MENSTRUAL DISORDERS - MENORRHAGIA AND DYSMENORRHOEA

<div style="text-align: justify;"><span style="font-family: georgia; text-align: left;">By </span><b style="font-family: georgia; text-align: left;">Deden Sura Agung</b></div><div style="text-align: justify;"><b style="font-family: georgia; text-align: left;"><br /></b></div><div style="text-align: justify;">Abnormalities of menstruation is most reason for women to visit obstetricians and gynecology, and menorrhagia are the most frequent cause in women with iron deficiency anemia in the western world. Menstrual disorders can be found abnormalities of blood ejected from the amount or duration of bleeding that occurs each cycle. Menstrual abnormalities that can be encountered is amenorrhoea, oligomenorrhoea, menorrhagia and dysmenorrhoea.</div><div style="text-align: justify;"><br /> </div><div style="color: orange; text-align: justify;"><b>AMENORRHOEA</b></div><div style="text-align: justify;">A symptom of ovarian dysfunction and reproductive systems are usually associated with infertility problems. His definition is a state of menstruation are not acquired more than 6 months (not in a state of pregnancy). Amenorrhoea can be divided into:</div><ol><li>Primary amenorrhoea, if a woman never got a period until the age of 16 years.</li> <li>Secondary amenorrhoea is the absence of menstruation for more than 6 months in women who usually have irregular menstrual cycles or up to 12 months in women who usually experience oligomenorrhoea.</li> </ol><div style="text-align: justify;">The cause of amenorrhoea is known to date are:</div><ol><li>Physiological; prepubertal, gestation, lactation, Postmenopouse.</li> <li>Pathological; Congenital testicular feminization, the absence of the uterus, imperforate hymen.</li> <li>Hipotalamic; Congenital - Kallman's syndrome, Learned - weight loss, excessive exercise, craniopharyngioma.</li> <li>Pituitary; Tumor - prolactinoma, Infarction - Sheehan's syndrome, Iatrogenic damage - surgery, radiotherapy.</li> <li>Ovary; Congenital - gonadotropin receptor abnormalities, ovarian resistance syndrome, ovarian dysgenesis, Learned - radiation, chemotherapy, surgery, autoimmune disease.</li> </ol><div style="text-align: justify;">As for amennorrhoea primer, because:<br /> Delay Puberty, familial, nutritional, Delay adrenarche, Congenital structural abnormalities, imperforate hymen, Absence of the uterus or vagina (chromosome abnormalities).<br /> <br /> The successful management of amenorrhoea depends on accurate diagnosis and assessment of patient needs. Patients should be given an explanation of fertility problem, hirsutism, delayed secondary sexual development and protection against osteoporosis. In addition to history and thorough physical examination, investigations are also needed, especially those leading to endocrine disorders.<br /> <br /> Therapy<br /> Women with ovarian disorders requiring sex steroid hormone therapy with estrogen and progesterone are periodic. Estrogen deficiency can adversely impact bone and blood vessels, and therefore there is a suspicion in women with Turner syndrome was not optimal bone growth and higher risk for fracture. In addition to hormone replacement therapy that can improve fertility in patients with ovarian disorders.<br /> In women with low concentrations of gonadotropins required ovulation induction with gonadotropin therapy.<br /> <br /> <b><span style="color: orange;">MENORRHAGIA</span></b><br /> Are spending too much blood and is usually accompanied by blood clots during menstruation, occurs in menstruation with regular cycle. Normal amount of blood ejected each period is about 50 ml, but the upper limit of normal menstrual bleeding was 80 ml​​. Causes of menorrhagia can be divided into four categories:</div><ol style="text-align: justify;"><li>Coagulation Disorders, The incidence of menorrhagia is closely linked to conditions such as thrombocytopenic purpura and von Willebrand's disease. In women with thrombocytopenia, excessive menstrual blood can be attributed to the low number of platelets that is when menstruation occurs. In these circumstances, splenectomi known to lower the amount of blood loss significantly. However, excessive menstrual bleeding can also be found on the state of the normal coagulation system.</li> <li>Dysfunctional Uterine Bleeding, Is abnormal bleeding from the uterus (long, frequency, amount) that occurs within and outside the menstrual cycle, with no organ abnormalities, hematological and pregnancy, and an abnormal process of hypothalamic - pituitary - ovarian.</li> <li>Suspected menorrhagia associated with uterine fibroids, pelvic infections, endometrial polyps, foreign bodies such as an intrauterine device, myometrial hypertrophy and vascular abnormalities.</li> <li>Medical Disorders, Menorrhagia associated with various endocrine disorders such as Cushing's disease hipothiroidism and although the mechanism is unknown. If thyroid disease is the cause, need to look for other symptoms such as abnormal weight gain, hair loss and constipation.</li> </ol>DYSMENORRHOEA<br /> Dysmenorrhoea means painful menstruation. A symptom complex, accompanied by cramps in the lower abdomen. Pain radiating to the back and legs, and usually accompanied by gastrointestinal disorders, neurological and malaise. Pain may be felt before, during and after menstruation. Could be colic or continuously. Based on the etiology, dysmenorrhoe can be divided into 2 primary dysmenorrhoea and secondary dysmenorrhoea.<br /> <ol style="text-align: justify;"><li>Dysmenorrhoea primary (idiopathic). There are various theories that explain why women may experience dysmenorrhoea (uterine hyperactivity, endothelins, prostaglandins, vasopressin).</li> <li>Secondary Dysmenorrhoea. This situation can be associated with abnormalities of the pelvis and uterus such as fibroids, IUDs, PID, adenomyosis, endometriosis or cervical stenosis. The cause of the pain itself is not so clear and the use of inhibitors of prostaglandin synthesis is not very effective to eliminate the pain. </li> </ol><div style="text-align: justify;">To search for the etiology of menorrhagia and dysmenorhoea, required a complete diagnose. Characteristics to look for bleeding. Bleeding a lot, regular, cyclic without any spotting between cycles can lead to dysfunctional uterine bleeding. While the history of progressive pain during menstruation and is accompanied disparenia can lead to endometriosis. Similarly Asked postkoitus pelvic pain and bleeding. Risk factor for endometrial carcinoma such as the use of tamoxifen, estrogen therapy, polycystic ovary syndrome and obesity should always be sought in the diagnose. On physical examination may be obtained hipoparatiroid symptoms, anemia or blood clotting disorder. Abdominal and pelvic examination is mandatory in patients with complaints of menorrhagia. In the laboratory examination of hemoglobin should not be overlooked when the patient's complaint is menorrhagia, and iron supplementation should be given when needed. Examination of TSH and T4 are not absolutely necessary, unless there are other things that lead to a state of thyroid disorders. Besides intra-uterine examination is also necessary to assess the direction of malignancy, which is usually found in women over the age of 45 years with irregular bleeding and acquired risk factors.</div><br /> <b><span style="color: orange;">MENORRHAGIA AND DYSMENORRHOEA MANAGEMENT</span></b><br /> Management that existed at the time is divided into three parts, namely:<br /> <ol style="text-align: justify;"><li>Non-hormonal (synthetic prostaglandin inhibitors, antifibrinolitik and ethamsylate). Antifibrinolitik commonly used is that tranexamic acid can reduce menstrual bleeding by 50%. These drugs are quite effective with minimal side effects that depend on the dose. NSAIDs is an inhibitor of prostaglandin synthesis which is the drug chosen for menorrhagia. The principle works is to decrease the concentration of endometrial prostaglandins. The drugs are usually used mefenamic acid, but keep in mind the side effects of gastrointestinal disorders such as dyspepsia syndrome, nausea and diarrhea. Ethamsylate believed to decrease capillary fragility of the endometrium, but not yet widely used because the results vary.</li> <li>Hormonal (progesterone, oral contraceptives and hormone replacement therapy). Synthetic progesterone is used widely for the treatment of menorrhagia. The effect thus suppress endometrial glands are depleted and epithelium and decidual transformation that is formed thinner. There are several types of cyclic progesterone as progesterone, progesterone or progesterone intrauterine sustainable. In addition progesterone may also be given estrogen-progesterone combinations such as danazol or GnRH analogues.</li> <li>Surgical treatment. There are several things you can do with the way surgery is hysterectomy, endometrial ablation techniques and endometrial resection transervikal by way of thermal balloon and microwave endometrial ablation.</li> </ol>

By  Deden Sura Agung Abnormalities of menstruation is most reason for women to visit obstetricians and gynecology, and menorrhagia are the m...

