan jaringan adiposa.<br />
Di dalam sel-sel hati dan jaringan adiposa, kilomikron segera dipecah menjadi asam-asam lemak dan gliserol. Selanjutnya asam-asam lemak dan gliserol tersebut, dibentuk kembali menjadi simpanan trigliserida. Proses pembentukan trigliserida ini dinamakan esterifikasi. <br />
Simpanan lemak: Simpanan lemak dalam tubuh terutama dilakukan di dalam sel lemak dalam jaringan adipos. Sel-sel adipos mempunyai enzim khusus pada permukaannya, yaitu lipoprotein lipase (LPL) yang dapat melepas trigliserida dan lipoprotein, menghidrolisisnya dan meneruskan hasil hidrolisis kedalam sel. Didalam sel terdapat enzim lain yang merakit kembali bahan-bahan hasil hidrolis menjadi trigliserida untuk disimpan sebagai cadangan energi. Sel-sel adipos menyimpan lemak setelah makan bilamana kilomikron dan VLDL yang mengandung lemak melewati sel-sel tersebut.<br />
Penggunaan lemak untuk energi: Bila sel membutuhkan energi, enzim lipase dalam sel adipos menghidrolisis simpanan trigliserida menjadi gliserol dan asam lemak serta melepasnya kedalam pembuluh darah. Di sel-sel yang membutuhkan, komponen-komponen ini kemudian di bakar dan menghasilkan energi, CO2 dan H2O. Pada tahap akhir hidrolisis, setiap pecahan berasal dari lemak mengikat pecahan berasal dari glukosa sebelum akhirnya dioksidasi secara komplit menjadi CO2 dan H2O. Proses pemecahan lemak jaringan ini dinamakan lipolisis. Asam lemak tersebut ditransportasikan oleh albumin ke jaringan yang memerlukan dan disebut sebagai asam lemak bebas (Free Fatty Acid/FFA). <br />
Lemak tubuh tidak dapat dihidrolisis secara sempurna tanpa kehadiran karbohidrat. Tanpa karbohidrat akan diperoleh hasil antara pembakaran lemak berupa bahan-bahan keton yang dapat menimbulkan ketosis. <br />
Proses oksidasi asam lemak dinamakan oksidasi beta dan menghasilkan asetil KoA. Selanjutnya sebagaimana asetil KoA dari hasil metabolisme karbohidrat dan protein, asetil KoA dari jalur ini pun akan masuk ke dalam siklus asam sitrat sehingga dihasilkan energi. Di sisi lain, jika kebutuhan energi sudah mencukupi, asetil KoA dapat mengalami lipogenesis menjadi asam lemak dan selanjutnya asam lemak mengalami esterifikasi yaitu membentuk ester dengan gliserol menjadi trigliserida sebagai cadangan energi jangka panjang. <br />
Tubuh mempunyai kapasitas tak terhingga untuk menyimpan lemak. Namun, lemak tidak sepenuhnya dapat menggantikan karbohidrat sebagai sumber energi. Otak,sistem saraf dan sel darah merah membutuhkan glukosa sebagai sumber energi.<br />
Beberapa lipid non gliserida disintesis dari asetil KoA. Asetil KoA mengalami kolesterogenesis menjadi kolesterol. Selanjutnya kolesterol mengalami steroidogenesis membentuk steroid. Asetil KoA sebagai hasil oksidasi asam lemak juga berpotensi menghasilkan badan-badan keton (aseto asetat, hidroksi butirat dan aseton). Proses ini dinamakan ketogenesis. Badan-badan keton dapat menyebabkan gangguan keseimbangan asam-basa yang dinamakan asidosis metabolik. Keadaan ini dapat menyebabkan kematian.<br />
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Gambar : Metabolisme Lipid<br />
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2.5 METABOLISME PROTEIN<br />
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Pencernaan protein dilanjutkan didalam usus halus oleh campuran enzim protease.pankreas mengeluarkan cairan yang bersifat sedikit basa dan mengandung berbagai precursor protease, seperti tripsinogen, kimotripsinogen, prokarboksipeptidase dan proelastase. Enzim-enzim ini menghidrolisis ikatan peptide. Sentuhan kimus terhadap mukosa usus halus merangsang dikeluarkannya enzim enterokinase yang merubah tripsinogen tidak aktif yang berasal dari pancreas menjadi tripsin aktif. Perubahan ini juga dilakukan oleh tripsin sendiri secara oto katalitik. Disamping itu tripsin dapat mengaktifkan enzim-enzim proteolitik lain berasal dari pancreas. Kimotripsinogen diubah menjadi kimotripsin aktif prokarboksipeptidase dan proelastase diubah menjadi karboksipeptidase dan elastase aktif. Enzim-enzim pancreas ini memecah protein dari polipeptida menjadi peptide lebih pendek, yaitu tripeptida, dipeptida dan sebagian menjadi asam amino.mukosa usus halus juga mengeluarkan enzim-enzim protease yang menghidrolisis ikatan peptide. Sebagian besar enzim mukosa usus halus ini bekerja didalam sel.<br />
Hidrolisis produk-produk lebih kecil hasil pencernaan protein dapat terjadi setelah memasuki sel-sel mukosa atau pada saat diangkut melalui dinding epitel .mukosa usus halus mengeluarkan enzim amino peptidase yang memecah polipeptida menjadi asam amino bebas.Enzim ini membutuhkan mineral Mn++ atau Mg++ untuk pekerjaannya.<br />
Enzim-enzim proteolitik yang ada dalam lambung dan usus halus pada akhirnya dapat mencernakan sebagian protein menjadi asam amino bebas.Tripsin dan kimotripsin dapat lebih cepat dan sempurna bekerja bila didahului oleh tindakan pepsin.Tetapi,kedua jenis enzim ini tanpa didahului oleh pepsin dapat juga membebaskan asam amino dari protein.<br />
Absorpsi dan transportasi<br />
Hasil akhir pencernaan protein terutama berupa asam amino dan ini segera diabsorpsi dalam waktu lima belas menit setelah makan. Absorpsi terutama terjadi dalam usus halus berupa empat system absorpsi aktif yang membutuhkan energy yaitu masing-masing untuk asam amino netral,asam amino dan basa,serta untuk prolin dan hidroksiprolin .Absorpsi ini menggunakan mekanisme transport natrium seperti halnya pada absorpsi glukosa.Asam amino yang diabsorpsi memasuki sirkulasi darah melalui vena porta dan dibawah kehati.Sebagian asam amino digunakan oleh hati,dan sebagian lagi melalui sirkulasi darah dibawa ke sel-sel jaringan .Kadang-kadang protein yang belum dicerna dapat memasuki mukosa usus halus dan muncul dalam darah.Hal ini sering terjadi pada protein susu dan protein telur yang dapat menimbulkan gejala alergi (immunological sensitive protein). Sebagian besar asam amino telah diabsorpsi pada saat asam amino sampai diujung usus halus. Hanya 1% protein yang dimakan ditemukan dalam feses.Protein endogen yang berasal darib sekresi saluran cerna dan sel-sel yang rusak juga dicerna dan diabsorpsi.<br />
Penguraian Protein dalam tubuh<br />
Asam amino yang dibuat dalam hati, maupun yang dihasilkan dalam metabolisme protein dalam hati, dibawa oleh darah kedalam jaringan untuk digunakan. Proses anabolik dan katabolik juga terjadi didalam jaringan diluar hati. Asam amino yang terdapat dalam darah berasal dari 3 sumber, yaitu absorbsi melalui dinding usus, hasil penguraian protein dalam seldan hasil sintesis asam amino dalam sel. Banyaknya asam amino dalam darah tergantung keseimbangan antara pembentukan asam amino dan penggunaannya. Hati berfungsi sebagai pengatur konsentradsi asam amino dalam darah. <br />
Dalam tubuh kita protein mengalami perubahan-perubahan tertentu dengan kecepatan yang berbeda untuk tiap protein. Protein dalam darah, hati dan organ tubuh lainnya mempunyai waktu paruh antara 2,5 sampai 10 hari. Protein yang terdapat pada jaringan otot mempunyai t1/2 = 120 hari. Rata-rata tiap hari 1,2 gram protein perkilogram berat badan diubah menjadi senyawa lain. Ada 3 kemungkinan mekanisme pengubahan protein yaitu :<br />
1. Sel-sel mati lalu komponennya mengalami proses penguraian atau katabolisme dan dibentuk sel-sel baru.<br />
2. Masing-masing protein mengalami proses penguraian dan terjadi sintesis protein baru, tanpa ada sel yang mati.<br />
3. Protein dikeluarkan dari dalam sel diganti dengan sintesis protein baru. <br />
Metabolisme protein dimulai setelah protein dipecah menjadi asam amino.Asam amino akan memasuki siklus TCA bila dibutuhkan sebagai sumber energy atau bila berada dalam jumlah berlebih dari yang dibutuhkan untuk sintesis protein .Mula-mula asam amino akan mengalami deaminase, yaitu melepas gugus amino. Proses ini mebutuhkan vitamin B6 dalam bentuk PLP Asam amino kemudian dikatabolisme melalui 3 cara .Kira-kira separuh dari asm amino yaitu alanin, serin, glisin, sistein, metionin dan tritofan diubah menjadi piruvat.Kurang lebih separuh lagi yaitu fenilalanin, tirosin, leusin, isoleusin dan lisin, seperti halnya asam lemak diubah menjadi asetil KoA. Sisa Asam amino kecuali asam aspartat diubah menjadi asam glutamat , dideaminase dan langsung memasuki siklus TCA. Asam amino diubah menjadi piruvat dapat diubah menjadi glukosa. Oleh karena itu,dinamakan asam amino glukogenik.Asam amino yang diubah mejadi asetil KoA dapat digunakan untuk memperoleh energy atau dapat diubah menjadi asetil KoA dapat digunakan untuk memperoleh energy atau dapat diubah menjadi lemak .Asam amino ini dinamakan ketogenik .Asam amino yang langsung masuk kedalam siklus TCA juga merupakan asam amino glugekonik ,karena dapat menghasilkan energy atau keluar dari siklus dan diubah menjadi glukosa.Berbeda dengan lemak,protein merupakan sumber glukosa bila karbohidrat tidak mencukupi .seperti halnya lemak dan karbohidrat ,bila berlebihan asam amino akan diubah menjadi lemak. jadi protein dalam jumlah berlebihan untuk pertumbuhan dan pemeliharaan tubuh, dapat diubah menjadi lemak tubuh dan menyebabkan kegemukan</div>
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2.5.1 Penggunaan protein untuk membentuk protein atau asam amino tidak esensial<br />
Bila sel membutuhkan protein tertentu ,sel tersebut akan membentuknya dari asam amino yang tersedia .Bila sel membutuhkan asam amino tidak esensial tertentu untuk pembentukan protein,sel akan membuatnya dengan cara memecah asam amino lain yang tersedia dan menggabungkan gugus aminonya dengan unit-unit karbon-karbon fragmen yang berasal dari glukosa.<br />
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2.5.2 Penggunaan Asam amino untuk membentuk ikatan-ikatan lain<br />
Sel juga dapat membentuk ikatan-ikatan lain dari asam amino.Misalnya asam amino tiroain merupakan precursor pengantar saraf norepinefrin dan epinefrin yang mengantrkan pesan-pesan saraf keseluruh tubuh.Tirosin juga dapat diubah menjadi melanin,yaitu pigmen tubuh,atau menjadi tiroksin ,hormone yang mengatur laju metabolism.Triptofan merupakan precursor pengantar saraf serotonin dan vitamin niasin<br />
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2.5.3 Penggunaan Asam amino sebagai energy<br />
Walaupun fungsi utama protein adalah untuk pertumbuhan,bilamana tubuh kekurangan zat energy fungsi protein untuk menghasilkan energy atau untuk membentuk glukosa akan didahulukan.Bila glukosa atau asam lemak didalam tubuh terbatas,sel terpaksa menggunakan protein untuk membentuk glukosa dan energy.Glukosa dibutuhkan sebagai sumber energy sel-sel otak dan system saraf.Pemecahan protein tubuh guna memenuhi kebutuhan energy sel-sel otak dan system saraf .pemecahan protein tubuh guna memenuhi kebutuhan energy dan glukosa pada akhirnya akan menyebabkan melemahnya otot-otot.Oleh karena itu ,dibutuhkan konsumsi karbohidrat dan lemak yang cukup tiap hari sehinnga potein dapat digunakan sesuai fungsi utamanya,yaitu untuk pembentukan sel-sel tubuh.Kelebihan asam amino dalam tubuh,setelah terlebih dahulu melepas gugus NH2 nya melalui proses deaminasi,akan memasuki jalur metabolism yang sama dengan yang digunakan oleh karbohidrat dan lipida.<br />
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2.5.4 Persediaan Metabolik Asam amino<br />
Didalam tubuh tidak ada persediaan besar asam amino .Kelebihan asam amino untuk keperluan sintesis protein dan berbagai ikatan nitrogen bukan ikatan ikatan protein akan dimetabolisme .Akan tetapi didalam protein sel-sel ada persediaan metabolic asam amino yang berada dalam keseimbangan dinamis yang dapat setiap waktu digunakan.Perubahan protein secara terus-menerus pada orang dewasa diperlukan untuk memelihara persediaan asam amino untuk memenuhi kebutuhan segera asam amino oleh berbagai sel dan jaringan guna pembentukan protein .Jaringan yang paling aktif dalam perubahan protein adalah protein plasma ,mukosa saluran cerna ,pancreas ,hati dan ginjal .jaringan otot dan kulit biasanya tidak terlalu aktif. <br />
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2.6 SIKLUS ASAM SITRAT MENGHASILKAN SUBSTRAT UNTUK RANTAI RESPIRATORIK<br />
Siklus diawali dengan reaksi antara gugus asetil pada asetil-KoA dan asam dikarboksilat empat-karbon oksaloasetat yang membentuk asam trikarboksilat enam-karbon ,yaitu sitrat.Padareaksi –reaksi berikutnya ,terjadi pembebasn dua molekul CO2 dan pembentukan ulang oksaloasetat.Hanya sejumlah kecil oksaloasetat yang dibutuhkan untuk mengoksidasi asetil-KoA dalam jumlah besar,senyawa ini dapat dianggap memiliki peran katalitik.<br />
Siklus asam sitrat adalah bagian integral dari proses penyediaan energi dalam jumlah besar yang dibebaskan selama oksidasi bahan bakar terjadi.Selama oksidasi asetil-KoA ,koenzim-koenzim mengalami reduksi dan kemudiam direoksidasi dirantai respiratorik yang dikaitkan dengan pembentukan ATP(fosforilasi oksidatif).Proses ini bersifat aerob yang memerlukan oksigen sebagai oksidan terakhir dari koenzim-koenzim yang tereduksi.Enzim-enzim pada siklus asam sitrat terletak di matriks mitokondria ,baik bebas maupun terikat pada membran dalam mitokondria serta membran krista,tempat enzim-enzim rantai respiratorik berada.<br />
2.6.1 REAKSI SIKLUS ASAM SITRAT MEMBEBASKAN EKUIVALEN PEREDUKSI & CO2<br />
Reaksi awal antara asetil-KoA dan oksaloasetat untuk membentuk sitrat dikatalis oleh sitrat sintase yang membentuk ikatan karbon –ke –karbon antara karbon metil pada asetil KoA dan karbon karbonil pada oksaloasetat.ikatan tioester pada sitril-KoA yang terbentuk mengalami hidrolisis dan membebaskan sitrat dan KoASH –suatu reaksi eksotermik.<br />
Sitrat mengalami isomerisasi menjadi isositrat oleh enzim akonitase(akonitat hidratase);reaksi ini terjadi dalam dua tahap:dehidrasi menjadi cis-akonitat dan rehidrasi menjadi isositrat.Meskipun sitrat adalah suatu molekul sistematis,namun akonitase bereaksi dengan sitratsecara asimetris sehingga dua atom karbon yang lenyap dalam reaksi-reaksi berikutnya pada siklus bukanlah atom karbon yang ditambahkan dari asetil-KoA.Perilaku asimetris terjadi karena channelling-pemindahan produk sitrat sintase secara langsung kebagian aktif akonitase,tanpa memasuki larutan bebas.Hal ini menghasilkan integrasi aktivitas siklus asam sitrat dan penyediaan sitrat disitosol sebagai sumber asetil-KoA untuk sintesis asam lemak.racunfluoroasetat bersifat toksik karena fluoroasetil –KoA berkondensasi dengan aksaloasetat untuk membentuk fluorositrat,yang enghambat akonitase sehingga terjadi penimbunan sitrat.<br />
Isositrat mengalami dehidrogenasi yang dikatalis oleh isositrat dehidrogenase untuk membentuk,oksalosuksinat pada awalnya,yang tetap terikat pada enzim dan mengalami dekarboksilasi menjadi α-ketoglutarat.Dekarboksilasi ini memerlukan ion Mg++ atau Mn ++.Terdapattiga isoenzim isositrat dehidrogenase.Salah satunya yang menggunakan NAD+,hanya terdapatdi mitokondria.Dua lainnya menggunakan NADP+ dan ditemukan di mitokondria dan sitosol.Oksidasi isositrat terkait-rantai respiratorik berlangsung hampir sempurna melalui enzim yang dpenden –NAD+. Α-Ketoglutarat mengalami dekarboksilasi oksidatif dalam suatu reaksi yang dikatalis oleh suatu komplek multi-enzim yang mirip dengan kompleks multienzim yang berperan dalam dekarboksilasi oksidatif pirupat.kompleks α-ketoglutarat dehidrogenase memerlukan kofaktor yang sama dengan kofaktor yang diperlukan kompleks piruvat dehidrogenase-timin difosfat,lipoat,NAD+,FAD,KoA-serta menyebabkan terbentuknya suksinil KoA.Kesetimbangan reaksi ini jauh lebih menguntungkan pembentukan suksinil KoA sehingga secara fisiologs reaksi ini harus dianggap berjalan satu arah.Seperrti halnya oksidasi piruvat,arsenil menghambat reaksi ini yang menyebabkan akumulasi substrat yaitu α-ketoglutarat.<br />
Suksinil –KoA diubah menjadi suksinal oleh enzim suksinat tiokinase(suksinil-KoA sintase).Reaksi ini adalah satu-satunya contoh fosforilasi tingkat substrat dalam siklus asam sitrat.Jaringan tempat terjadinya glukoneogenesis(hati dan ginjal)mengandung dua isoenzim suksinat tiokinase,satu spesifik untuk GDP dan yang lain untuk ADP.GTP yang terbentuk digunakan untuk dekarboksilasi oksaloasetat menjadi fosfoenolpiruvatdalam glukoneogenesis,dan menghasilkan hubungan regulatorik antara aktivitas siklus asam sitrat dan penghentian oksaloasetat untuk glukoneogenesis.Jaringan non-glukoneogenik hanya memiliki isoenzim yang mengandung ADP.<br />
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Gambar 17-2. Siklus asam sitrat: jalur kata bolik utama untuk asetil-KoA, produk katabolisme karbohidrat, protein, dan lipid, dibawa kesiklus asam sitrat dan dioksidasi menjadi co2 disertai pembahasan ekuivalen produksi (2H). Oksidasi 2H selanjutnya dirantai respiratorik menyebabkan fosforilasi ADP menjadi ATP. Untuk satu putaran siklus, dihasilkan 11 ATP melaui fosforilasi oksidatif dan 1 ATP di hasilkan ditingkat substrat dari perubahan suksinil-KoA menjadi suksinat. <br />
Jika metabolisme badan keton terjadi dijaringan ekstrahepatik ,terdapat suatu reaksi alternatif yang dikatalis oleh suksinil-KoA transferase(tioforase)yang melibatkan pemindahanKoA dari satu suksinil-KoA ke asetoasetat,dan membentuk saseoasetil-KoA.<br />
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Gambar 17-3. Siklus asam sitrat (krebs). Oksidasi NADH dan FADH2 dalam ranati respiratorik menyebabkan terbentuknya ATP melalui fosforilasi oksidatif. Untuk mengikuti perjalanan asetil-KoA melintasi siklus, dua atom karbon pada radikal asetil diperlihatkan berlabel pada karbon karboksil (*) dan pada karbon metil (.). meskipun dua atom karbon lennyap sebagai CO2 dalam satu putaran siklus, namun atom-atom ini tidak berasal dari asetil-KoA yang baru memasuki siklus, tetapi berasal dari bagian molekul sitrat yang berasal dari oksaloesetat. Namun, setelah satu putaran siklus selesai, oksaloesetat yang terbentuk kembali kini berlabel sehingga pada putaran kedua siklus CO2 menjadi berlabel. Karena suksinat adalah suatu senyawa simetris, pada tahap ini terjadi “pengacakan” lebel sehingga keempat atom karbon oksaloasetat tampaknya terlebel setelah satu putaran siklus. Selama glukoneogenesis, sebagian lebel di oksaloasetat terserap kedalam glukosa dan glikogen. Tampak tempat-tempat inhibisi oleh fluoroasetat, malonat, dan arsenit.<br />
Metabolisme suksinat yang menyebabkan terbentuknya oksaloasetat,memiliki rangkaian kimia yang sama seperti yang terjadi pada oksidasi-β asam lemak :dehidrogenasi untuk membentuk ikatan rangkap karbon-ke-karbon ,penambahan air untuk membentuk gugus hidroksil,dan dehidrogenasi lebih lanjut untuk menghasilkan gugus okso pada oksaloasetat.<br />
Reaksi dehidrogenasi pertama yang membentuk fumarat dikatalis oleh suksinat dehidrogenase yang terikat pada permukaan dalam membran dalam mitokondria.Enzim ini mengandung FAD dan protein besi-sulfur(Fe:S),dan secara langsung mereduksi ubikuinon dalam rantai transpor elektron.Funarase (fumarat hidrase) mengkatalis penambahan aiar pada ikatan rangkap fumarat sehingga menghasilkan malat.Malat diubah menjadi oksaloasetat oleh malat dehidrogenase,suatu reaksi yang memerlukan NAD+. Meskipun keseimbangan reaksi ini jauh menguntungkan malat,namun aliran netto reaksi tersebut adalah ke oksaloasetat karena oksaloasetat harus dikeluarkan (untuk membentuk sitrat,sebagai substrat glukoneogenesis,atau mengalami transminasi menjadi aspartat)serta reoksidasi NADH terjadi secara kontinu.<br />
2.6.2 SATU PUTARAN SIKLUS ASAM SITRAT MENGHASILKAN DUA BELAS ATP<br />
Akibat oksidasi yang dikatalisis berbagai dehidrogenase pada siklus asam sitrat, dihasil kan tiga molekul NADH dan satu FADH2 untuk setiap molekul asetil-KoA yang dikatabolisme per satu kali putaran siklus. Ekuivalen pereduksi ini dipindahkan kerantai respiratorik (lihat gambar 13-3), tempat reoksidasi masing masing NADH menghasilkan fosforilasi tingkat-substrat yang dikatalisis oleh suksinat tiokinase.<br />
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2.6.3 VITAMIN BERPERAN PENTING DALAM SIKLUS ASAM SITRAT<br />
Empat vitamin B merupakan faktor esensial dalam siklus asam sitrat sehingga juga penting dalam metabolisme penghasil energi:<br />
1. Riboflavin, dalam bentuk flavin adenin dinukleotida (FAD), suatu kofaktor untuk suksinat dehidrogenase <br />
2. Niasin, dalam bentuk nikotinamid adenin dinukleotida (NAD), akseptor elektron untuk isositrat dehidrogenase, alpha-ketoglutarat dehidrogenase, dan malat dehidrogenase<br />
3. Tiamin (vitamin B1), sebagai tiamin difosfat, koenzim untuk dekarboksilasi dalam reaksi alpha-ketoglutaratdehidrogenase<br />
4. Asam pantotenat, sebagai bagian dari koenzim A, faktor yang melekat pada residu asam karboksilat “aktif”, misalnya asetil-KoA dan suksinil-KoA.<br />
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2.6.4 SIKLUS ASAM SITRAT BERPERAN PENTING DALAM METABOLISME<br />
Siklus asam sitrat tidakm saja merupakan jalur untuk oksidasi unit dengan dua-karbon,tetapi juga merupakan jalur utama untuk pertukaran berbagai metabolik yanng berasal dari transaminasi dan deaminasi asam amino,serta menghasilkan substrat untuk sintesis asam amino melalui transaminasi,serta untuk gluko<br />
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neogenesis dan sintesis asam lemak.Karena fujngsinya dalam proses oksidatif dan sintesis,siklus ini bersifat amfibolik ( gambar 17-4).<br />
2.6.5 SILKUS ASAM SITRAT IKUT SERTA DALAM GLUKONEOGENESIS,TRANSAMINASI,DAN DEAMINASI<br />
Semua zat antara pada siklus berpotensi glukogenic karena dapat menghasilkan oksaloasetat,dan karenanya mampu mjenghasilkan glukosa (dihati dan ginjal,organ yang melaksanakan glukoneogenesis). Enzim kunci yang mengatalisis pemindahan netto keluar siklus untuk menuju glukoneogenesis adalah fosfoenolpiruvat karboksikinase yang mengatalisis dekarboksilasi oksaloasetat menjadi fosfoenolpiruvat dengan GTP yang berkerja sebagai donor fosfat.<br />
Pemindahan netto kedalam siklus terjadi melalui beberapa reaksi. Diantara berbagai reaksi anaplerotik tersebut,yang terpaenting badalah pembentukan oksaloasetat melalui karbiksilasi piruvat yang dikatalisis oleh piruvat karbksilase. Reaksi ini penting dalam mempertahanka konsentrasi oksaloasetat yangn memadai untuk reaksi kondensasin dengan asetil-KoA. Jika terjadi penimbuinan asetil-KoA,zat ini alkan berfungsi sebagai aktivator allosterik piruvat karboksilase dan inhibvitor piruvat dehidrogenase,sehinngga pasokan oksaloasetat terjamin. Laktat,suatu substrat penting untuk gluikoneogenesis, memaasuki siklus melalui oksidasi menjadi piruvat dan kemudian menggalami karboksilasi menjasdi oksaloasetat.<br />
Reaksi-reaksi ini aminotransperase (transaminase) membentuk piruvat dari alanin,oksaloasetat dari aspartat,dan alfa-ketoglutarat dari glutamat. Karena reaksi-reaksi ini bersifat reversibel,siklkus asam sitrat juga berfungsi sebagai sumber rangka karbon untuk membebtuik asam-asam amino ini. Asam2 amino lain berperan dalam glukoneogenesis karena ranngka karbonnya menghasilakan zat2 antara siklus asam sitrat. Alanin, glisin, hidroksiprolin, serin , treonin, dan triptofan menghasilkan piruvat arginin, <br />
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Gambar : keterlibatan siklus asam sitrat dalam transaminasi dan glukoneogenesis. Tanda panah tebal menunjukan jalur utamaglukoneogenesis.<br />
Histidin, glutamin, dan prolin menghasilkan alpha-ketoglutarat; isoleusin, metionin, dan valin menghasilkan suksinil-KoA; tirosin dan fenilalanin menghasilkan fumarat (lihat gambar 17-4).<br />
Pada hewan pemamah biak dengan bahan bakar metabolik utama berupa asam lemak rantai pendek yang dibentuk oleh fermentasi bakteri, perubahan propionat, produk glukogenik utama permentasi rumen, menjadi suksinil-KoA melalui jalur metilmalonil-KoA (gambar 20-2) sangat penting.<br />
2.6.6 SIKLUS ASAM SITRAT IKUT SERTA DALAM SINTESIS ASAM LEMAK<br />
Asetil-KoA yang dibentuk dari piruvat oleh kerja piruvat dehidrogenase adalah substrat utama untuk sintesi asam lemak rantai-panjang pada hewan bukan pemamah biak (gambar 17-5). (pada hewan pemamah biak, asetil-KoA berasal langsung dari asetat). Piruvat dehidrogenase adalah suatu enzim mitokondria, dan sintesis asam lemak berlangsung di sitosol; membran mitokondia bersipat impermiabel terhadap aseti-KoA. Asetil-KoA disediakan di sitosoldari sitrat yang disentesis dimitokondria, dipindahkan kesitosol, dan dipecah dalam suatu reaksi yang dikatalisis oleh ATP-sitrat liase. Sitrat hanya tersedia untuk pengangkutan keluar mitokondria ketika akonitase mengalami saturasi oleh substratnya, dan sitrat tidak dapat disalurkan langsung dari sitrat sintase ke akonitase. Hal ini menjamin agar sitrat digunakan untuk sintesis asam lemak hanya jika jumahnya adekuat untuk menjamin kontinuitas aktivitas siklus.<br />
2.6.7 REGULASI SIKLUS ASAM SITRAT BERGANTUNG TERUTAMA PADA PASOKAN KOFAKTOR TEROKSIDASI<br />
Di sebagian besar jaringan, dengan siklus asam sitrat yang berperan utama dalam metabolisme penghasil energi, aktivitas siklus asam sitrat diatur oleh kontrol respiratorik melalui rantai respiratorik dan fosforilasi oksidatif. Oleh sebab itu, aktivitas bergantung langsung pada pasokan <br />
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gambar 17-5. Peran serta siklus asam sitrat dalam sintesis asam lemak dari glukosa.<br />
NAD+, yang selanjutnya, karena keterkaitan erat antara oksidasi dan fosforilasi, bergantung pada ketersediaan ADP dan pada akhirnya, bergantung pada kecepatan pemakaian ATP dalam reaksi kimia dan kerja fisik. Selain itu, masing-masing enzim dalam siklus tersebut juga diatur. Tempat pengaturan yang paling mungkin adalah reaksi tak-setimbang yang dikatalisi oleh piruvat dehidrogenase, sitrat sintase, isositrat dehidrogenase, dan alpha-ketoglutarat dehidrogenase. Berbagai dehidrogenase diaktifkan oleh Ca2+ yang meningakat konsentrasinya selama kontraksi otot dan sekresi, saat terjadi peningkatan kebutuhan energi. Di jaringan seperti otak, yang sangat bergantung pada karbohidrat untuk memperoleh asetil-KoA, kontrol siklus asam sitrat dapat terjadi di piruvat dehidrogenase. Beberapa enzim berenspons terhadaf status energi seperti diperhatikan oleh rasio [ATP]/ [ADP] dan [NADH]/[NAD+]. Oleh sebab itu, terjadi inhibisi alosterik sitrat sintase oleh ATP dan asil-KoA lemak rantai panjang. Aktivitas alosterik isositrat dehidrogenase dependen–NAD mitokondria oleh ADP dilawan oleh ATP dan NADH. Kompleks alpha-ketoglutarat dehidrogenase diatur dengan cara yang sama seperti piruvat dehidrogenase(gambar 18-6). Suksianat dehidrogenase dihambat oleh oksaloasetat, dan ketersediaan oksaloasetat, seperti di kontrol oleh malat dehidrogenase, bergantung pada rasio[NADH]/[NAD+]. Karena K,,,, untuk oksaloesetat pada sitrat sintase serta dengan kosentrasi intramitokondria, kosentrasi oksaloasetat agaknya mengontrol laju pembentukan. Belum diketahui mekanisme mana dari berbagai mekanisme tersebut yang penting bagi tunuh.<br />
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BAB 3<br />
KESIMPULAN<br />
Proses yang terjadi pada tubuh laki-laki yang berolahraga teratur terjadi proses perubahan piruvat menjadi asetil KoA itu memasuki siklus krebs, sehingga tidajadi pembentk terkan asm lemak, sehingga proses metabolisme orang yang berolaharaga ini baik hingga tahap pembentkan energi.<br />
Sedangkan pada tubuh laki-laki B yang gemuk ini, hampir tidak pernah berolahraga, ini disebabkan proses perubahan piruvat menjadi asetil KoA, karena tidak membutuhkan energi maka asetil KoA ini tidak memasuki siklus krebs, tetapi digunakan untuk membentuk asam lemak, hal inilsh ysng menyebabkan penumpukan lemak pada si B sehingga ia menjadi gemuk.<br />
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<br /></div>arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-35306149549082934622012-05-13T18:32:00.003+07:002013-05-16T07:56:35.627+07:00LUKA BAKAR / COMBUSTIO / BURN<br /><div style="text-align: justify;">
<span style="font-family: inherit;">Pendahuluan</span></div>
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<span style="font-family: inherit;">Kejadian luka bakar sering terjadi di kehidupan sehari hari di masyarakat. Mengalami kejadian cedera panas adalah salah satu yang paling merusak fisik dan luka psikologis seseorang dan mengalami penderitaan yang amat sangat . Lebih dari 2 juta luka-luka akibat luka bakar yang memerlukan perhatian medis setiap tahun di Amerika Serikat, dengan 14.000 kematian akibat. Kebakaran di rumah bertanggung jawab atas hanya 5% dari cedera bakar tapi untuk luka bakar 50% dari kematian-paling karena inhalasi asap. Sekitar 75.000 pasien memerlukan rawat inap setiap tahun, dan 25.000 dari mereka tetap dirawat di rumah sakit selama lebih dari bulan 2 tingkat keparahan dari sakit yang terkait dengan cedera ini.</span></div>
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<span style="font-family: inherit;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgpQvIoEh3NV5mCRK1UfkL93-6gHNcPRX3lIhjnpMXLsraCK2lqobIo4E2W06eksdA5VV6AWfK59sEdN8qIasncbreXOsDzzdQdLio7LeCYTwMQ8L8-_p2AUlpkjtrxAS5G4-jIuleU8-ah/s1600/luka.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgpQvIoEh3NV5mCRK1UfkL93-6gHNcPRX3lIhjnpMXLsraCK2lqobIo4E2W06eksdA5VV6AWfK59sEdN8qIasncbreXOsDzzdQdLio7LeCYTwMQ8L8-_p2AUlpkjtrxAS5G4-jIuleU8-ah/s1600/luka.jpg" /></a></span></div>
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<span style="font-family: inherit;">Anatomi dan Fisiologi dari Kulit</span></div>
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<span style="font-family: inherit;">Kulit adalah organ terbesar dari tubuh, berkisar antara 0,25 dari bayi dan 1,8 m2 pada orang dewasa. Ini terdiri dari dua lapisan: epidermis dan dermis (corium). Sel-sel terluar dari epidermis adalah sel mati cornified yang bertindak sebagai pelindung tangguh terhadap lingkungan. Lapisan kedua tebal, yang corium (0,06-0,12 mm), terdiri terutama dari jaringan ikat berserat. corium berisi pembuluh darah dan saraf ke kulit dan epitel pelengkap fungsi khusus. Ujung saraf yang memediasi sakit hanya ditemukan di corium, sebagian-ketebalan cedera mungkin sangat menyakitkan, sedangkan luka bakar ketebalan penuh biasanya tidak menimbulkan rasa sakit.</span></div>
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<span style="font-family: inherit;">Corium adalah penghalang yang mencegah hilangnya cairan tubuh oleh penguapan dan hilangnya panas tubuh berlebih. kelenjar keringat membantu mempertahankan suhu tubuh dengan mengendalikan jumlah air yang menguap. Mereka juga mengeluarkan sejumlah kecil natrium klorida dan kolesterol dan jejak albumin dan urea. corium ini dihubungkan dengan ujung saraf sensoris yang menengahi sensasi sentuhan, tekanan, rasa sakit, panas, dan dingin. Ini adalah mekanisme perlindungan yang memungkinkan seorang individu untuk beradaptasi dengan perubahan lingkungan fisik.</span></div>
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<span style="font-family: inherit;">Kulit menghasilkan vitamin D, yang disintesis oleh aksi sinar matahari pada senyawa tertentu intradermal kolesterol. Kulit juga bertindak sebagai pelindung terhadap infeksi dengan mencegah penetrasi jaringan subdermal oleh mikroorganisme.</span></div>
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<span style="font-family: inherit;">Kedalaman Luka Bakar</span></div>
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<span style="font-family: inherit;">Kedalaman luka bakar berpengaruh signifikan terhadap semua kejadian klinis selanjutnya. kedalaman mungkin sulit untuk menentukan dan dalam beberapa kasus tidak diketahui sampai setelah penyembuhan spontan terjadi atau ketika eschar akan dihapus dan jaringan granulasi terlihat.</span></div>
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<span style="font-family: inherit;"> Luka bakar diklasifikasikan sebagai derajat pertama, kedua, dan derajat ketiga, namun saat ini penekanan pada penyembuhan luka bakar telah menyebabkan klasifikasi sebagai luka bakar parsial-tebal, yang sembuh secara spontan, dan luka bakar ketebalan penuh, yang memerlukan pencangkokan kulit.</span></div>
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<span style="font-family: inherit;">Penggolongan grade atau derajat luka pada pasien ini didasarkan pada ketentuan sebagai berikut :</span></div>
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<span style="font-family: inherit;"> Luka derajat I :</span></div>
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<span style="font-family: inherit;">- Kerusakan terbatas pada lapisan epidermis</span></div>
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<span style="font-family: inherit;">- Kulit kering terlihat eritem</span></div>
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<span style="font-family: inherit;">- Tidak dijumpai bulae</span></div>
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<span style="font-family: inherit;">- Nyeri karena ujung – ujung saraf teriritasi</span></div>
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<span style="font-family: inherit;">- Penyembuhan terjadi secara sepontan dalam waktu 5 – 10 hari.</span></div>
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<span style="font-family: inherit;"> Luka derajat II :</span></div>
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<span style="font-family: inherit;">- Kerusakan meliputi epidermis dan sebagian dermis, berupa reaksi inflamasi disertai reaksi eksudasi</span></div>
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<span style="font-family: inherit;">- Dijumpai bulae</span></div>
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<span style="font-family: inherit;">- Nyeri pada ujung – ujung saraf sensoris teriritasi</span></div>
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<span style="font-family: inherit;">- Dasar luka berwarna pucat atau merah, sering terletak lebih tinggi diatas kulit normal</span></div>
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<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Dibedakan atas 2 (dua) :</span></div>
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<span style="font-family: inherit;">1. Derajat II dangkal (superficial)</span></div>
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<span style="font-family: inherit;"> - Kerusakan mengenai bagian superficial dari dermis</span></div>
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<span style="font-family: inherit;"> - Organ-organ kulit seperti folikel rambut, kelenjar sebasea masih</span></div>
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<span style="font-family: inherit;"> utuh.</span></div>
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<span style="font-family: inherit;"> - Penyembuhan terjadi secara spontan dalam waktu 10 – 14 hari</span></div>
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<span style="font-family: inherit;">2. Derajat II dalam (deep)</span></div>
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<span style="font-family: inherit;"> - Kerusakan mengenai hampir seluruh bagian dermis</span></div>
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<span style="font-family: inherit;"> - Organ-organ kulit seperti folikel rambut, kelenjar keringat, </span></div>
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<span style="font-family: inherit;"> kelenjar sebasea sebagian besar masih utuh</span></div>
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<span style="font-family: inherit;"> - Penyembuhan terjadi lebih lama, tergantung biji epitel yang</span></div>
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<span style="font-family: inherit;"> tersisa. Biasanya penyembuhan terjadi dalam waktu lebih dari</span></div>
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<span style="font-family: inherit;"> satu bulan</span></div>
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<span style="font-family: inherit;"> Luka bakar derajat III :</span></div>
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<span style="font-family: inherit;">- Kerusakan meliputi seluruh tebal dermis dan lapisan yang lebih dalam.</span></div>
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<span style="font-family: inherit;">- Organ – organ kulit seperti folikel rambut, kalenjar keringat, kalenjar sebasea mengalami kerusakan</span></div>
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<span style="font-family: inherit;">- Tidak dijumpai bulae</span></div>
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<span style="font-family: inherit;">- Kulit yang terbakar berwarna abu – abu dan pucat. Karena kering,letaknya lebih rendah dibandingkan kulit sekitar</span></div>
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<span style="font-family: inherit;">- Terjadi koagulasi protein pada epidermis dan dermis yang dikenal sebagai eskar</span></div>
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<span style="font-family: inherit;">- Tidak dijumpai rasa nyeri dan hilang sensasi, karena ujung – ujung saraf sensorik mengalami kerusakan / kematian</span></div>
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<span style="font-family: inherit;">- Penyembuhan terjadi lama karena tidak ada proses epitelisasi spontan dari dasar luka</span></div>
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<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Derajat I hanya melibatkan epidermis dan ditandai dengan eritema dan perubahan mikroskopis kecil; kerusakan jaringan minimal, fungsi pelindung dari kulit utuh, edema kulit minimal, dan efek sistemik jarang terjadi. Nyeri, gejala utama, biasanya menyelesaikan dalam 48-72 jam, dan penyembuhan terjadi spontan. Dalam 5-10 hari, pada epitel kulit yang rusak dalam skala kecil, tanpa meninggalkan bekas luka residual. Penyebab paling umum luka bakar tingkat pertama adalah overexposure sinar matahari dan panas yang singkat.</span></div>
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<span style="font-family: inherit;">Derajat kedua luka bakar atau ketebalan parsial yang lebih dalam, melibatkan seluruh epidermis dan beberapa corium tersebut. Sistemik tingkat keparahan luka bakar dan kualitas penyembuhan berikutnya secara langsung berhubungan dengan jumlah corium rusak. luka bakar superfisial sering ditandai dengan pembentukan blister, sedangkan ketebalan lebih parsial-luka bakar memiliki penampilan kemerahan atau lapisan dermis nonviable keputihan tegas melekat pada jaringan yang layak tersisa. Lepuh, saat ini, terus meningkat dalam ukuran pada periode postburn sebagai partikel osmotik aktif dalam cairan melepuh menarik air. Komplikasi yang langka dari luka bakar tingkat dua yang dangkal, yang biasanya sembuh dengan jaringan parut yang minimal dalam 10-14 hari kecuali mereka menjadi terinfeksi.</span></div>
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<span style="font-family: inherit;">Luka bakar yang dalam sembuh selama 25-35 hari dengan epitel meliputi rapuh yang timbul dari epitel terluka sisa kelenjar keringat dalam kulit dan rambut. jaringan parut hipertrofik parah terjadi ketika seperti menyembuhkan cedera; yang meliputi epitel yang dihasilkan cenderung terik dan kerusakan. evaporative kehilangan setelah penyembuhan tetap tinggi dibandingkan dengan kehilangan di kulit normal. Konversi dengan ketebalan penuh terbakar oleh bakteri umum. Pencangkokan kulit luka bakar kulit dalam, jika memungkinkan, meningkatkan kualitas fisiologis dan tampilan penampang kulit.</span></div>
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<span style="font-family: inherit;">Luka bakar seluruh tebal (tingkat tiga) memiliki karakteristik putih, penampilan seperti lilin dan dapat muncul dengan mata yang tak terlatih sebagai kulit terbakar. Burns disebabkan oleh kontak yang terlalu lama, dengan keterlibatan jaringan lemak dan mendasarinya, mungkin cokelat, merah tua, atau hitam. Temuan diagnostik luka bakar ketebalan penuh adalah kurangnya sensasi di kulit terbakar, kurangnya isi ulang kapiler, dan tekstur kulit yang seperti kulit normal. Semua elemen epitel rusak, sehingga tidak ada potensi untuk reepithelialisasi.</span></div>
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<span style="font-family: inherit;">Penentuan Tingkat Keparahan Akibat Cedera</span></div>
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<span style="font-family: inherit;">Cara untuk menentukan luas luka bakar yang terkena:</span></div>
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<span style="font-family: inherit;">A. WALLACE</span></div>
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<span style="font-family: inherit;">B. RULE OF NINE</span></div>
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<span style="font-family: inherit;"> Kepala 9% ------------------- 9%</span></div>
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<span style="font-family: inherit;"> Lengan 9% ------------------- 18%</span></div>
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<span style="font-family: inherit;"> Badan depan ------------------- 18%</span></div>
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<span style="font-family: inherit;"> Badan belakang ------------------ 18%</span></div>
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<span style="font-family: inherit;"> Tungkai 18% ------------------ 36%</span></div>
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<span style="font-family: inherit;"> Genitalia/perineum ----------------- 1%</span></div>
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<span style="font-family: inherit;"> JUMLAH-------------- 100% </span></div>
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<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Berdasarkan berat / ringan luka bakar, diperoleh beberapa kategori penderita :</span></div>
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<span style="font-family: inherit;">1. luka bakar berat atau kritis</span></div>
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<span style="font-family: inherit;"> a. derajat II – III > 40%</span></div>
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<span style="font-family: inherit;"> b. derajat III pada muka, tangan dan kaki</span></div>
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<span style="font-family: inherit;"> c. adanya trauma pada jalan nafas (cedera inhalasi) tanpa memperhitungkan luas luka bakar</span></div>
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<span style="font-family: inherit;"> d. luka bakar listrik</span></div>
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<span style="font-family: inherit;"> e. disertai trauma lainnya (misalnya fraktur costae, dll)</span></div>
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<span style="font-family: inherit;">2. Luka bakar sedang</span></div>
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<span style="font-family: inherit;"> a. derajat II 15 – 40 %</span></div>
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<span style="font-family: inherit;"> b. derajat III < 10 % kecuali muka, tangan dan kaki</span></div>
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<span style="font-family: inherit;">3. luka bakar ringan</span></div>
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<span style="font-family: inherit;"> a. derajat II < 15%</span></div>
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<span style="font-family: inherit;"> B. derajat III < 2%</span></div>
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<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Adapun menurut American Burn Association, kriteria berat rinfannya luka bakar dibagi menjadi :</span></div>
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<span style="font-family: inherit;">1. Luka bakar ringan</span></div>
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<span style="font-family: inherit;"> - LB derajat II < 15%</span></div>
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<span style="font-family: inherit;"> - LB derajat II < 10% pada anak anak</span></div>
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<span style="font-family: inherit;"> - LB derajat III < 1%</span></div>
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<span style="font-family: inherit;">2. Luka bakar sedang</span></div>
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<span style="font-family: inherit;"> - LB derajat II 15-25% ( Dewasa)</span></div>
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<span style="font-family: inherit;"> - LB derajat II 10-20% ( Anak anak )</span></div>
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<span style="font-family: inherit;"> - LB derajat III < 10%</span></div>
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<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;"> Akibat pertama luka bakar adalah syok karena kaget dan kesakitan. Pembuluh kapiler yang terpajan suhu tinggi rusak dan permeabilitas meninggi. Sel darah yang ada didalamnya ikut rusak sehingga dapat terjadi anemia. Meningkatnya permeabilitas menyebabkan udem dan menimbulkan bula yang mengandung banyak elektrolit. Hal itu menyebabkan berkurangnya volume cairan intarvaskuler. Kerusakan kulit akibat luka bakar menyebabkan kehilangan cairan akibat penguapan yang berlebihan, masuknya cairan ke bula yang tterbentuk pada luka bakar derajat dua dan pengeluaran cairan dari keropeng luka bakar derajat tiga.</span></div>
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<span style="font-family: inherit;"> Bila luas luka bakar kurang dari 20%, biasanya mekanisme kompensasi tubuh masih bisa mengatasinya, tetapi bila lebih dari 20% akan terjadi syok hipovolemik dengan gejala yang khas seperti gelisah, pucat, dingin, berkeringat, nadi kecil dan cepat, tekanan darah menurun dan produksi urin berkurang. Pembengkakan terjadi pelan-pelan, maksimal setelah 8 jam.</span></div>
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<span style="font-family: inherit;"> Pada kebakaran pada ruang tertutup atau bila luka terjadi di daerah wajah, dapat terjadi kerusakan mukosa jalan nafas karena gas, asap atau uap panas yang terisap. Udem laring yang ditimbulkannya dapat menyebabkan hambatan jalan nafas dengan gejala sesak nafas, takipnea, stridor, suara serak dan dahak berwarna gelap akibat jelaga.</span></div>
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<span style="font-family: inherit;"> Dapat pula terjadi keracunan gas CO atau gas beracun lainnya. Karbon monoksida akan mengikat hemoglobin dengan kuat sehingga hemoglobin tidak mampu lagi mengikat oksigen. Tanda keracunan ringan adalah lemas, bingung, pusing, mual dan muntah. Pada keracunan yang berat terjadi koma. Bila lebih dari 60% hemoglobin terikat CO, penderita dapat meninggal.</span></div>
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<span style="font-family: inherit;"> Setelah 12-24 jam, permeabilitas kapiler mulai membaik dan terjadi mobilisasi serta penyerapan kembali cairan edema ke pembuluh darah. Ini ditandai dengan meningkatnya diuresis.</span></div>
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<span style="font-family: inherit;"> Luka bakar sering tidak steril. Kontaminasi pada kulit mati, yang merupakan medium yang baik untuk pertumbuhan kuman, akan mempermudah infeksi. Infeksi ini sulit diatasi karena daerahnya tidak tercapai oleh pembuluh kapiler yang mengalami trombosis. Padahal pembuluh ini membawa sistem pertahanan tubuh atau antibiotik. Kuman penyebab infeksi pada luka bakar, selain berasal dari kulit penderita sendiri, juga dari kontaminasi kuman saluran nafas atas dan kontaminasi di lingkungan rumah sakit. Infeksi nosokomial ini baisanya sangat berbahaya karena kumannya banyak yang sudah resisten terhadap berbagai antibiotik.</span></div>
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<span style="font-family: inherit;"> Pada awalnya, infeksi biasanya disebabkan oleh kokus Gram positif yang berasal dari kulit sendiri atau dari saluran nafas, tetapi kemudian dapat terjadi invasi kuman Gram negatif. Pseudomonas aeruginosa yang dapat menghasilkan eksotoksin protease dan toksin lain yang berbahaya, terkenal sangat agresif dalam invasinya pada luka bakar. Infeksi pseudomonas dapat dilihat dari warna hijau pada kassa penutup luka bakar. Kuman memproduksi enzim penghancur keropeng yang bersama dengan eksudasi oleh jaringan granulasi membentuk nanah.</span></div>
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<span style="font-family: inherit;"> Infeksi ringan dan noninvasi (tidak dalam) ditandai dengan keropeng yang mudah terlepas dengan nanah yang banyak. Infeksi yang invasif ditandai dengan keropeng yang kering dengan perubahan jaringan di tepi keropeng yang mula-mula sehat menjadi nekrotik, akibatnya luka bakar yang mula-mula derajat dua menjadi derajat tiga. Infeksi kuman menimbulkan vaskulitis pada pembuluh kapiler di jaringan yang terbakar dan menimbulkan trombosis hingga jaringan yang didarahinya nanti.</span></div>
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<span style="font-family: inherit;"> Bila luka bakar dibiopsi dan eksudatnya dibiak, biasanya ditemukan kuman dan terlihat invasi kuman tersebut ke jaringan sekelilingnya. Luka bakar demikian disebut luka bakar septik. Bila penyebabnya kuman Gram positif, seperti stafilokokus atau basil Gram negatif lainnya, dapat terjadi penyebaran kuman lewat darah (bakteremia) yang dapat menimbulkan fokus infeksi di usus. Syok septik dan kematian dapat terjadi karena toksik kuman yang menyebar di darah.</span></div>
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<span style="font-family: inherit;"> Bila penderita dapat mengatasi infeksi, luka bakar derajat dua dapat sembuh dengan meninggalkan cacat berupa parut. Penyembuhan ini dimulai dari sisa elemen epitel yang masih vital, misalnya sel kelenjar sebasea, sel basal, sel kelenjar keringat atau sel pangkal rambut. Luka bakar derajat dua yang dalam mungkin menggalkan parut hipertrofik yang nyeri, gatal, kaku dan secara estetik yang jelek.</span></div>
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<span style="font-family: inherit;"> Luka bakar derajat tiga yang dibiarkan sembuh sendiri akan mengalami kontraktur. Bila terjadi di persendian, fungsi sendi akan berkurang atau hilang.</span></div>
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<span style="font-family: inherit;"> Pada luka bakar berat dapat ditemukan ileus paralitik. Pada fase akut, peristalsis usus menurun atau berhenti karena syok, sedangkan pada fase mobilisasi, peristalsis dapat menurun karena kekurangan ion kalium.</span></div>
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<span style="font-family: inherit;"> Stres atau beban faali yang terjadi pada penderita luka bakar berat dapat menyebabkan terjadinya tukak di mukosa lambung atau duodenum dengan gejala yang sama dengan gejala tukak peptik. Kelainan ini dikenal sebagai tukak Curling. Yang dikhawatirkan pada tukak curling ini adalah penyulit perdarahan yang tampil sebagai hematemesis dan atau melena.</span></div>
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<span style="font-family: inherit;"> Fase permulaan luka bakar merupakan fase katabolisme sehingga keseimbangan protein menjadi negatif. Protein tubuh banyak hilang karena eksudasi, metabolisme tinggi dan infeksi. Penguapan berlebihan dari kulit yang rusak juga memerlukan kalori tambahan. Tenaga yang diperlukan tubuh pada fase ini terutama didapat dari pembakaran protein dari otot skelet. Oleh karena itu, penderita menjadi sangat kurus, otot mengecil dan berat badan menurun. Dengan demikian, korban luka bakar menderita penyakit berat yang disebut penyakit luka bakar. Bila luka bakar menyebabkan cacat, terutama bila luka mengenai wajah, sehingga rusak berat, penderita mungkin mengalami beban kejiwaan yang berat. Jadi prognosis luka bakar terutama ditentukan oleh luasnya luka bakar.</span></div>
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<span style="font-family: inherit;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Penyakit dan kematian berkaitan dengan ukuran (luas permukaan) dan kedalaman luka bakar, usia dan keadaan kesehatan sebelum korban, lokasi luka bakar, dan beratnya cedera yang terkait, jika ada-terutama cedera paru-paru.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Luas permukaan total tubuh yang terlibat dalam luka bakar yang paling akurat ditentukan dengan menggunakan grafik yang berhubungan dengan usia yang dirancang oleh Lund dan Browder. Satu set grafik ini harus diisi untuk setiap luka bakar pasien pada saat masuk dan resusitasi dimulai.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Sebuah perhitungan yang teliti dari persentase total tubuh luka bakar berguna untuk beberapa alasan. Pertama, ada kecenderungan klinis umum untuk meremehkan dan melebih-lebihkan ukuran luka bakar dan dengan demikian beratnya. The American Burn Association telah mengadopsi indeks keparahan luka bakar. Kedua, prognosis secara langsung berkaitan dengan tingkat cedera. Ketiga, keputusan tentang siapa yang harus diperlakukan dengan khusus luka bakar fasilitas atau dikelola sebagai pasien rawat jalan adalah sebagian didasarkan pada estimasi ukuran luka bakar.</span></div>
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<span style="font-family: inherit;">Pasien di bawah umur 2 tahun dan usia 60 ke atas memiliki tingkat kematian secara signifikan lebih tinggi untuk tingkat tertentu terbakar. Tingkat kematian yang lebih tinggi pada bayi hasil dari sejumlah faktor. Pertama, luas permukaan tubuh pada anak-anak relatif terhadap berat badan jauh lebih besar dari pada orang dewasa. Oleh karena itu, luka bakar luas permukaan sebanding memiliki dampak fisiologis yang lebih besar pada anak. Kedua, ginjal belum matang dan hati tidak memungkinkan untuk memindahkan beban yang terlarut tinggi dari jaringan yang terluka atau pemulihan yang cepat dari dukungan gizi yang memadai. Ketiga, meningkatkan kekebalan tubuh tidak lengkap dikembangkan sistem kerentanan terhadap infeksi. Berhubungan dengan kondisi seperti penyakit jantung, diabetes, dan paru obstruktif kronik secara akan memperburuk prognosis pada pasien terutama usia lanjut.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Luka bakar yang melibatkan tangan, wajah, kaki, atau perineum akan mengakibatkan cacat permanen jika tidak diobati. Pasien dengan luka bakar seperti itu harus selalu dirawat di rumah sakit, sebaiknya ke pusat terbakar. Kimia dan luka bakar listrik atau yang melibatkan saluran pernapasan yang selalu jauh lebih luas daripada yang terlihat pada pemeriksaan awal. Oleh karena itu, masuk rumah sakit diperlukan dalam kasus-kasus juga.</span></div>
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<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Patologi dan Patofisiologi</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> Mikroskopik dari luka bakar pada prinsipnya nekrosis koagulasi. Di bawah jaringan yang jelas hangus ada tiga zona yang berbeda. pertama adalah zona koagulasi dengan tidak ada aliran darah kapiler. Tingkat keparahan ditentukan oleh suhu dan lama pemaparan. Sekitarnya adalah zona stasis, ditandai dengan aliran darah kapiler lambat. Meskipun rusak, jaringan belum digumpalkan. Stasis dapat terjadi lebih awal atau terlambat. Menghindari cedera tambahan dari gosokan atau dehidrasi dapat mencegah perubahan stasis dari berkembang dan dalam cara mencegah perpanjangan kedalaman luka bakar. Pencegahan oklusi vena penting karena dapat menyebabkan trombosis dan infark di zona ini. Zona ketiga adalah "hiperemia," yang merupakan respons peradangan biasa dari jaringan sehat untuk cedera mematikan.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Sebuah kehilangan cairan intravaskuler cepat dan protein terjadi melalui kapiler panas-luka. Kehilangan volume terbesar dalam 6-8 jam pertama, dengan integritas kapiler kembali ke normal 36-48 jam. Selain itu, ada peningkatan tekanan osmotik edema interstisial yang menonjolkan itu. Peningkatan permeabilitas pembuluh darah sementara di juga terjadi di jaringan tak terbakar, mungkin sebagai akibat dari rilis awal mediator vasoaktif. Namun, edema yang berkembang di jaringan nonburned selama resusitasi tampaknya karena sebagian besar ke hypoproteinemia ditandai disebabkan oleh hilangnya protein ke dalam luka bakar sendiri. Penurunan umum dalam energi sel dan membran potensial terjadi sebagai akibat dari penurunan perfusi jaringan awal. Hal ini menyebabkan pergeseran natrium ekstraseluler dan air ke dalam ruang intraselular, yang pada gilirannya akan meningkatkan kebutuhan cairan. Proses ini juga dikoreksi sebagai stabilitas hemodinamik dipulihkan. Asap inhalasi nyata meningkatkan ketidakstabilan hemodinamik, kebutuhan cairan, dan tingkat kematian.</span></div>
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<span style="font-family: inherit;"><br /></span></div>
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<span style="font-family: inherit;">Respon Metabolisme Tubuh Untuk Luka Bakar & Metabolisme Tambahan</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Respon metabolik awal tampaknya diaktifkan oleh sitokin properadangan dan oksidan gilirannya. Sekresi katekolamin, kortisol, glukagon, renin-angiotensin, hormon antidiuretik, dan aldosteron juga meningkat. Respon awal, energi disediakan oleh pemecahan glikogen disimpan dan oleh proses glikolisis anaerobik.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Sebuah hipermetabolisme mendalam terjadi pada periode postburn, ditandai dengan peningkatan tingkat metabolisme yang mendekati dua kali lipat dari tingkat dasar pada luka bakar parah. Tingkat respon adalah proporsional dengan derajat cedera, dengan dataran tinggi yang terjadi saat luka bakar melibatkan sekitar 70% dari total permukaan tubuh. Yang memulai dan melestarikan faktor adalah mediator peradangan, khususnya sitokin dan endotoksin. Ditambahkan menekankan lingkungan seperti sakit, pendinginan, dan sepsis meningkatkan hipermetabolisme wajib.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Dalam periode minggu pertama postburn, tingkat metabolisme (atau panas produksi) dan konsumsi oksigen semakin meningkat dari saat ini tingkat normal selama resusitasi dan tetap tinggi sampai luka tertutup. Mekanisme patofisiologi khusus tetap belum bisa diketahui secara pasti, tetapi meningkat dan kuatnya sekresi Katekholamin dan kehilangan panas berlebihan evaporasi dari luka bakar adalah faktor utama, sehingga meningkatkan sirkulasi endotoksin dari luka atau usus.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Jumlah Kehilangan evaporasi air dari luka dapat mencapai 300 mL/m2/h (normal adalah sekitar 15 mL/m2/h). Ini menghasilkan kehilangan panas dari sekitar 580 kcal/L air menguap. Usaha Menutupi luka bakar dengan membran kedap, untuk pengganti kulit yang rusak, mengurangi hipermetabolisme tersebut. Demikian pula, dengan menempatkan pasien dalam sebuah lingkungan yang hangat, di mana konveksi dan kehilangan bercahaya panas diminimalkan, sehingga mengurangi laju metabolisme. Menempatkan pasien dalam lingkungan unwarmed (suhu ruang pada atau di bawah 27 ° C) menonjolkan kehilangan panas dan nyata meningkatkan hipermetabolik . Tingkat beredar terus menerus merangsang meningkatnya katekolamin secara berlebihan glukoneogenesis dan pemecahan protein. Protein katabolisme, intoleransi glukosa, dan ditandai kehilangan berat badan hasil total.</span></div>
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<span style="font-family: inherit;">Dukungan pemberian nutrisi agresif bersama dengan cepat menutup luka dan kontrol nyeri, stres, dan sepsis merupakan usaha yng harus dilakukan untuk mengurangi hypermetabolic negara. Penggunaan agen anti-inflamasi selektif mungkin manfaat di masa depan.</span></div>
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<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Faktor Imunologi Pada Luka Bakar</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Sejumlah kelainan kekebalan pada pasien luka bakar predisposisi infeksi. Serum IgA, IgM, dan IgG sering depresi, mencerminkan fungsi sel B tertekan. Cell-mediated imunitas atau fungsi sel T juga terganggu, seperti yang ditunjukkan oleh survival berkepanjangan homografts dan xenografts. Penurunan produksi interleukin-2 karena mediator yang beredar dapat bertanggung jawab. Kelebihan aktivitas sel T penekan terlihat pada pasien sangat terbakar, dan tingkat aktivitas telah ditemukan untuk menjadi alat ukur yang baik akhirnya sepsis dan kematian.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Aktivitas PMN chemotactic ditekan. Ini telah disebabkan oleh beberapa faktor penghambat untuk beredar dilepaskan dari luka bakar. Penurunan chemotaxis mendahului bukti sepsis klinis oleh beberapa hari. Penurunan konsumsi oksigen dan membunuh bakteri terganggu juga telah didemonstrasikan di PMNs. membunuh Tertekan mungkin karena penurunan produksi hidrogen peroksida dan superoksida; ini telah ditunjukkan oleh penurunan aktivitas PMN chemiluminescent dalam luka bakar pasien.</span></div>
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<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Penanganan Luka Bakar</span></div>
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<span style="font-family: inherit;">Resusitasi Akut</span></div>
