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Study Guide Special Topics SPECIAL TOPICS AIMS 1. To introduce the existence of Special Topics in the curriculum of the medical profession. 2. To understand the science and it's practices of health ergonomics in the medical profession. 3. To understand the science and it's practices of travelers medicine in the medical profession. 4. To understand the science and it's practices of health care in elderly in the medical profession. 5. To understand the science and it's practices of the palliative medicine in the medical profession. 6. To understand the science and it's practices of the complementary and alternative medicine in the medical profession. Udayana University Faculty of Medicine, MEU 1 Study Guide Special Topics PLANERS NO 1 2 NAME DEPARTMENT Prof.Dr.dr.I Nyoman Adiputra, MOH,PFK,Sp.Erg (Head) dr. N.K. Putri Ariani, SpKJ Fisiology Psychiatrist PHONE 0811397971 082237817384 LECTURER NO NAME DEPARTMENT PHONE 1 Prof.Dr.W.Suardana. Sp.THTKL (K) ENT 0811385299 2 3 dr.AA Ayu Srikandhyawati, Sp.KFR dr. Putu Anda Tusta Adiputra, SpB(K)Onk Dra. Retno Indaryati. S. Psi Dr. Tjokorda Gde Dharmayuda, Sp.PD KHOM. Prof.Dr.dr.I Nyoman Adiputra, MOH,PFK,Sp.Erg dr. Made Jawi, M.Kes DR.dr.Cok Jaya Lesmana, SpKJ Dr. Ida Bagus Putu Alit, spF, DFM dr. Dudut Rustyadi, SpF dr. Henky, Sp.F., M.BEth, FACLM dr. Kunthi Yulianti, SpKF Rehabilitation Medic Surgery 08156041505 08123826430 Rehabilitation Medic Internal Medicine 08123831862 0811394108 Fisiology 0811397971 Pharmacology Psychiatrist Forensic Forensic Forensic Forensic 08179787972 0816295779 081916613459 08123994234 08123988486 081338472005 4 5 6 7 8 9 10 11 12 Udayana University Faculty of Medicine, MEU 2 Study Guide Special Topics ~ FACILITATORS ~ Regular Class NO 1 2 3 4 5 6 7 8 9 10 NAME dr. Ni Made Renny Anggreni Rena , Sp.PD Drs.I. N Toya Wiartha, Apt dr. I B. Putrawan, Sp.PD dr. Sianny Herawati, Sp.PK dr. Gede Kambayana, Sp.PD-KR dr. Gede Eka Rusdi Antara, Sp.B dr. Gde Somayana, Sp.PD dr. Tjokorda Gde Agung Senapathi, Sp.An dr. Elysanti Dwi Martadiani, Sp.Rad dr. I Wayan Losen Adnyana, Sp PD GROUP DEPT PHONE ROOM A1 Interna 081803651656 A2 Pharmacy 0811399886 A3 Interna 081236194672 A4 Clinical Pathology 081236172840 A5 Interna 08124683416 A6 Surgery 081337794803 A7 Interna 081345136913 A8 Anasthesi 081337711220 A9 Radiology 081805673099 A10 Interna 08123995536 GROUP DEPT PHONE ROOM B1 Anasthesi 08123847675 2rd floor R.2.09 B2 Microbiology 081338291965 B3 Pulmonology 08123875875 B4 Biochemistry 081338776244 B5 Anasthesi 08175253037 B6 Obgyn 0817561966 B7 Interna 08123974128 B8 Opthalmology 08123846995 B9 Pharmacology 081936043700 B10 Neurology 08179782240 2rd floor R.2.09 2rd floor R.2.10 2rd floor R.2.11 2rd floor R.2.12 2rd floor R.2.13 2rd floor R.2.14 2rd floor R.2.15 2rd floor R.2.16 2rd floor R.2.22 2rd floor R.2.23 English Class NO 1 2 3 4 5 6 7 8 9 10 NAME Dr. dr. I Wayan Suranadi, Sp.An.KIC Dr. dr. I Dewa Made Sukrama, MSi, Sp.MK(K) dr. Dewa Made Artika , Sp.P dr. Desak Made Wihandani, M.Kes dr. Cynthia Dewi Sinardja, Sp.An dr. Anom Suardika, Sp.OG dr. Nyoman Astika, Sp.PDKger-FINASIM dr. Anak Agung Mas Putrawati Triningrat, Sp.M dr. I Wayan Sucindra Dewi, S.Ked dr. A.A.Bagus Ngurah Nuartha, Sp.S(K) Udayana University Faculty of Medicine, MEU 2rd floor R.2.10 2rd floor R.2.11 2rd floor R.2.12 2rd floor R.2.13 2rd floor R.2.14 2rd floor R.2.15 2rd floor R.2.16 2rd floor R.2.22 2rd floor R.2.23 3 Study Guide Special Topics CURRICULUM BLOCK : Sub Topic Paliatif Medicine Aims : To understand Paliatif Medicine is Part of Medical Education. Paliatif Medicine most important for patient with severe diseases, chronic illness, and in terminal stage To assess common forms of symptoms and sign patient in severe disease, chronic illness, and patient in terminal stage. To diagnose and manage common physical problem in severe disease, chronic illness, and patient in terminal stage. To aplly the basic principles of Palliatif medicine.for patient in severe disease, chronic illness, and patient in terminal stage. LEARNING OUTCOMES 1. Describe about Paliatif Medicine and its clinical implications 2. Describe the general principles of Paliatif medicine 3. Apply the general principles of Paliatif medicine for patient with severe diseases, chronic illnees, and in terminal stage. 4. Recognize or identify common forms of problem patient with severe diseases, chronic illnees, and in terminal stage. 5. Apply general principles the plan of Paliatif care for patient with severe diseases, chronic illnees, and in terminal stage. TIME TABLE Udayana University Faculty of Medicine, MEU 4 Study Guide Special Topics PALIATIVE MEDICINE No 1 DATE/ Lecture Friday Jan, 9 2015 Prof.Dr.W Suardana, SpTHTKL (K) L E C LECTURE TOPIC Concept, Philosophy and Principle of Palliative medicine CLASS B TIME ACTIVITIES TIME ACTIVITIES 08.00-09.00 Lecture Individual learning 09.00-10.00 SGD Break Student Project Planary Session 12.00-13.30 13.30-15.00 Lecture Student Project Independent Learning SGD Lecture Individual learning 09.00-10.00 12.00-13.30 13.30-15.00 12.30-14.00 SGD Break Student Project Lecture Student Project Independent Learning SGD 11.30.12.00 Break 14.00-15.00 Pleanary Session 15.00-16.00 Pleanary Session 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 2 Monday Jan, 12 2015 dr . AA Ayu Srikandhy awati, Sp.KFR 3 Tuesday Jan, 13 2015 08.00-09.00 09-00-10.00 In patient Hospice and Palliatif care dr. Putu Anda Tusta Adiputra, SpB(K)On k 4 Wednes day Jan, 14 2015 10.30-12.00 12.00-12.30 08.00-09.00 Emergency in Paliatif medicine Communica tion in Palliatif Care Udayana University Faculty of Medicine, MEU 10.00-11.30 1130-12.00 15.00-16.00 10.00-11.30 09.00-10.30 10.00-11.30 10.30-12.00 SGD 12.00-13.30 Lecture Student Project Independent Learning 12.00-12.30 13.30-15.00 SGD 12.30-14.00 Break Student Project 11.30-12.00 Break 14.00-15.00 Plenary Session 15.00-16.00 Plenary Session 08.00-09.00 Lecture 09.00-10.00 Lecture 09.00-10.30 Individual learning 10.00-11.30 12.30-14.00 SGD Break Student Project 09.00.10.00 Break Plenary Session Lecture Individual learning 10.30-12.00 12.00-12.30 Dra. Retno CLASS A 12.00-13.30 13.30-15.00 Student Project Indenpende nt Learning SGD 11.30-12.00 Break 5 Study Guide Special Topics Indaryati, S.Psi 14.00-15.00 5 Thursday Jan, 15 2015 Dr. Tjok Darmayud a, Sp.PD. KHOM Modern supportive care in Onkologi Holistic approach for Cancer patient 08-00-09.00 Pleanary Session 15.00-16.00 Pleanary Session Lecture Individual Learning 09.00-10.00 12.00-13.30 13.30-15.00 12.30-14.00 SGD Break Student Project Lecture Student Project Independent Learning SGD 11.30-12.00 Break 14.00-15.00 Pleanary Session 15.00-16.00 Pleanary Session 09.00-10.30 10.30-12.00 12.00-12.30 10.00-11.30 Feb, 03, 2015 Examination Team TIME TABLE Udayana University Faculty of Medicine, MEU 6 Study Guide Special Topics Complementary and Alternative Medicine (CAM) English Class (Class B) Day/date Friday 16 Jan 2015 Wednesday 21 Jan 2015 Thursday 22 Jan 2015 Time Activity Venue Conveyer 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 Lecture 1 Indiv. Learning SGD Break Student Project Pleanary Class room Dr.Md Jawi. Discussion Room Facillitator 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 Lecture 2 Indiv. Learning SGD Break Student Project Pleanary 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 Lecture 3 Indiv. Learning SGD Break Student Project Pleanary Dr.Md Jawi Class room Class room Discussion Room Monday 26 Jan 2015 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 Lecture 4 Indiv. Learning SGD Break Student Project Pleanary 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 Lecture 5 Indiv. Learning SGD Break Student Project Pleanary Facillitator Dr.Md Jawi Class room Class room Discussion Room Class room Friday 23 Jan 2015 Dr.Md Jawi. Class room Discussion Room DR.dr.Cok Jaya L, SpKJ Facillitator DR.dr.Cok Jaya L, SpKJ Prof. Adiputra Facillitator Prof. Adiputra Class room Class room Discussion Room Prof. Adiputra Facillitator Prof. Adiputra Class room Feb, 03, 2015 Examination Team Reguler Class (Class A) Day/date Time Activity Udayana University Faculty of Medicine, MEU Venue Conveyer 7 Study Guide Special Topics Friday 16 Jan 2015 Wednesday 21 Jan 2015 Thursday 22 Jan 2015 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 Lecture 1 Student Project Break Indiv. Learning SGD Pleanary Lecture 2 Student Project Break Indiv. Learning SGD Pleanary Lecture 3 Student Project Break Indiv. Learning SGD Pleanary Class room Dr. Md Jawi Discussion Room Facillitator Dr. Md Jawi Class room Class room Discussion Room Monday 26 Jan 2015 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 Lecture 4 Student Project Break Indiv. Learning SGD Pleanary Lecture 5 Student Project Break Indiv. Learning SGD Pleanary Facillitator Dr. Md Jawi Class room Class room Discussion Room Class room Friday 23 Jan 2015 Dr. Md Jawi Class room Discussion Room DR.dr.Cok Jaya L, SpKJ Facillitator DR.dr.Cok Jaya L, SpKJ Pof. Adiputra Facillitator Prof. Adiputra Class room Class room Discussion Room Pof. Adiputra Facillitator Prof. Adiputra Class room Feb, 03, 2015 Examination Team PALIATIF MEDICINE Lecture 1 : Concept, Philosophy and Principle of Palliative medicine Udayana University Faculty of Medicine, MEU Prof.dr.W.Suardana Sp.THT-KL(K) 8 Study Guide Special Topics Abstract Palliative care is any form of medical care or treatment that concentrates on reducing the severity of disease symptoms, rather than providing a cure, particularly for the disease which is treatment is not curable. Palliative care improves the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual and psychosocial support to from diagnosis to the end of life and bereavement. Concept and philosophy of Palliative care consist of provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten or postpone death; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible until death; offers a support system to help the family cope during the patients illness and in their own bereavement; uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated; will enhance quality of life, and may also positively influence the course of illness; is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications. The goal of palliative care is relief from suffering, treatment of pain and other distressing symptoms, psychological and spiritual care, a support system to help the individual live as actively as possible, and a support system to sustain the individual's family in other word is holistic approach of care (bio-psycho-socio-cultural and spiritual aspect). Hospice care is other term for palliative medicine which focuses for terminal ill while palliative care services beginning from the diagnosis of the disease. Learning task 1. What is palliative medicine? 