PARKINSON'S

<div style="text-align: justify;"><span style="font-family: georgia; text-align: left;">By </span><b style="font-family: georgia; text-align: left;">Deden Sura Agung</b></div><div style="text-align: justify;"><b style="font-family: georgia; text-align: left;"><br /></b></div><div style="text-align: justify;">It is important to realize that not every person with Parkinson's develops all signs or symptoms of the disease. For example, some people experience tremor as the primary symptom, while others may not have tremor but do have balance problems. Also, for some people the disease progresses quickly, and in others it does not. The following are descriptions of the most common primary symptoms of Parkinson's disease.<br /> Tremor: In the early stages of the disease, about 70 percent of people experience a slight tremor in the hand or foot on one side of the body, or less commonly in the jaw or face. It appears as a "beating" or oscillating movement. Because the Parkinson's tremor usually appears when a person's muscles are relaxed, it is called "resting tremor." This means that the affected body part trembles when it is not doing work, and it usually subsides when a person begins an action. The tremor often spreads to the other side of the body as the disease progresses, but remains most apparent on the original side of occurrence.<br /> Rigidity: Rigidity, also called increased muscle tone, means stiffness or inflexibility of the muscles. Muscles normally stretch when they move, and then relax when they are at rest. In rigidity, the muscle tone of an affected limb is always stiff and does not relax, sometimes resulting in a decreased range of motion. For example, a person who has rigidity may not be able to swing his or her arms when walking because the muscles are too tight. Rigidity can cause pain and cramping.<br /> Bradykinesia: Bradykinesia is the phenomenon of a person experiencing slow movements. In addition to slow movements, a person with bradykinesia will probably also have incomplete movement, difficulty initiating movements and sudden stopping of ongoing movement. People who have bradykinesia may walk with short, shuffling steps (this is called festination). Bradykinesia and rigidity can occur in the facial muscles, reducing a person's range of facial expressions and resulting in a "mask-like" appearance.<br /> Postural instability or impaired balance and coordination: People with Parkinson's disease often experience instability when standing or impaired balance and coordination. These symptoms, combined with other symptoms such as bradykinesia, increase the probability of falling. People with balance problems may have difficulty making turns or abrupt movements. They may go through periods of "freezing," which is when a person feels stuck to the ground and finds it difficult to start walking. The slowness and incompleteness of movement can also affect speaking and swallowing.<br /> <br /> <b><span style="color: orange; font-size: large;">What causes Parkinson's?</span></b><br /> Why an individual develops Parkinson's disease remains unclear. The cause is probably a combination of genetic and environmental factors, and may vary from person to person. Although the cause of Parkinson's remains unknown, scientists have identified factors that contribute to Parkinson's in some patients. For example, people over age 60 have a two-to-four percent risk of developing Parkinson's disease, compared with the one-to-two percent risk in the general population. <br /> Below is information on the two factors that scientists think are most likely to cause Parkinson's disease. <br /> Genetics About 15 to 25 percent of people with Parkinson's report having a relative with the disease. In large epidemiological studies (studies that deal with incidence, distribution and control of disease in a population), researchers have found that people with an affected first-degree relative, such as a parent or sibling, have a two-to-three fold increased risk of developing Parkinson's, as compared to the general population. This means that if your parent has Parkinson's, your chances of developing the disease are slightly higher than the risk in the general population.<br /> The vast majority of Parkinson's cases are not directly inherited, but researchers have discovered several genes that can cause the disease in a small number of families. Some of these genes involve proteins that play a role in dopamine cell functions. Because genetic forms of a disease can be studied in great detail in the laboratory, and because understanding the rare genetic forms of Parkinson's disease may help to understand more common forms of the disease, genetic aspects of PD are currently the subject of intense research. <br /> Environmental Factors Some scientists have suggested that Parkinson's disease may result from exposure to an environmental toxin or injury. Epidemiological research has identified several factors that may be linked to PD, including rural living, well water, herbicide use and exposure to pesticides. Also, a synthetic narcotic agent called MPTP can cause immediate and permanent parkinsonism if injected. These environmental factors are not useful in diagnosing the cause of Parkinson's disease in individual people. In fact, there is no conclusive evidence that any environmental factor, alone, can be considered a cause of the disease. However, these environmental factors have been helpful in studying laboratory models of Parkinson's disease. Scientists are continuing to pursue these clues to establish more concrete linkages.<br /> <br /> <span style="font-size: large;"><b><span style="color: orange;">Parkinson’s Medications</span></b></span><br /> People with Parkinson’s disease often take a variety of medications in different doses in order to manage the symptoms of the disease.  These factors, combined with the frequency with which one must take their medicines, can be confusing.  People with Parkinson’s and their caregivers should become familiar with their medications in order to use them most effectively and avoid possible interactions. Understanding a medication regime and sticking to it will provide the greatest benefit from the drug and avoid unpleasant “off” periods due to missed doses or confusion. <br /> Although there are general guidelines that doctors use to choose a treatment regimen, each patient must be individually evaluated to determine which drug or combination of drugs is best for them.  For some, a “first choice” drug might be one of the levodopa preparations, and for others, an initial prescription may be given for one of the agonists, an MAO inhibitor or an anticholinergic.  The choice of drug treatment depends on many variables including symptom presentation, other concurrent health issues (and the medications being used to treat them) and a person’s age.  And while the suggested starting dosages (as indicated by the package insert) are listed here, remember that they too can vary greatly depending on a person’s needs and metabolism.<br /> <br /> <span style="font-size: large;"><b><span style="color: orange;">Surgical Treatment for Parkinson's</span></b></span><br /> Surgery for Parkinson's disease has come a long way since it was first developed more than 50 years ago. The newest version of this surgery, deep brain stimulation or DBS, was developed in the 1990s and is now a standard treatment. Although it is certainly the most important therapeutic advance since the development of levodopa, it is not for every person with Parkinson's. It is most effective - sometimes, dramatically so - for individuals who experience disabling tremors, wearing-off spells and medication-induced dyskinesias.<br /> During deep brain stimulation surgery, electrodes are inserted into the targeted brain region using MRI and neurophysiological mapping to ensure that they are implanted in the right place. A device called an impulse generator or IPG (similar to a pacemaker) is implanted under the collarbone to provide an electrical impulse to a part of the brain involved in motor function. Patients have a controller, which allows them to check the battery and to turn the device on or off. An IPG battery lasts for about 3 to 5 years and is relatively easy to replace under local anesthesia.<br /> <br /> <span style="font-size: large;"><b><span style="color: orange;">The Role of the Patient</span></b></span><br /> Treating Parkinson's disease is not exclusively the doctor's job; there are many things a person with Parkinson's can do to contribute. Regular exercise, joining a support group, maintaining a healthy diet and taking part in a clinical trial are just some of the things you might consider.