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<span style="font-family: inherit;">Luka bakar pasien harus dinilai dan diperlakukan seperti pasien dengan trauma besar. Prioritas pertama adalah untuk memastikan saluran udara yang memadai. Jika ada kemungkinan bahwa menghirup asap telah terjadi-seperti yang disarankan oleh paparan terhadap kebakaran di ruang tertutup atau luka bakar pada wajah, nares, atau bagian atas badan-gas darah arteri dan saturasi oksigen hemoglobin arteri dan tingkat carboxyhemoglobin harus diukur dan oksigen harus diberikan.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Intubasi endotrakeal dilakukan jika pasien semicomatose, telah luka bakar mendalam pada wajah dan leher, atau dinyatakan menderita luka parah. Intubasi harus dilakukan pada awal semua kasus diragukan, karena tertunda intubasi akan sulit untuk mencapai dalam kasus-kasus yang berhubungan dengan edema faring atau cedera saluran napas atas, dan trakeostomi darurat dapat menjadi diperlukan kemudian dalam keadaan sulit. Jika luka bakar melebihi 20% dari luas permukaan tubuh, kateter kemih harus dimasukkan untuk memonitor urin output. Sebuah besar-menanggung kateter intravena harus dimasukkan, sebaiknya ke pembuluh darah perifer besar. Ada tingkat komplikasi yang signifikan dengan penggunaan garis sentral dalam luka bakar pasien karena peningkatan risiko infeksi.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Luka bakar yang parah ditandai oleh kehilangan besar cairan intravaskuler, yang terbesar selama 8-12 jam pertama. Fluida kehilangan terjadi sebagai akibat dari permeabilitas kapiler diubah, hipoproteinemia parah, dan pergeseran natrium ke dalam sel. Kedua pergeseran cairan berkurang secara signifikan sebesar 24 jam postburn. paru-paru yang tampaknya cukup baik dilindungi dari proses awal edema, dan edema paru jarang selama periode resusitasi kecuali ada cedera inhalasi dilapiskan.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Awalnya suatu larutan garam isotonik kristaloid diinfuskan untuk mengimbangi hilangnya volume plasma ke dalam ruang extravascular dan hilangnya cairan ekstraselular lebih lanjut ke dalam ruang intraselular. Solusi Ringer Lactat digunakan umumnya tingkat yang sedang didikte oleh output urin, pulsa (karakter dan tingkat), keadaan kesadaran, dan, pada tingkat lebih rendah, tekanan darah. Urin output harus dijaga pada 0,5 mL / kg / jam dan pulsa di 120 denyut / menit atau lebih lambat.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Swan-Ganz kateter dan pusat jaringan tekanan vena jarang diperlukan kecuali dalam hal menghirup asap cedera parah atau kecuali pasien menderita penyakit yang cukup cardiopulmonary sehingga pemantauan yang akurat tentang status volume akan sulit tanpa pengukuran tekanan atau kecuali mengisi defisit dasar gigih hadir, yang menunjukkan gangguan perfusi lanjutan. Diperkirakan bahwa jumlah yang diperlukan Ringer lactated dalam 24 jam pertama untuk resusitasi yang memadai adalah sekitar 3-4 mL / kg berat badan per persen luka bakar tubuh. Ini adalah jumlah cairan yang dibutuhkan untuk memulihkan diperkirakan defisit natrium. Setidaknya setengah dari fluida diberikan dalam 8 jam pertama karena kehilangan volume yang lebih besar awal. Telah ditunjukkan bahwa pasien dapat secara memadai menghidupkan kembali dengan cairan lebih sedikit dan, pada gilirannya, edema kurang jika larutan garam hipertonik digunakan sebagai ganti larutan Ringer Laktat. Perhatian utama dengan larutan garam hipertonik telah kemudahan dengan sebuah beban garam yang berlebihan dapat diberikan. Natrium serum harus dimonitor dengan hati-hati untuk menghindari melebihi nilai dari 160 meq / L. Penghentian dari larutan garam hipertonik dan kembali ke ringer laktat dibutuhkan jika hal ini terjadi. Mengandung solusi dekstrosa tidak digunakan pada awalnya karena intoleransi glukosa awal diinduksi stres.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Meskipun pentingnya memulihkan tekanan osmotik koloid dan protein plasma juga diakui, waktu infus koloid tetap agak bervariasi. Plasma protein yang biasanya tidak diresapi sampai setelah kebocoran plasma awal di jaringan nonburned mulai menurun. Hal ini biasanya terjadi sekitar 4-8 jam postburn. Penambahan infus protein untuk regimen pengobatan setelah periode ini akan mengurangi kebutuhan cairan dan-dalam sangat muda atau pasien tua dan pada pasien dengan luka bakar besar (lebih dari 50% permukaan tubuh)-akan meningkatkan stabilitas hemodinamik.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Setelah cairan intravena dimulai dan tanda-tanda vital stabil, lukanya harus didebridemen semua kulit longgar dan kotoran. Untuk menghindari hipotermia parah, debridemen paling baik dilakukan dengan melengkapi satu area tubuh sebelum memperlihatkan detik. Sebuah alternatif lain adalah dengan menggunakan pemanas seri overhead, yang akan mengurangi kehilangan panas. air dingin yang sangat baik analgesik pada luka bakar dangkal kecil, namun tidak boleh digunakan untuk luka bakar yang lebih besar karena risiko hipotermia. Nyeri terbaik dikendalikan dengan menggunakan infus daripada narkotika intramuskular. Tetanus toksoid, 0,5 mL, harus diberikan pada pasien dengan luka bakar yang signifikan.</span></div>
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<span style="font-family: inherit;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Periode Post-Recucitaion</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Terapi cairan intravena selama 24 jam kedua harus terdiri dari glukosa dalam larutan garam hipotonik untuk mengganti kehilangan menguapkan dan protein plasma untuk mempertahankan volume sirkulasi yang memadai. evaporative kehilangan cukup besar dan akan terus sampai luka sembuh atau telah dicangkokkan. Perkiraan kehilangan ini dalam mililiter per jam tiba di sebagai berikut:</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">• Pengobatan harus bertujuan untuk mengurangi rangsangan Katekholamin berlebihan dan menyediakan cukup kalori untuk mengimbangi efek hypermetabolism tersebut. Hipotermia, nyeri, dan kecemasan semua harus agresif dikendalikan. Hipovolemia harus dicegah dengan memberikan cairan yang cukup untuk menebus kehilangan tubuh.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">• Dukungan nutrisi harus dimulai sedini mungkin dalam periode postburn untuk memaksimalkan penyembuhan luka dan meminimalkan defisiensi imun. Pasien dengan luka bakar tubuh moderat mungkin dapat memenuhi kebutuhan gizi dengan asupan oral sukarela. Pasien dengan luka bakar yang besar selalu memerlukan kalori dan suplemen protein. Hal ini biasanya dapat dicapai dengan pemberian diet formula melalui slang kecil. Nutrisi parenteral juga kadang-kadang diperlukan, tetapi rute usus lebih disukai jika kebutuhan dapat dipenuhi dengan cara ini. Awal mengembalikan fungsi usus juga akan menurunkan translokasi bakteri usus dan kebocoran endotoksin.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">• Penggunaan penisilin profilaksis pada pasien terbakar adalah kontroversial. Hal ini mungkin lebih baik untuk mengobati infeksi streptokokus pada beberapa pasien yang mendapatkan mereka daripada untuk menutup semua pasien. Antibiotik spektrum luas tidak boleh diberikan untuk profilaksis.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">• Vitamin A, E, dan C dan seng harus diberikan sampai luka bakar ditutup. Dosis rendah terapi heparin mungkin memiliki beberapa keuntungan, seperti pasien amobil lain dengan cedera jaringan lunak.</span></div>
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<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Bila terjadi luka bakar berat, sehingga penatalaksanaannya sebagai berikut :</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">1. Terapi cairan</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Tujuan untuk mempertahankan perfusi jaringan yang adekuat yang dapat dipantau dari tekanan darah, nadi, pengeluaran urin, keseimbangan asam – basa, derajat kesadaran,serta hidrasi penderita.</span></div>
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<span style="font-family: inherit;">Formula Bexter</span></div>
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<span style="font-family: inherit;">` Hari Pertama :</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Dewasa : RL 4cc x BB x % luas LB/24 jam</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> Anak : RL : Dextran = 17 : 3</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> 2 cc x BB x % luas LB + Kebutuhan Faali :</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> < 1 tahun : BB x 100 cc</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> 1 – 3 tahun : BB x 75 cc</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> 3 - 5 tahun : BB x 50 cc</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">½ Jumlah cairan diberikan dalam 8 jam pertama</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">½ Diberikan 16 jam berikutnya </span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">In the field for practical fluid therapy using the following formula:</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">given the degree burns II / over an area of> = 20% in children, or> = 30% in adults. The amount is based on extensive burns (% lb) and weight.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Way of providing the Child:</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Plasma replacement = mm x% lb x 1 ml</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Electrolyte / RL = mm x% lb x 1 ml</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Glucose 5%: 0.9% NaCl, 3: 1 = insensible water loss (IWL).</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">BW <10 kg: 100 ml / kg</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">10 ± 20 kg: 50 ml / kg</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">> 20 kg: 20 ml / kg</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">The next day: plasma and electrolytes 1/2 the first day and the Stay IWL</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Adults:</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">together with the children; only IWL</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> given glucose 5% as much as 2000 ml</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">days I, 8 ½ jampertama amount of fluid given, the remaining 16 hours. hariberikutnya average 24 hours.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">2. Pembersihan dan perawatan luka</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Dalam pembalutan dilakukan kompres dengan caian rivanol guna mengurangi rasa panas luka bakar dan sekaligus membersihkan sisa kotoran yang ada. Pengompresan dihentikan pada hari ke-6, selanjutnya diberikan Darmazin zalf yang dioles tipis – tipis diatas luka 2 x sehari . guna zalf ini untuk mempercepat pengeringan luka. Dalam teori pergantian perban dalam kasus luka bakar adalah 8 – 24 jam sekali atau bila basah atau berbau.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">3. Pemberian TT dan ATS untuk mencegah tetanus</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">4. Pemberian antibiotik untuk mencegah infeksi sekunder yang merupakan komplikasi tersering yang terjadi pada luka bakar. Antibiotik yang diberikan adalah antibiotik sistemik spektrum luas. Yang banyak dipakai adalah golongan aminoglikosid yang efektif terhadap psudomonas.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">5. Pemberian analgetik untuk menghindari terjadinya syok neurogenik</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">6. Pemasangan dawer kateter untuk mengontrol urin /jam. Diuresis penderita luka bakar sekurang – kurangnya 1 ml/ kgbb/jam untuk memonitor fungsi ginjal. Warna urin dapat digunakan untuk menentukan apakah telah terjadi lisis eritrosit akibat panas.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">7. Diet tinggi kalori tinggi protein.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Nutrisi harus diberikan cukup untuk menutup kebutuhan kalori dan keseimbangan nitrogen yang negatif pada fase katabolisme dengan kadar protein tinggi.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">8. Rehabilitasi</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">a. Posisi pasien dalam perawatan</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Siku fleksi 300</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Aksila abduksi 600</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Lipat paha abduksi 100</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- lutut fleksi 100</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- pergelangan kaki 900</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Jari – jari kaki saling menjauh</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">b. Fisioterapi untuk mencegah kontraktur</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">9. Periksa lab anjuran</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Hb & Ht tiap 8 jam dalam 2 hari pertama dan tiap 2 hari pada 10 hari berikutnya</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Fungsi hati dan ginjal tiap minggu</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Pemeriksaan elektrolit tiap hari pada minggu pertama</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Pemeriksaan analisa gas darah bila nafas > 32 x/ menit</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Kultur jaringan pada hari I,III,IV</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Kematian pada luka bakar disebabkan oleh :</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">1. Shock, karena kehilangan cairan</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">2. Kegagalan jantung</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">3. Sepsis, infeksi nosokomial</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">4. Kegagalan ginjal akut</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">5. komplikasi lain, seperti pneumonia</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Walaupun demikian pada luka bakar patut selalu diingat bahwa luka bakar perlu pengawasan ketat terutama pada masa – masa awal hingga dua minggu.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Kematian pada pasien ini mungkin disebabkan akibat sepsis, infeksi yang terjadi dapat berasal dari beberapa faktor, antara lain infeksi nosokomia</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Perawatan Luka Bakar</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Dalam pengelolaan pertama dan luka bakar tingkat dua, kita harus memberikan sebagai aseptis lingkungan mungkin untuk mencegah infeksi. Namun, luka bakar superfisial umumnya tidak memerlukan penggunaan antibiotik topikal. dressing oklusif untuk mengurangi eksposur ke udara meningkatkan tingkat reepithelialization dan nyeri menurun. Jika tidak ada infeksi, luka bakar akan sembuh secara spontan.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Tujuan dalam mengelola penuh ketebalan (tingkat tiga) luka bakar adalah untuk mencegah infeksi invasif (misalnya, luka bakar sepsis), untuk membuang jaringan mati, dan untuk menutup luka dengan kulit secepat mungkin.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Semua antibiotik topikal menghambat penyembuhan luka pada tingkat tertentu dan karena itu harus digunakan hanya di dalam kedua-atau luka bakar atau luka dengan risiko tinggi infeksi.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Agen Antibakteri Topical</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Agen topical telah pasti maju merawat pasien luka bakar. Meskipun luka bakar sepsis masih merupakan masalah besar, insiden lebih rendah dan tingkat kematian telah berkurang, terutama pada luka bakar kurang dari 50% dari luas permukaan tubuh. Silver sulfadiazin sekarang adalah persiapan yang paling banyak digunakan. Mafenide, perak nitrat, povidone-iodine, dan salep gentamisin juga digunakan.</span></div>
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<span style="font-family: inherit;">Silver sulfadiazin efektif terhadap spektrum yang luas dari organisme gram-negatif dan cukup efektif dalam menembus eschar luka bakar. Sebuah leukopenia sementara sekunder untuk penekanan sumsum tulang sering terjadi dengan penggunaan sulfadiazin perak pada luka bakar besar, namun proses ini biasanya membatasi diri dan agen tidak harus dihentikan.</span></div>
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<span style="font-family: inherit;">Mafenide menembus luka bakar eschar dan lebih kuat antibiotik, tetapi ada komplikasi lebih dengan penggunaannya. Mafenide menyebabkan rasa sakit yang cukup besar pada aplikasi di lebih dari setengah dari pasien. Ini juga merupakan inhibitor anhydrase karbonat, dan asidosis metabolik dapat mengakibatkan jika digunakan melalui area permukaan besar, terutama pada anak-anak atau orang tua. Agen ini digunakan terutama pada luka bakar sudah terinfeksi atau ketika sulfadiazin perak tidak lagi efektif dalam mengontrol pertumbuhan bakteri.</span></div>
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<span style="font-family: inherit;">Penanganan Terbuka dan Tertutup</span></div>
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<span style="font-family: inherit;">Ada dua metode pengelolaan luka bakar dengan agen topikal. Dalam terapi pemaparan, tidak ada perban yang diaplikasikan di atas luka setelah aplikasi dari agen untuk luka dua kali atau tiga kali sehari. Kelebihan metode ini adalah bahwa pertumbuhan bakteri tidak ditingkatkan, karena mungkin kasus di bawah tertutup saus, dan luka itu tetap terlihat dan mudah diakses. Pendekatan ini biasanya digunakan pada wajah dan kepala. Kekurangan meningkat rasa sakit dan kehilangan panas akibat luka terbuka dan peningkatan resiko kontaminasi silang.</span></div>
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<span style="font-family: inherit;">Pada metode tertutup, sebuah occlusive dressing diaplikasikan di atas agen dan biasanya diubah dua kali sehari. Kehilangan dari metode ini adalah meningkatkan potensi pertumbuhan bakteri jika berpakaian tidak berubah dua kali sehari, terutama ketika eschar tebal hadir. Keunggulan adalah nyeri kurang, hilangnya panas yang lebih sedikit, dan kurang kontaminasi silang. Metode ditutup umumnya disukai.</span></div>
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<span style="font-family: inherit;">Substitusi Kulit Sementaara</span></div>
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<span style="font-family: inherit;">Kulit pengganti adalah alternatif lain untuk agen topikal untuk ketebalan-sebagian terbakar atau luka dipotong bersih. Split-ketebalan xenografts babi secara komersial tersedia dan telah mendapatkan popularitas sebagai ganti biologis yang dapat diterapkan untuk membersihkan luka-ketebalan parsial dan untuk menutupi daerah terutama dipotong ketika penyambungan harus ditunda atau ketika autografts tidak tersedia. Homografts (kulit manusia) bekerja lebih baik untuk tujuan ini tetapi sulit untuk mendapatkan. alternatif lain termasuk sejumlah pengganti kulit sintetis seperti Biobrane, membran plastik tipis yang mengurangi kehilangan air evaporasi.</span></div>
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<span style="font-family: inherit;">Agen ini sangat efektif pada luka bakar tingkat dua. Setelah pembersihan awal dan penghapusan lecet, aplikasi langsung mencegah hilangnya cairan, melindungi terhadap infeksi, dan nyeri berhenti. Pasien dapat berjalan-jalan dengan nyaman segera. Penyembuhan yang dihasilkan dikaitkan dengan jaringan parut minimal.</span></div>
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<span style="font-family: inherit;">Hydrotherapy</span></div>
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<span style="font-family: inherit;">Penggunaan hidroterapi untuk manajemen luka masih kontroversial. Sejumlah penelitian telah menunjukkan bahwa sebenarnya tingkat infeksi meningkat ketika pasien direndam dalam bak mandi karena inokulasi umum burn luka dengan bakteri dari apa yang sebelumnya infeksi lokal. Hidroterapi, bagaimanapun, adalah bentuk yang sangat berguna sekali terapi fisik luka sedang dalam proses menjadi debrided dan tertutup. Mandi juga efektif untuk membersihkan luka pada pasien yang lebih stabil.</span></div>
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<span style="font-family: inherit;">Debridement & Cangkok</span></div>
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<span style="font-family: inherit;">Luka bakar peradangan, bahkan tanpa adanya infeksi, dapat mengakibatkan disfungsi organ dan melestarikan hipermetabolicknegara. Awal penutupan luka akan diharapkan untuk mengontrol proses ini lebih efektif. manajemen pembedahan luka bakar kini telah menjadi jauh lebih agresif, dengan debridemen operasi awal dalam beberapa hari pertama postburn daripada setelah eschar telah sloughed. Lebih cepat penutupan luka bakar jelas menurunkan tingkat sepsis dan, dalam penuh luka bakar ketebalan lebih dari 60% dari permukaan tubuh, secara signifikan menurunkan tingkat kematian. Pendekatan untuk debridemen operasi bervariasi dari luas luka bakar eksisi dan pencangkokan dalam beberapa hari cedera pada pendekatan yang lebih moderat untuk membatasi debridements menjadi kurang dari 15% dari area yang terbakar dan tidak lebih dari empat unit kehilangan darah per prosedur. Eksisi dapat dilakukan ke fasia atau sisa dermis yang layak atau lemak. Eksisi untuk fasia memiliki keuntungan yang memungkinkan untuk korupsi hampir 100% mengambil dan juga memungkinkan penggunaan grafts lebar-menyatu jika perlu. Prosedur ini dapat dilakukan pada suatu ujung, menggunakan tourniquet untuk menurunkan kehilangan darah. mesh dapat ditutupi dengan biologis rias untuk menghindari pengeringan dari luka ditemukan. Eksisi untuk jaringan yang layak, disebut sebagai eksisi tangensial, menguntungkan karena menyediakan dasar vaskular untuk mencangkok sambil mempertahankan sisa jaringan yang layak, khususnya dermis. Kehilangan darah yang substansial dalam pandangan vascularity dari dermis.</span></div>
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<span style="font-family: inherit;"> pengganti kulit tetap sekarang sedang diuji yang lebih lanjut bisa memfasilitasi penutupan luka, terutama pada luka bakar masif dengan situs donor tidak cukup. budaya autologus epitel telah diterapkan dengan beberapa keberhasilan. Tetap pengganti kulit terdiri dari kedua dermis dan epidermis telah dirancang untuk mempertahankan cakupan dan meningkatkan fungsi kulit. Keberhasilan dari pengganti kulit masih tidak pasti.</span></div>
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<span style="font-family: inherit;">Pemeliharaan Fungsi</span></div>
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<span style="font-family: inherit;">Pemeliharaan gerak fungsional pada pasen luka bakar sangat diperlukan untuk menghindari kekakuan pada sendi. kontraksi luka, peristiwa normal selama penyembuhan, dapat mengakibatkan contracture ekstremitas. Imobilisasi dapat menyebabkan kekakuan sendi, yang pada suatu waktu dianggap disebabkan oleh edema tapi mungkin lebih karena sakit, tidak digunakan, atau immobilisasi dressing. Contracture dari bekas luka, otot, dan tendon di seluruh sendi juga menyebabkan hilangnya gerak dan dapat berkurang dengan traksi, gerakan awal, dan tekanan didistribusikan secara langsung atas luka untuk mengurangi pembentukan bekas luka hipertrofik.</span></div>
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<span style="font-family: inherit;"> Jaringan parut sering terjadi setelah luka bakar dapat mengakibatkan kontraktur menodai dan melumpuhkan, tapi mungkin bisa dihindari dengan menggunakan splints dan elevasi untuk mempertahankan posisi fungsional sebelum okulasi. Setelah graft kulit, pemeliharaan posisi yang tepat dengan splints . Pada saat pemulihan, penerapan tekanan rias dan tekanan dan splints isoprena akan menghasilkan jaringan parut hipertrofik dan contracture kurang. Tekanan harus dipelihara dengan pakaian elastis selama minimal 6 bulan dan dalam beberapa kasus mungkin diperlukan selama setahun. Awal luka bakar kontraktur biasanya dapat ditarik dengan kekuatan ringan serta konstan.</span></div>
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<span style="font-family: inherit;">Jika reinjury tidak terjadi, jumlah kolagen dalam bekas luka cenderung menurun. Stiff kolagen menjadi lebih lembut, dan pada permukaan datar dari tubuh, di mana reinjury dan peradangan akan dicegah, renovasi benar-benar dapat menghilangkan contracture. Namun, di sekitar sendi atau leher, kontraktur biasanya bertahan dan rekonstruksi bedah plastik sering perlu. The granulasi jaringan cepat dapat ditutup dengan cangkokan kulit, semakin kecil kemungkinan adalah kontraktur.</span></div>
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<span style="font-family: inherit;"> Komplikasi</span></div>
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<span style="font-family: inherit;">Adanya Infeksi tetap menjadi masalah kritis dalam luka bakar, meskipun insiden tersebut telah dikurangi dengan terapi agen antibakteri topikal. budaya kuantitatif berurutan dari bakar akan muncul bila konsentrasi 105-organisme yang menentukan tingkat infeksi invasif-hadir. Budaya juga menunjukkan sensitivitas bakteri, dan ketika melewati konsentrasi bakteri 105 organisme per gram, administrasi sistemik antibiotik spesifik harus dilembagakan.</span></div>
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<span style="font-family: inherit;">Sepsis bisa sulit untuk mendiagnosis, karena demam dan leukositosis sering hadir dengan luka bakar sendirian. ketidakstabilan hemodinamik adalah tanda terlambat. suhu mungkin turun di bawah normal, penampilan luka akan rusak, dan jumlah putih bisa jatuh, akhirnya berakhir dengan syok septik. terapi antibiotik agresif harus dimulai dan upaya dilakukan untuk mengidentifikasi sumber infeksi. Pneumonitis, infeksi saluran kemih, dan sepsis kateter intravena harus dipertimbangkan dalam diagnosis diferensial. Jika penyebab lain tidak ditemukan, luka biasanya fokus septik dan harus debrided. Volume darah, gizi, dan oksigenasi harus dinilai. Steroid tidak boleh diberikan karena mereka kompromi sudah lemah pertahanan kekebalan.</span></div>
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<span style="font-family: inherit;">Luka bakar keliling ekstremitas atau bagasi menimbulkan masalah khusus. Pembengkakan di bawah tak mau mundur eschar dapat bertindak sebagai tourniquet untuk darah dan aliran getah bening, dan ujung distal dapat menjadi bengkak dan menegangkan. Pembengkakan lebih luas dapat mengganggu pasokan arteri. Eskarotomi atau eksisi eschar yang mungkin diperlukan. Untuk menghindari kerusakan permanen, eskarotomi harus dilakukan sebelum iskemia arteri berkembang. Penyempitan melibatkan dada atau perut parah dapat membatasi ventilasi dan mungkin memerlukan escharotomies longitudinal. Anestesia jarang dibutuhkan, dan prosedur yang biasanya dapat dilakukan di kamar pasien.</span></div>
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<span style="font-family: inherit;">Bisa terjadi Gastroduodenal akut (Curling's) borok yang sekaligus merupakan komplikasi yang sering luka bakar yang parah, namun kejadian tersebut sekarang menurun, sebagian besar sebagai hasil dari lembaga awal dan rutin antasid dan terapi nutrisi dan penurunan tingkat sepsis. </span></div>
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<span style="font-family: inherit;">Sering komplikasi anak-anak adalah kejang, yang mungkin hasil dari ketidakseimbangan elektrolit, hipoksemia, infeksi, atau obat-obatan, dalam satu-sepertiga kasus, penyebabnya tidak diketahui. Hiponatremia, penyebab yang paling sering, menjadi kurang sama dengan berkurangnya penggunaan perak nitrat topikal. Obat yang telah terlibat termasuk penisilin, agen antipsikotik fenotiazin, diphenhydramine, dan aminofilin.</span></div>
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<span style="font-family: inherit;">Akut pelebaran lambung, yang terjadi pada minggu pertama setelah cedera, harus dicurigai saat pasien muntah berulang kali dalam jumlah kecil makanan. impaksi tinja akibat imobilisasi, dehidrasi, dan analgesik narkotika adalah fenomena yang cukup umum. hipertensi sistemik terjadi pada sekitar 10% kasus pada periode postresuscitation.</span></div>
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<span style="font-family: inherit;">Cedera Saluran Pernafasan Dalam Luka Bakar</span></div>
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<span style="font-family: inherit;">Penyebab utama kematian setelah luka bakar adalah cedera saluran pernafasan atau komplikasi pada saluran pernafasan. Masalah termasuk cedera inhalasi, aspirasi pada pasien tidak sadar, pneumonia bakteri, edema paru, emboli paru, dan insufisiensi paru pasca trauma.</span></div>
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<span style="font-family: inherit;">Cedera inhalasi langsung, yang predisposisi komplikasi lain, dibagi menjadi tiga kategori: keracunan karbon monoksida, cedera panas ke jalan napas, dan menghirup gas beracun.</span></div>
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<span style="font-family: inherit;">Inhalasi langsung panas kering merupakan penyebab kerusakan langka di bawah pita suara karena umumnya saluran napas bagian atas secara efektif mendinginkan gas terinspirasi sebelum mereka mencapai trakea dan karena refleks penutupan tali dan menghentikan spasme laring inhalasi penuh gas panas. Langsung luka bakar ke saluran napas bagian atas yang terkait dengan luka bakar pada wajah, bibir, dan rambut hidung dan nekrosis atau pembengkakan mukosa faring. Edema akut pada saluran atas dapat menyebabkan obstruksi jalan napas dan sesak napas tanpa merusak paru-paru. Edema laring harus diantisipasi pada pasien dengan luka bakar jalan napas, dan intubasi endotrakeal harus dilakukan baik sebelum manifestasi obstruksi saluran napas muncul. Tabung endotrakeal harus cukup besar untuk memungkinkan penghapusan sekresi berlebihan tebal selama perawatan berikutnya. Tracheostomies dilakukan melalui jaringan yang terbakar berhubungan dengan tingkat komplikasi yang sangat tinggi dan seharusnya hanya dilakukan jika intubasi endotrakeal tidak memungkinkan.</span></div>
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<span style="font-family: inherit;">Pengobatan terutama suportif, termasuk pemeliharaan toilet paru, ventilasi mekanik (ketika ditunjukkan), dan antibiotik.</span></div>
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<span style="font-family: inherit;">Keracunan karbon monoksida harus dipertimbangkan dalam setiap pasien yang diduga menderita cedera inhalasi atas dasar telah dibakar dalam ruang tertutup, bukti fisik inhalasi, atau dyspnea. gas darah arteri dan tingkat carboxyhemoglobin harus ditentukan. Tingkat carboxyhemoglobin di atas 5% pada bukan perokok dan di atas 10% pada perokok mengindikasikan keracunan karbon monoksida. Karbon monoksida mempunyai afinitas terhadap hemoglobin 200 kali dari oksigen, menggantikan oksigen, dan menghasilkan perubahan ke kiri dalam kurva disosiasi oksihemoglobin (P50, ketegangan oksigen di mana setengah hemoglobin jenuh dengan oksigen, diturunkan). Pengukuran saturasi oksihemoglobin dapat menyesatkan karena hemoglobin dikombinasikan dengan karbon monoksida tidak terdeteksi dan persentase saturasi oksihemoglobin mungkin tampak normal.</span></div>
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<span style="font-family: inherit;">Keracunan karbon monoksida ringan (<carboxyhemoglobin 20%) ditunjukkan oleh sakit kepala, dyspnea sedikit, kebingungan ringan, dan ketajaman visual berkurang. keracunan Sedang (20-40 carboxyhemoglobin%) menyebabkan mudah tersinggung, gangguan penilaian, visi redup, mual, dan fatigability. Parah keracunan (40-60 carboxyhemoglobin%) menghasilkan halusinasi, kebingungan, ataksia, runtuh, dan koma. Tingkat lebih dari 60 carboxyhemoglobin% biasanya fatal.</span></div>
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<span style="font-family: inherit;">Berbagai bahan kimia beracun dalam asap terinspirasi menghasilkan luka pernafasan tertentu. Menghirup asap minyak tanah, misalnya, relatif tidak berbahaya. Asap dari kayu bakar sangat menjengkelkan karena mengandung gas aldehida, khususnya akrolein. menghirup langsung dari akrolein, bahkan dalam konsentrasi yang rendah, mengganggu selaput lendir dan menghasilkan pencurahan cairan. Sebuah konsentrasi 10 ppm akan menyebabkan edema paru. Asap dari beberapa senyawa plastik, seperti polyurethane, adalah jenis yang paling serius dari iritasi beracun. Gas beracun seperti klorin, asam sulfat, atau sianida diberikan. Penyerapan Sianida dapat mematikan. Oksidan yang dirilis setelah semua dampak asap.</span></div>
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<span style="font-family: inherit;">Cedera inhalasi menyebabkan edema mukosa parah segera diikuti oleh peluruhan mukosa. Mukosa hancur dalam saluran udara lebih besar akan digantikan oleh membran mukopurulen. Cairan edema jalan napas masuk dan, ketika dicampur dengan nanah di lumen, bisa membentuk cetakan dan colokan di bronchioles lebih kecil. bronchioles Terminal dan alveoli mungkin berisi bahan karbon. Bronchiolitis dan bronkopneumonia akut biasanya berkembang dalam beberapa hari. sputum smear harus diperiksa setiap hari untuk mendeteksi infeksi bakteri tracheobronchial awal.</span></div>
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<span style="font-family: inherit;">Ketika cedera inhalasi dicurigai, pemeriksaan endoskopik awal saluran napas dengan bronkoskopi serat optik sangat membantu dalam menentukan area cedera, yaitu, apakah hanya jalan napas atas adalah terlibat atau saluran napas yang lebih rendah juga. Sayangnya, tingkat keparahan dari cedera yang tidak dapat diukur secara akurat oleh bronkoskopi-itu hanya dapat menunjukkan bahwa adanya luka. Laringoskopi langsung mungkin memberikan banyak informasi.</span></div>
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<span style="font-family: inherit;">Kurang penyebab umum kegagalan pernapasan merupakan embolus paru dan kelebihan edema paru. Emboli biasanya terjadi kemudian dalam perjalanan pengobatan setelah istirahat lama dan harus dicurigai, jika fungsi pernafasan tiba-tiba memburuk. Antikoagulasi heparin diindikasikan untuk emboli paru. edema paru dari cairan yang berlebihan selama resusitasi biasanya terjadi hanya pada pasien dengan penyakit jantung sudah ada sebelumnya. Paru-paru inhalasi-luka sangat rentan terhadap edema, yang sulit untuk mengelola, karena hypoperfusion sistemik ini harus dihindari oleh upaya diuresis.</span></div>
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<span style="font-family: inherit;">Mungkin penyebab paling umum dari kegagalan pernafasan adalah pneumonia bakteri baik karena cedera inhalasi, kontaminasi paru-paru melalui tabung endotrakeal atau trakeostomi, infeksi udara, atau penyebaran hematogenous bakteri dari luka bakar. Perubahan flora normal orofaringeal dengan kolonisasi oleh patogen dan selanjutnya aspirasi sekresi terinfeksi adalah penyebab paling umum dari infeksi paru-paru.</span></div>
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<span style="font-family: inherit;">Insufisiensi paru berhubungan dengan sepsis sistemik. Membedakan sindrom kesulitan pernafasan akut (ARDS) dari pneumonia bakteri mungkin sulit. Ada kerusakan pada kapiler paru dan kebocoran cairan dan protein ke ruang interstisial paru-paru, yang mengakibatkan hilangnya kepatuhan dan kesulitan dalam oksigenasi darah. Modern metode bantuan ventilasi dan toilet paru kuat secara signifikan mengurangi angka kematian dari insufisiensi paru.</span></div>
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<span style="font-family: inherit;">Penatalaksanaan</span></div>
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<span style="font-family: inherit;">Manajemen pasien luka bakar harus meliputi evaluasi sering paru-paru seluruh program rumah sakit. Semua pasien yang awalnya memiliki bukti dari menghirup asap harus menerima oksigen lembab dalam konsentrasi tinggi. Keracunan karbon monoksida Jika telah terjadi, oksigen 100% harus diberikan sampai kembali konten carboxyhemoglobin ke tingkat normal dan sampai mengatasi gejala keracunan karbon monoksida. Dengan eksposur yang parah, karbon monoksida mungkin masih terikat pada enzim sitokrom, menyebabkan hipoksia sel bahkan setelah tingkat carboxyhemoglobin telah kembali ke dekat normal. oksigen Lanjutan administrasi juga akan membalik proses ini.</span></div>
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<span style="font-family: inherit;">Penggunaan kortikosteroid untuk cedera inhalasi tidak lagi kontroversial dan jelas kontraindikasi dengan pengecualian obliterans bronchiolitis.</span></div>
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<span style="font-family: inherit;">Bronkodilator dengan aerosol atau aminofilin intravena dapat membantu jika mengi karena bronkospasme refleks. Dada terapi fisik dengan drainase postural juga diperlukan.</span></div>
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<span style="font-family: inherit;">Ketika intubasi endotrakeal yang digunakan tanpa ventilasi mekanik (misalnya, untuk obstruksi saluran napas atas), kabut dan tekanan positif kontinu bantuan ventilasi harus disertakan. kelembaban ini akan membantu mengendurkan cairan dan mencegah pengeringan saluran pernafasan; tekanan positif kontinyu akan membantu mencegah atelektasis dan penutupan dari paru-paru unit distal saluran udara bengkak. Trakeostomi ditunjukkan dalam beberapa hari pertama bagi pasien yang diperkirakan membutuhkan bantuan ventilasi selama beberapa minggu atau lebih. Jika leher dibakar, eksisi dan pencangkokan diikuti oleh trakeostomi diindikasikan dalam rangka meningkatkan toilet paru.</span></div>
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<span style="font-family: inherit;">Ventilasi mekanik harus menerapkan awal jika cedera paru signifikan diantisipasi. Tubuh yang besar dengan keterlibatan luka bakar dinding dada akan menghasilkan kepatuhan dinding dada menurun, meningkatnya kerja pernapasan, dan atelektasis berikutnya. cedera Tracheobronchial dari bahan kimia terhirup adalah ditekankan oleh kehadiran tubuh luka bakar, dengan peningkatan resultan pada potensi atelektasis dan infeksi. ventilasi Terkendali bersama dengan sedasi akan mengurangi tingkat cedera dan juga menghemat pengeluaran energi. Awal eksisi dinding dada dalam penutupan luka bakar dan akan membantu menghapus komponen konstriksi. Penutupan luka dalam akan menurunkan produksi CO2 yang berlebihan yang disebabkan oleh daerah hipermetabolik.</span></div>
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<span style="font-family: inherit;">Bila terjadi luka bakar berat, sehingga penatalaksanaannya sebagai berikut :</span></div>
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<span style="font-family: inherit;">1. Terapi cairan</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Tujuan untuk mempertahankan perfusi jaringan yang adekuat yang dapat dipantau dari tekanan darah, nadi, pengeluaran urin, keseimbangan asam – basa, derajat kesadaran,serta hidrasi penderita.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Formula Bexter</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">` Hari Pertama :</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Dewasa : RL 4cc x BB x % luas LB/24 jam</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> Anak : RL : Dextran = 17 : 3</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> 2 cc x BB x % luas LB + Kebutuhan Faali :</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> < 1 tahun : BB x 100 cc</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> 1 – 3 tahun : BB x 75 cc</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> 3 - 5 tahun : BB x 50 cc</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">½ Jumlah cairan diberikan dalam 8 jam pertama</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">½ Diberikan 16 jam berikutnya </span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">2. Pembersihan dan perawatan luka</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Dalam pembalutan dilakukan kompres dengan caian rivanol guna mengurangi rasa panas luka bakar dan sekaligus membersihkan sisa kotoran yang ada. Pengompresan dihentikan pada hari ke-6, selanjutnya diberikan Darmazin zalf yang dioles tipis – tipis diatas luka 2 x sehari . guna zalf ini untuk mempercepat pengeringan luka. Dalam teori pergantian perban dalam kasus luka bakar adalah 8 – 24 jam sekali atau bila basah atau berbau.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">3. Pemberian TT dan ATS untuk mencegah tetanus</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">4. Pemberian antibiotik untuk mencegah infeksi sekunder yang merupakan komplikasi tersering yang terjadi pada luka bakar. Antibiotik yang diberikan adalah antibiotik sistemik spektrum luas. Yang banyak dipakai adalah golongan aminoglikosid yang efektif terhadap psudomonas.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">5. Pemberian analgetik untuk menghindari terjadinya syok neurogenik</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">6. Pemasangan dawer kateter untuk mengontrol urin /jam. Diuresis penderita luka bakar sekurang – kurangnya 1 ml/ kgbb/jam untuk memonitor fungsi ginjal. Warna urin dapat digunakan untuk menentukan apakah telah terjadi lisis eritrosit akibat panas.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">7. Diet tinggi kalori tinggi protein.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Nutrisi harus diberikan cukup untuk menutup kebutuhan kalori dan keseimbangan nitrogen yang negatif pada fase katabolisme dengan kadar protein tinggi.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">8. Rehabilitasi</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">a. Posisi pasien dalam perawatan</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Siku fleksi 300</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Aksila abduksi 600</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Lipat paha abduksi 100</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- lutut fleksi 100</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- pergelangan kaki 900</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Jari – jari kaki saling menjauh</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">b. Fisioterapi untuk mencegah kontraktur</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">9. Periksa lab anjuran</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Hb & Ht tiap 8 jam dalam 2 hari pertama dan tiap 2 hari pada 10 hari berikutnya</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Fungsi hati dan ginjal tiap minggu</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Pemeriksaan elektrolit tiap hari pada minggu pertama</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Pemeriksaan analisa gas darah bila nafas > 32 x/ menit</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">- Kultur jaringan pada hari I,III,IV</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Kematian pada luka bakar disebabkan oleh :</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">1. Shock, karena kehilangan cairan</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">2. Kegagalan jantung</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">3. Sepsis, infeksi nosokomial</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">4. Kegagalan ginjal akut</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">5. komplikasi lain, seperti pneumonia</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Walaupun demikian pada luka bakar patut selalu diingat bahwa luka bakar perlu pengawasan ketat terutama pada masa – masa awal hingga dua minggu.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Kematian pada pasien ini mungkin disebabkan akibat sepsis, infeksi yang terjadi dapat berasal dari beberapa faktor, antara lain infeksi nos</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Penyembuhan Pasien Dengan Luka Bakar</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Revisi bedah plastik dari bekas luka sering diperlukan setelah penyambungan awal, terutama untuk melepaskan kontraktur di sendi dan untuk alasan kosmetik. Dokter harus realistis dalam menentukan hasil yang diterima, dan pasien harus diberitahu bahwa mungkin diperlukan waktu bertahun-tahun untuk dicapai. Luka bakar sering menyakitkan mata, dan harapan-meskipun harus diperluas bahwa peningkatan resolusi dapat dibuat-total adalah tidak mungkin dalam banyak kasus.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Kulit memanfaatkan teknik ekspansi tas Silastic subdermal yang diperluas secara bertahap telah banyak perbaikan manajemen bekas luka revisi. Kemampuan untuk memperbesar kulit yang tersedia akan digunakan untuk penggantian bekas luka meningkatkan baik tampilan kosmetik dan fungsi. Kemajuan dalam bedah flap mikrovaskuler juga menghasilkan perbaikan substansial dalam hasil.</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">Pasien harus berhati-hati dari kulit bekas luka bakar. berkepanjangan paparan sinar matahari harus dihindari, dan ketika luka itu melibatkan bidang-bidang seperti wajah dan tangan, yang sering terkena sinar matahari, agen penyaringan ultraviolet harus digunakan. hipertrofik dan keloid bekas luka sangat mengganggu dan dapat dikurangi dengan menggunakan pakaian tekanan, yang harus dikenakan sampai bekas luka jatuh tempo-sekitar 12 bulan. Karena pelengkap kulit sering dihancurkan oleh luka bakar ketebalan penuh, krim dan lotion yang diperlukan untuk mencegah pengeringan dan cracking dan untuk mengurangi gatal. Zat seperti lanolin, vitamin A dan D salep, dan krim Eucerin semua efektif.</span></div>
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<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">DAFTAR PUSTAKA</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">1. R. Sjamsuhidayat, Wim de Jong : Buku Ajar Ilmu Bedah ; luka bakar hal </span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"> 73 – 81</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">2. R yefta M : Luka bakar Pengetahuan klinis praktis </span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">3. David C sabiston : buku Ajar Bedah ; Luka Bakar hal 151- 160</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">4. Jonatan Oswani, Bedah Minor Hal : 91-99, Medan</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;">5. Soelarto Reksoparjo, Kumpulan Kuliah Ilmu Bedah Hal 435-442 UI jakarta</span></div>
<div style="text-align: justify;">
<span style="font-family: inherit;"><br /></span></div>
arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com1tag:blogger.com,1999:blog-2501725445038181687.post-87750134781216159612012-05-13T18:16:00.000+07:002012-05-13T18:16:12.695+07:00Ensefalopati Hepatik<div style="text-align: justify;">
BAB 1<br />
PENDAHULUAN<br />
Hati merupakan salah satu organ yang sangat penting peranannya dalam mengatur metabolisme tubuh, yaitu dalam proses anabolisme atau sintesis bahan-bahan yang penting untuk kehidupan manusia seperti sintesis protein dan pembentukan glukosa ; sedangkan dalam proses katabolisme dengan melakukan detoksikasi bahan-bahan seperti amonia, berbagai jenis hormon dan obat-obatan. Di samping itu hati juga berperan sebagai gudang tempat penyimpanan bahan-bahan seperti glikogen dan beberapa vitamin dan memelihara aliran normal darah splanknikus. Oleh karena itu terjadi kerusakan sel-sel parenkhim hati akut maupun kronik yang berat, fungsi-fungsi tersebut akan mengalami gangguan atau kekacauan, sehingga dapat timbul kelainan seperti ensefalopati hepatikum.<br />
Ensefalopati Hepatik adalah suatu sindrom neuropsikiatri, mempunyai spektrum klinik yang luas, dapat timbul akibat penyakit hati yang berat, baik akut maupun yang menahun ditandai adanya gangguan tingkah laku, gejala neurologik, astriksis, berbagai derajat gangguan kesadaran sampai koma, dan kelainan elektro ensefalografi.<br />
Enselafalopati Hepatik (EH) merupakan sindrom neuropsikiatrik yang terjadi pada penyakit hati. Definisi tersebut menyiratkn bahwa spektrum klinis (EH) sangat luas, karena di dalamnya juga termauk pasien hepatitis fulminan serta pasien sirosis dalam stadium Ensefalopati Hepatik Subklinis (EHS) <br />
Pasien sirosis hati yang telah dapat diatasi keadaan EH akutnya, berada dalam keadaan EH kronik, yang setiap saat dapat kembali mengalami episode akut apabila terdapat faktor seperti infeksi, pendarahan gastrointestinal dan asupan protein diet berlebihan. Karena terjadinya episode EH akut biasanya didahului oleh keadaan dekompensasi (fungsi) hati, pengobatan ini juga dapat bermakna mempertahankan “keadaan kompensasi selama mungkin”. Dengan tercapainya kompensasi, berarti secara subjektif pasien memperoleh kualitas hidup yang lebih baik (sympton-free). Hal – hal tersebut perlu dicermati agar pengelolaan penderita-penderita EH lebih terarah dengan hasil optimal.<br />
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BAB 2<br />
PEMBAHASAN<br />
2.1 Definisi Ensefalopati Hepatik<br />
Ensefalopati hepatik merupakan suatu sindrom neuropsikiatrik yang umumnya terjadi karena kadar protein yang tinggi di saluran pencernaan atau karena stress metabolik akut (perdarahan saluran pencernaan, infeksi, dan gangguan elektrolit pada pasien dengan portal-systemic shunting. Gejala-gejala yang muncul umumnya gejala neuropsikiatrik (confusion, flapping tremor, koma). <br />
Ensefalopati hepatik adalah suatu kompleks suatu gangguan susunan saraf pusat yang dijumpai yang mengidap gagal hati. Kelainan ini ditandai oleh gangguan memori dan perubahan kepribadian (Corwin., 2001).<br />
Ensefalopati hepatik (ensefalopati sistem portal, koma hepatikum) adalah suatu kelainan dimana fungsi otak mengalami kemunduran akibat zat-zat racun di dalam darah, yang dalam keadaan normal dibuang oleh hati (Stein 2001).<br />
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2.2 Etiologi Ensefalopati Hepatik<br />
Ensefalopati hepatik dapat muncul pada hepatitis fulminan yang disebabkan oleh obat-obatan, atau racun, namun umumnya muncul pada sirosis atau penyakit kronik lainnya saat terjadi kolateral portal-sistemik yang besar sebagai komplikasi dari hipertensi portal. Bahan-bahan yang diserap kedalam aliran darah dari usus, akan melewati hati, dimana racun-racunnya dibuang pada ensefalopati hepatic yang terjadi adalah:<br />
a. Racun-racun ini tidak dibuang karena funsi hati terganggu.<br />
b. Telah terbentuk hubungan antara system portal dan sirkulasi umum(sebagai akibat dari penyakit hati),sehingga racun tadak melewati hati.<br />
c. Pembedahan by pass untuk memperbaiki hipertensi portal(shunt system portal)juga akan menyebabkan beberapa racun tidak melewati hati.apapun penyebabnya ,akibatnya adalah sampainya racun di otak dan mempengaruhi fungsi otak.<br />
Bahan apa yang bersifat racun terhadap otak,secara pasti belum diketahui.tetapi tingginya kadar hasil pemecahan protein dalam darah,misalnya ammonia,tampaknya memegang peranan yang penting.<br />
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Pada pasien dengan penyakit hati kronis, episode akut ensefalopati umumnya dicetuskan oleh beberapa faktor, antara lain :<br />
<br />
Jenis Penyebab<br />
Excessive<br />
nitrogen<br />
load Intake protein dalam jumlah tinggi, pendarahan gastrointestinal seperti pada kondisi varises esophagus (dimana darah dalam keadaan tinggi protein, yang direabsorbsi oleh usus), gagal ginjal (ketidakmampuan untuk mengekskresikan nitrogen yang mengandung produk sisa seperti urea), konstipasi<br />
Gangguan<br />
elektrolit<br />
atau<br />
metabolik Hyponatraemia, hypokalaemia, yang biasanya terjadi pada pasien yang menggunakan diuretic, sering digunakan untuk mengobati asites, alkalosis, hypoxia (insufficient oxygen levels), dehydration<br />
Obat-<br />
obatan Sedatives seperti benzodiazepines (sering digunakan untuk menekan enxietas dan alcohol withdrawal), narkotik (sebagai pain kellers), (sering digunakan untuk menekan penarikan alkohol atau gangguan kecemasan), isoniazid (sering digunakan untuk penyakit infeksi paru)<br />
Infeksi Pneumonia, infeksi saluran kemih , peritonitis bakteri spontan , infeksi lain<br />
Lain-lain pembedahan, perburukan dari penyakit hati, menyebabkan kerusakan hati kerusakan hati (misalnya hepatitis alkoholik , hepatitis A )<br />
idiopathik Pada 20-30% kasus, tidak ada penyebab yang jelas<br />
<br />
Enselopati hepatik akut<br />
Pada tipe akut terjadi prekoma/koma hepatikum dalam waktu singkat (kurang dari 8 minggu); sedangkan pada tipe subakut terjadi prekoma/koma hepatikum dalam waktu 8 minggu dari gejala awal. Etiologi umumnya adalah hepatitis akut (fulminan), hepatitis alkoholik, reaksi/keracunan obat, bahan kimia. Dapat juga karena penyakit lain, seperti ; kelainan pembuluh darah, seperti iskemia hati, veno occlusive disease, heat stroke, infiltrasi maligna, syok berat atau tanpa sepsis<br />
<br />
Penyebab enselopati hepatik kronik :<br />
Tipe kronik sering terjadi pada sirosis hati dengan kolateral porto-sistemik yang ekstensif. Di sini didapatkan gejala-gejala gangguan mental, emosional atau kelainan neurologik dalam periode berbulan-bulan atau bertahun-tahun.<br />
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Faktor etiologinya :<br />
a. Penyakit hati menahun dengan kolateral portal-sistemik yang ekstensif, diit protein yang berlebihan, aktivitas bakteri usus yang berlebihan.<br />
b. Sirosis hati dengan atau tanpa komplikasi<br />
c. Hepatoma (karsinoma hepatoseluler)<br />
Koma hepatikum tipe kronik dapat timbul pada sirosis hepatis tahap terminal atau akibat faktor pencetus seperti ; diuresis yang berlebihan, perdarahan, parasentesis cairan asites, diare dan muntah berlebihan, pembedahan, terlalu banyak minum alkohol, pemberian sendatif, infeksi dan konstipasi.<br />
<br />
2.3 Klasifikasi Ensefalopati hepatik<br />
Klasifikasi Ensefalopati Hepatikum yang banyak dianut adalah :<br />
2.3.1. Menurut cara terjadinya<br />
a. EH tipe akut :<br />
Timbul tiba-tiba dengan perjalanan penyakit yang pendek, sangat cepat memburuk jatuh dalam koma, sering kurang dari 24 jam. Tipe ini antara lain hepatitis virus fulminan, hepatitis karena obat dan racun, sindroma reye atau dapat pula pada sirosis hati.<br />
b. EH tipe kronik :<br />
Terjadi dalam periode yang lama, berbulan-bulan sampai dengan bertahun-tahun. Suatu contoh klasik adalah EH yang terjadi pada sirosis hepar dengan kolateral sistem porta yang ekstensif, dengan tanda-tanda gangguan mental, emosional atau kelainan nueurologik yang berangsur-angsur makin berat.<br />
<br />
2.3.2. Menurut faktor etiologinya<br />
a. EH primer / Endogen<br />
Terjadi tanpa adanya faktor pencetus, merupakan tahap akhir dari kerusakan sel-sel hati yang difus nekrosis sel hati yang meluas. Pada hepatitis fulminan terjadi kerusakan sel hati yang difus dan cepat, sehingga kesadaran terganggu, gelisah, timbul disorientasi, berteriak-teriak, kemudian dengan cepat jatuh dalam keadaan koma, sedangkan pada siridis hepar disebabkan fibrosi sel hati yang meluas dan biasanya sudah ada sistem kolateral, ascites. Disini gangguan disebabkan adanya zat racun yang tidak dapat dimetabolisir oleh hati. Melalui sistem portal / kolateral mempengaruhi susunan saraf pusat.<br />
b. EH Sekunder / Eksogen<br />
Terjadi karena adanya faktor-faktor pencetus pada pederita yang telah mempunyai:<br />
1. kelainan hati. Faktor-faktor antara lain adalah:<br />
Gangguan keseimbangan cairan, elektrolit dan PH darah : (Dehidrasi / hipovolemia, Parasintesis abdomen, Diuresis berlebihan), 2. Pendarahan gastrointestinal, 3. Operasi besar, 4. Infeksi berat, 5. Intake protein berlebihan, 6. Konstipasi lama yang berlarut-larut, 7. Obat – obat narkotik/ hipnotik, 8. Pintas porta sistemik, baik secara alamiah maupun pembedahan, 9. Azotemia<br />
EH dapat diklasifikasikan berdasarkan gangguan dari hepar, yaitu :<br />
- tipe A : berhubungan dengan gangguan hepar akut<br />
- tipe B : berhubungan dgn bypass portosistemik tanpa penyakit hepatoselular intrinsik<br />
- tipe C : berhubungan dengan sirosis dan hipertensi portal atau shunt portosistemik. <br />
Pada kasus dengan penyakit hati kronik, tipe ini dapat muncul secara episodik atau bahkan menetap <br />
<br />
2.4 Epidemiologi Ensefalopati hepatik<br />
Ensefalopati hepatic adalah sindrom yang ditemukan pada pasien dengan sirosis hati. Data kepustakaan tentang ensifalopati hepatikum di Indonesia ternyata masih sedikit. Diluar negri kejadian ensifalopati hepatic subklinik berkisar antara 30 – 84%. Tanda-tanda samar ensefalopati hepatik ditemukan pada 70% pasien sirosis hati. Pada penelitian Mmorgan dan Strangen diketahui 18% dari 71 penderita sirosis hati memberikan tes psikometri normal, 48% memperlihatkan gambaran ensefalopati hepatic subklinik sedangkan 34% jelas tampak jelas dengan gejala dan tanda ensefalopati hepatic. <br />
Di bagian penyakit dalam FKUI selama setahun ditemukan penderita sirosis hati 109 pasien, diantaranya dengan 55 pasien ensefalo hepatic. Ensefalo hepatic yang spontan didapatkan 13 pasien atau 37%, sedangkan pada 22 pasien diduga factor pencetus dari perdarahan saluran cerna13 pasien atau 37% , infeksi akut 6 pasien atau 17% , dan hipokolemi 3 pasien atau 9%. Ensefalopati hepatic stadium II ditemukan 9 pasien, stadium III 19 pasien dan stadium IV 7 pasien. Beberapa penelitian yang menunjukan bahwa sirosis hati yang terlihat normal, ternyata 34-80% didapatkan ensefalopati hepatic ringan atau laten / subklinik. Hal ini dapat dideteksi dengan uji psikometrik, uji entelegensi, kemampuan konsentrasi dan EEG. <br />
2.5 Patofisiologi Ensefalopati hepatika<br />
Ensefalopati hepatika sebagian besar timbul akibat penimbunan toksin di dalam darah, yang terjadi apabila hati gagal mengubah atau mendetoksifikasi toksin – toksin tersebut secara adekuat. Hati yang sakit tidak hanya gagal mendetoksifikasi darah karena gangguan fungsi hepatosit tetapi juga hanya mendapatkan sedikit darah untuk mendetoksifikasi dari jumlah biasanya karena sebagian besar aliran darah porta di alirkan oleh tingginya resistensi dan hipertensi porta . Tekanan osmotik meningkat karena penumpukan toksin dan produk sisa metabolik, sehingga terjadi pembengkakan otak dan edema serebral .<br />
Salah satu toksin yang menumpuk dan yang diduga merupakan penyebab dari banyak gejala ensefalopati hepatika adalah amonia. Amonia adalah produk sampingan metabolisme protein dan kerja bakteri usus. Salah satu fungsi penting hati adalah mengubah amonia menjadi urea. Tidak seperti amonia, urea mudah diekskresikan oleh ginjal. <br />
Apabila amonia tidak di ubah menjadi urea, maka kadarnya di dalam darah meningkat dan amonia tersebut akan mencapai otak. Pada penyakit hati stadium lanjut, zat – zat lain misalnya hormon, obat, berperan menyebabkan ensefalopati hepatika. Ensefalopati hepatik biasanya dipercepat oleh keadaan seperti : perdarahan saluran cerna, asupan protein berlebihan, obat diuretik, parasentesis, hipokalemia, infeksi akut, pembedahan , azotemia, dan pemberian morfin, sedati, tau obat mengandung 〖NH〗_3. Azotemia adalah retensi zat nitrogenosa ( misal urea ) dalam darah yang normal nya difiltrasi oleh ginjal. Efek berbahaya dari zat – zat ini dapat ditelusuri pada mekanisme yang mengakibatkan pembentukan amonia dalam jumlah besar dalam usus . Enselofati yang menyertai kekurangan kalium atau parasentesis dapat dihubungkan dengan pembentukan 〖NH〗_3 yang berlebihan oleh ginjal dan perubahan keseimbangan asam / basa.<br />
Sirkulasi ammonia normal dan abnormal (NHᴣ).Normal, Ammonia protein yang termakan di ubah menjadi NHᴣ dan amine oleh bakteri di usus, di absorpsi ke dalam sistem vena porta, dan mengalami detoksifikasi melalui konversi menjadi urea oleh hepatosit. Urea sebagian besar diekskresi oleh ginjal (75%), tetapi 25% di ekskresi di usus. Ginjal juga memproduksi NHᴣ dalam jumlah yang bervariasi, sebagian besar oleh deaminasi glutamine. Normalnya hanya sedikit NHᴣ yang memasuki sirkulasi sistemik. Tidak normal, dua mekanisme utama penyebab hiperamonia pada sirosis hati: (1) kegagalan hati untuk membentuk urea akibat kerusakan hepatoselular, dan (2) pirau portosistemik (pemintasan hati) melalui aliran kolateral portosistemik ketika terjadi hipertensi porta. Operasi pirau portakaval seperti yang terlihat dalam diagram dapat memiliki efek yang sama. NHᴣ berlebihan dalam<br />
Beberapa hipotesis yang telah dikemukakan pada pathogenesis ensefalopati hepatic adalah :<br />
1. Hipotesis amoniak<br />
Amonia berasal dari mukosa usus sebagai hasil degradasi protein dalam lumen usus dan dari bakteri yang mengandung urease. Dalam hati amonia diubah menjadi urea pada sel hati periportal dan menjadi glutamine pada sel hati perivenus,sehingga jumlah amonia yang masuk ke sirkulasi dapat dikontrol dengan baik. Glutamin juga diproduksi oleh otot (50%), hati, ginjal, dan otak (7%). Pada penyakit hati kronis akan terjadi gangguan metabolisme amonia sebesar 5 – 10 kali lipat. <br />
2. Hipotesis toksisitas sinergik<br />
Neurotoksin lain yang mempunyai efek sinergis dengan amonia seperti merkaptan,asam lemak rantai pendek (oktanoid),fenol,dan lain – lain. <br />
3. Hipotesis neurotransmitter palsu<br />
Pada keadaan normal pada otak terdapat neurotransmitter dopamine dan nor-adrenalin, sedangkan pada keadaan gangguan fungsi hati,neurotransmitter palsu seperti oktapamin dan feniletanolamin, yang lebih lemahdibanding dopamine / nor-adrenalin.<br />
4. Hipotesis GABA dan benzodiazepine<br />
Ketidakseimbangan antara asam amino neurotransmitter yang merangsang dan menghambat fungsi otak merupakan factor yang berperan pada terjadinya ensefatopati hepatic. Terjadinya penurunan trasmiter yang memiliki efek merangsang seperti glutamate,aspartat dan dopamine sebagai akibat meningkatnya amonia dan gama (GABA) yang menghambat transmisi impuls.Efek GABA yang meningkat bukan karena influks yang meningkat ke dalam otak tetapi akibat perubahan reseptor GABA dalam otak akibat suatu substansi yang mirip benzodiazepine.<br />
Beberapa bahan toksik yang diduga berperan :<br />
1. Ammonia<br />
Ammonia merupakan bahan yang paling banyak diselidiki. Zat ini berasal dari penguraian nitrogen oleh bakteri dalam usus, di samping itu dihasilkan oleh ginjal, jaringan otot perifer, otak dan lambung. Secara teori ammonia mengganggu faal otak melalui. Pengaruh langsung terhadap membran neuron Mempengaruhi metabolisme otak melalui siklus peningkatan sintesis glutamin dan ketoglutarat, kedua bahan ini mempengaruhi siklus kreb sehingga menyebabkan hilangnya molekul ATP yang diperlukan untuk oksidasi sel. Peneliti lain mendapatkan bahwa kadar ammonia yang tinggi tidak seiring dengan beratnya kelainan rekaman EEG. Dilaporkan bahwa peran ammonia pada EH tidak berdiri sendiri. Tetapi bersama-sama zat lain seperti merkaptan dan asam lemak rantai pendek. Diduga kenaikan kadar ammonia pada EH hanya merupakan indikator non spesifik dari metabolisme otak yang terganggu. <br />