2. What are the objectives of palliative care? 3. Did you know about holistic approach in the palliative medicine? 4. Who are the targets in the palliative care? 5. Describe the concept and principle of palliative medicine! 6. What is bereavement consultation? To who will be doing? 7. Describe of past model and modern model of palliative care! 8. Describe of hospice care and differentiation from palliative care! Lecture 2 : In Patient Hospice and Paliatif Care dr.AA Ayu Srikandhyawati, Sp.KFR Udayana University Faculty of Medicine, MEU 9 Study Guide Special Topics Lecture 3 : Emergency in Palliative Care dr. Putu Anda Tusta Adiputra, SpB(K)Onk Abstract The World Health Organization defines palliative care as an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Patients receiving palliative care may deteriorate suddenly due to their illness or another acute medical or surgical problem. At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. Major emergencies in palliative care : Hypercalcaemia Bleeding Superior venal caval obstruction Spinal cord compression Bone fractures Seizure Emergencies in palliative care also include sudden severe exacerbation of symptoms. Therefore, onset of severe pain, exacerbation of breathlessness, and worsening of other symptoms are also discussed with their appropriate treatment. A small armamentarium of appropriate medications is thus shown to cover treatment of the various emergencies that may arise. As palliative care deals with patients who are suffering from progressive fatal conditions, death is the expected end. Lecture 4 : Communication in Palliative care Retno Indaryati Kusuma, Dra, Psikolog Lecture 5 : Holistic Approach for Cancer Patient Dr. Tjokorda Gde Dharmayuda, Sp.PD KHOM Udayana University Faculty of Medicine, MEU 10 Study Guide Special Topics . COMPLEMENTARY AND ALTERNATIVE MEDICINE ( CAM ) Lecture 1 : Complimentary and Alternative Medicine (CAM) Dr. Made Jawi, M Kes Abstract Public awareness and use of complementary and alternative medicine (CAM) are complex phenomena that have grown extraordinarily in the past decade. One reason for this phenomenon no doubt is the enormous increase in public access to worldwide information through the world wide web and widespread newsmedia coverage. Commercial advertising and an endless exposure through the lay press, ranging from tabloid publications to magazines, medical journals, and books, have vigorously promoted the concepts of disease prevention and healing by unconventional means, striking a sensitive (and highly lucrative) chord in a truly global population.Another reason for the popularity of CAM is the upwardly spiraling cost of modern allopathic medical care. New technologies have been developed at a record pace, producing many medical, surgical and diagnostic innovations, most of which are unquestionably improvements but which also are very expensive. The expense and the resulting rationing of these new modalities by managed care programs in an attempt to reduce the costs of medical care have placed them out of reach of a large segment of the population. One consequence appears to be the creation of a strong public desire for a wide range of complementary and alternative modalities to prevent and treat the full gamut of human illness. The younger generation, in particular, seems to be developing distrust of the technological innovations of the medical profession and their potential for adverse effects, while becoming more interested in CAM and preventive medicine. The elderly population has also turned to CAM, but perhaps for different reasons. Whatever the reasons, a veritable blitz of advertising and recommendations for CAM products has arrived and has received strong public interest and approval, with very little support or encouragement from the medical community. Many patients are more informed of alternative therapies than their physicians, a situation that, in itself, should encourage physicians to learn more about CAM. No matter how a physician feels about the usefulness of CAM, it is no longer adequate simply to brush off the patients' questions with an uninformed answer; doing so only serves to broaden the communication gap between the public and the medical profession.Therefore, as a medical student who will be leading the medical staff should know to bridge information gaps or provide correct information to the CAM. In this lecture (the learning process) will be discussed in outline on CAM, so that, future integrated treatment system can be achieved. References 1. The Journal of Alternative and Complementary Medicine 2. BMC Complementary and Alternative Medicine Udayana University Faculty of Medicine, MEU 11 Study Guide Special Topics 3. Evidence-Based Complementary and Alternative Medicine Lecture 2 : Herbal Medicine Dr. Made Jawi, M Kes Abstract Plants had been used for medicinal purposes long before recorded history.In the early 19th century, when chemical analysis first became available, scientists began to extract and modify the active ingredients from plants. Recently, the World Health Organization estimated that 80% of people worldwide rely on herbal medicines for some part of their primary health care. Herbal medicine , also called botanical medicine or phytomedicine, refers to using a plant's seeds, berries, roots, leaves, bark, or flowers for medicinal purposes. Herbalism has a long tradition of use outside of conventional medicine. It is becoming more mainstream as improvements in analysis and quality control along with advances in clinical research show the value of herbal medicine in the treating and preventing disease. In many cases, scientists aren’t sure what specific ingredient in a particular herb works to treat a condition or illness. Whole herbs contain many ingredients, and they may work together to produce a beneficial effect. Many factors determine how effective an herb will be. For example, the type of environment (climate, bugs, soil quality) in which a plant grew will affect it, as will how and when it was harvested and processed. The herbs available in most stores come in several different forms: teas, syrups, oils, liquid extracts, tinctures, and dry extracts (pills or capsules). Teas can be made from dried herbs left to soak for a few minutes in hot water, or by boiling herbs in water and then straining the liquid. Syrups, made from concentrated extracts and added to sweet tasting preparations, are often used for sore throats and coughs. Oils are extracted from plants and often used as rubs for massage, either by themselves or as part of an ointment or cream. Tinctures and liquid extracts are made of active herbal ingredients dissolved in a liquid (usually water, alcohol, or glycerol). Tinctures are typically a 1:5 or 1:10 concentration, meaning that one part of the herb is prepared with 5 - 10 parts (by weight) of the liquid. Liquid extracts are more concentrated than tinctures and are typically a 1:1 concentration. A dry extract form is the most concentrated form of an herbal product (typically 2:1 - 8:1) and is sold as a tablet, capsule, or lozenge. Often, herbs may be used together because the combination is more effective and may have fewer side effects. Health care providers must take many factors into account when recommending herbs, including the species and variety of the plant, the plant's habitat, how it was stored and processed, and whether or not there are contaminants (including heavy metals and pesticides). All medicinal agents have potentiallyunexpected effects including toxicity, andherbs are no different.As with otherdrugs, the risk of unexpected effects maybe influenced by a user’s age, gender,genetics, nutrition status, and concurrentdisease states and treatments.In clinicalpractice recognizing adverse effects of herbalmedicine is not routine and their reporting iseven less frequent.It is important to be aware of anysubstances that have the potential to causetoxicities and to interact with prescribedmedications. Most adverse reactions involvethe skin, liver, GI tract but can involve theheart (e.g.ephedra). Significant hepatotoxiceffects were reported with kava or Echinacea when taken concurrently with otherheptatoxic drugs. The use of a drug and aherb that are both associated with potentialhepatotoxic effects should be avoided. Udayana University Faculty of Medicine, MEU 12 Study Guide Special Topics Herbal medicine is used to treat many conditions, such as asthma, eczema, premenstrual syndrome, rheumatoid arthritis, migraine, menopausal symptoms, chronic fatigue, irritable bowel syndrome, and cancer, among others. Herbal supplements are best taken under the guidance of a trained health care provider. For example, one study found that 90% of arthritic patients use alternative therapies, such as herbal medicine.Be sure to consult with your doctor or pharmacist before taking any herbs. Some common herbs and their uses are discussed in this lecture. References Journal of Herbs, Spices & Medicinal Plants Journal of Herbal Medicine Lecture 3 : Hypnosis Dr. dr. Cokorda Bagus Jaya Lesmana, SpKJ Abstract Hypnosis is a way to harness the imagination to therapeutic strategies designed to help people feel and live better, from reducing pain and anxiety to controlling habits and dissociation. Hypnosis has occupied an unusual position in relation to both mainstream and complementary or, as it is now more often referred to, integrative medicine. It has a long history of being used both within and outside of medicine. Hypnotic capacity can be identified and mobilized as a valuable adjunct to a variety of psychotherapeutic strategies. The word hypnosis comes from the Greek root hypnos, which means sleep. This is misleading, because hypnosis, as a phenomenon, is not a form of sleep; rather, it is a complex process of attentive, receptive concentration. Although peripheral awareness is reduced in sleep and hypnosis, focal attention, which is diffuse in sleep, is heightened during the hypnotic trance. Since the days of Franz Anton Mesmer, techniques of trance induction and the use of trance phenomena for psychotherapeutic change have been confused. This has led to a lack of understanding of the differences between aspects of the hypnotic experience that are influenced by the therapist and those that are due to the individual's degree of hypnotizability, personality style, and motivation. The hypnotist does not project hypnosis onto the subject. The role of the hypnotist is rather to assess an individual's inherent biological capacity for trance and to teach the patient how to use it in a given psychotherapeutic program. The therapist must reassure the subject that