<br /> •    Exercise <br /> •    Support Groups <br /> •    Diet <br /> •    A Healthy Patient / Doctor Relationship <br /> •    Physical, Speech and / or Occupational Therapy <br /> •    Clinical Trials <br /> <b>Exercise</b>: For people with Parkinson's, regular exercise or physical therapy is crucial for maintaining and improving mobility, flexibility, balance, range of motion and for warding off many of the disease's secondary symptoms such as depression and constipation. PDF offers Motivating Moves for People with Parkinson's, a unique program of 24 seated and stimulating exercises that were created especially for people with Parkinson's. Copies are available for ordering through the website, or you can call or email PDF for more information. As with every aspect of your care, always consult your doctor before starting an exercise program.<br /> <b>Support groups</b>: For many people, support groups play an important role in the emotional well-being of patients and families. They can provide a caring environment for asking questions about Parkinson's, for sharing stories and advice and for creating friendships with people who have experienced similar problems. To find a support group in your area, please call or email PDF. In addition to in-person support groups, many people also find online groups and list servs helpful. For a listing of list servs that serve the Parkinson's community, please request our publication, Web Resources for People with Parkinson's Disease.<br /> <b>Diet</b>: Many people with Parkinson's lose weight because of poor appetite and inadequate food intake. It is recommended to maintain a full diet that contains all the daily nutritional requirements, including extra fresh fruits and vegetables for fiber to help prevent constipation and plenty of fluids to keep hydrated.<br /> Some people who take levodopa find that protein may interfere with the medication's effect. Limiting protein intake or staggering the medication dosing to avoid conflicts with meals can help this problem. However, adjustments in protein intake are only worthwhile for those very few people whose response to levodopa is indeed sensitive to dietary protein.<br /> People with Parkinson's who lose weight for no clear reason should discuss this with a physician.<br /> <b>A Healthy Patient/Doctor Relationship</b>: Making an accurate diagnosis of Parkinson's - specifically in its early stages - is difficult, but a skilled practitioner can come to a reasoned conclusion that it is Parkinson's. Every person diagnosed with Parkinson's should consider getting a second opinion from a neurologist who specializes in movement disorders and is up-to-date on research and approaches to therapy. <br /> Locating a qualified physician is a first step; next is considering whether the physician is the right one. A person with Parkinson's will work with a physician for many years. Consider these questions: <br /> •    Are you comfortable speaking with your physician? <br /> •    Do you feel respected by your doctor? <br /> •    Are questions answered to your satisfaction or do you come away from a visit feeling that you have not been taken seriously? <br /> •    Can you get in touch with the doctor between visits? <br /> To find a neurologist or movement disorder specialist in your area: <br /> •    Ask your primary care physician for a referral <br /> •    Seek referrals from other living with Parkinson's <br /> •    Contact your insurance provider for a list of neurologists or movement disorder specialists in your network <br /> •    Contact PDF for a referral. <br /> <b>Physical, Speech and/or Occupational Therapy</b>: These therapies can help Parkinson's patients control their symptoms and make daily life easier. Physical therapy may increase muscle strength and flexibility and decrease the incidence of falls. Speech therapy can increase voice volume and assist with word pronunciation. The Lee Silverman technique is a special speech therapy that can be very beneficial to people with Parkinson's - for further information see www.lsvt.org.<br /> Occupational therapy gives people alternative methods of doing tasks that they can no longer perform with ease. These options may provide a stronger sense of control when living with Parkinson's disease. A neurologist should be able to provide recommendations for these therapies and, if needed, a referral. These therapies may or may not be covered by insurance.<br /> <b>Clinical Trials</b>: Clinical trials (also called medical research, clinical research or a clinical study) help researchers answer specific questions about the safety and efficacy of new treatments by studying its effects in people. They are an essential and necessary component of the scientific research process. Simply put, there is no other way for research to show that a proposed treatment works. In addition to contributing to research, joining a clinical trial can provide a person with early access to potentially-helpful Parkinson's treatments and drugs that are not yet on the market.</div>

By  Deden Sura Agung It is important to realize that not every person with Parkinson's develops all signs or symptoms of the disease. ...

COMA is a state of unconsciousness

<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span style="font-family: georgia; text-align: left;">By </span><b style="font-family: georgia; text-align: left;">Deden Sura Agung</b></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;">Coma is a medical condition that needs treatment sooner, because the basic course of the disease was the cause of 'coma' and direction of development of the disease can cause severe brain damage and irreversible. So rapid and systematic examination is needed to provide appropriate therapy and diagnostic work properly. <span class="hps"><span lang="EN">Neurologic</span></span><span lang="EN"> <span class="hps">evaluation</span> <span class="hps">and management</span> <span class="hps">of</span> <span class="hps">patients</span> <span class="hps">'</span>coma' or <span class="hps">loss of consciousness</span> <span class="hps">is very</span> <span class="hps">difficult</span>, <span class="hps">because patients</span> <span class="hps">in such conditions</span> <span class="hps">usually</span> <span class="hps">in critical condition</span> <span class="hps">and</span> <span class="hps">need help</span> <span class="hps">fast</span></span>. 'Coma' is the result of brain dysfunction that can cause damage rekticular activation system such as loss of consciousness. </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;">In formulating a diagnosis of 'coma', there are two axioms that must be followed: (1) that found a single clue about the causes of 'coma' is not meant to prove the cause, (2) a complete Neurology examination itself is not efficient, because the examination of other organ systems should also be done . <span class="hps"><span lang="EN">Disturbance</span></span><span lang="EN"> <span class="hps">of consciousness</span> <span class="hps">is a</span> <span class="hps">marker</span> <span class="hps">of</span> <span class="hps">nervous system disorders</span>. <span class="hps">In the examination</span> <span class="hps">must</span> <span class="hps">be</span> <span class="hps">distinguished from</span> <span class="hps">abnormalities in the</span> <span class="hps">level of consciousness</span> <span class="hps">(</span>somnolence, <span class="hps">stupor</span>, <span class="hps">coma</span>) <span class="hps">and</span> <span class="hps">/</span> <span class="hps">or</span> <span class="hps">the contents</span> <span class="hps">of</span> <span class="hps">consciousness</span> <span class="hps">(</span>confuse, <span class="hps">hallucinations</span>).</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">DEFINITION</span></b></span><b><span style="font-size: 12pt;"></span></b></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Coma</span></span><span lang="EN"> <span class="hps">is</span> <span class="hps">a state of</span> <span class="hps">'</span>unresponsiveness' <span class="hps">in which</span> <span class="hps">a person can not</span> <span class="hps">feel or</span> <span class="hps">react</span> <span class="hps">in the environment</span>. <span class="hps">Circumstances</span> <span class="hps">where a person</span> <span class="hps">looks</span> <span class="hps">like</span> <span class="hps">falling asleep</span> <span class="hps">and at the</span> <span class="hps">same time</span> <span class="hps">can not be</span> <span class="hps">awakened</span> <span class="hps">by</span> <span class="hps">external stimuli</span> <span class="hps">and</span> <span class="hps">the needs</span> <span class="hps">of</span> <span class="hps">the body</span> <span class="hps">in a state</span> <span class="hps">referred to as</span> <span class="hps">'</span>coma'.