2. Asam amino neurotoksik (triptofan, metionin, dan merkaptan) <br />
Triptopan dan metabolitnya serotonin bersifat toksis terhadap SSP. Metionin dalam usus mengalami metaolisme oleh bakteri menjadi merkaptan yang toksis terhadap SSP. Di samping itu merkaptan dan asam lemak bebas akan bekerja sinergistik mengganggu detoksifikasi ammonia di otak, dan bersama-sama ammonia menyebabkan timbulnya koma.<br />
3. Gangguan keseimbangan asam amino<br />
Asam Amino Aromatik ( AAA) meningkat pada EH karena kegagalan deaminasi di hati dan penurunan Asan Amino Rantai Cabang (AARC) akibat katabolisme protein di otot dan ginjal yang terjadi hiperinsulinemia pada penyakit hati kronik.AAA ini bersaing dengan AARC untuk melewati sawar otak, yang permeabilitasnya berubah pada EH. Termasuk AAA adalah metionin, fenilalanin, tirosin, sedangkan yang termasuk AARC adalah valin, leusin, dan isoleusin.<br />
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4. Asam lemak rantai pendek<br />
Pada EH terdapat kenaikan kadar asam lemak rantai pendek seperti asam butirat, valerat, oktanoat, dan kaproat, diduga sebagai salah satu toksin serebral penyebab EH. Bahan-bahan ini bekerja dengan cara menekan sistem retikuler otak, menghemat detoksifikasi ammonia.<br />
5. Neurotramsmitter palsu<br />
Neurotrasmitter palsu yang telah diketahui adalah Gamma Aminobutyric Acid (GABA), oktapamin, histamin, feniletanolamin, dan serotonin. Neurotransmitter palsu merupakan inhibitor kompepetif dari true neurotrasmitter (dopamine dan norephinephrine) pada sinaps di ujung saraf, yang kadarnya menurun pada penderita PSE maupun FHF.<br />
Penelitian menunjukkan bahwa GABA bekerja secara sinergis dengan benzodiasepine membentuk suatu kompleks, menempati reseptor ionophore chloride di otak, yang disebut reseptor GABA/BZ. Pengikatan reseptor tersebut akan menimbulkan hiperpolarisasi sel otak, di samping itu juga menekan fungsi korteks dan subkorteks, rangkaian peristiwa tersebut menyebabkan kesadaran dan koordinasi motorik terganggu. Hipotesis ini membuka jalan untuk penelitian lebih lanjut untuk keperluan (Gitlin., 1996).<br />
6. Glukagon<br />
Peningkatan AAA pada EH/ koma hepatik mempunyai hubungan erat dengan tingginya kadar glukagon. Peninggian glukagon turut berperan atas peningkatan beban nitrogen. Karena hormon ini melepas Asam Amino Aromatis dari protein hati untuk mendorong terjadinya glukoneogenesis. Kadar glukagon meningkat akibat hipersekresi atau hipometabolisme pada penyakit hati terutama bila terdapat sirkulasi kolateral.<br />
7. Perubahan sawar darah otak<br />
Pembuluh darah otak dalam keadaan normal tidak permiabel terhadap berbagai macam substansi. Terdapat hubungan kuat antara endotel kapiler otak, ini merupakan sawar yang mengatur pengeluaran bermacam-macam substansi dan menahan beberapa zat essensial seperti neurotrasmitter asli. Pada koma hepatikum khususnya FHF ditemukan kerusakan kapiler, rusaknya hubungan endotel, terjadi edema serebri sehingga bahan yang biasanya dikeluarkan dari otak akan masuk dengan mudah seperi fenilalanin dalam jumlah besar, sehingga kadar asam amino lainnnya meningkat di dalam otak.<br />
Pathofisiologi dari gejala yang timbul :<br />
1. BAB Hitam<br />
Melena berarti tinja berwarna hitam mirip ter (lunak serta lengket). Adanya melena menunjukkan adanya perdarahan pada saluran pencernaan bagian atas (mulai mulut sampai usus halus). Kadang-kadang keluhan disertai muntah darah/hitam seperti kopi (hematemesis). Bila darah terpapar asam lambung, maka akan berubah warna menjadi coklat kehitaman. Bila perdarahnnya hebat, maka pasien akan mengeluh BAB darah merah dalam jumlah banyak (hematokezia).<br />
Salah satu penyebab penting dari perdarahan saluran cerna bagian atas adalah kerusakan mukosa hingga luka lambung oleh penggunaan obat-obat anti radang/nyeri dan alcohol.<br />
2. Foetor Hepaticus<br />
Bau mulut hepaticus atau hepaticus foetor (lihat perbedaan ejaan), juga dikenal sebagai napas orang mati, adalah suatu kondisi yang terlihat pada hipertensi portal dimana shunting portosystemic memungkinkan mercaptans untuk lulus langsung ke paru-paru. Ini adalah tanda akhir gagal hati. Kemungkinan penyebab lainnya adalah adanya amonia dan keton dalam napas. Nafas memiliki bau manis feses untuk itu.<br />
3. Flapping Tremor<br />
Asteriksis (juga disebut tremor mengepak, atau flap hati) adalah tremor dari pergelangan tangan ketika pergelangan tangan diperpanjang, kadang-kadang dikatakan menyerupai burung mengepakkan sayapnya. Gangguan motorik ditandai dengan gerakan yang menghentak (seperti tangan terulur) dan berhubungan dengan berbagai encephalopathies karena terutama untuk metabolisme rusak. [1] Istilah berasal dari bahasa Yunani yang, "tidak" dan stērixis, "posisi tetap".<br />
4. Spider Nevi<br />
Dilatasi, pada gilirannya, disebabkan oleh peningkatan tingkat estrogen dalam darah. Banyak ibu hamil, atau wanita yang menggunakan kontrasepsi hormonal, memiliki angioma laba-laba, karena kadar estrogen yang tinggi dalam darah mereka. Orang yang memiliki penyakit hati yang signifikan juga menunjukkan angioma laba-laba banyak, karena hati mereka tidak dapat detoksifikasi estrogen dari darah, menghasilkan kadar estrogen yang tinggi. [3] Sekitar 33% pasien dengan sirosis memiliki angioma laba-laba. [4] Dengan demikian, microhemorrhages dapat diamati sebagai laba-laba angioma.<br />
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5. Hepar Teraba<br />
Kebanyakan abses hati piogenik adalah infeksi sekunder di dalamabdomen. Infeksi yang terjadi di hati dapat berasal dari:<br />
1. Sistem biliaris langsung dari kandung empedu atau melalui saluran-saluran empedu.<br />
2. Visera abdomen melalui vena porta yaitu secara langsung atau pleloflebitis atau embolisasi. Biasanya berasal dari appendisitis,divertikulitis atau penyakit Crohn. Kollitis ulseratif jarang denganabses hati.<br />
3. Arteri hati pada bakteriemia/septikemia akibat infeksi di tempat lain.<br />
4. Penyebaran langsung dari infeksi organ sekitar hati seperti gaster,duodenum, ginjal, rongga subdiafragma atau pankreas.<br />
5. Trauma tusuk atau tumpul.<br />
6.Kriptogenik.Di negara barat, penyakit sistem biliaris merupakan penyebab abseshati yang paling sering. Ini dikarenakan semakin tinggi umur harapan hidupdan semakin banyak orang lanjut usia ini yang dikenai penyakit kandungempedu.<br />
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2.6. Manifestasi Klinis Ensefalopati Hepatik<br />
Koma hepatic merupakan suatu sindron neuropsikiatri yang dapat dijumpai pada pasien gagal fungsi hati baik yang akut maupun yang kronik.pada umumnya gambaran klinis berupa kelainan mental,kelainan neurologis,terdapatnya kelainan parenkim hati serta kelainan laboratorium.<br />
Sesuai dengan perjalanan penyakit hati,maka koma hepatic dibedakan atas:<br />
1). Koma hepatic akut(fulminant) hepatic failure (ditemukan pada pasien hepatitis virus,hepatitis toksik obat(halotan),asetaminofen(perlemakan hati pada kehamilan,kerusakan parenkim hati yang pulminan tanpa factor pencetus presipitasi.Perjalanan penyakit eksflosif,ditandai dengan delirium,kejang disertai dengan edema otak.Dengan perawatan intensif angka kematian masih tinggi sekitar 80%.Kematian terutama disebabkan edema serebral.<br />
2). Pada penyakit hati kronik dengan koma portosistemik,perjalanan progresif sehingga gejala neuropsikiatri terjadi pelan-pelan dan dicetuskan oleh beberapa factor pencetus,Beberapa factor pencetus seperti azotemia,sedative,analgetik,perdarahan gastrointestinal,alkalosis metabolic,kelebihan protein,infeksi,obstipasi,gangguan keseimbangan cairan ,dan pemakaian diuretic akan dapat mencetuskan koma hepatic.<br />
Pada permulaan perjalanan koma hepatikum gambaran gangguan mental mungkin berupa perubahan dalam mengambil keputusan dan gangguan konsentrasi.Keadaan ini dapat dinilai dengan uji psikomotor atau pada pasien dengan intelektual cukup dapat dites dengan membuat gambar-gambar atau dengan uji hubung angka,dengan menghubungkan angka-angka dari 1 sampai 25,kemudian diukur lama penyelesaian oleh pasien dalam satuan detik.<br />
Gambaran klinis adalah sebagai berikut:<br />
Gejala-gejala psikiatrik yang hilang timbul ,hipersomnia,gerakan-gerakan involuntary seperti tremor pada pergelangan tangan yang dinamakan asteriksis(flapping tremor,)rigiditas,muscular twitching “kejang,stupor dan koma.<br />
Gejala dan klinis ensefalopati hepatic dapat timbul sangat cepat dan berkembang menjadi koma,bila terjadi gagal hati pada penderita hepatitis fulminin.Pada penderita sirosis ,perkembangannya berlangsug lebih lambat dan bila ditemukan pada stadium dini masih bersifat reversibel.Perkembangan ensefalopati hepatic menjadi koma biasanya dibagi dalam empat stadium.<br />
Tanda-tanda pada stadium I tidak begitu jelas dan mungkin sukar diketahui .Tanda yang berbahaya adalah sedikit perubahan kepribadian dan tingkah laku ,termasuk penampilan tidak terawatt baik,pandangan mata kosong,bicara tidak jelas,tertawa sembarangan,pelupa,dan tidak mampu memusatkan pikiran.Penderita mungkin cukup rasional ,hanya terkadang tidak kooperatif atau sedikit kurang ajar.Pemantauan yang seksama menunjukkan bahwa mereka lebih letargi atau tidur lebih lama dari biasa,atau irama tidurnya terbalik.<br />
Tanda-tanda pada stadium II lebih menonjol dari pada stadium I dan mudah diketahui Terjadi perubahan perilaku yang tidak semestinya,dan pengendalian sfingter tidak dapat terus dipertahankan .Kedutan otot generalisata dan asteriksis merupakan temuan khas.Asteriksis(atau flapping tremor) dapat dicetuskan bila penderita disuruh mengangkat kedua lengannya dengan lengan atas difiksasi ,pergelangan tangan hiperekstensi dan jari –jari terpisah .Perasat ini menyebabkan gerekan fleksi dan ekstensi involuntary cepat dari pergelangan tangan dan sendi metakarpofalang .Asteriksis merupakan suatu manifestasi perifer gangguan metabolisme otak.Keadaan semacamini dapat juga timbul pada sindrom uremia .Pada tahap ini,letargi serta perubahan sifat dan kepribadian menjadi lebih jelas terlihat.<br />
Apraksia konstitusional adalah gambaran lain yang mencolok enselopati hepatic.Penderita tidak dapat menulis atau menggambar dengan baik seperti menggambar dengan menggambar bintang atau rumah.Sederetan tulisan tangan atau gambar merupakan cara berguna untuk menentukan perkembangan enselopati.<br />
Pada stadium III, pada penderita dapat mengalami kebingunan yang nyata dengan perubahan perilaku .Bila pada saat ini penderita hanya diberi sedative dan bukan pengobatan untuk mengatasi proses toksisknya,maka enselopati mungkin akan berkembang menjadi koma,dan prognosisnya fatal .Selama stadium ini penderita dapat tidur sepanjang waktu.Elektro enselopalogram mulai berubah pada stadium II dan menjadi abnormal pada stadium III dan stadium IV.<br />
Pada stadium IV ,penderita masuk dalam keadaan koma yang tidak dapat dibangunkan,sehingga timbul reflex hiperaktif dan tanda babinsky. Pada saat ini bau apek yang manis (fetor hepatikum) dapat tercium pada nafas penderita,atau bahkan waktu masuk kedalam kamarnya.Fetor hepatikum ,merupakan tanda prognosisnya buruk,dan intensitas baunya sangat berhubungan dengan derajat somnolensia dan kekacauan .Hasil pemeriksaan laboratorium tambahan adalah kadar ammonia darah yang meningkat,dan hal ini dapat membantu mendeteksi enselopati. <br />
2.7 DIAGNOSIS ENSEFALOPATI HEPATIK<br />
Diagnosis ditegakkan atas dasar anamnesis riwayat penyakit pemeriksaan fisik dan laboratorium (Gitlin., 1996).<br />
2.7.1 Anamnesis <br />
• Riwayat penyakit hati <br />
• Riwayat kemungkinan adanya faktor-faktor pencetus. <br />
• Adakah kelainan neuropsikiatri : perubahan tingkah laku, kepribadian, kecerdasan, kemampuan bicara dan sebagainya.<br />
2.7.2 Keluhan pokok<br />
a) Mungkin ada riwayat hepatitis kronis atau sirosis hepatis<br />
b) Anoreksi, mual<br />
c) Berat badan turun<br />
d) Kadang demam disertai menggigil<br />
e) Nyeri tumpul perut kanan atas (sering tidak nyeri), tidak terus menerus<br />
f) Rasa penuh pada perut kanan atas<br />
2.7.3 Pemeriksaan fisik <br />
a) Tentukan tingkat kesadaran / tingkat ensefalopati.<br />
b) Stigmata penyakit hati (tanda-tanda kegagalan faal hati dan hipertensi portal).<br />
c) Adanya kelainan neuroogik : inkoordinasi tremor, refleks patologi, kekakuan.<br />
d) Kejang<br />
e) Gejala infeksi berat / septicemia.<br />
f) Tanda-tanda dehidrasi.<br />
g) Ada pendarahan gastrointestinal.<br />
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2.7.4 Tanda penting<br />
a) Ikterus<br />
b) Ada tanda-tanda sirosis hepatis<br />
c) Hepatomegali (pembesaran hati), konsistensi keras, permukaan tidak rata, sering tidak nyeri tekan<br />
d) Ada bising hepar, tanda khas<br />
2.7.5 Pemeriksaan laboratorium<br />
a) Fosfotase alkali naik<br />
b) Gamma GT naik<br />
c) Serum alfa-feto protein lebih besar dari 15 µg/ml<br />
d) Hiperkolesterolemi<br />
e) Bilirubin total naik<br />
f) Hematologi :<br />
• Hemoglobin, hematokrit, hitung lekosit-eritrosit-trombosit, hitung jenis leukosit<br />
• Jika diperlukan : Faal pembekuan darah <br />
• Biokimia darah :<br />
• Uji faal hati : Transaminase, bilirubin, elektroforesis protein, kolesterol, fosfatase alkali<br />
• Uji faal ginjal : Urea nitrogen (BUN), kreatinin serum<br />
• Kadar amonia darah<br />
• Atas indikasi : HBsAg, Anti-HCV, AFP, elektrolit, analisis gas darah<br />
g) Urine dan tinja rutin.<br />
h) Pemeriksaan lain (tidak rutin ) : EEG, CT Scan dll. <br />
• EEG (Elektroensefaloram) dengan potensial picu visual (visual evoked potential) merupakan suatu metode yang baru untuk menilai perubahan dini yang halus dalam status kejiwaan pada sirosis.<br />
• CT Scan pada kepala biasanya dilakukan dalam stadium ensefalopatia yang parah untuk menilai udema otak dan menyingkirkan lesi structural (terutama hematoma subdura pada pecandu alkohol).<br />
• Pungsi lumbal, umumnya mengungkapkan hasil-hasil yang normal, kecuali peningkatan glutamin. Cairan serebrospinal dapat berwarna zantokromat akibat meningkatnya kadar bilirubin. Hitung sel darah putih cairan spinal yang meningkat menunjukan adanya infeksi. Edema otak dapat menyebabkan peningkatan tekanan.<br />
2.7.6 Pemeriksaaan khusus<br />
a) USG : ada lesi fokal atau difus<br />
b) ST Scan abdomen<br />
c) Biopsi hati<br />
d) Angiografi hepar<br />
2.7.7 Pemeriksaan penunjang lainnya<br />
a) Pemeriksaan radiologis barium meal dapat melihat varises untuk konfirmasi adanya hipertensi porta. <br />
b) Ultrasonografi (USG) sudah secara rutin digunakan karena pemeriksaannya non invasif dan mudah digunakan, namun sensitivitasnya kurang. Pemeriksaan hati yang bisa dinilai dengan USG meliputi sudut hari, permukaan hati, ukuran, homogenitas, dan adanya massa. Pada sirosis lanjut, hati mengecil dan nodular, permukaan irregular, dan adanya peningkatan ekogenitas parenkim hati. Selain itu USG juga bisa untuk melihat asites, splenomegali, trombosis vena porta dan pelebaran vena porta, serta skrening adanya karsinoma hati pada pasien sirosis.<br />
c) Tomografi komputerisasi (Computerized Axial Tomography) informasinya sama dengan USG, tidak rutin digunakan karena biayanya relatif mahal.<br />
d) Magnetic resonance imaging-peranannya tidak jelas dalam mendiagnosis sirosis selain mahal biayanya<br />
e) Test Psikometri<br />
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f) Pemeriksaan Amonia Darah<br />
• Normal, amonia dikeluarkan oleh hati dengan pembentukan urea<br />
• jika hati rusak → terjadi peningkatan konsentrasi amonia darah.<br />
Biopsi hati untuk mengkonfirmasikan diagnosis. Untuk biopsi, digunakan jarum yang kecil untuk memeriksa jaringan parut dan tanda-tanda lainnya dibawah mikroskop. <br />
g) EEG (Elektroencefalografi). <br />
Dengan pemeriksaan EEG terlihat peninggian amplitudo dan menurunnya jumlah siklus gelombang perdetik. Terjadi penurunan frekuensi dari gelombang normal Alfa (8-12Hz). Tes psikometriUHA dapat dipakai untuk menilai tingkat encepalopati hepatik terutama untuk pasien sirosis hepatik yang rawat jalan.<br />
h) CT Scan Kepala <br />
Biasanya dilakukan dalam stadium koma hepatik yang parah untuk menilai udema otak dan menyingkirkan lesi structural (terutama hematoma subdural pada alkoholis). <br />
i) Pungsi lumbal.<br />
Umumnya mengungkapkan hasil-hasil yang normal, kecuali peningkatan glutamin. Cairan serebrospinal dapat berwarna zantokromat akibat meningkatnya kadar bilirubin. Hitung sel darah putih cairan spinal yang meningkat menunjukan adanya infeksi. Edema otak dapat menyebabkan peningkatan tekanan<br />
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2.7.8 DIAGNOSIS BANDING<br />
<br />
a) Koma intoksikasi obat & alkohol<br />
b) Trauma kepala, ex: kontusio cerebri , komosio cerebri, epidural hematom, subdural hematom<br />
c) Tumor Otak<br />
d) Koma akibat gangguan metabolisme, ex: Uremia, koma hipoglikemia, koma hiperglikemia<br />
e) Epilepsi<br />
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<br />
Ditemukan: <br />
a) Globulin kadarnya meningkat pada sirosis. Akibat sekunder dari pintasan, antigen bakteri dari sistem porta ke jaringan limfoid, selanjutnya menginduksi produksi imunoglobulin.<br />
b) Waktu protrombin mencerminkan derajat/tingkatan disfungsi sintesis hati, sehingga pada sirosis memanjang.<br />
c) Natrium serum-menurun terutama pada sirosis dengan asites, dikaitkan dengan ketidakmampuan ekskresi air bebas.<br />
d) Kelainan hematologi-anemia penyebabnya bisa bermacam-macam, anemia monokrom, normositer, hipokrom mikrositer atau hipokrom makrositer. Anemia dengan trombositopenia, lekopenia, dan netropenia akibat splenomegali kongestif yang berkaitan dengan hipertensi porta sehingga terjadi hipersplenisme.<br />
2.8 Penatalaksanaan Ensefalopati Hepatik<br />
Secara umum penatalaksanaan pasien dengan ensefalopati hepatik adalah memperbaiki osigenasi jaringan , pemberian vitamin terutama golongan vitamin B, memperbaiki keseimbangan elektrolit dan cairan, serta menjaga agar jangan terjadi dehidrasi.<br />
Upaya yang dilakukan pada penatalaksanaan ensefalopati hepatik adalah:<br />
Mengobati penyakit dasar hati<br />
Mengidentifikasi dan menghilangkan factor-faktor pencetus.<br />
<br />
Faktor – faktor pencetus yaitu : <br />
a. peningkatan beban nitrogen yaitu terjadi pendarahan saluran cerna makanan yang mengandung protein dalam jumlah banyak.<br />
b. Ketidakseimbangan elektrolit yaitu alkalosis, hipokalemia, hipovolemia.<br />
c. Obat-obatan yaitu obat diuretik,tranquilizer, narkotika , sedatif dan anastetik.<br />
d. Serta infeksi pembedahan<br />
<br />
Tujuan pemberian asam amino rantai cabang pada koma hepatic (ensepalopati hepatic )antara lain adalah:<br />
1. Untuk mendapatkan energi yang dibutuhkan tanpa memperberat fungsi hati;<br />
2. Pemberian asam amino rantai cabang akan mengurangi asam amino aromatic dalam darah;<br />
3. Asam amino rantai cabang akan memperbaiki sintesis katekolamin pada jaringan perifer;<br />
4. pemberian asam amino rantai cabang (AARC) untuk Memperbaiki neurotransmitter misalnya dengan : aminoleban (IVFD)<br />
5. Pemberian antagonis benzodiazepin,flumazenil merupakan antagonis benzodiazepin yang ada dipasaran. beberapa studi memperlihatkan manfaat obat ini pada sejumlah pasien dengan EH. Diberikan dengan dosis 1-2 mg secara intravena<br />
6. Pemberian asam amino rantai cabang untuk memenuhi kebutuhan nutrisi<br />
<br />
2.8.1 Pencegahan Ensefalopati Hepatik<br />
Beberapa tindakan dapat dilakukan untuk mencegah ensefalopati pada pasien yang memiliki pirau portakaval atau yang sembuh dari ensefalopati.<br />
Tindakan ini mencakup :<br />
diet dengan protein dalam jumlah sedang,<br />
Makanan yang diberikan berbentuk jus buah manis atau glukosa IV.Tindakan ini biasanya berhasil dilakukan bila diberikan pada awal perjalanan prakoma dan bila kerusakan hati tidak begitu berlanjut.<br />
tidak memberikan obat diuretik yang menurunkan kalium.<br />
Upaya suportif dengan memberikan kalori yang cukup serta mengatasi komplikasi yang mungkin ditemui seperti hipoglikemia, perdarahan saluran cerna,dan keseimbangan elektrolit.<br />
<br />
2.9. PROGNOSIS<br />
Angka kematian akibat gagal hati akut masih tinggi, beberapa penulis melaporkan sekitar 50-80%; pada gagal hati sub akut sektar 20-40%, sedangkan pada gagal hati kronik dengan eksaserbasi akut (sirosis hati dengan komplikasi) 0-20% asalkan factor pencetus dikelola dengan baik, tetapi kalau keadaan penyakit sudah terminal angka kematian hampir 100%. <br />
Prognosis sangat tergantung dari : <br />
1. umur penderita, makin muda prognosis makin baik <br />
2. factor penyebab, halotan memberikan prognosis yang jelek, virus hepatitis A lebih baik dari hepatitis B, sebaliknya hepatitis B lebih baik dari NANB <br />
3. keadaan epidemic, kalau terjadi epidemic sering prognosisnya lebih jelek; <br />
4. derajat koma <br />
5. jenis kelamin, wanita lebih jelek dari pria <br />
6. kemampuan hati untuk melakukan regenerasi. <br />
Kematian umumnya disebabkan oleh perdarahan, kegagalan system sirkulasi dan pernapasan. Gagal ginjal, infeksi, hipoglikemi dan pancreatitis. Perbaikan atau kesembuhan sempurna dapat terjadi bila dilakukan pengelolaan yang cepat dan tepat. Prognosis penderita EH tergantung dari : <br />
a. Penyakit hati yang mendasarinya. <br />
b. Faktor-faktor pencetus. <br />
c. Usia, keadaan gizi. <br />
d. Derajat kerusakan parenkim hati. <br />
e. Jenis kelamin. <br />
f. Kemampuan regenerasi hati. <br />
<br />
2.10. KOMPLIKASI ENSELOPATI HEPATIK<br />
1. Edema otak : dapat mengakibatkan meningkatnya tekanan intra kranial, sehingga dapat menyebabkan kematian. Dijumpai pada 30-40% dari kasus-kasus yang fatal.<br />
2. Gagal ginjal: akibat penurunan perfusi ke korteks ginjal. Terdapat pada sekitar 40% kasus.<br />
3. Kelainan asam-basa: hampir selalu terjadi alkalosis respiratorik hiperventilasi, sedangkan alkalosis metabolik terjadi akibat hipokalemi. Asidosis metabolik dapat terjadi karena penumpukan asam laktat atau asam organik lainnya karena gagal ginjal.<br />
4. Hipoksia: sering terjadi karena edema paru atau radang paru akibat peningkatan permeabilitas pembuluh darah kapiler di jaringan interstisiil atau alveoli.<br />
5. Gangguan faal hemostasis dan perdaraahan terjadi pada 40-70% kasus.<br />
6. Gangguan metabolisme (hipoglikemia) dan gangguan keseimbangan elektrolit (hipokalsemia).<br />
7. Kerentanggan terhadap infeksi: sering terjadi sepsis terutama karena bakteri gram negatif, peritonitis, infeksi jalan napas atau paru.<br />
8. Gangguan sirkulasi: pada tahap akhir dapat terjadi hipotensi, bradikardi maupun henti jantung.<br />
9. Pankreatitis akut: jarang terjadi, sulit diketahui semasih hidup dan sering ditemukan post mortem.<br />
<br />
<br />
<br />
<br />
<br />
KESIMPULAN<br />
Pak satrio mengalami kegagalan fungsi hati, sel-sel hati tidak dapat melakukan metabolisme sehingga terjadi hipertensi porta yg mengakibatkan dilatasi vaskular terutama pada kapiler-kapiler pembuluh darah seperti pada lambung dan esofagus, pada saat pembuluh darah pecah pada daerah tersebut dan bertemu dgn HCl (asam lambung), maka akhir dari proses pencernaan (feses) akan berwarna hitam. Akibat dari tekanan pada hati maka, hati mengalami pembesaran sehingga pada saat dilakukan palpasi hati teraba. dan tekanan darah yang tinggi ada kaitannya dengan terjadinya hipertensi porta. Ketika seseorang memakan protein, protein tsb akan dipecah menjadi amonia (NH3) dan dialirkan kehati untuk dirubah menjadi urea yang akan diekskresikan ke ginjal dan sebahagian amonia tertinggal di duodenum untuk direabsorbsi, dan terlihat pada hipertensi portal dimana shunting portosystemic memungkinkan mercaptans untuk lulus langsung ke paru-paru. Ini adalah tanda akhir gagal hati. Kemungkinan penyebab lainnya adalah adanya amonia dan keton dalam napas sehingga timbul foetor hepatikum.<br />
Yang harus dilakukan yaitu Diet rendah protein (nabati) (20gram/hari) untuk stadium I-II. Segera setelah fase akut terlewati, intake protein mulai ditingkatkan dari beban protein kemudian ditambahkan 10 gram secara bertahap sampai kebutuhan maintanance (40-60 gram/ hari). Mengurangi populasi bakteri kolon (urea splitting organism), Laktulosa peroral untuk stadium I-II dengan dosis 15-30 ml per oral 2-4 x sehari, pemberian neomisisn 4x1-2gram/hari peroral, untuk stadium I-II Antagonis benzodiaepin reseptor (Flumazenil) memberi hasil memuaskan terutama untuk stadium I-II diberikan dengan dosis 1-2 mg secara intravena. Neomycin, metrronidazon, suatu anti biotic akan mengurangi jumlah bakteri usus yang dalam keadaan normal membantu mencernakan protein.<br />
<br />
<br />
<br />
<br />
<br />
DAFTAR PUSTAKA<br />
<br />
Price a. Selvia, wilson lorraine m; ensefalopati hepatik; patofisiologi; konsep klinis proses-proses penyakit; vol.i edisi 6 halaman 499; penerbit buku kedokteran-egc, jakarta; 2006<br />
Ilmu penyakit dalam jilid 1 edisi v<br />
Sylvia A Price, Patofisiologi, Konsep Klinis Proses Penyakit – Penyakit Ed. 6 Vol. 1<br />
Harisson , Prinsip – Prinsip Penyakit Dalam Ed. 13 Vol . 4<br />
Zubir, Nasrul. Buku Ajar Ilmu Penyakit Dalam Ed. 5 Jilid. 2<br />
Gawat Darurat di Bidang Penyakit Dalam, EGC, Cetakan 1<br />
http://www.scribd.com/doc/35329396/4/Ensefalopati-Hepatik <br />
Buku ajar ilmu penyakit dalam, jilid i, edisi v, 2009, internal publishing<br />
Mega astera, w. Gawat darurat dibidang penyakit dalam.<br />
Price a.s, wilson m.l., 1995., patofisiologi ; konsep klinis proses-proses penyakit, ecg.<br />
Sood, gagan k. Porto-systemic encephalopathy. Baylor college medicine.2010. Http://emedicine.medscape.com/gastroenterolog y#liver Herrine, steven k. Portal-systemic encephalopathy. Merck & co.2009. Http://www.merck.com/mmpe/sec03/ch022/ch022g.html<br />
http://www.infokedokteran.com/info-obat/diagnosis-dan-penatalaksanaan-pada-penyakit-hepatoma.html#more-515<br />
patofisiologi edisi 6<br />
buku saku patofisiologi<br />
Buku gawat darurat di bidang penyakit dalam , prof.dr. Dr. I . Made balela sppd(kitom), dr. I . Ketut suastika, sppd(ke) <br />
<br />
<br /></div>arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com1tag:blogger.com,1999:blog-2501725445038181687.post-28341890405450358162012-03-20T13:00:00.002+07:002012-03-20T13:04:07.021+07:00Diabetes mellitus<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtU2k0ECmevCEgg4GpXLzM6ub1WlI56a7PPfd2-rJf5mrLS3PUf3fOPTad6P1LJlveY50LLXJrFm2cJwdIPw20jXAfhyphenhypheniyJO34rZtaWQml4AM2wiRpPIMz1T8TxA58iaYoguh6Vky0w2X0/s1600/cover_brosur_dm.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtU2k0ECmevCEgg4GpXLzM6ub1WlI56a7PPfd2-rJf5mrLS3PUf3fOPTad6P1LJlveY50LLXJrFm2cJwdIPw20jXAfhyphenhypheniyJO34rZtaWQml4AM2wiRpPIMz1T8TxA58iaYoguh6Vky0w2X0/s320/cover_brosur_dm.JPG" width="263" /></a><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 14pt; line-height: 150%;"> </span></b><br />
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Diabetes
melitus adalah gangguan metabolisme yang secara genetis dan klinis termasuk
heterogen dengan manifestasi berupa hilangnya toleransi karbohidrat.
Berdasarkan <span class="textexposedshow">Klasifikasi Diabetes Melitus dibagi
atas 4 yaitu: Diabetes melitus tipe 1</span>, <span class="textexposedshow">Diabetes
melitus tipe 2</span>, <span class="textexposedshow">Diabetes gestasional
(diabetes kehamilan )</span>, <span class="textexposedshow">Tipe khusus lain.
Faktor-faktor penyebab diabetes diantaranya: </span>Genetik atau faktor
keturunan, Virus dan bakteri, Pola makan, Obesitas (kegemukan), bahan-bahan
kimia dan obat-obatan, Penyakit dan infeksi pada pancreas, dan pola hidup.
Prognosis untuk seseorang dengan diabetes sepenuhnya tergantung pada dedikasi
mereka dalam mengelola penyakit. Mereka yang mengelola penyakit ini dapat
berharap untuk hidup lama. Mereka yang tidak mengelola penyakit mereka dengan
obat yang benar atau perubahan gaya hidup menderita berbagai penyakit dan
risiko incuding gagal ginjal, penyakit jantung dan kematian. Penyakit Diabetes
Melitus dapat dicegah yaitu dengan pencegahan primer, sekunder dan tersier dan
dapat dilakukan pengobatan.</span></div>
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<a name='more'></a><br /></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 14pt; line-height: 150%;">BAB II</span></b></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 14pt; line-height: 150%;">PEMBAHASAN</span></b></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.1 </span></b><b><span style="font-family: "Arial","sans-serif";">METABOLISME
KARBOHIDRAT DAN PATOFISIOLOGI DIABETES MELITUS</span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></b></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.1.1 METABOLISME KARBOHIDRAT</span></b></div>
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<span style="font-family: "Arial","sans-serif";">Melalui glikolisis, glukosa segera terlibat dalam
produksi ATP, Karbohidrat yang ada dalam diet sebagian besar adalah polimer
heksosa, diantaranya yang paling penting adalah glukosa, galaktosa, dan
fruktosa.</span></div>
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<span style="font-family: "Arial","sans-serif";">
Begitu masuk ke dalam sel, glukosa secara normal difosforilasi untuk membentuk
glukosa-6-fosfat, Enzim yang mengkatalisis reaksi ini adalah heksokinase.
Kemudian dipolimerisasi atau dikatabolisme menjadi glikogen. Proses pembentukan
glikogen disebut dengan <b>glikogenesis</b>, dan pemecahan glikogen disebut
dengan <b>glikogenolisis</b>. Glikogen terdapat banyak pada jaringan tubuh,
tetapi pasokan utama adalah hati dan otot rangka. Pemecahan glikogen menjadi
piruvat atau laktat disebut dengan <b>glikolisis</b>.Glikolisis berlangsung di
dalam sitosol semua sel, glikolisis juga dapat bekerja tanpa oksigen.glikolisis
memerlukan : glukosa, 2 ATP, 2 ADP, 2PO<sub>4</sub><sup>2-</sup>, NAD<sup>+</sup>
dengan bantuan 10 enzim sehingaglikolisis menghasilkan : <b>2 piruvat, 2NADH,
2H<sub>2</sub>O, 4 ATP</b> dengan kata lain proses glikolisis menghasilkan 2
ATP dan 2 buah piruvat yang akan dilanjutkan menuju siklus asam sitrat.</span></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.1.2 PATOFISIOLOGI</span></b></div>
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<span style="font-family: "Arial","sans-serif";">Pancreas yang disebut kelenjar ludah perut, adalah
kelenjar penghasil insulin yang terletak di belakang lambung. Di dalamnya
terdapat kumpulan sel yang berbentuk seperti pulau pada peta, karena itu
disebut pulau-pulau Langerhans yang berisi sel beta yang mengeluarkan hormone
insulin yang sangat berperan dalam mengatur kadar glukosa darah.</span></div>
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<span style="font-family: "Arial","sans-serif";">Insulin
adalah hormon utama yang mengatur penyerapan glukosa dari darah ke dalam
sel-sel yang paling (terutama otot dan sel lemak, tetapi tidak sel-sel sistem
saraf pusat). Oleh karena defisiensi insulin atau ketidakpekaan reseptor yang
memainkan peran sentral dalam semua bentuk diabetes mellitus. Sebagian besar
karbohidrat dalam makanan akan diubah dalam waktu beberapa jam untuk
monosakarida glukosa, karbohidrat utama yang ditemukan dalam darah dan
digunakan oleh tubuh sebagai bahan bakar. Pengecualian yang paling signifikan
adalah fruktosa, disakarida yang paling (kecuali sukrosa dan dalam beberapa
laktosa orang), dan semua polisakarida yang lebih kompleks, dengan pengecualian
yang beredar dari pati. Insulin dilepaskan ke dalam darah oleh sel-sel beta
(β-sel), ditemukan di pulau Langerhans di pankreas, sebagai respons terhadap
meningkatnya kadar glukosa darah, biasanya setelah makan. Insulin digunakan
oleh sekitar dua-pertiga dari sel-sel tubuh menyerap glukosa dari darah untuk
digunakan sebagai bahan bakar, untuk konversi ke molekul lain yang diperlukan,
atau untuk penyimpanan. </span><span style="font-family: "Arial","sans-serif";"></span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Insulin
juga sinyal kontrol utama untuk konversi glukosa menjadi glikogen untuk
penyimpanan internal dalam hati dan sel-sel otot. Menurunkan kadar glukosa
hasil baik dalam mengurangi pelepasan insulin dari sel beta dan dalam konversi
kebalikan dari glikogen menjadi glukosa bila kadar glukosa turun. Hal ini
terutama dikendalikan oleh hormon glukagon yang bertindak secara berlawanan
terhadap insulin. Glukosa sehingga pulih oleh hati kembali memasuki aliran
darah, sel otot kurangnya mekanisme ekspor yang diperlukan. Kadar insulin lebih
tinggi meningkatkan beberapa ("membangun") proses anabolik seperti
pertumbuhan sel dan duplikasi, sintesis protein, dan penyimpanan lemak. Insulin
(atau kurangnya) adalah sinyal utama dalam mengkonversi banyak proses
metabolisme bidirectional dari katabolik ke arah anabolik, dan sebaliknya.
Secara khusus, tingkat insulin rendah adalah pemicu untuk memasuki atau
meninggalkan ketosis (fase metabolisme pembakaran lemak). </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Jika
jumlah insulin yang tersedia tidak cukup, jika sel-sel merespon buruk terhadap
efek insulin (insulin ketidakpekaan atau perlawanan), atau jika insulin itu
sendiri rusak, maka glukosa tidak akan diserap dengan baik oleh sel-sel tubuh
yang memerlukannya dan tidak akan disimpan tepat di hati dan otot. Efek bersih
adalah tingkat tinggi terus-menerus dari glukosa darah, sintesis protein
miskin, dan derangements metabolik lainnya, seperti asidosis. </span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Kemungkinan
induksi diabetes tipe 2 dari berbagai macam kelainan hormonal, seperti hormon
sekresi kelenjar adrenal, hipofisis dan tiroid merupakan studi pengamatan yang
sedang laik daun saat ini. Sebagai contoh, timbulnya IGT dan diabetes mellitus
sering disebut terkait oleh akromegali dan hiperkortisolisme atau sindrom
Cushing.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Hipersekresi
hormon GH pada akromegali dan sindrom Cushing sering berakibat pada resistansi
insulin, baik pada hati dan organ lain, dengan simtoma hiperinsulinemia dan
hiperglisemia, yang berdampak pada penyakit kardiovaskular dan berakibat
kematian.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">GH
memang memiliki peran penting dalam metabolisme glukosa dengan menstimulasi
glukogenesis dan lipolisis, dan meningkatkan kadar glukosa darah dan asam
lemak. Sebaliknya, <i>insulin-like growth factor 1</i> (IGF-I) meningkatkan
kepekaan terhadap insulin, terutama pada otot lurik. Walaupun demikian, pada
akromegali, peningkatan rasio IGF-I tidak dapat menurunkan resistansi insulin,
oleh karena berlebihnya GH.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Terapi
dengan somatostatin dapat meredam kelebihan GH pada sebagian banyak orang,
tetapi karena juga menghambat sekresi insulin dari pankreas, terapi ini akan
memicu komplikasi pada toleransi glukosa.</span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> </span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Sedangkan
hipersekresi hormon kortisol pada hiperkortisolisme yang menjadi penyebab
obesitas viseral, resistansi insulin, dan dislipidemia, mengarah pada
hiperglisemia dan turunnya toleransi glukosa, terjadinya resistansi insulin,
stimulasi glukoneogenesis dan glikogenolisis. Saat bersinergis dengan kofaktor
hipertensi, hiperkoagulasi, dapat meningkatkan risiko kardiovaskular.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Hipersekresi
hormon juga terjadi pada kelenjar tiroid berupa tri-iodotironina dengan
hipertiroidisme yang menyebabkan abnormalnya toleransi glukosa.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Pada
penderita tumor neuroendokrin, terjadi perubahan toleransi glukosa yang
disebabkan oleh hiposekresi insulin, seperti yang terjadi pada pasien bedah
pankreas, feokromositoma, glukagonoma dan somatostatinoma.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Hipersekresi
hormon ditengarai juga menginduksi diabetes tipe lain, yaitu tipe 1. Sinergi
hormon berbentuk sitokina, interferon-gamma dan TNF-α, dijumpai membawa sinyal
apoptosis bagi sel beta, baik <i>in vitro</i> maupun <i>in vivo</i>.Apoptosis
sel beta juga terjadi akibat mekanisme Fas-FasL,dan/atau hipersekresi molekul
sitotoksik, seperti granzim dan perforin; selain hiperaktivitas sel T CD8<sup>-</sup>
dan CD4<sup>-</sup>.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Beberapa factor yang dapat menyuburkan dan sering
merupakan factor pecetus diabetes mellitus adalah :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l28 level1 lfo15; tab-stops: list 14.2pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">kurang gerak/ malas</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l28 level1 lfo15; tab-stops: list 14.2pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">makanan berlebihan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l28 level1 lfo15; tab-stops: list 14.2pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">kekurangan produksi hormone insulin</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l28 level1 lfo15; tab-stops: list 14.2pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">penyakit hormone yang kerjanya berlawanan dengan
insulin.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Gejala dan Tanda-Tanda Awal</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Adanya penyakit diabetes ini pada awalnya seringkali
tidak dirasakan dan tidak disadari oleh penderita. Beberapa keluhan dan
gejala yang perlu mendapat perhatian ialah :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 21.3pt; margin-right: 0cm; margin-top: 0cm; mso-list: l49 level1 lfo16; text-align: justify; text-indent: 0cm;">
<b><span style="font-family: "Arial","sans-serif";">1.<span style="font: 7pt "Times New Roman";"> </span></span></b><b><span style="font-family: "Arial","sans-serif";">keluhan klasik
</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l48 level2 lfo20; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">1.1<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Penurunan berat badan (BB) dan rasa lemah</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Penurunan BB yang berlangsung dalam waktu relative
singkat harus menimbulkan kecurigaan. Rasa lemah hebat yang menyebabkan
penurunan prestasi di sekolah dan lapangan olah raga juga mencolok. Hal ini
disebabkan glukosa dalam darah tidak dapat masuk ke dalam sel, sehingga sel
kekurangan bahan bakar untuk menghasilkan tenaga. Untuk kelangsungan hidup,
sumber tenaga terpaksa diambil dari cadangan lain yaitu sel lemak dan otot.
Akibatnya penderita kehilangan jaringan lemak dan otot sehingga menjadi kurus.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l48 level2 lfo20; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">1.2<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Banyak kencing</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Karena sifatnya, kadar glukosa darah yang tinggi akan
menyebabkan banyak kencing. Kencing yang sering dan dalam jumlah banyak akan
sangat mengganggu penderita, terutama pada waktu malam hari.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l48 level2 lfo20; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">1.3<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Banyak minum</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Rasa haus amat sering dialami oleh penderita karena
banyaknya cairan yang keluar melalui kencing. Keadaan ini justru sering
disalahtafsirkan. Dikiranya sebab rasa haus ialah udara yang panas atau beban
kerja yang berat. Untuk menghilangkan rasa haus itu penderita minum banyak.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">1.4 Banyak makan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Kalori dari makanan yang dimakan, setelah
dimetabolisasikan menjadi glukosa dalam darah tidak seluruhnya dapat
dimanfaatkan, penderita selalu merasa lapar.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 21.3pt; margin-right: 0cm; margin-top: 0cm; mso-list: l49 level1 lfo16; text-align: justify; text-indent: 0cm;">
<b><span style="font-family: "Arial","sans-serif";">2.<span style="font: 7pt "Times New Roman";"> </span></span></b><b><span style="font-family: "Arial","sans-serif";">Keluhan Lain</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l33 level2 lfo21; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">2.1<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">gangguan saraf tepi/ kesemutan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">penderita mengeluh rasa sakit atau kesemutan terutama
pada kaki di waktu malam, sehingga mengganggu tidur.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l33 level2 lfo21; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">2.2<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">gangguan penglihatan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">pada fase awal penyakit diabetes sering dijumpai
gangguan penglihatan yang mendorong penderita untuk mengganti kacamatanya
berulang kali agar ia tetap dapat melihat dengan baik.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l33 level2 lfo21; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">2.3<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">gatal/bisul</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">kelainan kulit berupa gatal, biasanya terjadi di
daerah kemaluan atau daerah lipatan kulit seperti ketiak dan di bawah payudara.
Seringpula dikeluhkan timbulnya bisul dan luka yang lama sembuhya. Luka ini
dapat timbul akibat hal yang sepele seperti luka lecet karena sepatu atau
tertusuk peniti.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Diagnosis</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Apabila ditemukan gejala dan tanda-tanda seperti di
atas, sebaiknya segera pergi ke dokter untuk berkonsultasi. Diagnosis diabetes
mellitus hanya bisa ditegakkan setelah terbukti dengan pemeriksaan glukosa
darag. Pemeriksaan dengan air seni sering kurang dapat dipercaya karena
beberapa keadaan dapat menyebabkan negative maupun positif palsu.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Pengobatan</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Tujuan utama pengobatan diabetes mellitus yaitu :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; mso-list: l8 level1 lfo17; tab-stops: list 0cm 18.0pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Mengembalikan konsentrasi glukosa darah menadi
senormal mungkin agar penyandang DM
merasa nyaman dan sehat.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; mso-list: l8 level1 lfo17; tab-stops: list 0cm 18.0pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Mencegah atau memperlambat timbulnya komplikasi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; mso-list: l8 level1 lfo17; tab-stops: list 0cm 18.0pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Mendidik penderita dalam pengetahuan dan motivasi agar
dapat merawat sendiri penyakitnya sehingga mampu mandiri.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pokok-pokok
pengobatan :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; mso-list: l24 level1 lfo18; tab-stops: list 0cm 18.0pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Edukasi penyandang DM</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; mso-list: l24 level1 lfo18; tab-stops: list 0cm 18.0pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Mengatur makanan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; mso-list: l24 level1 lfo18; tab-stops: list 0cm 18.0pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Latihan jasmani</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l24 level1 lfo18; tab-stops: list 0cm 18.0pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Obat-obatan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l24 level1 lfo18; tab-stops: list 0cm 18.0pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Pemantauan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pengelolaan diabetes mellitus tanpa komplikasi akut
pada umumnya selalu dimulai dengan pengaturan makanan dan latihan jasmani dulu.
Apabila dengan pendekatan tersebut belum mencapai target yang diinginkan, baru
diberikan obat-obatan baik oral maupun suntikan sesuai indikasi.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Mengingat sifat diabetes mellitus yang menahun, tak
dapat dipungkiri bahwa edukasi yang terus menerus dan berkesinambungan menjadi
sangat penting. Pada akhirnya tujuan pengobatan diabetes mellitus harus
ditetapkan bersama antara penyandang DM dengan tim yang mengelola.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Komplikasi</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Betapa seriusnya penyakit diabetes yang menyerang
penyandang DM dapat dilihat pada setiap komplikasi yang ditimbulkannya. Lebih
rumit lagi, penyakit diabetes tidak menyerang satu alat saja, tetapi berbagai
komplikasi dapat diidap secara bersamaan yaitu :</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l31 level1 lfo19; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Jantung diabetes</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l31 level1 lfo19; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Ginjal diabetes</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l31 level1 lfo19; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Mata diabetes</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l31 level1 lfo19; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Saraf diabetes</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l31 level1 lfo19; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Kaki diabetes</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Pencegahan</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pencegahan pada diabetes mellitus sangat penting
mengingat sifat penyakitnya yang menahun dan bila telah timbul komplikasi,
biaya perawatannya sangat mahal.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Masyarakat perlu dilibatkan dalam program pencegahan
dan pengelolaan penyakit diabetes ini. Dengan pengetahuan yang memadai,
masyarakat dilibatkan dalam program skrining kasus baru terutama pada kelompok
risiko tinggi untuk timbulnya penyakit diabetes mellitus, disebut pencegahan
primer. Sementara itu untuk kelompok masyarakat yang telah menjadi penyandang
diabetes, dapat diajak melakukan pencegahan mandiri terhadap kemungkinan
timbulnya komplikasi, disebut pencegahan sekunder atau mencegah berlanjutnya
koomplikasi menjadi lebih buruk atau fatal, disebut pencegahan tersier. Dengan
program pencegahan pada tingkat manapun, akans angat membantu penyandang DM dan
keluarga serta masyarakat secara keseluruhan.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Penutup</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Memang penyakit diabetes tidak bisa disembuhkan,
kecuali beberapa jenis diabetes. Tetapi dengan kemauan keras, penyakit ini
dapat dikendalikan. Dengan berbekal pengetahuan yang cukup, disiplin dan
keinginan yang besar, maka penyakit diabetes ini bukan merupakan penyakit yang
menakutkan. Ibarat delman, penderita adalah kusir dan diabetes adalah kudanya.
Sepanjang pak kusir masih memegang kendalinya, selama itu pula kudanya akan
menuruti apa keinginan kusir. Dengan prinsip hidup yang positif, pada akhirnya
penyandang DM dapat hidup bahagia bersama diabetes, seperti orang lain
berbahagia tanpa diabetes.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.2<span style="font: 7pt "Times New Roman";"> </span></span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";"> DEFENISI DAN KLASIFIKASI </span></b><b><span style="font-family: "Arial","sans-serif";">DIABETES MELITUS</span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></b></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.2.1<span style="font: 7pt "Times New Roman";"> </span></span></b><b><span style="font-family: "Arial","sans-serif";">PENGERTIAN</span></b><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<span style="font-family: "Arial","sans-serif";">Diabetes
melitus adalah gangguan metabolisme yang secara genetis dan klinis termasuk
heterogen dengan manifestasi berupa hilangnya toleransi karbohidrat. Jika
berkembang penuh secara klinis, maka diabetes melitus di tandai dengan
hiperglikemia puasa dan postprandial,aterosklerotikdan penyakit vaskular
mikroangiopati dan <span class="textexposedshow">neuropati.Manifestasi klinis
biasanya sudah bertahun-tahun mendahului timbulnya kelainan toleransi glukosa
ringan(penggangguan glukosa puasa dan gangguan toleransi glukosa)dapat tetap
berisiko mengalami komplikasi metabolik diabetes.</span></span><span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></span></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.2.2<span style="font: 7pt "Times New Roman";"> </span></span></b><span class="textexposedshow"><b><span style="font-family: "Arial","sans-serif";">KLASIFIKASI
DIABETES MELITUS</span></b></span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">Beberapa klasifikasi diabetes melitus telah
diperkenalkan, berdasarkan metode presentasi klinis, umur awitan, dan riwayat
penyakit. Klasifikasi yang diperkenalkan oleh American Diabetes Association
(ADA) berdasarkan pengetahuan mutakhir mengenai patonegesis sindrom diabetes
dan gangguan toleransi glukosa. Klasifikasi ini telah disahkan oleh world
health organization (WHO) dan telah dipakai seluruh dunia. Empat klasifikasi
klinis gangguan toleransi glukosa:</span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";">1.<span style="font: 7pt "Times New Roman";">
</span></span></span><span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">Diabetes melitus tipe 1</span></span><span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></span></div>
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<span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.<span style="font: 7pt "Times New Roman";">
</span></span></span><span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">Diabetes melitus tipe 2</span></span><span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></span></div>
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<span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";">3.<span style="font: 7pt "Times New Roman";">
</span></span></span><span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">Diabetes gestasional (diabetes
kehamilan )</span></span><span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></span></div>
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<span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";">4.<span style="font: 7pt "Times New Roman";">
</span></span></span><span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">Tipe khusus lain</span></span><span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></span></div>
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<span style="font-family: "Arial","sans-serif";"><br />
<span class="textexposedshow">Dua kategori lain dari toleransi glukosa abnormal
adalah gangguan toleransi glukosa dan gangguan glukosa puasa.</span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">1) Diabetes tipe 1 dulu dikenal sebagai tipe
juvenileonset dan tipe dependen insulin; namun, kedua tipe ini dapat muncul
pada sembarang usia. Insidens diabetes tipe 1 sebannyak 30.000 kasus baru
setiap tahunnya dan dapat dibagi dalam dua subtipe:</span></span><span style="font-family: "Arial","sans-serif";"><br />
<span class="textexposedshow">a. Autoimun, akibat disfungsi autoimun dengan
kerusakan sel-sel beta </span><br />
<span class="textexposedshow">b. Idiopatik, tampa bukti adanya autoimun dan tidak
diketahui sumbernya. </span><br />
<span class="textexposedshow">2) Diabetes tipe 2 dulu dikenal sebagai tipe dewasa
atau tipe onset maturitas dan tipe nondependen insulin. Insidens diabetes tipe
2 sebesar 650.000 kasus baru setiap tahunnya. Obesitas sering dikaitkan dengan
penyakit ini.</span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">3) Diabetes gestasional (GDM) dikenali pertama kali
kehamilan dan mempengaruhi 4% dari semua kehamilan. Faktor resiko terjadinya
GDM adalah usia tua, etnik, obesitas, multiparitas, riwayat keluarga, dan
riwayat diabetes gestasiona terdahulu. Karena peningkatan sekresi berbagai
hormon yang mempunyai efek metabolik terhadap toleransi glukosa, maka kehamilan
adalah suatu keadaan diabetogenik. Pasien pasien yang mempunyai predisposisi
diabetes secara genetik mungkin akan memerlihatkan intoleransi glukosa atau
manifestasi klinis diabetes pada kehamilan. Kriteria diagnosis biokimia
diabetes kehamilan yang dianjurkan adalah kriteria yang di usulkan oleh O’sullivan
dan mahan (1973). Menurut kriteria ini, GDM terjadi apabila dua atau lebih dari
nilai berikut ini ditemukan atau dilampaui sesudah pemberian 75 g glukosa oral
: puasa 105 mg/dl ; 1 jam, 190 mg/dl; 2 jam, 165 mg/dl; 3 jam, 145 mg/dl.
Pengenalan diabetes seperti ini penting karena penderita beresiko tinggi
terhadap morbiditas dan mortalitas perinatal dan mempunyai frekuensi kematian.
Janin viabel yang lebih tinggi. Kebanyakan perempuan hamil harus menjalani
penapisan untuk diabetes selama usia kehamilan 24 minggu hingga 28 minggu.</span></span><span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></span></div>
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<span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">4) Tipe kasus lain adalah :</span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";">a)<span style="font: 7pt "Times New Roman";"> </span></span></span><span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">Kelainan
genetik dalam sel beta seperti yang dikenali pada MODY. Diabetes subtipe ini
memiliki prevalensi familial yang tinggi dan bermanifestasi sebelum usia 14
tahun. Pasien sering kali obesitas dan resistem terhadap insulin. Kelainan
genetik telah dikenali dengan baik dalam empat bentuk mutasi dan fenotif yang
berbeda (MODY 1, MODY 2, MODY 3, MODY 4 )</span></span><span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></span></div>
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<span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";">b)<span style="font: 7pt "Times New Roman";"> </span></span></span><span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">Kelainan
genetik pada kerja insulin,menyebabkan sindrome resistensi insulin berat dan
akantosis negrikans</span></span><span class="textexposedshow"><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></span></div>
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<span lang="EN-US" style="font-family: "Arial","sans-serif";">c)<span style="font: 7pt "Times New Roman";"> </span></span><span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">Penyakit
pada eksokrin pankreas menyebabkan pankreatitis kronik</span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<span lang="EN-US" style="font-family: "Arial","sans-serif";">d)<span style="font: 7pt "Times New Roman";"> </span></span><span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">Penyakit
endokrin seperti sindrome cushing dan akromegali </span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<span lang="EN-US" style="font-family: "Arial","sans-serif";">e)<span style="font: 7pt "Times New Roman";"> </span></span><span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">Obat-obat
yang bersifat toksik terhadap sel-sel beta</span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<span lang="EN-US" style="font-family: "Arial","sans-serif";">f)<span style="font: 7pt "Times New Roman";"> </span></span><span class="textexposedshow"><span style="font-family: "Arial","sans-serif";">infeksi</span></span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<b><span lang="EN-US" style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">2.3 </span></b><b><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">ETIOLOGI </span></b><b><span lang="EN-US" style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">DAN EPIDEMIOLOGI </span></b><b><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">DIABETES
MELLITUS</span></b></div>
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<b><span lang="EN-US" style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">2.3.1 ETIOLOGI</span></b></div>
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<span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Penyebab diabetes yang utama adalah</span></div>
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<span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">1.</span><span lang="EN-US" style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> </span><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">DM type I.
atau disebut DM yang tergantung pada insulin. DM ini disebabkan akibat
kekurangan insulin dalam darah yang terjadi karena kerusakan dari sel beta
pancreas. Gejala yang menonjol adalah terjadinya sering kencing (terutama malam
hari), sering lapar dan sering haus, sebagian besar penderita DM type ini berat
badannya normal atau kurus. Biasanya terjadi pada usia muda dan memerlukan
insulin seumur hidup. </span></div>
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<span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">2. </span><span lang="EN-US" style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> </span><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">DM type II atau disebutDM yang tidak tergantung pada insulin.
DM ini disebabkan insulin yang ada tidak dapat bekerja dengan baik, kadar
insulin dapat normal, rendah atau bahkan meningkat tetapi fungsi insulin untuk
metabolisme glokosa tidak ada/ kurang . Akibatnya glukosa dalam darah tetap
tinggi sehingga terjadi hiperglikemia, 75 % dari penderita DM type II dengan
obesitas atau sangat kegemukan dan biasanya diketahui DM setelah usia 30 tahun. </span><span lang="EN-US" style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif";">Namun jika dirunut lebih lanjut, ada
beberapa faktor yang menyebabkan DM sebagai berikut:</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<b><span style="font-family: "Arial","sans-serif";">1.<span style="font: 7pt "Times New Roman";">
</span></span></b><b><span style="font-family: "Arial","sans-serif";">Genetik
atau faktor keturunan</span></b></div>
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<span style="font-family: "Arial","sans-serif";">DM sering diturunkan atau diwariskan,
bukan ditularkan. Anggota keluarga</span></div>
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<span style="font-family: "Arial","sans-serif";">penderita DM memiliki kemungkinan
lebih besar terserang penyakit ini</span></div>
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<span style="font-family: "Arial","sans-serif";">dibandingkan dengan anggota keluarga
yang tidak menderita DM. Para ahli</span></div>
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<span style="font-family: "Arial","sans-serif";">kesehatan juga menyebutkan DM
merupakan penyakit yang terpaut kromosom</span></div>
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<span style="font-family: "Arial","sans-serif";">seks atau kelamin. Biasanya kaum
laki-laki menjadi penderita sesungguhnya,</span></div>
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<span style="font-family: "Arial","sans-serif";">sedangkan kaum perempuan sebagai pihak
yang membawa gen untuk diwariskan</span></div>
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<span style="font-family: "Arial","sans-serif";">kepada
anak-anaknya (Maulana, Mirza:2008).</span></div>
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<b><span style="font-family: "Arial","sans-serif";">2.<span style="font: 7pt "Times New Roman";">
</span></span></b><b><span style="font-family: "Arial","sans-serif";">Virus
dan bakteri</span></b></div>
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<span style="font-family: "Arial","sans-serif";">Virus penyebab DM adalah rubella,
mumps, dan human coxsackievirus B4. Melalui</span></div>
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<span style="font-family: "Arial","sans-serif";">mekanisme infeksi sitolitik dalam sel
beta. Virus ini mengakibatkan destruksi atau</span></div>
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<span style="font-family: "Arial","sans-serif";">perusakan sel. Bisa juga, virus ini
menyerang melalui reaksi autoimunitas yang</span></div>
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<span style="font-family: "Arial","sans-serif";">menyebabkan hilangnya otoimun dalam
sel beta. Sedangkan bakteri masih belum</span></div>
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<span style="font-family: "Arial","sans-serif";">bisa dideteksi, tapi menurut ahli
mengatakan bahwa bakteri juga berperan penting</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">menjadi
penyebab timbulnya DM (Maulana, Mirza, 2008).</span></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">3.<span style="font: 7pt "Times New Roman";"> </span></span></b><b><span style="font-family: "Arial","sans-serif";">Pola makan</span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">Makan
secara berlebihan dan melebihi jumlah kadar kalori yang dibutuhkan oleh tubuh
dapat memacu timbulnya diabetes mellitus. konsumsi makan yang berlebihan dan
tidak diimbangi dengan sekresi insulin dalam jumlah yang memadai dapat
menyebabkan kadar gula dalam darah meningkat dan pastinya akan menyebabkan
diabetes melitus.Atau bisa juga dari konsumsi makanan dan minuman yang tidak
bersih dan di masak secara sembarangan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">4.Obesitas(kegemukan</span></b><span style="font-family: "Arial","sans-serif";">)<br />
Orang gemuk dengan berat badan lebih dari 90 kg cenderung memiliki peluang
lebih besar untuk terkena penyakit diabetes militus. Sembilan dari sepuluh
orang gemuk berpotensi untuk terserang diabetes mellitus.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">5.