he or she will not be embarrassed or humiliated, will not be asked to do anything he or she would not want to do in the waking state, and that it will be a temporary procedure only. Some subjects may be concerned that if they can be hypnotized, it shows they are weak or stupid. On the contrary, therapists explain that only subjects who can strongly focus their attention can be hypnotized. Hypnotherapy brings the patient to an awareness of the feelings and desires of their unconscious mind. It enables them to reframe an experience (e.g., with family, friends, coworkers) or proto-experience, laden with distressing feelings or conflict, into a positive one. The patient is brought to see and feel memories of the past, place them into their present, project them into their future life, and understand and reframe them. The patient actively expresses emotions from their unconscious mind, and develops a different understanding of these memories. The hypnotic state further enables them to modify past situations and feelings, and record these as newly changed in conscious memory. Udayana University Faculty of Medicine, MEU 13 Study Guide Special Topics Treatment using hypnosis involves not merely abreaction of trauma, but also working through it by assisting with the management of uncomfortable affect, enhancing patients' control over it, and enabling them to cognitively restructure its meaning. Catharsis is a beginning but not an end in itself, and it can lead to retraumatization if it is not accompanied by support in managing affective response, control over the accessing of traumatic memories, and help in working through them. Udayana University Faculty of Medicine, MEU 14 Study Guide Special Topics Learning program THE BALINESE TRADITIONAL MEDICINE I Nyoman Adiputra INTRODUCTION In every nation or sub-nation there is a traditional way to remedy the aillment or illnesses or diseases. The intended knowledge is handed down generation to generation, informs of traditions and it's practices. The traditions might be written or spoken orally. In case the source of traditional healing knowledge is written, there is a factual thing that those information is written on a various of materials. For example in the Balinese the intended knowledge is written on a palm leaf (lontar). In other sub-ethnic may use skin of tree or other materials. The Balinese traditional knowledges had been known since those day. It is generally known as usadha, which is means medicines. Lecture 4 : Why traditional healing still used in Bali? Prof. Dr. dr. I Nyoman Adiputra, MOH,PFK,SpErg It is a matter of culture; culture of people who believe on that. Generally the Balinese do believe on traditional healing due to the fact that there are three basic elements for the it's efficacy. The elements are: 1) the source of knowledge; 2) the provider; and 3) the consumer. The source of knowledge informs written materials which called usadha. There are many kinds of usadha. Belong to the usadha group are: 1) general knowledge (tatwa), such as brahmanda tatwa (cosmology), atma tatwa (soul), wrehaspati tatwa (philosophy), aji sangkhya (philosophy), wariga (caleder), agama (religion), rwa bhineda (philosophy); 2) medical knowledge: such as panca maha bhuta (medical physic), saraswati (anatomy), sastra sanga (anatomy), buwana mahbah (pathology), pinarah pitu (patophysiology), kahilangan kawah (pathopa=hysiology), and pati urip (patho-physiology)' taru premana, sundari siksa, (the great pharmacopea), budha kecapi, kalimaha usadha-usadhi (the complete medical knowledge; 3) summary (kaputusan) such as kaputusan punggung tiwas. The naming system of usadha is based on: a) the subject to be treated; b) by using the name of color. Based on subject to be treated there are classification of usadha as the followings: 1) usadha rare (paediatrics); 2) usadha dalem (internal medicine); 3) usadha buduh (mental illness); 4) usadha gondong (goitre disease); 5) usadha kecacar (smallpox); 6) usadha ila (leprozy), 6) usadha cukil daki (dermatology); 7) usadha manak (obstetrics), 8) usadha kamatus (venerology). Udayana University Faculty of Medicine, MEU 15 Study Guide Special Topics Based on color name, there are usadha classification as the followings: 1) usadha kuning/yelow (paediatrics); 2) usadha putih/white (for adolescent); 3) usadha bang/red ( for adult); 4) usadha cemeng/black (geriatrics). All of those subject must be studied by those who like to become a traditional healer or balian. Balian in this case is called Balian Usadha. In fact in Bali there are many type of traditional healers, such as 1) Balian Usadha, who are equivalent to medical doctor; they become Balian after a long and hard study on the usadha. 2) Balian Ketakson, a traditional healer by incidently he (she) got a magical thing, by which he (she) has a power and capability to cure an illness person. This kind of Balian can not be duplicated. 3) Balian Manak, traditional healer who specializing in delivery as a midwife. 4) Balian elung, as a bone setter for patient suffering from a fracture. 5) Balian tenung, those who are offering the service as a fortune teller; 6) Balian engengan, those who are ......... Who will become a Balian? Theoretically, every body and both sexes, who learn about the sources of traditional knowledges could become a Balian. But, as a preference there are a certain prerequirements such as there is a gynealogy; it means that the candidate should has ancester as a Balian; the candicate also should pass by the general knowledge first, and the age should at the late of thirty. The candidate also shoul directly to approach a Balian who will become his (her) teacher during the learning process. The process of learning is very very informal. Eventhough, there is a process of evaluation of the learning processs, which can be done by both ways (candidate and the teacher). When a candidate is allowed to practice what he or she being studied is depend on evaluation process. Consumer in this case are the Balinese who are believe on the traditional healing, without considering the educational level, economic class, rescidences (in the town or rural). Usually, the Balinese may come to Balian at the beginning of suffering, or at the late stage after getting some medical doctor helps, but, without any improvement. The consumer in this case are aksing the help of the traditional healer not only for the illnesses, but also for other thing such as consultation in conducting a ceremony, asking time to start any activity for a better result. Or might be also for asking as a mediator for a certain porpuse. Lecture 5 : A Balian is morally conduct Prof. Dr. dr. I Nyoman Adiputra, MOH,PFK,SpErg In offering the service a Balian may examining the patient. The procedure for that is equivalent to what the MD is doing. It consist of: 1) interviewing (anamnesis); 2) inspecting (by watching or seing; 3) palpating; 4) percussing, 5) auscultating. Another additional examination such as environmental condition is also done. Usually interview is done in a longer time. After a diagnose had been done the Balian will give a treatment to the patient in hand. The treatment procedure consist of a) medication using herbals or other material such as minerals, oils, and part of animals' organ; it can be for causative therapy; symptomatic therapy and supportive therapy; b) religious ceremony such as purification. The drugs used is given by the traditional healer based on their prescriptions. In doing their jobs the traditional healer has never seek for money. Therefore, there is no exact tariff; the patient usually offer the payment informs of in natural things. Udayana University Faculty of Medicine, MEU 16 Study Guide Special Topics Another hint that the traditional healer do their job in moral conduct is that whenever he (she) knows the cause of the sickness , he or she will not tell to any others or if it must be open just for the limited one. He or she always advice to be kept secretly for the better future relationship. The traditional healer always to offer his or her service in accordance to the ethic and moral guidances. In doing so, he or she should also know the calender and it's practice. He or she is mastering on some other topics for example as mediator to the evil or devil spirits, knows about the future (fortune teller), as a consultant for the villiger, as an artist, as a priest, as a village council, as a village administrator and as a informal leader in the village. The traditional healer knows about the basic concept of health and illness. An individual is considered in a healthy condition if there is harmony or in a balance between physical and mental one; or between micro-cosmic and macro-cosmic. If due to a certain thing there is disharmony or imbalance it will cause a sickness. Therefore the treatment is by change the disharmony into a harmony; or imbalance into a balance The cause of the diseases traditionally, could be divided into two parts, namely internally and externally. Internal cause, it is due to a dysharmony between the kanda Pat (the four siblings), panca maha bhuta (the five principle elements), sad ripu (the six enemies), and sapta timira (the sevent sins). The external cause of disease interms of supra natural power, demons, evil spirits, toxic agents (from the plants, animals, metals, minerals); environmental aspect such as mal-construction or mal-composition of house, wind or sin. One thing should keep in mind is that in the usadha as a reference for the traditional healer is not always the dose of drug written completely; how many leaves how many gram of roots and how many time given in a day.. That is as one disadvantage of the traditional healing process. Udayana University Faculty of Medicine, MEU 17 Study Guide Special Topics LEARNING TASKS Day 1 Case • Aunt Tilly is diagnosed with breast cancer and is recommended to start chemotherapy and radiation treatments. Aunt Tilly knows that chemotherapy can make her feel horrible and radiation can be painful. She is referred to a palliative care program for symptom management and receives excellent treatment of her chemotherapy induced nausea, fatigue, and oral thrush (a yeast infection of the mouth common in chemotherapy patients). She is also visited by a Medical Social Worker who helps her complete her advance directives, just in case she loses the ability to speak for herself. She gets weekly visits from a chaplain who prays with her and discusses Aunt Tilly's theological questions. Well, Aunt Tilly endured three rounds of chemotherapy and a week of radiation but her breast cancer is aggressive and resistant to treatment. Aunt Tilly is told that she has six months to live and is referred to hospice care. Hospice comes to Aunt Tilly's home and continues with the expert symptom management that the palliative care team started. They address new symptoms as the arise and begin to talk to Aunt Tilly about her impending death and what her goals and priorities are. Hospice helps Aunt Tilly to fulfill her life-long dream of riding in a Porsche and helps her reconcile with her long estranged daughter Talula. Aunt Tilly dies peacefully surrounded by her family. 