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">ANATOMY AND PHYSIOLOGY</span></b></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">State of</span></span><span lang="EN"> <span class="hps">human consciousness</span> <span class="hps">is a</span> <span class="hps">reflection</span> <span class="hps">of the</span> <span class="hps">level of '</span>arousal' <span class="hps">and</span> <span class="hps">combined</span> <span class="hps">cognitive</span> <span class="hps">brain</span> <span class="hps">functions</span>. <span class="hps">'</span>Arousal' <span class="hps">played by</span> <span class="hps">the integrity of</span> <span class="hps">the physiological</span> <span class="hps">mechanisms</span> <span class="hps">of</span> <span class="hps">formation</span> <span class="hps">rektikularis</span> <span class="hps">and structures</span> <span class="hps">located at the</span> <span class="hps">top of the brainstem</span>, <span class="hps">starting</span> <span class="hps">from</span> <span class="hps">the front</span> <span class="hps">until</span> <span class="hps">the mid-</span>pons <span class="hps">to</span> <span class="hps">the hypothalamus</span>. <span class="hps">Behavior</span> <span class="hps">'</span>conscious' tend <span class="hps">in</span> <span class="hps">played</span> <span class="hps">by</span> <span class="hps">functional</span> <span class="hps">areas of</span> <span class="hps">the</span> <span class="hps">hemisphere</span> <span class="hps">cerebri</span> <span class="hps">each other</span> <span class="hps">and</span> <span class="hps">interact with each other</span> <span class="hps">is widely</span> <span class="hps">associated with the</span> <span class="hps">activation system</span> <span class="hps">that</span> <span class="hps">is more</span> <span class="hps">noble</span> <span class="hps">than</span> <span class="hps">the upper brain</span> <span class="hps">stem</span>, <span class="hps">hypothalamus</span>, <span class="hps">and</span> <span class="hps">thalamus</span>. <span class="hps">Moruzzi</span> <span class="hps">and</span> <span class="hps">Mogoun</span> <span class="hps">(1949)</span>, argued <span class="hps">that</span> <span class="hps">the</span> <span class="hps">rektikularis</span> <span class="hps">formasio</span> <span class="hps">area</span> <span class="hps">located at the</span> <span class="hps">rostral</span> <span class="hps">brain stem</span>, <span class="hps">which when</span> <span class="hps">stimulated</span> <span class="hps">will cause</span> <span class="hps">a general</span> <span class="hps">activation of</span> <span class="hps">the</span> <span class="hps">non</span><span class="atn">-</span>specific <span class="hps">in the</span> <span class="hps">cortex</span> <span class="hps">cerebri</span>, <span class="hps">which</span> <span class="hps">is referred to as</span> <span class="hps">'</span>Ascending <span class="hps">Recticular</span> <span class="hps">Activating</span> <span class="hps">System'</span>. <span class="hps">This system</span> <span class="hps">includes areas</span> <span class="hps">in the middle of</span> <span class="hps">the brain stem</span>, extending <span class="hps">from</span> <span class="hps">the midbrain</span> <span class="hps">to</span> <span class="hps">the hypothalamus</span> <span class="hps">and</span> <span class="hps">thalamus</span>, <span class="hps">and</span> <span class="hps">describe</span> <span class="hps">these structures</span> <span class="hps">in</span> <span class="hps">transmitting</span> <span class="hps">the physiological</span> <span class="hps">effects of</span> <span class="hps">a diffuse</span> <span class="hps">to the cortex</span> <span class="hps">either directly</span> <span class="hps">or indirectly</span>, <span class="hps">in the role</span> <span class="hps">of the</span> <span class="hps">arousal</span> <span class="hps">of consciousness</span>. <span class="hps">Gellhorn</span> <span class="hps">(1953)</span>, <span class="hps">suggests</span> <span class="hps">thinking</span> <span class="hps">about the</span> <span class="hps">process of '</span>consciousness', <span class="hps">which is</span> <span class="hps">known</span> <span class="hps">as</span> <span class="hps">the hypothalamus</span> <span class="hps">or</span> <span class="hps">hypothalamic</span> <span class="hps">activation</span> <span class="hps">system</span> <span class="hps">controle</span> <span class="hps">system</span>, which is <span class="hps">composed of</span> <span class="hps">fibers of</span> <span class="hps">the projection</span> <span class="hps">between the</span> <span class="hps">hypothalamus</span> <span class="hps">with the front</span> <span class="hps">lobe of</span> <span class="hps">the piriformis</span>, <span class="hps">nucleus of</span> <span class="hps">the amygdala</span> <span class="hps">and</span> <span class="hps">hippocampus</span> <span class="hps">formasio</span> <span class="hps">rear</span>, <span class="hps">to</span> <span class="hps">deliver</span> <span class="hps">visceral</span> <span class="hps">feelings</span> <span class="hps">and</span> <span class="hps">impulses</span> <span class="hps">of organic</span> <span class="hps">sensations</span> <span class="hps">through</span> <span class="hps">the neocortex</span> <span class="hps">without</span> <span class="hps">direct contact with</span> <span class="hps">formasio</span> <span class="hps">rektikularis</span>. <span class="hps">In this case the</span> <span class="hps">activation of</span> <span class="hps">the cortex</span> <span class="hps">cerebri</span> <span class="hps">is controlled</span> <span class="hps">by a</span> <span class="hps">two-</span>way <span class="hps">through</span> <span class="hps">the hypothalamus</span>, <span class="hps">the</span> <span class="hps">activation</span> <span class="hps">/</span> <span class="hps">facilitation</span> <span class="hps">and</span> <span class="hps">inhibition</span> <span class="hps">systems</span>. <span class="hps">And</span> <span class="hps">this system</span> <span class="hps">is closely related to</span> <span class="hps">the setting</span> <span class="hps">instinktuil</span>, <span class="hps">emotional</span>, <span class="hps">autonomic</span>, <span class="hps">and</span> <span class="hps">hormonal</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Formasio</span></span><span lang="EN"> <span class="hps">rektikularis</span> <span class="hps">extends</span> <span class="hps">from the</span> <span class="hps">caudal</span> <span class="hps">medulla</span> <span class="hps">oblongata</span> <span class="hps">to the</span> <span class="hps">midbrain</span> <span class="hps">rostal</span>, <span class="hps">with</span> <span class="hps">no</span> <span class="hps">clear</span> <span class="hps">boundaries</span>. <span class="hps">In it</span> <span class="hps">lie</span> <span class="hps">many</span> <span class="hps">vital</span> <span class="hps">centers</span> <span class="hps">such as</span> <span class="hps">the respiratory center</span>, <span class="hps">blood</span> <span class="hps">pressure</span>, <span class="hps">heart rate</span>, <span class="hps">and</span> <span class="hps">other</span> <span class="hps">vegetative</span> <span class="hps">functions</span>, and also <span class="hps">contain</span> <span class="hps">components of</span> <span class="hps">ascending</span> <span class="hps">and</span> <span class="hps">descending</span> <span class="hps">pathways</span> <span class="hps">that</span> <span class="hps">play an important role</span> <span class="hps">in the regulation of</span> <span class="hps">endocrine</span> <span class="hps">secretion</span>, <span class="hps">reflex</span>, <span class="hps">sensory</span> <span class="hps">input</span>, <span class="hps">and</span> <span class="hps">awareness</span>. <span class="hps">'</span>Ascending Recticular Activating System' <span class="hps">receiving</span> <span class="hps">stimulation</span> <span class="hps">by</span> <span class="hps">all</span> <span class="hps">the general</span> <span class="hps">somatic</span> <span class="hps">sensory</span> <span class="hps">pathways</span> <span class="hps">and specific</span>. <span class="hps">Rektikularis</span> <span class="hps">excitation</span> <span class="hps">system</span> <span class="hps">is</span> <span class="hps">a complex</span> <span class="hps">trajectory</span> <span class="hps">polisinaps</span>, <span class="hps">because apart</span> <span class="hps">from</span> <span class="hps">the sensory</span> <span class="hps">tract</span>, <span class="hps">also derived</span> <span class="hps">from the</span> <span class="hps">trigeminal</span> <span class="hps">system</span>, <span class="hps">hearing</span>, sight, <span class="hps">and</span> <span class="hps">smell.