Respiratory management with intubation for emergency personnel (SURGERY)

Chapter I

INTRODUCTION

Since the surgery, the medical community has actually attempted to perform acts of anesthesia aims to reduce and eliminate pain or pain. (Anonymous, 1989) In principle, a patient will be unconscious to perform actions that are performed physical such as hitting, choking, and so forth. It had to be done so that the patient does not feel pain, and finally jumped off the table which resulted in disruption of the proceedings of operation. (Anonymous, 1986).
Since the introduction of ether gas usage by William Thomas Greene Morton in 1846 in Boston United States, then gradually in ways that physical violence is often done to achieve a state of anesthesia becoming obsolete. Discovery was a turning point in the history of surgery, because it opens up the possibility of surgical horizons broader, easier and humane. (Anonymous, 1986).
In an operation, a surgeon can not work alone in dissecting patients while creating a state of anesthesia. Required the presence of an anesthetist to seek, handle and maintain a state of anesthesia the patient. The job of an anesthesiologist in an operating event include:
A. Relieve pain and emotional stress during the process of doing surgery or other medical procedures.
2. To manage common medical measures to the patients operated, keeping the functions of the organs of the body goes in the normal range so that patient safety is maintained.
3. Create the best possible operating conditions so that the surgeon can perform their duties easily and effectively.

One business that absolutely must be performed by an anesthesiologist is to maintain the functioning of organs in normal patients, with no significant effect due to the surgical process. Airway management became one of the most important part in an act of anesthesia. Because some of the effects of drugs used in anesthesia may affect the state of the airway goes well.

One attempt to maintain the patient's airway with endotracheal intubation action, namely by inserting a tube into the upper respiratory tract. Because the main requirements that must be considered in the general anesthesia is to keep the airway and breathing are always free to run smoothly and orderly. In fact, according to Halliday (2002) use of endotracheal intubation is also recommended for neonates with complicating factors that can interfere with the airway. This paper will elaborate on endotracheal intubation, and will only be limited to the issue.
Chapter II
Anatomy and Physiology


2.1 Anatomy - Upper Respiratory Physiology.

            Endotracheal intubation in action we must first understand the anatomy and physiology of the upper airway where intubation was installed. In the discussion of the anatomy and physiology, the authors will elaborate on some matters relating to the physiology of the oropharynx cavity, naso pharynx and some will be more emphasized in the larynx.
Human respiratory system has a picture of a common design that can be attributed to a number of important activities. This system would essentially consist of surface respiration and branched into conducting passages that make up the respiratory tree. Surface respiration is an area of approximately 200 m2, and forming something very thin, moist barrier to air and blood capillaries surrounding the millions of bags called alveoli that eventually form a mass of lung (Williams, 1995: 1630).

2.2 Internal and External Respiration

            Respiration is a combination of physiological processes in which oxygen is inhaled and carbon dioxide released by cells in the body. This is an important process of gas exchange. Respiration is divided into two phases. The first phase of external expiratory in the same sense with breathing. It is a combination of movement and skeletal muscle, where the air for the first time pushed into the lungs and then removed. These events include the inspiration and expiration. Phase to another is internal respiration which includes transfer / movement of the molecules of the respiratory gases (oxygen and carbon dioxide) through the membrane, fluid displacement, and the cells of the body as needed.

2.3 Respiratory Organs

Respiratory tract include: (a) nasal cavity (b) of the larynx (c) trachea (d) bronchi (e) lung and (f) pleura. Pharynx has two functions: to the respiratory system and digestive system. Some of the muscles involved in breathing process. The diaphragm is the most important respiratory muscle in addition to the internal and external muscular intercostalis some other muscles.

TERAPI / RESUSITASI CAIRAN (THERAPY / FLUID RESUSCITATION)

BAB I

PENDAHULUAN

Sebagaimana kita ketahui,sebagian besar tubuh manusia terdiri atas cairan yang jumlahnya berbeda-beda tergantung usia dan jenis kelamin serta banyaknya lemak di dalam tubuh. Dengan makan dan minum tubuh mendapatkan air, elektrolit serta nutrien-nutrien yang lain. Dalam waktu 24 jam jumlah air dan elektrolit yang masuk setara dengan jumlah yang keluar. Pengeluaran cairan dan elektrolit dari tubuh dapat berupa urin, tinja, keringan dan uap air pada saat bernapas.

Terapi cairan dibutuhkan bila tubuh tidak dapat memasukka air, elektrolit serta zat-zat makanan ke dalam tubuh secara oral misalnya pada saat pasien harus berpuasa lama, karena pembedahan saluran cerna, perdarahan banyak, syok hipovolemik, anoreksia berat, mual muntah dan lain-lain. Dengan terapi cairan kebutuhan akan air da elektrolit akan terpenuhi. Selain itu terapi cairan juga dapat digunakan untuk memasukkan obat dan zat makanan secara rutin atau juga digunakan untuk menjaga keseimbangan asam basa.

BAB II

TINJAUAN PUSTAKA

I. Definisi Cairan Tubuh

Cairan tubuh adalah cairan suspensi sel di dalam tubuh makhluk multiseluler seperti manusia atau hewan yang memiliki fungsi fisiologis tertentu. 

MALIGNANT SKIN TUMOR / SKIN CANCER AT AGLANCE ( etiology,sign, symptoms,diagnosis and management of Basal Cell Carcinoma, Squamous Cell Carcinoma,and Malignant Melanoma )

 Malignant SKIN TUMOR AT AGLANCE

  ( Basal Cell Carcinoma, Squamous Cell Carcinoma, Malignant Melanoma )

Definition
Malignant skin tumor is a disease characterized by the growth of skin cells that are not controlled, can damage surrounding tissue and can spread to other parts of the body. Because the skin consists of several types of cells, the skin cancer also vary according to cell type affected.

Epidemiology

Adult skin cancer tend to have increased in number especially in the Americas, Australia and Britain. Based on several studies, those white people are more likely to suffer this type of skin cancer. It is predicted as a result of their frequent exposure (lots of exposure) sunlight. In Indonesia people with skin cancer is fairly small compared to the third-countries, however, skin cancer needs to be understood because in addition to causing defects (damage the appearance) is also at an advanced stage can be fatal to the patient (1).

Malignant skin tumor types that are found throughout the world are basal cell carcinoma (basalioma), squamous cell carcinoma, a relatively non melanoma and malignant melanoma. Basal cell carcinoma is the most common. In America, about 800,000 people suffering this cancer every year. 75% of skin cancer are basal cell kanser. Squamous cell carcinomas are found to be what the 200,000 Americans each year. Melanoma is the most rare but cause the most deaths. According to WHO, as many as 160,000 people  suffering melanoma each year and as many as 48 000 deaths are reported each year (3).