1. Describe the disease suffered aunt Telly! 2. What is recommended by doctor to treat aunt Telly? 3. Describe the effect of treatment which is recommended by doctor! 4. Aunt Tilly knows that chemotherapy can make her feel horrible and radiation can be painful. Discussed of this effect of treatment knows by aunt Tilly! 5. Discussed of yeast infection of the mouth very common in chemotherapy patients! 6. Describe what Palliative team will do to aunt Telly who’s suffered of late stage of cancer disease! What objective of the strategies! 7. Discuss why aunt Telly need hospice care! 8. What will the Hospice team take care for aunt Telly condition? 9. Aunt Tilly dies peacefully surrounded by her family. Discussed of this statement! Udayana University Faculty of Medicine, MEU 18 Study Guide Special Topics Day 2 Case : Mr. Ketut, 60 years old, hospitalized in Sanglah with Lung Cancer, stadium Paliative since one month ago. He know about his diagnosis and no other treatment (surgery or chemotherapy) for him. He want to die at home among his family. The primary doctor consult him to Paliative team. LEARNING TASK : 1. 2. 3. 4. Definition of Paliative Medicine. Taking and formulate a complete history of this case. Make the plan for this patient. What is your opinion when the patient feel short of breath at home. SELF ASSESSMENT : 1. What do you know about Paliative Medicine? 2. Explain about Paliative Care. 3. Discribe 10 (ten) dimension of Quality of Life (Jennifer J . Clinich & Harvey Schipper). Where is the place of Paliative care and give the explaination. Day 3 . Vignette 1 A woman, 55 years old diagnosed with mestastastic breast cancer come to the emergency unit with chief complain of loss of consciousness. 1. Palliative care is necessarily multidisciplinary. What does the principles of palliative care? 2. Hypercalcaemia is the commonest life threatening metabolic disorder encountered in patients with cancer. What is the presenting features of hypercalcaemia? 3. What is the etiology of hypercalcaemia in patient with cancer? Explain about it! 4. Explain the management of hypercalcaemia in the palliative care? Udayana University Faculty of Medicine, MEU 19 Study Guide Special Topics Day 4 Mrs. Ann is a 43-year-old woman with metastatic melanoma. She has completed two cycles of treatment with a combination therapy that she has tolerated not-quite well. Her major complaints had been fatigue, loss her weight and insomnia. Before starting a third cycle of treatment, she experienced some visual hallucination, and emotional disturbances. The doctor presumed there are another metastatic site of disease in the brain. The drug responses occur many disturbances in her metabolism, make her nausea, and sometime vomiting. According to the family, all of information about the symptoms made her very anxious. That is the reason, her family meet and ask to the doctor to keep all the bad news about her disease. The doctor must let only the family know the reality, and the patient only know the good ones, so she will get better improve and recovery. Learning Task 1. Please describe what must the doctor said and explain to the family 2. Please give the best explanation to the patient, while you know she is in depressed condition. 3. Why Palliative care serves as a bridge between the therapist, the patient, and the family? 4. Depression and other mental disorders often complicate the treatment of medical illness, and deviant illness behavior such as suicide is a common problem in patients who are organically ill. What will you suggest to the patient who suffered the disorders? 5. When the best time you give the worsening of symptoms to the patients? 6. Is that necessary to report all the side effects of the medication, so the patient can be prepared before? 7. Why must we give much attention to the palliative staff and care-giver? Day 5 Soon will be added Udayana University Faculty of Medicine, MEU 20 Study Guide Special Topics Day 6 Learning Task Cancer patients using or considering complementary or alternative therapy. The patients discuss this decision with their doctor or nurse, as they would any therapeutic approach. Some complementary and alternative therapies may interfere with standard treatment or may be harmful when used with conventional treatment. It is also a good idea to become informed about the therapy, including whether the results of scientific studies support the claims that are made for it. As a doctor you could explain this problem. A. What benefits can be expected from this therapy? What are the risks associated with this therapy? Do the known benefits outweigh the risks? What side effects can be expected? Will the therapy interfere with conventional treatment? Is this therapy part of a clinical trial? If so, who is sponsoring the trial? Will the therapy be covered by health insurance? B. What the role of complementary therapies bellow for Cancer patients? Acupuncture Exercise Expressive arts (art and writing) yoga Humor therapy Massage therapy Music therapy Qigong Reflexology Day 7 Learning task Many patients use herbal medicine with conventional drugs in treating diseases, or use of herbal products and medications together. For example, diabetic patients might benefit from taking Korean red ginseng or Panax ginseng because this herb can lower blood sugar levels and might allow patients to rely on less medication. However, interactions between herbal products and medication can sometimes result in adverse clinical outcomes. A. If you to be a medical doctor, what are your opinion about that case ? B. 1. What is herbal medicine? 2. How do herbal medicinework? 3. How is herbal medicine sold in stores? 4. What is the future of herbal medicine? Udayana University Faculty of Medicine, MEU 21 Study Guide Special Topics Day 8 Case I Mrs. K. was a 44-year-old well-trained psychiatrist with 4 years of psychoanalytic training who had failed her board examinations 2 years in a row. This was especially disturbing because she was well informed and her colleagues knew her as a competent psychiatrist. Yet something happened in the examination process that led to blocking and intellectual paralysis. Question: 1. Explain treatment option for her condition 2. Explain the role of therapist 3. Explain how to assess her hypnotic capacity 4. Explain the restructuring of the problems 5. Explain how hypnotherapy can help her problems Case II Andy, 38 years oldwas a world-class athlete who collapsed suddenly inan alley. He was brought to a hospital emergency room,where he nearly died of internal bleeding from a lymphomathe size of a grapefruit in his abdomen. He was hospitalizedand placed on chemotherapy. He was extremely anxious,and increasing doses of opiates had little effect on hispain. He was literally “climbing the walls” and alienatingthe nursing staff charged with his care. His parents wereafraid that he was becoming a drug addict. Question: 1. Explain treatment option for her condition 2. Explain the role of therapist 3. Explain how to assess her hypnotic capacity 4. Explain the restructuring of the problems 5. Explain how hypnotherapy can help her problems Self-assessment: 1. Explain principles of psychotherapy with hypnosis 2. Explain the use of hypnosis in forensic psychiatry 3. Explain about hypnotic dissociation 4. Explain some indication for hypnosis use 5. Explain about hypnotic induction profile Udayana University Faculty of Medicine, MEU 22 Study Guide Special Topics Day 9 1. How does the traditional medicine still function in Bali? 2. Mention the basic elements which make it function! 3. Discuss the traditional knowledges of the Balinese traditional medicine you know, and it’s correspondences to the modern medicine. 4. Discuss how the classification of usadha is done, and give some example accordingly! 5. Classify the traditional healer in Bali you know and discuss what is (are) the advantages & disadvantages of those types. 6. Before some one become a traditional healer (Balian) could you summarize how the process he or she did? 7What do you thing, whether a Balian is a professional one or not? 8 Elaborate how the diagnosis is made by a Balian Usadha? 9 According to the traditional knowledges, could you summarize the cause of disease? 10 Try to compare the modern aspect and the traditional aspect of disease aetiology? 11Try to explain the pathogenesis of disease traditionally? 12. How many roles or functions of Balian Usadha do you know? 13. Try to find out that the Balian Usadha is morally conduct. Supports your opinion! 14. Is there any fixed-tariff for Baliaj Usadha in offering his or her services? Day 10 1. How the process of healing is done by Balian Usadha in Bali? 2. What kind of materials for medication used by a Balian Usadha that you know? 3. Is there any source of traditional knowledge for medicinal plants in Bali? 4. Discuss the role of the medicinal plants you know! 5. Discuss how the patient shall use the herbal medicine as you know! 6. Discuss the dosage of drug used in the source of knowledges traditionally! 7. How the medicinal plants’ effect could be estimated? Is there any hint practically? 