Bahan-bahan kimia dan obat-obatan</span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Bahan-bahan
kimia dapat mengiritasi pankreas yang menyebabkan radang pankreas, radang pada
pankreas akan mengakibatkan fungsi pankreas menurun sehingga tidak ada sekresi
hormon-hormon untuk proses metabolisme tubuh termasuk insulin. Segala jenis
residu obat yang terakumulasi dalam waktu yang lama dapat mengiritasi pankreas.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 21.3pt; margin-right: 0cm; margin-top: 0cm; mso-list: l8 level2 lfo17; text-align: justify; text-indent: 0cm;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">6.<span style="font: 7pt "Times New Roman";"> </span></span></b><b><span style="font-family: "Arial","sans-serif";">Penyakit dan infeksi pada pankreas</span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Infeksi
mikroorganisme dan virus pada pankreas juga dapat menyebabkan radang pankreas
yang otomatis akan menyebabkan fungsi pankreas turun sehingga tidak ada sekresi
hormon-hormon untuk proses metabolisme tubuh termasuk insulin. Penyakit seperti
kolesterol tinggi dan dislipidemia dapat meningkatkan resiko terkema diabetes
mellitus.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 21.3pt; margin-right: 0cm; margin-top: 0cm; mso-list: l8 level2 lfo17; text-align: justify; text-indent: 0cm;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">7.<span style="font: 7pt "Times New Roman";"> </span></span></b><b><span style="font-family: "Arial","sans-serif";">Pola hidup</span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pola
hidup juga sangat mempengaruhi faktor penyebab diabetes mellitus. Jika orang
malas berolah raga memiliki resiko lebih tinggi untuk terkena penyakit diabetes
mellitus karena olah raga berfungsi untuk membakar kalori yang berlebihan di
dalam tubuh. Kalori yang tertimbun di dalam tubuh merupakan faktor utama
penyebab diabetes mellitus selain disfungsi pankreas.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Dan karena Faktor Kebiasaan seperti :</span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></b></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l15 level1 lfo23; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Mengkonsumsi Teh manis</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l15 level1 lfo23; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Gorengan</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l15 level1 lfo23; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Suka ngemil</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l15 level1 lfo23; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Kurang tidur.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l25 level1 lfo24; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Sering stres</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l25 level1 lfo24; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Kecanduan rokok</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l25 level1 lfo24; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Menggunakan pil kontrasepsi</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l25 level1 lfo24; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Keranjingan soda</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.3.2 </span></b><b><span style="font-family: "Arial","sans-serif";">EPIDEMIOLOGI DIABETES MELITUS</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pola
penyakit saat ini dapat di pahami dalam rangka transisi epidemiologis,suatu
konsep mengenai perubahan pola kesehatan dan penyakit. Konsep tersebut hendak
mencoba menghubungkan hal-hal tersebut dengan morbiditas dan mortalitas pada
beberapa golongan penduduk dan menghubungankannya dengan faktor sosial ekonomi serta
demografi masyarakat masing-masing .</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Dikenal
3 periode dalam transisi epidemiologis.hal tersebut terjadi tidak saja di
indonesia tetapi juga di negara-negara lain yang sedang berkembang.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Periode
I</span></b><span style="font-family: "Arial","sans-serif";">.Era pestilence dan
kelaparan.Dengan kedatangan orang-orang barat ke Asia pada akhir abad ke
15,datang pula penyakit-penyakit menular seperti
pes,kolera,influenza,tuberkulosis dan penyakit kelamin,yang meningkatkan angka
kematian.harapan hidup bayi-bayi rendah dan pertambahan penduduk juga sangat
rendah pada waktu itu.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Periode
II</span></b><span style="font-family: "Arial","sans-serif";">.pandami berkurang
pada akhir abad ke 19.dengan perbaikan gizi,higiene serta sanitasi,penyakit
menular menular berkurang dan mortalitas menurun.rata-rata harapan hidup pada
waktu lahir meningkat dan jumlah penduduk sepeti di pulau jawa nampak
bertambah.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Periode
III.</span></b><span style="font-family: "Arial","sans-serif";">periode ini
merupakan era penyakit degeneratif dan pencemaran.karena komunikasi yang lebih
baik dengan masyarakat barat serta adopsi cara kehidupan
barat,penyakit-penyakit degeneratif,seperti hipertensi,penyakit kordiovaskular
dan diabetes melitus meningkat.tetapi apabila kontak dengan barat kurang dan
masih terdapat kehidupan tradisional,seperti di daerah perdesaan
penyakit-penyakit tersebut umumnya jarang di temukan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Dari
penelitian Zimmet (1978) dapat di dilihat bahwa beberapa golongan etnik
mempunyai semacam proteksi terhadap efek buruk pengaruh barat.antara lain
bangsa melanesia dan eskimo.Di samudera pasifik,diabetes melitus sangat jarang
terdapat pada </span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">orang
polinesia yang masih melakukan gaya hidup tradisional, beda dengan daerah urban
seperti mikronesia,guam,Nauru dan negara-negara polinesia seperti
tonga,hawai,tahiti,di mana jumlah pasien diabetes sangat tinggi.begitu pula
banyak penilitian yang menunjukkan adanya kenaikan prevalensi diabetes pada
penduduk emigran seperti pada orang yahudi yang berasal dari yaman dan pindah
ke israel,masyarakat india di afrika selatan,orang indian di Amerika serikat
dan penduduk asli australia yang ber “migrasi”ke daerah perkotaan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Sebagai
dampak positif pembangunan yang di laksanakan oleh pemerintah dalam kurun waktu
60 tahun merdeka,pola penyakit di indonesia mengalami pergeseran yang cukup
menyakinkan . penyakit infeksi dan kekurangan gizi berangsur turun,meskipun di
akui bahwa angka penyakit infeksi ini masih di pertanyakan dengan timbulnya
penyakit baru seperti Hepatitis B dan AIDS,juga angka kesakitan TBC yang
tampaknya masih tinggi.dan akhir-akhir ini flu burung,demam berdarah dengue
(DBD),antraks dan polio melanda negara kita yang kita cintai ini.di lain pihak
penyakit menahun yang di sebabkan oleh penyakit degeneratif,di antaranya
diabetes meningkat dengan tajam.perubahan pola penyakit itu di duga ada
hubungan dengan cara hidup yang berubah.pola makan di kota-kota telah bergeser
dari pola makan tradisional yang mengandung banyak karbohidrat dan serat dari
sayuran,ke pola makan ke barat-baratan,dengan komposisi makanan yang terlalu
banyak mengandung protein,lemak,gula,garam dan mengandung sedikit
serat.komposisi makanan seperti ini terutama terdapat pada makanan siap santap
yang akhir-akhir ini sangat di gemari terutama oleh anak-anak muda.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Disamping
itu cara hidup yang sangat sibuk dengan pekerjaan dari pagi smpai sore bahkan
kadang-kadang sampai malam hari duduk dibelakang meja menyebabkantidak adanya
kesempatan untuk berekreasi atau olahraga,apalagi bagi para eksekutif hampir
tiap hari harus lunch atau dinner dengan cara relasinya dengan menu makanan
barat yang “aduhai”. Pola <b>hidup beresiko</b> inilah yang menyebabkan
tingginya kekerapan penyakit jantung koroner (pjk), hipertensi, diabetes,
hiperdilemia.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Menarik
sekali apa yang dimuat dalam majalah fortune edisi bulan juni 1991yang
menganalis perkembangan ekonomi di Asia. Dikatakan bahwa perkembangan ekonomi
dikawasan ini sangat menggembirakan. Yang aneh tapi nyata adalah di antara parame</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">ter
untuk mengukur kemajuan ekonomi itu adalah jumlah restoran McDonald. Di
Thailand ada 6 buah, di Malaysia 23 buah, di Singapura ada 37 buah, di
Filippina 34 buah dan di Jepang 809 buah dan dua negara yang mempunyai hanya 1
buah restoran McDonald di Indonesia dan Cina. Pada Tahun 1996 hanya dalam waktu
5 tahun saja di Indonesia sudah ada 40 gerai. 33 di antaranya berada di
Jakarta. Data terakhir tahun 2006 jumlah restoran McDonald di Indonesia sudah
mencapai 120 gerai. Akibat lain dari cara hidup beresiko ini adalah biaya
kesehatan lebih sangat mahal. Sebagai contoh, dapat dikemukakan angka-angka
dibawah ini. Di Massachussetts AS, seorang laki-laki berumur 80 Tahun dirawat
karena sakit jantung. Biaya perawatannya mencapai 800.000 Dolar. Masyarakat AS
memang mulai gelisah menghadapi biaya kesehatan yang makin membengkak ini.
Anggaran biaya kesehatan tahun 1991 di negara ini mencapai 671 miliar dollar
(12% GNP AS). Anehnya adalah, meskipun
sudah sedemikian besarnya biaya yang dikeluarkan,taraf ksehatan mereka tidak
lebih baik dibanding negara maju lain, seperti Kanada, Inggris, Jerman, Swedia,
dan Jepang. Keadaan ini dapat dilihat pada angka </span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">kematian
bayi (tiap 1000 kelahiran) misalnya AS 10,4, jauh lebih tinggi daripada di
Kanada 7,3, di Inggris 7,3, Jerman 5,6, Swedia 5,9, dan Jepang 4,5. Begitu
dengan usia harapan hidup di AS baru mencapai 75,6 tahun, sedangkan di Kanada
79,2 tahun, Inggris 76,3 tahun, Jerman 77,2 tahun, Swedia 77,7 tahun dan Jepang
79,3 tahun. Ironisnya adalah bahwa biaya kesehatan di negara-negara itu lebih
murah.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Diakui
bahwa perkembangan ilmu dan teknologi kedokteran telah banyak menyelamatkan
nyawa manusia. Penyakit-penyaqkit yang selama ini tidah terdiagnosis dan
terobati sekarang sudah banyak yang teratasi. Tetapi untuk memperbaiki taraf
kesehatan secara global tidak dapat mangandalkan hanya pada tindakan kuratif,
karena penyakit-penyakit yang memerlukan biaya mahal itu sebagian besar dapat
mencegah dengan<b> pola hidup sehat </b>dan menjauhi<b> pola hidup beresiko</b>.
Artinya para pengambil kebijakan harus mempertimbangkan untuk mngalokasikan
dana kesehatan yang lebih menekan kepada segi preventif daripada kuratif.
Rupanya inilah keunggulan negara-negara maju di luar AS yang td tersebut.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Selain
itu tingkat prevalensi dari diabetes melitus adalah tinggi.Diduga terdapat
sekitar 10 juta kasus diabetes di Amerika serikat dan setiap tahunnya
didiagnosis 600.000 kasus baru.Diabetes merupakan penyebab kematian ke tiga di
amerika serikat dan merupakan penyebab utama ke butaan akibat retinopati diabetik.pada
usia yang sama,penderita diabetes paling sedikit 2 ½ kali lebih sering terkena
serangan jantung dibandingkan dengan mereka yang tidak menderita diabetes.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Tujuh
puluh lima persen penderita diabetes akhirnya meninggal karena penyakit
vaskular.komplikasi yang paling utama adalah serangan jantung,payah
ginjal,stroke dan gangren.selain itu,kematian neonatal intrauterin pada ibu-ibu
yang menderita diabetes meningkat.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Dampak
ekonomi pada diabetes jelas terlihat akibat biaya pengobatan dan hilangnya
pendapatan,di samping konsekuensi finansial karena banyaknya komplikasi seperti
kebutaan dan penyakit vaskular.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";"> </span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.4 </span></b><b><span style="font-family: "Arial","sans-serif";">Tanda dan Gejala, Pemeriksaan Fisik</span></b><b><span style="font-family: "Arial","sans-serif";"> </span></b><b><span style="font-family: "Arial","sans-serif";">dan Pemeriksaan Penunjang Diabetes
Mellitus</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span class="fullpost"><b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.4.</span></b></span><span class="fullpost"><b><span style="font-family: "Arial","sans-serif";">1. Tanda dan Gejala</span></b></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span class="fullpost"><span style="font-family: "Arial","sans-serif";">Tanda
awal yang dapat diketahui bahwa seseorang menderita DM atau kencing manis yaitu
dilihat langsung dari efek peningkatan kadar gula darah, dimana peningkatan
kadar gula dalam darah mencapai nilai 160 - 180 mg/dL dan air seni (urine)
penderita kencing manis yang mengandung gula (glucose), sehingga urine sering
dilebung atau dikerubuti semut.</span></span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span class="fullpost"><span style="font-family: "Arial","sans-serif";">Penderita
kencing manis umumnya menampakkan tanda dan gejala dibawah ini meskipun tidak
semua dialami oleh penderita :</span></span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l35 level1 lfo33; tab-stops: 18.0pt; text-align: justify; text-indent: 0cm;">
<span class="fullpost"><span style="font-family: "Arial","sans-serif";">1.<span style="font: 7pt "Times New Roman";"> </span></span></span><span class="fullpost"><span style="font-family: "Arial","sans-serif";">Jumlah urine yang
dikeluarkan lebih banyak (Polyuria</span></span><span class="fullpost"><span lang="EN-US" style="font-family: "Arial","sans-serif";">)</span></span><span class="fullpost"><b><span style="font-family: "Arial","sans-serif";"></span></b></span></div>
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<span style="font-family: "Arial","sans-serif";">2.<span style="font: 7pt "Times New Roman";"> </span></span><span class="fullpost"><span style="font-family: "Arial","sans-serif";">Sering atau cepat
merasa haus/dahaga (Polydipsia)</span></span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">3.<span style="font: 7pt "Times New Roman";"> </span></span><span class="fullpost"><span style="font-family: "Arial","sans-serif";">Lapar yang
berlebihan atau makan banyak (Polyphagia)</span></span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">4.<span style="font: 7pt "Times New Roman";"> </span></span><span class="fullpost"><span style="font-family: "Arial","sans-serif";">Frekwensi urine
meningkat/kencing terus (Glycosuria)</span></span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">5.<span style="font: 7pt "Times New Roman";"> </span></span><span class="fullpost"><span style="font-family: "Arial","sans-serif";">Kehilangan berat
badan yang tidak jelas sebabnya</span></span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">6.<span style="font: 7pt "Times New Roman";"> </span></span><span class="fullpost"><span style="font-family: "Arial","sans-serif";">Kesemutan/mati
rasa pada ujung syaraf ditelapak tangan & kaki</span></span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">7.<span style="font: 7pt "Times New Roman";"> </span></span><span class="fullpost"><span style="font-family: "Arial","sans-serif";">Cepat lelah dan
lemah setiap waktu</span></span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">8.<span style="font: 7pt "Times New Roman";"> </span></span><span class="fullpost"><span style="font-family: "Arial","sans-serif";">Mengalami rabun
penglihatan secara tiba-tiba</span></span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">9.<span style="font: 7pt "Times New Roman";"> </span></span><span class="fullpost"><span style="font-family: "Arial","sans-serif";">Apabila
luka/tergores (korengan) lambat penyembuhannya</span></span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">10.<span style="font: 7pt "Times New Roman";"> </span></span><span class="fullpost"><span style="font-family: "Arial","sans-serif";">Mudah terkena
infeksi terutama pada kulit.</span></span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span class="fullpost"><span style="font-family: "Arial","sans-serif";">Kondisi
kadar gula yang drastis menurun akan cepat menyebabkan seseorang tidak sadarkan
diri bahkan memasuki tahapan koma. Gejala kencing manis dapat berkembang dengan
cepat waktu ke waktu dalam hitungan minggu atau bulan, terutama pada seorang
anak yang menderita penyakit diabetes mellitus tipe 1.</span></span><span style="font-family: "Arial","sans-serif";"></span></div>
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<span class="fullpost"><span style="font-family: "Arial","sans-serif";">Lain
halnya pada penderita diabetes mellitus tipe 2, umumnya mereka tidak mengalami
berbagai gejala diatas. Bahkan mereka mungkin tidak mengetahui telah menderita
kencing manis.</span></span><span class="fullpost"><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></span></div>
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<b><span style="font-family: "Arial","sans-serif";">Gejala
paling umum yang berhubungan dengan diabetes tipe 1 adalah:</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
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<span style="font-family: "Arial","sans-serif";">1.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif";">Mudah lelah</span></div>
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<span style="font-family: "Arial","sans-serif";">2.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif";">Sering kencing</span></div>
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<span style="font-family: "Arial","sans-serif";">3.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif";">Sering haus walaupun sudah minum</span></div>
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<span style="font-family: "Arial","sans-serif";">4.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif";">Sering merasa lapar</span></div>
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<span style="font-family: "Arial","sans-serif";">5.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif";">Berat badan meningkat</span></div>
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<span style="font-family: "Arial","sans-serif";">Sangat
mudah untuk memahami gejala-gejala diabetes tipe 1. Lapar, berat badan dan
kelelahan adalah gejala yang menunjukan ketidakmampuan tubuh dalam mengolah
glukosa menjadi energi. Sering kencing dan kehausan terjadi, karena ini
merupakan cara tubuh Anda untuk dapat membuang kelebihan glukosa melalui
kandung kemih.</span></div>
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<b><span style="font-family: "Arial","sans-serif";">Gejala
paling umum yang berhubungan dengan diabetes tipe 2 adalah:</span></b></div>
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<span style="font-family: "Arial","sans-serif";">Sekitar
90% penderita </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; text-decoration: none;">diabetes</span></a><span style="font-family: "Arial","sans-serif";">
menderita </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; text-decoration: none;">diabetes
tipe-2</span></a><span style="font-family: "Arial","sans-serif";">. </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; text-decoration: none;">Diabetes</span></a><span style="font-family: "Arial","sans-serif";"> sering disebut </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; text-decoration: none;">silent killer </span></a><span style="font-family: "Arial","sans-serif";">karena memiliki </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; text-decoration: none;">gejala </span></a><span style="font-family: "Arial","sans-serif";">yang samar. Jika Anda memiliki </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; text-decoration: none;">gejala-gejala</span></a><span style="font-family: "Arial","sans-serif";"> seperti berikut, segera periksakan
diri ke pusat layanan </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; text-decoration: none;">kesehatan</span></a><span style="font-family: "Arial","sans-serif";">
atau </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; text-decoration: none;">dokter</span></a><span style="font-family: "Arial","sans-serif";">:</span></div>
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<b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">1.<span style="font: 7pt "Times New Roman";">
</span></span></b><a href="http://kalayan.wordpress.com/"><b><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">Sering buang air
kecil dan haus berlebihan</span></b></a><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></b></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Sering
terbangun malam hari untuk buang air kecil bisa menjadi </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">gejala diabetes</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.
Pada kondisi ini, </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">ginjal</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
bekerja sangat aktif untuk menyingkirkan kelebihan </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">glukosa</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> dalam </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">darah</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">. Sedang rasa haus yang berlebihan
adalah respon tubuh untuk mengisi cairan yang hilang akibat sering buang air
kecil. Kedua gejala ini berjalan seiring sebagai mekanisme tubuh untuk </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">menurunkan kadar gula darah</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">2.<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Kehilangan berat badan</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">Kadar gula darah yang tinggi</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
bisa menyebabkan penurunan berat badan yang cepat, katakanlah 5-10 kilo selama
dua atau tiga bulan (tapi ini bukan penurunan berat badan yang sehat). Karena </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">hormon insulin</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> tidak mampu mengirim </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">glukosa </span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">ke dalam sel untuk digunakan
sebagai energi, tubuh mulai memecah protein dari otot-otot sebagai sumber
energi alternatif. </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">Ginjal</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
juga bekerja ekstra untuk menghilangkan </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">kelebihan gula</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">, dan menyebabkan kehilangan
kalori yang dapat </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">membahayakan ginjal</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.</span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">3.<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Kelaparan</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Rasa
lapar berlebihan adalah </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">tanda lain dari
diabetes</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">. Ini terjadi akibat </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">kadar gula yang tinggi</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> namun tidak dapat
masuk ke dalam sel untuk digunakan dalam </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">proses metabolisme</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">. Ketika kadar gula darah
tidak dapat masuk ke dalam sel, tubuh berpikir belum mendapatkan asupan makanan
sehingga mengirim sinyal lapar untuk mendapatkan </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">glukosa</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> lebih banyak agar sel-sel
dapat berfungsi.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">4.<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Masalah kulit</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Kulit
gatal, dan kering, bisa menjadi </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">tanda diabetes</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.
Contoh lain adalah <i><span style="font-family: "Arial","sans-serif";">acanthosis
nigricans</span></i> yaitu penggelapan kulit di sekitar leher atau ketiak.
Orang yang memiliki kondisi ini sudah mengalami proses </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">resistensi insulin </span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">meskipun </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">gula darah</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> mereka mungkin tidak
tinggi.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">5.<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Penyembuhan luka yang lambat</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">Infeksi</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">, luka, dan memar yang tidak
kunjung sembuh adalah </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">tanda klasik
diabetes</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">. Hal ini terjadi karena </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">pembuluh darah vena </span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">dan arteri rusak
akibat jumlah </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">glukosa berlebih</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">. </span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Kondisi
ini membuat </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">darah</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
sulit menjangkau daerah-daerah tubuh yang luka untuk memfasilitasi proses </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">penyembuhan</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">6.<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Infeksi jamur</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">Diabetes</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> akan </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">menurunkan sistem kekebalan tubuh</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
secara umum. Tubuh menjadi </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">rentan</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
terhadap berbagai </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">infeksi</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">,
termasuk </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">infeksi</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
paling umum seperti </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">jamur</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
(candida). Jamur dan bakteri mampu berkembang biak pesat di lingkungan yang </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">kaya gula</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">. Perempuan, khususnya,
perlu waspada terhadap </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">infeksi candida</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
seperti </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">keputihan</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">7.<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Kelelahan dan mudah marah</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Orang
yang memiliki </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">kadar gula darah
tinggi</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">, umumnya akan merasa tidak enak badan. Sering terbangun
di malam hari untuk berkemih, akan membuat badan tidak segar keesokan harinya.
Kondisi inilah yang membuat orang tersebut </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">menjadi lelah</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> dan </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">mudah marah</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">8.<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Penglihatan kabur</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<a href="http://kalayan.wordpress.com/" target="_blank"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">Penglihatan yang kabur</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
atau sesekali </span><a href="http://kalayan.wordpress.com/" target="_blank"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">seperti melihat
cahaya</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> berkedip merupakan </span><a href="http://kalayan.wordpress.com/" target="_blank"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">akibat</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
langsung dari </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">kadar gula darah
tinggi</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">. </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">Kadar glukosa tinggi</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
mampu </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">mengubah bentuk lensa dan mata</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.
Kabar baiknya gejala ini </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">reversibel</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
(bisa kembali normal) saat </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">kadar gula darah</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
kembali atau mendekati </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">normal</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.
Namun, </span><a href="http://kalayan.wordpress.com/" target="_blank"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">kadar gula</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
yang tidak terkontrol akan menyebabkan </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">kerusakan permanen</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">, bahkan </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">kebutaan</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">9.<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Kesemutan atau mati rasa</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<a href="http://kalayan.wordpress.com/" target="_blank"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">Kesemutan</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> dan
mati rasa di tangan dan kaki, bersama dengan </span><a href="http://kalayan.wordpress.com/" target="_blank"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">rasa sakit terbakar</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
atau bengkak merupakan </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">tanda-tanda </span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">bahwa
</span><a href="http://kalayan.wordpress.com/" target="_blank"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">saraf</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
sedang dirusak oleh </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">diabetes</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.
Jika dibiarkan, kondisi ini dapat </span><a href="http://kalayan.wordpress.com/" target="_blank"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">menyebabkan</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">neuropati</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">(kerusakan saraf) </span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">permanen.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">10.<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Hasil tes </span></b><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">darah</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Beberapa
metode tes dapat digunakan untuk memeriksa </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">diabetes</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">, tapi hasil </span><a href="http://kalayan.wordpress.com/" target="_blank"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">tes tunggal</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
tidak pernah cukup untuk </span><a href="http://kalayan.wordpress.com/" target="_blank"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">mendiagnosa</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">diabetes</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> (tes harus diulang). Salah
satu tes adalah </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">tes glukosa plasma</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
setelah puasa. Tes dilakukan untuk memeriksa </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">gula darah</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> setelah semalam (atau
delapan jam) tidak makan. </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Glukosa darah</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> di atas 126 miligram per
desiliter (mg/dL) pada dua tes yang berbeda akan berarti </span><a href="http://kalayan.wordpress.com/"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">diabetes</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.4</span></b><b><span style="font-family: "Arial","sans-serif";">.2 Pemeriksaan Fisik</span></b></div>
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<span style="font-family: "Arial","sans-serif";">1.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Pemeriksaan kepala</span></div>
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<span style="font-family: "Arial","sans-serif";">a.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Xanthelasma adalah</span><span style="font-family: "Arial","sans-serif";"> plak kuning yang terjadi paling umum
dekat canthus bagian dalam kelopak mata, lebih sering pada tutup bagian atas
dari tutup rendah. </span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">b.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">cranial nerve palsy merupakan b</span><span style="font-family: "Arial","sans-serif";">entuk cerebral yang melibatkan satu
atau lebih dari </span><a href="http://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dcranial%2Bnerve%2Bpalsy%26hl%3Did%26biw%3D1366%26bih%3D636%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&u=http://www.wisegeek.com/what-are-cranial-nerves.htm&usg=ALkJrhi59gFPbAWH9PQtC5_i8kP51niuRg"><span style="color: windowtext; font-family: "Arial","sans-serif";">saraf kranial</span></a><span style="font-family: "Arial","sans-serif";"> . Cerebral terjadi ketika otot
menjadi lumpuh atau seseorang kehilangan kendali itu, mengalami gerakan otot
yang tidak menentu, tersentak kejang, dan masalah lainnya. Kelumpuhan saraf
kranial biasanya sangat mudah untuk mengidentifikasi karena melibatkan
otot-otot wajah, dan wajah orang-orang berubah akibat cerebral tersebut.
Seorang pasien mungkin merasa sulit untuk </span><a href="http://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dcranial%2Bnerve%2Bpalsy%26hl%3Did%26biw%3D1366%26bih%3D636%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&u=http://www.wisegeek.com/how-many-muscles-are-used-to-smile.htm&usg=ALkJrhgXq4KcilkF5OLLJMGUZheElBW3HQ"><span style="color: windowtext; font-family: "Arial","sans-serif";">tersenyum</span></a><span style="font-family: "Arial","sans-serif";">, untuk mengontrol gerakan mata, dan
untuk terlibat dalam ekspresi wajah lainnya.</span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
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<span style="font-family: "Arial","sans-serif";">c.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Eye
movement ptosis adalah melorot dari kelopak mata atas. Hal ini dapat memblokir
penglihatan normal. Ptosis bisa hadir pada anak-anak atau orang dewasa.</span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: "Arial","sans-serif";">2. Pemeriksaan mata</span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: "Arial","sans-serif";">a. Visual acuity (ketajaman mata)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: "Arial","sans-serif";">b. Conjunktiva</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: "Arial","sans-serif";">c. Adanya katarak</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: "Arial","sans-serif";">d. Pemeriksaan dengan fundoscopy untuk
memeriksa papil saraf optik, retina, mokula lutea, pembuluh darah retina dan
choroid.</span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l47 level1 lfo38; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">3.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Pemeriksaan leher</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l37 level1 lfo27; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">a.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Carotid pulses merupakan pemeriksaan
pembuluh nadi di leher</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l37 level1 lfo27; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">b.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Bruits adalah suara yang terdengar
vaskular yang berhubungan dengan aliran darah turbulen, biasanya di dengan
dengan menggunakan stetoskop</span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l37 level1 lfo27; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">c.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Pemeriksaan kelenjar tiroid</span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l47 level1 lfo38; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">4.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Pemeriksaan ketiak</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: "Arial","sans-serif";">acanthosis
nigricans merupakan </span><span style="font-family: "Arial","sans-serif";">kelainan
kulit dimana ada gelap, tebal, kulit beludru pada lipatan tubuh dan lipatan.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l47 level1 lfo38; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">5.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Pemeriksaan tekanan darah</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l47 level1 lfo38; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">6.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Pemeriksaan bagian perut</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-layout-grid-align: none; text-align: justify; text-autospace: none;">
<span style="font-family: "Arial","sans-serif";">Hepatomegaly
adalah </span><span style="font-family: "Arial","sans-serif";">pembengkakan hati
di luar ukuran normal.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l47 level1 lfo38; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">7.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Pemeriksaan kulit</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l27 level1 lfo28; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">a.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Bullosis adalah </span><span style="font-family: "Arial","sans-serif";">produksi, atau kondisi yang ditandai
oleh, lesi bulosa.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l27 level1 lfo28; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">b.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Warna
kulit atau penyakit mikrovaskular pada kulit</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l27 level1 lfo28; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">c.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Virtiligo dikarenakan </span><span style="font-family: "Arial","sans-serif";">Hal ini terjadi ketika </span><a href="http://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dvitiligo%26hl%3Did%26client%3Dfirefox-a%26sa%3DX%26rls%3Dorg.mozilla:en-US:official%26biw%3D1366%26bih%3D636%26prmd%3Dimvnsl&rurl=translate.google.co.id&sl=en&u=http://en.wikipedia.org/wiki/Melanocyte&usg=ALkJrhhI3FaNSQTmkrrfdsNTosJJ0dTaow" title="Melanosit"><span style="color: windowtext; font-family: "Arial","sans-serif";">melanosit</span></a><span style="font-family: "Arial","sans-serif";"> , sel-sel yang bertanggung jawab
untuk </span><a href="http://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dvitiligo%26hl%3Did%26client%3Dfirefox-a%26sa%3DX%26rls%3Dorg.mozilla:en-US:official%26biw%3D1366%26bih%3D636%26prmd%3Dimvnsl&rurl=translate.google.co.id&sl=en&u=http://en.wikipedia.org/wiki/Human_skin_color&usg=ALkJrhgpqTqjdhNmMhH6EL-adNWEZSSUhQ" title="Manusia kulit warna"><span style="color: windowtext; font-family: "Arial","sans-serif"; text-decoration: none;">pigmentasi kulit</span></a><span style="font-family: "Arial","sans-serif";"> , mati atau tidak dapat berfungsi</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l47 level1 lfo38; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">8.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Pemeriksaan kaki</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l20 level1 lfo29; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">a.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Muscle wasting adalah </span><span style="font-family: "Arial","sans-serif";">Otot atrofi, atau atrofi tidak
digunakan, didefinisikan sebagai penurunan massa otot</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l20 level1 lfo29; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">b.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Kelainan sensorik</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l20 level1 lfo29; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">c.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Hilangnya rambut kaki</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l20 level1 lfo29; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">d.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Refleks tendon</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-layout-grid-align: none; mso-list: l20 level1 lfo29; text-align: justify; text-autospace: none; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif";">e.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Ditemukan necrobiosis lipoidica adalah </span><span style="font-family: "Arial","sans-serif";">Necrobiosis gangguan degenerasi
kolagen dengan respon granulomatosa, penebalan dinding pembuluh darah, dan
penumpukan lemak.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.4.</span></b><b><span style="font-family: "Arial","sans-serif";">3 Pemeriksaan
Penunjang</span></b></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Dalam
menegakkan diagnosis diabetes mellitus, patokan yang dijadikan acuan tentu saja
adalah pemeriksaan glukosa darah. Dalam hal ini dikenal adanya istilah
pemeriksaan penyaring dan uji diagnostik diabetes mellitus.<b><span style="font-family: "Arial","sans-serif";"> </span></b></span><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></b></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 21.3pt; margin-right: 0cm; margin-top: 0cm; mso-list: l41 level1 lfo49; text-align: justify; text-indent: 0cm;">
<b><span style="font-family: "Arial","sans-serif";">1.<span style="font: 7pt "Times New Roman";">
</span></span></b><b><span style="font-family: "Arial","sans-serif";">Pemeriksaan
Penyaring</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pemeriksaan
penyaring ditujukan untuk mengidentifikasi kelompok yang tidak menunjukkan
gejala diabetes mellitus tetapi memiliki resiko diabetes mellitus, yaitu: 1)
Umur > 45 tahun, 2) Berat badan lebih (dengan kriteria: BBR > 110% BB
idaman atau IMT >23 kg/m2), 3) Hipertensi (≥ 140/90 mmHg), 4) Terdapat
riwayat diabetes mellitus dalam garis keturunan, 5) terdapat riwayat abortus
berulang, melahirkan bayi cacat, atau BB lahir bayi > 4000 gram, 6) Kadar
kolesterol HDL ≤ 35 mg/dl dan atau trigliserida ≥ 250 mg/dl. </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l48 level1 lfo20; text-align: justify; text-indent: 0cm;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">2<span style="font: 7pt "Times New Roman";">
</span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Pemeriksaan Diagnostik</span></b></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Uji
diagnostik dikerjakan pada kelompok yang menunjukkan gejala atau tanda diabetes
mellitus. Bagi yang mengalami gejala khas diabetes mellitus, kadar GDS ≥ 200
mg/dl atau GDP ≥ 126 mg/dl sudah cukup untuk menegakkan diagnosis diabetes
mellitus. Sedangkan pada pasien yang tidak memperlihatkan gejala khas diabetes
mellitus, apabila ditemukan kadar GDS atau GDP yang abnormal maka harus
dilakukan pemeriksaan ulang GDS/GDP atau bila perlu dikonfirmasi pula dengan
TTGO untuk mendapatkan sekali lagi angka abnormal yang merupakan kriteria
diagnosis diabetes mellitus (GDP ≥ 126 mg/dl, GDS ≥ 200 mg/dl pada hari yang
lain, atau TTGO ≥ 200 mg/dl). </span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<br /></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Pemeriksaan
Diagnostik pada penderita DM :</span></b></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l2 level1 lfo31; text-align: justify; text-indent: 0cm;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">a)<span style="font: 7pt "Times New Roman";">
</span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Glukosa darah puasa</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> (<i><span style="font-family: "Arial","sans-serif";">fasting blood glucose</span></i>) </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Pengujian
terhadap kadar gula dalam darah dengan melakukan puasa minimal 8 jam sebelum
test dilakukan. Bahan yang diperiksa dapat berupa darah lengkap atau plasma
dengan menggunakan reaksi reduksi atau dengan test strip. Untuk nilai normal
adalah <b>70-110 mg/dL</b> Seseorang dinyatakan diabetes melitus apabila kadar
glukosa darah puasanya lebih dari <b>126 mg/dL</b> Sedangkan kadar glukosa
darah puasa di antara <b>110 dan 126 mg/dL</b> menunjukkan gangguan pada <b>toleransi
glukosa</b>, yang perlu diwaspadai dapat berkembang menjadi diabetes melitus di
masa mendatang.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Hiperglikemia
didefenisikan sebagai kadar glukosa puasa yang <b>>110 mg/dL</b>, sedangkan
hipoglikemia bila kadarnya <b>< 70 mg/dl</b>. Biasanya orang tersebut
disuruh makan malam terakhir pada pukul 22.00; dan keesokan paginya sebelum ia
makan apa-apa, dilakukan pemeriksaan darah.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<br /></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">b)</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> <b><span style="font-family: "Arial","sans-serif";">Glukosa
darah sewaktu</span></b> atau <b><span style="font-family: "Arial","sans-serif";">glukosa
darah 2 jam postprandial</span></b> (2 jam setelah makan) adalah
pemeriksaan gula darah terhadap seseorang yang tidak dipuasakan terlebih
dahulu. Tanpa ditanya apa-apa atau disuruh apa-apa, glukosa darah langsung
diperiksa. Jika hasilnya > 200 mg/dl dengan gejala poliuri, polidipsi, dan
polifagi merupakan penentu diagnostik diabetes. Sedangkan untuk diagnostik
(penegakkan diagnosa) dilakukan <b>Pemeriksaan gula darah 2 jam postprandial dengan
metode test toleransi glukosa oral</b> adalah test yang digunakan untuk menilai buangan glukosa. Metode ini lebih
sensitif untuk mengetahui adanya kelainan dalam metabolisme glukosa plasma
yaitu diukur kadar glukosa plasma setelah pemberian beban glukosa. Tes ini
digunakan untuk mendiagnosis diabetes awal secara pasti. Individu nondiabetik
yang memakan glukosa menunjukkan kenaikan kadar glukosa plasma yang memicu
sekresi insulin, dan jika pembuangan glukosa dengan diperantarai insulin kadar
gula dalam darahnya akan kembali ke keadaan normal. Cara pemeriksaan TTGO adalah :</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l34 level1 lfo30; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Tiga hari sebelum pemeriksaan pasien makan
seperti biasa</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l34 level1 lfo30; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Kegiatan jasmani sementara cukup, tidak
terlalu banyak</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l34 level1 lfo30; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Pasien puasa selama 10-12 jam semalam</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l34 level1 lfo30; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Periksa glukosa darah puasa</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l34 level1 lfo30; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Berikan glukosa 75 gr yang dilarutkan dalam
air 250 ml, lalu minum dalam waktu 5 menit.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l34 level1 lfo30; text-align: justify; text-indent: 0cm;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">-<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Hitung kadar glukosa setiap ½ jam selama 2
jam, dengan syarat selama pemeriksaan pasien tetap istirahat dan tidak merokok</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Setelah
pemberian glukosa, kadar glukosa akan meningkat pada awalnya namun akan kembali
ke keadaan semula dalam waktu 2 jam. Kadar glukosa serum yang kurang dari 200
mg/dl setelah ½ jam, 1 jam dan 1<sub><span style="position: relative; top: -3pt;">1/2 </span></sub>jam dan kurang dari 140 mg/dl setelah 2 jam
ditetapkan sebagai nilai OGTT normal. Atau jika > 200 mg/dl mengindikasikan
diabetes dan jika OGTT 2 jam tersebut antara 140 hingga 199 mg/dl
mengindikasikan prediabetes (Toleransi Glukosa Terganggu), dengan demikian
dengan indikasi prediabetes ini memungkinkan untuk dilakukan intervensi dini
pada pasien.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">WHO (1985) menganjurkan pemeriksaan standar metode
OGTT, tetapi kita hanya memakai pemeriksaan glukosa darah 2 jam saja.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<i><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">c) Glycosylated hemoglobin / Hemoglobin
Glikosilat </span></b></i><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> <b>(HbA1c)</b></span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">adalah
pemeriksaan penunjang diabetes melitus yang ditujukan untuk menilai kontrol
glikemik seorang pasien. HbA1c adalah salah satu fraksi hemoglobin (bagian sel
darah merah) yang berikatan dengan glukosa secara enzimatik. HbA1c ini
menunjukkan kadar glukosa dalam 3 bulan terakhir, karena sesuai dengan umur
eritrosit (sel darah merah) yaitu 90-120 hari. Nilai HbA1c yang baik adalah
4-6%. Nilai 6-8% menunjukkan kontrol glikemik sedang; dan lebih dari 8%-10%
menunjukkan kontrol yang buruk. Pemeriksaan ini penting untuk menilai kepatuhan
seorang pasien diabetes dalam berobat. Bisa saja seorang pasien yang sudah tahu
akan diperiksa glukosa darahnya melakukan olahraga ekstra keras atau menjaga
makanannya dengan hati-hati agar saat diperiksa glukosa darah sewaktunya
memberi hasil yang normal; namun dengan pemeriksaan HbA1c, semua itu tidak bisa
dibohongi. Kepatuhan pasien dalam 3 bulan terakhir terlihat dari tinggi
rendahnya kadar HbA1c. Selain itu, HbA1c juga dapat meramalkan perjalanan
penyakit, apakah pasien berpeluang besar mengalami komplikasi atau tidak;
berdasarkan kadar kontrol glikemiknya.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<br /></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l30 level1 lfo32; text-align: justify; text-indent: 0cm;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">d)<span style="font: 7pt "Times New Roman";">
</span></span></b><b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Pemeriksaan reduksi urine</span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">merupakan
bagian dari pemeriksaan urine rutin yang selalu dilakukan di klinik. Hasil yang
(+) menunjukkan adanya glukosuria. Beberapa hal yang perlu diingat dari hasil
pemeriksaan reduksi urine adalah: Digunakan pada pemeriksaan pertama sekali
untuk tes skrining, bukan untuk menegakkan diagnosis<b>. </b>Jika reduksi (+):
masih mungkin oleh sebab lain, seperti: renal glukosuria, obat-obatan, dan
lainnya.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Reduksi
(++) kemungkinan KGD: 200 –300 mg%</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Reduksi
(+++) kemungkinan KGD: 300 –400 mg%</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Reduksi
(++++) kemungkinan KGD: �� 400 mg%. Dapat digunakan untuk kontrol hasil
pengobatan. Bila ada gangguan fungsi ginjal, tidak bisa dijadikan<b> </b>pedoman.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Kesimpulan
: </span></b><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Untuk
penegakkan diagnosa pada umumnya dipakai Pemeriksaan Kadar Gula puasa dan Kadar
gula postprandial yang 2 jam saja, dan sekarang sudah dianjurkan penggunaan
pemeriksaan hemoglobin glikosilat, sedangkan untuk pemeriksaan dgn metode OGTT
(oral Glukosa Tolerancy Test) tidak digunakan. Dan pemeriksaan reduksi urin
hanya digunakan untuk skreening bukan penegakkan diagnosa karena hasilnya dapat
pula dipengaruhi oleh kerusakan renal, obat-obatan dsb.</span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<br /></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<br /></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.5</span></b><span lang="EN-US" style="font-family: "Arial","sans-serif";"> </span><span style="font-family: "Arial","sans-serif";"> </span><b><span lang="EN-US" style="font-family: "Arial","sans-serif";">DIAGNOSIS
DAN </span></b><b><span style="font-family: "Arial","sans-serif";">PENATALAKSANAAN</span></b><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.5.1 PENATALAKSANAAN</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Penatalaksanaan
diabetes melitus didasarkan pada (1)rencana diet (2) latihan fisik dan
pengaturan aktifitas fisik dan pengaturan aktifitas fisik,</span><span style="font-family: "Arial","sans-serif";"> </span><span style="font-family: "Arial","sans-serif";">(3)agen agen hipoglikemik oral (4)
terapi insulin (5) pengawasan glukosa di
rumah ,dan (6) pengetahuan tentang diabetes dan perawatan diri</span><span style="font-family: "Arial","sans-serif";"> </span><span style="font-family: "Arial","sans-serif";">pasien dengan diabetes tipe 1 adalah
defisiensi insulin dan selalu membutuhkan terapi insulin.pada tipe pasien tipe
2 terdapat resistensi insulin dan defisiensi insulin relatif dan</span><span style="font-family: "Arial","sans-serif";"> </span><span style="font-family: "Arial","sans-serif";">dapat ditangani tanpa insulin.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Rencana
diet pada pasien diabetes dimaksudkan untuk mengatur jumlah kalori yang disarankan
bervariasi,bergantung jumlah kalori dan karbohidrat yang dikonsumsi setiap hari
.Jumlah kalori yang disarankan bervariasi tergantung pada kebutuhan apakah
untuk mempertahankan,menurunkan atau meningkatkan berat tubuh.sebagai
contoh,pada pasien obesitas,dapat
ditentukan diet dengan kalori yang dibatasi hingga berat badan pasien turun
hingga kekisaran optimal untuk pasien tersebut.sebaliknya,pada pasien muda
dengan diabetes tipe 1,berat badannya dapat menurun selama keadaan
dekompensasi,pasien ini harus menerima kalori yang cukup untuk mengembalikkan
pertumbuhan.Rencana diet harus didapat dengan berkonsultasi dahulu dengan ahli
gizi yang terdaftar dan berdasarkan pada riwayat diet pasien,makanan yang lebih
disukai,gaya hidup,latar belakang budaya dan aktifitas fisik.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Untuk
mencegah hiperglikemia postprandial dan glikosuria,pasien;pasien diabetik tidak
boleh makan karbohidrat berlebihan,umumnya karbohidrat merupakan 50% dari
jumlah kalori perhari yang di izinkan.karbohidrat ini harus di bagi rata sedemikian
rupa sehingg apa yang dimakan oleh pasien sesuai dengan kebutuhannya sepanjang
hari.Contohnya jumlah yang lebih besar dimakan pada waktu melakukan kegiatan
fisik yang lebih berat. Lemak yang dimakan harus dibatasi sampai 30% dari total
kalori perhari yang diizinkan,dan sekurang;kurangnya setengah dari lemak itu
harus dari jenis polyunsaturated.Sistem makanan penukar telah dikembangkan
untuk membantu pasien menangani dietnya
sendiri.Sistem ini mengelompokkan makanan;makanan dengan karbohidrat,protein,dan
lemak yang hampir sama,sehingga kalorinya sama .Cara ini memungkinkan
pasien”menukar” makanannya dengan makanan lain dalam kelompok yang
sesuai.pendekatan lain dalam merencanakan diet untuk menghitung jumlah
karbohidrat dan disesuaikan dengan dosis insulin kerja pendek yang
sesuai.pasien dapat menghitung jumlah karbohidrat yang disajikan maupun gram
karbohidratn total.Insulin dapat digunakan rasio 1 unit per 15gram karbohidrat
total.Rasio ini dapat ditingkatkan bergantung pada respons pasien.pasien dengan
diabetes tipe 2yang resisten terhadap
insulin mungkin membutuhkan 2 hingga 5 unit untuk setiap karbohidrat yang
disajikan atau untuk 15gram karbohidrat total.Latihan fisik kelihatannya
mempermudah transpor kedalam sel-sel meningkatkan kepekaan terhadap insulin.pada
individu sehat,pelepasan insulin menurun selama latihan fisik sehingga menimbulkan hipoglikemia .faktor ini penting
khususnya ketika pasien melakukan latihan fisik saat insulin telah mencapai kadar maksimal atau
puncaknya.dengan menyesuaikan waktu pasien dalam melakukan latihan fisik,pasien
mungkin dapat meningkatkan pengontrolan kadar glukosa mereka .</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Contohnya
,bila pasien melakukan latihan fisik saat kadar glukosa darahnya tinggi,mereka
mungkin dapat menurunnkan kadar glukosanya hanya dengan latihan fisik itu
sendiri.sebaliknya,bila pasien merasa perlu melakukan latihan fisik ketika
kadar glukosa rendah ,mereka mungkin harus mendapat karbohidrat tambahan untuk mencegah
hipoglikemia.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pasien-pasien
dengan gejala diabetes militus tipe 2 dini dapat mempertahankan kadar glukosa
darah normal hanya dengan menjalankan rencana diet dan latihan fisik saja.
Tetapi ,sebagai penyakit yang progresif,obat-obat oral dan hiperglikemik juga
di anjurkan.Obat-obatan yang digunakan adalah pensensitif insulin dan
sulfonilurea.Dua tipe pensensitif yang tersedia adalah metformin dan
tiazolidineon.Meltformin yang merupakan suatu biguanid,dapat diberikan sebagai
terapi tunggal pertama dengan dosis 500 hingga 1700mg/hari.Meltrformin
menurunkan produksi glukosa hepatik,menurunkan absorbsi glukosa pada usus,dan
meningkatkan kepekaan insulin sehingga biasa digunakan ,khususnya pada pasien
dengan obesitas.Asidosis laktat jarang terjadi namun merupakan komplikasi yang
serius ,khususnya pada insufisiensi ginjal dan gagal jantung kongestif.Tiazolidinedion
meningkatkan kepekaan insulin perifer dan menurunkan produksi glukosa
hepatik.Efek obat-obatan ini kelihatannya menjadi perantara interaksi dengan
proliferator peroksisom reseptor inti mengaktifkan reseptor gamma.Dua analog tiazolidinedion
yaitu rosigtazon dengan dosis 4 hingga 8mg/hari dan pioglitazon dengan dosis 30
hingga 45/hari dapat diberikan sebagai terapi tunggal atau dikombinasikan
dengan meltformin,sulfonilurea atau insulin.Obat-obatan ini dapat menyebabkan
resistensi air dan tidak dianjurkan untuk diberikan pada pasien dengan gagal
jantung kongestif.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Bila
kadar glukosa tidak dapat dikontrol secara optimal dengan menggunakan cara-cara
yang telah dijelaskan ,pasien-pasien diabetik tipe 2dengan sel-sel pulau
langerhans yang masih berfungsi,merupakan calon yang tepat untuk menggunakan
sulfonilurea.Obat-obat ini merangsang fungsi sel beta dan meningkatkan sekresi
insulin.Sebaliknya,pasien pasien dengan diabetes tipe 1 telah kehilangan
kemampuannya untuk menyekresi insulin,pengobatan dengan sulfonilurea menjadi
tidak efektif.Sulfonilurea generasi kedua menyebabkan sedikit resistensi air
atau tidak ada sama sekali,merupakan masalah potensial dengan beberapa agen
generasi pertama.Dua bahan campuran sulfonilurea yang sering digunakan adalah
glipizid 2,5 hingga 40mg/hari.Gliburid 2,5 hingga 25mg/hari .griburid memiliki
waktu paruh yang lebih lama dari pada
glipizid dan dosis total hariannnya dapat diberikan sekali sehari.Gabungan
sulfonilurea dengan pensensitif insulin adalah terapi obat yang paling sering
digunakan untuk pasien-pasien dengan diabetes tipe 2.Untuk menurunkan
peningkatan kadar glukosa posprandial pada pasien ini ,absorpsi karbohidrat
dapat diturunkan atau diperlambat dengan mengkonsumsi akarbosa preprandial yaitu
menghambat alfa glukosida yang bekerja pada usus halus dengan menyekat
pencernaan kompleks karbahidrat.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Pemberian
Insulin</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pada
individu sehat sekresi insulin mengimbangi jumlah asupan makanan yang
bermacam-macam dengan latihan fisik sebaiknya individu menderita diabetes tidak
mampu menyekresi jumlah insulin yang cukup untuk mempertahankan euglikemia
.Sebagai akibatnya ,kadar glukosa darah meningkat tinggi sebagai respons dari
makanan.Perubahan rangkaian struktur kristalin dan asam amino dalam molekulinsulin
mengakibatkan waktu kerja preparat yang berbeda yang dapat digunakan untuk
memodifikasi pengobatan insulin dengan kebutuhan khusus pasien .Insulin
diklasifikasikan sebagai insulin masa kerja pendek,masa kerja sedang,atau masa
kerja panjang berdasarkan waktu yang digunakan untuk mencapai efek penurunan
glukosa plasma yang maksimal yaitu wuktu untuk meringankan efek yang terjadi
setelah pemberian suntikan. Insulin masa kerja pendek mencapai k</span><span lang="EN-US" style="font-family: "Arial","sans-serif";">e</span><span style="font-family: "Arial","sans-serif";">rja maksimal dalam waktu beberapa
menit hingga 6 jam se</span><span lang="EN-US" style="font-family: "Arial","sans-serif";">te</span><span style="font-family: "Arial","sans-serif";">lah
penyuntikan dan digunakan untuk mengontrol hipoglikemia postprondial.Insulin
masa kerja pendek juga digunakan untuk pengobatan intervena dan penatalaksanaan
pasien ketosidosis diabetik.</span><span style="font-family: "Arial","sans-serif";"> </span><span style="font-family: "Arial","sans-serif";">Insulin
masa kerja pendek juga dapat</span><span lang="EN-US" style="font-family: "Arial","sans-serif";">. </span><span style="font-family: "Arial","sans-serif";">Insulin
masa kerja sedang mencapai kerja maksimal antara 6hingga 8 jam setelah
penyuntiikan dan digunakan untuk pengontrol harian pasien dengan diabetes
.Insulin masa kerja panjang mencapai kadar puncaknya dalam waktu 14 hingga 20
jam setelah pemberian dan jarang digunakan untuk pemakaian rutin pada pasien
diabetes.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Satu
dari dua analog yang terbaru adalah lispro yaitu analoginsulin dengan masa
kerja sangat singkat dan menurunkan kemampuan gabungan dan absorbsinya yang
lebih cepat:lispro memiliki awitan kerja yang sangat cepat dan dapat digunakan</span><span lang="EN-US" style="font-family: "Arial","sans-serif";">
sesaat sebelum dan sesudah makan.Jika diberikan setelah makan ,dosis dapat
disesuaikan untuk menutupi makanan yang dimakan ,dan memenuhi fleksibilitas
pasien dalam pilihan makanan mereka .Tipe lain insulisin adalah glargine yaitu
pada pada posisi 21 rantai A,asparagin digantikan oleh glisin dan dua molekul orginin telah ditambahkan
pada posisi rantai B.analog insulin ini memiliki masa kerja yang sangat panjang
tanpa puncak dan dapat digunakan untuk menetapkan kadar basal insulin pada
pasien dalam program terapi insulin yang intensif</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"> </span><span lang="EN-US" style="font-family: "Arial","sans-serif";">.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span lang="EN-US" style="font-family: "Arial","sans-serif";">Pengendalian glukosa darah pasien-pasien diabetes yang
memerlukan insulin dapat dicapai dengan pemberian insulin masa kerja sedang
sebelum sarapan dan makan makan malam,dengan dosis yang lebih besar diberikan
sebelum sarapan.Insulin dengan masa kerja singkat sering dikombinasi dengan
insulin masa kerja sedang untuk pengaturanfosiologis dari glukosa pada fase
postprandial,khususnya pada pasien diabetes tipe 1.Pasien dapat menyiapkan
kombinasi ini dengan mencampur dua tipe
insulin dalam jumlah yang tidak sama atau dapat diberikan sebagai
campuran yang sudah tersedia yang terdiri dari 70% NPH,30% insulin regular
(70/30),atau 75% NPH,25 insulin lispro (75/25).Terapi insulin lebih tepat dapat
dicapai dengan suntikan yang lebih sering atau system infus insulin subkutan
yang terus menerus.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span lang="EN-US" style="font-family: "Arial","sans-serif";"> Jika
sering di berikan suntikan insulin,insulin regular masa kerja cepat diberikan
setiap kali sebelum makan,sedangkan insulin NPH masa kerja sedang diberikan
saat menjelang tidur .Pengobatan yang tepatuntuk jenis penyakit ini adalah
insulin glargline yang diberikan sekali sehari menjelang tidur,dikombinasikan
dengan lispro dosis multilevel pada saat makan .Dosis regular insulin
disesuaikan sebelum ditentukan algoritme yang menghitung kadar glukosa secara
luas dan jumlah makanan.Pasien-pasien membutuhkan spuit insulin dan jarum yang
harus dibeli untuk penyuntikan insulin secara subkutan pada dirinya sendiri.Pen
yang diisi insulin dengan jumlah yang sudah ditetapkan juga tersedia untuk digunakan
secara tepat bagi pasien.Suntikan biasanya diberikan di abdomen atau di
lengan.pastikan bahwa tempat penyuntikan tersebut bergerak dan insulin tidak
disuntikan masuk kedalam pembuluh darah atau kedalam jaringan parut.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span lang="EN-US" style="font-family: "Arial","sans-serif";">Terapi insulin yang intensif dapat diberikan melalui
pompa infuse insulin subkutan .Beberapa pompa infuse insulin yang ringan dan
mudah dibawa telah tersedia sehingga dapat diberikan infuse basal yang terus
menerus dan bolus preprandial yang diberikan 30 menit sebelum makan.Pemakaian system
ini sering kali menghasilkan control glukosa yang lebih baik .pasien yang
sedang diterapiinsulin harus di awasi kadar glukosa mereka sebelum diberikan
setiap dosis insulin.Penilaian ini dilakukan pada ujung jari ,yang dapat
menghasilkan darah kapiler yang menetes.Darah diletakkan pada sebuah uji strip
dan dibaca dengan pengukur glukosa dalam memorinya,dan informasi ini dapat
dilihat oleh ahli kesehatan untuk saran selanjutnya dalam program
insulin.Terapi insulin yang intensif sering kali berakibat pada perbaikan
control glukosa.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span lang="EN-US" style="font-family: "Arial","sans-serif";">Pada pasien diabetes relative dapat hidup normal
asalkan mereka mengetahui dengan baik keadaan dan cara penatalaksanaan penyakit
yang dideritanya,mereka dapat belajar menyuntikan sendiri insulin,memantau
kadar glukosa darah mereka,dan memanfaatkan informasi ini untuk mengatur dosis
insulin dan merencanakan diet serta latihannya sedemikian rupa sehingga dapat
mengurangi hiperglikemia atau hipoglikemia.Pada pasien-pasien dengan diabetes
tipe 2.Yang mengalami obesitas,asistomatik,dan mempunyai kadar glukosa yang
cukup tinggi,pengobatan pilihan adalah pembatasan diet dan penurunan berat
badan.Namun tingkat keberhasilan penurunan berat badan diantara pasien-pasien
ini rendah,dan pada akhirnya mereka
membutuhkan terapi agen hipoglikemik.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span lang="SV" style="font-family: "Arial","sans-serif";">A. Terapi Farmakologi</span></b><span lang="SV" style="font-family: "Arial","sans-serif";"> </span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Penatalaksanaan diabetes mempunyai tujuan akhir untuk
menurunkan morbiditas dan mortalitas DM, yang secara spesifik ditujukan untuk
mencapai 2 target utama yaitu:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">1.
Menjaga agar kadar glukosa plasma berada dalam kisaran normal.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2.
Mencegah atau meminimalkan kemungkinan terjadinya komplikasi diabetes.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";"> Penatalaksanaan DM secara non
farmakologi dapat dilakukan dengan cara:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">1.
Pengaturan Diet</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Diet yang
baik merupakan kunci keberasilan penatalaksaan diabetes. Diet yang dianjurkan
adalah makanan dengan komposisi yang seimbang, dalam hal karbohidrat, protein
dan lemak, sesuai dengan kecukupan gizi yang baik sebagai berikut:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt 90.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";"> Karboidrat
: 60 – 70 %</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt 90.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">
Protein
: 10 – 15 %</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt 90.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";"> Lemak
: 20 – 25 %</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";"> Jumlah kalori disesuaikan dengan
pertumbuhan, status gizi, umur, stress akut dan kegiatan fisik yang pada
dasarnya ditujukan untuk mencapai dan mempertahankan berat badan ideal. </span><span lang="FI" style="font-family: "Arial","sans-serif";">Selain jumlah kalori, pilihan jenis bahan makanan juga
sebaiknya diperhatikan. Masukan kolesterol tetap diperlukan namun jangan
melebihi 300 mg perhari. Sumber lemak diupayakan yang berasal dari nabati, yang
mengandung lebih banyak asam lemak tak jenuh daripada asam lemak jenuh. Sebagai
sumber protein sebaiknya diperoleh dari ikan, ayam (terutama daging dada), tahu
dan tempe. </span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";"> Masukan serat sangat penting bagi
penderita diabetes, diusahakan paling tidak 25 g perhari. Di samping akan
menolong menghambat penyerapan lemak, makanan berserat yang tidak dapat dicerna
oleh tubuh juga dapat membantu mengatasi rasa lapar yang kerap dirasakan
penderita DM.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Tabel 1</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Kebutuhan
Energi Berdasarkan Usia, Jenis Kelamin, dan Aktivitas Fisik</span><span style="font-family: "Arial","sans-serif";"></span></div>
<table border="1" cellpadding="0" cellspacing="3" class="MsoNormalTable" style="border: 3pt outset; margin-left: 0.1pt; width: 490px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td rowspan="2" style="padding: 0cm 5.4pt 0cm 5.4pt; width: 72.0pt;" valign="top" width="96"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<b><span lang="SV" style="font-family: "Arial","sans-serif";">Usia
(tahun)</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td colspan="2" style="padding: 0cm 5.4pt 0cm 5.4pt; width: 183.7pt;" valign="top" width="245"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<b><span lang="SV" style="font-family: "Arial","sans-serif";">Jenis
kelamin (Kilo Calori)</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td rowspan="2" style="padding: 0cm 5.4pt 0cm 5.4pt; width: 104.15pt;" valign="top" width="139"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<b><span lang="SV" style="font-family: "Arial","sans-serif";">Aktivitas
Fisik</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 99.0pt;" valign="top" width="132"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Pria</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 82.7pt;" valign="top" width="110"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Wanita</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 72.0pt;" valign="top" width="96"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">20 – 34</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 99.0pt;" valign="top" width="132"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2300</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2900</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 82.7pt;" valign="top" width="110"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">1800</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2200</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 104.15pt;" valign="top" width="139"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Ringan </span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Sedang</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 72.0pt;" valign="top" width="96"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">35 – 54</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 99.0pt;" valign="top" width="132"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2100</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2700</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 82.7pt;" valign="top" width="110"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">1700</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2100</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 104.15pt;" valign="top" width="139"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Ringan </span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Sedang</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 72.0pt;" valign="top" width="96"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">55 - 74</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 99.0pt;" valign="top" width="132"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2000</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2500</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 82.7pt;" valign="top" width="110"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">1650</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2000</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 104.15pt;" valign="top" width="139"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Ringan </span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Sedang</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5; mso-yfti-lastrow: yes;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 72.0pt;" valign="top" width="96"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Diatas 75</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 99.0pt;" valign="top" width="132"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">1800</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2200</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 82.7pt;" valign="top" width="110"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">1550</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">1900</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 104.15pt;" valign="top" width="139"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Ringan </span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Sedang</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">2.
Olah Raga</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";"> Berolah raga secara teratur dapat
menurunkan dan menjaga kadar gula darah tetap normal. Saat ini terdapat dokter
olah raga yang dapat dimintakan nasihatnya untuk mengatur jenis dan porsi olah
raga yang sesuai untuk penderita diabetes. Prinsipnya, tidak perlu olah raga
berat, olah raga ringan asal dilakukan secara teratur akan sangat bagus
pengaruhnya bagi kesehatan. Misalnya dengan olah raga jalan kaki, bersepeda,
jogging, lari dan renang.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span lang="SV" style="font-family: "Arial","sans-serif";">B. Terapi Farmakologi</span></b><span lang="SV" style="font-family: "Arial","sans-serif";"> </span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 54.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">a.
Diabetes Mellitus Tipe 1 : <i>Insulin Dependent Diabetes Mellitus</i></span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Pasien ini
selalu diobati dengan insulin, karena sel-sel betanya tidak aktif lagi, begitu
pula pada keadaan khusus seperti ketoasidosis, kehamilan, infeksi, pembedahan
atau gangguan hati dan ginjal, tidak dapat digunakan antidiabetikum oral,
tetapi segera diinjeksi insulin. Secara kimiawi insulin terdiri dari 2 rantai
peptide (A dan B) dengan masing-masing 21 dan 30 asam amino, yang saling
dihubungi oleh dua jembatan disulfide.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Lama kerja
sediaan insulin:</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt list 72.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">a) Insulin Kerja Singkat</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Sediaan ini
terdiri dari insulin tunggal biasa. Mula kerjanya baru sesudah setelah ½ jam.
Injeksi subkutan mencapai puncak 1-2,5 jam kemudian dan bertahan 7 – 8 jam.