Skin Embryology (4)

The skin has a double origin:

(A) the superficial layer (epidermis), formed from the surface ectoderm.

(B) inner layer (dermis), derived from the underlying mesenchyme.

A. Epidermis

At first, the embryo diilapisi by a single layer of ectoderm cells (Fig. 20.1A). At the beginning of the second month, the epithelium is split and formed a flat layer of cells, or epitrikium periderm, on its surface (Figure 20.1B). In the subsequent cell proliferation in the basal layer, forming a third zone (intermediate zone) (Figure 20.1C). Finally, at the end of the fourth month, the epidermis obtain definitive arrangement, and can be recognized four layers (Fig. 20.1D)

DIAGNOSIS and MANAGEMENT OF VARICOSE LEG

DISCUSSION

Peripheral vascular disease is a term referring to the partial or complete blockage of major blood vessels outside the heart that supplies blood to other vital areas of the body, such as brain, kidneys, arms and legs. There are two types: Peripheral arterial disease and peripheral venous disorders.

In this opportunity we will discuss about the problems / peripheral venous disease. Peripheral venous disorders, refers to problems in the peripheral veins such as:

1. Thrombophlebitis - a disease that prevents blood clots (which is a thrombus) if formed, it will cause nearby 

     blood vessels to become inflamed (phlebitis).

2. Buerger's disease - (thromboangitis obliterans) is a peripheral vascular occlusive disease is probably due to 

   an autoimmune disorder of blood vessels, which results ultimately led panangitis stenosis and occlusion of 

   blood vessels.

3. Varicose - abnormally dilated vein picture, swollen, darker colored and winding .. Usually occurs in the 

    legs, and can cause swelling (edema), pain and dark color around the ankles.

4. Chronic venous insufficiency - An advanced stages of venous leg disease in which blood vessels causing 

     the blood to the incompetent hands and feet. Blood does not return to the heart properly, resulting in 

     swelling and ulcers on the feet.

Anatomy of veins

Vena

Veins are veins that drain blood from the systemic return to the heart (atrium dextra), except v.pulmonalis derived from the lung into the left atrium. All systemic veins will lead to the vena cava superior and inferior vena cava.

Venous bleeding head

Veins in the head as v.emisaria and v.fasialis v.jugularis will lead to some internal, some external to the v.jugularis. Eventually will lead to external v.jugularis v.subclavia, where v.subclavia will anastomose with the internal v.jugularis v.brachiocephalica form. There are two v.brachiocephalica, respectively dextra and left. Both will be fused as v.cava superior.

Upper extremity venous bleeding

Veins in the hand, like v.intercapitular, v.digiti palmar and dorsal v.metacarpal will lead to v.cephalica and v.basilica in the forearm. From distal to proximal, the veins will undergo branching and reuniting to form v.mediana cephalica, v.mediana basilica, v.mediana cubiti, v.mediana deep and v. before reaching the region of the median antebrachii cubiti. After cubiti region, the veins are re-forming and v.basilica v.cephalica. V.basilica will unite with v.brachialis (which is meeting v.radialis and v.ulnaris) form v.cephalica v.aksilaris which will also be one with it (v.aksilaris). V.aksilaris will continue to walk to the heart as v.jugularis v.subclavia then anastomoses with the internal and external (from the head) to form the next v.brachiocephalica to get into the atrium dextra as superior vena cava.

Figure 1: Bleeding of the upper limb veins

Lower extremity venous bleeding

The dorsal venous arch on the dorsum pedis will ride through v.saphena magna in the anterior medial lower leg. V.saphena magna will be geared at v.femoralis. While v.saphena parva derived from the posterior lower leg will lead to v.poplitea and ends at v.femoralis. Anterior and posterior V.tibialis v.tibialis v.poplitea also boils down to.

Of v.femoralis, will continue to v.iliaca v.iliaca communis externa and then head further v.cava inferior. In addition there is also v.glutea superior, inferior and v.pudenda v.glutea internal gluteus area, which empties into the internal v.iliaca

                                                Figure 2: lower extremity venous bleeding

Management of Patients with Haematuria Complaints

Management of Patients with Haematuria Complaints

Hematuri is a medical term that describes the discovery of blood in the urine. Hematuria is an important phenomenon in the field of urology that reflect a variety of renal diseases and channel. Hematuri always causes sufferers seek medical help. A person who suffers hematuri should be examined more to see to it that causes localized bleeding and that can be known and determined the severity and persistence. When we review the possible causes of each patient with hematuri hematuri should we consider a serious condition.
Hematuri clinically divided into two groups, namely hematuri macroscopic (= makrohematuri) and hematuri microscopic (= mikrohematuri). Hematuri macroscopic urine is mixed with blood and can be seen with the naked eye. Makrohematuri already can occur if there is 1 cc of blood in 1 liter of urine. The color of urine from gross hematuria originating from the glomerulus brown, tea or coca-cola, while gross hematuria originating from the lower urinary tract (bladder or urethra) colored younger.
Mikrohematuri hematuri which is in plain view can not be seen as the red-colored urine, but on microscopic examination found more than 2 red blood cells per field of view. If the enlargement of 500 times in urine sediment was found more than ten erythrocyt it will give a positive benzidine test. Presence of hematuria should be confirmed by urine sediment examination in the microscope, because many causes other than blood clots that can cause red or brown urine and give a false positive dipstick test.
Isolated microhematuria, with no history or abnormalities on routine urine examination. Urinalysis should be repeated 2 or 3 times in recent months (without preceded by physical exercise) before the start of the next inspection. When microscopic hematuria menetao, a thorough anamnesis should dibut about drug use, family history of hematuria, deafness, kidney failure, urinary tract stones, a history of sickle cell disease or trait.
Macroscopic hematuria that continues over time can be life threatening because it may cause diseases such as: the formation of blood clots that can block the flow of urine, resulting in hypovolemic shock eksanguinasi / anemia and cause urosepsis.

Estimates of Origin hematuri

The blood may come from different parts of kidneys, the glomeruli, tubules and interstisium or from the urinary tract, bladder and urethra. Red blood cells regardless of the glomerular capillaries through gaps in the capillary walls which can not be seen even with an electron microscope examination. Proteinuria, erythrocytes and erythrocyte piston which experienced deformity usually accompanies hematuria in urine from glomerular damage. Renal papillae can be damaged by microthrombi and / or anoxia in patients with hemoglobinopathy or toxin. Patients with renal parenchymal abnormalities may indicate the presence of microscopic or macroscopic hematuria during a systemic infection, or after moderate physical activity. It was as a result of renal hemodynamic response to physical activity or fever. It is important to distinguish between the cause of glomerular hematuria and non-glomerular in order to limit the possibility of diagnosis and direct a more focused examination.