8. Try to compare the traditional medicine and modern medicine!. Udayana University Faculty of Medicine, MEU 23 Study Guide Special Topics TIME TABLE FORENSIC No 1 DATE/ Lecture Tuesday Jan, 27 2015 dr. Henky, Sp.F., M.BEth, FACLM L E C LECTURE TOPIC Lecture 1 : Introduction to Forensic Medicine Lecture 2 : Ethics in Forensic Medicine CLASS B TIME ACTIVITIES TIME ACTIVITIES 08.00-08.30 08.30-0900 Lecture 1 Lecture 2 Individual learning 09.00-09.30 09.30-10.00 SGD Break Student Project Planary Session 12.00-13.30 13.30-15.00 Lecture 1 Lecture 2 Student Project Independent Learning SGD Lecture Individual learning 09.00-10.00 SGD Break Student Project 12.00-13.30 13.30-15.00 Lecture Student Project Independent Learning SGD 11.30.12.00 Break 15.00-16.00 09.00-10.30 Pleanary Session Lecture Individual learning 10.30-12.00 SGD 12.00-13.30 Pleanary Session Lecture Student Project Independent Learning 12.00-12.30 Break Student Project Plenary Session Lecture Individual learning 13.30-15.00 SGD 11.30-12.00 12.00-13.30 13.30-15.00 12.30-14.00 SGD Break Student Project Break Plenary Session Lecture Student Project Indenpenden t Learning SGD 11.30-12.00 Break 14.00-15.00 Pleanary Session 15.00-16.00 Pleanary Session 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 2 Wednesday Jan, 28 2015 dr. Dudut Rustyadi, SpF 08.00-09.00 09-00-10.00 Lecture : Aspek Medikolegal Kematian 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 3 Thursday Jan, 29 2015 08.00-09.00 Lecture : Asfiksia dan Tenggelam dr. Kunthi Yulianti, SpKF 12.30-14.00 4 Friday Jan, 30 2015 Dr. Ida Bagus Putu Alit, spF, DFM Lecture : Kekerasan Fisik (Penganiaya an) dan Kejahatan Seksual (Sexual Assault) Udayana University Faculty of Medicine, MEU CLASS A 14.00-15.00 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 10.00-11.30 1130-12.00 15.00-16.00 10.00-11.30 09.00.10.00 10.00-11.30 15.00-16.00 09.00-10.00 10.00-11.30 Break Plenary Session 24 Study Guide Special Topics 5 Monday Peb, 02 2015 dr. Henky, Sp.F., M.BEth, FACLM Lecture 1 : Sudden Death 08.00-08.30 08.30-0900 09.00-10.30 Lecture 2 : Forensic Toxicology 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 Lecture 1 Lecture 2 Individual Learning SGD 09.00-09.30 09.30-10.00 10.00-11.30 Break Student Project Pleanary Session 13.30-15.00 12.00-13.30 11.30-12.00 15.00-16.00 Lecture 1 Lecture 2 Student Project Independent Learning SGD Break Pleanary Session Feb, 03, 2015 Examination Team Udayana University Faculty of Medicine, MEU 25 Study Guide Special Topics Lecture: Introduction to Forensic Medicine dr. Henky, Sp.F., M,BEth., FACLM. Abstract Forensic medicine is a branch of medicine specialising in the application of medical knowledge for the purposes of administration of the law and judicial proceeding. In order to solve criminal cases related to human body, investigators usually seek medical advice from physicians since the doctors have a thorough knowledge of human body. Therefore, only medical officers are authorised to examine the human body because of their competency. The relationship between medicine and law has been noted since 3000 BC in Egypt, Babylon, Greece, Rome, and the Middle East. At that time, medicine was strongly influenced by religion, superstition, and magic. The priest, as the intermediary between God and man, had a dual function as the physician and the jurist. Thus, at that moment, scientific method has not yet been adapted for medico-legal investigation. The pioneer of scientific medico-legal death investigation was begun in China in 1236, which was followed by a tremendous development of forensic medicine in Europe. In the US, history recorded that the application of scientific forensic evidence in the court was less developed because of political interest. In Indonesia, forensic medicine was first introduced in the Dutch Colonial Era around 1920 by H.J.F.Roll in STOVIA. Later, this field of study was continuously growing which produced many forensic medicine specialists. Subsequently, they established Perhimpunan Dokter Forensik Indonesia (PDFI) in 1990. In order to fulfil the need of forensic services in society, PDFI has founded five divisions, namely forensic pathology, clinical forensic medicine, forensic serology and bio-molecular, forensic toxicology, ethics and medico-legal. In general, there are two roles of medical officers: as an assessing physician and as a certifying physician. If medical doctors are requested to assist the judicial proceedings, they must collect every scientific evidence by documenting and analysing any information, facts, and findings. Finally, every step of these processes is concluded in medical certificate or medico-legal report. References: 1. Sampurna B, Samsu Z. Peranan Ilmu Forensik Dalam Penegakan Hukum. Jakarta: Bagian Kedokteran Forensik Fakultas Kedokteran Universitas Indonesia; 2003. 2. Knight B. Forensic pathology. Second Edition. Great Britain: Arnold; 2004. 3. Smith S. The History and Development of Forensic Medicine. British Medical Journal. Mar 24, 1951; 1(4707): 599–607. 4. Buchanan D. Forensic Medicine: A Clinician’s View. In: Legal and Forensic Medicine. Beran RG, editor. Berlin: Springer-Verlag; 2013. 5. Beran RG. Analysis - What Is Legal Medicine? Journal of Forensic and Legal Medicine. 2008; 15(3): 158-62. 6. Wecht CH. The History of Legal Medicine. J Am Acad Psychiatry Law. 2005; 33:245–51. Learning Outcomes Able to understand the definition, concept, and scope of forensic medicine. Able to understand the role of physician to assist law enforcement and legal proceeding Udayana University Faculty of Medicine, MEU 26 Study Guide Special Topics Learning Task Vignette A-28-year-old man’s dead body with a gunshot wound in his left chest has been transferred to the department of forensic medicine. The investigator asks you as a medical officer to issue a medico-legal report (Visum et Repertum). Assignments: 1. What is the definition of forensic medicine? 2. Why does the investigator ask for a medico-legal report (Visum et Repertum)? What is the legal basis? 3. In relation to this case, please mention and explain any scientific evidence which must be documented in the medico-legal report (Visum et Repertum)! Self Assessment 1. Explain the history of forensic medicine! 2. Explain the legal proofing system in Indonesia! 3. Mention and explain the divisions of forensic medicine! 4. Mention and explain the scope, role, and duty of forensic medicine! Lecture: Ethics in Forensic Medicine dr. Henky, Sp.F., M,BEth., FACLM. Abstract Aristotle has argued that everything in this life has an end or a goal (telos). According to him, the ultimate goal of human life is to achieve human flourishing (eudaimonia). This goal could be achieved if one can fulfill his/her role to be functioning well as a human being in accordance with his/her specific specialties. For instances, the function of a good knife is to cut well, and the function of a good doctor is to treat the patient well. The main purpose of forensic medicine is to assist the administration of the law and judicial proceeding. Hence, a good forensic medicine specialist is a doctor who is useful to assist law enforcement. This goal can be accomplished by applying ethical principle when conducting forensic medical service which leads to good forensic medical practice. In daily practice, ethics in forensic medicine has specific and unique characteristics because of the interaction between forensic practitioners and investigators, and dualism role between patient and victim/perpetrator. This uniqueness is formed as a consequence of the specific role of forensic physician that is as a certifying doctor. Therefore, the principles of professionalism, objectivity, impartiality, as well as intra- and inter- professional teamwork are the core substances of the code of ethics of forensic medicine. Forensic medicine physicians, either clinical forensic medicine practitioners or forensic pathologists, frequently encounter many ethical dilemmas. The four principles of biomedical ethics, introduced by Beauchamp and Childress could be applied to resolve these moral disputes while performing clinical forensic medicine practice since these principles, historically, were formulated to protect living research subjects. The four principles could also be utilized by forensic pathologists to respect the dead. These basic moral principles combined with the code of conduct for forensic mortuary personnel can be applied to make decisions when dealing with ethical quandaries which arise while dealing with the dead body as well as interacting with the grieving families. Udayana University Faculty of Medicine, MEU 27 Study Guide Special Topics References: 1. Aristotle. excerpt from Nichomachean Ethics. In: Cahn SM, editor. Classics of Political and Moral Philosophy. New York: Oxford University Press; 2002. p. 182221. 2. Beauchamp TL, Childress JF. The Principles of Biomedical Ethics 7th ed. New York: Oxford University Press; 2013. 3. El-Nageh M, Linehan B, Cordner S, Wells D, McKelvie H. Ethical Practice in Laboratory Medicine and Forensic Pathology. WHO Regional Publications; 1999. 4. Kode Etik Kedokteran Forensik Indonesia; 2004. Learning Outcomes Able to act and behave in accordance with the highest ethical standards of forensic medicine. Able to act and behave in line with the basic principle of medical ethics and Indonesian ethical guidelines for forensic medicine practitioners. Able to resolve ethical issues faced while conducting forensic medicine practice. Learning Task Vignette 1 A 38-year-old-woman has been taken by a police to the hospital with an allegation of adultery. The investigator asks the doctor to issue a medico-legal report (Visum et Repertum). Unfortunately, the woman refutes genitalia examination planned by physician, including collecting samples and taking photographs for evidence. Assignments: 1. What is the ethical issue in this case? 2. What is the conflict between ethical principles in this case? 3. What is your decision in this situation? Explain your justification! Vignette 2 A-28-year-old man’s dead body with a gunshot wound in his left chest has been transferred to the department of forensic medicine. The investigator asks you as a medical officer to perform an autopsy. However, his relatives do not give their permission to conduct the autopsy. Assignments: 1. What is the ethical issue in this case? 2. What is the conflict between ethical principles in this case? 3. What is your decision in this situation? Explain your justification! Self Assessment 1. Mention the basic moral principles contained in several articles of Indonesian ethical guidelines for forensic medicine practitioners below! 2. Dokter forensik harus tetap objektif dan menggunakan kemampuannya sebaikbaiknya sehingga keadilan dapat dilayani dengan fakta kedokteran forensik yang akurat. 3. Keterangan ahli dan atau visum et repertum yang diajukan ke depan pengadilan harus merupakan keterangan ahli yang independen dan imparsial dan juga harus terlihat demikian (should be and should be seen to be), tidak dipengaruhi oleh apa dan siapapun, baik bentuk maupun isinya). 4. Sebagai saksi ahli, dokter forensik harus memberikan bantuan yang independen kepada pengadilan dengan pendapatnya yang objektif dan tidak bias, serta tidak sekali-kali berperan sebagai advokat. Udayana University Faculty of Medicine, MEU 28 Study Guide Special Topics 5. Sebagai saksi ahli, dokter forensik harus menyajikan fakta yang objektif dan menyeluruh serta dasar pemikiran dan sumber dari mana pendapatnya dikemukakan. 6. Sebagai saksi ahli, dokter forensik harus dapat menjelaskan sedemikian rupa dengan tidak menjawab pertanyaan atau menerangkan masalah yang berada di luar keahliannya. 7. Sebagai saksi ahli, dokter forensik harus memastikan bahwa keterangannya adalah benar, seluruhnya benar dan tiada lain selain benar. 