(Actrapid, Velosulin, Hhumulin Regular).</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt list 72.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">b) Insulin <i>Long Acting</i></span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Guna
memperpanjang kerjanya tela dibuat sediaan <i>longg acting</i>. Dengan mempersulit
daya larutanya dicairan jaringan dan menghambat resorpsinya dari tempat injeksi
ke dalam darah.Metode yang digunakan mencampurkan insulin dengan protein, seng
atau mengubah bentuk fisiknya.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt list 72.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">c) Medium <i>Acting</i></span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Jangka waktu
efeknya dapat divariasikan dengan mencampurkan bentuk beberapa insulin dengan
lama kerja berlainan.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Tabel 2</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Penggolongan
Sediaan Insulin Berdasarkan Mula dan Masa Kerja</span><span style="font-family: "Arial","sans-serif";"></span></div>
<table border="1" cellpadding="0" cellspacing="3" class="MsoNormalTable" style="border: 3pt outset; margin-left: 8.35pt; width: 452px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 111.55pt;" valign="top" width="149"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<b><span lang="FI" style="font-family: "Arial","sans-serif";">Jenis
Sediaan Insulin</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 96.55pt;" valign="top" width="129"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Mulai
Kerja</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">(Jam)</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 60.9pt;" valign="top" width="81"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Puncak</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">(Jam)</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 59.0pt;" valign="top" width="79"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Masa</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">(Jam)</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 111.55pt;" valign="top" width="149"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Masa kerja
singkat (<i>Reguler Insulin</i>)</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 96.55pt;" valign="top" width="129"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">0,5</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 60.9pt;" valign="top" width="81"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">1 – 4</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 59.0pt;" valign="top" width="79"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">6 – 8</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 111.55pt;" valign="top" width="149"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Masa Kerja
Sedang</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 96.55pt;" valign="top" width="129"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">1 – 2</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 60.9pt;" valign="top" width="81"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">6 – 12</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 59.0pt;" valign="top" width="79"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">18 – 24</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 111.55pt;" valign="top" width="149"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Masa Kerja
Sedang mula kerja cepat</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 96.55pt;" valign="top" width="129"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">0 – 5</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 60.9pt;" valign="top" width="81"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">4 – 15</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 59.0pt;" valign="top" width="79"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">18 – 24</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 111.55pt;" valign="top" width="149"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">MMasa
Kerja Panjang (<i>Long Acting</i>)</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 96.55pt;" valign="top" width="129"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">4 – 6</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 60.9pt;" valign="top" width="81"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">14 – 20</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 59.0pt;" valign="top" width="79"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">24 – 36</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt 45.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";"> b. Diabetes
Mellitus Tipe 2: Non Insulin Dependent Diabetes Mellitus</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Penggolongan
DM Tipe 2 dengan menggunakan beberapa golongan obat yaitu :</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Tabel 3.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Penggolongan
Obat DM Tipe 2</span><span style="font-family: "Arial","sans-serif";"></span></div>
<table border="1" cellpadding="0" cellspacing="3" class="MsoNormalTable" style="border: 3pt outset; margin-left: 8.35pt; width: 499px;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 78.7pt;" valign="top" width="105"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Golongan</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 127.3pt;" valign="top" width="170"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Contoh
Senyawa</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 159.45pt;" valign="top" width="213"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Mekanisme
Kerja</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 78.7pt;" valign="top" width="105"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Sulfonil
Urea</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 127.3pt;" valign="top" width="170"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Gliburide/libenklamid</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Glipizida</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Glikazida</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Glimepirida</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Glikuidon</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 159.45pt;" valign="top" width="213"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Merangsan
sekresi insulin di kelenjar pankreas, seina anya efektif pada penderita
diabetes yang sel-sel pankreasnya masih berfungsi</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 78.7pt;" valign="top" width="105"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Meglitinida</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 127.3pt;" valign="top" width="170"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Refaglinid</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 159.45pt;" valign="top" width="213"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Merangsang
sekresi insulin di kelenjar pankreas</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 78.7pt;" valign="top" width="105"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Turunan
fenilalanin</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 127.3pt;" valign="top" width="170"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Nateglinide</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 159.45pt;" valign="top" width="213"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Meninkatkan
kecepatan insulin di kelenjar pankreas</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 78.7pt;" valign="top" width="105"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Biuanida</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 127.3pt;" valign="top" width="170"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Metformin</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 159.45pt;" valign="top" width="213"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Bekerja
lansung pada hati, menurunkan produksi glukosa hati. Tidak merangsang sekresi
insulin oleh kelenjar pankreas</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 78.7pt;" valign="top" width="105"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Tiazolidindion</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 127.3pt;" valign="top" width="170"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="SV" style="font-family: "Arial","sans-serif";">Roziglitazone</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 159.45pt;" valign="top" width="213"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Meningkatkan
kepekaan tubuh teradap insulin. Berkaitan dengan PPARY (Peroxisome Proferator
activated receptor gamma) di otot, jarinan lemak dan hasil untuk menurunkan
resistensi insulin</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6; mso-yfti-lastrow: yes;">
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 78.7pt;" valign="top" width="105"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
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<span lang="FI" style="font-family: "Arial","sans-serif";">Inhibitor </span><span style="font-family: "Arial","sans-serif";"></span></div>
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<span lang="FI" style="font-family: "Arial","sans-serif";">a-glukosidase</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 127.3pt;" valign="top" width="170"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Acarbose
Miglitol</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
<td style="padding: 0cm 5.4pt 0cm 5.4pt; width: 159.45pt;" valign="top" width="213"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; tab-stops: 27.0pt; text-align: justify;">
<span lang="FI" style="font-family: "Arial","sans-serif";">Menghambat
kerja enzim-enzim pencernaan yang mencerna karboidrat, sehingga memperlambat
absorbsi glukosa ke dalam darahh</span><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.5.2 </span></b><b><span style="font-family: "Arial","sans-serif";">Diagnosis</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Diagnosis DM harus didasarkan atas pemeriksaan
kadarglukosa darah, tidak dapat ditegakkan hanya atas dasar adanya glukosuria</span><span style="font-family: "Arial","sans-serif";"> </span><span style="font-family: "Arial","sans-serif";">saja. Dalam menegakkan diagnosis DM harus diperhatikan asal bahan darahyang
diambil dan cara pemeriksaan yang dipakai. Untuk diagnosis DM,pemeriksaan yang
dianjurkan adalah pemeriksaan glukosa dengan cara enzimatik dengan bahan
glukosa darah plasma vena. Untuk memastikandiagnosis DM, pemeriksaan glukosa
darah seyogyanya dilakukan dilaboratorium klinik yang terpercaya . Untuk
memantau kadar glukosa darahdapat dipakai bahan darah kapiler. Saat ini
banyak dipasarkan alatpengukur kadar glukosa darah cara reagen kering yang
umumnya sederhanadan mudah dipakai. Hasil pemeriksaan kadar glukosa darah memakaialat-alat
tersebut dapat dipercaya sejauh kalibrasi dilakukan denganbaik dan cara
pemeriksaan sesuai dengan cara standar yang dianjurkan.Secara berkala , hasil
pemantauan dengan cara reagen kering perlu dibandingkan dengan cara
konvensional.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pemeriksaan penyaring perlu dilakukan pada
kelompok dengan salah satu faktor risiko untuk DM, yaitu :</span></div>
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<span style="font-family: "Arial","sans-serif";">-
kelompok usia dewasa tua (>45 tahun )</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">-
kegemukan{BB (kg)>120% BB idaman atau IMT>27 (kg/m<sup>2</sup>)}</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">-
tekanan darah tinggi (>140/90 mmHg)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">-
riwayat keluarga DM</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">-
riwayat kehamilan dengan BB lahir bayi>4000 gram</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">-
riwayat DM pada kehamilan</span></div>
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<span style="font-family: "Arial","sans-serif";">-
dislipidemia (HDL<35 mg/dl dan atau Trigliserida>250 mg/dl</span></div>
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<span style="font-family: "Arial","sans-serif";">-
pernah TGT (Toleransi Glukosa Terganggu) atau GDPT (Glukosa Darah Puasa
Terganggu)</span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">B.</span></b><span style="font-family: "Arial","sans-serif";"> <b>Langkah-langkah untuk
menegakkan diagnosis Diabetes Melitus</b></span></div>
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<span style="font-family: "Arial","sans-serif";">Diagnosis klinis DM umumnya akan dipikirkan bila ada
keluhan khas DM berupa poliuria, polidipsia, polifagia, lemah, dan penurunan
berat badan yang tidak dapat dijelaskan sebabnya. Keluhan lain yang mungkin
dikemukakan pasien adalah kesemutan, gatal, mata kabur dan impotensia pada
pasien pria, serta pruritus vulvae pada pasien wanita. Jika keluhan
khas,pemeriksaan glukosa darah sewaktu 200 mg/dl sudah cukup untuk
menegakkan diagnosis DM. Hasil pemeriksaan kadar glukosa darah puasa 126
mg/dl juga digunakan untuk patokan diagnosis DM. Untuk kelompoktanpa
keluhan khas DM, hasil pemeriksaan glukosa darah yang baru satu kali saja
abnormal , belum cukup kuat untuk menegakkan diagnosis klinis DM.
Diperlukan pemastian lebih lanjut dengan menddapatkan sekali lagi angka
abnormal, baik kadar glukosa darah puasa126 mg/dl, kadar glukosa darah
sewaktu200 mg/dl pada hari yang lain, atau dari hasil tes toleransi glukosa oral
(TTGO) yang abnormal.</span></div>
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<span style="font-family: "Arial","sans-serif";">Kriteria diagnostik Diabetes Melitus*</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">1. Kadar glukosa darah sewaktu (plasma vena)200
mg/dl , atau</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">2. Kadar glukosa darah puasa (plasma vena)126
mg/dl</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">(Puasa berarti tidak ada masukan kalori sejak 10 jam
terakhir ) atau</span></div>
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<span style="font-family: "Arial","sans-serif";">Kadar glukosa plasma200 mg/dl pada 2 jam sesudah
beban glukosa 75 gram pada TTGO**</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-pagination: none; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">* Kriteria diagnostik tersebut harus dikonfirmasi ulang pada hari yang lain,
kecuali untuk keadaan khas hiperglikemia dengan dekompensasi metabolik akut,
seperti ketoasidosis atau berat badan yang menurun cepat.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span lang="NO-BOK" style="font-family: "Arial","sans-serif";">**Cara diagnosis dengan
kriteria ini tidak dipakai rutin diklinik.</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Upaya pencegahan penyakit diabetes mellitus dapat
dilakukan dengan cara sebagai berikut:<br />
<b>a. Pencegahan Primer</b></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Cara ini adalah cara yang paling sulit karena
sasarannya orang sehat. Hal ini dilakukan dengan tujuan untuk mencegah agar DM
tidak terjadi pada orang atau populasi yang rentan (risiko tinggi), yang
dilakukan sebelum timbul tanda-tanda klinis dengan cara :</span></div>
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<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Makan seimbang artinya yang dimakan dan yang
dikeluarkan seimbang disesuiakan dengan aktifitas fisik dan kondisi tubuh,
dengan menghindari makanan yang mengandung tinggi lemak karena bisa menyebabkan
penyusutan konsumsi energi. Mengkonsusmsi makanan dengan kandungan karbohidrat
yang berserat tinggi dan bukan olahan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l29 level1 lfo43; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Meningkatkan kegiatan olah raga yang berpengaruh pada
sensitifitas insulin dan menjaga berat badan agar tetap ideal.</span></div>
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<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Kerjasama dan tanggung jawab antara instansi
kesehatan, masyarakat, swasta dan pemerintah, untuk melakukan penyuluhan kepada
masyarakat</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: -18.0pt; margin-right: 0cm; margin-top: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">b. Pencegahan Sekunder</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
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<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif";">Ditujukan pada
pendeteksian dini DM serta penanganan segera dan efektif, sehingga </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"> komplikasi
dapat dicegah.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l16 level1 lfo44; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";"> Hal ini dapat
dilakukan dengan skrining, untuk menemukan penderita sedini mungkin </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: -18.0pt; margin-right: 0cm; margin-top: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"> terutama individu/populasi.</span></div>
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<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Kalaupun ada komplikasi masih reversible / kembali
seperti semula.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l16 level1 lfo44; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Penyuluhan kesehatan secara profesional dengan
memberikan materi penyuluhan seperti : apakah itu DM, bagaimana penatalaksanaan
DM, obat-obatan untuk mengontrol glukosa darah, perencanaan makan, dan olah
raga.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"><br />
<b>c. Pencegahan Tersier</b></span></div>
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<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Upaya dilakukan untuk semua penderita DM untuk
mencegah komplikasi.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l39 level1 lfo45; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Mencegah progresi dari komplikasi supaya tidak terjadi
kegagalan organ.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l39 level1 lfo45; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Mencegah kecacatan akibat komplikasi yang ditimbulkan.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Strategi yang bisa dilakukan untuk pencegahan DM
adalah :<br />
<br />
<b>a. Population/Community Approach (Pendekatan Komunitas) :</b></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Mendidik masyarakat menjalankan gaya hidup sehat
dengan cara:</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l18 level1 lfo46; tab-stops: list 5.5pt; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Arial","sans-serif";">Mengendalikan
berat badan, glukosa darah, lipid, tekanan darah, asam urat.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l18 level1 lfo46; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";"> Menghindari
gaya hidup berisiko</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l18 level1 lfo46; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";"> Kerjasama
dengan semua lapisan masyarakat.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"><br />
<b>b. Individual High Risk Approach (Pendekatan Individu) :</b></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l38 level1 lfo47; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Umur > 40th</span></div>
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<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Obesitas</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l38 level1 lfo47; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Hipertensi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l38 level1 lfo47; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Riwayat keluarga / keturunan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l38 level1 lfo47; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Dislipidemia / timbunan lemak dalam darah yang
berlebihan</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l38 level1 lfo47; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Riwayat melahirkan > 4 kg</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l38 level1 lfo47; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Riwayat DM pada saat kehamila</span><span lang="EN-US" style="font-family: "Arial","sans-serif";">n</span><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-outline-level: 1; text-align: justify;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.6 </span></b><b><span style="font-family: "Arial","sans-serif";">PROGNOSIS DAN KOMPLIKASI
DIABETES MELLITUS</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-outline-level: 1; text-align: justify;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.6.1 </span></b><b><span style="font-family: "Arial","sans-serif";">Prognosis
diabetes melitus </span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-outline-level: 1; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">prognosis
untuk seseorang dengan diabetes sepenuhnya tergantung pada dedikasi mereka
dalam mengelola penyakit. Mereka yang mengelola penyakit ini dapat berharap
untuk hidup lama. Mereka yang tidak mengelola penyakit mereka dengan obat yang
benar atau perubahan gaya hidup menderita berbagai penyakit dan risiko incuding
gagal ginjal, penyakit jantung dan kematian.</span><b><span style="font-family: "Arial","sans-serif";"></span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-outline-level: 1; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Diabetes cara dikelola perubahan dengan usia. Produksi
insulin berkurang karena berkaitan dengan usia penurunan sel beta pankreas.
Selain itu, resistensi insulin meningkat karena hilangnya jaringan lemak dan
penimbunan lemak, lemak terutama intra-abdomen, dan kepekaan jaringan terhadap
insulin menurun. Toleransi glukosa semakin menurun dengan bertambahnya usia,
menyebabkan tingginya prevalensi diabetes tipe 2 dan hiperglikemia
postchallenge pada populasi lebih tua. Berkaitan dengan usia intoleransi glukosa
pada manusia sering disertai dengan resistensi insulin, tetapi tingkat insulin
yang beredar mirip dengan orang yang lebih muda. </span><span style="font-family: "Arial","sans-serif";">Pengobatan tujuan untuk pasien yang lebih tua dengan
diabetes bervariasi dengan individu, dan mempertimbangkan status account kesehatan,
serta harapan hidup, tingkat ketergantungan, dan kemauan untuk mematuhi rejimen
pengobatan. </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Orang
dengan diabetes tipe 1 umumnya disesuaikan dengan cepat untuk waktu dan
perhatian yang diperlukan untuk memonitor gula darah, mengobati penyakit dan
mempertahankan gaya hidup normal. Dengan berjalannya waktu, risiko komplikasi
substansial. Tapi itu bisa dikurangi jika sangat ketat memantau dan
mengendalikan darah kadar glukosa. Rencana perawatan mungkin memerlukan
penyesuaian dari waktu ke waktu. Resistensi insulin meningkat dengan usia. Dan
sel yang memproduksi insulin di pankreas mungkin usang sebagai pankreas mencoba
untuk bersaing dengan kebutuhan ekstra tubuh insulin. </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Setelah
beberapa tahun pertama, sebagian besar orang dengan diabetes tipe 2 membutuhkan
lebih dari satu obat untuk menjaga gula darah mereka terkontrol. Sekitar satu
dari tiga orang dengan diabetes tipe 2 membutuhkan insulin. Prognosis pada
orang dengan diabetes tipe 2 bervariasi, Hal ini tergantung pada seberapa baik
seorang individu memodifikasi risiko komplikasi. Serangan jantung, stroke dan
penyakit ginjal dapat mengakibatkan kematian dini. Cacat akibat kerusakan
kebutaan, amputasi, penyakit jantung, stroke dan saraf dapat terjadi. Beberapa
orang dengan diabetes tipe 2 menjadi tergantung pada perawatan dialisis karena
gagal ginjal. </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<a href="http://translate.googleusercontent.com/translate_c?act=url&hl=id&ie=UTF8&prev=_t&rurl=translate.google.co.id&sl=en&tl=id&twu=1&u=http://www.news-medical.net/health/Gestational-Diabetes-What-is-Gestational-Diabetes.aspx&usg=ALkJrhiBGlPkwi0hcqrL7DinP_H2fcxfqw"><b><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">Gestational diabetes</span></b></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
umumnya sembuh setelah bayi lahir. Berdasarkan studi yang berbeda, kemungkinan
mengembangkan GDM pada kehamilan kedua adalah antara 30 dan 84%, tergantung
pada latar belakang etnis. Sebuah kehamilan kedua dalam waktu 1 tahun dari
kehamilan sebelumnya memiliki tingkat tinggi kambuh. </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Wanita
didiagnosis dengan gestational </span><a href="http://translate.googleusercontent.com/translate_c?act=url&hl=id&ie=UTF8&prev=_t&rurl=translate.google.co.id&sl=en&tl=id&twu=1&u=http://www.news-medical.net/health/What-is-Diabetes.aspx&usg=ALkJrhio2HBLTPEqZyZptUTCzcXfuQjTKQ"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">diabetes</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
memiliki peningkatan risiko terkena </span><a href="http://translate.googleusercontent.com/translate_c?act=url&hl=id&ie=UTF8&prev=_t&rurl=translate.google.co.id&sl=en&tl=id&twu=1&u=http://www.news-medical.net/health/What-is-Diabetes.aspx&usg=ALkJrhio2HBLTPEqZyZptUTCzcXfuQjTKQ"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">diabetes melitus</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> di
masa depan. Risikonya adalah tertinggi pada wanita yang membutuhkan </span><a href="http://translate.googleusercontent.com/translate_c?act=url&hl=id&ie=UTF8&prev=_t&rurl=translate.google.co.id&sl=en&tl=id&twu=1&u=http://www.news-medical.net/health/What-is-Insulin.aspx&usg=ALkJrhjClm4pv6eddOgrjn4rPoTOeAwGPQ"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">insulin</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> pengobatan,
memiliki </span><a href="http://translate.googleusercontent.com/translate_c?act=url&hl=id&ie=UTF8&prev=_t&rurl=translate.google.co.id&sl=en&tl=id&twu=1&u=http://www.news-medical.net/health/Antibody-What-is-an-Antibody.aspx&usg=ALkJrhiEjfvnnRa4fcqng2hc2H7K5L4G9A"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">antibodi</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">
yang terkait dengan diabetes (seperti antibodi terhadap dekarboksilase
glutamat, antibodi sel islet dan / atau antigen insulinoma-2), wanita dengan
lebih dari dua kehamilan sebelumnya, dan wanita yang obesitas ( dalam urutan
kepentingan). Wanita membutuhkan insulin untuk mengelola gestational diabetes
memiliki risiko 50% terkena diabetes dalam lima tahun ke depan. </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Tergantung
pada populasi yang diteliti, kriteria diagnostik dan panjang tindak lanjut,
risiko dapat bervariasi sangat besar. Risiko tampaknya tertinggi dalam 5 tahun
pertama, mencapai dataran tinggi setelahnya. Studi lain menemukan risiko
diabetes setelah GDM lebih dari 25% setelah 15 tahun. Pada populasi dengan
risiko rendah untuk </span><a href="http://translate.googleusercontent.com/translate_c?act=url&hl=id&ie=UTF8&prev=_t&rurl=translate.google.co.id&sl=en&tl=id&twu=1&u=http://www.news-medical.net/health/What-is-Type-2-Diabetes.aspx&usg=ALkJrhjkJAeB8kkeDAtS_SIauAqUA-SjcA"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">diabetes tipe 2</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> ,
dalam mata pelajaran ramping dan pada pasien dengan auto-antibodi, ada tingkat
lebih tinggi dari wanita mengembangkan </span><a href="http://translate.googleusercontent.com/translate_c?act=url&hl=id&ie=UTF8&prev=_t&rurl=translate.google.co.id&sl=en&tl=id&twu=1&u=http://www.news-medical.net/health/What-is-Type-1-Diabetes.aspx&usg=ALkJrhjyFPcT1H8S3f9E_BtmWZCuSLtfVg"><span style="color: windowtext; font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%; text-decoration: none;">diabetes tipe 1</span></a><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"> . </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Risiko
ini berkaitan dengan peningkatan nilai glukosa ibu. Sekarang ini belum jelas
berapa banyak kerentanan genetik dan faktor lingkungan masing-masing
berkontribusi terhadap risiko ini, dan jika pengobatan GDM dapat mempengaruhi
hasil ini. </span><span lang="EN-US" style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;"></span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Ada
banyak sekali yang dapat Anda lakukan untuk mengurangi risiko komplikasi: </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l22 level1 lfo39; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Makan makanan yang sehat </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l22 level1 lfo39; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Berolah raga secara teratur </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l22 level1 lfo39; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Perhatikan kadar gula darah Anda </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l22 level1 lfo39; tab-stops: list 0cm; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol; font-size: 10pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif"; font-size: 11pt; line-height: 150%;">Mengurangi risiko lain penyakit jantung </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: -18.0pt; margin-right: 0cm; margin-top: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">2.6.2 </span></b><b><span style="font-family: "Arial","sans-serif";">KOMPLIKASI
DM</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Komplikasi
jangka panjang timbul pada semua bentuk diabetes. Walaupun berkembangnya
komplikasi tak dapat diramalkan, kendali glikemik yang bagus mencegah atau
memperbaiki komplikasi mikrovaskular diabetes pada pasien tipe I dan tipe II.
The UK Prospective Diabetes Study (UKPDS, Hal.179) menunjukan bahwa setelah 10
tahun pasien tipe 2 memiliki mortalitas dua kali lebih tinggi dibanding dengan
populasi umum, dan sepertiga pasien memiliki komplikasi makro- atau
mikrovaskular (mata atau ginjal) yang memerlukan perhatian medis.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Komplikasi jangka panjang dari diabetes</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border: outset #009966 1.0pt; margin-left: 4.5pt; mso-border-alt: outset #009966 .75pt; mso-cellspacing: 0cm; mso-padding-alt: 3.75pt 3.75pt 3.75pt 3.75pt; mso-yfti-tbllook: 160; width: 104.7%;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="background: #99CCCC; border-left: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-right-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 16.52%;" width="16%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Organ/jaringan yg terkena</span></div>
</td>
<td style="background: #99CCCC; border: inset #009966 1.0pt; mso-border-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 49.82%;" width="49%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Yg terjadi</span></div>
</td>
<td style="background: #99CCCC; border-right: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-left-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 33.64%;" width="33%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Komplikasi</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-left: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-right-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 16.52%;" width="16%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pembuluh darah</span></div>
</td>
<td style="border: inset #009966 1.0pt; mso-border-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 49.82%;" width="49%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Plak aterosklerotik terbentuk & menyumbat arteri
berukuran besar atau sedang di jantung, otak, tungkai & penis.<br />
Dinding pembuluh darah kecil mengalami kerusakan sehingga pembuluh tidak
dapat mentransfer oksigen secara normal & mengalami kebocoran</span></div>
</td>
<td style="border-right: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-left-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 33.64%;" width="33%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Sirkulasi yg jelek menyebabkan penyembuhan luka yg
jelek & bisa menyebabkan penyakit jantung, stroke, gangren kaki &
tangan, impoten & infeksi</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-left: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-right-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 16.52%;" width="16%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Mata</span></div>
</td>
<td style="border: inset #009966 1.0pt; mso-border-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 49.82%;" width="49%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Terjadi kerusakan pada pembuluh darah kecil retina</span></div>
</td>
<td style="border-right: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-left-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 33.64%;" width="33%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Gangguan penglihatan & pada akhirnya bisa
terjadi kebutaan</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-left: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-right-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 16.52%;" width="16%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Ginjal</span></div>
</td>
<td style="border: inset #009966 1.0pt; mso-border-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 49.82%;" width="49%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"> Penebalan
pembuluh darah ginjal </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"> Protein
bocor ke dalam air kemih </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"> Darah tidak
disaring secara normal </span></div>
</td>
<td style="border-right: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-left-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 33.64%;" width="33%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Fungsi ginjal yg buruk <br />
Gagal ginjal</span></div>
</td>
</tr>
<tr style="height: 110.6pt; mso-yfti-irow: 4;">
<td style="border-left: none; border: inset #009966 1.0pt; height: 110.6pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-right-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 16.52%;" width="16%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Saraf</span></div>
</td>
<td style="border: inset #009966 1.0pt; height: 110.6pt; mso-border-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 49.82%;" width="49%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Kerusakan saraf karena glukosa tidak dimetabolisir
secara normal & karena aliran darah berkurang</span></div>
</td>
<td style="border-right: none; border: inset #009966 1.0pt; height: 110.6pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-left-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 33.64%;" width="33%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"> Kelemahan
tungkai yg terjadi secara tiba-tiba atau secara perlahan </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">
Berkurangnya rasa, kesemutan & nyeri di tangan & kaki </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"> Kerusakan
saraf menahun </span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="border-left: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-right-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 16.52%;" width="16%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Sistem saraf otonom</span></div>
</td>
<td style="border: inset #009966 1.0pt; mso-border-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 49.82%;" width="49%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Kerusakan pada saraf yg mengendalikan tekanan darah
& saluran pencernaan</span></div>
</td>
<td style="border-right: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-left-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 33.64%;" width="33%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<i><span style="font-family: "Arial","sans-serif";">Tekanan darah yg naik-turun </span></i></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<i><span style="font-family: "Arial","sans-serif";"> Kesulitan
menelan & perubahan fungsi pencernaan disertai serangan diare </span></i><span style="font-family: "Arial","sans-serif";"></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td style="border-left: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-right-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 16.52%;" width="16%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Kulit</span></div>
</td>
<td style="border: inset #009966 1.0pt; mso-border-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 49.82%;" width="49%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Berkurangnya aliran darah ke kulit & hilangnya
rasa yg menyebabkan cedera berulang</span></div>
</td>
<td style="border-right: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-left-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 33.64%;" width="33%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"> Luka,
infeksi dalam (<i>ulkus diabetikum</i>) </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"> Penyembuhan
luka yg jelek </span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 7;">
<td style="border-left: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-right-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 16.52%;" width="16%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Darah</span></div>
</td>
<td style="border: inset #009966 1.0pt; mso-border-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 49.82%;" width="49%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Gangguan fungsi sel darah putih</span></div>
</td>
<td style="border-right: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-left-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 33.64%;" width="33%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Mudah terkena infeksi, terutama infeksi saluran
kemih & kulit</span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8; mso-yfti-lastrow: yes;">
<td style="border-left: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-right-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 16.52%;" width="16%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Jaringan ikat</span></div>
</td>
<td style="border: inset #009966 1.0pt; mso-border-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 49.82%;" width="49%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Gluka tidak dimetabolisir secara normal sehingga
jaringan menebal atau berkontraksi</span></div>
</td>
<td style="border-right: none; border: inset #009966 1.0pt; mso-border-bottom-alt: inset #009966 .75pt; mso-border-left-alt: inset #009966 .75pt; mso-border-top-alt: inset #009966 .75pt; padding: 3.75pt 3.75pt 3.75pt 3.75pt; width: 33.64%;" width="33%"><div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";"> Sindroma
terowongan karpal <i>Kontraktur Dupuytren</i></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Komplikasi
vaskular</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">kelainan
pembuluh darah besar. Komplikasi vaskular menyebabkan 75%<b> </b>kematian.
Insidensi oklusi arteri koroner yang ditemukan pada pemeriksaan postmortem lima
kali lebih tinggi dibanding pada penyandang diabetes dibanding dengan non
diabetes, tanpa melihat usia atau jenis kelamin. Terdapat peningkatan resiko
penyakit jantung koroner dan infark miokard sebesar 2-3 kali lipat. Oklusi arteri
perifer pada tungkai 40 kali lebih sering ditemukan pada penyandang diabetes,
menyebabkan klaudikasio, nyeri saat istirahat, pembentukan ulkus, dan gangren.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Kelainan
pembuluh darah kecil (mikro-angiopati diabetikum) menyebabkan gagal ginjal,
hampir selalu berhubungan dengan retinopati, dan gangren pada kulit serta kaki
dengan infark berbentuk baji-nadi arteri pada kaki biasanya teraba dan kulit
terasa hangat.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Mata</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Penyakit
mata diabetes adalah penyebab tersering hilangnya penglihatan pada orang dewasa
usia produktif di Inggris. Lima puluh persen pasien mengalami retinopati
setelah 10 tahun menyandang diabetes.
Pada stadium awal, dimana pengobatan paling efektif bila dilakukan,
tidak ada tanda gejala penglihatan. Skrining retina rutin oleh ahli adalah bagian
dari perawatan diabetes yang baik. Faktor resiko yang bisa dikendalikan
diantaranya adalah hipertensi dan merokok. Gangguan penglihatan ditandai oleh:</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l43 level1 lfo40; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Mikroaneurisma-dilatasi
fokal dinding kapiler, tidak terlihat dengan oftalmoskop;</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l43 level1 lfo40; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Titik
atau bintik pendarahan intraretinal;</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l43 level1 lfo40; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Eksudat
lunak (seperti kapas) yang disebabkan oleh mikroinfark pada serabut saraf
superfisial;</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l43 level1 lfo40; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Eksudat
keras akibat kebocoran plasma ke retina; dan</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l43 level1 lfo40; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Edema
retina.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pada
retinopati proliferatif terjadi proliferasi pembuluh darah baru sebagai respons
terhadap iskemia, terutama didekat batas diskus. Pembuluh darah rapuh ini mudah
mengalami pendarahan ke retina dan vitreus. Pendarahan vitreus menyebabkan
kebutaan mendadak, diikuti fibrosis dan kontraksi yang menyebabkan ablasio
retina dan glaukoma. Foto koagulasi menghancurkan pembuluh darah baru dan
menurunkan kebutuhan oksigen di seluruh bagian retina, sehingga memperlambat
proliferi pembuluh darah baru. </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Ginjal</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Tiga
puluh persen pasien diabetes tipe I mengalami gagal ginjal stadium akhir.
Hiperfiltrasi dan peningkatan klirens kreatinin terjadi dini setelah onset
diabetes. Setelah beberapa tahun, perubahan mikrovaskular (penebalan membran
basalis, degenerasi hialin arteriol aferen dan eferen) dihubungkan dengan
meningkatnya permeabilitas glomerulus dan proteinuria. Nodul kimmelstie-wilson
(glomerulosklerosis nodular) adalah tanda patognomonik dari nefropati
diabetikum.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Mikroalbuminuria
merupakan tanda kardinal onset penyakit ginjal akibat diabetes, dan menunjukan
adanya penyakit vaskular progresif yang menyeluruh. Laju eksresi albumin
(albumin excretion rate/AER) urin 24-jam yang normal adalah < 15 mg
(konsentrasi < 20 mg/L). Yang disebut mikroalbuminuria adalah AER sebesar
50-300 mg (konsentrasi < 20-200 mg/L). Begitu terjadi proteinuria persisten
(> 300 mg dalam 24 jam), gagal ginjal stadium akhir biasanya terjadi setelah
5 tahun.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Berkembangnya
mikroalbuminuria berhubungan erat dengan perubahan tekanan darah, dan
pengendalian tekanan darah mungkin lebih penting daripada pengendalian glikemik
untuk mencegah penyakit ginjal. Inhibitor ACE mencegah berkembangnya
mikroalbuminuria menjadi proteinuria pada pasien non hipertensif yang
menyandang IDDM. Keadaan ini biasanya membaik dengan pengobatan hipertensi pada
diabetes, baik dalam pemberian obat tunggal ataupun gabungan dengan obat lain. </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Pielonefritis
lebih sering ditemukan pada diabetes. Nekrosis papiler ginjal bisa terjadi
akibat iskemia papila, yang bisa terlepas dan menyebabkan obstruksi.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Komplikasi
Neuromuskular</span></b><span style="font-family: "Arial","sans-serif";"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Arial","sans-serif";">Sampai
50% pasien dengan diabetes yang sudah berlangsung lama mengalami komplikasi
neuromuskular.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l45 level1 lfo41; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Neuropati
perifer adalah komplikasi tersering, pada awalnya menyebabkan hilangnya
sentakan pergelangan kaki dan tidak adanya sensasi getar pada eksremitas bawah.
Kemudian sensasi raba dan nyeri menghilang. Pasien sering sekali mengeluh baal,
dan rasa seperti terbakar yang lebih berat dimalam hari. Ulkus kronis tanpa
nyeri berkembang di tempat-tempat yang terkena trauma berulang (misalnya
titik-titik tekanan pada penggunaan sepatu yang tidak pas). Artropati
neuropatik tanpa nyeri (sendi charcot) paling sering mengenai sendi
tarssometatarsal.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l45 level1 lfo41; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Neuropati
perifer yang terasa nyeri mungkin merespon terhadap pemberian gabapentin atau
trisiklik (antidepresan) oral atau pemberian krim capsaicin topikal.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l45 level1 lfo41; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Mononeuritis
diduga timbul akibat iskemia setelah terjadi oklusi vasa nervorum. Saraf
kranialis III, n. Ulnaris atau n. Poplitealis lateralis adalah yang paling
sering terkena. Bisa mengenai lebih dari satu saraf. Seringkali transien, dan
biasanya terjadi pemulihan fungsi yang spontan dalam periode berbulan-bulan. </span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l45 level1 lfo41; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Amiotrofi
diabetikum biasanya terjadi pada penyandang diabetes usia paruh baya yang
mengalami kelemahan dan pengecilan otot kuadriseps asimetris dan nyeri.
Perbaikan kontrol diabetes seringkali berhubungan dengan pemulihan.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l45 level1 lfo41; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Neuropati
otonom menyebabkan: disfungsi ereksi (impotensi) pada 25% pasien pria; diare,
seringkali nokturnal; gastroparesis; hipotensi postural; berliur; dan gangguan
kantung kemih neuropatik.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<b><span style="font-family: "Arial","sans-serif";">Kulit</span></b><span style="font-family: "Arial","sans-serif";"> </span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l11 level1 lfo42; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Sensitivitas
insulin bisa terjadi pada bulan pertama terapi insulin dengan timbulnya
benjolan yang nyeri setelah tiap disuntikan. Terjadi penyembuhan spontan, dan
bukan merupakan indikasi untuk mengubah terapi.</span></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-list: l11 level1 lfo42; text-align: justify; text-indent: 0cm;">
<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Lipodistropi
adalah atrofi atau hipertrofi ditempat suntikan tanpa disertai nyeri. Jarang
terjadi setelah ditemukannya insulin manusia rekombian.</span></div>
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<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Nekrobiosis
lipoidika (diabetikorum) yang tampak patognomonik untuk diabetes, terjadi pada
1% kasus dan bisa timbul sebelum terjadinya diabetes. Ditandai dengan atrofi kolagen
subkutan, biasanya pada betis. Lesi berawal sebagi bercak kecil berwarna
kecoklatan dan mengkilat dan bisa timbul cincin ungudan massa kuning dibagian
perifer dan berbentuk parut, atrofi, dan kadang-kadang ulserasi dibagian
tengah. Penatalaksanaan yang paling penting adalah melindungi lesi dari trauma.
Kamuflase kosmetik bisa mengurangi trauma emosional. Tidak ada terapi kuratif.</span></div>
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<span style="font-family: Symbol;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Arial","sans-serif";">Fotosensitivitas
bisa terjadi pada pemberian klorpropamid.</span></div>
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<b><span style="font-family: "Arial","sans-serif";">Penyakit
Kaki Diabetikum</span></b><span style="font-family: "Arial","sans-serif";"> </span></div>
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<span style="font-family: "Arial","sans-serif";">Tim
perawatan kaki dirumah sakit meliputi ahli kaki (podiatri), ahli bedah
vaskular, dokter umum, ahli radiologi, dan perawat. Faktor resiko utama yaitu
hiperglikemia, merokok, dan hipertensi, harus diidentifikasi dan dikendalikan
bila perlu. Neuropati dan penyakit vaskular perifer serta halus dinilai dan
dipertimbangkan untuk melakukan rekontruksi vaskular. Ulserasi, gangren, dan
amputasi bisa sangat dikurangi dengan penyuluhan pada pasien mengenai perawatan
kaki.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></div>
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<b><span style="font-family: "Arial","sans-serif";">Infeksi
Penyerta</span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";"></span></b></div>
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<b><span lang="EN-US" style="font-family: "Arial","sans-serif";">I</span></b><span style="font-family: "Arial","sans-serif";">nfeksi
penyerta sering ditemukan pada penyandang diabetes, khususnya infeksi saluran
kemih dan kulit. Tuberkolosis dan kandidiasis (vulvitis dan balanitis) lebih
sering ditemukan pada diabetes</span></div>
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<a href="http://www.blogger.com/post-edit.g?blogID=2501725445038181687&postID=2834189040545035816&from=pencil" name="_PictureBullets"><span lang="EN-US" style="display: none; font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 150%;"><img alt="*" border="0" height="15" src="file:///C:/Users/COMPAQ/AppData/Local/Temp/msohtmlclip1/01/clip_image001.gif" width="15" /></span></a><span style="font-family: "Arial","sans-serif";"></span></div>arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-78266562691410651152012-03-18T13:38:00.002+07:002013-05-16T08:08:15.814+07:00Malnutrisi (Gizi buruk)<span style="font-size: small;"><span style="font-family: inherit;"><br /></span></span><div style="text-align: justify;">
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<span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">PENDAHULUAN</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Gizi buruk merupakan status kondisi seseorang yang kekurangan nutrisi, atau nutrisinya di bawah standar. Gizi masih menjadi masalah yang belum terselesaikan sampai saat ini. Gizi buruk banyak di alami oleh bayi di bawah 5 tahun (balita).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Banyak factor – factor yang dianggap mempengaruhi gizi buruk. Nmun penyebab dasar tejadinya gizi buruk ada 2 hal yaitu sebab langsung dan tidak langsung. Sebab langsung adalah kurangnya asupa gizi dari makanan dan akibat terjadinya penyakit bawaan yang mengakibatkan mudah terinfeksi penyakit DBD, Diare dan lain – lain. Sedangkan kemiskinan di duga menjadi penyebab utama terjadinya gizi buruk. Kurangnya asupan gizi bias di sebabkan oleh terbatasnya jumlah makanan yang di konsumsi atau makanannya tidak memenuhi unsur gizi yang di butuhkan oleh tubuh.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">PEMBAHASAN</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.1 DEFINISI DAN CIRI-CIRI GIZI BURUK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.1.1 Definisi Gizi Buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Gizi buruk adalah keadaan kurag gizi yang di sebabkan oleh rendahnya konsumsi energi dan protein dalam makanan sehari-hari atau disebabkan oleh gangguan penyakit tertentu, sehingga tidak memenuhi angka kecukupan gizi (depkes RI, 1999). Gizi buruk adalah bentuk terparah dari proses terjadinya kekurangan gizi menahun (Nency, 2005).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Jadi, Gizi buruk adalah suatu kondisi di mana seseorang dinyatakan kekurangan nutrisi, atau dengan ungkapan lain status nutrisinya berada di bawah standar rata-rata. Nutrisi yangdimaksud bisa berupa protein, karbohidrat dan kalori. Di Indonesia, kasus KEP (Kurang EnergiProtein) adalah salah satu masalah gizi utama yang banyak dijumpai pada balita. Gizi buruk atau lebih dikenal dengan gizi di bawah garis merah adalah keadaan kurang gizi tingkat berat yang disebabkan oleh rendahnya konsumsi energi dan protein dari makanan sehari-hari dan terjadi dalam waktu yang cukup lama. Tanda-tanda klinis dari gizi buruk secaragaris besar dapat dibedakan marasmus, kwashiorkor atau marasmic-kwashiorkor (RI dan WHO,Rencana Aksi Pangan dan Gizi Nasional 2001 2005, Jakarta, Agustus 2000).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Klasifikasi KEP:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. KEP ringan : > 80-90% BB ideal terhadap TB</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. KEP sedang : > 70-80% BB ideal terhadap TB</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. KEP berat : 70% BB ideal terhadap TB</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><a name='more'></a><br /><span style="font-size: small;"><span style="font-family: inherit;">Menurut departemen kesehatan RI (1999) dalam tata buku tata laksana KEP pada anakdi pukesmas dan di rumah tangga, KEP berdasarkan gejala klinis ada tiga yaitu KEP ringan, sedang, dan berat (gizi buruk). Untuk KEP ringan dan sedang, gejala klinis yang ditemukan hanya anak tampak kurus. Gejala klinis KEP berat atau gizi buruk secara garis besar dapat di bedakan sebagai marasmus, kwashiorkor, dan marasmus-kwashiorkor.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.1.2 Ciri-Ciri Gizi Buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. Kwashiokor</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. Edema umumnya diseluruh tubuh dan terutama pada kaki ( dorsumpedis)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b. Wajah membulat dan sembab</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c. Otot-otot mengecil,lebih mengecil,lebih nyata apabila diperiksa pada posisi berdiri dan duduk,anak berbaring terus menerus.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d. Perubahan status menta; cengeng.rewel,kadang apatis</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e. Anak sering menolak segala jenis makanan (Anoreksia)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">f. Pembesaran hati</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">g. Rambut berwarna kusam dan mudah dicabut</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">h. Gangguan kulit berupa bercak merah yang meluas dan berubah menjadi hitam terkelupas ( crazy pavement dermatosis)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">i. Pandangan mata anak nampak sayu</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Marasmus</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. Anak sangat kurus</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b. Wajah seperti orang tua</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c. Cengeng dan rewel</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d. Rambut tipis,jarang,dan kusam</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e. Kulit keriput</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">f. Tulang Iga tampak jelas</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">g. Pantat kendur </span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">h. Perut cekung</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">i. Sering disertai diare kronik atau konstipasi/susah buang air,serta penyakit kronik.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">j. Tekanan darah,detak jantung dan pernafasan berkurang</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. Marasmus-Kwashiokor</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Merupakan campuran dari beberapa ciri-ciri kwashiorkor dan marasmus.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.3 JENIS-JENIS GIZI BURUK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.3.1 Marasmus</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Marasmus ditandai olehpenciutan/pengurusan (wasting) otot generalisata dan tidak adanya lemak subkutis. Anak marasmus tampak kakektis dan sangat kurus. Mereka derita wasting yang parah dan sering juga mengalami hambatan pertumbuhan linear. Kulit mereka kering, tanpa tugor, dan tampak longgar dan berkerut karena hilangnya lemak subkubis. , klasik wajah cekung atu berkeriput yan g mirip orang tua,terjadi akibat hilannya banantalan lemak temporal dan bukal.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.3.2 Kwasiorkor</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Kwasiorkor disebabkan oleh insufesiensi asupan protein yang bernilai biologis adekuat,dan seing berkaitan dengan defisiensi asupan energi. Gambaran utama pada malnutrisi tersebut adalah edema yang lunak,pitting, dan tidak nyeri ,biasanya di kakl tungkai kaki dapat meluas.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.3.3 Kwasior Marasmus</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Bentuk kwasior marasmus dari malnutrisi protein protein-energi ditandai dengan gambaran klinis kedua jeni8smalnutrisi. Keadaan ini dapat terjadi pada malnutrisi kronik saat saat jaringan subkutis, massa otot, dan simpanan lemak menghilang. Gambaran utama tanpa lesi kulit, kekaksia marasmus.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.3 Epidemiologi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Masalah kesehatan yang menimbulkan perhatian masyarakat cukup besar akhir-akhir ini adalah masalah gizi kurang dan gizi buruk. Walaupun sejak tahun 1989 telah terjadi penurunan prevalensi gizi kurang yang relatif tajam, mulai tahun 1999 penurunan prevalensi gizi kurang dan gizi buruk pada balita relatif lamban dan cenderung tidak berubah. Saat ini terdapat 10 provinsi dengan prevalensi gizi kurang di atas 30, dan bahkan ada yang di atas 40 persen, yaitu di Provinsi Gorontalo, Nusa Tenggara Barat (NTB), Nusa Tenggara Timur (NTT), dan Papua.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Kurang energi dan protein pada tingkat parah atau lebih populer disebut busung lapar, dapat menimbulkan permasalahan kesehatan yang besar dan bahkan dapat menyebabkan kematian pada anak. Menurut data Susenas 2003, diperkirakan sekitar 5 juta (27,5 persen) anak balita menderita gizi kurang, termasuk 1,5 juta (8,3 persen) di antaranya menderita gizi buruk. Data Departemen Kesehatan menunjukkan bahwa pada tahun 2004 masih terdapat 3,15 juta anak (16 persen) menderita gizi kurang dan 664 ribu anak (3,8 persen) menderita gizi buruk. Pada tahun 2005 dilaporkan adanya kasus gizi buruk tingkat parah atau busung lapar di Provinsi NTB dan NTT, serta beberapa provinsi lainnya. Penderita kasus gizi buruk terbesar yang dilaporkan terjadi di Provinsi NTB, yaitu terdapat 51 kasus yang dirawat di rumah sakit sejak Januari sampai dengan Mei 2005. Jumlah kasus di sembilan provinsi sampai Juni 2005 dilaporkan sebanyak 3.413 kasus gizi buruk dan 49 di antaranya meninggal dunia.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Munculnya kejadian gizi buruk ini merupakan “fenomena gunung es” yang menunjukkan bahwa masalah gizi buruk yang muncul hanyalah sebagian kecil dari masalah gizi buruk yang sebenarnya terjadi. Di Provinsi NTB, misalnya, berdasarkan hasil pencatatan dan pelaporan sejak Januari-Juni 2005 hanya ditemukan sekitar 900 kasus. Namun, diperkirakan terdapat 2.200 balita marasmus kwashiorkor. Masalah busung lapar terutama dialami oleh anak balita yang berasal dari keluarga miskin.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Dua faktor penyebab utama terjadinya gizi buruk tersebut adalah rendahnya konsumsi energi dan protein dalam makanan sehari-hari dan terjadi dalam kurun waktu yang lama. Penyebab kedua adalah terjadinya serangan penyakit infeksi yang berulang. Kedua faktor ini disebabkan oleh tiga hal secara tidak langsung, yaitu (1) ketersediaan pangan yang rendah pada tingkat keluarga; (2) pola asuh ibu dalam perawatan anak yang kurang memadai; dan (3) ketersediaan air bersih, sarana sanitasi, dan sarana pelayanan kesehatan dasar yang terbatas. Penyebab tidak langsung tersebut merupakan konsekuensi dari pokok masalah dalam masyarakat, yaitu tingginya pengangguran, tingginya kemiskinan, dan kurangnya pangan.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Gizi buruk ini menjadi masalah di negara-negara miskin dan berkembang di Afrika, Amerika Tengah, Amerika Selatan dan Asia Selatan. Di negara maju sepeti Amerika Serikat kwashiorkor merupakan kasus yang langka. Berdasarkan SUSENAS (2002), 26% balita di Indonesia menderita gizi kurang dan 8% balita menderita gizi buruk (marasmus, kwashiorkor, marasmus-kwashiorkor).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pada umumnya masyarakat indonesia telah mampu mengkonsumsi makanan yang cukup secara kuantitatif. Namun dari segi kualitatif masih cukup banyak yang belum mampu mencukupi kebutuhan gizi minimum. Departemen Kesehatan juga telah melakukan pemetaan, dan hasilnya menunjukan bahwa penderita gizi kurang ditemukan di 72% kabupaten di Indonesia. Indikasinya 2 – 4 dari 10 balita di Indonesia menderita gizi kurang.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Sesuai dengan survai di lapangan, insiden gizi buruk dan gizi kurang pada anak balita yang dirawat mondok di rumah sakit masih tinggi. 935 (38%) penderita malnutrisi dari 2453 anak balita yang dirawat di RSU Dr. Pirngadi Medan. Mereka terdiri dari 67% gizi kurang dan 33% gizi buruk. Penderita gizi buruk yang paling banyak dijumpai ialah tipe marasmus. Arif di RS. Dr. Sutomo Surabaya mendapatkan 47% dan Barus di RS Dr. Pirngadi Medan sebanyak 42%. Hal ini dapat dipahami karena marasmus sering berhubungan dengan keadaan kepadatan penduduk dan higiene yang kurang di daerah perkotaan yang sedang membangun dan serta terjadinya krisis ekonomi di ludonesia.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.4 ETIOLOGI GIZI BURUK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Menurut UNICEF ada dua penyebab langsung terjadinya gizi buruk, yaitu :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1) Kurangnya asupan gizi dari makanan. Hal ini disebabkan terbatasnya jumlah makanan yang dikonsumsi atau makanannya tidak memenuhi unsur gizi yang dibutuhkan karena alasan sosial dan ekonomi yaitu kemiskinan.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2) Akibat terjadinya penyakit yang mengakibatkan infeksi. Hal ini disebabkan oleh rusaknya beberapa fungsi organ tubuh sehingga tidak bisa menyerap zat-zat makanan secara baik.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Faktor lain yang mengakibatkan terjadinya kasus gizi buruk yaitu :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1) Faktor ketersediaan pangan yang bergizi dan terjangkau oleh masyarakat.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2) Perilaku dan budaya dalam pengolahan pangan dan pengasuhan asuh anak. </span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3) Pengelolaan yang buruk dan perawatan kesehatan yang tidak memadai.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Menurut Ikatan Dokter Anak Indonesia (IDAI), ada 3 faktor penyebab gizi buruk pada balita, yaitu :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1) Keluarga miskin.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2) Ketidaktahuan orang tua atas pemberian gizi yang baik bagi anak.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3) Faktor penyakit bawaan pada anak, seperti: jantung, TBC, HIV/AIDS, saluran pernapasan dan diare.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.5 PATOFISIOLOGI GIZI BURUK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> </span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Patofisiologi gizi buruk pada balita adalah anak sulit makan atau anorexia bisa terjadi karena penyakit akibat defisiensi gizi, psikologik seperti suasana makan, pengaturan makanan dan lingkungan. Rambut mudah rontok dikarenakan kekurangan protein, vitamin A, vitamin C dan vitamin E. Karena keempat elemen ini merupakan nutrisi yang penting bagi rambut. Pasien juga mengalami rabun senja. Rabun senja terjadi karena defisiensi vitamin A dan protein. Pada retina ada sel batang dan sel kerucut. Sel batang lebih hanya bisa membedakan cahaya terang dan gelap. Sel batang atau rodopsin ini terbentuk dari vitamin A dan suatu protein. Jika cahaya terang mengenai sel rodopsin, maka sel tersebut akan terurai. Sel tersebut akan mengumpul lagi pada cahaya yang gelap. Inilah yang disebut adaptasi rodopsin. Adaptasi ini butuh waktu. Jadi, rabun senja terjadi karena kegagalan atau kemunduran adaptasi rodopsin.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Turgor atau elastisitas kulit jelek karena sel kekurangan air (dehidrasi). Reflek patella negatif terjadi karena kekurangan aktin myosin pada tendon patella dan degenerasi saraf motorik akibat dari kekurangn protein, Cu dan Mg seperti gangguan neurotransmitter. Sedangkan, hepatomegali terjadi karena kekurangan protein. Jika terjadi kekurangan protein, maka terjadi penurunan pembentukan lipoprotein. Hal ini membuat penurunan HDL dan LDL. Karena penurunan HDL dan LDL, maka lemak yang ada di hepar sulit ditransport ke jaringan-jaringan, pada akhirnya penumpukan lemak di hepar.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Tanda khas pada penderita kwashiorkor adalah pitting edema. Pitting edema adalah edema yang jika ditekan, sulit kembali seperti semula. Pitting edema disebabkan oleh kurangnya protein, sehingga tekanan onkotik intravaskular menurun. Jika hal ini terjadi, maka terjadi ekstravasasi plasma ke intertisial. Plasma masuk ke intertisial, tidak ke intrasel, karena pada penderita kwashiorkor tidak ada kompensansi dari ginjal untuk reabsorpsi natrium. Padahal natrium berfungsi menjaga keseimbangan cairan tubuh. Pada penderita kwashiorkor, selain defisiensi protein juga defisiensi multinutrien. Ketika ditekan, maka plasma pada intertisial lari ke daerah sekitarnya karena tidak terfiksasi oleh membran sel dan mengembalikannya membutuhkan waktu yang lama karena posisi sel yang rapat. </span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Edema biasanya terjadi pada ekstremitas bawah karena pengaruh gaya gravitasi, tekanan hidrostatik dan onkotik (Sadewa, 2008).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Sedangkan menurut Nelson (2007), penyebab utama marasmus adalah kurang kalori protein yang dapat terjadi karena : diet yang tidak cukup, kebiasaan makan yang tidak tepat seperti hubungan orang tua dengan anak terganggu, karena kelainan metabolik atau malformasi kongenital. Keadaan ini merupakan hasil akhir dari interaksi antara kekurangan makanan dan penyakit infeksi. Selain faktor lingkungan ada beberapa faktor lain pada diri anak sendiri yang dibawa sejak lahir, diduga berpengaruh terhadap terjadinya marasmus. Secara garis besar sebab-sebab marasmus adalah sebagai berikut :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. Masukan makanan yang kurang : marasmus terjadi akibat masukan kalori yang sedikit, pemberian makanan yang tidak sesuai dengan yang dianjurkan akibat dari ketidaktahuan orang tua si anak, misalnya pemakaian secara luas susu kaleng yang terlalu encer.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b. Infeksi yang berat dan lama menyebabkan marasmus, terutama infeksi enteral misalnya infantil gastroenteritis, bronkhopneumonia, pielonephiritis dan sifilis kongenital.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c. Kelainan struktur bawaan misalnya : penyakit jantung bawaan, penyakit Hirschpurng, deformitas palatum, palatoschizis, mocrognathia, stenosis pilorus. Hiatus hernia, hidrosefalus, cystic fibrosis pankreas</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d. Prematuritas dan penyakit pada masa neonatus. Pada keadaan tersebut pemberian ASI kurang akibat reflek mengisap yang kurang kuat</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e. Pemberian ASI yang terlalu lama tanpa pemberian makanan tambahan yang cukup</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">f. Gangguan metabolik, misalnya renal asidosis, idiopathic hypercalcemia, galactosemia, lactose intolerance</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">g. Tumor hypothalamus, kejadian ini jarang dijumpai dan baru ditegakkan bila penyebab maramus yang lain disingkirkan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">h. Penyapihan yang terlalu dini desertai dengan pemberian makanan tambahan yang kurang akan menimbulkan marasmus</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">i. Urbanisasi mempengaruhi dan merupakan predisposisi untuk timbulnya marasmus, meningkatnya arus urbanisasi diikuti pula perubahan kebiasaan penyapihan dini dan kemudian diikuti dengan pemberian susu manis dan susu yang terlalu encer akibat dari tidak mampu membeli susu, dan bila disertai infeksi berulang terutama gastroenteritis akan menyebabkan anak jatuh dalam marasmus</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.5.1 Perjalanan Penyakit Gizi Buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Seorang anak bisa menjadi gizi buruk bisa berada dalam 3 tahap :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Status Gizi Normal</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Ibu tidak mengetahui makanan yang tepat untuk diberikan pada balita.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Anak balita terpajan dengan iklan panganan ringan yang tidak bergizi.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Asupan buat anak tidak diistimewakan sebagaimana yang dipersiapkan untuk ayah atau ibunya.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Tidak rutin datang ke Posyandu.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Pada saat seperti ini anak masih berada dalam keadaan status gizi normal, namun berpotensi mendapatkan gangguan gizi. Pada usia < 6 bulan sebagian besar bayi (> 80%) masih disusui ibu. Dengan menetek, anak mendapatkan gizi yg seimbang & zat kebal dari asi anak jarang sakit pertumbuhan anak masih baik.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Status Gizi Kurang / Menurun (Fase Gangguan Gizi)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pada saat ini balita mengalami gangguan gizi, ini terjadi karena tidak terpantaunya berat badan anak. Pada usia 6 bln – 12 bln sebagian bayi sudah mulai disapih perlindungan zat kebal dari asi mulai berkurang & pemberian mp-asi kurang memenuhi syarat : jenis, jumlah, jadwal, higienis (3j-1h). Anak mudah jatuh sakit dan pertumbuhan mulai terganggu.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Status Gizi Buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pada saat ini status anak makin memburuk dan sudah menampakkan gejala-gejala penyakit. Anak sudah terlihat kurus sampai dengan sangat kurus. Pada saat ini anak rentan terhadap hawa dingin, khususnya pada bayi bisa berakibat kematian. Anak juga mengalami kekurangan energi (glukosa darah menurun) dan kekurangan protein. Pada beberapa kasus yang severe tidak hanya pembentukan otot yang gagal bahkan sampai dengan pembentukan otak bisa tidak terjadi (microcephali). Kematian bisa terjadi di tahap ini, bisa karena berbagai sebab.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> </span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.6 MANIFESTASI KLINIS GIZI BURUK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Gizi buruk atau malnutrisi dapat diartikan sebagai asupan gizi yang buruk. Hal ini bisa diakibatkan oleh kurangnya asupan makanan, pemilihan jenis makanan yang tidak tepat ataupun karena sebab lain seperti adanya penyakit infeksi yang menyebabkan kurang terserapnya nutrisi dari makanan. Secara klinis gizi buruk ditandai dengan asupan protein, energi dan nutrisi mikro seperti vitamin yang tidak mencukupi ataupun berlebih sehingga menyebabkan terjadinya gangguan kesehatan.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">KEP berat secara klinis terdapat 3 tipe yaitu kwashiorkor, marasmus, dan marasmik- kwashiorkor. KEP ringan atau sedang disertai edema yang bukan karena penyakit lain disebut KEP berat TIPE Kwashiorkor.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.6.1. Gejala Klinis Kurang Energi Protein (KEP) dari marasmus</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. Tampak sangat kurus (tulang terbungkus kulit)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Wajah seperti orang tua</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. Cengeng dan Rewel</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4. Sering disertai: penyakit kronik, diare kronik</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5. Kulit keriput, jaringan lemak subkutis sangat sediki tsampai tidak ada (~pakai celana longgar-baggy pants)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">6. Perut cekung</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">7. Iga gambang</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.6.2 GejalaKlinisKurangEnergi Protein (KEP) dari kwashiorkor</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. gejala terpenting ialah pertumbuhan yang terganggu. Selain berat badan juga tinggi badan kurang dibandingkan dengan anak sehat</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Perubahan mental biasanya penderita cengeng dan pada stadium lanjut menjadi apatis.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. pada sebagian besar penderita ditemukan edema baik ringan maupun yang berat.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4. Wajah membulatdansembab</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5. Pandangan mata sayu</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">6. Rambut tipis, kemerahan seperti seperti warna rambut jagung, mudah dicabut tanpa rasa sakit, rontok</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">7. Pembesaran hati</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">8. Otot mengecil (hipotrofi), lebih nyata bila diperiksa pada posisi berdiri atau duduk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">9. Kelainan kulit berupa bercak merah muda yang meluas dan berubah warna menjadi coklat kehitaman dan terkupas( crazy pavement dermatosis)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">10. Sering disertai: infeksi, anemia, diare</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.6.3 Gejala Klinis Marasmus-Kwashiorkor</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Gejala Klinis Kurang Energi Protein (KEP) dari Marasmus-kwashiorkor pada dasarnya adalah campuran dari gejala marasmus dan kwashiorkor, cirri khas yang dapat terlihat secara klinis yakni :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. Beberapagejalaklinik marasmus, terlihatsangatburukberat badan kurang dari 60% berat anak normal seusianya.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Kwashiorkorsecaraklinisterlihatdisertai edema yang tidakmencolokpadakeduapunggung kaki</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pada setiap penderia KEP berat, selalu periksa adanya gejala defisiensi Nutrien Mikro yang sering menyertai seperti:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. xerophthalmia (defisiensi Vitamin A), </span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Anemia (Kekurangan Fe, Cu, Vit. B12, Asam Folat)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. Stomatitis (kekurangan vit. B, vit. C)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4. Kelainan pada kulit, gangguan pertumbuhan (kekurangan Zn)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5. Beri-beri (kekurangan vitamin B1)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.7 DIAGNOSIS GIZI BURUK( ANAMNESIS & PEMERIKSAAN FISIK)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.7.1 Anamnesis Awal (Untuk Kedaruratan)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. badan kurus sejak 3 bulan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b. sulit makan </span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c. rambut mudah rontok</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d.tangan dan kaki sering keram dan rabun senja</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.7.2 Anamnesis lanjutan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. Makanan biasa sebelum sakit</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b.Riwayat ASI</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c. frekuensi, dan konsistensi muntah atau diare</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d.Kehamilan perawatan antenatal:di ...setiap minggu/bulan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e.Kelahiran:Tempat kelahiran:RS/Rumah</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> f.Penolong persalinan :Dokter/bidan/dukun</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">g.Keadaan Bayi:Berat lahir g:,panjang cm,lingkar kepala cm, langsung ...menangis/tidak h.Kelainan bawaan:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">i.Tumbuh kembang</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Tengkurap : bulan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Duduk bulan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Berdiri bulan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Berjalan: bulan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Bicara: bulan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">j.Imunisasi Lengkap</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Jenis imunisasi:BCG,campak,folio,DPT,Hepatitis</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> k.Apakah ditimbang setiap bulan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">l.Lingkungan keluarga (untuk memahami latar belakang sosial anak)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> </span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.7.3.Pemeriksaan Fisik</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a) Inspeksi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">• Mata : agak menonjol</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">• Wajah : membulat dan sembab</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">• Kepala : rambut mudah rontok dan kemerahan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">• Abdomen : perut terlihat buncit</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">• kulit : adakah Crazy pavement dermatosis, keadaan turgor kulit,odema</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b) Palpasi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c) Auskultasi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d) Peristaltic usus abnormal</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e) Apakah anak tampak sangat kurus/ odema/ pembengkakan kedua kaki</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">f) Tanda-tanda terjadinya syok (rejatan) : tangan dan kaki dingin, nadi lemah, dan kesadaran menurun</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">g) Frekuensi dan tipe pernapasan: pneumonia atau gagal jantung</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">h) Tanda dehidrasi: tampak haus, mata cekung, turgor buruk (hati-hati menentukan status dehidrasi pada gizi buruk).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">i) Frekuensi pernafasan dan tipe pernafasan: gejala pneumonia atau gejala gagal jantung</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">j) Tentukan status gizi dengan menggunakan BB/TB-PB.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">k) Pembesaran hati dan adanya kekuningan (ikterus) pada bagian putih mata (conjunktiva)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">l) Adanya perut kembung, suara usus, suara usus, dan adanya suara seperti pukulan pada permukaan air (abdominal splash)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">m) Pucat yang sangat berat</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">- Kulit: tanda infeksi atau purpura</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">- pemeriksaan tanda utama pasien di mulai dari frekuensi nadi,frekuensi nafas,pengukuran suhu tubuh.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">n) Penilaian status gizi pada pasien dimulai dengan pengukuran berat badan, tinggi badan, lingkar kepala dan lingkar lengan atas.Dengan menggunakan pengukuran status gizi berdasarkan CDC maka BB/TB x 100% =memberikan hasil bahwa status gizi pasien gizi kurang.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">o) Pemeriksaan pasien dilanjutkan dengan pemeriksaan khusus, Dimulai dengan pemeriksaan kulit, pemeriksaan kepala, pemeriksaan mulut, pemeriksaan leher, Pemeriksaan thoraks, Pemeriksaan dilanjutkandengan pemeriksaan paru, Pemeriksaan abdomen, pemeriksaan genitalia, Lalu pemeriksaan anak ini dilanjutkan pada daerah ekstremitas,</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.8 PROGNOSIS GIZI BURUK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Gizi buruk yang hebat mempunyai angka kematian yang tinggi. Kematian sering disebabkan oleh infeksi sering tidak dapat dibedakan kematian karena infeksi atau karena gizi buruk itu sendiri. Prognosis tergantung dari stadium saat pengobatan mulai dilaksanakan. Pada penderita gizi buruk pemberian diet tinggi kalori dan tinggi protein serta mencegah kekambuhan penderita gizi buruk tanpa komplikasi dapat berobat jalan asal diberi penyuluhan tentang pemberian makanan yg baik, sedangkan penderita yang komplikasi serta dehidrasi , syok dan lain-lain perlu mendapat perawatan dirumah sakit.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Lebih dari 40% anak menderita gizi buruk meninggal. Kematian ini terjadi mulai dari hari pertama pengobatan biasanya disebabkan oleh</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Ø Gangguan elektrolit</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Ø Infeksi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Ø Hipotermia (suhu tubuh yang sangat rendah)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Ø Kegagalan jantung</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Keadaan setengah sadar (stupor), jaundice (sakit kuning), pendarahan kulit, rendahnya kadar natrium darah, dan diare yang menetap merupakan pertanda buruk. Pertanda baik adalah hilangnya apati, edema dan pertambahan nafsu makan.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Efek jangka panjang pada masa kanak-kanak tidak diketahui. Jika anak-anak diobati dengan tepat maka sistem kekebalan, hati akan sembuh sempurna. Tetapi pada beberapa anak penyerapan gizi di usus tetap mengalami gangguan.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Beratnya gangguan mental yang dialami berhubungan dengan lamanya anak menderita gizi buruk, beratnya gizi buruk, dan usia anak saat mederita gizi buruk keterbelakangan mental yang bersifat ringan bisa menetap sampai anak mencapai usia sekolah dan mungkin lebih.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pengobatan pada penderita gizi buruk tentu saja harus disesuaikan pada tingkatannya. Penderita gizi buruk stadium ringan contohnya diatasi dengan perbaikan gizi. Dalam sehari anak-anak ini harus mendapatkan asupan protein sekitar 2-3 gram atau setara dengan 100-150 Kkal.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pengobatan gizi buruk berat cenderung lebih kompleks karena masing-masing penyakit yang menyertai harus diobati satu persatu. Penderita pun sebaiknya harus dirawat dirumah sakit agar mendapat perhatian medis secra penuh. Sejalan dengan pengobatan penyakit penyerta maupun infeksinya status gizi anak tersebut terus diperbaiki hingga sembuh. Memulihkan keadaan gizinya dengan cara mengobati penyakit penyerta, peningkatan taraf gizi dan mencegah gejala dan kekambuhan dari gizi buruk.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.9 PENCEGAHAN DARI GIZI BURUK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Cara pencegahan gizi buruk secara umum ialah dapat dicegah dengan memberikan makanan yang bergizi pada anak berupa sayur mayur, buah-buahan, makanan yang mengandung karbohidrat (seperti nasi, kentang, jagung), makanan yang mengandung protein (telur, ikan ,daging) melakukan posyiandu secara rutin seperti(imunisasi) , dan berikanlah ASI bagi anak usia 0 – 2 tahun.