DIAGNOSA DAN PENANGANAN TORSIO TESTIS / TESTICULAR TORSION

TORSIO TESTIS / TESTICAL TORSION

 DAFTAR ISI

Bab I

Pendahuluan……………………………………………………………………….1

Bab II

            Pembahasan

                        Definisi……………………………………………………………………..…….3

                        Etiologi……………………………………………………………………..…….4

                        Gambaran Klinis………………………………………………………...6

                        Pemeriksaan Fisik………………………………………………………..7

                        Pemeriksaan Penunjang…………………………………………………8

                        Diagnosis………………………………………………………………………..11

                        Diagnosis Banding………………………………………………………13

                        Penatalaksanaan…………………………………………………………………16

                        Komplikasi………………………………………………………………………20

Daftar Pustaka…………………………………………………………………………...21

                                                     BAB I

PENDAHULUAN

Kelainan testis yang cukup sering salah satunya adalah torsio testis ini. Sehingga perlu adanya pembahasan yang lebih terperinci.

Secara anatomi ,Testis adalah organ genitalia pria yang teletak di skrotum. Ukuran tetstis pada orang dewasa adalah 4 x 3 x 2.5 cm. dengan volume 15-25 ml berbentuk ovoid. Kedua buah testis terbungkus oleh jaringan tunika albuginea yang melekat pada testis. Di luar tunika albugine terdapat tunika vaginalis yang terdiri atas lapisan viseralis dan parietalis, serta tunika dartos. Otot kremaster yang berada disekitar testis memungkinkan testis untuk dapat digerakkan mendekati rongga abdomen untuk mempertahankan temperature testis agar tetap stabil.

Secara histopatologis, testis terdiri atas ± 250 lobuli dan tiap lobulus terdiri atas tubuli seminiferi. Di dalam tubulus seminiferus terdapat sel-sel spermatogonia dan sel Sertoli, sedang di antara tubuli seminiferi terdapat sel-sel Leydig. Sel-sel spermatogonium pada proses spermatogenesis menjadi sel-sel spermatozoa. Sel-sel Sertoli berfungsi memberi makan pada bakal sperma, sedangkan sel-sel Leydig atau disebut sel-sel interstisial testis berfungsi dalam menghasilkan hormone testosterone.

Sel-sel spermatozoa yang diproduksi di tubuli seminiferi testis disimpan dan mengalami pematangan/maturasi di epididimis. Setelah matur (dewasa) sel-sel spermatozoa bersama-sama dengan getah dari epididimis dan vas deferens disalurkan menuju ke ampula vas deferens. Sel-sel itu setelah bercampur dengan cairan-cairan dari epididimis, vas deferens dan vesikula seminalis, serta cairan prostate, membentuk cairan semen atau mani.

Testis mendapat darah dari beberapa cabang arteri, yaitu arteri spermatika interna yang merupakan cabang dari aorta, arteri deferensialis cabang dari arteri vesikalis inferior, dan arteri kremasterika yang merupakan cabang arteri epigastrika. Pembuluh vena yang meninggalkan testis berkumpul meninggalkan testis berkumpul membentuk pleksus Pampiniformis. Pleksus ini pada beberapa orang mengalami dilatasi dan dikenal sebagai varikokel. ⁽²⁾

 

DIAGNOSIS AND MANAGEMENT AMELOBLASTOMA / ADAMANTINOMA

Ameloblastoma

A. Definition

Ameloblastoma is a tumor derived from cells - embryonic cells and are formed of cells - the cells berpontesial for the formation of enamel. These tumors are usually slow-growing, histologically benign but clinically malignant neoplasm is, occurs more frequently in the body or ramus of the mandible than the maxilla and can be encapsulated or not encapsulated. (1,3,4,5)


Definition of  Ameloblastoma ( amel, meaning enamel and   blastos, meaning germ) is a rare, benign tumor of odontogenic epithelium (ameloblasts, or outside portion) much more commonly appearing in the lower jaw than the upper jaw. It was recognized in by Cusack. This type of odontogenic neoplasm was designated as an adamantinoma  .
These  tumors are rarely malignant or metastatic (that is, they rarely spread to other parts of the body), and progress slowly, the resulting lesions can cause severe abnormalities of the face and jaw. Additionally, because abnormal cell growth easily infiltrates and destroys surrounding bony tissues, wide surgical excision is required to treat this disorder.

NEURO SURGRY SERIES : ETIOLOGY,SIGN , SYMPTON ,DIAGNOSIS AND MANAGEMENT CEREBRAL ABSCESS

INTRODUCTION
         

The incidence of cerebral abscess case /100.000 population is estimated at 1 per year. This incidence decreased after 1950 in line with the increasingly widespread use of antibiotics. Comparison of prevalence between men and women are 3:1.

75-90% is a solitary abscess, of which 35-45% are located in the frontal lobe, temporal lobe at 30-40%, 15-20% in the parietal lobe, and 15% in the occipital, cerebellum and brain stem.

DEFINITION

Brain abscess is an infection process by which localized pus between brain tissue caused by a wide variety of bacteria, fungus and protozoa. Brain abscess were present in all ages. Most at the age of the second decade of life, between 20-50 years.Comparison between male patients with female is 3:1.

Etiology and predisposing

DIAGNOSIS AND MANAGEMENT CHOLELITHIASIS / GALLSTONES

CHAPTER I

INTRODUCTION

Gallstone disease is often found in developed countries and rarely found in developing countries. With the improvement of socio-economic circumstances, changes in western-style food menu as well as improved means of diagnosis, especially ultrasound, the prevalence of gallstone disease in developing countries tend to increase. Gallstone disease is an important health problem in western countries, while in Indonesia a new clinical attention.

Approximately 5.5 million people with gallstones in the UK and 50,000 cholecystectomy performed each year. Cases of gallstones are often found in America, namely in 10 to 20% of the adult population. Every year several hundred thousand patients are undergoing surgery. Two-thirds of gallstones are asymptomatic when the patient does not have any complaints and that evolved into an annual colicky pain is only 1-4%. While the symptoms of patients with symptomatic gallstones develop complications 12% and 50% had colicky pain in the next episode. Risk for people with gallstones have symptoms and complications are relatively small. However, once gallstone colic pain attacks pose a problem specific to the risk of experiencing problems and complications will continue to increase.