8. Dokter forensik harus mendukung sejawatnya yang telah melakukan profesinya sesuai dengan standar tetapi memperoleh penekanan oleh pihak lain sehingga kebebasan profesinya terganggu. LECTURE : ASPEK MEDIKOLEGAL KEMATIAN Oleh : dr. Dudut Rustyadi, SpF Abstrak Di Indonesia, menurut Pasal 117 Undang-Undang No. 36 tahun 2009 tentang Kesehatan, seseorang dinyatakan telah meninggal apabila fungsi jantung-sirkulasi dan sistem pernapasan terbukti telah berhenti secara permanen, atau apabila kematian batang otak telah dapat dibuktikan. Thanatologi adalah ilmu yang mempelajari tentang kematian dan perubahan yang terjadi setelah kematian dan faktor-faktor yang mempengaruhi perubahan tersebut. Ada beberapa jenis kematian yaitu Mati Somatis / Mati Klinis, Mati Seluler / Mati Molekuler, Mati Serebral / Mati Otak, Mati Batang Otak . Mati Suri / Mati Semu. Terdapat aspek medikolegal dari peristiwa kematian dan isu-isu terkait kematian yaitu Cara Kematian, Penyebab Kematian, Mekanisme Kematian, Lokasi Kematian dan Konsekuensi Kematian. Untuk menjawab isu-isu tersebut langkah yang sangat penting pada investigasi kematian adalah pemeriksaan jenazah. Pemeriksaan jenazah lengkap (otopsi) meliputi pemeriksaan luar, pemeriksaan dalam dan pemeriksaan laboratorium penunjang. Masingmasing pemeriksaan tidak dapat berdiri sendiri, merupakan satu kesatuan sehingga didapatkan kesimpulan sebab, mekanisme dan perkiraan cara kematian. Dokter sering dimintai bantuan untuk melakukan pemeriksaan jenazah karena dianggap yang paling mengetahui mengenai seluk beluk tubuh manusia. Penyidik bila ingin meminta bantuan dokter dalam memeriksa jenazah harus sesuai dengan prosedur medikolegal yang berlaku. Pada kondisi bencana massal atau jenazah tidak dikenal peran pemeriksaan identifikasi sangatlah penting. Identifikasi forensik merupakan upaya yang dilakukan dengan tujuan untuk menentukan identitas seseorang, karena identitas adalah hak asasi manusia, hak dan kewajiban hukum negara, menentukan status keluarga ( anak, istri / suami ), status social, dan penentuan langkah dalam penyidikan. Tujuan utama dalam proses identifikasi adalah pada kasus yang bukan pidana agar korban dapat diserahkan kepada pihak keluarga untuk ditindak lanjuti seperti dilakukan penguburan, kremasi, penyelesaian klaim asuransi atau masalah waris, dan lain-lain. Sedangkan pada kasus pidana, identifikasi korban merupakan hal pertama yang perlu dilakukan sebelum menemukan tersangka (sebagai langkah awal dalam proses penyidikan). Prinsip-prinsip dalam proses identifikasi adalah ; Pengumpulan Data Post Mortem Merupakan data berupa hasil dari pemeriksaan mayat, bagian mayat atau kerangka yang meliputi data tentang keadaan umum dan keadaan khusus Pengumpulan Data Ante Mortem Merupakan data berupa informasi dari pihak keluarga yang merasa kehilangan anggota keluarganya tentang data keluarga, data pekerjaan, data polisi, data medis/gigi baik termasuk Foto rontgen, Laboratorium dan data benda – benda milik korban dan sebagainya. Perbandingan Data Ante Mortem dan Data Post Mortem ( Rekonsiliasi ) Udayana University Faculty of Medicine, MEU 29 Study Guide Special Topics References: 1. Budiyanto A, Widiatmaka W, Sudiono S, Winardi T, Mun’im A, Sidhi, Hertian S, et al. Ilmu kedokteran forensik. First Edition. Jakarta: Bagian Kedokteran Forensik Fakultas Kedokteran Universitas Indonesia; 1997. 2. Sampurna B, Samsu Z. Peranan Ilmu Forensik Dalam Penegakan Hukum. Jakarta: Bagian Kedokteran Forensik Fakultas Kedokteran Universitas Indonesia; 2003 3. Shepherd R. Simpson’s forensic medicine. Twelfth Edition. Great Britain: Arnold; 2003. 4. Knight B. Forensic pathology. Second Edition. Great Britain: Arnold; 2004. 5. Di Maio VJ, Di Maio D. Forensic pathology. Second Edition. USA: CRC Press; 2001 Learning Objective : 1. 2. 3. 4. 5. 6. 7. 8. 9. Mampu menjelaskan aspek medikolegal dari peristiwa kematian Mampu menjelaskan cara penentuan kematian Mampu menjelaskan jenis-jenis kematian Mampu menjelaskan perkiraaan waktu kematian (Post Mortem Interval) Mampu menjelaskan membedakan cara kematian, sebab kematian dan mekanisme kematian Mampu menjelaskan proses identifikasi Mampu menjelaskan peran dokter dalam proses identifikasi Mampu menjelaskan jenis-jenis identifier Mampu menjelaskan manfaat identifikasi Skenario 1 : Dokter Ahmad bekerja disebuah RSUD. Pada suatu hari saat jaga di IGD datang pasien dalam keadaan tidak sadar, diantar keluarganya dengan keterangan megalami kecelakaan lalu lintas sekitar 1 jam yang lalu. Pada saat diperiksa ternyata pasien sudah dalam keadaan meninggal atau Death On Arrival (DOA). Assignments : 1. Bagaimanakah caranya dokter Ahmad menentukan bahwa telah terjadi kematian klinis pada pasien tersebut? 2. Jelaskan perubahan-perubahan yang terjadi apabila seseorang telah meninggal dunia dan cara memastikan telah terjadi kematian! 3. Bila keluarga meminta Surat Keterangan Kematian, apakah boleh langsung diterbitkan? Jelaskan! 4. Pada pemeriksaan luar ditemukan berupa lebam mayat berwarna merah keungguan pada tubuh bagian belakang yang hilangpada penekanan dan kaku mayat yang mudah dilawan, tentukan perkiraan waktu kematian pasien tersebut! 5. Jelaskan pengertian dan jenis jenis dari cara kematian, sebab kematian dan mekanisme kematian! Skenario 2 : Jenazah laki-laki ditemukan disebuah tanah kosong. Petugas kepolisian setempat kesulitan menentukan identitas laki-laki tersebut karena pada diperiksa tidak membawa dokumen identitas ataupun tanda pengenal. Jenazah kemudian dievakuasi ke RSUD untuk dilakukan pemeriksaan forensik. Udayana University Faculty of Medicine, MEU 30 Study Guide Special Topics Assignments : 1. Pada pemeriksaan luar jenazah, sebutkan dan jelaskan hal-hal yang menjadi petunjuk identifier agar identitas jenazah dapat diketahui! 2. Data Ante Mortem apa sajakah yang diperlukan agar dapat diketahui identitas jenazah tersebut? 3. Dapatkah diterbitkan Surat Keterangan Kematian pada jenazah yang belum dikenal? Jelaskan alasannya! 4. Bagaimanakah caranya menentukan identitas jenazah yang belum dikenal tersebut? LECTURE : ASFIKSIA DAN TENGGELAM Oleh : dr. Kunthi Yulianti, SpKF Abstrak Asfiksia adalah suatu keadaan yang menimbulkan halangan dalam pertukaran gas di saluran nafas atau di paru-paru. Keadaan tersebut menimbulkan peningkatan kadar CO2 disertai penurunan kadar O2 dalam darah. Penyebab asfiksia dapat berbagai macam diantaranya adalah mekanik, berbagai penyakit, obat-obatan dan trauma listrik. Disebut asfiksia mekanik bila penyebabnya adalah sumbatan mekanik pada saluran nafas. Menurut letak sumbatannya asfiksia mekanik dibedakan menjadi : gagging, choking, smothering (bekap), throttling or manual strangulation (cekik), strangulation by ligature (jerat), hanging (gantung), traumatik asfiksia (fiksasi otot pernafasan dada dan perut) serta sufokasi. Tenggelam (drowning) adalah masuknya cairan yang cukup banyak ke dalam saluran nafas hingga ke paru-paru. Keadaan dimana tubuh seluruhnya masuk ke dalam air belum tentu menunjukkan orang tersebut tenggelam, sebaliknya tubuh yang tidak sepenuhnya masuk ke dalam air dapat merupakan peristiwa tenggelam. Masuknya air ke dalam saluran nafas hingga ke paru-paru menimbulkan mekanisme yang tidak serupa dengan asfiksia mekanik, karenanya tenggelam tidak dimasukan ke dalam penyebab yang menimbulkan asfiksia. References: 1. Budiyanto A, Widiatmaka W, Sudiono S, Winardi T, Mun’im A, Sidhi, Hertian S, et al. Ilmu kedokteran forensik. First Edition. Jakarta: Bagian Kedokteran Forensik Fakultas Kedokteran Universitas Indonesia; 1997. 2. Sampurna B, Samsu Z. Peranan Ilmu Forensik Dalam Penegakan Hukum. Jakarta: Bagian Kedokteran Forensik Fakultas Kedokteran Universitas Indonesia; 2003 3. Idries AM, Tjiptomartono AL, editors. Penerapan Ilmu Kedokteran Forensik dalam Proses Penyidikan. Jakarta: CV Sagung Seto; 2008 4. Shepherd R. Simpson’s forensic medicine. Twelfth Edition. Great Britain: Arnold; 2003. 5. Knight B. Forensic pathology. Second Edition. Great Britain: Arnold; 2004. 6. Di Maio VJ, Di Maio D. Forensic pathology. Second Edition. USA: CRC Press; 2001. Learning Objective : 1. 2. 3. 4. Memahami pengertian dan klasifikasi asfiksia mekanik Mampu menjelaskan perbedaan masing-masing jenis asfiksia mekanik Memahami pengertian dan klasifikasi tenggelam Mampu menjelaskan mekanisme kematian pada tenggelam di air tawar dan di air asin. 5. Mampu menyebutkan temuan postmortem pada korban tenggelam 6. Mampu menjelaskan pemeriksaan getah paru dan diatom pada kasus tenggelam Udayana University Faculty of Medicine, MEU 31 Study Guide Special Topics Skenario 1 : Jenazah Tn. IMD datang diantar oleh penyidik dari kepolisan ke Instalasi Kedokteran Forensik RSUD dengan membawa Surat Permintaan Visum et Repertum Jenazah. Dari keterangan polisi yang mengantar, jenazah ditemukan dalam posisi setengah duduk di bawah pohon mangga pada kebun yang jauh dari pemukiman dengan tali melilit dilehernya yang diikatkan pada dahan terendah dari pohon mangga tersebut. Dari pemeriksaan didapatkan : Lebam mayat pada pinggang, bokong, kedua lengan bawah sampai ujung jari dan kedua tungkai, warna merah keunguan yang tidak hilang pada penekanan. Lebam mayat tidak tampak pada kedua telapak kaki Kaku mayat pada seluruh tubuh Pembusukan tidak ada Sebuah luka lecet tekan yang melingkari leher secara tidak penuh dari arah depan bawah ke belakang atas. Tidak ditemukan luka-luka lain. Assignments 1. Informasi apa lagi yang perlu digali pada kasus ini! 2. Sebelum melakukan pemeriksaan jenazah apa yang perlu diperhatikan dokter! 3. Berdasarkan gambaran dan pola lukanya termasuk dalam asfiksia mekanik yang mana kasus ini, berikan alasannya! 4. Berdasarkan pemeriksaan jenazah, tentukan dan jelaskan perkiaraan cara kematian pada kasus ini! Self assessment 1. 2. 3. 4. 5. Sebutkan klasifikasi asfiksia mekanik! Jelaskan pengertian masing-masing klasifikasi asfiksia mekanik! Jelaskan perbedaan antara gaging dan choking! Jelaskan perbedaan cekik, gantung dan jerat! Berdasarkan letak simpul dan posisi jenazah, jelaskan pembagian tipe gantung (hanging)! 6. Sebutkan temuan postmortem pada jenazah yang meninggal akibat asfiksia! Skenario 2 : Jenazah Tn. IKD datang diantar oleh penyidik dari kepolisan ke Instalasi Kedokteran Forensik RSUD dengan membawa Surat Permintaan Visum et Repertum Jenazah. Dari keterangan polisi yang mengantar, jenazah ditemukan tergeletak di pantai. Assignments: 1. Jelaskan apa yang perlu diperhatikan oleh seorang dokter, saat melakukan pemeriksaan luar jenazah pada kasus ini! 2. Bagaimana cara menenentukan penyebab kematian pada kasus ini! 3. Mengapa tubuh yang ditemukan di dalam air belum tentu meninggal karena tenggelam! Self assessment 1. Jelaskan perbedaan mekanisme kematian pada tenggelam di air tawar dan air asin ! 2. Jelaskan perbedaan mekanisme kematian pada asfiksia mekanik dan tenggelam ! 