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Gizi buruk terbagi menjadi 3 yaitu :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. Marasmus</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Marasmus adalah penyakit kelaparan dan terdapat banyak diantara kelompok social ekonomi rendah di sebagian besar Negara sedang berkembang dan lebih banyak dari pada kwashiorkor.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Cara pencegahan :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Tindakan pencegahan terhadap marasmus dapat dilaksanakan dengan baik bila penyebab diketahui.Usaha-usaha tersebut memerlukan sarana dan prasarana kesehatan yang baik untuk pelayanan kesehatan dan penyuluhan gizi.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. Pemberian air susu ibu (ASI) sampai umur 2 tahun merupakan sumber energi yang paling baik untuk bayi.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b. Ditambah dengan pemberian makanan tambahan yang bergizi pada umur 6 tahun ke atas.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c. Pencegahan penyakit infeksi, dengan meningkatkan kebersihan lingkungan dan kebersihan perorangan.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d. Pemberian imunisasi.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e. Mengikuti program keluarga berencana untuk mencegah kehamilan terlalu kerap.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">f. Penyuluhan/pendidikan gizi tentang pemberian makanan yang adekuat merupakan usaha pencegahan jangka panjang.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">g. Pemantauan (surveillance) yang teratur pada anak balita di daerah yang endemis kurang gizi, dengan cara penimbangan berat badan tiap bulan.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Kwashiorkor</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Kwashiorkor merupakan syndrome klinis akibat dari defisiensi berat dan masukan kalori tidak cukup.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Cara Pencegahan :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. Pencegahannya dapat berupa diet adekuat dengan jumlah-jumlah yang tepat dari protein (12 % dari total kalori). Sentiasa mengamalkan konsumsi diet yang seimbang dengan cukup karbohidrat, cukup lemak. Protein terutamanya harus disediakan dalam makanan. Untuk mendapatkan sumber protein yang bernilai tinggi bisa didapatkan dari protein hewan seperti susu, keju, daging, telur dan ikan. Bisa juga mendapatkan protein dari protein nabati seperti kacang ijo dan kacang kedelei,karena kwashiorkor tidak hanya mengalami perjalanan serius dan sering mematikan tetapi sering menimbulkan pengaruh di kemudian hari yang permanen dan merusak pada anak yang sembuh dan keturunannya.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b. Menjaga kebersihan, terutama keadaan lingkungan dan makanan supaya tidak mudah dihinggapi infeksi dan infestasi parasit dan timbulnya diare, mempercepat atau merupakan trigger mechanisme dari penyakit ini.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. Marasmus – Kwashiorkor</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Cara pencegahan marasmus – kwashiorkor adalah gabungan dari pencegahan yang ada pada marasmus dan kwashiorkor.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.10 PEMERIKSAAN PENUNJANG GIZI BURUK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. Pemeriksaan Laboratorium</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. Pada pemeriksaan darah meliputi Hb, albumin, globulin, protein total, elektrolit serum, biakan darah</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b. Profil lipid (lipid total, trigliserida, kolesterol, LDL, HDL)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Pemeriksaan urine</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Pemeriksaan urine meliputi urine lengkap dan kulture urine</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. Uji faal hati</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4. EKG</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5. X foto paru</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">6. Pemeriksaan radiologis: usia tulang, osteoporosis / osteomalsia</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">7. Pemeriksaan antropometris: BB, TB, BB/TB, LLA, LK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.10.1 Pemeriksaan Laboratorium</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pada pemeriksaan laboratorium, anemia selalu ditemukan terutama jenis normositik normokrom karena adanya gangguan sistem eritropoesis akibat hipoplasia kronis sum-sum tulang di samping karena asupan zat besi yang kurang dalam makanan, kerusakan hati dan gangguan absorbsi. Selain itu dapat ditemukan kadar albumin serum yang menurun. Pemeriksaan radiologis juga perlu dilakukan untuk menemukan adanya kelainan pada paru.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pemeriksaan ini meliputi kaidah pemeriksaan laboratorium klinis secara umum. Berupa pemeriksaan metabolit abnormal, perubahan aktivitas enzim, komponen darah atau fungsi fisiologis yang tergantung dari zat gizi tertentu (Gibson,2005), yaitu :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. Pemeriksaan status protein yang digunakan untuk penilaian status nutrisi : kadar albumin serum dengan nilai normal 3,5-5,0 gr/dl</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Transferin Serum dengan nilai normal > 200 mg/dl</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. Fungsi imunitas ; hitung limfosit total (%limfosit x sel darah putih)/100 dengan nilai normal diatas 1500 sel/mm2</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4. Pemeriksaan lain : Gula darah (BSS), profil lipid (kolesterol,triglyserid,LDL dan HDL), fungsi ginjal (ureum, kreatinin), fungsi hati (sgot,sgpt, bilirubin,gama gt dan alkalin fosfatase), fungsi tulang, otot dan sendi (asam urat, ASTO,CRP dan Rematic Factor)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pemeriksaan penunjang status gizi lainnya dengan foto rontgen, CT scan, MRI dan USG.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Diagnosa kerja pada kelainan nutrisi yaitu Status Gizi Antropometrik : obesitas,pre-obes,marasmus, kwarshiorkor, chronic energy deficiency</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pemeriksaan biokimia adalah pemeriksaan spesimen yang diuji secara laboratoris yang dilakukan pada berbagai macam jaringan tubuh. Jaringan tubuh yang digunakan antara lain: darah, urine, tinja dan juga beberapa jaringan tubuh seperti hati dan otot .</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Uji biokimiawi yang penting ialah pemeriksaan kadar hemoglobin, pemeriksaan apusan darah untuk malaria, pemeriksaan protein. Ada dua jenis protein, viseral dan somatik, yang layak dijadikan parameter penentu status gizi. Pemeriksaan tinja cukup hanya pemeriksaan occult blood dan telur cacing saja.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.10.2 Pemeriksaan Antropometris</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Antropometri secara umum digunakan untuk melihat ketidakseimbangan asupan protein dan energi. Ketidakseimbangan ini terlihat pada pola pertumbuhan fisik dan proporsi jaringan tubuh seperti lemak, otot, dan jumlah air dalam tubuh (Supariasa, 2002).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Penilaian antropometris yang penting dilakukan ialah penimbangan berat dan pengukuran tinggi badan, lingkar lengan, dan lipatan kulit triseps. Pemeriksaan ini penting, terutama pada anak yang berkelas ekonomi dan sosial rendah. Pengamatan anak dipusatkan terutama pada percepatan tumbuh.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Antropometri adalah pengukuran berbagai dimensi fisik tubuh manusia pada berbagai usia. Pengukuran dilakukan untuk mendapatkan nilai/data mentah pada seorang individu, misalnya umur, BB, TB, LLA, LK dan sebagainya. Indeks merupakan kombinasi hasil pengukuran, misalnya BB/U, TB/U dan sebagainya. Indikator adalah cut-off points untuk suatu indeks.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.10.2.1 Berat badan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Berat badan merupakan parameter pertumbuhan yang paling sederhana, mudah dilakukan dan diulang serta merupakan indeks untuk status gizi sesaat. Pengukuran dilakukan tanpa pakaian atau pakaian seminim mungkin dan tanpa sepatu. Keakuratan penimbangan pada anak besar 0,5 kg dan anak kecil/bayi 0,1 kg. Untuk mengevaluasinya diperlukan data umur yang tepat, jenis kelamin dan acuan standar. Interpretasi:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">BB/U dibandingkan standar yang diacu, dalam persentase:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">80-120% Gizi baik</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">60-80% Gizi kurang (tanpa edema), gizi buruk bila disertai</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">edema.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">< 60% Gizi buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Penilaian:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5-10% kehilangan BB ringan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">15-25% kehilangan BB sedang</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">> 25% kehilangan BB berat</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.10.2.2 Tinggi badan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Tinggi badan merupakan parameter sederhana, mudah dilakukan dan diulang serta bila dihubungkan dengan BB akan memberikan informasi yang bermakna. Cara pengukurannya adalah anak berdiri tegak dan mata menatap lurus ke depan, punggung menempel pada alat pengukur panjang pada tembok/dinding tegak lurus. Untuk bayi atau anak yang belum bisa berdiri, pengukuran dilakukan dalam posisi terlentang.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.10.2.3 Berat badan menurut tinggi badan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Rasio BB/TB sangat penting dan lebih akurat dalam penilaian status gizi karena mencerminkan proporsi tubuh serta dapat membedakan antara wasting dan stunting atau perawakan pendek. Indeks pada anak perempuan hanya sampai 135 cm dan anak laki-laki sampai TB 145 cm dan setelah itu rasio BB/TB tidak begitu banyak berarti karena adanya percepatan tumbuh. Indeks ini tidak memerlukan faktor umur.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">BB/TB (%) = [BB aktual/BB menurut TB aktual] x 100%</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Interpretasi:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. Jika BB/TB (%):</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> > 120% Obesitas</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">110-120% Overweight</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> 90-110% Normal</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> 70-90% Gizi kurang</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> <70% Gizi buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Nilai BB/TB di sekitar persentil 50 menunjukkan normal. Makin jauh deviasi yang terjadi makin besar pula kelebihan atau kekurangan gizi pada individu tersebut.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.10.2.4 Lingkar lengan atas</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Pemeriksaan ini digunakan pada anak 1-5 tahun, dan sudah dapat menunjukkan status gizi anak. Pengukuran dilakukan pada lengan kiri, pertengahan akromion dan olekranon, menggunakan pita pengukur yang tidak melar atau pita khusus (WHO/CARE) yang diberi warna hijau (> 12,5 cm), kuning (11,5-12,5 cm) dan merah (<11,5 cm).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Interpretasi:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"><11,5 cm Gizi buruk (merah)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">11,5-12,5 cm Gizi kurang (kuning)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">>12,5 cm Gizi baik (hijau)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Interpretasi LLA/U:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">85-10% Gizi baik/normal</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">70-85% Gizi kurang</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">< 70% Gizi buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Interpretasi LLA/TB:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> >85% Gizi baik/normal</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">80-85% Borderline / KKP-I</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">75-80% Gizi kurang / KKP-II</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">< 75% Gizi buruk / KKP-III</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.10.2.5 Lingkaran kepala</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Lingkar kepala dipengaruhi oleh status gizi anak sampai usia 36 bulan. Pengukuran rutin dilakukan untuk menjaring kemungkinan adanya penyebab lain yang dapat mempengaruhi pertumbuhan otak. Pengukuran dilakukan dengan pita pengukur yang tidak melar, tepat diatas supra orbita pada bagian yang paling menonjol dan melalui oksiput sehingga didapat nilai lingkar kepala yang maksimal.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Interpretasi:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">LK < persentil 5 atau < -2SD menunjukkan kemungkinan malnutrisi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">kronik pada masa intrauterin atau masa bayi/anak dini.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.10.3 Pemeriksaan EKG (Elektrokardiogram)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">EKG adalah salah satu bagian dalam pemeriksaan penunjang untuk mengevaluasi keadaan jantung kita. Beberapa gangguan jantung (misalnya infark -adanya kerusakan otot jantung karena kekurangan oksigen-, atau adanya pembesaran jantung, dan lainnya) dapat menyebabkan gangguan aktivitas listrik jantung. Jadi, adanya gangguan ini dapat terlihat di EKG</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.11PENATALAKSANAAN GIZI BURUK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.11.1 Deteksi Dini Penyimpangan Tumbuh Kembang Anak</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pedoman dalam deteksi pertumbuhan anak balita adalah dengan menggunakan berat badan (BB) terhadap tinggi badan (TB). Deteksi dini penyimpangan tumbuh kembang anak dapat dilakukan melalui :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. Menimbang berat badan dan mengukur tinggi badan anak di posyandu atau puskesmas</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Mencatat berat badan anak dalam KMS (kartu menuju sehat)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. Membaca kecenderungan berat badan anak pada KMS, meliputi :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. jika berat badan naik dibanding bulan lalu lebih cepat dari garis baku disebut N 1 (tumbuh kejar)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b. jika berat badan naik dibanding bulan lalu sesuai dengan garis baku disebut N 2 (tumbuh normal)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c. jika berat badan naik dibanding bulan lalu lebih lambat dibanding garis baku disebut T1 (tumbuh tidak memadai)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d. jika berat badan tetap dibanding bulan lalu sehingga garis pertumbuhan mendatar disebut T2 (tidak tumbuh)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e. jika berat badan dibanding bulan lalu turun sehingga garis pertumbuhan turun disebut T3 ( tumbuh negatif)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4. Melakukan pemeriksaan adanya tanda bahaya, yang meliputi : adanya renjatan atau syok, keadaan tidak sadar atau letargis serta adanya muntah/diare/dehidrasi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5. Melakukan pemeriksaan fisik</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">6. Merujuk anak apabila</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. ditemukan 2 kali T berturut-turut meskipun BB di KMS masih diatas garis merah</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b. BB dibawah garis merah di KMS (kartu menuju sehat)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.11.2 Pengobatan Dan Perawatan Anak Gizi Buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.11.2.1 Pengobatan dan perawatan fase stabilisasi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"> Prosedur tindakan pengobatan dan perawatan terhadap anak balita gizi buruk sebelum dirujuk, meliputi :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1) Pengobatan atau pencegahan hipoglikemia</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2) Pengobatan dan pencegahan hipotermia</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3) Pengobatan dan pencegahan dehidrasi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4) Pemulihan gangguan keseimbangan elektrolit</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5) Pengobatan atau pencegahan infeksi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">6) Pemberian makanan yang sesuai dengan kondisi anak balita</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">7) Pemberian multivitamin</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">8) Pemantauan masa tumbuh kejar</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.11.2.2 Pengobatan dan perawatan fase stabilisasi dibagi dalam :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1) Perawatan Awal pada Fase Stabilisasi, yang meliputi:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a) pemeriksaan berat badan dan suhu tubuh (aksila)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b) memberikan oksigen apabila disertai renjatan atau syok</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c) menghangatkan tubuh</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d) memberikan cairan dan makanan sesuai dengan rencana</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e) memberikan antibiotic sesuai umur</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2) Perawatan Lanjutan pada Fase Stabilisasi, yang meliputi:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a) melakukan anamnesa untuk konfirmasi kejadian campakdan TB paru</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b) melakukan pemeriksaan umum, meliputi tinggi badan, thorax, abdomen, otot dan jaringan lemak</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c) melakukan pemeriksaan khusus, meliputi mata, kulit, telinga, hidung, tenggorokan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d) melakukan pemeriksaan laboratorium, meliputi kadar guladarah dan Hemoglobin</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e) memberikan tindakan meliputi Vitamin A, asam folat, multivitamin tanpa Fe/ ferrum (besi), pengobatan penyakit penyulit</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">f) melakukan stimulasi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3) Perawatan Lanjutan pada Fase Transisi :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a) melakukan pemeriksaan berat badan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b) memberikan makanan untuk tumbuh kejar</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c) memberikan multivitamin tanpa Fe (besi)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d) melakukan stimulasi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e) pengobatan penyakit penyulit</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4) Perawatan lanjutan pada Fase Rehabilitasi :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a) melakukan monitoring tumbuh kembang</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b) memberikan multivitamin dengan Fe (besi)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c) pengobatan penyakit penyulit</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d) melakukan persiapan pada ibu</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e) melakukan stimulasi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.11.3 Prosedur tetap penatalaksanaan fase rehabilitasi di puskesmas</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1) mengkaji berat badan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2) observasi keadaan kesehatan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3) memberikan makanan secara bertahap</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4) menentukan kebutuhan energi dan protein pada anak</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5) memberikan makanan porsi kecil dan sering</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">6) menganjurkan ASI sampai 2 tahun</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">7) menimbang berat badan anak setiap 2 minggu</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">8) penyuluhan pada orangtua</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">9) menganjurkan keluarga untuk memantau kesehatan secarateratur ke posyandu</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.11.4 Perawatan Tindak Lanjut di Rumah Bagi Anak Gizi Buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Setelah anak pulang dari tempat perawatan, harus dilakukan:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1) pemberian makan yang baik, </span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2) stimulasi tumbuh kembang,</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3) penyuluhan kepada orang tua untuk kunjungan ulang, pemberian makanan, terapi bermain, serta imunisasi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4) pemberian vitamin A</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5) pemantauan anak di rumah</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Perawatan fase tindak lanjut bagi anak gizi buruk meliputi :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1) Melanjutkan pola pemberian makan yang baik dan stimulasi dilanjutkan di rumah setelah pulang dari rumah sakit</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2) Memberikan contoh kepada orang tua cara membuat menu dan makanan dengan kandungan energi dan zat gizi yang padat sesuai dengan umur dan berat badan anak</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3) Memberikan contoh pada orang tua cara terapi bermain</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4) Menyarankan kepada orang tua untuk memberikan makanan dengan porsi kecil tapi sering sesuai dengan umur anak</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5) Menyarankan kepada orang tua untuk membawa control secara teratur yaitu :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a) bulan I : 1 x setiap minggu</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b) bulan II : 1x setiap 2 minggu</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c) bulan III - IV : 1x setiap bulan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">6) Memberikan imunisasi dasar dan ulangan (booster)</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">7) Memberikan vitamin A dosis tinggi setiap 6 bulan sekali</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.11.5 Cara Memberikan Stimulasi Sensorik Dan Dukungan Emosional Pada Anak Gizi Buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pada anak gizi buruk terjadi keterlambatan perkembangan mental dan perilaku, oleh karena itu harus diberikan :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">a. Kasih sayang</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">b. Lingkungan yang ceria</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">c. Terapi bermain selama 15-30 menit setiap hari, contohnya bermaincilukba</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">d. Aktifitas fisik segera setelah sembuh</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">e. Keterlibatan ibu dalam memberi makan, memandikan, bermain danlain-lain.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.11.6 Pedoman Pemberian Makanan Balita Gizi Buruk</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pemberian makanan bagi anak dengan gizi buruk antara lain :</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. Apabila anak belum mencapai umur 2 tahun maka ASI tetap diberikan. Bila selama dirawat anak tidak diberi ASI, maka setelahkembali dari rawat inap anak harus tetap diberi ASI.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Balita gizi buruk setelah kembali dari rawat inap di Puskesmaas /Rumah Sakit, perlu diikuti dengan pengamatan dan perhatian terusmenerus terhadap kesehatan dan gizi, antara lain denganpemberian makanan yang sesuai dengan kebutuhannya.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. Pemberian makanan sedapat mungkin dibuat dari bahan makananyang tersedia di rumah tangga, harga murah dan pembuatannyamudah. Disamping itu anak gizi buruk setelah kembali dari rawatinap harus tetap mendapat vitamin A di posyandu dua kali setahundan sirup besi.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4. Anak yang menderita gizi buruk biasanya mempunyai masalah pada fungsi alat pencernaan, sehingga dalam pemberianmakanannya memerlukan perhatian khusus. Sebagai patokanyang digunakan dalam pemberian makanan kepada anak giziburuk adalah berat badan, bukan umur.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5. Karena sebagian alat pencernaan tubuh anak yang menderita gizi buruk belum berfungsi dengan baik, maka bentuk makanan sampaianak mencapai berat badan 7kg mengikuti bentuk makanan pendamping ASI (MP ASI), berupa makanan cair, lembik dan lunak.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">6. Petugas harus selalu memantau dan membina melalui konselingdengan cara kunjungan ke rumah tangga paling sedikit sekalidalam seminggu</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">7. Jika anak sudah diberi makan sesuai ketentuan, tetapi dalam satubulan berat badan tidak naik, anak harus segera dirujuk kepuskesmas</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">8. Jika anak sudah mencapai berat badan 7 kg dan telah diberimakanan orang dewasa, akan tetapi berat badannya tidak naik,maka anak harus kembali diberi makanan formula seperti semula</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">9. Dalam mempersiapkan dan memberikan makanan formula, harus selalu dijaga kebersihannya, antara lain : mencuci tangan sebelummemasak, alat makan harus selalu dicuci terlebih dahulu, bahanmakanan harus dimasak, harus selalu menggunakan air yangsudah dimasak</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">10. Bila menggunakan produk hasil industri, gunakan jenis produkmakanan bayi untuk umur 4 bulan keatas, dan untuk anak dibawah4 bulan bila ada indikasi medis anak diberi susu formula.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2.12 KOMPLIKASI GIZI BURUK</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pada penderita gangguan gizi sering terjadi gangguan asupan vitamin dan mineral. Karena begitu banyaknya asupan jenis vitamin dan mineral yang terganggu dan begitu luasnya fungsi dan organ tubuh yang terganggu maka jenis gangguannya sangat banyak.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pengaruh KEP bisa terjadi pada semua organ sistem tubuh. Beberapa organ tubuh yang sering terganggu adalah saluran cerna, otot dan tulang, hati, pancreas, ginjal, jantung, dan gangguan hormonal.Anemia gizi adalah kurangnya kadar Hemoglobin pada anak yang disebabkan karena kurangnya asupan zat Besi (Fe) atau asam Folat. Gejala yang bisa terjadi adalah anak tampak pucat, sering sakit kepala, mudah lelah dan sebagainya.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Pengaruh sistem hormonal yang terjadi adalah gangguan hormon kortisol, insulin, Growht hormon (hormon pertumbuhan) Thyroid Stimulating Hormon meninggi tetapi fungsi tiroid menurun. Hormon-hormon tersebut berperanan dalam metabolisme karbohidrat, lemak dan tersering mengakibatkan kematian (Sadewa, 2008).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Mortalitas atau kejadian kematian dapat terjadi pada penderita KEP, khususnya pada KEP berat. Beberapa penelitian menunjukkan pada KEP berat resiko kematian cukup besar, adalah sekitar 55%. Kematian ini seringkali terjadi karena penyakit infeksi (seperti Tuberculosis, radang paru, infeksi saluran cerna) atau karena gangguan jantung mendadak. Infeksi berat sering terjadi karena pada KEP sering mengalami gangguan mekanisme pertahanan tubuh. Sehingga mudah terjadi infeksi atau bila terkena infeksi beresiko terjadi komplikasi yang lebih berat hingga mengancam jiwa (Nelson, 2007).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Selain itu ada juga komplikasi yang lain,yaitu:</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">1. Hipotemi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Hipotermia adalah suatu kondisi dimana mekanisme tubuh untuk pengaturan suhu kesulitan mengatasi tekanan suhu dingin. Hipotermia juga dapat didefinisikan sebagai suhu bagian dalam tubuh di bawah 35 °C.Tubuh manusia mampu mengatur suhu pada zona termonetral, yaitu antara 36,5-37,5 °C. Di luar suhu tersebut, respon tubuh untuk mengatur suhu akan aktif menyeimbangkan produksi panas dan kehilangan panas dalam tubuh.Gejala hipotermia ringan adalah penderita berbicara melantur, kulit menjadi sedikit berwarna abu-abu, detak jantung melemah, tekanan darah menurun, dan terjadi kontraksi otot sebagai usaha tubuh untuk menghasilkan panas. Pada penderita hipotermia moderat, detak jantung dan respirasi melemah hingga mencapai hanya 3-4 kali bernapas dalam satu menit. Pada penderita hipotermia parah, pasien tidak sadar diri, badan menjadi sangat kaku, pupil mengalami dilatasi, terjadi hipotensi akut, dan pernapasan sangat lambat hingga tidak kentara (kelihatan).</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">2. Hipoglikemi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Hipoglikemia adalah suatu keadaan dimana kadar gula darah hingga dibawah 60 mg/dl. Padahal kinerja tubuh,terutam otak dan sistem syaraf,membutuhkan glukosa dalam darah yang berasal dari makanan berkarbohidrat dalam kadar yang cukup. Kadar gula darah normal adalah 80-120 mg/dl pada kondisi puasa,100-180 mg/dl pada kondisi setelah makan </span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">3. Infeksi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Infeksi adalah kolonalisasi yang dilakukan oleh spesies asing terhadap organisme inang, dan bersifat pilang membahayakan inang. Organisme penginfeksi, atau patogen, menggunakan sarana yang dimiliki inang untuk dapat memperbanyak diri, yang pada akhirnya merugikan inang. Patogen mengganggu fungsi normal inang dan dapat berakibat pada luka kronik, gangrene, kehilangan organ tubuh, dan bahkan kematian. Respons inang terhadap infeksi disebut peradangan. Secara umum, patogen umumnya dikategorikan sebagai organisme mikroskopik, walaupun sebenarnya definisinya lebih luas, mencakup bakteri, parasit, fungi, virus, prion, dan viroid.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">4. Diare dan Dehidrasi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Diare adalah sebuah penyakit di mana penderita mengalami rangsangan buang air besar yang terus-menerus dan tinja atau feses yang masih memiliki kandungan air berlebihan.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">5. Syok</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Syok adalah suatu keadaan dimana pasokan darah tidak mencukupi</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">untuk kebutuhan organ-organ di dalam tubuh. Shock juga didefinisikan sebagai</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">gangguan sirkulasi yang mengakibatkan penurunan kritis perfusi jaringan vital atau menurunnya volume darah yang bersirkulasi secara efektif.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">6. ISPA</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Infeksi saluran napas akut (ISPA) adalah penyakit infeksi akut yang melibatkan organ saluran pernapasan, hidung, sinus, faring, atau laring.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">7. Cacingan</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Cacingan adalah kumpulan gejala gangguan kesehatan akibat adanya cacing parasit di dalam tubuh.Penyebab kecacingan yang populer adalah cacing pita, cacing kremi, dan cacing tambang.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">8. Tuberkulosis</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Tuberkulosis atau TB (singkatan yang sekarang ditinggalkan adalah TBC) adalah penyakit infeksi yang disebabkan oleh bakteri Mycobacterium tuberculosi.</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">9. Malaria</span></span><br /><span style="font-size: small;"><span style="font-family: inherit;"></span></span><br /><span style="font-size: small;"><span style="font-family: inherit;">Malaria adalah penyakit yang disebabkan oleh parasit bernama Plasmodium. Penyakit ini ditularkan melalui gigitan nyamuk yang terinfeksi parasit tersebut. Di dalam tubuh manusia, parasit Plasmodium akan berkembang biak di organ hati kemudian menginfeksi sel darah merah.</span></span></div>
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arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com2tag:blogger.com,1999:blog-2501725445038181687.post-21180766696701701452012-03-18T13:11:00.003+07:002012-03-20T19:13:30.297+07:00Cushing Sindrom<div align="center" class="MsoNormal" style="line-height: 150%; margin-bottom: 0.0001pt; text-align: center;">
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">KAJIAN TEORI</span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1.</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pengertian</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Cushing Sindr</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">om</span></b><span class="a"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span></span><span class="a"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></b></span></div>
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<span class="a"><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">adalah
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">adalah
kumpulan gejala penyakit yang menyebabkan gangguan hormonal yang disebabkan
kortisol plasma berlebihan dalam tubuh (hiperkortisolisme),baik oleh pemberian
glukokortikoid jangka panjang dalam dosis farmakologik (iatrogen ) atau oleh
sekresi kortisol yang berlebihan akibat
gangguan aksis hipotalamus - hipofisis
adrenal ( Spontan ).</span><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Nama sindrom cushing
diambil dari Harvey cushing, seorang ahli bedahyang pertama kali
mengidentifikasikan penyakit ini pada tahun 1912.penyakit ini ditandai truncal
obesity,hipertensi, mudah lelah, amenorea, hirsutisme, striae abdomen berwarna
ungu dll.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Sindrom cushing
relative langka dan paling sering terjadi pada usia 20 hingga 50 tahun.orang
yang menderita obesitas dan DM- tipe 2,disertai dengan hipertensi dan gula
darah yang tidak terkontrol,akan meningkatkan resiko terserang penyakit ini.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Sindrom cushing terbagi 2:</span><br />
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1.</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">DEPENDEN ACTH</span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">(dijelaskan oleh Harvey Cushing –
1932)</span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Disebabkan oleh:</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Hiperfungsi
adrenal mungkin disebabkan oleh sekresi ACTH kelenjar hipofisis yang abnormal
dan berlebihan .Ini bisa di sebabkan oleh berkurangnya kadar kortisol dalam
darahACTH juga dapat disekresi berlebihan
pada pasien-pasien dengan neoplasma dengan kapasitas untuk
menyintesis dan melepaskan peptide mirip
ACTH baik secara kimia maupu secara fisiologik.ACTH berlebihan yang dikeluarkan
dalam keadaan ini menyebabkan rangsangan yang berlebihan terhadap sekresi
kortisol oleh korteks adrenal.dan disebabkan oleh penekanan pelepasan ACTH
hipofisis. Indpenden ACTH</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> Hiperplasia
korteks</span></div>
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<span style="height: 33px; margin-left: 134px; margin-top: 35px; position: absolute; width: 47px; z-index: 251661312;"><img height="33" src="file:///C:/Users/COMPAQ/AppData/Local/Temp/msohtmlclip1/01/clip_image001.gif" width="47" /></span><span style="height: 34px; margin-left: 134px; margin-top: 3px; position: absolute; width: 47px; z-index: 251660288;"><img height="34" src="file:///C:/Users/COMPAQ/AppData/Local/Temp/msohtmlclip1/01/clip_image002.gif" width="47" /></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Independen (adrenal autonom) </span></div>
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<span style="height: 19px; margin-left: 371px; margin-top: 17px; position: absolute; width: 48px; z-index: 251662336;"><img height="19" src="file:///C:/Users/COMPAQ/AppData/Local/Temp/msohtmlclip1/01/clip_image003.gif" width="48" /></span><span style="height: 24px; margin-left: 371px; margin-top: 34px; position: absolute; width: 48px; z-index: 251663360;"><img height="24" src="file:///C:/Users/COMPAQ/AppData/Local/Temp/msohtmlclip1/01/clip_image004.gif" width="48" /></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">ACTH Hiperfungsi
korteks adenoma</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">(adrenal
autonom)</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> karsinoma</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Ada 4 jenis sindrom
cushing :</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1. </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Penyakit cushing</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Ditemukan
pada kira-kira 80% pasien,kerusakan mugkin terletak di hipotalamus(belum
jelas)yang jelas hipotalamus anterior terlibat dan mengeluarkan ACTH
berlebihan. </span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">2.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Tumor adrenal</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Dijumpai
kira-kira pada 15% pasien.</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">3.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">ACTH ectopic</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pada
kebanyakan pasien tidak menunjukkan gambaran sindrom cushing yang khas ,gejala
klinis dapat di tandai dengan penyakit
yang cepat menjadi berat,penurunan berat badan,edema dan pigmentasi</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">4.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Alkoholisme</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span class="a"><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="background: none repeat scroll 0% 0% white; border: 1pt none windowtext; color: black; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%; padding: 0cm;">Ciri -Ciri Cushing Sindrom</span></b></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Muka
menjadi bulat berwarna kemerah- merahan ( moon face)</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">2.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Berpunuk</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">3.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Badan
gemuk dengan anggota gerak tetap kurus.</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">4.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kelemahan
umum</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">5.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gangguan
siklus haid pada wanita</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">6.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Lemah
syahwat pada pria</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">7.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kelainan
tulang</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">8.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Jerawat</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">9.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Tekanan
darah tinggi</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">10.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Hirsutisme</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">11.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Daya
tahan terhadap infeksi berkurang</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">12.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Mudah
memar</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">13.<span style="font: 7pt "Times New Roman";"> </span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gangguan
mental</span></div>
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"><br clear="all" style="mso-special-character: line-break; page-break-before: always;" />
</span></b>
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<b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">2. Epidemiologi</span></b></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Sindrom Cushing ( disebabkan
oleh pengobatan dengan kortikosteroid) adalah bentuk paling umum dari sindrom
cushing.insiden tumor hipofisis mungkin relative tinggi, sebanyak satu dari
lima orang,tetapi hanya sebagian kecil menit yang aktif dan memproduksi hormone
yang berlebihan.Orang dewasa dengan penyakit ini juga mungkin memiliki gejala
berat badan yang ekstrim,pertumbuhan rambut berlebihan pada wanita, tekanan
darah tinggi, dan masalah kulit.Selain itu, mereka dapat menunjukkan : </span></div>
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<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kelemahan otot dan tulang </span></div>
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<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Osteoporosis</span></div>
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<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Diabetes Melitus</span></div>
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<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Hipertensi</span></div>
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<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kemurungan,Lekas merah , atau depresi</span></div>
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<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gangguan tidur</span></div>
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<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Menstruasi Gangguan seperti amenore pada wanita dan
kesuburan menurun pada pria</span></div>
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<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kepala botak</span></div>
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<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Hiperkolesterolemia</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; text-align: justify;">
<br /></div>
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<b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">3.<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%; padding: 0cm;">Etiologi</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Sindrom Cushing</span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">
adalah </span><a href="http://id.wikipedia.org/wiki/Sindrom" title="Sindrom"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">sindrom</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> yang disebabkan berbagai hal</span><a href="http://id.wikipedia.org/wiki/Sindrom_Cushing#cite_note-A13812980-0"><sup><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">[1]</span></sup></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> seperti </span><a href="http://id.wikipedia.org/wiki/Obesitas" title="Obesitas"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">obesitas</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">, impaired glucose tolerance, </span><a href="http://id.wikipedia.org/wiki/Hipertensi" title="Hipertensi"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">hipertensi</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">, </span><a href="http://id.wikipedia.org/wiki/Diabetes_mellitus" title="Diabetes mellitus"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">diabetes mellitus</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> dan disfungsi gonadal
yang berakibat pada berlebihnya rasio </span><a href="http://id.wikipedia.org/wiki/Serum_darah" title="Serum darah"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">serum</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><a href="http://id.wikipedia.org/wiki/Hormon" title="Hormon"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">hormon</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">
</span><a href="http://id.wikipedia.org/wiki/Kortisol" title="Kortisol"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">kortisol</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">. Nama penyakit ini diambil dari </span><a href="http://id.wikipedia.org/wiki/Harvey_Cushing" title="Harvey Cushing"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Harvey Cushing</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">, seorang ahli bedah
yang pertama kali mengidentifikasikan penyakit ini pada tahun </span><a href="http://id.wikipedia.org/wiki/1912" title="1912"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1912</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-size: 13pt; line-height: 150%;">Sindrom
cushing disebabkan oleh pemberian glukortikoid jangka panjang dalam dosis
farmakologik atau oleh sekresi kortisol yang berlebihan akibat gangguan aksis
hipotalamus-hipofisis-adrenal (spontan). Sindrom cushing terjadi ketika
jaringan tubuh yang terkena tingkat tinggi kortisol terlalu lama. Banyak orang
mengembangkan sindrom cushing karena mereka mengambil hormon
glukokortikoid-steroid yang secara kimiawi mirip dengan kortisol yang
diproduksi secara alami seperti prednisone untuk asma, rheumatoid arthritis,
lupus, dan penyakit inflamasi lainnya. Bahan tersebut juga digunakan untuk
menekan sistem kekebalan tubuh setelah transplantasi untuk menjaga tubuh dari
menolak organ baru atau jaringan. Orang lain mengembangkan sindrom cushing
karena tubuh mereka memproduksi terlalu banyak hormon kortisol.</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-size: 13pt; line-height: 150%;">Penyebab
paling umum dari sindrom Cushing adalah pemberian glukokortikoid eksogen
ditentukan oleh seorang praktisi kesehatan untuk mengobati penyakit lain
(disebut sindrom cushing iatrogenik’s). Hal ini dapat menjadi efek pengobatan
steroid dari berbagai gangguan seperti asma dan rheumatoid arthritis, atau
dalam imunosupresi setelah transplantasi organ. Penambahan ACTH sintetik juga
mungkin, tapi ACTH kurang sering diresepkan karena biaya dan kegunaan yang
lebih rendah. Meskipun jarang, Sindrom Cushing juga dapat disebabkan penggunaan
medroksiprogesteron. Selain itu, beberapa kekacauan sistem tubuh sendiri akan
merespon untuk mensekresi kortisol. Biasanya, ACTH dilepaskan dari kelenjar
pituitari bila diperlukan untuk merangsang pelepasan kortisol dari kelenjar
adrenal. Dalam pituitari Cushing, seorang adenoma jinak mengeluarkan ACTH
hipofisis. Ini juga dikenal sebagai penyakit Cushing dan bertanggung jawab atas
70% dari sindrom Cushing endogen’s. Sindrom Cushing juga disebabkan oleh tumor
hipofisis atau tumor yang melepaskan ACTH (Niemen, 2005).</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-size: 13pt; line-height: 150%;">Pada
tumor korteks adrenal dapat terjadi tanpa bergantung pada kontrol ACTH yang
dengan kemampuannya untuk menyekresi kortisol secara autonomi dalam korteks
adrenal. Tumor korteks adrenal yang akhirnya menjadi sindrom cushing yang jinak
(adenoma) atau yang ganas (karsinoma). Adenoma korteks adrenal dapat
menyebabkan sindrom cushing berat, namun biasanya berkembang secara lamba dan
gejala dapat timbul bertahun-tahun sebelum diagnosis ditegakkan. Sebaliknya,
karsinoma adreokortikal berkembang secara cepat dan dapat menyebabkan
metastasis serta kematian (Niemen, 2005).</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">kadangkala tumor yang
tidak bersifat kanker(adenoma) terjadi pada kelenjar adrenalin,yang menyebabkan
kelenjar adrenalin menghasilkan kortikosteroid secara berlebihan.adrenal
adenomas sangat umum.setengah orang mengalaminya pada usia 70.hanaya bagian
kecil pada adenomas menghasilkan hormone berlebihan,meskipun begitutumor yang
tidak bersifat kanker pada kelenjar adrenalin sangat langka.<br />
sindrom cushim bisa terjadi juga pada orang yang harus menggunakan
kortikosteroid dosis tinggi karena keadaan medis serius.mereka yang harus
menggunakan dosis tinggi memiliki gejala yang sama dengan mereka yang
menghasilkan terlalu banyak hormon tersebut.gejala-gejalanya bisa kadangkala
terjadi bahkan jika kortikosteroid dihirup,seperti untuk asma,atau di gunakan
khususnya untuk sebuah kondisi kulit.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Penyebab paling sering
dari sindrom cushing adalah iatrogenic dengan pemberian steroid untuk alasan
yang bervariasi. Meskipun corak klinis membawa kemiripan terhadap mereka dengan
tumor adrenal, pasien ini biasanya dibedakan dalam riwayat dasar dan studi laboratorium.
</span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-size: 13pt; line-height: 150%;">Sindrom
Cushing dapat dibagi menjadi dua jenis : (1) dependen ACTH dan (2) independen
ACTH. Diantara jenis dependen ACTH, hiperfungsi korteks adrenal mungkin
disebabkan oleh sekresi ACTH kelenjar hipofisis yang abnormal dan berlebihan.
Karena tipe ini mula-mula dijelaskan oleh Harvey Cushing pada tahun 1932, maka
keadaan ini disebut dengan penyakit Cushing. Pada 80% pasien ini ditemukan
adenoma hipofisis yang mensekresi ACTH. Pada 20% sisanya terdapat bukti-bukti
histology hyperplasia hipofisis kortikotrop. Masih tidak jelas apakah
hyperplasia timbul akibat gangguan pelepasan CRH oleh neurohipotalamus. Pada
kasus lain didapatkan kelebihan sekresi ACTH, hilangnya irama sirkadian normal
ACTH, dan berkurangnya sensitivitas system kontrol umpan balik ke tingkat
kortisol dalam darah. ACTH juga dapat disekresi berlebihan pada pasien-pasien
dengan neoplasma yang memiliki kapasitas untuk menyintesis dan melepaskan
peptide mirip ACTH baik secara kimia maupun fisiologik. ACTH yang berlebihan
dihasilkan dalam keadaan ini menyebabkan rangsangan yang berlebihan terhadap
sekresi kortisol oleh korteks adrenal, dan disebabkan oleh penekanan pelepasan
ACTH hipofisis. Jadi, kadar ACTH yang tinggi pada penderita ini berasal dari
neoplasma, bukan dari kelenjar hipofisisnya. Sejumlah besar neoplasma dapat
menyebabkan sekresi ektopik ACTH. Neoplasma-neoplasma ini biasanya berkembang
dari jaringan-jaringan yang berasal dari lapisan neuroektadermal selama
perkembangan embrional. Karsinoma sel oat paru, karsinoid bronchus, timoma, dan
tumor sel-sel pulau dipankreas, merupakan contoh-contoh yang paling sering
ditemukan. Beberapa tumor ini mampu menyekresi CRH ektopik. Pada keadaan ini,
CRH ektopik merangsang sekresi ACTH hipofisis, yang menyebabkan terjadinya
sekresi kortisol secara berlebihan oleh korteks adrenal. Jenis sindrom cushing
yang disebabkan oleh sekresi ACTH yang berlebihan- hipofisis atau ektopik-
seringkali disertai hiperpigmentasi. Hiperpigmentasi ini disebabkan oleh
sekresi peptide yang berhubungan dengan ACTH dan kerusakan-kerusakan
bagian-bagian ACTH yang memiliki aktivitas melanotropik. Pigmentasi terdapat
pada kulit dan selaput lebdir. </span></div>
<div style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; text-align: justify; text-indent: 18.0pt;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 22.5pt; mso-add-space: auto; mso-list: l0 level1 lfo15; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">4.<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 115%; padding: 0cm;">Pato</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 115%; padding: 0cm;">fisiologi</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">
</span><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 22.5pt; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 22.5pt; mso-add-space: auto; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Penyebab cushing sindrom adalah peninggian
kadar glukokortikoid dalam darah yang menetap.akibat-akibat metabolik dari
kelebihan glikokorikoid, Korteks adrenal mensintesis dan mensekresi ada empat
jenis hormon:</span></div>
<div class="MsoNormal" style="text-indent: 36.0pt;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Glukokortikoid</span></b><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">
adalah golongan hormon steroid yang memberikan pengaruh
terhadapmetabolismenutrisi.</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">a. Glukokortikoid.
Glukokortikoid fisiologis yang disekresi oleh adrenal manusia adalah kortisol</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">b. Mineralokortikoid.
Mineralokortikoid yang fisiologis yang diproduksi adalah aldosteron,</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">c. Androgen. adalah
sekelompok senyawa steroid yang berfungsi terutama sebagai </span><a href="http://id.wikipedia.org/wiki/Hormon" title="Hormon"><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">hormon</span></a><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">
</span><a href="http://id.wikipedia.org/wiki/Seks" title="Seks"><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">seks</span></a><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">
pria.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">d. Estrogen. adalah
sekelompok senyawa steroid yang berfungsi terutama sebagai </span><a href="http://id.wikipedia.org/wiki/Hormon" title="Hormon"><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">hormon</span></a><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">
</span><a href="http://id.wikipedia.org/wiki/Seks" title="Seks"><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">seks</span></a><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">
</span><a href="http://id.wikipedia.org/wiki/Wanita" title="Wanita"><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">wanita</span></a><span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">.</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Kelebihan
glukokortikoid dapat menyebabkan keadan-keadaan seperti :</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">1. Metabolisme protein
dan karbohidrat.</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Glukokortikoid
mempunyai efek katabolik dan antianabolik pada protein, menyebabkan menurunnya
kemampuan sel-sel pembentuk protein untuk mensistesis protein, sebagai
akibatnya terjadi kehilangan protein pada jaringan seperti kulit, otot,
pembuluh darah, dan tulang.</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Secara
klinis dapat ditemukan: Kulit mengalami atropi dan mudah rusak, luka- luka
sembuh dengan lambat. Ruptura serabut-serabut elastis pada kulit menyebabkan
tanda regang pada kulit berwarna ungu (striae),Otot-otot mengalami atropi dan
menjadi lemah,Penipisan dinding pembuluh darah dan melemahnya jaringan
penyokong vaskule menyebabkan mudah timbul luka memar.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Matriks protein tulang
menjadi rapuh dan menyebabkan osteoporosis, sehingga dapat dengan mudah terjadi
fraktur patologis. Metabolisme karbohidrat dipengaruhi dengan merangsang
glukoneogenesis dan menganggu kerja insulin pada sel-sel perifer, sebagai
akibatnya penderita dapat mengalami hiperglikemia. Pada seseorang yang
mempunyai kapasitas produksi insulin yang normal, maka efek dari glukokortikoid
akan dilawan dengan meningkatkan sekresi insulin untuk meningkatkan toleransi
glukosa. Sebaliknya penderita dengan kemampuan sekresi insulin yang menurun
tidak mampu untuk mengkompensasi keadaan tersebut, dan menimbulkan manifestasi
klinik DM.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">2. Distribusi jaringan
adiposa.</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Distribusi
jaringan adiposa terakumulasi didaerah sentral tubuh Obesitas Wajah bulan (moon
face). Memadatnya fossa supraklavikulare dan tonjolan servikodorsal (punguk
bison), Obesitas trunkus dengan ekstremitas atas dan bawah yang kurus akibat
atropi otot memberikan penampilan klasik perupa penampilan Chusingoid.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">3. Elektrolit</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Efek
minimal pada elektrolit serum. Kalau diberikan dalam kadar yang terlalu besar
dapat menyebabkan retensi natrium dan pembuangan kalium. Menyebabkan edema,
hipokalemia dan alkalosis metabolic.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">4. Sistem kekebalan</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Ada
dua respon utama sistem kekebalan; yang pertama adalah pembentukan antibody
humoral oleh sel-sel plasma dan limfosit B akibat ransangan antigen yang
lainnya tergantung pada reaksi-reaksi yang diperantarai oleh limfosit T yang
tersensitasi.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Glukokortikoid
mengganggu pembentukan antibody humoral dan menghabat pusat-pusat germinal
limpa dan jaringan limpoid pada respon primer terhadap anti gen.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">5. Sekresi lambung</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Sekeresi
asam lambung dapat ditingkatkan sekresi asam hidroklorida dan pepsin dapat
meningkat. Faktor-faktor protekitif mukosa dirubah oleh steroid dan
faktor-faktor ini dapat mempermudah terjadinya tukak.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">6. Fungsi otak</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Perubahan
psikologik terjadi karena kelebihan kortikosteroid, hal ini ditandai dengan
oleh ketidak stabilan emosional, euforia, insomnia, dan episode depresi
singkat.</span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">7. Eritropoesis</span></div>
<div class="MsoNormal" style="text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 14pt; line-height: 115%;">Involusi
jaringan limfosit, rangsangan pelepasan neutrofil dan peningkatan
eritropoiesis. Namun secara klinis efek farmakologis yang bermanfaat dari
glukokortikoid adalah kemampuannya untuk menekan reaksi peradangan. Dalam hal
ini glukokortikoid dapat menghambat hiperemia, ekstra vasasi sel, migrasi sel,
dan permeabilitas kapiler, menghambat pelapasan kiniin yang bersifat pasoaktif
dan menekan fagositosis. Efeknya pada sel menghambat sintesis histamin dan
menekan reaksi anafilaktik akut yang berlandaskan hipersensitivitas yang
dperantarai anti bodi. </span></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoNormal" style="text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo15; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">5.<span style="font: 7pt "Times New Roman";">
</span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="border: 1pt none windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%; padding: 0cm;">Manifestasi klinis</span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l31 level1 lfo18; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pasien dengan sindrom cushing dapat
mengeluhkan berat badan bertambah, terutama di wajah, supraclavicula, punggung
atas, dan dada.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l11 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pasien sering melihat perubahan di kulit mereka, termasuk <i style="mso-bidi-font-style: normal;">stretch mark</i> ungu, mudah memar, dan
tanda-tanda lain dari kulit yang menipis.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l11 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Karena kelemahan otot proksimal yang
progresif, pasien mungkin mengalami kesulitan naik tangga, keluar dari kursi
yang rendah, dan mengangkat tangan mereka.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l11 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Haid tidak teratur, amenore,
infertilitas, dan penurunan libido dapat terjadi pada wanita karena inhibisi
sekresi berdenyut dari luteinizing hormon (LH ) dan follicle-simulati hormone
yang kemungkinan di sebabkan gangguan luteinizing hormone –releasing hormone
(LHRH).</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l11 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pada pria, penghambatan LHRH dan FSH/LH
fungsi dapat menyebabkan penurunan libido dan impotensi</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l11 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Masalah-masalah psikologis seperti
depresi, disfungsi kognitif, dan emosional.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l11 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Memburuknya hipertensi dan diabetes
militus, kesulitan dengan penyembuhan luka, peningkatan infeksi osteopenia, dan
osteoporosis sehinggan dapat terjadi fraktur.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l11 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pasien dengan tumor pituitari yang
menghasilkan ACTH (penyakit cushing) dapat mengeluh sakit kepala, poliuria,
nokturia, masalah penglihatan, atau galaktorea.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l11 level1 lfo16; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gejala kelebihan glukokortikoid dalam
hubungannya dengan virilisasi pada wanita atau feminisasi pada pria menunjukan
sebuah karsinoma adrenal sebagai penyebab sindrom cushing.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">PADA
PEMERIKSAAN FISIK AKAN DI DAPATKAN</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l27 level1 lfo17; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Obesitas</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l28 level1 lfo19; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pasien
mengalami peningkatan jaringan adiposa di wajah atau (moon face ), punggung
atas di pangka leher (buffalo hump).</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l28 level1 lfo19; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Obesitas
sentral dengan jaringan adiposa meningkat</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l27 level1 lfo17; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kulit</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l29 level1 lfo20; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Facial plethora terutama di pipi</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l29 level1 lfo20; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Violaceous (striae ungu) umumnya di
abdomen, punggung bawah, pantat, paha atas, lengan atas, dan payudara.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l29 level1 lfo20; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Atrosfi cutanoeus</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l29 level1 lfo20; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Acanthosis nigricans, yang berhubungan
dengan resistensi insulin. Umumnya di temukan di axial, siku, leher, dan di
bawah payudara.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l29 level1 lfo20; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Jantung dan renal</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l26 level1 lfo21; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Hipertensi
dan edema dapat terjadi karena ativasi kortisor dari reseptar mineralokortikoid
menuju natrium dan retensi air</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l24 level1 lfo22; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gastroenterologi</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l27 level1 lfo17; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Ulkuspeptikum
dapat terjadi dengan atau tanpa gejala. Khususnya pada resiko pasien yang di
beri dosis tinggi glukokortikoid.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l24 level1 lfo22; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Endrokrin</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l27 level1 lfo17; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Dapat
terjadi ketika tumor hipofisis anterior menghambat tangkai hipofisis yang
mengarah tingkat proklatin tinggi.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Rendahnya kadar testosteron pada
pria dapat mengakibatkan penurunan volume testisdari penghambatan LHRH dan LH /
FSH fungsi</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l24 level1 lfo22; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Rangka / otot</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Dapat terjadi kelemehan otot
proksimal</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Terjadi osteoporosis dapat
menyebabkan patah tulang, kyphosis, kehilangan tinggi</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 22.5pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l0 level1 lfo15; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">6.<span style="font: 7pt "Times New Roman";">
</span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Anamnesis dan pemeriksaan fisik pada penderita cushing
sindrom</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 0cm; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Anamnesis</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l5 level1 lfo23; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1.<span style="font: 7pt "Times New Roman";">
</span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Identitas</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l24 level1 lfo22; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Nama (+ nama keluarga</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">)</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l24 level1 lfo22; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Umur/usia</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 72.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l20 level1 lfo25; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Neonates/bayi
belita/prasekolah</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 72.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l20 level1 lfo25; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Sekolah</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 72.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l20 level1 lfo25; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Akil
balik</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l3 level1 lfo26; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Jenis
kelamin</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l3 level1 lfo26; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Nama
orang tua</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l3 level1 lfo26; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Alamat</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l3 level1 lfo26; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Umur/pendidikan/pekerjaan
ortu</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l3 level1 lfo26; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Agama
dan suku bangsa</span></div>
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"><br clear="all" style="mso-special-character: line-break; page-break-before: always;" />
</span></b>
<br />
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l5 level1 lfo23; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">2.<span style="font: 7pt "Times New Roman";">
</span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat penyakit</span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l41 level1 lfo27; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Keluhan
utama</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 72.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l27 level1 lfo17; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Keluhan/gejala
yang menyebebkan pasien di bawa berobat</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 72.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l27 level1 lfo17; text-align: justify; text-indent: -18.0pt;">
<span lang="EN-US" style="font-family: Wingdings; font-size: 13pt; line-height: 150%;">Ø<span style="font: 7pt "Times New Roman";">
</span></span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Tidak
harus sejalan dengan diagnosis utama</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 9.0pt; margin-top: 0cm; mso-add-space: auto; mso-list: l5 level1 lfo23; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">3.<span style="font: 7pt "Times New Roman";">
</span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat perjalanan penyakit</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l21 level1 lfo24; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Cerita kronologis, rinci, jelas tentang
keadaan pasien sebelum ada keluhan sampai dibawa beroba</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">t</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l21 level1 lfo24; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pengobatan sebelumnya dan hasilnya
(macam obat dll)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l21 level1 lfo24; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Tindakan sebelumnya (suntikan,
penyinaran)</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l21 level1 lfo24; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Reaksi alergi</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l21 level1 lfo24; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Perkembangan penyakit – gejala sisa/
cacat</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l21 level1 lfo24; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat penyakit pada anggota keluarga,
tetangga</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l21 level1 lfo24; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat penyakit lain yg pernah diderita
sebelumnya</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l5 level1 lfo23; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">4.<span style="font: 7pt "Times New Roman";">
</span></span></b><b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Hal-hal
yang perlu tentang keluhan/gejala </span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l6 level1 lfo28; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Lama keluhan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l6 level1 lfo28; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Mendadak, terus-menerus, perlahan-lahan,
hilang timbul, sesaat</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l6 level1 lfo28; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Keluhan lokal: lokasi, menetap,
pindah-pindah, menyebar</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l6 level1 lfo28; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Bertambah berat/ berkurang</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l6 level1 lfo28; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Yang mendahului keluhan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l6 level1 lfo28; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pertama kali dirasakan/ pernah
sebelumnya</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l6 level1 lfo28; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Keluhan yang sama adalah pada anggota
keluarga, orang serumah, sekelilingnya</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Upaya yang dilakukan dan hasilnya</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l5 level1 lfo23; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">5.<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat
kehamilan</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l39 level1 lfo29; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kesehatan ibu saat kehamilan</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l39 level1 lfo29; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pernah sakit panas (rubella dsb)</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l39 level1 lfo29; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Makan obat-obatan</span></div>
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"><br clear="all" style="mso-special-character: line-break; page-break-before: always;" />
</span></b>
<br />
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l5 level1 lfo23; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">6.<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat
kelahiran</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Tanggal lahir</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l10 level1 lfo30; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Tempat lahir</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l10 level1 lfo30; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Ditolong oleh siapa</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Cara kelahiran</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kehamilan ganda</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Keadaan stlh lahir, pasca lahir,
hari-hari 1 kehidupan</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Masa kehamilan</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Berat badan dan panjang badan lahir
(apakah sesuai dengan masa kehamilan, kurang atau besar).</span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">7.<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat
pertumbuhan</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Syndrome
cushing bisa timbul dengan hirsutisme,berat badan bertambah,perubahan bentuk
badan atau wajah,mudah melar,atau ditemukan secara tidak sengaja terhadap umur</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l5 level1 lfo23; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">8.<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat
perkembangan</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Patokan perkembangan (milestones)</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pada bidang: motor kasar, motor halus,
sosial-personal, bahasa pada balita</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 54.0pt; margin-right: 0cm; margin-top: 0cm; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Prestasi
belajar pada anak usia sekolah</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span lang="EN-US" style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Masa pubertas</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">9.<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat
imunisasi</span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">10.<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat
makanan</span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">11.<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat
penyakit yang pernah di derita</span></b></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l5 level1 lfo23; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">12.<span style="font: 7pt "Times New Roman";"> </span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Riwayat
keluarga</span></b></div>
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"><br clear="all" style="mso-special-character: line-break; page-break-before: always;" />
</span></b>
<br />
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm;">
<br /></div>
<div class="MsoListParagraph" style="line-height: 150%; margin-bottom: .0001pt; margin: 0cm; mso-add-space: auto; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pemeriksaan fisik</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Apakah pasien memiliki:</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l14 level1 lfo32; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kulit tipis</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Banyak ekimosis</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Wajah “bulan”(moon face)</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Obesitas</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Hipertensi</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l14 level1 lfo32; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Glikosuria</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l9 level1 lfo34; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1.<span style="font: 7pt "Times New Roman";">
</span></span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; letter-spacing: 0.75pt; line-height: 150%;">Inspeksi</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; letter-spacing: 0.75pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; letter-spacing: 0.75pt; line-height: 150%;"> : Pernapasan
cuping hidung kadang terlihat, pergeraka</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; letter-spacing: 0.75pt; line-height: 150%;">n </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">dada simetris.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Palpasi </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">: Vocal premitus teraba rate, tidak terdapat
nyeri tekan</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Perkusi </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">: Suara sonor </span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Auskultasi</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">:
Terdengar bunyi nafas normal, tidak terdengar bunyi </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">nafas
</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">tambahan</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Perkusi pekak , S1 S2 Terdengar tunggal
, hipertensi, TDmeningkat</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">2.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Composmentis, kelabilan alam perasaan
depresi sampai mania7</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">3.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Poliuri, kadang terbentuk batu ginjal,
retensi natrium.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l40 level1 lfo33; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">4.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Terdapat peningkatan berat badan, nyeri
pada daerah lambung,terdapat striae di
daerah abdomen, mukosa bibir
kering, suararedup.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; mso-list: l40 level1 lfo33; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">5.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">(Muskuloskeletal Dan Integument)</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto; text-align: justify;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kulit
tipis, peningkatan pigmentasi, mudah memar, atropi otot,ekimosis, penyembuhan
luka lamb</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">a</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">t
kelemahan otot,osteoporosis, moon face, punguk bison, obesitas tunkus.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l17 level1 lfo35; text-align: justify; text-indent: -18.0pt;">
<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">7<span style="font: 7pt "Times New Roman";">
</span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pemeriksaan cushing sindrom</span></b></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l18 level1 lfo36; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pada pemeriksaan laboratorium sederhana,
didapati limfositofeni, jumlah netrofil antara 10.000 – 25.000/mm3. eosinofil
50/ mm3 hiperglekemi (Dm pada 10 % kasus) dan hipokalemia.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l18 level1 lfo36; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">2.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pemeriksaan laboratorik diagnostik.
Pemeriksaan kadar kortisol dan “overnight dexamethasone suppression test” yaitu
memberikan 1 mg dexametason pada jam 11 malam, esok harinya diperiksa lagi
kadar kortisol plasma. Pada keadaan normal kadar ini menurun. Pemerikaan 17
hidroksi kortikosteroid dalam urin 24 jam (hasil metabolisme kortisol), 17
ketosteroid dalam urin 24 jam.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l18 level1 lfo36; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">3.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Tes-tes khusus untuk membedakan
hiperplasi-adenoma atau karsinoma :</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">a.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Urinary deksametasone suppression test.
Ukur kadar 17 hidroxikostikosteroid dalam urin 24 jam, kemudian diberikan dexametasone
4 X 0,5 mg selama 2 hari, periksa lagi kadar 17 hidroxi kortikosteroid bila
tidak ada atau hanya sedikit menurun, mungkin ada kelainan. Berikan
dexametasone 4 x 2 mg selama 2 hari, bila kadar 17 hidroxi kortikosteroid
menurun berarti ada supresi-kelainan adrenal itu berupa hiperplasi, bila tidak
ada supresi kemungkinan adenoma atau karsinoma.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">b.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Short oral metyrapone test. Metirapone
menghambat pembentukan kortisol sampai pada 17 hidroxikortikosteroid. Pada
hiperplasi, kadar 17 hidroxi kortikosteroid akan naik sampai 2 kali, pada
adenoma dan karsinoma tidak terjadi kenaikan kadar 17 hidroxikortikosteroid
dalam urine.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">c.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pengukuran kadar ACTH plasma.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">d.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Test stimulasi ACTH, pada adenoma
didapati kenaikan kadar sampai 2 – 3 kali, pada kasinoma tidak ada kenaikan
(Mansjoer, 2007).</span></div>
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</span>
<br />
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">8<span style="font: 7pt "Times New Roman";">
</span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Penatalaksanaan cushing sindrom</span></b></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pengobatan sindrom cushing tergantung
ACTH tidak seragam, bergantung apakah sumber ACTH adalah hipofisis / ektopik.</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">a.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Jika
dijumpai tumor hipofisis. Sebaiknya diusahakan reseksi tumor tranfenoida.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">b.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Jika terdapat bukti hiperfungsi
hipofisis namun tumor tidak dapat ditemukan maka </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">sebagai
gantinya dapat dilakukan radiasi kobait pada kelenjar hipofisis.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">c.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kelebihan kortisol juga dapat
ditanggulangi dengan adrenolektomi total dan diikuti pemberian kortisol dosis
fisiologik.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">d.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Bila kelebihan kortisol disebabkan oleh
neoplasma disusul kemoterapi pada penderita dengan karsinoma/ terapi
pembedahan.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">e.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Digunakan obat dengan jenis metyropone,
amino gluthemide yang bisa mensekresikan kortisol (Silvia A. Price ; Patofisiologi
Edisi 4 hal 1093).</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> Sesuai pada penyebabnya,
Penyakit Cusing dapat dilakukan iradiasi dari hipofise, kombinasi iradiasi
dengan unilateral adrenalektomi. Pada adenoma basofil yang menimbulkan gejala
peningkatan tekanan intra kranial dan tidak berhasil dengan radiotherafi,
dilakukan ekstirpasi. Pada kasus berat dimana iradiasi hipofise tidak memberi
hasil, dilakukan adrenalektomi bilateral, kemudian substitusi dengan
hidrokortison, kortison atau fludrokortison. Bila disebabkan oleh adenoma atau
karsinoma adrenal, dilakukan operasi kemudian terapi substitusi.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> Ada 3 jenis obat yang
sekarang tersedia yang digunakan untuk menekan sekresi kortisol karsinoma.