Gallstones are commonly found in the gall bladder, but the stones can migrate through the cystic duct into the bile duct into the bile duct stones and called the secondary bile duct stones.

In Western countries 10-15% of patients with gallbladder stones are also accompanied by bile duct stones. In some circumstances, bile duct stones can form in the bile ducts of primary intra-or extra-hepatic without involving the gallbladder. Primary bile duct stones are more common in patients in Asia compared with patients in Western countries.

Journey secondary bile duct stones are not clear, but the complications will be more frequent and severe than asymptomatic gallbladder stones.

In about 80% of cases, is the largest component of cholesterol gallstones. Usually the stone - stone also contains calcium carbonate, phosphate or bilirubinat, but these stones are rarely pure than one component.

CHAPTER II

REVIEW REFERENCES

2.1 Definition of Cholelithiasis

Cholelithiasis also known is synonymous with gallstones, gallstones, biliary calculus. Kolelitiasis term meant to the formation of stones in the gallbladder. Gallbladder stones is a combination of several elements that make up a stone-like material that form in the gallbladder (kolesistolitiasis) or in the bile ducts (koledokolitiasis) or on both.

                             Gambar1. Gambaran batu dalam kandung empedu (Emedicine, 2007)

KELAINAN KONGENITAL PADA SUSUNAN SARAF PUSAT DAN VERTEBRAE (CENTRAL NERVOUS SYSTEM AND VERTEBRAE CONGENITAL DISORDERS)

                                                                            BAB I

                                                PERKEMBANGAN DAN ANOMALI SSP

Patogenesis malformasi SSP belum sepenuhnya  diketahui. Perlu untuk mengerti tahap perkembangan SSP saat  dimana anomali mungkin berkembang. Karena  tahap perkembangan SSP memakan waktu  panjang, sejak tahap awal pembentukan tabung neural hingga perinatal, kelainan organogenesis akan menyebabkan malformasi serebral yang sangat berragam. Kebanyakan  anomali  morfologis terjadi selama 8 minggu tahap  embrionik.  Secara umum semakin dini kelainan terjadi,  makin berat malformasinya.

Perkembangan normal diklasifikasikan kedalam empat tingkat, dan malformasi mungkin terjadi pada setiap tahap.

Proses Induktif Primer (Tahap Pertama)

Perubahan  berikut  terjadi pada minggu  gestasi  kedua hingga keenam:

a. Minggu kedua

Mesoderm menginduksi ektoderm sekitarnya membentuk pelat neural.

b. Minggu ketiga 

Mesoderm menginduksi pelat neural untuk membentuk forebrain, dan entoderm  foregut  membentuk muka. Tepi lateral pelat neural membentuk lipatan  neural yang bersatu kearah  dorsal  membentuk tabung neural. Kegagalan lipatan neural bersatu kearah dorsal berakibat disrafia dan menyebabkan  anensefali, ensefalomeningosel dan meningosel, malforma si  Arnold-Chiari dengan rakhiskhisis spinal,  serta keadaan lain.

c. Minggu keempat 

Gelembung prosensefalik,  metensefalik,  dan rombensefalik berkembang dari tabung  neural.

d. Minggu kelima 

Telensefalon dan diensefalon  berkembang dari garis fusi dorsal dari prosensefalon. Telensefalon meluas kelateral membentuk hemisfer serebral. Kegagalan mesoderm berinteraksi dengan entoderm dan ektoderm mencegah  ekspansi bilateral telensefa  lon serta formasi normal diensefalon. Konsekuensinya terbentuk holoprosensefali dan anomali fasial seperti siklopia, ethmosefali, sebosefali, bibir bercelah dan langit-langit bercelah.

e. Minggu keenam 

Pelat komisural dibentuk sebelah  medial  dari telensefalon sebagai bentuk primitif dari korpus kalosum. Gangguan pembentukan pelat komisural berakibat agenesis korpus kalosum.

Type of Hypospadia and Urethroplasty

HYPOSPADIA

I. INTRODUCTION

I.1. Embryology

At the age of 2 weeks a new embryo contained two layers of the ectoderm and entoderm. Only then formed indentation in the middle - the middle of the mesoderm which then migrate to the periphery, separating the ectoderm and entoderm. In the caudal ectoderm and entoderm remain united to form cloacal membrane. At the beginning of week 6, the protrusions are formed between the umbilical cord and the tail is called the genital tubercle. Formed underneath the indentation where the center line of the lateral section there are two elongated folds called the genital fold. During week 7, the genital tubercle will elongate and form the glans. It is the primordial form of the penis when the embryo is male. When the woman would be the clitoris.

If there is agenesis of the mesoderm, the genital tubercle was formed, so that the penis is also not formed. Bagisan anterior of the cloacal membrane, the membrane will rupture and form urogenitalia sinus. Meanwhile, a pair of folds called the genital fold will form the sides of the sinus urogenitalia. When the genital fold failed to unite over the sinus will arise urogenitalia hypospadias. During this period, formed genital swelling in the lateral left and right. Hypospadias is the hardest type of penoskrotal skrotal and perineal, occurs due to failure to fold and genital sweling to unite in the middle.

Figure 1. anatomy of the penis

I.2. anatomy of the penis
Normal anatomy of the penis consists of a pair of the corpora cavernous tunica covered by a thick and fibrous albugenia with a septum in the middle. Urethra through the penis in the corpus spongiosum which lies in a ventral position in the groove between the corpora cavernous. Urethra appears at the distal end of the conical shaped glans penis. Spermatic fascia or tunica dartos, is a loose layer of the penis, located on the fascia. Under the tunica dartos Bucks are facia that surrounds the corpora cavernous and then split to cover the corpus spongiosum separately. Dorsal neurovascular beam lies in the Bucks fascia between the two corpora cavernous.

BASIC KNOWLEDGE OF WOUND HEALING

A. INTRODUCTION

Definition of  wound is a disorder that causes tearing of the tissue integrity of the vascular and extra-cellular matrix of the direct exposure of the platelet. Or can also be defined as the loss or destruction of some body tissues. This situation can be caused by sharp or blunt trauma, temperature changes, chemicals, explosions, electric shock, or animal bites. When injuries occur, some effects will appear:

A. The loss of all or part of organ function

2. Sympathetic stress response

3. Bleeding and blood clots

4. Bacterial contamination

5. Cell death

The process then occurs in the damaged tissue is healing the wound that can be divided into three phases, namely the inflammatory phase, proliferation, and remodeling of the tissue re perupaan.

2. TYPE OF WOUND

Kind of wound is often described by how to get the wound and show the degree of injury.