3. Sebutkan temuan postmortem pada jenazah yang ditemukan di air! Udayana University Faculty of Medicine, MEU 32 Study Guide Special Topics 4. 5. 6. 7. Sebutkan temuan postmortem pada jenazah yang meninggal karena tenggelam! Jelaskan cara pemeriksaan getah paru! Jelaskan cara pemeriksaan diatom ! Jelaskan perbedaan kecepatan pembusukan di dalam tanah, di atas permukaan tanah (suhu lingkungan) dan di dalam air! LECTURE : KEKERASAN FISIK (PENGANIAYAAN) DAN KEJAHATAN SEKSUAL (SEXUAL ASSAULT) Oleh : dr. Ida Bagus Putu Alit,SpF.DFM Kekerasan fisik dapat terjadi dimana-mana, baik dalam bentuk penganiayaan atau kekerasan fisik di dalam rumah tangga (domestic violence). Kekerasan fisik yang sengaja dilakukan untuk menimbulkan penderitaan pada korban disebut penganiayaan (torture). Penganiayaan menimbulkan luka-luka diluar tubuh dan juga bisa mengenai organ dalam (organ visceral) dan bahkan kematian. Berdasarkan penyebab luka, luka dibedakan menjadi Luka Mekanis, Luka Fisik dan Luka Kimia. Luka Mekanis dapat disebabkan oleh kekerasan tumpul (blunt force trauma). Kekerasan tajam (sharp force trauma) dan luka tembak. Luka Fisik dapat disebabkab oleh suhu, elektrik dan barotrauma. Sedangkan luka kimia dapat disebabkan zat asam kuat dan Basa kuat. Luka adalah salah satu bukti medis dari kasus tindak pidana penganiayaan disamping akibat yang ditimbulkannya.Sehubungan dengan bukti medis, Luka memiliki berbagai sifat yaitu sebagai bukti transient, bukti pola, bukti kontak dan bukti kondisional. Luka sebagai bukti transient karena luka cepat mengalami perubahan yaitu menyembuh atau mengalami komplikasi pada korban hidup atau berubah karena proses pembusukan pada korban meninggal. Bukti pola menunjukkan terjadinya luka mengikuti pola-pola tertentu baik bentuk maupun distribusinya. Pola benda penyebab,pola luka penaniayaan,pola luka akibat usaha bunuh diri atau akibat kecelakaan dapat ditentukan dari gambarannya. Luka juga sebagai bukti kondisional yaitu bukti yang dipengaruhi oleh berbagai factor. Usia dan status kesehatan korban merupakan salah satu factor yang mempengaruhi gambaran luka. Kasus penganiayaan adalah tindak pidana dengan delik material dimana pertangungjawaban pelaku karena akibat dari perbuatannya. Pemeriksaan terhadap korban tindak pidana penganiayaan adalah kewajiban hukum bagi dokter, maka seorang dokter harus (obligasi) bertanggung jawab untuk memeriksa, mendokumentasikan dan menginterpretasikan luka untuk kepentingan penegakan hukum. Interpretasi akibat dari luka yang menjadi bukti hukum (legal evidence) adalah derajat luka atau kualifikasi luka yang akan memberikan keyakinan Hakim di Pengadilan. Setelah ditetapkan Undang-undang Perlindungan Anak (UU PA) dan Penghapusan Kekerasan dalam Rumah Tangga (UU PKDRT), maka kekerasan dibedakan menjadi beberapa bentuk kekerasan yaitu : Kekerasan Fisik, Kekerasan Psikologis,Kekerasan seksual dan penelantaran (negligence) serta perampasan kemerdekaan. Selain kekerasan fisik, kekerasan seksual memiliki angka kejadian yang tinggi terutama pada korban anakanak. Komnas Perlindungan Anak menyatakan tahun 2014, Indonesia sudah mengalami kedaruratan kekerasan seksual anak. Secara hukum, kejahatan seksual adalah kejahatan yang menentang kehendak (crime against will) dan kejahatan terhadap kepemilikan (crime against property). Kejahatan yang menentang kehendak apabila hubungan seksual dilakukan tanpa persetujuan (without consent) atau diperoleh dari persetujuan yang tidak sah. Persetujuan yang sah harus Udayana University Faculty of Medicine, MEU 33 Study Guide Special Topics memenuhi syarat Alamiah (natural), spontan, tidak ada keraguan (unequivocal) dan atas keinginan sendiri (volunteer). Persetujuan tidak sah bila diperoleh dengan kekerasan (force), ancaman kekerasan (fear) dan tipu daya (fraud). Kejahatan seksual sebagai kejahatan terhadap kepemilikan (crime against property) apabila hubungan seksual dilakukan terhadap pasangan yang sudah dalam ikatan perkawinan yang sah, termasuk dalam hal ini adalah perselingkuhan (overspel). Overspel bersifat Delik aduan yang hanya bisa dipidanakan bila salah satu pasangan merasa dirugikan. Perkosaan (rape) adalah salah satu bentuk dari kejahatan seksual yang menentang kehendak. Hukum di Indonesia memandang perkosaan dari persepsi tertentu yang mungkin berbeda dengan pandangan hukum di Negara-negara lain. Perkosaan di Indonesia adalah pelakunya laki-laki (male crime),diluar perkawinan (extra marital crime),hanya lewat genitogenital (intra-vaginal crime) dan tanpa persetujuan (without consent). Secara mengkhusus (lex spesialis), UU perlindungan Anak dan UU PKDRT menyatakan kekerasan seksual juga termasuk memaksa wanita berhubungan seksual dengan orang lain untuk tujuan tertentu termasuk penjualan orang (human traficing) Peran dokter dalam kasus kejahatan seksual adalah membantu proses pembuktian hukum terhadap kasus tersebut. Pembuktian hukum adalah membuktikan memang benar tindak pidana (kejahatan seksual) itu terjadi dan memang benar tersangka adalah pelakunya. Dalam membuktikan terjadinya kejahat seksual, seorang dokter harus memberikan buktibukti medis berupa tanda kedewasaan korban, ada tidaknya tanda-tanda kekerasan,ada tidaknya tanda persetubuhan,waktu terjadinya persetubuhan dan akibat persetubuhan bila ditemukan. Tanda kedewasaan untuk membuktikan konpeten atau tidaknya korban dalam memberikan persetujuan dilakukannya hubungan seksual. Tanda kekerasan adalah bukti medis yang menunjukkan korban tidak setuju (without consent) yang dapat berupa lukaluka terutama pada daerah extra-aerogen atau tanda keracunan yang menurunkan kesadaran korban. Bukti persetubuhan dapat berupa tanda penetrasi dan atau tanda ejakulasi.Waktu persetubuhan dapat dibuktikan dengan proses penyembuhan pada genetalia atau karakteristik dari komponen mani yang diperiksa di laboratorium. Membuktikan pelaku dengan memeriksa tersangka baik pemeriksaan fisik maupun pemeriksaan penunjang terhadap bukti runut (trace evidence) yang didapatkan. Adanya luka-luka akibat perlawanan korban,adanya sel epithel vagina pada glans penis atau pemeriksaan serologi dan molekuler (DNA) dapat membuktikan tersangka sebagai pelaku. References: 1. Budiyanto A, Widiatmaka W, Sudiono S, Winardi T, Mun’im A, Sidhi, Hertian S, et al. Ilmu kedokteran forensik. 1st ed. Jakarta: Bagian Kedokteran Forensik Fakultas Kedokteran Universitas Indonesia; 1997. 2. Idries AM. Pedoman ilmu kedokteran forensik. 1st ed. Jakarta: Binarupa Aksara; 1997. 3. Sampurna B, Samsu Z. Peranan ilmu forensik dalam penegakan hukum: sebuah pengantar. Jakarta; 2003. 4. Shepherd R. Simpson’s forensic medicine. Twelfth Edition. Great Britain: Arnold; 2003. 5. Knight B. Forensic pathology. Second Edition. Great Britain: Arnold; 1996. 6. Di Maio VJ, Di Maio D. Forensic pathology. Second Edition. USA: CRC Press; 2000 7. Angelo PG,Elizabeth M, Janica B. Sexual Assault,G.W Medical Publishing Inc;2008. Udayana University Faculty of Medicine, MEU 34 Study Guide Special Topics Learning Objective : 1. Mampu memahami dan menjelaskan luka sebagai bukti medis 2. Mampu memahami dan menjelaskan deskripsi luka sesuai dengan interpretasi medikolegal serta alasannya (reasoning) 3. Mampu memahami dan menjelaskan kualifikasi atau derajat luka. 4. Mampu membuat kesimpulan dalam Visum et Repertum Perlukaan berdasarkan Medical Reasoning dan Legal Reasoning. 5. Mampu memahami dan menjelaskan tentang aspek Mediko legal kejahatan sexual 6. Mampu memahami dan menjelaskan prosedur pemeriksaan korban kejahatan seksual 7. Mampu memahami dan menjelaskan pemeriksaan terhadap korban kejahatan seksual 8. Mampu memahami dan menjelaskan pemeriksaan penunjang pada korban kejahatan seksual dan interpretasinya Skenario 1 : Seorang laki-laki, umur 35 tahun, dipukul dengan balok kayu oleh teman sekerjanya karena alasan kecemburuan terhadap pacarnya. Korban mengalami luka-luka memar dan patah tulang iga ruas ketiga dan keempat kanan. Pada pemeriksaan penunjang ditemukan hemato-thorax kanan dengan perkiraan perdarahan 500 cc. Pada kepala dengan CT scan ditemukan perdarahan epidural dan tanda patah tulang dasar tengkorak. Pada korban dilakukan pemasangan WSD dan operasi Trepanasi untuk menghilangkan perdarahan intrakranialnya. Assignments: 1. 2. 3. 4. Jelaskan konsep dualism biomedik pada kasus tersebut diatas Jelaskan prosedur pemeriksaan orang tersebut diatas sebagai korban. Bagaimana cara mendeskripsikan luka pada korban tersebut Bagaimana interpretasi kualifikasi atau derajat luka pada korban tersebut Self Assessment : 1. Jelaskan hubungan pandangan medis dan pandangan hukum terhadap luka 2. Jelaskan alasan hukum (Legal reasoning) dari luka Ringan, Sedang dan Berat 3. Jelaskan aplikasi Acuan Medis Baku TRISS,Leefort,TBSA,PTS,PTSD dalam membuat kualifikasi luka Skenario 2 : Seorang anak wanita, umur 6 tahun diajak oleh orangtuanya ke IRD Rumah Sakit karena dicurigai telah terjadi pelecehan seksual oleh tetangganya. Orang tua korban sudah melapor ke Polisi dan dating ke rumah sakit dengan membawa Surat permintaan Visum (SPV). Pada heteroanamnesis, orang tua korban menyatakan melihat anaknya dipangku dalam keadaan telanjang oleh tetangganya sekitar empat jam sebelum ke rumah sakit. Pada pemeriksaan fisik keadaan umum anak dalam batas normal. Pada pemeriksaan gynekologis ditemukan bercak pada hymen arah jam 6 sesuai dengan arah jarum jam. Udayana University Faculty of Medicine, MEU 35 Study Guide Special Topics Assignments: 1. Informasi apa saja yang masih perlu digali sehubungan kasus diatas. 2. Pemeriksaan apa saja yang dilakukan untuk memberikan bukti medis kasus kejahatan seksual tersebut diatas. 3. Jelaskan bagaimana cara pemeriksaan gynekologis pada korban diatas dan jelaskan alasan prosedur tersebut. 4. Kelainan-kelainan apa saja yang mungkin didapatkan pada pemeriksaan genetalia dan pada hymen (selaput dara) pada korban anak tersebut 5. Pemeriksaan penunjang apa yang diperlukan dalam pembuktian kasus tersebut 6. Jelaskan akibat yang mungkin terjadi pada kasus kejahatan seksual. Self Assessment : 1. 2. 3. 4. 5. 6. 7. 8. 