Terdiri dari metyrapone, amino gluthemide dan o, p-DDD. Bisa digunakan untuk
mengendalikan syndrome Chusing (dan untuk mengurangi resiko operasi) sebelum
pengobatan radikal atau sebagai alternative jika tindakan bedah merupakan
kontraindikasi.</span></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> Jika sindrom Cushing
merupakan akibat dari pemberian kortikosteroid eksternal (eksogen), pemberian obat
tersebut harus diupayakan untuk di kurangi atau dihentikan secara bertahap
hingga tercapai dosis minimal yang adekuat untuk mengobati proses penyakit yang
ada di baliknya. Biasanya terapi yang dilakukan setiap dua hari sekali aan
menurunkan gejala sindrom Cushing dan memungkinkan pemulihan daya responsive
kelenjar adrenal terhadap ACTH.</span></div>
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<br /></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Terapi obat: metirapon (menghambat
sisntesis kortisol) atau ketokonazol (menghambat sitokrom P450) menurunkan
kadar kortisol untuk jangka pendek sebelum pembedahan atau jangka panjang
apabila pembedahan tidak mungkin dilakukan.</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Adenoma hipofisis: adenomektomi
trans-sfenoidalis menyebabkan relaps pada > 70% kasus radioterapi dapat
digunakan untuk kasus relaps yang tidak dapat disembuhkan. Adrenalektomi
bilateral menyebabkan pembesaran tumor hipofisis dengan cepat dan
hiperpigmentasi sebagai akibat sekresi ACTH yang berlebihan (sindrom Nelson),
kecuali apabila diberikan juga radioterapi pada hipofisis.</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Adenoma adrenal: dapat disembuhakan
dengan adrenalektomi.</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Karsinoma adrenal: tidak dapat
disembuhkan dengan pembedahan. Terapi obat dengan miotan, sebuah obat
adrenolitik, dapat membantu.</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> Sekresi ektopik: pengankatan tumor dengan
embedahan bila memungkinkan,jika tidak, berikan terapi medis atau lakukan
adrenalektomi.</span></div>
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<span style="font-family: Symbol; font-size: 13pt; line-height: 150%;">·<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pengobatan syndrome chusing tergantung
ACTH tidak seragam,bergantung apakah sumber ACTH adalah hipofisis /Ektopik </span></div>
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Penatalaksanaan Medis</span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pengobatan biasanya di arahkan pada kelenjar hipofisis
karena mayoritas kasus disebabkan oleh tumor hipofisis ketimbang oleh tumor
korteks adrenal.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">a. Pengankatan
melalui pembedahan merupakan pengobatan pilihan yang sering dilakukan.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">b. Implantasi
jarum yang mengandung isotop radioaktif kedalam kelenjar hipofisis.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">c. Adrenalektomi
pada pasien dengan hipertrofi adrenal primer.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">d. Pascaoperatif,
terapi penggantian hidrokortison temporer mungkin diberikan sampaat elenjar
adrenal mulai berespon secara normal (mungkin membutuhkan waktu beberapa
bulan).</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">e. Jika
dilakukan adrenalektomi bilateral, maka dibutuhkan terapi penggantian hormon
korteks adrenal seumur hidup.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">f. Jika
Sindrom <i style="mso-bidi-font-style: normal;">Cushing</i> di sebabkan oleh
kortikosteroid eksogen, maka lakukan penurunan obat sampai kadar minum untuk
mengobati penyakit yang mendasari.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">9. Prognosis</span></b></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Sindrom cushing yang tidak di obati akan fatal dalam beberapa tahun oleh
karena gangguan kardiovaskular dan sepsis. Setelah pengobatan redikal kelihatan
membaik, tergantung kepada apakah gangguan kerusakan kardiovaskularireversibel.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pengobatan substitusi permanen memberikan resiko pada waktu pasien
mengalami stress dan di perlukan perawatan khusus. Karsinoma adrenal atau yang
lainnya cepat terjadi fatal oleh karena kekeksia dan atau metastatis.</span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Adenoma adrenal yang berhasil di obati dengan pembedahan mempunyai
prognosis baik dan tidak mungkin kekambuhan terjadi. Prognosis tergantung pada
efek jangka lama dari kelebihan kortisol sebelum pengobatan, terutama
aterosklerosis dan osteoporosis.</span></div>
<div class="MsoNoSpacing" style="line-height: 150%; text-align: justify; text-indent: 18.0pt;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Harapan hidup pasien non-ganas penyebab sindrom
Cushing, sekali penyakit seragam fatal, telah meningkat secara dramatis dengan
perawatan bedah dan medis yang efektif. Penyakit cushing syndrome peningkatan
risiko kardiovaskular dan bukti penyakit aterosklerosis bertahan ketika diukur
5 tahun setelah remisi penyakit Cushing, dan karena itu penting untuk agresif
mengobati kondisi terkait seperti hipertensi dan diabetes. Hasil dari penyakit
Cushing pediatrik adalah sangat baik jika dirawat di pusat dengan
pengalaman yang sesuai. </span></div>
<div class="MsoNoSpacing" style="line-height: 150%; text-align: justify;">
<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> Prognosis penyebab berpotensi ganas
sindrom Cushing lebih bervariasi. Kanker adrenal yang terkait dengan sindrom
Cushing memiliki prognosis yang sangat buruk. Tumor yang memproduksi ACTH
ektopik cenderung memiliki prognosis yang lebih buruk, dibandingkan dengan
tumor dari jaringan yang sama yang tidak menghasilkan ACTH dalam waktu 2 minggu
dari awal kemoterapi </span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">10<span style="font: 7pt "Times New Roman";">
</span></span></b><b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">komplikasi</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">. </span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Hirsutisme</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">2.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Ikhtisar</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; mso-list: l16 level1 lfo39; text-indent: -18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">3.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Obesitas</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">4.<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Osteoporosis</span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">5.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Fibrosa</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">1)<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Hirsutisme</span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Seorang wanita dengan hirsutisme memiliki rambut
tubuh yang berlebihan yang tumbuh di lokasi yang sama seperti pada laki-laki.
Kebanyakan kasus disebabkan oleh ketidakseimbangan hormon ringan. Jarang,
hirsutisme disebabkan oleh penyakit yang mendasarinya. Sekitar 8 persen wanita
di Amerika Serikat telah hirsutisme. Terapi obat efektif mencegah pertumbuhan
rambut tambahan, namun tidak mengurangi rambut yang ada.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gejala hirsutisme</span></b><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; mso-add-space: auto; text-align: justify; text-indent: 18.0pt;">
<span style="background: none repeat scroll 0% 0% rgb(230, 236, 249); font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gejala
hirsutisme meliputi pertumbuhan rambut yang berlebiha</span><span lang="EN-US" style="background: none repeat scroll 0% 0% rgb(230, 236, 249); font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">n , </span><span style="background: none repeat scroll 0% 0% rgb(230, 236, 249); font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">jerawat
, infertilitas , suara yang dalam, klitoris membesar, periode menstruasi yang
berat, dan periode menstruasi yang tidak teratu</span><span lang="EN-US" style="background: none repeat scroll 0% 0% rgb(230, 236, 249); font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">r.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Apakah yang dimaksud dengan defisiensi sistem kekebalan tubuh?</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">
<br />
Seseorang dengan defisiensi sistem kekebalan tubuh memiliki sistem kekebalan
tubuh yang lemah, yang biasanya melawan infeksi. <span style="background: none repeat scroll 0% 0% rgb(230, 236, 249);">Mereka
yang memiliki sistem kekebalan tubuh lemah tidak mampu untuk melawan infeksi
tepat.</span> Penyebab umum dari kekurangan sistem kekebalan tubuh termasuk
diabetes , </span><a href="http://translate.googleusercontent.com/translate_c?hl=id&langpair=en%7Cid&rurl=translate.google.co.id&u=http://www.freemd.com/aids/overview.htm&usg=ALkJrhg57nEqoMHMqw24-zts93vzoCBsew"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%; text-decoration: none;">AIDS</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">
, dan </span><a href="http://translate.googleusercontent.com/translate_c?hl=id&langpair=en%7Cid&rurl=translate.google.co.id&u=http://www.freemd.com/cancer/overview.htm&usg=ALkJrhjZ3Viz10_rWqS0eVG10J1TlhbRlw"><span style="color: windowtext; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%; text-decoration: none;">kanker</span></a><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">2)<span style="font: 7pt "Times New Roman";"> </span></span><b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">obesitas?</span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">
</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Seseorang dengan obesitas
memiliki jumlah abnormal jaringan lemak dalam tubuh. Dalam rangka untuk menjadi
gemuk, berat badan harus 30 persen lebih tinggi dari normal, atau indeks massa
tubuh harus lebih dari 30.</span></div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gejala obesitas</span></b></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; text-align: justify; text-indent: 18.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Obesitas umumnya tidak
menimbulkan gejala. Obesitas ekstrim dapat mengakibatkan </span><a href="http://translate.googleusercontent.com/translate_c?hl=id&langpair=en%7Cid&rurl=translate.google.co.id&u=http://www.freemd.com/weakness-or-fatigue/overview.htm&usg=ALkJrhhkR_fpel-6nkhuE83pQb1VhKPKRw"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%; text-decoration: none;">kelemahan</span></a><span style="color: black; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> , </span><a href="http://translate.googleusercontent.com/translate_c?hl=id&langpair=en%7Cid&rurl=translate.google.co.id&u=http://www.freemd.com/weakness-or-fatigue/overview.htm&usg=ALkJrhhkR_fpel-6nkhuE83pQb1VhKPKRw"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%; text-decoration: none;">kelelahan</span></a><span style="color: black; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> , </span><a href="http://translate.googleusercontent.com/translate_c?hl=id&langpair=en%7Cid&rurl=translate.google.co.id&u=http://www.freemd.com/dyspnea-on-exertion/overview.htm&usg=ALkJrhgP4Qdkk7ISi1aogrD38f9Byfby5g"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%; text-decoration: none;">meningkatkan
sesak napas dengan pengerahan tenaga</span></a><span style="color: black; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> , dan </span><a href="http://translate.googleusercontent.com/translate_c?hl=id&langpair=en%7Cid&rurl=translate.google.co.id&u=http://www.freemd.com/leg-swelling/overview.htm&usg=ALkJrhhAJ1GawooVsbMmUxssB34aHASpdA"><span style="color: black; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%; text-decoration: none;">kaki
bengkak</span></a><span style="color: black; font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">.</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">3)<span style="font: 7pt "Times New Roman";">
</span></span><b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">osteoporosis</span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Seseorang dengan osteoporosis telah kehilangan
struktur tulang normal yang membuat tulang kuat. Massa tulang dan kepadatan
tulang menurun, dan tulang-tulang menjadi lemah. Osteoporosis membuat tulang
lebih rentan untuk melanggar. Sebuah patah tulang pergelangan tangan , patah
tulang pinggul , atau fraktur kompresi vertebral adalah lebih umum pada mereka
dengan osteoporosis. Sekitar 35 persen wanita di AS mengalami osteoporosis.</span></div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gejala osteoporosis</span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="background: none repeat scroll 0% 0% rgb(230, 236, 249); font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gejala osteoporosis meliputi
kehilangan tinggi, kifosis tulang belakang, nyeri punggung kronis , sakit
pinggul , dan nyeri pergelangan tangan .</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> Gejala patah tulang
meliputi tiba-tiba, nyeri tulang yang parah.</span></div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Fibrosa</span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Seorang anak dengan displasia fibrosa memiliki
pertumbuhan tulang abnormal yang menghasilkan tulang melemah. Para tulang lemah
yang rentan terhadap fraktur. Displasia fibrosa terjadi pada anak yang adalah
antara 3 dan 15 tahun. <span style="background: none repeat scroll 0% 0% rgb(230, 236, 249);">Displasia fibrosa
biasanya hanya mempengaruhi satu tulang, bukan seluruh kerangka.</span>
Penyebab displasia fibrosa disebabkan oleh mutasi gen yang menghasilkan
pembentukan tulang abnormal.</span></div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Apa saja gejala displasia fibrosa?</span></b><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">
</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 18.0pt; margin-right: 0cm; margin-top: 0cm; text-align: justify; text-indent: 36.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Gejala displasia fibrosa meliputi nyeri tulang ,
patah tulang, tulang cacat, kulit gelap , dan kesulitan berjalan.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">BAB VI</span></b></div>
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<b style="mso-bidi-font-weight: normal;"><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kesimpulan</span></b></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 150%;">Berdasarkan gejala yang ada,tindakan yang harus dilakukan adalah
menegakkan diagnosis, diagnosis sementara penyakit pasien adalah sindrom
cushing.Sindrom cushing bisa diakibatkan oleh adenoma adrenal, karsinoma
adrenal, penyakit cushing, dan ACTH ektopik. pengobatan sementara untuk pasien
sambil menunggu hasil pemeriksaan laboratorium dan CT scan adalah pengobatan
terhadap hipertensi, obesita, kelemahan, dan osteoporosis.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">
</span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Pengobatan
sindrom cushing tergantung ACTH tidak seragam, bergantung apakah sumber ACTH
adalah hipofisis / ektopik.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Dan
Penatalaksanaan cushing sindrom</span></div>
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<span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">a.<span style="font: 7pt "Times New Roman";"> </span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Jika
dijumpai tumor hipofisis. Sebaiknya diusahakan reseksi tumor tranfenoida.</span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"></span></div>
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</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Jika terdapat bukti hiperfungsi
hipofisis namun tumor tidak dapat ditemukan maka </span><span lang="EN-US" style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;"> </span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">sebagai
gantinya dapat dilakukan radiasi kobait pada kelenjar hipofisis.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">c.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Kelebihan kortisol juga dapat
ditanggulangi dengan adrenolektomi total dan diikuti pemberian kortisol dosis
fisiologik.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">d.<span style="font: 7pt "Times New Roman";">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 13pt; line-height: 150%;">Bila kelebihan kortisol disebabkan oleh
neoplasma disusul kemoterapi pada penderita dengan karsinoma/ terapi
pembedahan.</span></div>
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<i style="mso-bidi-font-style: normal;"><u><span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 150%;"></span></u></i>arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com2tag:blogger.com,1999:blog-2501725445038181687.post-83718833115670943882012-02-01T17:19:00.000+07:002013-05-16T08:09:20.529+07:00OBESITAS<div style="text-align: justify;">
<span style="font-family: inherit;"><span style="font-size: small;">1.1 OBESITAS DAN JENIS-JENIS OBESITAS<br />1.1.1 OBESITAS<br />Obesitas adalah keadaan patologis dengan terdapatnya dengan penimbunan lemak yang berlebihan dari pada yang di perlukan untuk fungsi tubuh. Masalah gizi karena kelebihan kalori biasanya di sertai karena kelebihan lemak dan protein hewani, kelebihan gula dan garam, tetapi terjadi kelebihan serat dan mikro-nutrien, yang kelak dapat merupakan faktor resiko untuk terjadinya berbagai jenis penyakit degeneratif, seperti diabetes mellitus, hipertensi, penyakit jantung koroner, reumatik, dan berbagai jenis keganasan (kanker) dan gangguan kesehatan lain yang akan memerlukan biaya pengobatan yang sangat besar.<br />Berdasarkan etiologinya, umumnya obesitas di bagi menjadi:<br />1. Obesitas primer : disebabkan faktor nutrisi dengan berbagai faktor yang dapat mempengaruhi masukan makanan, yaitu masukan makanan berlebih dibanding dengan kebutuhan enargi yang diperlukan tubuh.<br />2. Obesitas skunder : yang di sebabkan adanya penyakit/kelainan congenital (mielodisplasia), endokrin (sindrom Cushing, sindrom freulich, sindrom Mauriac, pseudoparatiroidisme) atau kondisi lain ( sindrom klinefelter, sindrom turner, sindrom Down, dll ).<br />Menurut pathogenesis dapat di bagi dua golangan yaitu:<br />1. Regulatori obesity : gangguan primernya berada pada pusat yang mengatur masukan makanan.<br />2. Obesitas metabolik: kelainan pada metabolisme lemak dan karbohidrat.<br />1.1.2 Jenis-jenis obesitas<br />Seseorang yang memiliki berat badan 20% lebih tinggi dari nilai tengah kisaran berat badannya yang normal dianggap mengalami obesitas.<br /><br />Obesitas digolongkan menjadi 3 kelompok:<br />1. Obesitas ringan : kelebihan berat badan 20-40%<br />2. Obesitas sedang : kelebihan berat badan 41-100%<br />3. Obesitas berat : kelebihan berat badan >100% (Obesitas berat ditemukan sebanyak 5% dari antara orang-orang yang gemuk).</span></span></div>
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<span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Perhatian tidak hanya ditujukan kepada jumlah lemak yang ditimbun, tetapi juga kepada lokasi penimbunan lemak tubuh. Pola penyebaran lemak tubuh pada pria dan wanita cenderung berbeda. Wanita cenderung menimbun lemaknya di pinggul dan bokong, sehingga memberikan gambaran seperti buah pir. Sedangkan pada pria biasanya lemak menimbun di sekitar perut, sehingga memberikan gambaran seperti buah apel. Tetapi hal tersebut bukan merupakan sesuatu yang mutlak, kadang pada beberapa pria tampak seperti buah pir dan beberapa wanita tampak seperti buah apel, terutama setelah masa menopause.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Seseorang yang lemaknya banyak tertimbun di perut mungkin akan lebih mudah mengalami berbagai masalah kesehatan yang berhubungan dengan obesitas. Mereka memiliki risiko yang lebih tinggi. Gambaran buah pir lebih baik dibandingkan dengan gambaran buah apel.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Untuk membedakan kedua gambaran tersebut, telah ditemukan suatu cara untuk menentukan apakah seseorang berbentuk seperti buah apel atau seperti buah pir, yaitu dengan menghitung rasio pinggang dengan pinggul. Pinggang diukur pada titik yang tersempit, sedangkan pinggul diukur pada titik yang terlebar; lalu ukuran pinggang dibagi dengan ukuran pinggul. Seorang wanita dengan ukuran pinggang 87,5 cm dan ukuran pinggul 115 cm, memiliki rasio pinggang-pinggul sebesar 0,76. Wanita dengan rasio pinggang:pinggul lebih dari 0,8 atau pria dengan rasio pinggang:pinggul lebih dari 1, dikatakan berbentuk apel.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.2 FAKTOR – FAKTOR PENYEBAB OBESITAS</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Obesitas merupakan keadaan yang tidak dikehendaki, yaitu dengan terdapatnya penimbunan lemak yang berlebihan dari yang diperlukan untuk fungsi tubuh yang normal. Tetapi tidak semua orang yang mempunyai berat badan lebih disebut sebagai obesitas. Jadi untuk mengatakan seorang anak mengalami obesitas di samping gejala klinis harus juga didukung oleh pemeriksaan antropometri (fisik) yang jauh di atas normal. Pemeriksaan fisik tersebut antara lain berat badan terhadap tinggi badan, berat badan terhadap umur dan tebalnya lipatan kulit dan paling sedikit perbandingannya 10 % di atas nilai normal. </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Menurut para ahli, didasarkan pada hasil penelitian, obesitas dapat dipengaruhi oleh berbagai faktor. Zainun Mu’tadin (2002) mengemukakan bahwa faktor-faktor penyebab obesitas diantaranya adalah faktor genetik, disfungsi salah satu bagian otak, pola makan yang berlebih,Faktor fisik kurang gerak / olahraga,faktor psikis, dan faktor status social.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.2.1 Faktor Genetik ( Keturunan )</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Seorang individu yang memiliki berat badan gemuk, menurut pandangan genetic ini, dikarenakan keturunan dari kondisi orang tua yang juga memiliki badan gemuk. Dalam penelitian yang dilakukan Bouchard (dalam Santrock, 1999), terbukti sebanyak 25-27% orang yang gemuk karena memang dari orang tuanya berbadan gemuk. Jadi, kondisi badan seseorang sudah terdeterminasi sejak masa kandungan atau kelahiran. Pada saat ibu yang obesitas sedang hamil maka unsur sel lemak yang berjumlah besar dan melebihi ukuran normal, secara otomatis akan diturunkan kepada sang bayi selama dalam kandungan. Dengan demikian tidak heran apabila bayi yang dilahirkan pun memiliki unsur lemak tubuh yang relatif sama besar.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.2.2 Kerusakan pada Salah Satu bagian Otak </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Perilaku makan seseorang dikendalikan oleh sistem pengontrol yang terletak pada suatu bagian otak yang disebut hipotalamus. Hipotalamus merupakan sebuah kumpulan inti sel dalam otak yang langsung berhubungan dengan bagian-bagian lain dari otak dan kelenjar dibawah otak. Hipotalamus mengandung lebih banyak pembuluh darah dari daerah lain pada otak, sehingga lebih mudah dipengaruhi oleh unsur kimiawi dari darah. Dua bagian hipotalamus yang mempengaruhi penyerapan makan yaitu hipotalamus lateral (HL) yang menggerakan nafsu makan (awal atau pusat makan); hipotalamus ventromedial (HVM) yang bertugas merintangi nafsu makan (pemberhentian atau pusat kenyang). Dari hasil penelitian didapatkan bahwa bila HL rusak/hancur maka individu menolak untuk makan atau minum, dan akan mati kecuali bila dipaksa diberi makan dan minum (diberi infus). Sedangkan bila kerusakan terjadi pada bagian HVM maka seseorang akan menjadi rakus dan kegemukan. </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.2.3 Faktor Aktifitas </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Pola aktifitas yang minim berperan besar dalam peningkatan resiko kegemukan dan obesitas pada anak. Kegemukan dan obesitas lebih mudah diderita pada anak yang kurang aktifitas maupun olahraga. Kegemukan dan obesitas pada anak yang kurang beraktifitas fisik maupun berolahraga disebabkan oleh jumlah kalori yang dibakar lebih sedikit dibanding kalori yang diperoleh dari makanan yang dikonsumsi sehingga berpotensi menimbulkan penimbunan lemak berlebih di dalam tubuh.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.2.4 Faktor Pola Makan Berlebih</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Pola makan berlebihan cenderung dimiliki oleh orang yang kegemukan. Orang yang kegemukan biasanya lebih responsif dibanding dengan orang yang memiliki berat badan normal terhadap isyarat lapar eksternal, seperti rasa dan bau makanan, atau saatnya waktu makan. Mereka cenderung makan bila ia merasa ingin makan, bukan makan pada saat ia lapar. Pola makan yang berlebihan inilah yang menyebabkan mereka sulit untuk keluar dari kegemukan apabila tidak memiliki kontrol diri dan motivasi yang kuat untuk mengurangi berat badan.. Makanan yang mesti dihindari untuk mencegah kegemukan dan obesitas pada anak adalah yang tinggi kadar kalorinya, rendah serat , dan minim kandungan gizinya.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Para orangtua berperan penting dalam membentuk kebiasaan dan pola makan anak-anak mereka. Anak sering kali bersikap pasif dan hanya mengonsumsi makanan yang disediakan oleh orangtuanya. Oleh karena itu, alangkah baiknya bila para orangtua aktif menggali berbagai informasi mengenai bahan – bahan makanan maupun produk olahan makanan yang aman dan sehat bagi anak.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.2.5 Faktor Psikis</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Pada beberapa kasus obesitas bermula dari masalah emosional yang tidak teratasi. Orang-orang yang memiliki permasalahan menjadikan makanan sebagai pelarian untuk melampiaskan masalah yang dihadapinya. Makanan juga sering dijadikan sebagai subtitusi untuk pengganti kepuasan lain yang tidak tercapai dalam kehidupannya. Dengan menjadikan makanan sebagai pelampiasan penyelesaian masalah maka apabila tidak diimbangi dengan aktifitas yang cukup akan menyebabkan terjadinya kegemukan.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.2.6 Faktor Status Sosial Ekonomi</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Santrock (1999) mencatat bahwa wanita yang berasal dari status social ekonomi yang rendah cenderung memiliki berat badan yang gemuk dibandingkan dengan wanita yang berasal dari status ekonomi tinggi. Kemungkinan timbulnya kegemukan tersebut disebabkan seberapa intensitas perhatian individu terhadap perawatan fisiknya. Mereka yang mapan secara ekonomis, lebih memiliki perhatian yang tinggi. Mereka munkin akan merasa cemas kalau berat badannya mengalami kenaikan secara cepat.. Karena itu, mereka pun segera melakukan perawatan intensif dengan bantuan tenaga professional ahli gizi, dokter) serta membeli bahan-bahan untuk merampingkan tubuhnya. Tentu harganya cukup mahal. </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Sementara itu, mereka yang berasal dari kalangan social ekonomi yang belum mapan tak mampu membeli bahan – bahan tersebut.Akibatnya, kurang perhatian terhadap kondisi fisiknya. Dengan demikian, ia cenderung berbadan gemuk.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.2.7 Efek Samping Obat</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Semua jenis obat yang biasa dikonsumsi seperti obat antidepresi, kontrasepsi, dalam beberapa kasus dapat menyebabkan peningkatan berat badan yang sangat drastis.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.3 CIRI-CIRI OBESITAS</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Ciri-ciri anak yang mengalami obesitas antara lain: anak tersebut memiliki wajah bulat, pipi tembem, dagu rangkap, leher terlihat pendek, dada membusung, payudara membesar, perut buncit, burried penis, lengan dan paha besar dengan ujung jari kecil dan runcing. </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Penatalaksanaan yang baik untuk anak obesitas yaitu dengan memperhatikan pola makan, meningkatkan aktivitas, perubahan perilaku, penggunaan obat-obatan dan bisa juga dengan melakukan pembedahan. Pengaturan makan yang harus dilakukan pada anak obesitas harus dilakukan secara bertahap, yaitu dengan menurunkan kalori makanannya 300-500 kcal/hari, penurunan dengan jumlah kalori ini dapat menurunkan sekitar 0,5 kg/minggu. Pemberian makan pun harus dengan pola makan sehat. selain pengaturan makan aktivitas anak tersebut juga perlu diperhatikan dimana anak tersebut harus dibiasakan hidup aktif, serta mengurangi kegiatan pasif seperti nonton TV dan bermain playstation, anak tersebut juga harus dibiasakan olah raga.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Ciri obesitas yang mudah dilihat adalah dari ciri fisik bayi tersebut. Jika bayi nampak gemuk dan besar maka periksalah berat badan bayi untuk meyakinkan apakah dia obesitas atau tidak. Berat bayi yang berada di atas rata-rata berat normal untuk usianya menandakan gejala obesitas. Selain itu, index massa tubuh bayi bisa dihitung untuk lebih meyakinkan lagi. Index massa tubuh sama dengan berat badan bayi (kg) dibagi {tinggi badan bayi (cm)/100) x 2}. Jika nilainya sama dengan atau lebih dari 0,95 maka bayi mengalami obesitas. Ciri obesitas juga dapat diketahui dengan perbandingan antara berat badan bayi dengan berat badan ideal yang seharusnya. Jika nilai perbandingannya sama dengan atau lebih dari 120% maka bayi positif terkena obesitas. Dan lagi, jika berat bayi naik secara berlebihan selama 1 hingga 3 bulan dan kenaikannya di atas rata-rata kenaikan berat bayi maka bisa saja bayi terkena obesitas.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Tidak hanya dari pengukuran berat badan, ciri obesitas bisa dilihat dari bentuk fisik yang lebih spesifik. Kegemukan pada bayi ditandai dengan adanya banyak lipatan pada tubuhnya terutama di bagian dagu. Pipi bayi tampak tembam dan lehernya pendek. Tubuh bayi terlihat tidak proporsional karena tinggi badan tidak senormal tinggi badan ideal seusianya.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pada bayi laki-laki, ciri obesitas terlihat dari pembesaran payudara di dadanya. Selain itu, bayi laki-laki ini justru memiliki alat kelamin yang kecil. Hal ini disebabkan karena jaringan lemak di daerah alat kelaminnya menumpuk dan menghambat perkembangan alat kelaminnya. Kegemukan pada bayi bisa juga dikenali dari pola makan dan pola hidup yang dialami oleh bayi. Misalnya jika bayi memang jarang bergerak atau kurang melakukan kegiatan dan aktivitas. Pola makan bayi yang berlebihan serta tidak bergizi. Jika hal ini terjadi maka orangtua harus mewaspadai obesitas pada bayi mereka.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Secara klinis mudah dikenali, karena mempunyai ciri-ciri yang khas, antara lain :</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1. wajah bulat dengan pipi tembem dan dagu rangkap;</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">2. leher relatif pendek;</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">3. dada membusung dengan payudara membesar;</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Bentuk payudara mirip dengan payudara yang telah tumbuh. Pada anak pria menimbulkan perasaan yang kurang menyenangkan.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">4. perut membuncit (pendulous abdomen) dan striae abdomen;</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Membuncit dan menggantung serupa dengan bentuk bandul lonceng (pendulum), kadang-kadang terdapat stria putih atau ungu.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">5. pada anak laki-laki : Burried penis, gynaecomastia;</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">6. pubertas dini;</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">7. genu valgum (tungkai berbentuk X) dengan kedua pangkal paha bagian dalam saling menempel dan bergesekan yang dapat menyebabkan laserasi kuli.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">8. anggota badan;</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Lengan atas dan paha tampak besar, terutama pada bagian proksimal. Tangan relatif kecil dan jari-jari yang berbentuk runcing. Terdapat kelainan koksa vara dengan genu valvum pada tungkai.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">9. Kelainan emosi;</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pada penderita sering ditemukan gejala gangguan emosi yang mungkin merupakan penyebab atau akibat dari keadaan obesitas.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4 KOMPLIKASI PENYAKIT OBESITAS</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4.1 Diabetes Melitus</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Sudah sejak lama diketahui dan diterima umum bahwa obesitas merupakan salah satu resiko faktor yang paling penting untuk timbulnya diabetes. Bahka diantara penduduk yang gemuk pada semua suku bangsa, diabetes sering ditemukan. Insidensi diabetes bertambah menjadi 4 kali lebih besar pada orang dewasa dengan obesitas berat. Banyak pennyelidikan epidemiologis lain membenarkan pendapat ini. Pennyelidikan pada orang indian pima dengan kadar gula darah normal pada awal penelitian, ternyata menunjukkan bahwa resiko untuk menderita diabetes melitus menjadi 3,4 kali lebih besar bila berat badan meningkat sampai 125-150% standar. Sedangkan pada orang dengan berat sama atau lebih besar dari 150% standar, resiko terjadinya diabetes menjadi 6,4 kali lebih besar. Pada suatu pennyelidikan dijakarta (1982), juga ditemukan bahwa kegemukan merupakan salah satu resiko penting bagi timbulnya diabetes melitus. Prevalensi diabetes pada kelompok gemuk pada pennyelidikan ini ialah 6,7% sedang kan pada kelompok overweight, normal dan underweight masing-masing dengan prevalensi diabetes 3,7%, 0,9% dan 0,4%.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pada analisis lebih lanjut, memang terlihat pada kolerasi yang bermakna antara obesitas dengan kadar gula darah. Kegemukan secara tersendiri tidak sampai menimbulkan diabetes, walaupun jelas dapat menaikan kadar gula darah. Pada derajat kegemukan dengan body mass index (BMI) 24 (laki-laki dikatakan gemuk bila BMI > 27 kg/m2), akibat pengaruh kegemukan itu dapat menyebabkan kadar gula menjadi 200 mg%. Pennyelidikan lain menemukan bahwa obesitas tersendiri dapat menyebabkan diabetes (kampner), walupun pada saat penyelidikan tersebut kriteria diabetes melitus yang dipakai masih kriteria lama, yaitu lebih rendah dari pada kriteria diabetes melitus 1980. </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Disamping derajat obesitas, lamanya obesitas juga berpengaruh pada terjadinya diabetes. 11 diantara 18 kasus obesitas yang diselidiki ogilvie, ternyata menderita diabetes setelah gemuk selama 18 tahun.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Mengenai mekanisme hubungan antara obesitas sebagai faktor resiko diabetes, sampai saat ini masih belum jelas benar. Yang sudah diketahui adalah bahwa diabetes melitus mempunyai etiologi multifaktorial dengan obesitas sebagai salah satu faktornya. Pada obesitas terjadi hipertrofi sel beta pankreas dan hiperinsulinisme. Jika mekanisme kompetensi sudah tidak mencukupi lagi, apakah karna ada pakror genetik maupun lingkungan tidak menguntungkan, dapat terjadi diabetes melitus pada orang obeis tersebut.</span></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4.2 Hipertensi</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Ada pendapat yang menyatakan bahwa obesitas membahayakan pasien terutama karena tekanan darah tinggi yang ditimbulkannya. Penyelidikan di Framingham menunjukkan bahwa prevalensi hipertensi adalah 10 kali lebih besar pada kelompok yang overweight sampai 20%. Lagi pula prevalensi hipertensi mempunyai hubungan langsung dengan berat badan. BMI yang tinggi selalu merupakan salah satu ciri masyarakat hipertensif pada penyelidikan-penyelidikan yang telah dilakukan.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Hubungan antara tekanan darah dan berat badan lebih nyata untuk tekanan sistolik dari pada tekanan diastolik. Juga hubungan tersebut lebih menonjol pada wanita dari pada laki-laki. Kenyataan bahwa orang dengan tekanan darah tinggi cendrung untuk menjadi gemuk, dan adanya hubungan bahwa orang gemuk dengan tekanan darah normal cendrung untuk menjadi hipertensif menunjukkan adanya hubungan antara hipertensi esensial dengan obesitas.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Dasar mekanisme kenaikan tekanan darah pada orang gemuk sampai saat ini belum jelas. Disangka beberapa hal yang mengacaukan dapat terjadi, antara lain persoalan pengukuran tekanan darah. Alat pengukur (cuff) yang terlalu kecil, sehingga tidak dapat menutup (melingkar) lengan dengan sempurna akan menghasilkan tekanan darah tinggi palsu. Dengan alat pengukur standar yang dipasang pada orang gemuk akan terjadi kenaikan 8-12 mmHg lebih tinggi dari pada seharusnya.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pada beberapa penyelidikan hemodinamik orang gemuk yang normotensif ditemukan kenaikan kosumsi o2 dan juga denyut jantung yang sedikit lebih meningkat. Penyelidikan lain menunjukan adanya kenaikan volume darah yang beredar berhubungan dengan curah jantung yang juga meningkat. Juga ditemukan peningkatan kerja ventrikel kiri. Alexander menemukan diameter trensversal jantung yang 20-55% lebih besar pada autopsi orang gemuk. Volume darah yang meningkat pada orang gemuk kebanyakan disebabkan oleh meningkatnya volume darah dalam jaringan lemak. Backman dkk melaporkan adanya kenaikan curah jantung yang sebanding dengan konsumsi O2 dan derajat kegemukan.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pengaruh penurunan berat badan terhadap tekanan darahtidak jelas secara menyeluruh. Ada penyelidik yang mendapatkan penurunan tekanan darah, walau pun tidak konsisten, tapi ada pula yang tidak menganggap penting penurunan berat badan untuk menurunkan tekanan darah. Ramsey dkk memperkirakan bahwa penurunan berat badan sebesar 1kg akan menurunkan tekanan darah sebesar 2,5 mmHg sistolik dan 1,5 mmHg diastolik.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4.3 Penyakit Kardiovaskular (Penyakit jantung iskemik)</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Kematian yang lebih tinggipada orang gemuk terutama disebabkan oleh penyulit kardiovaskular. Suatu penyelidikan pada lebih dari 5000 penduduk di framingham, menunjukan bahwa kenaikan berat badan mempunyai hubungan yang bermakna dengan frekuensi kematian mendadak, angina pektoris, teteapi tidak berhubungan dengan infark miokard akut. Kebanyakan mati mendadak agaknya disebabkan karena penyakit kardiovaskular, sehingga data dari framingham tersebut dapat dianggap menyokong adanya hubungan antara obesitas dan kelainan jantung yang fatal. Tetapi bila faktor resiko lain seperti hipertensi dan kadar kolesterol darah yang tinggi ikut diperhitungkan, maka hubungan resiko kardioveskular dengan obesitas secara tersendiri tidak bermakna.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pada orang gemuk terjadi peningkatan konsumsi o2, isi sekuncup juga meningkat sesuai dengan derajat kegemukannya. Pada orang yang sangat gemuk dapat terjadi tanda overload, dan fungsi ventrikel kiri yang berkurang sebanding dengan kegemukannya, dan hal ini kemudian dapat menyebabkan terjadi payah jantung yang patal.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Kelainan kardiovaskular selain payah jantung adalah kelainan koroner. Seperti juga dengan penentuan faktor yang berpengaruh pada fungsi ventrikei kiri, di sini juga banyak faktor yang berpengaruh pada tingkat kejadian penyakit koroner. Terdapat pengaruh yang kompleks antara jenis kelamin, umur, tekanan darah, kadar serum lipid, merokok, diabetes dan berat badan. Untuk menentukan faktor mana yang di dominan agak sulit, karena memerlukan penyelidikan yang luas dan besar. Tetapi karena faktor tersebut, tidak hanya berhubungan penyakit koroner, tetapi juga saling berkaitan di antara sesamanya maka tentu penentuan faktor tersendiri menjadi lebih sulit.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4.4 Hipoventilasi Alveolar </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pada orang gemuk dapat terjadi hipoventilasi alveolar, yang pada keadaan berat dapat menyebabkan sindrom pickwickian dengan gejala terdiri atas obesitas berat, somnolensia, edema, kelainan npernafasan berat disertai adanya periode apnea dengan sianosis.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Patogenesis sindrom hipoventilasi pada obesitas ini masih belum jelas. Pada penyelidikan rochester yang membandingkan kelompok gemuk tampa gangguan pernapasan (obesitas simpel) dengan orang gemuk yang disertai gangguan pernapasan (sindrom hipoventilasi alveolar) ditemukan perbedaan dalam kelenturan 20%. Pada kelompok yang sindrom hipoventilasi alveolar ditemukan penurunan kelenturan sampai 30%. Kekurangan otot pernapasan pada kelompok hipoventilasi alveolar juga berkurang sampai 30% dari normal, sedang kelenturan paru sendiri berkurang sampai 40%.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Kelainan sirkulasi yang ditemukan pada kelompok obesitas ini adalah karena adanya kenaikan volume darah total dan volume darah paru. Perfusi paru normal, tetapi ventilasi paru berkurang. Tekanan akhir diastolik ventikel kiri meninggi walaupun peninggian ini tidak ditemukan pada semua pasien. Hipoventilasi alveolar dan asidemia akan menyebabkan vasokonstriksi pulmonal selanjutnya menimbulkan hipertensi pulmonal, yang akhirnya mengakibatkan pembesaran ventrikel kanan dan kor-pulmonal dengan dekompensasi. Kelainan tersebut sudah mulai tampak pada kelompok dengan obesitas simpel, dan perubahan tersebut dapat membaik dengan penurunan berat badan. Pada kelompok obesitas simpel disangka adanya gangguan ventilasi dan perfusi tersebut masih dapat dikompensasi melalui pengaruh sentral dan juga oleh otot pernapasan yang relatip masih baik, sedang pada kelompok sindrom hipoventilasi berat, mekanisme kompensasi sudah tidak berpungsi baik sehingga dapat mengakibatkan keadaan yang lebih buruk lagi.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4.5 Batu Empedu</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Batu empedu lebih banyak terjadi pada obesitas dari pada populasi umum, juga risiko kematian pada orang gemuk dengan batu empedu lebih besar dibanding yang tidak gemuk dengan batu empedu.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Penyelidikan horn pada wanita berumur di bawah 60 tahun, menemukan bahwa mereka yang mengidap batu empedu mempunyai berat badan 12 kg lebih berat dari pada yang tidak mengidap batu empedu. Van den liden mendapatkan adanya korelasi yang bermakna antara lipatan kulit supskapular dan patela dengan insidensi batu empedu pada wanita yang di oprasi batu empedunya. Batu empedu umumnya lebih banyak ditemukan dinegara maju dan negara yang telah menikuti cara kehidupan barat. Dasar kolerasi antara obesitas dengan batu empedu masih belum jelas benar. Beberapa penyidik menyatakan bahwa aktivitas fisis merupakan salah satu faktor yang penting. Sebaliknya jumlah dan komposisi makanan juga merupakan hal yang berpengaruh. Kaneda menemukan bahwa di jepang isidensi batu kolesterol meningkat dan hal ini disangka ada hubungannya dengan perubahan kebiasaan makanan yang lebih kebarat-baratan. Penyelidik tersebut, serta beberapa survei lainya, menyokong hipotesis bahwa kenaikan kadar kolesterol dalam empedu adalah sebagai akibat perubahan pola diet. Mungkin kadar kolesterol empedu mempunyai hubungan tidak langsung dengan kadar serum kolesterol. Pada hiperkolesterolemia familial tidak terjadi kenaikan pembentukan batu empedu.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4.6 Obesitas Dengan Kehamilan</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Obesitas memberikan risiko yang lebih besar pada wanita hamil bagi timbulnya kelainan tertentu seperti hipertensi dan diabetes melitus. Pada penyelidikan terhadap wanita gemuk yang hamil ditemukan kemunginan anak dengan berat badan lebih dari 4000 g 2 kali lebih besar dari pada normal, walaupun tidak menunjukan resiko operatif yang lebih tinggi. Di samping itu, insidensi persalinan yang lebih lama dari 24 jamsetelah amniotomi, juga meningkatkan kejadian hemoragia postpartum primer, asfiksia neonatal, dan pireksia puerpural. Walaupun demikian dengan pengelolaan antenatal yang baik termasuk pemantauan glukosa darah, fungsi fetoplasental dan disproporsi sefalopelvik, maka adanya obesitas tidak menyebabkan kematian perinatal dan matemal yang lebih banyak.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Gross menemukan adanya resiko antepartum yang lebih besar pada kelompok gemuk yang hamil. Juga ditemukan hipertensi dan diabetes yang lebih banyak, kehamilan kembar, diperlukan induksi partus dan kemungkinan seksio sesaria yang lebih sering walaupun tidak ada komplikasi persalinan yang lebih besar.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4.7 Kelainan Sendi</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Setiap peningkatan berat badan lebih dari normal akan menimbulkan beban yang berlebihan pada sendi penyangga berat badan, dan ini cenderung menyebabkan trauma ringan tetapi terus-menerus dan akan berakhir menjadi osteoartrosis (OA) baik primer ataupun sekunder. Engel dalam penelitiannya atas populasi penduduk yang dibagi menjadi 4 grup, ternyata grup yang mempunyai berat badan berlebihan dengan umur makin tua cenderung lebih cepat menderita OA. Sendi yang terkena adalah sendi penyangga berat badan yaitu punggung, pangkal paha, lutut dan pergelangan kaki.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4.8 Stroke</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Stroke termasuk penyakit serebrovaskuler (pembuluh darah otak) yang ditandai dengan kematian jaringan otak (infark serebral) yang terjadi karena berkurangnya aliran darah dan oksigen ke otak. Berkurangnya aliran darah dan oksigen ini bisa dikarenakan adanya sumbatan, penyempitan atau pecahnya pembuluh darah. Dengan demikian penyumbatan atau penyempitan pembuluh darah dikarenakan salah satu faktornya adalah obesitas.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4.9 Apnea obstruktif saat tidur</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">merupakan timbulnya episode abnormal pada frekuensi napas yang berhubungan dengan penyempitan saluran napas atas pada saat tidur selama paling tidak 10 sampai 30 detik per episode kejadian, 1-2 episode per menit. Dengan demikian penyebab gangguan Apnea obstruktif saat tidur kebanyakan karena akibat berat badan yang berlebihan atau obesitas.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.4.10 Sesak napas </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Tipe ini dihubungkan dengan peningkatan karbondioksida karena kegagalan ventilasi dengan oksigen yang relatif cukup. Beberapa kelainan utama yang dihubungkan dengan gagal nafas tipe ini adalah kelainan sistem saraf sentral, kelemahan neuromuskuler dam deformiti dinding dada.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.5 CARA MENGATASI OBESITAS (PENATALAKSANAAN)</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Melihat besarnya dan bnyaknya resiko medis maupun non medis, obesitas dirasakan perlu untk dilakukan pengelolaan, sehingga akibat-akibat buruk dapat dicegah. Pada umumnya pengobatan pada obesitas ditujukan pada perbaikan gizi. Namun perlu juga diperhatikan pula tentang factor psikososial yang mengizinkan atau memperkuat sikap anak untuk makan banyak dan kurang bergerak. Usaha pencegahan obesitas yang utama adalah pencegahan terhadap terjadinya obesitas. Secara keseluruhan pengelolaan obesitas mencakup :</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1. Pengelolaan non farmakologis</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> usaha ini dapat dikerjakan seiring dengan usaha pencegahan terhadap diabetes mellitus, dislipidemia, dan hipertensi, berupa anjuran pola hidup sehat sedini mungkin untuk memperoleh dan mempertahankan berat badan normal dengan pedoman sebagai berikut :</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">a. Mengatur pola makan. Prinsip pengaturan makan untuk obesitas adalah menurunkan masukan kalori sehingga tercapai berat badan yang diidamkan. Dalam mengurangi masukan kalori lebih baik dilakukan secara bertahap tetapi mantap. Jika cara yang ketat dilakukan memang tampaknya akan segera menurunkan berat badan secara drastis, tetapi tidak dapat dikatakan melakukan pola makan yang baik, sehingga berat badan akan meningkat kembali. Dalam mengurangi masukan kalori dapat dilakukan dengan meningkatkan konsumsi sayuran dan buah sebagai sumber serat, sehingga dapat mengurangi absorpsi kalori dan lemak di usus halus, membatasi konsumsi makanan tinggi lemak dan karbohidrat sederhana dan mengurangi konsumsi alcohol dan terutama berhenti merokok, menghindari makanan cepat saji (fast food), karena banyak mengandung lemak dan garam yang tinggi.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">b. Melakukan kegiatan jasmani yang cukup, sesuai dengan umur dan kemampuan (olahraga).</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">2. Pengelolaan Farmakologis. </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Dalam mengatasi obesitas dilakukan dengan pengobatan yang bertujuan mengurangi nafsu makan, sehingga mencapai tujuan penurunan berat badan. Sampai saat ini pun banyak didapatkan upaya penurunan berat badan memakai cara tradisional. Sejauh masih aman untuk kesehatan pada umumnya cara tradisioamal perlu diselidiki dan dikembangkan lebih lanjut. </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">3. Pengelolaan bedah pada kasus tertentu.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.5.1 Tatalaksana Obesitas pada Anak</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Mengingat penyebab obesitas bersifat multifaktor, maka penatalaksanaan obesitas seharusnya dilaksanakan secara multidisiplin dengan mengikut sertakan keluarga dalam proses terapi obesitas. Prinsip dari tatalaksana obesitas adalah mengurangi asupan energi serta meningkatkan keluaran energi, dengan cara pengaturan diet, peningkatan aktifitas fisik, dan mengubah / modifikasi pola hidup. </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1. Menetapkan target penurunan berat badan</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Untuk penurunan berat badan ditetapkan berdasarkan: umur anak, yaitu usia 2 - 7 tahun dan diatas 7 tahun, derajat obesitas dan ada tidaknya penyakit penyerta/komplikasi. Pada anak obesitas tanpa komplikasi dengan usia dibawah 7 tahun, dianjurkan cukup dengan mempertahankan berat badan, sedang pada obesitas dengan komplikasi pada anak usia dibawah 7 tahun dan obesitas pada usia diatas 7 tahun dianjurkan untuk menurunkan berat badan. Target penurunan berat badan sebesar 2,5 - 5 kg atau dengan kecepatan 0,5 - 2 kg per bulan.</span></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"><span style="font-size: small;">2. Pengaturan diet</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Prinsip pengaturan diet pada anak obesitas adalah diet seimbang sesuai dengan RDA, hal ini karena anak masih mengalami pertumbuhan dan perkembangan. Intervensi diet harus disesuaikan dengan usia anak, derajat obesitas dan ada tidaknya penyakit penyerta. Pada obesitas sedang dan tanpa penyakit penyerta, diberikan diet seimbang rendah kalori dengan pengurangan asupan kalori sebesar 30%. Sedang pada obesitas berat (IMT > 97 persentile) dan yang disertai penyakit penyerta, diberikan diet dengan kalori sangat rendah (very low calorie diet ).</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Dalam pengaturan diet ini perlu diperhatikan tentang:</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">a. Menurunkan berat badan dengan tetap mempertahankan pertumbuhan normal.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">b. Diet seimbang dengan komposisi karbohidrat 50-60%, lemak 20-30% dengan lemak jenuh < 10% dan protein 15-20% energi total serta kolesterol < 300 mg per hari.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">c. Diet tinggi serat, dianjurkan pada anak usia > 2 tahun dengan penghitungan dosis menggunakan rumus: (umur dalam tahun + 5) gram per hari.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">3. Pengaturan aktifitas fisik </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Peningkatan aktifitas fisik mempunyai pengaruh terhadap laju metabolisme. Latihan fisik yang diberikan disesuaikan dengan tingkat perkembangan motorik, kemampuan fisik dan umurnya. Aktifitas fisik untuk anak usia 6-12 tahun lebih tepat yang menggunakan ketrampilan otot, seperti bersepeda, berenang, menari dan senam. Dianjurkan untuk melakukan aktifitas fisik selama 20-30 menit per hari.</span></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Tabel Jenis kegiatan dan jumlah kalori yang dibutuhkan:</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Jenis kegiatan Kalori yang digunakan/jam</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Jalan kaki 3 km/jam</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Jalan kaki 6 km/jam</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Joging 8 km/jam</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Lari 12 km/jam</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Tenis tunggal</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Tenis ganda</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Golf</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Berenang </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Bersepeda 150</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">300</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">480</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">600</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">360</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">240</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">180</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">350</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">660</span></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"><span style="font-size: small;">4. Mengubah pola hidup/perilaku</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Untuk perubahan perilaku ini diperlukan peran serta orang tua sebagai komponen intervensi, dengan cara:</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">a. Pengawasan sendiri terhadap: berat badan, asupan makanan dan aktifitas fisik serta mencatat perkembangannya.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">b. Mengontrol rangsangan untuk makan. Orang tua diharapkan dapat menyingkirkan rangsangan disekitar anak yang dapat memicu keinginan untuk makan.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">c. Mengubah perilaku makan, dengan mengontrol porsi dan jenis makanan yang dikonsumsi dan mengurangi makanan camilan.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">d. Memberikan penghargaan dan hukuman.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">e. Pengendalian diri, dengan menghindari makanan berkalori tinggi yang pada umumnya lezat dan memilih makanan berkalori rendah.5</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">5. Peran serta orang tua, anggota keluarga, teman dan guru.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Orang tua menyediakan diet yang seimbang, rendah kalori dan sesuai petunjuk ahli gizi. Anggota keluarga, guru dan teman ikut berpartisipasi dalam program diet, mengubah perilaku makan dan aktifitas yang mendukung program diet.</span></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"><span style="font-size: small;">6. Terapi intensif </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Terapi intensif diterapkan pada anak dengan obesitas berat dan yang disertai komplikasi yang tidak memberikan respon pada terapi konvensional, terdiri dari diet berkalori sangat rendah (very low calorie diet), farmakoterapi dan terapi bedah. </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">a. Indikasi terapi diet dengan kalori sangat rendah bila berat badan > 140% BB Ideal atau IMT > 97 persentile, dengan asupan kalori hanya 600-800 kkal per hari dan protein hewani 1,5 - 2,5 gram/kg BB Ideal, dengan suplementasi vitamin dan mineral serta minum > 1,5 L per hari. Terapi ini hanya diberikan selama 12 hari dengan pengawasan dokter. </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">b. Farmakoterapi dikelompokkan menjadi 3, yaitu: mempengaruhi asupan energi dengan menekan nafsu makan, contohnya sibutramin; mempengaruhi penyimpanan energi dengan menghambat absorbsi zat-zat gizi contohnya orlistat, leptin, octreotide dan metformin; meningkatkan penggunaan energi. Farmakoterapi belum direkomendasikan untuk terapi obesitas pada anak, karena efek jangka panjang yang masih belum jelas.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">c. Terapi bedah di indikasikan bila berat badan > 200% BB Ideal. Prinsip terapi ini adalah untuk mengurangi asupan makanan atau memperlambat pengosongan lambung dengan cara gastric banding, dan mengurangi absorbsi makanan dengan cara membuat gastric bypass dari lambung ke bagian akhir usus halus. Sampai saat ini belum banyak penelitian tentang manfaat dan bahaya terapi ini pada anak.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.6 PEMERIKSAAN PENUNJANG OBESITAS</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.6.1 Pemeriksaan Diagnostic</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1. DEXA(dual energy X-ray absorptiometry), menyerupai skening tulang. Sinar X digunakan untuk menentukan jumlah dan lokasi dari lemak tubuh.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">2. BOD PODmerupakan ruang berbentuk telur yang telah dikomputerisasi. Setelah seseorang memasuki BOD POD, jumlah udara yang tersisa digunakan untuk mengukur lemak tubuh.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">3. Jangka kulit, ketebalan lipatan kulit di beberapa bagian tubuh diukur dengan jangka (suatu alat terbuat dari logam yang menyerupai forseps).</span></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"><span style="font-size: small;">4. Bioelectric impedance analysis (analisa tahanan bioelektrik)</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Penderita berdiri di atas skala khusus dan sejumlah arus listrik yang tidak berbahaya dialirkan keseluruh tubuh lalu dianalisa.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1.6.2 Pemeriksaan laboratorium</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Tas darah selama pemeriksaan fisik, dokter akan mengeluarkan tes darah untuk memeriksa kondisi banyak termasuk diabetes, kolesterol tinggi, masalah jantung, dan gangguan hati. Dengan tes darah, dokter dapat menangkap kondisi tertentu sebelum mereka menjadi masalah.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">1. Pemeriksaan penunjang diabetesmilitus</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pemeriksaan penyaring perlu dilakukan pada kelompok dengan resiko tinggi untuk DM,yaitu kelompok usia dewasa tua(>40 tahun>obesitas,tekanan darah tinggi,riwayat keluarga DM, riawayat kehamilan dengan berat badan lahir bayi>4.000 g,riwayat DM pada kehamilan ,dan dislipidemia.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pemeriksaan penyaring dapat dilakukan dengan pemeriksaan glukosa darah sewaktu,kadar glukosa darah puasa,kemudian dapat diikuti dengan tes toleransi glukosa oral(TTGO)standar.Untuk kelompok resiko tinggi yang hasil pemeriksaan penyaringny negative ,perlu pemeriksaan penyaring ulangan tiap tahun .bagi pasien berusia>45tahun tanpa factor risiko,pemeriksaan penyaring dapat dilakukan setiap tahun</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Cara pemeriksaan TTGO adalah:</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">a. Tiga hari sebelum pemeriksaan pasien makan seperti biasa</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">b. kegiatan jasmani sementara cukup ,tidak terlalu banyak </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">c. Pasien puasa semalam selama 10-12 jam</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">d. periksa gula darah puasa</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">e. berikan glukosa 75g yang dilarutkan dalam air 250ml,lalu minum dalam waktu 5menit</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">f. periksa glukosa darah 1jam dan 2 jam sesudah beban glukosa </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">g. selama pemeriksaan,pasien pasien yang diperiksa tetap istrahat dan tidak merokok.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">h. WHO(1985)menganjurkan pemeriksaan standar seperti ini,tetapi kita hanya memakai pemeriksaan glukosa darah 2 jam saja</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">2. Pemeriksaan Penunjang stroke</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">a. CT Scan</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">b. Memperlihatkan adanya edema , hematoma, iskemia dan adanya infark</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">c. Angiografi serebral</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">d. Membantu menentukan penyebab stroke secara spesifik seperti perdarahan atau obstruksi arteri</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">e. Pungsi Lumbal</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Menunjukan adanya tekanan normal</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> Tekanan meningkat dan cairan yang mengandung darah menunjukan adanya perdarahan</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">f. MRI : Menunjukan daerah yang mengalami infark, hemoragik.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">g. EEG: Memperlihatkan daerah lesi yang spesifik</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">h. Ultrasonografi Dopler : Mengidentifikasi penyakit arteriovena</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">i. Sinar X kepala : Menggambarkan perubahan kelenjar lempeng pineal</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">3. pemeriksaan penunjang hipertensi</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Selain pemeriksaan fisik, data laboratorium ikut membantu diagnosis dan perencanaan. Urin dapat menunjukkan proteinuria, hematuri dan silinder. Hal ini terjadi karena tingginya tekanan darah juga menandakan keterlibatan ginjal apalagi bila ureum dan kreatinin meningkat. Gangguan elektrolit bisa terjadi pada hipertensi sekunder dan berpotensi menimbulkan aritmia.</span></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pemeriksaan penunjang dilakukan dua cara yaitu :</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">a.Pemeriksaan yang segera seperti :</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> - darah : darah rutin, BUN, creatinine, elektrolit, KGD.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">- urine : Urinalisa dan kultur urine.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">- EKG : 12 Lead, melihat tanda iskemi, untuk melihat adanya hipertrofi ventrikel kiri ataupun gangguan koroner</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">- Foto dada : apakah ada oedema paru ( dapat ditunggu setelah pengobatan terlaksana ).</span></span><br /><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"><span style="font-size: small;">b.Pemeriksaan lanjutan ( tergantung dari keadaan klinis dan hasil ....pemeriksaan yang pertama ) :</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> - Sangkaan kelainan renal : IVP, Renal angiography ( kasus tertentu ), ......biopsi renald ( kasus tertentu ).</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> - Menyingkirkan kemungkinan tindakan bedah neurologi : Spinal tab, CAT .....Scan.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> - Bila disangsikan Feokhromositoma : urine 24 jam untuk Katekholamine, .....metamefrin, venumandelic Acid ( VMA ).</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">¬ - USG untuk melihat struktur ginjal dilaksanakan sesuai kondisi klinis .....pasien</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">4. Pemeriksaan penunjang jantung </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pada foto toraks posisi posteroanterior pasien hipertrofi konsentrik,besar jantung dalam batas normal.pembesaran jantung ke kiri terjadi bila sudah ada dilatasi ventrikel kiri.terdapat elongasi aorta pada hipertensi yang kronik dan tanda-tanda bendungan pembuluh paru pada stadium payah jantung hipertensi.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pemeriksaan laboratorium darah rutin yang diperlukan adalah Ht serta ureum dan keratin untuk menilai fungsi ginjal .selain itu juga elektrolit untuk melihat kemungkinan adanya kelainan hormonal aldosteron.pemeriksaan laboratorium urinalisis juga diperlukan untuk melihat adanya kelainan pada ginjal.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pada EKG tampak tanda-tanda hipertrofi ventrikel kiri dan strain.ekokardiografi dapat mendeteksi hipertrofi ventrikel kiri secara dini mencakup kelainan anatomic dan fungsional jantung pasien hipertensi asimtomatik yang belum didapatkan kelainan pada EKG dan radiologi.Perubahan-perubahan yang dapat dilihat adalah:</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> a.Tanda-tanda hipersirkulasi pada stadium dini,seperti .....hiperkinesis,hipervolemia</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> b.Hipertrofi yang difus(konsentrik)atau yang irregular eksentrik</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> c.Dilatasi ventrikel yang dapat merupakan tanda-tanda payah .....jantung,serta tekanan akhir diastolik ventrikel kiri meningkat</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> d.Tanda-tanda iskemia seperti hipokinesis dan pada stadium lanjut .....adanya diskinetik:</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> - Pada EKG terdapat elevasi segmen ST diikuti dengan perubahan ..........sampai inversi gelombang T; kemudian muncul peningkatan ..........gelombang Q minimal di 2 sadapan.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> - Peningkatan kadar enzim atau isoenzim merupakan indikator spesifik ..........infark miokard akut yaitu kreatinin fosfoskinase (CPK/CK), SGOT, ..........LDH, alfa hidroksi butirat dehidrogenase, dan isoenzim CK-MB.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"> - Yang paling awal meningkat adalah CPK tetapi paling cepat turun.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">5. Pemeriksaan Penunjang Asma</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Uji faal dan paru analisis gas darah dapat menggambarkan derajat serangan asma.uji provokasi bronkus dilakukan dengan menggunakan histamine,metakolin,atau beban lari. Pada foto dada PA akan tampak corakan paru yang meningkat,hiperflasi terdapat pada serangan akut dan asma kronik.atelektasis sering di temukan pada anak umur > 6 tahun.foto sinusparanasalis diperlukan jika asma sulit terkontrol untuk melihat adanya sinusitis.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">Pemeriksaan eosinofil dalam darah,secret hidung,dan dahak menunjang diagnosis asma dalam sputum dapat di temukan Kristal charcod-leaden dan spiral curshman.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">a. Foto rontgen; selama episode akut rontgen dada dapat menunjukkan hiperinflasi dan pendataran diafragma.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">b. Pemeriksaan fungsi paru, dapat ditemukan menurunnya tidal volume, kapasitas vital, eosinofil biasanya meningkat dalam darah atau sputum</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">c. Pemeriksaan alergi; test kulit + yang menyebabkan reaksi melepuh dan hebat yang dapaat mengidentifikasikan allergen spesifik.</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">d. Pulse oximetry ; ditemukan saturasi O2 perifer menurun ( cyanosis )</span></span><br /><span style="font-family: inherit;"><span style="font-size: small;">e. Analisa gas darah; menunjukkan hipoksia selama serangan akut, awalnya terdapat hipokapnea dan respirasi alkalosis, PCO2 yang rendah</span></span><br /><span style="font-family: inherit;"></span></div>
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arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0tag:blogger.com,1999:blog-2501725445038181687.post-19178004231452833982011-12-19T13:40:00.000+07:002011-12-19T13:45:46.592+07:00KEKUATAN HATI MELEBIHI KEKUATAN PIKIRAN<h2 class="uiHeaderTitle" style="font-family: Arial,Helvetica,sans-serif; font-weight: normal; text-align: justify;">
<span class="" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" class="photo_img img" height="240" src="http://a8.sphotos.ak.fbcdn.net/hphotos-ak-snc6/197946_182238378489340_167385529974625_440975_6599873_n.jpg" width="320" /></span><span style="color: black; font-size: small;">Banyak
orang sangat meyakini bahwa kekuatan pikiran positif dapat membawa
manusia meraih kesuksesan dalam mencapai tujuannya. Memang, tidak
diragukan lagi, kalau kekuatan pikiran positif ini dan membawa manusia
pada kesuksesan dalam meraih tujuannya. Mereka yang dapat mengarahkan
pikirannya selalu kearah positif, maka diyakini bahwa hasilnya adalah
sesuatu kehidupan yang positif juga.</span></h2>
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<span style="font-size: small;">Meskipun
demikian, kita sebagai manusia yang memiliki keyakikan keimanan kepada
ALLAH, sebaiknya menyadari bahwa bukan hanya mengandalkan kekuatan otak
semata, bukan hanya mengandalkan akal dan kekuatan pikiran semata.