2.1. Based on the level of contamination

a) Clean Wounds (clean wound), the surgical wound takterinfeksi which is not a process of inflammation (inflammatory) and infections of the respiratory system, gastrointestinal, genital and urinary does not occur. Clean the wound usually results in a closed wound, if necessary put a closed drainage. The likelihood of wound infection around 1% - 5%.

b) Clean-contamined Wounds (clean-contaminated wound), a surgical wound in which the respiratory tract, gastrointestinal, genital, or urinal in controlled conditions, the contamination is not always the case, the likelihood of wound infection is 3% - 11%.

c) Contamined Wounds (Wound contamination), including open wounds, fresh, accidental wounds and surgery with major damage or contamination by aseptic technique from the gastrointestinal tract; in this category also includes the incision of acute, inflammatory nonpurulen. The possibility of wound infection 10% - 17%.

d) Dirty or Infected Wounds (gross injury or infection), the presence of microorganisms in the wound.

2.2. Based on the depth and breadth of the wound

a) Stage I: Superficial wounds ("Non-blanching Erithema): the injury that occurs in the epidermal layer of skin.

b) Stage II: Wounds "Partial Thickness": a loss of skin layers on layers of the epidermis and upper dermis. A superficial wound and the presence of clinical signs such as abrasion, blister or shallow holes.

c) Stage III: Wounds "Full Thickness": a loss of the entire skin covering damage or necrosis of subcutaneous tissue that may extend to bottom but not through the underlying network. Wound up in the epidermis, dermis and fascia but not the muscle. Injuries occur clinically as a deep hole with or without damaging the surrounding tissue.

d) Stage IV: Luka "Full Thickness" which has reached a layer of muscle, tendon and bone in the presence of destruction / damage is extensive.

Figure 1. The depth of the injury rate

2.3. Based on the time of wound healing
a. Acute wounds: the wound healing period in accordance with the concept of healing that has been agreed.

Figure 2. Acute wounds

b. Chronic wounds are wounds that have failed in the healing process, may be due to exogenous and endogenous factors.

Figure 3. Chronic wounds

SENGATAN DINGIN / FROZ BITE DAN PENANGANANNYA

FROZ  BITE

Sengatan dingin

Kejadian sengatan dingin sering terjadi di daerah-daerah  subtropis. Sengatan dingin akan menyebabkan pembekuan jaringan.  kristal  terbentuk es antara sel  dan tumbuh dengan mengorbankan air intraseluler.  Dehidrasi seluler yang dihasilkan digabungkan dengan iskemia karena vasokonstriksi dan viskositas darah meningkat  merupakan  mekanisme cedera jaringan.  Kulit dan otot jauh lebih rentan terhadap kerusakan pembekuan dari urat dan tulang, yang menjelaskan mengapa pasien masih dapat bergerak.

 paparan dingin, yang efeknya dapat diperbesar oleh uap air atau angin. Misalnya, efek dingin pada kulit adalah sama dengan suhu udara sebesar 6,7°C) dan angin 40 mil per jam sebagai dengan suhu udara dari -40°C dan hanya 2 mil per jam angin. Kontak dengan logam atau bensin di cuaca sangat dingin dapat menyebabkan hampir beku sesaat. Risiko sengatan dingin meningkat oleh hipotermia umum, yang menghasilkan vasokonstriksi perifer sebagai bagian dari mekanisme untuk mempertahankan suhu inti tubuh.

Dua cedera terkait, kejang kaki dan kaki perendaman, melibatkan kontak yang terlalu lama untuk dingin dan basah di atas titik beku (misalnya, 10°C). Kerusakan jaringan yang dihasilkan diproduksi oleh iskemia.

LUKA BAKAR TERKENA LISTRIK

CEDERA LISTRIK

Cidera listrik sering didapatkan pada praktek sehari hari dan pasen akan datang ke emergency. jenis cedera listrik: terdiri dari tiga macam yaitu  cedera arus listrik, luka bakar electrothermal dari pencetusan saat ini, dan luka bakar yang disebabkan oleh penyalaan api pakaian. Kadang-kadang, ketiga akan hadir dalam korban yang sama. 

Flash atau luka bakar listrik adalah cedera  panas untuk kulit yang disebabkan oleh tegangan tinggi arus listrik mencapai kulit dari konduktor. Luka panas untuk kulit yang intens dan mendalam, karena arus listrik memiliki suhu sekitar 2500°C (cukup tinggi untuk melelehkan tulang). Api membakar pakaian dari sering memicu bagian paling serius dari cedera. Perawatan lukanya  sama seperti untuk setiap cedera termal.

Akibat Kerusakan dari arus listrik secara langsung proporsional terhadap intensitas sebagai diatur oleh hukum Ohm. Dengan demikian, arus listrik tergantung pada tegangan dan perlawanan yang diberikan oleh berbagai bagian tubuh. Tegangan di atas 40 V dianggap berbahaya. 

Setelah saat ini telah memasuki tubuh, jalur bergantung pada resistensi itu pertemuan dalam berbagai organ. Berikut ini adalah tercantum dalam urutan resistensi: tulang, lemak, urat, kulit, otot, darah, dan saraf. Jalur dari menentukan saat ini bertahan hidup, misalnya, jika sedang melewati jantung atau batang otak, kematian dapat langsung dari fibrilasi ventrikel atau apnea. Lancar lewat melalui dapat menyebabkan kejang otot cukup parah untuk menghasilkan patah tulang-tulang panjang atau dislokasi. 

Jenis saat ini juga terkait dengan tingkat keparahan cedera. siklus arus bolak balik yang menyebabkan cedera paling  parah. 