</span> <span class="hps">Conductive</span> <span class="hps">pathway</span> <span class="hps">talamikus</span> <span class="hps">spino</span><span class="atn">-</span>walk <span class="hps">toward the</span> <span class="hps">medulla</span> <span class="hps">and</span> <span class="hps">pons</span> <span class="hps">tegmentum</span> <span class="hps">is a</span> <span class="hps">morphological</span> <span class="hps">pathway</span> <span class="hps">of the</span> <span class="hps">excitatory</span> <span class="hps">noksius</span> <span class="hps">of</span> <span class="hps">'</span>consciousness'. <span class="hps">Some</span> <span class="hps">pathways</span> <span class="hps">of</span> <span class="hps">formasio</span> <span class="hps">rektikularis</span> <span class="hps">routed through</span> <span class="hps">the thalamus</span> <span class="hps">to</span> <span class="hps">the next</span> <span class="hps">projected</span> <span class="hps">evenly on</span> <span class="hps">the cortex</span> <span class="hps">cerebri</span> <span class="hps">(</span>specific <span class="hps">projections</span>), <span class="hps">while others</span> <span class="hps">will end up in</span> <span class="hps">nuckleus</span> <span class="hps">specific</span> <span class="hps">thalamus</span> <span class="hps">to then</span> <span class="hps">projected</span> <span class="hps">diffusely</span> <span class="hps">to the cortex</span> <span class="hps">(</span>the projection <span class="hps">of non</span><span class="atn">-</span>specific).</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Broadly speaking</span></span><span lang="EN">, <span class="hps">the causes of</span> <span class="hps">'</span>coma' could be <span class="hps">in</span> <span class="hps">for</span> <span class="hps">two</span>, <span class="hps">namely</span> <span class="hps">intracranial</span> <span class="hps">and</span> <span class="hps">metabolic</span>. <span class="hps">The cause of</span> <span class="hps">intracranial</span> <span class="hps">such as head trauma</span>, <span class="hps">infections</span>, <span class="hps">neoplastic</span>, <span class="hps">and</span> <span class="hps">vascular</span> <span class="hps">disorders</span>. <span class="hps">On</span> <span class="hps">the causes</span> <span class="hps">can</span> <span class="hps">be</span> <span class="hps">metabolic</span> <span class="hps">imbalance</span> <span class="hps">of electrolytes</span> <span class="hps">and</span> <span class="hps">acid</span>-base, <span class="hps">endocrine</span> <span class="hps">disorders</span>, <span class="hps">hepatic</span> <span class="hps">coma</span>, <span class="hps">uremic</span> <span class="hps">coma</span>, <span class="hps">anoxia</span> <span class="hps">encephalopathy</span>, vitamin deficiency <span class="hps">(</span>thiamine, <span class="hps">niacin</span>, <span class="hps">vitamin</span> <span class="hps">B12</span>), <span class="hps">toxins</span> <span class="hps">and</span> <span class="hps">intoksikan</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">The causes of</span></span><span lang="EN"> <span class="hps">'</span>coma' can be <span class="hps">categorized</span> <span class="hps">into:</span></span><span class="hps"></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">a.</span></span>      <span class="hps"><span lang="EN">Dysfunction of</span></span><span lang="EN"> <span class="hps">the cerebral cortex</span> <span class="hps">of</span> <span class="hps">bilateral</span> <span class="hps">multifocal</span> <span class="hps">or</span> <span class="hps">diffuse</span>, <span class="hps">where the</span> <span class="hps">substantia</span> <span class="hps">grisea</span> <span class="hps">cortex</span> <span class="hps">is destroyed or</span> <span class="hps">depressed</span> <span class="hps">by</span> <span class="hps">acute</span> <span class="hps">and</span> <span class="hps">diffuse</span> <span class="hps">so that</span> <span class="hps">the curved</span> <span class="hps">trajectory of</span> <span class="hps">physiological</span> <span class="hps">feedback</span> <span class="hps">cortical</span><span class="atn">-</span>subcortical <span class="hps">damage</span>, <span class="hps">the mechanism</span> <span class="hps">of autonomic</span> <span class="hps">arousal</span> <span class="hps">of</span> <span class="hps">the brain</span> <span class="hps">stem</span> <span class="hps">and cause</span> <span class="hps">shock</span> <span class="hps">terinhibisi</span> <span class="hps">acute</span> <span class="hps">rektikulaer</span> <span class="hps">below the level of</span> <span class="hps">lesion</span> <span class="hps">(</span>eg <span class="hps">:</span> <span class="hps">necrosis</span> <span class="hps">due to</span> <span class="hps">hypoxia</span><span class="atn">-</span>iskhaemia <span class="hps">heavy</span>, <span class="hps">prolonged</span> <span class="hps">hipol</span></span><span class="hps">eu</span><span lang="EN">khaemia, <span class="hps">metabolic</span> <span class="hps">depression</span> <span class="hps">in</span> <span class="hps">ensefalopatia</span> <span class="hps">hepatica</span>).</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">b.</span>     </span><span class="hps"><span lang="EN">Direct damage</span></span><span lang="EN"> <span class="hps">to the</span> <span class="hps">paramedian</span> <span class="hps">upper brain</span> <span class="hps">stem</span> <span class="hps">and</span> <span class="hps">posterior</span>-inferior <span class="hps">diencephalic</span> <span class="hps">ascending</span> <span class="hps">arousal</span> <span class="hps">system that is</span> <span class="hps">blocking</span> <span class="hps">the normal</span> <span class="hps">cortical</span> <span class="hps">activity</span> <span class="hps">(ie</span>: <span class="hps">encephalitis</span> <span class="hps">infrak</span> <span class="hps">or</span> <span class="hps">certain</span> <span class="hps">inflammatory</span> <span class="hps">lesions</span>).</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">c.</span>    </span><span class="hps"><span lang="EN">Wide</span></span><span lang="EN"> <span class="hps">disconnection</span> <span class="hps">between</span> <span class="hps">the cortex</span> <span class="hps">and</span> <span class="hps">subcortical</span> <span class="hps">mechanisms of</span> <span class="hps">activity</span> <span class="hps">similar to</span> <span class="hps">the above</span> <span class="hps">two</span> <span class="hps">conditions</span> <span class="hps">(</span>for example: <span class="hps">dismielinisasi</span> <span class="hps">or</span> <span class="hps">extensive</span> <span class="hps">damage</span> <span class="hps">of the</span> <span class="hps">substantia</span> <span class="hps">alba</span> <span class="hps">severe</span> <span class="hps">cerebral</span> <span class="hps">hemisphere</span> <span class="hps">pascahipoperfusi</span><span class="atn">-</span>old <span class="hps">cerebral</span> <span class="hps">hypoxemia</span> <span class="hps">due to</span> <span class="hps">CO poisoning</span>).<br /> <span class="hps">d.</span> <span class="hps">Diffuse</span> <span class="hps">abnormalities</span> <span class="hps">are</span> <span class="hps">usually</span> <span class="hps">caused</span> <span class="hps">by a</span> <span class="hps">metabolic</span> <span class="hps">disorder</span> <span class="hps">affecting</span> <span class="hps">competing</span> <span class="hps">cortical</span> <span class="hps">and</span> <span class="hps">subcortical</span> <span class="hps">arousal</span> <span class="hps">mechanisms</span> <span class="hps">(</span>eg <span class="hps">metabolic</span> <span class="hps">encephalopathy</span>).