Karena sesungguhnya ada kekuatan lain yang lebih dahsyat dari kekuatan
otak, akal dan pikiran. Kekuatan ini bukan hanya mengantarkan manusia
meraih sukses namun juga mampu mengantarkan manusia pada kemuliaan
hidup. Yakni kekuatan hati atau kekuatan hati yang positif, kekuatan
hati yang jernih. Kekuatan hati ini memiliki kedahsyatan yang melebihi
kekuatan pikiran manusia. Karena hati adalah rajanya, hatilah yang
mengatur dan memerintahkan otak, pikiran dan panca indra manusia.<a name='more'></a></span></div>
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<span style="font-size: small;">Tuhan
melalui berbagai ajaran yang dibawa oleh para Nabi, maupun melalui
kitab suci-NYA telah mengajarkan kepada manusia untuk senantiasa
mendengarkan suara hati nuraninya. Mengajarkan manusia untuk dapat
memelihara kejernihan hatinya, sehingga sifat-sifat mulia yang tertanam
dalam hati dapat memancar kepermukaan. Karena didalam hati manusia
sudah tertanam <i>"built in" </i> percikan sifat-sifat <i>"Illahiah”</i>
dari ALLAH Tuhan Sang Pencipta Kehidupan. Diantara sifat-sifat mulia
ALLAH yang tertanam dalam hati manusia adalah sifat kepedulian,
kesabaran, kebersamaan, cinta dan kasih sayang, bersyukur, ikhlas,
damai, kebijaksanaan, semangat, dan lain sebagainya. Karena itu
sesungguhnya kekuatan hati ini sangat <i>"powerfull”</i> untuk meraih kesuksesan dan kemuliaan dalam segala bidang kehidupan.</span></div>
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<span style="font-size: small;">Didalam
hati tempatnya pusat ketenangan, kedamaian, kesehatan, dan kebahagiaan
sejati yang hakiki. Bahkan hati merupakan cerminan dari diri dan hidup
manusia secara keseluruhan. Didalam hati terdapat sumber kesehatan
fisik, kekuatan mental, kecerdasan emosional, serta penuntun bagi
manusia dalam meraih kemajuan spiritualnya. Hati menjadi tempat dimana
sifat-sifat mulia dari ALLAH SWT Sang Pencipta Kehidupan bersemayam.
Hati adalah tempat dimana semua yang hal yang terindah, hal yang
terbaik, termurni, dan tersuci berada didalamnya.</span></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<br /></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<span style="font-size: small;">Dengan demikian, kekuatan hati ini sangat <i>"powerfull”</i>
dan sangat dahsyat dalam membawa manusia meraih sukses dan kemuliaan
dalam segala bidang kehidupan. Hati yang jernih akan melahirkan
pikiran-pikiran yang jernih dan pada akhirnya melahirkan
tindakan-tindakan mulia berdasarkan suara hati nurani. Kejernihan hati
dapat menjadikan manusia menjadi mampu betindak bijaksana, memiliki
semangat positif, cerdas dan berbagai sifat-sifat mulia lainnya. Dengan
hati yang jernih, kita dapat berpikir jernih dan menjalani kehidupan
dengan lebih produktif, lebih semangat, lebih efisien dan lebih efektif
untuk meraih tujuan.</span></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<br /></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<span style="font-size: small;">Hati
adalah kunci hubungan manusia dengan Tuhannya. Karena Hati adalah
tempat bersemayamnya Iman, dengannya kita bisa berkomunikasi dengan
sang Khaliq. Hati juga menjadi kunci hubungan dengan sesama manusia.
Hubungan yang dilandasi kejernihan hati dapat menjadikan hubungan yang
lebih sehat, baik dan konstruktif dengan siapapun. Karena hubungan yang
dilandasi kejernihan hati akan mengedepankan kasih sayang, kejujuran,
kebersamaan dan saling menghormati. Hubungan dengan manusia akan terasa
menyenangkan, menghadirkan kedamaian dan kebahagiaan. Dengan demikian
akan semakin banyak orang lain yang akan memberikan dukungan bagi
kesuksesan kita.</span></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<br /></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<span style="font-size: small;">Dalam
meraih kesuksesan sebaiknya jangan hanya mengandalkan kekuatan otak
semata. Karena otak atau pikiran merupakan sesuatu yang terbatas dan
bersifat sementara. Berusahalah menggunakan kekuatan hati nurani,
menggunakan kekuatan kejernihan hati dengan seimbang. Gunakanlah
kekuatan hati yang positif, karena dialah sesungguhnya diri sejati
Anda. Hatilah tempat sifat mulia AALLAH SWT Sang Pencipta bersemayam
didalam diri kita. Dengan senantiasa menggunakan kekuatan hati,
mendengarkan suara hati, akan membawa manusia menjalani kehidupan
dengan penuh kedamaian dan kebahagiaan. Kalau seseorang dapat merasakan
kedamaian hati dan kebahagiaan hati, maka akan memiliki hidup yang
penuh dengan sukses dan kemuliaan.</span></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<br /></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<span style="font-size: small;">Namun,
berbagai godaan kehidupan modern seringkali dapat mengotori kejernihan
hati. Sikap egoisme, mementingkan hawa nafsu, mengikuti ambisi meraih
kekuasaan dengan menghalalkan segala cara dan berbagai emosi-emosi
negatif seperti amarah, dendam, benci dan iri hati dapat menjadikan
kejernihan hati terbelenggu. Hati yang terbelenggu cahaya kejernihannya
tidak dapat memancar kepermukaan. Inilah yang dapat melemahkan
kehidupan spiritual umat manusia. Kalau dibiarkan, dapat menjadikan
kita semakin sulit mendengarkan bisikan hati dan lebih mempercayai atau
mengandalkan kemampuan otak serta produk-produk pikiran atau akal
semata. Inilah yang akan melahirkan ketidak seimbangan antara kemampuan
nalar dengan hati nurani, sehingga melahirkan berbagai masalah dalam
kehidupan.</span></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<br /></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<span style="font-size: small;">Jadikanlah
hati nurani kita sebagai pembimbing dalam setiap langkah kehidupan.
Berusahalah menjaga kejernihan hati, agar rahmat dan berkah dari ALLAH
senantiasa mengalir dan memberikan yang terindah untuk hati, perasaan
dan seluruh diri kita<b>.</b></span></div>
<span style="font-size: small;"><span class="" style="font-family: Arial,Helvetica,sans-serif;"><img alt="" class="photo_img img" height="255" src="http://a4.sphotos.ak.fbcdn.net/hphotos-ak-snc6/205774_182238405156004_167385529974625_440977_4279845_n.jpg" width="320" /></span></span>arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com1tag:blogger.com,1999:blog-2501725445038181687.post-90664722958047379372011-12-14T17:08:00.000+07:002011-12-19T13:35:06.855+07:00AUTOPSI<link href="file:///C:%5CUsers%5CRIDZ_A%7E1%5CAppData%5CLocal%5CTemp%5Cmsohtmlclip1%5C01%5Cclip_filelist.xml" rel="File-List"></link><link href="file:///C:%5CUsers%5CRIDZ_A%7E1%5CAppData%5CLocal%5CTemp%5Cmsohtmlclip1%5C01%5Cclip_themedata.thmx" rel="themeData"></link><link href="file:///C:%5CUsers%5CRIDZ_A%7E1%5CAppData%5CLocal%5CTemp%5Cmsohtmlclip1%5C01%5Cclip_colorschememapping.xml" rel="colorSchemeMapping"></link><style>
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<div class="MsoListParagraph" style="line-height: 150%; margin-left: 18pt; text-indent: -18pt;">
<span style="font-size: small;"><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.1<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">AUTOPSI
DAN TUJUANNYA</span></b><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;"><o:p></o:p></span></b></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.1.1 Defenisi<o:p></o:p></span></b></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Autopsi berasal
kata dari Auto = sendiri dan Opsis = melihat. </span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Otopsi adalah
pemeriksaan terhadap tubuh mayat, yang meliputi pemeriksaan terhadap bagian
luar maupun dalam, dengan tujuan menemukan proses penyakit dan atau adanya
cedera, melakukan interpretasi atau penemuan-penemuan tersebut, menerangkan
penyebab kematian serta mencari hubungan sebab akibat antara kelainan-kelainan
yang ditemukan dengan penyebab kematian (Mansjoer, dkk, 2000)<o:p></o:p></span></span></div>
<div class="MsoListParagraph" style="line-height: 150%; text-indent: -36pt;">
<span style="font-size: small;"><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.1.2<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">Sejarah
Autopsi</span></b><b><span style="font-family: "Arial","sans-serif"; font-weight: normal; line-height: 150%;"><o:p></o:p></span></b></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pada
zaman dahulu, sebelum adanya praktek forensik menimbulkan begitu banyak
kerancuan dalam penyelesaian suatu peristiwa kejahatan. Sehingga menyebabkan
tidak terungkapnya suatu kasus dan memberikan kemudahan bagi pelaku untuk
melarikan diri. Buruknya lagi, manusia-manusia yang hidup di zaman kuno
seringkali membuat penyelesaian tidak logis dalam suatu peristiwa, misalnya ada
suatu kasus pembunuhan, peradilan terhadap orang yang dianggap pelaku
diserahkan pada dewa api dengan cara menyuruh orang tersebut berjalan diatas
api, kalau kakinya terbakar orang itu dianggap bersalah. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Walaupun
begitu pembedahan dan pemisahan organ jenazah telah dilakukan oleh manusia
setidaknya 3000 tahun SM oleh bangsa Mesir Kuno dalam praktek mumifikasi.
Pembedahan mayat yang digunakan untuk autopsi sendiri bermula pada sekitar awal
millenium ketiga SM, walaupun sebenarnya hal ini berlawanan dengan norma
masyarakat saat itu yang menganggap pengrusakan terhadap tubuh jenazah akan
menghalanginya ke akhirat.<a name='more'></a><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Konsep
ilmu forensik modern saat ini bagaimanapun juga tidak bisa dilepaskan dari
jasa-jasa orang-orang di zaman dahulu. Buku berjudul “Xi Yuan Lu” , ditulis
oleh Song Ci (1186–1249) pada masa Dinasti Song -tepatnya tahun 1248- adalah
salah satu tulisan pertama tentang penggunaan obat atau zat kimia dan
Entomology untuk menemukan penyebab suatu kematian. Buku ini juga memberikan
nasihat tentang bagaimana membedakan antara korban yang tewas karena tenggelam
atau pencekikan, bersama dengan bukti-bukti lain dari hasil pemeriksaan mayat
yang pernah dilakukan untuk menentukan apakah kematian disebabkan oleh
pembunuhan, bunuh diri, atau kecelakaan. Sejarah mencatat bangsa Romawi Kuno
telah membuat peraturan tentang autopsi sekitar 150 SM. Pada tahun 44 SM,
jenazah Julius Caesar adalah salah satu yang beruntung menjadi obyek resmi
autopsi, belakangan para autopsist menemukan bahwa tusukan kedua pada tubuhnya
lah yang fatal sehingga berakibat pada kematian. Yunani kuno pada abad ketiga
SM juga memiliki 2 orang autopsist handal dan terkenal, Erasistratus dan
Herophilus Khalsedon yang tinggal di Alexandria, tetapi secara umum autopsi
kurang begitu dikenal di Yunani kuno. Selain mereka, pembedahan jenazah untuk
alasan medis juga dilakukan oleh bangsa-bangsa lain misalnya seperti yang
dilakukan dokter Arab Avenzoar dan Ibn al-Nafis, tapi proses autopsi modern
berasal dari para anatomis dari Renaissance. Giovanni Morgagni (1682-1771),
yang dikenal sebagai bapak patologi anatomi, menulis karya lengkap pertama pada
patologi, “De Sedibus et Causis Morborum per Anatomen Indagatis” (The Seats and
Causes of Diseases Investigated by Anatomy, 1769).Sedangkan sidik jari mulai
digunakan untuk bukti ketika Juan Vucetich memecahkan kasus pembunuhan di
Argentina dengan memotong sebagian dari pintu dengan sidik jari berdarah di
atasnya.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Di
Eropa abad keenam belas, praktisi medis ketentaraan dan universitas mulai
mengumpulkan informasi tentang sebab dan cara kematian. Ambroise Pare, seorang
ahli bedah tentara Prancis, mempelajari efek kematian karena kekerasan pada
organ internal. Dua ahli bedah Italia, Fortunato Fidelis dan Paolo Zacchia,
membangun fondasi munculnya patologi modern dengan mempelajari perubahan yang
terjadi dalam struktur tubuh akibat penyakit.Pada akhir 1700-an,
tulisan-tulisan tentang topik ini mulai muncul. Hal ini termasuk: A Treatise on
Forensic Medicine and Public Health oleh Fodéré, seorang dokter Prancis. Dan
The Complete System of Police Medicine oleh ahli medis Jerman Johann Peter
Franck. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pada
tahun 1776, kimiawan Swedia Carl Wilhelm Scheele menemukan cara untuk
mendeteksi oksida arsenous alias arsenik, di mayat meskipun hanya dalam kasus
arsenik yang berjumlah besar. Penyelidikan ini diperluas, pada tahun 1806, oleh
kimiawan Jerman Valentin Ross, yang mempelajari cara mendeteksi racun pada
dinding perut korban, dan oleh ahli kimia Inggris James Marsh, yang menggunakan
proses kimia untuk mengkonfirmasi penggunaan arsenik dalam suatu percobaan
pembunuhan di tahun 1836. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Dua
contoh awal penggunaan ilmu forensik Inggris dalam proses hukum menimbulkan
berkembangnya penggunaan logika dan prosedur logis dalam penyelidikan kriminal.
Pada 1784, di Lancaster, John Toms diadili dan dihukum karena membunuh Edward
Culshaw dengan pistol. Ketika mayat Culshaw diperiksa, “pistol wad” (kertas
dihancurkan yang digunakan untuk menjaga bubuk dan bola di moncong) yang ditemukan
di luka pada kepalanya cocok dengan surat kabar robek yang ditemukan di saku
Toms. Di Warwick pada tahun 1816, seorang buruh tani diadili dan dihukum karena
pembunuhan seorang pembantu muda.Dia tenggelam di kolam dangkal dan menanggung
tanda serangan kekerasan. Polisi menemukan jejak kaki dan bekas cap dari kain
corduroy bertambalan di tanah lembab di dekat kolam renang. Selain itu juga
tersebar butir gandum dan sekam. Celana dari buruh tani yang tengah mengolah
gandum di dekat situ diperiksa dan ternyata cocok dengan bekas cap di tanah
dekat kolam renang. Kemudian pada abad ke-20, beberapa patologist Inggris,
Bernard Spilsbury, Francis Camps, Sydney Smith dan Keith Simpson merintis
metode baru ilmu forensik di Britania. Pada 1909, Rodolphe Archibald Reiss
mendirikan sekolah ilmu forensik pertama di dunia, "Institut de polisi
scientifique" di University of Lausanne (UNIL).<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Dua
besar peneliti medis abad kesembilan belas Rudolf Virchow dan Carl von
Rokitansky telah menurunkan dua teknik otopsi yang berbeda yang masing-masing
dinamai sesuai dengan nama mereka. Demonstrasi mereka atas ketekaitan antara
kondisi patologis dalam tubuh yang telah mati dan gejala dan penyakit dalam
hidup membuka jalan bagi cara berpikir yang berbeda tentang penyakit dan
pengobatannya.<o:p></o:p></span></span></div>
<div class="MsoListParagraph" style="line-height: 150%; text-align: justify; text-indent: -36pt;">
<span style="font-size: small;"><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">1.1.3<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">Pembagian
Autopsi</span></b><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;"> berdasarkan tujuan</span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;"><o:p></o:p></span></b></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Berdasarkan tujuannya,
otopsi terbagi atas :</span><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: -35.45pt;">
<span style="font-size: small;"><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">1.1.3.1<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">Otopsi
Anatomi,</span></b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;"> dilakukan untuk keperluan pendidikan
mahasiswa fakultas kedokteran. Bahan yang dipakai adalah mayat yang dikirim ke
rumah sakit yang setelah disimpan 2 x 24 jam di laboratorium ilmu kedokteran
kehakiman tidak ada ahli waris yang mengakuinya. Setelah diawetkan di
laboratorium anatomi, mayat disimpan sekurang-kurangnya satu tahun sebelum
digunakan untuk praktikum anatomi. Menurut hukum, hal ini dapat dipertanggungjawabkan
sebab warisan yang tak ada yang mengakuinya menjadi milik negara setelah tiga
tahun (KUHPerdata pasal 1129). Ada kalanya, seseorang mewariskan mayatnya
setelah ia meninggal pada fakultas kedokteran, hal ini haruslah sesuai dengan
KUHPerdata pasal 935. <o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 42.55pt; text-align: justify; text-indent: -42.55pt;">
<span style="font-size: small;"><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">1.1.3.2<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">Otopsi
Klinik,</span></b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;"> dilakukan terhadap mayat seseorang yang
diduga terjadi akibat suatu penyakit. Tujuannya untuk menentukan penyebab
kematian yang pasti, menganalisa kesesuaian antara <i><span style="font-family: "Arial","sans-serif";">diagnosis klinis</span></i> dan <i><span style="font-family: "Arial","sans-serif";">diagnosis postmortem (diagnosis
setelah autopsi)</span></i>, <i><span style="font-family: "Arial","sans-serif";">pathogenesis</span></i>
penyakit, dan sebagainya. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36pt; text-align: justify;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Tujuan dilakukannya Otopsi klinik
adalah untuk:</span><span style="font-family: "Arial","sans-serif"; line-height: 150%;"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 63pt; text-indent: -22.5pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">a)<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Menentukan sebab kematian yang pasti.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 63pt; text-indent: -22.5pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">b)<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Menentukan apakah diagnosis klinik yang dibuat selama
perawatan sesuai dengan diagnosis postmortem, <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 63pt; text-indent: -22.5pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">c)<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mengetahui korelasi proses penyakit yang ditemukan
dengan diagnosis klinis dan gejala-gejala klinik. <o:p></o:p></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">d)<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Menentukan efektifitas pengobatan. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 63pt; text-indent: -22.5pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">e)<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mempelaiari perjalanan lazim suatu proses penyakit. <o:p></o:p></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">f)<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pendidikan para mahasiswa kedokteran dan para dokter.<o:p></o:p></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Otopsi
klinis dilakukan dengan persetujuan tertulis ahli waris, ada kalanya ahli waris
sendiri yang memintanya.Sebaiknya autopsy dilakukan secara lengkap.</span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Otopsi klinik yang lengkap, meliputi
pembukaan rongga tengkorak, dada dan
perut/panggul, serta melakukan pemeriksaan terhadap seluruh alat-alat
dalam/organ.</span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">, </span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">namun
bila pihak keluarga berkeberatan untuk dilakukannya otopsi klinik lengkap,
masih dapat diusahakan untuk melakukan Autopsi klinik parsial, yaitu yang
terbatas pada satu atau dua rongga badan. Apabila ini masih ditolak, kiranya dapat
diusahakan dilakukannya suatu <i>needle
autopsy </i>terhadap organ tubuh tertentu, untuk kemudian dilakukan pemeriksaan
histopatologik.<o:p></o:p></span></span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 36pt; text-align: justify; text-indent: 27pt;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-left: 54pt; text-align: justify; text-indent: -54pt;">
<span style="font-size: small;"><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.1.3.3<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">Otopsi
Forensik/Medikolegal</span></b><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">, </span><span style="font-family: "Arial","sans-serif"; line-height: 150%;"><o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-left: 54pt; text-align: justify;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">dilakukan
terhadap mayat seseorang yang diduga meninggal akibat suatu sebab yang tidak
wajar seperti pada kasus kecelakaan, pembunuhan, maupun bunuh diri. Otopsi ini
dilakukan atas permintaan penyidik sehubungan dengan adanya penyidikan suatu
perkara. Hasil pemeriksaan adalah temuan obyektif pada korban, yang diperoleh
dari pemeriksaan medis. Tujuan dari otopsi medikolegal adalah : </span><span style="font-family: "Arial","sans-serif"; line-height: 150%;"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 58.5pt; text-align: justify; text-indent: -22.5pt;">
<span style="font-size: small;"><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.2<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Untuk
memastikan identitas seseorang yang tidak diketahui atau belum jelas.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 58.5pt; text-align: justify; text-indent: -22.5pt;">
<span style="font-size: small;"><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.3<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Untuk
menentukan sebab pasti kematian, mekanisme kematian/ cara kematian (kecelakaan,
bunuh diri, atau pembunuhan), dan saat kematian.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 58.5pt; text-align: justify; text-indent: -22.5pt;">
<span style="font-size: small;"><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.4<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Untuk
mengumpulkan dan memeriksa tanda bukti untuk penentuan identitas benda penyebab
dan pelaku kejahatan.<o:p></o:p></span></span></div>
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<span style="font-size: small;"><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.5<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Membuat
laporan tertulis yang objektif berdasarkan fakta dalam bentuk visum et
repertum. <o:p></o:p></span></span></div>
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<span style="font-size: small;"><b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.6<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></b><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pada
kasus bayi baru lahir adalah untuk memastikan apakah bayi dilahirkan hidup atau
tidak.<o:p></o:p></span></span></div>
<h1 style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.2 </span><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">CARA
MELAKUKAN OTOPSI<o:p></o:p></span></span></h1>
<h1 style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.2.1 </span><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">PEMERIKSAAN
LUAR</span><span style="font-family: "Arial","sans-serif"; line-height: 150%;"><o:p></o:p></span></span></h1>
<h1 style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">Bagian
pertama dari teknik otopsi adalah pemeriksaan luar. Sistematika pemeriksaan
luar adalah :<o:p></o:p></span></span></h1>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Memeriksa label mayat (dari pihak kepolisian)
yang biasanya diikatkan pada jempol kaki mayat. Gunting pada tali pengikat,
simpan bersama berkas pemeriksaan. Catat warna, bahan, dan isi label selengkap
mungkin. Sedangkan label rumah sakit, untuk identifikasi di kamar jenazah,
harus tetap ada pada tubuh mayat.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">2.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mencatat jenis/bahan, warna, corak, serta
kondisi (ada tidaknya bercak/pengotoran) dari penutup mayat.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">3.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mencatat jenis/bahan, warna, corak, serta
kondisi (ada tidaknya bercak/pengotoran) dari bungkus mayat. Catat tali
pengikatnya bila ada.<o:p></o:p></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">4.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mencatat pakaian mayat dengan teliti mulai dari
yang dikenakan di atas sampai di bawah, dari yang terluar sampai terdalam.
Pencatatan meliputi bahan, warna dasar, warna dan corak tekstil, bentuk/model
pakaian, ukuran, merk penjahit, cap binatu, monogram/inisial, dan
tambalan/tisikan bila ada. Catat juga letak dan ukuran pakaian bila ada
tidaknya bercak/pengotoran atau robekan. Saku diperiksa dan dicatat isinya.<o:p></o:p></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">5.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mencatat perhiasan mayat, meliputi jenis,
bahan, warna, merek, bentuk serta ukiran nama/inisial pada benda perhiasan
tersebut.<o:p></o:p></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">6.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mencatat benda di samping mayat.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">7.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mencatat perubahan tanatologi : <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Lebam
mayat; letak/distribusi, warna, dan intensitas lebam.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Kaku
mayat; distribusi, derajat kekakuan pada beberapa sendi, dan ada tidaknya
spasme kadaverik.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Suhu
tubuh mayat; memakai termometer rektal dam dicatat juga suhu ruangan pada saat
tersebut.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pembusukan.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Lain-lain;
misalnya mumifikasi atau adiposera.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">8.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mencatat identitas mayat, seperti jenis
kelamin, bangsa/ras, perkiraan umur, warna kulit, status gizi, tinggi badan,
berat badan, disirkumsisi/tidak, striae albicantes pada dinding perut.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">9.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mencatat segala sesuatu yang dapat dipakai
untuk penentuan identitas khusus, meliputi rajah/tatoo, jaringan parut,
kapalan, kelainan kulit, anomali dan cacat pada tubuh.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">10.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Memeriksa
distribusi, warna, keadaan tumbuh, dan sifat dari rambut. Rambut kepala harus
diperiksa, contoh rambut diperoleh dengan cara memotong dan mencabut sampai ke
akarnya, paling sedikit dari 6 lokasi kulit kepala yang berbeda. Potongan
rambut ini disimpan dalam kantungan yang telah ditandai sesuai tempat
pengambilannya.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">11.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Memeriksa
mata, seperti apakah kelopak terbuka atau tertutup, tanda kekerasan, kelainan.
Periksa selaput lendir kelopak mata dan bola mata, warna, cari pembuluh darah
yang melebar, bintik perdarahan, atau bercak perdarahan. Kornea jernih/tidak,
adanya kelainan fisiologik atau patologik. Catat keadaan dan warna iris serta
kelainan lensa mata. Catat ukuran pupil, bandingkan kiri dan kanan.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">12.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Mencatat
bentuk dan kelainan/anomali pada daun telinga dan hidung.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">13.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Memeriksa
bibir, lidah, rongga mulut, dan gigi geligi. Catat gigi geligi dengan lengkap,
termasuk jumlah, hilang/patah/tambalan, gigi palsu, kelainan letak, pewarnaan,
dan sebagainya.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">14.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Bagian
leher diperiksa jika ada memar, bekas pencekikan atau pelebaran pembuluh darah.
Kelenjar tiroid dan getah bening juga diperiksa secara menyeluruh.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">15.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pemeriksaan
alat kelamin dan lubang pelepasan. Pada pria dicatat kelainan bawaan yang
ditemukan, keluarnya cairan, kelainan lainnya. Pada wanita dicatat keadaan
selaput darah dan komisura posterior, periksa sekret liang sanggama. Perhatikan
bentuk lubang pelepasan, perhatikan adanya luka, benda asing, darah dan
lain-lain.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">16.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Perlu
diperhatikan kemungkinan terdapatnya tanda perbendungan, ikterus, sianosis,
edema, bekas pengobatan, bercak lumpur atau pengotoran lain pada tubuh.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">17.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Bila
terdapat tanda-tanda kekerasan/luka harus dicatat lengkap. Setiap luka pada
tubuh harus diperinci dengan lengkap, yaitu perkiraan penyebab luka, lokasi,
ukuran, dll. Dalam luka diukur dan panjang luka diukur setelah kedua tepi
ditautkan. Lokalisasi luka dilukis dengan mengambil beberapa patokan, antara
lain : garis tengah melalui tulang dada, garis tengah melalui tulang belakang,
garis mendatar melalui kedua puting susu, dan garis mendatar melalui pusat.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">18.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pemeriksaan
ada tidaknya patah tulang, serta jenis/sifatnya.<o:p></o:p></span></span></div>
<h1 style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.2.1 </span><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">PEMERIKSAAN
DALAM</span><span style="font-family: "Arial","sans-serif"; line-height: 150%;"><o:p></o:p></span></span></h1>
<h1 style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">Pemeriksaan
dalam bisa dilakukan dengan beberapa cara berikut ini :<o:p></o:p></span></span></h1>
<ul type="disc">
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Insisi I dimulai di bawah tulang rawan krikoid di
garis tengah sampai prosesus xifoideus kemudian 2 jari paramedian kiri
dari puat sampai simfisis, dengan demikian tidak perlu melingkari pusat.<o:p></o:p></span></span></li>
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Insisi Y, merupakan salah satu tehnik khusus otopsi
dan akan dijelaskan kemudian.<o:p></o:p></span></span></li>
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Insisi melalui lekukan suprastenal menuju simfisis
pubis, lalu dari lekukan suprasternal ini dibuat sayatan melingkari bagian
leher. (3,4)<o:p></o:p></span></span></li>
</ul>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div style="line-height: 150%;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Pada
pemeriksaan dalam, organ tubuh diambil satu persatu dengan hati-hati dan
dicatat :<o:p></o:p></span></span></div>
<ol start="1" type="1">
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Ukuran : Pengukuran secara langsung adalah dengan
menggunakan pita pengukur. Secara tidak langsung dilihat adanya penumpulan
pada batas inferior organ. Organ hati yang mengeras juga menunjukkan
adanya pembesaran.<o:p></o:p></span></span></li>
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Bentuk.<o:p></o:p></span></span></li>
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Permukaan : Pada umumnya organ tubuh mempunyai
permukaan yang lembut, berkilat dengan kapsul pembungkus yang bening.
Carilah jika terdapat penebalan, permukaan yang kasar , penumpulan atau
kekeruhan.<o:p></o:p></span></span></li>
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Konsistensi: Diperkirakan dengan cara menekan jari
ke organ tubuh tersebut.<o:p></o:p></span></span></li>
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Kohesi: Merupakan kekuatan daya regang anatar
jaringan pada organ itu. Caranya dengan memperkirakan kekuatan daya regang
organ tubuh pada saat ditarik. Jaringan yang mudah teregang (robek)
menunjukkan kohesi yang rendah sedangkan jaringan yang susah menunjukkan
kohesi yang kuat.<o:p></o:p></span></span></li>
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Potongan penampang melintang: Disini dicatat warna
dan struktur permukaan penampang organ yang dipotong. Pada umumnya warna
organ tubuh adalah keabu-abuan, tapi hal ini juga dipengaruhi oleh jumlah
darah yang terdapat pada organ tersebut. Warna kekuningan, infiltrasi
lemak, lipofisi, hemosiferin atau bahan pigmen bisa merubah warna organ.
Warna yang pucat merupakan tanda anemia.<o:p></o:p></span></span></li>
</ol>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Struktur organ juga bisa
berubah dengan adanya penyakit. Pemeriksaan khusus juga bisa dilakukan terhadap
sistem organ tertentu, tergantung dari dugaan penyebab kematian. (4)</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"> </span><span lang="EN-US" style="font-family: "Arial","sans-serif";">Insisi pada masing-masing
bagian-bagian tubuh yaitu :<o:p></o:p></span></span></div>
<ol start="1" type="1">
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Dada : <o:p></o:p></span></span></li>
<ul type="circle">
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Seksi Jantung :<o:p></o:p></span></span></li>
</ul>
</ol>
<div style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Jantung dibuka menurut aliran darah :
pisau dimasukkan ke vena kava inferior sampai keluar di vena superior dan
bagian ini dipotong. Ujung pisau dimasukkan melalui katup trikuspidalis keluar
di insisi bilik kanan dan bagian ini dipotong. Ujung pisau lalu dimasukkan arteri
pulmonalis dan otot jantung mulai dari apeks dipotong sejajar dengan septum
interventrikulorum.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"> </span><span lang="EN-US" style="font-family: "Arial","sans-serif";">Ujung
pisau dimasukkan ke vena pulmonalis kanan keluar ke vena pulmonalis kiri dan
bagian ini dipotong. Ujung pisau dimasukkan melalui katup mitral keluar di
insisi bilik kiri dan bagian ini dipotong. Ujung pisau kemudian dimasukkan
melalui katup aorta dan otot jantung dari apeks dipotong sejajar dengan septum
inetrventrikulorum. Jantung sekarang sudah terbuka, diperiksa katup, otot
kapiler, chorda tendinea, foramen ovale, septum interventrikulorum</span><span style="font-family: "Arial","sans-serif";">. </span><span lang="EN-US" style="font-family: "Arial","sans-serif";">Arteri koronaria diiris
dengan pisau yang tajam sepanjang 4-5 mm mulai dari lubang dikatup aorta. Otot
jantung bilik kiri diiris di pertengahan sejajar dengan epikardium dan
endokardium, demikian pula dengan septum</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"> </span><span lang="EN-US" style="font-family: "Arial","sans-serif";">interventrikulorum.</span><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Paru-paru
:<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Paru-paru kanan dan kiri dilepaskan
dengan memotong bronkhi dan pembuluh darah di hilus, setelah perkardium
diambil. Vena pulmonalis dibuka dengan gunting, kemudian bronkhi dan terakhir
arteri pulmonalis. Paru-paru diiris longitudinal dari apeks ke basis.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Tulang dada diangkat dengan
memotong tulang rawan iga 1 cm dari sambungannya dengan cara pisau dipegang
dengan tangan kanan dengan bagian tajam horizontal diarahkan pada tulang rawan
iga dan dengan tangan yang lain menekan pada punggung pisau. Pemotongan dimulai
dari tulang rawan iga no. 2. Tulang dada diangkat dan dilepaskan dari diafragma
kanan dan kiri kemudian dilepaskan mediastinum anterior. Rongga paru-paru
diperiksa adanya perlengketan, darah, pus atau cairan lain kemudian diukur.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Kemudian pisau dengan
tangan kanan dimasukkan dalam rongga paru-paru, bagian tajam tegak lurus
diarahkan ke tulang rawan no.1 dan tulang rawan dipotong sedikit ke lateral,
kemudian bagian tajam pisau diarahkan ke sendi sternoklavikularis dengan
menggerak-gerakkan sternum, sendi dipisahkan. Prosedur diulang untuk sendi yang
lainnya.</span><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Mediastinum anterior diperiksa adanya
timus persistens. Perikardium dibuka dengan Y terbalik, diperiksa cairan
perikardium, normal sebanyak kurang lebih 50 cc dengan warna agak kuning. Apeks
jantung diangkat, dibuat insisi di bilik dan serambi kanan diperiksa adanya
embolus yang menutup arteri pulmonalis. Kemudian dibuat insisi di bilik dan
serambi kiri. Jantung dilepaskan dengan memotong pembuluh besar dekat perikardium.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">2.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Perut : <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Esofagus-Lambung-Doudenum-Hati
:<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 35.45pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Semua organ tersebut di
atas dikeluarkan sebagai satu unit. Esofagus diikat ganda dan dipotong.
Diafragma dilepaskan dari hati dan esofagus dan unit tadi dapat diangkat.
Sebelum diangkat, anak ginjal kanan yang biasanya melekat pada hati dilepaskan
terlebih dahulu.</span><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 35.45pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Esofagus dibuka terus ke
kurvatura mayor, terus ke duodenum. Perhatikan isi lambung, dapat membantu
penentuan saat kematian. Kandung empedu ditekan, bulu empedu akan menonjol
kemudian dibuka dengan gunting ke arah papila Vater, kemudian dibuka ke arah
hati, lalu kandung empedu dibuka. Perhatikan mukosa dan adanya batu.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Buluh kelenjar ludah diperut dibuka
dari papila Vater ke pankreas. Pankreas dilepaskan dari duodenum dan
dipotong-potong transversal.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Hati : perhatikan tepi hati, permukaan
hati, perlekatan, kemudian dipotong longitudinal.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"> </span><span lang="EN-US" style="font-family: "Arial","sans-serif";">Usus halus dan usus besar
dibuka dengan gunting ujung tumpul, perhatikan mukosa dan isinya, cacing.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Ginjal,
Ureter, Rektum, dan Kandung Urine:<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 35.45pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Organ tersebut di atas
dikeluarkan sebagai satu unit. Ginjal dengan suatu insisi lateral dapat
diangkat dan dilepaskan dengan memotong pembuluh darah di hilus, kemudian
ureter dilepaskan sampai panggul kecil. Kandung urine dan rektum dilepaskan
dengan cara memasukkan jari telunjuk lateral dari kandung urine dan dengan cara
tumpul membuat jalan sampai ke belakang rektum. Kemudian dilakukan sama pada
bagian sebelahnya. Tempat bertemunya kedua jari telunjuk dibesarkan sehingga 4
jari kanan dan kiri dapat bertemu, kemudian jari kelingking dinaikkan ke atas
dengan demikian rektum lepas dari sakrum. Rektum dan kandung urine dipotong
sejauh dekat diafragma pelvis.</span><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 35.45pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Anak ginjal dipotong
transversal. Ginjal dibuka dengan irisan longitudinal dari lateral ke hilus.
Ureter dibuka dengan gunting sampai kandung urine, kapsul ginjal dilepas dan
perhatikan permukaannya. Pada laki-laki rektum dibuka dari belakang dan kandung
urine melalui uretra dari muka. Rektum dilepaskan dari prostat dan dengan
demikian terlihat vesika seminalis. Prostat dipotong transversal, perhatikan
besarnya penampang.</span><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 35.45pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Testis dikeluarkan melalui
kanalis spermatikus dan diiris longitudinal, perhatikan besarnya, konsistensi,
infeksi, normal, tubuli semineferi dapat ditarik seperti benang.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Urogenital
Perempuan :<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Kandung urine dibuka dan
dilepaskan dari vagina. Vagina dan uterus dibuka dengan insisi longitudinal dan
dari pertengahan uterus insisi ke kanan dan ke kiri. Ke kornu. Tuba diperiksa
dengan mengiris tegak lurus pada jarak 1-1,5 cm. Ovarium diinsisi longitudinal.</span><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Pada abortus provokatus
kriminalis yang dilakukan dengan menusuk ke dalam uterus, seluruhnya : kandung
urine, uterus dan vagina, rektum difiksasi dalam formalin 10% selama 7 hari,
setelah itu dibuat irisan tegak lurus pada sumbu rektum setebal 1,25 cm,
kemudian semuanya direndam dalam alkohol selama 24 jam. Saluran tusuk akan
terlihat sebagai noda merah, hiperemis. Dari noda merah ini dibuat sediaan
histopatologi</span><span style="font-family: "Arial","sans-serif";">.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Usus halus dipisahkan dari
mesenterium, usus besar dilepaskan, duodenum dan rektum diikat ganda kemudian
dipotong.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"> </span><span lang="EN-US" style="font-family: "Arial","sans-serif";">Limpa
: dipotong di hilus, diiris longitudinal, perhatikan parenkim, folikel, dan
septa.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">3.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Leher <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 35.45pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Lidah,
laring, trakea, esofagus, palatum molle, faring dan tonsil dikeluarkan sebagai
satu unit. Perhatikan obstruksi di saluran nafas, kelenjar gondok dan tonsil.
Pada kasus pencekikan tulang lidah harus dibersihkan dan diperiksa adanya patah
tulang.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">4.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Kepala :<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Kulit kepala diiris dari
prosesus mastoideus kanan sampai yang kiri dengan mata pisau menghadap keluar
supaya tidak memotong rambut terlalu banyak. Kulit kepala kemudian dikelupas ke
muka dan ke belakang dan tempurung tengkorak dilepaskan dengan menggergajinya.
Pahat dimasukkan dalam bekas mata gergaji dan dengan beberapa ketukan tempurung
lepas dan dapat dipisahkan. Durameter diinsisi paralel dengan bekas mata
gergaji. Falx serebri digunting dibagian muka. Otak dipisah dengan memotong
pembuluh darah dan saraf dari muka ke belakang dan kemudian medula oblongata.
Tentorium serebri diinsisi di belakang tulang karang dan sekarang otak dapat
diangkat. Selaput tebal otak ditarik lepas dengan cunam. Otak kecil dipisah dan
diiris horisontal, terlihat nukleus dentatus. Medula oblongata diiris
transversal, demikiaan pula otak besar setebal 2,5 cm. Pada trauma kepala
perhatikan adanya edema, kontusio, laserasi serebri.<o:p></o:p></span></span></div>
<div style="line-height: 150%; margin-left: 36pt; text-align: justify;">
<br /></div>
<div style="line-height: 150%; margin-left: 36pt; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">5.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Tengkorak Neonatus :<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Kulit kepala dibuka seperti
biasa, tengkorak dibuka dengan menggunting sutura yang masih terbuka dan tulang
ditekan ke luar, sehingga otak dengan mudah dapat diangkat. (3)</span><span style="font-family: "Arial","sans-serif";"><o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><b><span style="font-family: "Arial","sans-serif";">1.2.2
</span></b><b><span lang="EN-US" style="font-family: "Arial","sans-serif";">PEMERIKSAAN KHUSUS<o:p></o:p></span></b></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Pada beberapa keadaan tertentu,
diperlukan berbagai prosedur khusus dalam tindakan otopsi, antara lain : insisi
”Y”, insisi pada kasus dengan kelainan leher, tes emboli udara, tes apung paru,
tes pada pneumothorax, dan tes alphanaphthylamine.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Symbol; line-height: 150%;">·<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Insisi ”Y” <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Insisi yang dilakukan dangkal (shallow
incision) yang dilakukan pada tubuh pria. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: -10.9pt;">
<span style="font-size: small;"><span style="font-family: Wingdings; line-height: 150%;">§<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Buat
sayatan yang letaknya tepat di bawah tulang selangka dan sejajar dengan tulang
tersebut, kiri dan kanan, sehingga bertemu pada bagian tengah (incisura
jugularis).<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: -10.9pt;">
<span style="font-size: small;"><span style="font-family: Wingdings; line-height: 150%;">§<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Lanjutkan
sayatan, dimulai dari incisura jugularis ke arah bawah tepat di garis
pertengahan sampai ke sympisis os pubis menghindari daerah umbilikus.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: -7.1pt;">
<span style="font-size: small;"><span style="font-family: Wingdings; line-height: 150%;">§<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Kulit
daerah leher dilepaskan secara hati-hati sampai ke rahang bawah; tindakan ini
dimulai dari sayatan yang telah dibuat pertama kali.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: -7.1pt;">
<span style="font-size: small;"><span style="font-family: Wingdings; line-height: 150%;">§<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Dengan
kulit daerah leher dan dada bagian atas tetap utuh, alat-alat dalam rongga
mulut dan leher dikeluarkan.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: -7.1pt;">
<span style="font-size: small;"><span style="font-family: Wingdings; line-height: 150%;">§<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Tindakan
selanjutnya sama dengan tindakan pada bedah mayat yang biasa.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 35.45pt; text-align: justify; text-indent: -1cm;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">2.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Insisi yang lebih dalam (deep incision), yang
dilakukan untuk kaum wanita. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Wingdings; line-height: 150%;">§<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Buat
sayatan yang letaknya tepat di bawah buah dada, dimulai dari bagian lateral
menuju bagaian medial (proc. Xiphoideus); bagian lateral disini dapat dimulai
dari ketiak, ke arah bawah sesuai dengan arah garis ketiak depan (linea
axillaris anterior), hal yang sama juga dilakukan untuk sisi yang lain (kiri
dan kanan).<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 49.65pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: Wingdings; line-height: 150%;">§<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Lanjutkan
sayatan ke arah bawah seperti biasa, sampai simphisis os pubis, dengan demikian
pengeluaran dan pemeriksaan alat-alat yang berada dalam rongga mulut, leher,
dan rongga dada lebih sulit bila dibandingkan dengan insisi ”Y” yang dangkal.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 31.65pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Insisi ”Y”, dilakukan
semata-mata untuk alasan kosmetik, sehingga jenazah yang sudah diberi pakaian,
tidak memperlihatkan adanya jahitan setelah dilakukan bedah mayat. Ada dua
macam insisi ”Y”, yaitu :<o:p></o:p></span></span></div>
<ul type="disc">
<li class="MsoNormal" style="line-height: 150%; text-align: justify;"><span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Insisi pada Kasus dengan Kelainan di Daerah Leher <o:p></o:p></span></span></li>
</ul>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Buat
insisi ”I”, yang dimulai dari incisura jugularis, ke arah bawah seperti biasa,
sampai ke simpisis os pubis.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Buka
rongga dada, dengan jalan memotong tulang dada dan iga-iga.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Keluarkan
jantung, dengan menggunting mulai dari v.cava inferior, vv.pulmonalis,
a.pulmonalis, v.cava superior dan terakhir aorta.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Buka
rongga tengkorak, dan keluarkan organ otaknya.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 2cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Dengan
adanya bantalan kayu pada daerah punggung, maka daerah leher akan bersih dari
darah, <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">oleh karena darah
telah mengalir ke atas ke arah tengkorak dan ke bawah, ke arah rongga dada;
dengan demikian pemeriksaan dapat dimulai.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Insisi ini dimaksudkan agar
daerah leher dapat bersih dari darah, sehingga kelainan yang minimalpun dapat
terlihat; misalnya pada kasus pencekikan, penjeratan, dan penggantungan.
Prinsip dari teknik ini adalah pemeriksaan daerah dilakukan paling akhir.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Tes emboli udara <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">buat
sayatan ”I”, dimulai dari incisura jugularis, ke arah bawah sampai ke symphisis
pubis,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">potong
rawan iga mulai dari iga ke-3 kiri dan kanan, pisahkan rawan iga dan tulang
dada keatas sampai ke perbatasan antara iga ke-2 dan iga ke-3,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">potong
tulang dada setinggi perbatasan antara tulang iga ke-2 dan ke-3,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">setelah
kandung jantung tampak, buat insisi pada bagian depan kandung jantung dengan
insisi ”I”, sepanjang kira-kira 5-7 sentimeter; kedua ujung sayatan tersebut
dijepit dan diangkat dengan pinset (untuk mencegah air yang keluar),<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">masukkan
air ke dalam kandung jantung, melalui insisi yang telah dibuat tadi, sampai
jantung terbenam; akan tetapi bila jantung tetap terapung, maka hal ini
merupakan pertanda adanya udara dalam bilik jantung,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">tusuk
dengan pisau organ yang runcing, tepat di daerah bilik jantung kanan, yang
berbatasan dengan pangkal a. Pulmonalis, kemudian putar pisau itu 90 derajat;
gelembung-gelembung udara yang keluar menandakan tes emboli hasilnya positif,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">bila
tidak jelas atau ragu-ragu, lakukan pengurutan pada a. Pulmonalis, ke arah
bilik jantung, untuk melihat keluarnya gelembung udara,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">bila
kasus yang dihadapi adalah kasus abortus, maka pemeriksaan dengan prinsip yang
sama, dilakukan mulai dari rahim dan berakhir pada jantung,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">semua
yang disebut di atas adalah untuk melakukan tes emboli pulmoner, untuk tes
emboli sistemik, pada prinsipnya sama, letak perbedaannya adalah : pada tes
emboli sistemik tidak dilakukan penusukan ventrikel, tetapi sayatan melintang
pada a. Coronaria sinistra ramus desenden, secara serial beberapa tempat, dan
diadakan pengurutan atas nadi tersebut, agar tampak gelembung kecil yang
keluar,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">dosis
fatal untuk emboli udara pulmoner 150-130 ml, sedangkan untuk emboli sistemik
hanya beberapa ml.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Emboli udara, baik yang
sistemik maupun emboli udara pulmoner, tidak jarang terjadi.</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"> </span><span lang="EN-US" style="font-family: "Arial","sans-serif";">Pada emboli sistemik udara
masuk melalui pembuluh vena yang ada di paru-paru, misalnya pada trauma dada
dan trauma daerah mediastinum yang merobek paru-paru dan merobek pembuluh
venanya.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Emboli pulmoner adalah
emboli yang tersering, udara masuk melalui pembuluh-pembuluh vena besar yang
terfiksasi, misalnya pada daerah leher bagian bawah, lipat paha atau daerah
sekitar rahim (yang sedang hamil); dapat pula pada daerah lain, misalnya
pembuluh vena pergelangan tangan sewaktu diinfus, dan udara masuk melalui jarum
infus tadi. Fiksasi ini penting, mengingat bahwa tekanan vena lebih kecil dari
tekanan udara luar, sehingga jika ada robekan pada vena, vena tersebut akan
menguncup, hal ini ditambah lagi dengan pergerakan pernapasan, yang ”menyedot”.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Tes Apung Paru-paru <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Keluarkan
alat-alat dalam rongga mulut, leher dan rongga dada dalam satu kesatuan,
pangkal dari esophagus dan trakea boleh diikat.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Apungkan
seluruh alat-alat tersebut pada bak yang berisi air.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Bila
terapung lepaskan organ paru-paru, baik yang kiri maupun yang kanan.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Apungkan
kedua organ paru-paru tadi, bila terapung lanjutkan dengan pemisahan
masing-masing lobus, kanan terdapat lima lobus dan kiri dua lobus.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Apungkan
semua lobus tersebut, catat yang mana yang tenggelam dan mana yang terapung.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Lobus
yang terapung diambil sebagian, yaitu tiap-tiap lobus 5 potong dengan ukuran 5
mm x 5 mm, dari tempat yang terpisah dan perifer.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Apungkan
ke 25 potongan kecil-kecil tersebut, bila terapung, letakkan potongan tersebu
pada dua karton, dan lakukan penginjakan dengan menggunakan berat badan,
kemudian dimasukkan kembali ke dalam air.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Bila
terapung berarti tes apung paru positif, paru-paru mengandung udara, bayi
tersebut pernah dilahirkan hidup.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Bila
hanya sebagian yang terapung, kemungkinan terjadi pernafasan partial, bayi
tetap pernah dilahirkan hidup.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 1cm;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Tes apung paru-paru
dikerjakan untuk mengtahui apakah bayi yang diperiksa itu pernah hidup. Untuk
melaksanakan test ini, persyaratannya sama dengan test emboli udara, yakni
mayatnya harus segar. Cara melakukan tes apung paru-paru:<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Tes Pada Pneumothoraks <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">buka
kulit dinding dada pada bagian yang tertinggi dari dada, yaitu sekitar iga ke 4
dan 5 ( udara akan berada pada tempat yang tertinggi ),<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">buat
”kantung” dari kulit dada tersebut mengelilingi separuhnya dari daerah iga 4
dan 5 ( sekitar 10 x 5 cm )<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">pada
kantung tersebut kemudian diisi air, dan selanjutnya tusuk dengan pisau, adanya
gelembung udara yang keluar berarti ada pneumothorax; dan bila diperiksa
paru-parunya, paru-paru tersebut tampak kollaps,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">cara
lain; setelah dibuat kantung , kantung ditusuk dengan spuit besar dengan jarum
besar yang berisi air separuhnya pada spuit tersebut; bila ada pneumothorax,
tampak gelembung-gelembung udara pada spuit tadi.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 1cm;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Pada trauma di daerah dada,
ada kemungkinan jaringan paru robek, sedemikian rupa sehingga terjadi mekanisme
”ventil” di mana udara yang masuk ke paru-paru akan diteruskan ke dalam rongga
dada, dan tidak dapat keluar kembali, sehingga terjadi kumulasi udara, dengan
akibat paru-paru akan kolaps dan korban akan mati.<br />
Diagnosa pneumothorax yang fatal semata-mata atas dasar test ini, bila test ini
tidak dilakukan, diagnosa sifatnya hanya dugaan. Cara melakukan test ini adalah
sebagai berikut:<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Tes Alpha Naphthylamine <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">kertas
saring Whatman direndam dalam larutan alpha-naphthylamine, dan keringkan
dalamoven, hindari jangan sampai terkena sinar matahari,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">pakaian
yang akan diperiksa, yaitu yang diduga mengandung butir-butir mesiu, dipotong
dan di atasnya diletakkan kertas saring yang telah diberi alpha-naphthylamine,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">di
atas kertas saring yang mengandung alpha-naphthylamine tadi ditaruh lagi kertas
saring yang dibasahi oleh aquadest,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">keringkan
dengan cara menyeterika tumpukan tersebut, yaitu kain yang akan diperiksa,
kertas yang mengandung alpha-naphthylamine dan kertas saring yang basah,<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 1cm; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">test
yang positif akan terbentuk warna merah jambu (pink colour), pada kertas saring
yang mengandung alpha-naphthylamine; bintik-bintik merah jambu tadi sesuai
dengan penyebaran butir-butir mesiu pada pakaian. (5)<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 1cm;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Test ini dilakukan untuk
mengetahui adanya butir-butir mesiu khususnya pada pakaian korban penembakan,</span><span lang="EN-US" style="font-family: "Arial","sans-serif";"> </span><span lang="EN-US" style="font-family: "Arial","sans-serif";">Setelah otopsi selesai,
semua organ tubuh dimasukkan kembali ke dalam rongga tubuh. Lidah dikembalikan
ke dalam rongga mulut sedangkan jaringan otak dikembalikan ke dalam rongga
tengkorak. Jahitkan kembali tulang dada dan iga yang dilepaskan pada saat
membuka rongga dada. Jahitkan kulit dengan rapi menggunakan benang yang kuat,
mulai dari dagu sampai ke daerah simfisis. Atap tengkorak diletakkan kembali
pada tempatnya dan difiksasi dengan menjahit otot temporalis, baru kemudian
kulit kepala dijahit dengan rapi. Bersihkan tubuh mayat dari darah sebelum
mayat diserahkan kembali pada pihak keluarga. (1)<o:p></o:p></span></span></div>
<h1 style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.2.3 </span><span lang="EN-US" style="font-family: "Arial","sans-serif"; line-height: 150%;">PEMERIKSAAN
PENUNJANG<o:p></o:p></span></span></h1>
<div style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Pada otopsi juga dilakukan prosedur
laboratorium yaitu :<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">1.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Sediaan histopatologi dari masing-masing
organ.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Dari tiap organ diambil sediaan
sebesar 2 x 2 x1 cm kubik dan difiksasi dalam formalin 10%.Organ yang diambil
adalah: paru-paru, hati, limpa, pankreas, otot jantung, arteri koronaria,
kelenjar gondok, ginjal, prostat, uterus, korteks otak, basal ganglia dan dari
bagian lain yang menunjukkan adanya kelainan.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">2.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pemeriksaan toksikologi. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Lambung
dan isinya.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Seluruh
usus dan isinya dengan membuat sekat dengan ikatan-ikatan pada pada usus setiap
jarak sekitar 60 cm.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Darah,
yang berasal dari sentral (jantung) dan yang berasal dari perifer (v,jugularis;
a.femoralis, dan sebagainya), masing-masing 50 ml dan dibagi dua, yang satu
diberi bahan pengawet dan yang lain tidak diberi bahan pengawet.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Hati,
sebagai tempat detoksifikasi , diambil sebanyak 500 gram.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Ginjal,
diambil keduanya yaitu pada kasus keracunan logam berat khususnya atau bila
urine tidak tersedia.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Otak,
diambil 500 gram. Khusus untuk keracunan chloroform dan sianida, dimungkinkan
karena otak terdiri dari jaringan lipoid yang mempunyai kemampuan untuk
meretensi racun walaupun telah mengalami pembususkan.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Urine,
diambil seluruhnya. Karena pada umunya racun akan diekskresikan melalui urine,
khususnya pada test penyaring untuk keracunan narkotika, alkohol dan stimulan.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Empedu,
diambil karena tempat ekskresi berbagai racun.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Courier New"; line-height: 150%;">o<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pada
kasus khusus dapat diambil: jaringan sekitar suntikan, jaringan otot, lemak di
bawah kulit dinding perut, rambut, kuku dan cairan otak.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 35.45pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Prinsip
pengambilan sampel pada kasus keracunan adalah diambil sebanyak-banyaknya
setelah kita sisihkan untuk cadangan dan untuk pemeriksaan histopatolgik.
Secara umum sampel yang harus diambil adalah: Pada pemeriksaan intoksikasi,
digunakan alkohol dan larutan garam jenuh pada sampel padat atau organ. NaF 1%
dan campuran NaF dan Na sitrat digunakan untuk sampel cair. Sedangkan natrium
benzoate dan phenyl mercuric nitrate khusus untuk pengawet urine.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 21.3pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">3.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pemeriksaan bakteriologi.<o:p></o:p></span></span></div>
<div style="line-height: 150%; text-align: justify; text-indent: 36pt;">
<span style="font-size: small;"><span lang="EN-US" style="font-family: "Arial","sans-serif";">Dalam hal ada dugaan sepsis
diambil darah dari jantung dan sediaan limpa untuk pembiakan kuman. Permukaan
jantung dibakar dengan menempelkan spatel yang dipanaskan sampai merah,
kemudiaan darah jantung diambil dengan tabung injeksi yang steril dan dipindah
dalam tabung reagen yang steril. Permukaan limpa dibakar dengan cara tersebut
di atas dan dengan pinset dan gunting yang steril diambil sepotong limpa dan
dimasukkan dalam tabung reagen yang steril dan kedua tabung dikirim ke
laboratorium bakteriologi.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 150%; margin-left: 14.2pt; text-align: justify; text-indent: -18pt;">
<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">4.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Sediaan apus bagian korteks otak, limpa dan
hati. Mungkin perlu dilakukan untuk melihat parasit malaria.Sediaan hapus
lainnya adalah dari tukak sifilis atau cairan mukosa.<o:p></o:p></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">5.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Darah dan cairan cerebrospinalis diambil
untuk pemeriksaan analisa biokimia.<o:p></o:p></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">6.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Pemeriksaan urine dan feces.<o:p></o:p></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">7.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Usapan vagina dan anus, utamanya pada kasus
kejahatan seksual.<o:p></o:p></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Arial","sans-serif"; line-height: 150%;">8.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span><span style="font-family: "Arial","sans-serif"; line-height: 150%;">Cairan uretra. (3,4)<o:p></o:p></span></span></div>arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com1tag:blogger.com,1999:blog-2501725445038181687.post-33641765926428178092011-11-30T18:31:00.000+07:002011-11-30T18:31:09.713+07:00Misteri Ka'bah yang Menggegerkan NASA<div style="font-family: Arial,Helvetica,sans-serif; text-align: center;">
<a href="http://t1.gstatic.com/images?q=tbn:AktxNZOd0wUy5M:http://islamislife.org/wp-content/uploads/2010/01/kabah-from-above.jpg&t=1" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="http://t1.gstatic.com/images?q=tbn:AktxNZOd0wUy5M:http://islamislife.org/wp-content/uploads/2010/01/kabah-from-above.jpg&t=1" border="0" height="267" src="http://t1.gstatic.com/images?q=tbn:AktxNZOd0wUy5M:http://islamislife.org/wp-content/uploads/2010/01/kabah-from-above.jpg&t=1" width="400" /></a><span style="font-size: small;"></span></div>
<div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<span style="font-size: small;"><span><a href="http://islam.bloggermu.com/"><b></b></a>Neil Amstrong telah membuktikan bahwa kota Mekah adalah pusat dari
planet Bumi. Fakta ini telah di diteliti melalui sebuah penelitian
Ilmiah. </span><span>Ketika
Neil Amstrong untuk pertama kalinya melakukan perjalanan ke luar
angkasa dan mengambil gambar planet Bumi, dia berkata, “Planet Bumi
ternyata menggantung di area yang sangat gelap, siapa yang
menggantungnya ?.”</span><br /><span></span></span>
<span style="font-size: small;"><br /><span> Para
astronot telah menemukan bahwa planet Bumi mengeluarkan semacam radiasi,
secara resmi mereka mengumumkannya di Internet, tetapi sayang nya 21
hari kemudian website tersebut raib yang sepertinya ada alasan
tersembunyi dibalik penghapusan website tersebut.</span></span>
<span style="font-size: small;"><br /><span></span></span>
<span style="font-size: small;"><a name='more'></a><br /><span>
Setelah melakukan penelitian lebih lanjut, ternyata radiasi tersebut
berpusat di kota Mekah, tepatnya berasal dari Ka’Bah. Yang mengejutkan
adalah radiasi tersebut bersifat infinite ( tidak berujung ), hal ini
terbuktikan ketika mereka mengambil foto planet Mars, radiasi tersebut
masih berlanjut terus. Para peneliti Muslim mempercayai bahwa radiasi
ini memiliki karakteristik dan menghubungkan antara Ka’Bah di planet
Bumi dengan Ka’bah di alam akhirat.</span></span>
<span style="font-size: small;"><br /><span><img alt="" border="0" src="http://samudro.files.wordpress.com/2009/08/magnet-bumi.jpg?w=300&h=164" /> <img alt="" border="0" src="http://samudro.files.wordpress.com/2009/08/magnet-bumi.jpg?w=300&h=164" /></span></span>
<span style="font-size: small;"><br /><span> Di
tengah-tengah antara kutub utara dan kutub selatan, ada suatu area yang
bernama ‘Zero Magnetism Area’, artinya adalah apabila kita mengeluarkan
kompas di area tersebut, maka jarum kompas tersebut tidak akan bergerak
sama sekali karena daya tarik yang sama besarnya antara kedua kutub.</span></span>
<span style="font-size: small;"><br /><br /><span> Itulah
sebabnya jika seseorang tinggal di Mekah, maka ia akan hidup lebih
lama, lebih sehat, dan tidak banyak dipengaruhi oleh banyak kekuatan
gravitasi. Oleh sebab itu lah ketika kita mengelilingi Ka’Bah, maka
seakan-akan diri kita di-charged ulang oleh suatu energi misterius dan
ini adalah fakta yang telah dibuktikan secara ilmiah.</span></span>
</div>
<span style="font-family: Arial,Helvetica,sans-serif; font-size: small;"><img alt="http://www.eriricaldo.com/wp-content/uploads/2009/09/hajaraswad.jpg" src="http://www.eriricaldo.com/wp-content/uploads/2009/09/hajaraswad.jpg" /></span><div style="font-family: Arial,Helvetica,sans-serif; text-align: justify;">
<span style="font-size: small;"><span>Penelitian
lainnya mengungkapkan bahwa batu Hajar Aswad merupakan batu tertua di
dunia dan juga bisa mengambang di air. Di sebuah musium di negara
Inggris, ada tiga buah potongan batu tersebut ( dari Ka’bah ) dan pihak
musium juga mengatakan bahwa bongkahan batu-batu tersebut bukan berasal
dari sistem tata surya kita.</span><br /><br /><span> <span style="font-style: italic; font-weight: bold;">Dalam salah satu sabdanya, Rasulullah SAW bersabda:</span></span></span>
<span style="font-size: small;"><br /><span> Hajar
Aswad itu diturunkan dari surga, warnanya lebih putih daripada susu, dan
dosa-dosa anak cucu Adamlah yang menjadikannya hitam.<span> (Sumber: <a href="http://kaskus.us/">kaskus.us</a>)</span></span></span>
</div>arijal azmihttp://www.blogger.com/profile/01056730217905406608noreply@blogger.com0