DIAGNOSTICS APPROACH TO ACUTE ABDOMEN

INTRODUCTION

To understand the meaning of the term "acute abdomen" indicating that an abnormality nontraumatik spontaneous and suddenly the main manifestations in the abdominal region with the main symptom is usually pain. may require operative measures when more than 6 hours duration .. Because usually the cause of intra-abdominal abnormalities are progressive, it is not good late in the diagnosis and treatment because of worsening outcomes.
Step approach to patients with acute abdominal condition must be carefully and thoroughly. Allegation of suspected acute abdomen should remain even if patients only have mild symptoms and atypical. History and physical examination performed to find probable cause and directs the option to set the primary diagnosis. A clinician then decides if the observation at the hospital to ensure that if additional inspection is required, if the initial surgery is indicated, or if the treatment is more operatif.
Obligation of the clinician must carefully identify the onset of symptoms of the most common cause of general acute abdomen. What's more, they must recognize the specific symptoms of the disease in endemic areas and where they practice.
Common cause of acute abdomen
A. Gastrointestinal tract
- Abdominal pain nonspecific
- Appendicitis
- Obstruction of the small intestine and colon
- Perforation of the peptic ulcer
- Hernia inkarserata
- Perforation of the intestine
- Diverticulitis

2. Liver, spleen and gall
- Acute kolesistisis
- Acute kholangitis
- Liver Abscess
- Acute Hepatitis
- Infrak spleen
3. Pancreas
- Acute pancreatitis
4. Urinary tract
- Renal colic
- Acute pyelonephritis
5. Gynecology
- Acute salpingitis
- A ruptured ectopic pregnancy
6. Vascular
- Acute ischemic colitis
- Mesenteric thrombosis
7. Peritoneum
- Intra-abdominal abscess
- Peritonitis tuberculosis
8. Retroperitoneum
- Bleeding retroperitoneum

we must know about :

PENDEKATAN DIAGNOSTIK TERHADAP AKUT ABDOMEN UNTUK DOKTER JAGA EMERGENSI / UGD (UNIT GAWAT DARURAT) DIAGNOSTIC APPROACH TO ACUTE ABDOMINAL FOR PHYSICIAN IN EMERGENCY DEPARTMENT

PENDEKATAN DIAGNOSTIC Acute Abdomen

PENDAHULUAN 

Untuk memahami Arti dari Istilah “acute abdomen” itu suatu yang menandakan kelainan nontraumatik spontan dan tiba-tiba yang manifestasi utamanya di regio abdomen dengan gejala utamanya biasanya  nyeri. mungkin memerlukan tindakan operative bila lebih dari 6 jam berlangsungnya.. Karena biasanya penyebab kelainan intra abdomen bersifat progresif, maka tidak baik terlambat dalam diagnosis dan penatalaksanaan karena memperburuk hasil terapi.

Langkah pendekatan kepada pasien dengan keadaan acute abdomen harus teliti dan seksama.  Sangkaan adanya Acute abdomen harus tetap dicurigai bahkan jika pasien hanya mempunyai gejala ringan dan atypical. Anamnesis dan pemeriksaan fisik dilakukan untuk menemukan kemungkinan penyebab dan mengarahkan pilihan  untuk menetapkan diagnosis utama. Seorang  Klinisi lalu memutuskan jika observasi di rumah sakit menjamin, kalau pemeriksaan tambahan dibutuhkan, jika operasi awal diindikasikan, atau jika perawatan nonoperatif lebih diperlukam.

Kewajiban  klinisi harus  seksama mengenali timbulnya gejala umum dari penyebab tersering dari acute abdomen. Terlebih lagi, mereka harus mengenali gejala penyakit yang spesifik pada wilayah endemik dan tempat mereka praktek.

THERAPI FROZ BITE / COLD SHOCK

FROZ BITE

Froz bite events often occur in subtropical areas. Froz bite will cause tissue freezing. ice crystals are formed between the cells and grow at the expense of intracellular water. The resulting cellular dehydration combined with ischemia due to vasoconstriction and increased blood viscosity is a mechanism of tissue injury. Skin and muscle is much more susceptible to freezing damage of tendons and bones, which explains why the patient can still move.
 cold exposure, the effect can be magnified by moisture or wind. For example, the effect of cold on the skin is the same as the air temperature by 6.7 ° C) and winds of 40 miles per hour as the air temperature of -40 ° C and only 2 miles per hour winds. Contact with metals or petrol in very cold weather can cause almost frozen for a moment. Increased risk of froz bite by general hypothermia, which results in peripheral vasoconstriction as part of a mechanism to maintain core body temperature.
Two related injuries, trench foot and immersion foot, involving prolonged exposure to cold and wet in above freezing (eg, 10 ° C). The resulting tissue damage produced by ischemia.

APPROACH TO DIAGNOSIS AND MANAGEMENT OF JAUNDICE AND HEPATO BILIER DISORDERS

APPROACH TO DIAGNOSIS AND MANAGEMENT OF JAUNDICE

AND HEPATO  BILIER DISORDERS

CHAPTER I

INTRODUCTION

Jaundice is a change of skin color, eye sclera or other tissues (mucous membranes), which became yellow due to staining by an increased concentration of bilirubin in the blood circulation. Bilirubin (Bile) is formed as a result of solving hem ring, usually as a result of red blood cell metabolism.

The word jaundice (jaundice) derived from the French word meaning yellow Jaune. Jaundice should be examined under a bright light during the day, by looking at the eye sclera. Jaundice can be divided into two groups: Hemo ¬ lytic jaundice and obstructive jaundice.

Obstructive jaundice, caused by bile duct obstruction (¬ ter so often when a gallstone or cancer of the duct cover koledokus) or liver cell damage (which was finished in hepatitis ¬), speed of formation of bile is normal, but the bilirubin formed does not get through from the blood into the intestine.

Obstructive jaundice, also called cholestasis were divided into 2 of intrahepatic cholestasis and extrahepatic. The most common cause is intrahepatic cholestatic hepatitis, drug toxicity, alcoholic liver disease due to hepatitis and autoimmune diseases, while the most frequent cause of extrahepatic cholestasis is koledokus duct stones and pancreatic cancer. Other causes are relatively rare benign stricture (previous surgery) on koledokus duct, ductal carcinoma koledokus, pancreatitis or pancreatic pseudocyst and sklerosing cholangitis.

                Extra-hepatic biliary obstruction usually require surgery, extraction of gallstones diduktus, or stent insertion, via catheter for drainage and stricture (often malignant) or narrowing of the majority. For non-malignant obstruction operabel, palliative biliary drainage can be done through the stent is placed through the liver (transhepatic) or endoscopic.

Generally, non-obstructive jaundice does not require surgical intervention, whereas obstructive jaundice usually requires surgical intervention or other interventional procedures for treatment.

CHAPTER II

JAUNDICE

DEFINITION II.1 JAUNDICE
Jaundice (derived from French 'Jaune' meaning yellow) or jaundice (Latin for jaundice) is a yellow coloring of the skin, sclera, and mucous membranes by the deposit of bilirubin (bile pigment yellow-orange) on the network. Jaundice is a condition in which tissue yellowish due to deposition of bilirubin occurs when blood levels of bilirubin reaches 2 mg / dL or 35-40 mmol / L.

II.2 SYSTEM ANATOMY HEPATOBILIER
An accurate knowledge of the anatomy of the liver and biliary tract, and its relationship to blood vessels critical to the performance of surgery hepatobilier because there is usually a wide anatomic variations. Classical anatomical description of the biliary tract occurs only in 58% of the population.