</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">CLINICAL APPROACH</span></b></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">As the</span></span><span lang="EN"> <span class="hps">algorithm</span> <span class="hps">approaches</span> <span class="hps">the patients</span> <span class="hps">'</span>coma' or <span class="hps">loss of consciousness</span>:</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">1.</span></span>   <span class="hps"><span lang="EN">ABC</span></span><span lang="EN">: <span class="hps">in patients</span> <span class="hps">who experienced</span> <span class="hps">loss of consciousness</span>, <span class="hps">carried out</span> <span class="hps">the liberation</span> <span class="hps">of the airway</span>, <span class="hps">breathing</span> <span class="hps">and</span> <span class="hps">circulation</span> <span class="hps">should be</span> <span class="hps">checked</span> <span class="hps">and</span> <span class="hps">maintained</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">2.</span></span>   <span class="hps"><span lang="EN">Look for</span></span><span lang="EN"> <span class="hps">signs or</span> <span class="hps">clues</span> <span class="hps">about the</span> <span class="hps">cause of the</span> <span class="hps">decline in</span> <span class="hps">consciousness</span> <span class="hps">through</span> <span class="hps">anamnesa</span> <span class="hps">(</span>a history of <span class="hps">hereditary diseases</span>, <span class="hps">the state</span> <span class="hps">and</span> <span class="hps">condition of the patient</span> <span class="hps">is found</span>, <span class="hps">etc.</span>), <span class="hps">physical examination</span> <span class="hps">(</span>odor <span class="hps">breathing</span>, signs of <span class="hps">meningeal</span> <span class="hps">perangsagan</span>, scar <span class="hps">injections</span>, <span class="hps">etc.</span>), <span class="hps">laboratory</span> <span class="hps">and</span> <span class="hps">radiological</span> <span class="hps">examinations.</span></span><span class="hps"></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">3.</span></span>      <span class="hps"><span lang="EN">Addressing</span></span><span lang="EN"> <span class="hps">a common cause</span> <span class="hps">of</span> <span class="hps">reversible</span>: <span class="hps">giving</span> <span class="hps">naloxone</span>, <span class="hps">thiamine</span>, and <span class="hps">dextrose</span> <span class="hps">50%</span> <span class="hps">in patients</span> <span class="hps">with decreased</span> <span class="hps">consciousness and</span> <span class="hps">the cause is unknown</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">4.</span></span>      <span class="hps"><span lang="EN">Neurology</span></span><span lang="EN"> <span class="hps">examination</span>: <span class="hps">check the</span> <span class="hps">brainstem and the</span> <span class="hps">search for</span> <span class="hps">focal lesions</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">DIAGNOSIS</span></b></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Physical </span>E</span><span class="hps"><span lang="EN">xamination</span></span><span lang="EN">:</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Note</span></span><span lang="EN"> <span class="hps">vital signs</span> <span class="hps">like</span> <span class="hps">blood</span> <span class="hps">pressure</span>, pulse, respiration and <span class="hps">temperature</span>, <span class="hps">whether</span> <span class="hps">there are abnormalities</span> <span class="hps">or</span> <span class="hps">not</span>. <span class="hps">In</span> <span class="hps">general</span> <span class="hps">observations</span> <span class="hps">views</span> <span class="hps">posture</span>, patient age, <span class="hps">stigmata</span> <span class="hps">of chronic</span> <span class="hps">disease</span>, <span class="hps">breathing patterns</span>, <span class="hps">and skin color</span> <span class="hps">(</span>jaundice, <span class="hps">cyanosis</span>, pallor, <span class="hps">red</span> <span class="hps">cherry</span>). <span class="hps">Looking for</span> <span class="hps">signs of</span> <span class="hps">trauma to the</span> <span class="hps">head</span> <span class="hps">(</span>skull <span class="hps">fracture</span>, <span class="hps">laceration</span>), seizures <span class="hps">(</span>myoclonic, <span class="hps">deserebrasi</span>), <span class="hps">the smell</span> <span class="hps">of</span> <span class="hps">breathing</span> <span class="hps">(</span>alcohol, <span class="hps">acetone</span>, <span class="hps">ammonia</span>), <span class="hps">check the</span> <span class="hps">ears</span> <span class="hps">and</span> <span class="hps">nose</span> <span class="hps">(</span>bleeding <span class="hps">or discharge of</span> <span class="hps">cerebrospinal</span> <span class="hps">fluid</span>), <span class="hps">check the</span> <span class="hps">extremities</span> <span class="hps">body</span> <span class="hps">if there is</span> <span class="hps">a fracture</span> <span class="hps">or</span> <span class="hps">not,</span> <span class="hps">and</span> <span class="hps">palpation</span> <span class="hps">-</span> <span class="hps">percussion</span> <span class="hps">and</span> <span class="hps">auscultation</span> <span class="hps">of the thorax</span> <span class="hps">area</span>, heart <span class="hps">and</span> <span class="hps">abdomen</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Examination</span></span><span lang="EN"> </span><span class="hps">N</span><span class="hps"><span lang="EN">eurolgi</span>c</span><span lang="EN">:</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">First of all</span></span><span lang="EN"> <span class="hps">examined</span> <span class="hps">the level of</span> <span class="hps">consciousness</span> <span class="hps">using the</span> <span class="hps">GCS</span> <span class="hps">-</span> <span class="hps">Glasgow</span> <span class="hps">Coma Scale</span> <span class="hps">which consists</span> <span class="hps">of</span>:</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><i><u><span lang="EN">EYE</span></u></i></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Opening</span></span><span lang="EN"> <span class="hps">eyes</span> <span class="hps">spontaneously.</span> <span class="hps">(</span>4)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Open the</span></span><span lang="EN"> <span class="hps">eyes with</span> <span class="hps">the sound</span> <span class="hps">stimuli</span>. <span class="hps">(</span>3)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Open the</span></span><span lang="EN"> <span class="hps">eye</span> <span class="hps">with</span> <span class="hps">painful</span> <span class="hps">stimuli</span>. <span class="hps">(</span>2)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Unable to open</span></span><span lang="EN"> <span class="hps">the eyes</span>. <span class="hps">(</span>1)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><i><u>MOTORIC</u></i></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Moving</span></span><span lang="EN"> <span class="hps">according to</span> <span class="hps">the command</span>. <span class="hps">(</span>6)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">It can</span></span><span lang="EN"> <span class="hps">locate</span> <span class="hps">pain.