9. Apakah definisi Kejahatan seksual Jelaskan aspek Mediko Legal kejahatan seksual Jelaskan bukti-bukti pada korban yang membuktikan kedewasaan Jelaskan bukti-bukti pada korban yang menunjukkan tanda kekerasan Jelaskan bukti-bukti pada korban yang menunjukkan tanda persetubuhan Jelaskan pengertian penetrasi partial/minimal dan penetrasi komplit Jelaskan bukti-bukti yang signifikans membuktikan kejahatan seksual Jelaskan bukti-bukti yang membuktikan waktu terjadinya persetubuhan Jelaskan pemeriksaan anus dan temuan yang mungkin didapatkan. Lecture: Sudden Death dr. Henky, Sp.F., M,BEth., FACLM. Abstract Sudden death could be defined as an instantaneous and unexpected death without any obvious illness or preexisting condition which leads to death. Historically, the term “sudden death” is derived from “sudden unexpected natural death”, indicating the cause of death is natural. Although by definition sudden death could be assumed as natural, in reality, every sudden death case should be treated as unnatural manner of death or unexplained death because anyone could die anytime and anywhere without any known cause. Generally speaking, instantaneous death might be caused by diseases, physiological and biochemical disorders as a result of certain substances (poisons), or triggers which worsen the pathology of the disease (trauma / stressors / physical activity). Sudden death will be considered as natural if it is preceded by specific symptoms / signs, confirmed as a disease based on history from medical record, and witnessed by doctors in clinics / primary health care / hospital. However, if the death occurred without medical history and without witnesses, it is vitally important to investigate the possibility of criminal acts in relation to the sudden death. Articles 133 and 134 Indonesian Criminal Procedure Code has authorized the investigators to seek physicians’ assistance to determine the cause of death. The role of medical officers to assist the investigators in this case is applying the best knowledge of medicine. Physicians should be able to establish the initial diagnosis of cause of death properly. It could be estimated by conducting epidemiological study, taking history from close relatives / investigators / witnesses, and performing the external examination of the body. Moreover, blood and urine samples should be drawn from the body for further Udayana University Faculty of Medicine, MEU 36 Study Guide Special Topics laboratory testing to confirm the diagnosis. Afterwards, general practitioners should refer the case to forensic medicine specialists to reveal the definite cause of death. References: 1. Budiyanto A, Widiatmaka W, Sudiono S, Winardi T, Mun’im A, Sidhi, Hertian S, et al. Ilmu kedokteran forensik. First Edition. Jakarta: Bagian Kedokteran Forensik Fakultas Kedokteran Universitas Indonesia; 1997. 2. Shepherd R. Simpson’s forensic medicine. Twelfth Edition. Great Britain: Arnold; 2003. 3. Knight B. Forensic pathology. Second Edition. Great Britain: Arnold; 1996. 4. Di Maio VJ, Di Maio D. Forensic pathology. Second Edition. USA: CRC Press; 2001. Learning Outcomes Able to understand and explain about unexplained death. Able to estimate the clinical diagnosis of sudden death. Able to aptly manage and refer sudden death cases. Learning Task Vignette A-45-year-old man was found dead in his apartment room. His stiff body was found in a bend position with his right arm on the chest. The investigators ought to discover the cause of death so they send the body to your primary health care facility. Assignments: 1. Mention and explain any information which should be collected to estimate the diagnosis of cause of death! 2. Mention and explain every focused step while conducting external examination to estimate the diagnosis of cause of death! 3. Mention and explain any laboratory test to estimate the diagnosis of cause of death! 4. Based on your answer on questions 1 – 3, please mention the possible diagnoses of cause of death! 5. Choose one of the possible diagnoses as your definitive diagnosis and then explain how you establish the diagnosis! Self Assessment 1. What is the definition of sudden death? 2. Mention and explain the possibilities of cause of death in unexplained death! 3. Mention and explain the cause of sudden death in relation to cardiovascular system! 4. Mention and explain the cause of sudden death in relation to central nervous system! 5. Mention and explain the cause of sudden death in relation to gastrointestinal and hepatobiliary systems! 6. Mention and explain the cause of sudden death in relation to genitourinary system! 7. Mention and explain the cause of sudden death in relation to endocrine, hematology, and other systems! Udayana University Faculty of Medicine, MEU 37 Study Guide Special Topics Lecture: Forensic Toxicology dr. Henky, Sp.F., M,BEth., FACLM. Abstract Toxicology is a branch of science dealing with poison. Hence, forensic toxicology can be defined as the application of toxicology for the purposes of administration of the law and judicial proceeding. A broader definition concerned with the source, nature, effects, clinical symptoms/signs, treatment, and detection of poison. The definition of poison is every substance which influences the body chemically and physiologically, which in toxic doses, always lead to death or disease as a consequence of the malfunction of the body. However, in Indonesian jurisdictions, there is no definition of poison. They merely mention “poisoning” (article 133 Indonesian Criminal Procedure Code) and “the deliberate act of poisoning” which is classified as an assault crime (articles 356 Indonesian Penal Code). Physicians who study forensic toxicology should answer several questions which arise during the investigation, including: whether the victim has been poisoned intentionally, unintentionally, or self-poisoning? What type of poison used? How does the toxic chemical get into the body? What are the effects of poison on the body? How much is the lethal dose of this poison? Establishing the clinical or postmortem diagnosis of intoxication is somewhat difficult due to the difficulty of obtaining historical data in relation to poisoning. Therefore, it is important to note any specific symptoms and signs of poisoning in living subjects. Moreover, physicians should carefully examine the dead body to notice specific findings, both macroscopically and microscopically, which are specific for particular poison. The chemical analysis of remaining evidence (i.e residual vomit, food, and beverages) in crime scene is very crucial to estimate the cause of death. In order to determine the cause of death, it must be proven that the poison has been circulating throughout the body by performing laboratory test to demonstrate that the poison and its metabolites are present in sufficient quantities in different body fluids and tissues. References: 1. Budiyanto A, Widiatmaka W, Sudiono S, Winardi T, Mun’im A, Sidhi, Hertian S, et al. Ilmu kedokteran forensik. 1st ed. Jakarta: Bagian Kedokteran Forensik Fakultas Kedokteran Universitas Indonesia; 1997. 2. Wirasuta IMAG. Buku Ajar Analisis Toksikologi Forensik. Bukit Jimbaran: Jurusan Farmasi FMIPA Universitas Udayana; 2008. 3. Gallo MA. History and scope of toxicology. In: Casarett & Doull's Toxicology: The Basic Science of Poisons. 7th ed. Klaassen CD, editor. USA: McGraw-Hill; 2008. 4. Moffat AC, Osselton MD, Widdop B, Jickells S, Negrusz A. Introduction to forensic toxicology. In: Clarke's Analytical Forensic Toxicology. 2nd ed. Negrusz A, Jickells S, editors. Great Britain: Pharmaceutical Press; 2013. Learning Outcomes Able to understand and explain about forensic toxicology. Able to estimate the clinical and postmortem diagnosis of poisoning. Able to aptly manage and refer poisoning cases. Learning Task Udayana University Faculty of Medicine, MEU 38 Study Guide Special Topics Vignette A young couple found dead in a luxury car with the engine running. Several tiny white and yellow pills were found inside the car. Assignments: 1. Mention and explain any information which should be collected to estimate the poisons which cause the death! 2. Mention and explain every focused step while conducting external examination to estimate the poisons which cause the death! 3. Mention and explain any laboratory test to estimate the poisons which cause the death! 4. Based on your answer on questions 1 – 3, please mention the possible poisons which cause the death! 5. Choose one of the possible poisons as your definitive cause of death and then explain how you establish the diagnosis! 6. Explain the source, nature, port d entrée, mechanism of action, and lethal dose of this poison! 7. What is the manner of death in this case? Explain! Self Assessment 1. What is the meaning of poisoning? 2. Mention and explain the classification of poison! 3. How is the mechanism of action of CO, CN, heavy metals, insecticides, barbiturates, alcohol, narcotics, psychotropic, and other addictive drugs! 4. Explain every step to establish the clinical diagnosis of CO, CN, heavy metals, insecticides, barbiturates, alcohol, narcotics, psychotropic, and other addictive drugs intoxication! 5. Explain every step to establish the postmortem diagnosis of CO, CN, heavy metals, insecticides, barbiturates, alcohol, narcotics, psychotropic, and other addictive drugs intoxication! 6. Explain the medico-legal management of poisoning case! Udayana University Faculty of Medicine, MEU 39 Study Guide Special Topics ~ CURRICULUM MAP ~ Smstr Program or curriculum blocks 10 Senior Clerkship 9 Senior Clerkship 8 Senior clerkship 7 Medical Emergency (3 weeks) Special Topic: -Travel medicine (2 weeks) Elective Study III (6 weeks) Clinic Orientation (Clerkship) (6 weeks) 6 BCS (1 weeks) The Respiratory System and Disorders (4 weeks) The Cardiovascular System and Disorders (4 weeks) The Urinary System and Disorders (3 weeks) The Reproductive System and Disorders (3 weeks) BCS (1 weeks) Alimentary & hepatobiliary systems & disorders (4 Weeks) BCS (1 weeks) The Endocrine System, Metabolism and Disorders (4 weeks) BCS (1 weeks) Clinical Nutrition and Disorders (2 weeks) BCS (1 weeks) BCS (1 weeks) Musculoskeletal system & connective tissue disorders (4 weeks) Neuroscience and neurological disorders (4 weeks) Behavior Change and disorders (4 weeks) BCS (1 weeks) Hematologic system & disorders & clinical oncology (4 weeks) BCS (1 weeks) Immune system & disorders (2 weeks) BCS(1 weeks) Infection & infectious diseases (5 weeks) BCS (1 weeks) The skin & hearing system & disorders (3 weeks) BCS (1 weeks) Medical Professionalism (2 weeks) BCS(1 weeks) Evidence-based Medical Practice (2 weeks) BCS (1 weeks) Health Systembased Practice (3 weeks) BCS(1 weeks) Community-based practice (4 weeks) - BCS (1 weeks) Studium Generale and Humaniora (3 weeks) Medical communication (3 weeks) BCS (1 weeks) The cell as biochemical machinery (3 weeks) Growth & development (4 weeks) BCS (1 weeks) BCS(1 weeks) BCS: (1 weeks) BCS (1 weeks) Elective Study II (1 weeks) 5 4 3 2 1 BCS (1 weeks) Special Topic : - Palliative medicine -Compleme ntary & Alternative Medicine - Forensic (3 weeks) Elective Study II (1 weeks) Special Topic - Ergonomi - Geriatri (2 weeks) Elective Study I (2 weeks) The Visual system & disorders (2 weeks) Pendidikan Pancasila & Kewarganegaraan (3 weeks) Udayana University Faculty of Medicine, MEU 40 Study Guide Special Topics Udayana University Faculty of Medicine, MEU 41