Liver, gallbladder, and biliary branches arise from the ventral bud (hepatic diverticulum) from the most caudal foregut early in the fourth week of life. This section is divided into two sections as part of the ventral mesenterik grow between layers: a larger cranial part (pars hepatic) is the origin of the heart / liver, and a smaller caudal part (pars sistika) extended form of the gallbladder, the stem into the cystic duct. Initial relationship between the hepatic diverticulum, and narrowing of the foregut, will form the common bile duct. As a result of changes in the position of the duodenum, bile duct entrance is located around the dorsal aspect of the duodenum.
Biliary system is broadly divided into two components, pathways of hepatic intra-and extra-hepatic. Unit secretion of the liver (hepatocytes and biliary epithelial cells, including gland peribilier), kanalikuli bile, bile duktulus (Hearing canal), and intrahepatic bile duct intrahepatic form a channel in which the extrahepatic bile ducts (right and left), the communist hepatikus duct, cystic duct, bladder bile, and the common bile duct is a component of extrahepatic biliary branching.
Ekstrahepatal bile duct consists of left and right hepatikus duct, common hepatic duct, cystic duct and common bile duct or hepatic duct koledokus.Duktus right and left out of the heart and joined the Communist hepatic hilum to form ducts, usually the anterior bifurcation of the portal vein and the Cosmos proximal hepatic artery close to the right. Duct extrahepatic part of the left tend to be longer. Duct hepatikus communists built left border of Calot triangle and continues with duct koledokus. Division occurs at the level of the cystic duct. Koledokus duct about 8 cm in length and lies between the ligamentum hepatoduodenalis, to the right of the hepatic artery and anterior to the portal vein. Koledokus distal segment of the duct located within the substance of the pancreas. Koledokus duct empties its contents into the duodenum through the ampulla of Vater, surrounded by a muscular orifisiumnya of sphincter of Oddi. Typically, there are common channels of the pancreatic duct and the duct distal koledokus.
The blood supply to the gall bladder is through the arteries sistika; to be divided into anterior and posterior, typically a branch of the right hepatic artery, but the origin of the artery sistika vary. Sistika arteries arise from the Calot triangle (formed by the cystic duct, common hepatic duct and the tip of the liver). Venous drainage of the gallbladder varies, usually into the right branch of portal vein. Lymph flow directly entered into the heart and also to the lymph-nodes along the surface of the portal vein .. Persarafannya derived from the vagus and sympathetic branches of the celiac plexus passes (preganglionic T8-9). Impulses from the liver, gallbladder, and bile ducts melewari through sympathetic afferent nerve and causing pain splanknik colic. Nerves arise from the celiac axis and located along the hepatic artery. Pain sensation is mediated by visceral fibers, sympathetic. Motor stimulus for gallbladder contraction is carried through the branches of the vagus and the celiac ganglion.

DIAGNOSIS AND FIRST AID FOR HEAT STROKE

HEAT STROKE

 When the temperature exceeds 40 ° C, the condition of heat stroke will occur and will central nervous system dysfunction is severe. Two other related conditions that are caused by exposure to heat cramps and heat exhaustion.

In the desert country with frequent outdoor physical activity in these cases. When pilgrims outdoor  activity in place. Circumstances Heat cramps - muscle pains after the heat energy in hot environments, usually are associated with a deficit of salt. examples such as exertional rhabdomyolysis. The last condition, which may also be a complicating factor in heat stroke, involving acute muscle injury due to severe exertional effort beyond the limits that have been ditelorir individuals. This often results in myoglobinuria, which can affect kidney function, especially when heat stroke occurs when patients. There is a term Heat exhaustion - is made up of fatigue, muscle weakness, tachycardia, postural syncope, nausea, vomiting, and urge to defecate caused by dehydration and hypovolemia from heat stress. Although the normal body temperature in heat exhaustion, there is a relationship between the syndrome and heat stroke.

Actually, the Heat stroke, a result of an imbalance between heat production and heat dissipation, heat stroke can kill. heat stroke that most often affects young people with physical activity. in hot environments, usually without adequate training and knowledge. heat stroke is a disease of sedentary elderly or sick heart of the system can not adapt to the stress of hot environments, although not active. heat stroke in the elderly can be predicted when the ambient temperature exceeds 32.2 ° C and relative humidity 50-76%.

 heat elimination from the skin by radiation, conduction, convection, and evaporation. When the temperature rises, heat loss by the first three distracted; loss by evaporation is blocked by high relative humidity. Some factors predisposing to heat accumulation dermatitis; use of phenothiazines, beta-blockers, diuretics, or anticholinergics, intercurrent fever from other diseases: obesity, alcohol, and heavy clothing. Cocaine and amphetamines may increase metabolic heat production.

Mechanism of heat damage to parenchymal organs and blood vessels. Central nervous system is extremely vulnerable, and cellular necrosis was found in the brains of people who died from heat stroke. Hepatocellular and renal tubular damage seen in severe cases. Subendocardial damage and transmural infarcts are sometimes found in fatal cases. disseminated intravascular coagulation are common, aggravating the injury in all organ systems and predisposing bleeding complications.

Clinical symptoms

A. Symptoms and Signs

Heat stroke should be suspected in anyone who develops a sudden coma in a hot environment. If the patient's temperature is above 40 ° C (range: 40-43 ° C), a definitive diagnosis of heat stroke. Measurement of rectal body temperature should be done. A prodrome including dizziness, headache, nausea, chills and goose bumps from the chest and arms appear occasionally but not commonly. In most cases, patients were recalled after a warning symptoms except weakness, fatigue, or dizziness. Confusion, aggressive behavior, or fainting may precede coma. Seizures may occur after admission to hospital.

Pink or pale skin and sometimes, strangely, dry and hot, dry skin in the presence of hyperpyrexia heat stroke is almost pathognomonic. Excessive sweating is usually on the runners and other athletes are exposed to heat stroke. Heart rate ranged from 140/min to 170/min; central venous pressure or pulmonary wedge high, and in some cases of low blood pressure. Hyperventilation can be reached 60/min and may cause respiratory alkalosis. pulmonary edema and bloody sputum may develop in severe cases. Jaundice is often the first few days after onset of symptoms.

Dehydration, which can produce the same system as the central nervous symptoms of heat stroke, an irritating factor in approximately 15% of cases.