</span> <span class="hps">(</span>5)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">avoidance</span></span><span lang="EN"> <span class="hps">reaction</span>. <span class="hps">(</span>4)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Reaction</span></span><span lang="EN"> <span class="hps">dekortikasi</span> <span class="hps">/</span> <span class="hps">flexion</span>. <span class="hps">(</span>3)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Directors</span></span><span lang="EN"> <span class="hps">deserebrasi</span> <span class="hps">/</span> <span class="hps">extension</span>. <span class="hps">(</span>2)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">There was no</span></span><span lang="EN"> <span class="hps">reaction</span>. <span class="hps">(</span>1)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><i><u><span lang="EN">VERBAL</span></u></i></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">Good</span></span><span lang="EN"> <span class="hps">and no</span> <span class="hps">disorientation</span>. <span class="hps">(</span>5)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">'</span></span>C<span lang="EN">onfuse'. <span class="hps">(</span>4)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">Talk is not</span></span><span lang="EN"> <span class="hps">appropriate</span>. <span class="hps">(</span>3)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">Can only</span></span><span lang="EN"> <span class="hps">groaned</span>. <span class="hps">(</span>2)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">There is no sound</span></span><span lang="EN">. <span class="hps">(</span>1)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">As a</span></span><span lang="EN"> <span class="hps">benchmark</span> <span class="hps">for</span> <span class="hps">'</span>coma' <span class="hps">then according to</span> <span class="hps">GCS</span> <span class="hps">equal to</span> <span class="hps">3,</span> <span class="hps">where</span> <span class="hps">there were no</span> <span class="hps">eye-opening</span> <span class="hps">response</span>, <span class="hps">verbal</span> <span class="hps">and motor</span></span><span class="hps">ic</span><span lang="EN">.</span><span lang="EN"> </span><span class="hps"><span lang="EN">Then note</span></span><span lang="EN"> <span class="hps">the pattern of</span> <span class="hps">breathing</span> <span class="hps">and</span> <span class="hps">motor</span></span><span class="hps">ic</span> <span class="hps"><span lang="EN">examination</span></span><span lang="EN">. </span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">On</span></span><span lang="EN"> <span class="hps">motor</span></span><span class="hps">ic</span> <span class="hps"><span lang="EN">examination</span></span><span lang="EN">, which is seen <span class="hps">is the</span> <span class="hps">patient's</span> <span class="hps">posture</span> <span class="hps">and</span> <span class="hps">if there are</span> <span class="hps">seizures</span> <span class="hps">or</span> <span class="hps">not</span>. <span class="hps">Cranial</span> <span class="hps">nerves</span> <span class="hps">examination</span> <span class="hps">was conducted to assess</span> <span class="hps">the function</span> <span class="hps">of the brain stem</span>. <span class="hps">Where</span> <span class="hps">in the patients</span> <span class="hps">who experienced</span> <span class="hps">loss of consciousness</span> <span class="hps">or '</span>coma' will <span class="hps">happen</span> <span class="hps">some</span> <span class="hps">decline in</span> <span class="hps">brain</span> <span class="hps">stem</span> <span class="hps">reflexes</span>, <span class="hps">then</span> <span class="hps">examined</span> <span class="hps">the</span> <span class="hps">pupillary</span> <span class="hps">reflex</span>, <span class="hps">corneal</span>, <span class="hps">okulocefalik</span> <span class="hps">(</span>doll's <span class="hps">eye</span>), and <span class="hps">vomiting</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><span lang="EN">To help find out the causes of 'coma', then the examination can be performed with CT-scan or MRI, was conducted to determine abnormalities in the brain are like a tumor mass or increased intracranial fluid. If meningitis is suspected, then examination lumbar puncture. In laboratory tests that examined the levels of blood glucose, iodine, calcium, and urea nitrogen or creatinine; arterial pH, pO</span><span lang="EN" style="font-size: 8pt; position: relative; top: 3pt;">2</span><span lang="EN">, and PCO</span><span lang="EN" style="font-size: 8pt; position: relative; top: 3pt;">2</span><span lang="EN">; the concentration of ethanol in blood and urine; blood cultures and cerebrospinal fluid; and liver function.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">TREATMENT</span></b></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">The principle of</span></span><span lang="EN"> <span class="hps">treatment</span> <span class="hps">is generally</span> <span class="hps">required to</span> <span class="hps">be applied</span> <span class="hps">immediately</span> <span class="hps">although the</span> <span class="hps">diagnosis of</span> <span class="hps">the cause</span> <span class="hps">has not been</span> <span class="hps">enforced.</span> <span class="hps">Starting</span> <span class="hps">from</span>:</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">1.</span></span>      <span class="hps"><span lang="EN">ABC</span></span><span lang="EN">: <span class="hps">the liberation</span> <span class="hps">of the airway</span>, <span class="hps">breathing</span> <span class="hps">and</span> <span class="hps">circulation</span> <span class="hps">maintenance</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">2.</span>      </span><span class="hps"><span lang="EN">Overcome</span></span><span lang="EN"> <span class="hps">state of</span> <span class="hps">shock</span>, <span class="hps">if any.</span></span><span class="hps"></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">3.</span>      </span><span class="hps"><span lang="EN">Provision of</span></span><span lang="EN"> <span class="hps">naloxone</span> <span class="hps">0.5 mg</span> <span class="hps">iv</span> <span class="hps">(</span>if <span class="hps">the cause is</span> <span class="hps">an overdose</span> <span class="hps">of narcotics</span>), <span class="hps">infusion</span> <span class="hps">of glucose</span> <span class="hps">50</span>% 25 <span class="hps">50ml</span>. <span class="hps">And</span> <span class="hps">given the</span> <span class="hps">thiamine</span> <span class="hps">50 -</span> <span class="hps">100mg</span> <span class="hps">after administration of</span> <span class="hps">a bolus</span> <span class="hps">injection of</span> <span class="hps">glucose</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">4.</span></span>      <span class="hps"><span lang="EN">Giving</span></span><span lang="EN"> <span class="hps">Mannitol</span> <span class="hps">50gr</span> <span class="hps">in a solution</span> <span class="hps">of 20%</span> <span class="hps">iv</span> <span class="hps">every</span> <span class="hps">10 -20</span> <span class="hps">minutes</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">5.</span></span>      <span class="hps"><span lang="EN">Perform</span></span><span lang="EN"> <span class="hps">lumbar</span> <span class="hps">puncture</span> <span class="hps">if</span> <span class="hps">meningitis</span> <span class="hps">is suspected</span> <span class="hps">or</span> <span class="hps">subarakhnoi</span> <span class="hps">hemorrhage,</span> <span class="hps">or</span> <span class="hps">perform</span> <span class="hps">a CT</span><span class="atn">-</span>scan.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">6.</span></span>      <span class="hps"><span lang="EN">Giving</span></span><span lang="EN"> <span class="hps">anticonvulsant</span> <span class="hps">such as</span> <span class="hps">phenytoin</span> <span class="hps">500 -</span> <span class="hps">1000mg</span> <span class="hps">iv</span>, <span class="hps">doses</span> <span class="hps"><</span>50mg/mnt.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">7.</span></span>      <span class="hps"><span lang="EN">Rinse</span></span><span lang="EN"> <span class="hps">and</span> <span class="hps">gastric</span> <span class="hps">lavage</span> <span class="hps">with normal saline</span> <span class="hps">is very</span> <span class="hps">useful</span> <span class="hps">if the</span> <span class="hps">coma</span> <span class="hps">is because</span> <span class="hps">taking</span> <span class="hps">drugs.</span></span><span class="hps"></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">8.</span></span>      <span class="hps"><span lang="EN">The use of</span></span><span lang="EN"> <span class="hps">cooling</span> <span class="hps">mat</span> <span class="hps">to</span> <span class="hps">cope with</span> <span class="hps">hyperthermia</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">9.</span></span>      <span class="hps"><span lang="EN">Installation of</span></span><span lang="EN"> <span class="hps">a catheter to</span> <span class="hps">help the</span> <span class="hps">urine output</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">10.</span></span>   <span class="hps"><span lang="EN">Installation of</span></span><span lang="EN"> <span class="hps">stomach</span> <span class="hps">tube</span> <span class="hps">to</span> <span class="hps">assist</span> <span class="hps">the provision</span> <span class="hps">of food and drink</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">11.</span></span>   <span class="hps"><span lang="EN">Changing the</span></span><span lang="EN"> <span class="hps">sleeping position</span> <span class="hps">of patients</span> <span class="hps">and</span> <span class="hps">restriction</span> <span class="hps">of</span> <span class="hps">oral</span> <span class="hps">fluids</span>. <span class="hps">Patient's legs</span> <span class="hps">should</span> <span class="hps">be checked</span> <span class="hps">to prevent</span> <span class="hps">phlebothrombosis</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">CONCLUSION</span></b></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">'</span></span><span lang="EN">Coma' <span class="hps">is</span> <span class="hps">a state of</span> <span class="hps">reduced consciousness</span> <span class="hps">that</span> <span class="hps">causes people to</span> <span class="hps">look like</span> <span class="hps">falling asleep</span> <span class="hps">but can not be</span> <span class="hps">aroused</span> <span class="hps">by</span> <span class="hps">stimuli</span> <span class="hps">from the outside</span> <span class="hps">or</span> <span class="hps">the surrounding</span> <span class="hps">environment</span> <span class="hps">and</span> <span class="hps">by</span> <span class="hps">stimulation</span> <span class="hps">of</span> <span class="hps">the body</span>. <span class="hps">The causes of</span> <span class="hps">'</span>coma' <span class="hps">can be divided</span> <span class="hps">into </span></span><span class="hps">two</span><span lang="EN">, <span class="hps">the first</span> <span class="hps">of</span> <span class="hps">abnormalities</span> <span class="hps">in the</span> <span class="hps">intracranial</span> <span class="hps">and</span> <span class="hps">the second</span> <span class="hps">by</span> <span class="hps">metabolic abnormalities.</span> </span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">What makes</span></span><span lang="EN"> <span class="hps">'</span>coma' <span class="hps">as</span> <span class="hps">a state</span> <span class="hps">of</span> <span class="hps">emergency</span> <span class="hps">is</span> <span class="hps">the cause of</span> <span class="hps">the disease course</span> <span class="hps">and</span> <span class="hps">progression</span> <span class="hps">of the disease</span> <span class="hps">that can cause</span> <span class="hps">severe</span> <span class="hps">brain</span> <span class="hps">damage</span> <span class="hps">and</span> <span class="hps">irreversible</span>, <span class="hps">and usually</span> <span class="hps">patients</span> <span class="hps">with a</span> <span class="hps">'</span>coma' <span class="hps">was in</span> <span class="hps">critical condition</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Therefore</span></span><span lang="EN">, <span class="hps">in</span> <span class="hps">treating patients</span> <span class="hps">with decreased</span> <span class="hps">consciousness</span> <span class="hps">or</span> <span class="hps">'</span>coma' should be <span class="hps">quick</span> <span class="hps">and</span> <span class="hps">systematic</span>, <span class="hps">is intended</span> <span class="hps">to provide</span> <span class="hps">appropriate therapies</span> <span class="hps">and</span> <span class="hps">diagnostics</span> <span class="hps">work</span> <span class="hps">properly</span>. <span class="hps">In an effort</span> <span class="hps">to</span> <span class="hps">provide</span> <span class="hps">relief</span>, <span class="hps">then the</span> <span class="hps">following steps</span> <span class="hps">can be followed</span>:</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 14.2pt; text-align: justify; text-indent: -14.2pt;"><span class="hps"><span lang="EN">1.</span></span>   <span class="hps"><span lang="EN">Remember</span></span><span lang="EN"> <span class="hps">ABC</span>: <span class="hps">the liberation</span> <span class="hps">of the airway</span>, <span class="hps">breathing</span> <span class="hps">and</span> <span class="hps">circulation</span> <span class="hps">maintenance</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 14.2pt; text-align: justify; text-indent: -14.2pt;"><span class="hps"><span lang="EN">2.</span></span>   <span class="hps"><span lang="EN">Find</span></span><span lang="EN"> <span class="hps">the clues</span> <span class="hps">of</span> <span class="hps">the cause of the</span> <span class="hps">reduction</span> <span class="hps">state of</span> <span class="hps">awareness.</span> <span class="hps">In this case</span>, <span class="hps">do</span> <span class="hps">diagnose</span>, <span class="hps">checking</span> <span class="hps">vital signs</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 14.2pt; text-align: justify; text-indent: -14.2pt;"><span class="hps"><span lang="EN">3.</span></span>   <span class="hps"><span lang="EN">The management</span></span><span lang="EN"> <span class="hps">of</span> <span class="hps">circumstances</span> <span class="hps">that are still</span> <span class="hps">reversible</span>, <span class="hps">such as</span> <span class="hps">provision of</span> <span class="hps">naloxone</span>, <span class="hps">thiamine</span>, and <span class="hps">dextrose</span> <span class="hps">to patients</span> <span class="hps">with decreased</span> <span class="hps">awareness of</span> <span class="hps">the</span> <span class="hps">cause is unknown</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 14.2pt; text-align: justify; text-indent: -14.2pt;"><span class="hps"><span lang="EN">4.</span></span>   <span class="hps"><span lang="EN">Check your</span></span><span lang="EN"> <span class="hps">brain stem</span> <span class="hps">reflexes</span> <span class="hps">and</span> <span class="hps">look for</span> <span class="hps">the symptoms</span> <span class="hps">/</span> <span class="hps">signs of</span> <span class="hps">focal lesions</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span lang="EN"><br /> </span><span class="hps"><b><span style="font-size: 12pt;">LITERATUR</span></b></span></div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">1.<span style="font: 7pt "Times New Roman";">         </span>Adams R.D, Maurice V. Coma and Related Disorders of Consciousness, Principles of Neurology, 5^th edition. McGraw-Hill Co,Inc. 1993: 300 – 318;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">2.<span style="font: 7pt "Times New Roman";">         </span>Drislane F.W, Benatar M, Chang B.S, et all. The Approach to Coma and Altered Consciousness, Blueprints Neurology, 2^nd edition. Lippincott Williams & Wilkins. 2002: 20 – 26;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">3.<span style="font: 7pt "Times New Roman";">         </span>LeBlond R.F, DeGowin R.L, Brown D.D. Coma, DeGowin’s Diagnostic Examination The Complete Guide to Assessment Examination Differential Diagnosis, 8^th edition, International edition. McGraw-Hill Co,Inc. 2004: 865 – 868;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">4.<span style="font: 7pt "Times New Roman";">         </span>Kasper D.L, Braunwald E, Fauci A.S, et all. Confusion, Stupor, and Coma, Harrison’s Manual of Medicine, 16^th edition, International edition. McGraw-Hill Co,Inc. 2005: 54 – 58;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">5.<span style="font: 7pt "Times New Roman";">         </span>Gilroy J. Coma, Basic Neurology, 3^rd edition, International edition. McGraw-Hill Co,Inc. 61 – 70;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">6.<span style="font: 7pt "Times New Roman";">         </span>Listiono D. Koma dan Gangguan Kesadaran, Ilmu Bedah Saraf Satyanegara, edisi Ketiga. PT.Gramedia Pustaka Utama, Jakarta, 1998 : 130 – 143;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">7.<span style="font: 7pt "Times New Roman";">         </span>Brust  J.C.M. Coma, Current Diagnosis & Treatment in Neurology, International edition. Lange Medical Books/McGraw-Hill Co,Inc. 2007: 29 – 34.</div>

By  Deden Sura Agung Coma is a medical condition that needs treatment sooner, because the basic course of the disease was the cause of '...