B. Laboratory

There is no pattern to the changing characteristics of the electrolytes: sodium serum concentrations may be normal or high, and potassium concentrations are usually low on admission or at some point during resuscitation. General hypocalcemia, and hipofosfatemia may occur. In the first few days, AST, LDH, and CK may increase, especially in exertional heat stroke. Alkalosis may follow hyperventilation; acidosis can be caused by lactic acidosis or acute renal failure. Proteinuria and granular cells and casts seen in urine specimens of red were collected immediately after diagnosis. If urine is dark red or brown, it may contain myoglobin. Blood urea nitrogen and serum creatinine increased transiently in most patients and continued to go up if kidney failure develops. Hematological findings may be normal or may be typical of disseminated intravascular coagulation (ie, low fibrinogen, increased fibrin split products, prothrombin time and partial thromboplastin slow, and decreased platelet count).

Prevention

For the most part, heat stroke in military recruits and athletes in training can be prevented by following a schedule of graduation requirements that enable improved performance of acclimatization for 2-3 weeks. Heat generated by exercise is dissipated by increased cardiac output, vasodilation in the skin, and increased sweating. With acclimatization there is an increased efficiency to the working muscles, improve cardiac muscle performance, expanded extracellular fluid volume, the output is greater than a certain amount of sweat to work, lower salt content of sweat, and a lower central temperature for a certain amount of work.

Access to drinking water should be restricted during vigorous physical activity in hot environments. Free water is better than a solution containing electrolytes. Most of the training regimen should not include the additional use of salt tablets, because the salt is enough (10-15 g / h) will be consumed with food to meet the electrolytes lost in sweat and since hypernatremia can develop if swallowed salt tablets are not taken with enough water. Clothing and protective equipment should be alleviated as the production of heat and air temperatures rise, and strenuous exercise should not be scheduled at the hottest time of the day, especially at the beginning of the training schedule. Long distance running with an open competition, which attracted a beginner runner, should be held in late summer or autumn, when the heat acclimatization is more likely to occur, and must start before 8 am or after 6 pm.

management

The first step after step, namely ABC Patients should be cooled quickly. The most efficient method is to drive the evaporative heat loss by the patient by spraying water at 15 ° C and fanned by the warm air. Soaking in a tub of ice water or use ice packs are also effective but causes vasoconstriction and shivering skin and make patient monitoring more difficult. Monitor the temperature of the rectum often. To avoid overshooting the end point, strong cooling should be discontinued when the temperature reached 38.9 ° C. Shivering should be controlled with parenteral phenothiazines. Oxygen should be given, and if PaO2 falls below 65 mm Hg, tracheal intubation was performed to control ventilation. Fluid, electrolyte, and acid-base balance should be controlled with frequent monitoring. Intravenous fluid administration should be based on central venous pressure or pulmonary artery wedge, blood pressure and urine output; overhydration should be avoided. On average, approximately 1400 mL of fluid required in the first 4 hours of resuscitation. Intravenous mannitol (12.5 g) can be given early if myoglobinuria is present. Kidney failure may require hemodialysis. Disseminated intravascular coagulation may require treatment with heparin. Digitalis and sometimes inotropic agents (eg, isoproterenol, dopamine) may be indicated for cardiac insufficiency, which should be suspected when persistent hypotension after hypovolemia has been corrected.

Prognosis

 poor prognosis when the body temperature of 42.2 ° C or more, coma lasting more than 2 hours, shock, hyperkalemia, and AST more than 1000 units / L during the first 24 hours. The death rate is about 10% in patients who are diagnosed correctly and treated promptly. Death within the first few days is usually due to brain damage; Death comes perhaps from hemorrhage or perhaps because of the heart, kidney, or liver failure.

Diagnosis and Management Haemorrhoid ( Conventional Haemorrhoidectomy or Surgical Stappler or Laser surgery)./ Diagnosis dan Manajemen Ambeien atau wasir atau hemoroid dengan Haemorrhoidectomy Konvensional atau Stappler Bedah atau operasi Laser).

• Diagnosis and Management Haemorrhoid / hemoroid / wasir / ambeien

CHAPTER I

INTRODUCTION

1.1 Background

Hemorrhoidal disease is one of the problems that are increasingly being encountered by physicians, at least 5% of the general population suffer from symptoms associated with hemorrhoids. Increased incidence of hemorrhoids caused by the wrong diet,  eat food less  fiber as well as changing as we get older, it seems that approximately 50% of people aged over 50 years have a higher risk for this disease, the disease is not confined to older individuals and also can occur at any age, including childhood. The prevalence of hemorrhoids seems to be higher in developed countries in the West, and lower in people who have traditionally lived in developing countries, and growing. Low-fiber diet as the main cause of constipation , while constipation caused tensions expenditure of feces.

Hemorrhoids are more commonly known by the common people with hemorrhoids is a widening of the veins in the plexus hemoroidalis is not a pathological condition. Only if the hemorrhoids are causing complaints or complications, necessary action. Bleeding from the rectal venous plexus / hemoroidalis this is one of the causes of bleeding in the anal area. When this disease and its complications can not be overcome by the medical, it should be recommended for a more thorough action. Although the disease is included in the mild disease group, but not infrequently are found due to the disease, patients treated with severe anemia, hemoglobin levels decreased up to 4%.

CHAPTER II

DISCUSSION

2.1 Haemorrhoids

2.1.1 DEFINITION

Hemorrhoids is an abnormal widening of the veins (venous dilation in the plexus hemoroidalis). Bleeding from the rectal venous plexus / hemoroidalis this is one of the causes of anal bleeding area.

Generally considered a synonym of the term hemorrhoids piles, and the term can replace each other. But etymologically the two terms have very different sense of the term. The term hemorrhoids Haimorrhoides derived from the Greek word which means bleeding (haema = blood, rhoos = flow), according to the most prominent symptom in most cases. But this term can not properly be used for all cases, because there is also a never give hemorrhoidal bleeding symptoms. The term comes from the Latin word piles pile, which means the ball, in accordance with the fact that all cases of symptomatic hemorrhoids cause swelling or lump in the presence of various sizes, although sometimes the bumps are not visible from the outside.

2.1.2 PHYSIOLOGICAL ANATOMY AND ANOREKTUM

The anal canal is derived from an invagination proktoderm ectoderm, while the rectum comes from the entoderm. Because of differences in the anus and rectum is the bleeding, neurological, and drainage limfenya different too, as well as the epithelial covering. Rectum is lined by intestinal mucosa glanduler anoderm whereas the anal canal by a continuation of the outer squamous epithelium-lined. No one called the intestinal mucosa. Boundary regions of the rectum and anal canal is marked by changes in the epithelial type. Anal canal and the outer skin surrounding somatic sensory-rich persyarafan and sensitive to pain stimuli, while the rectal mucosa has persyarafan autonomic and insensitive to pain. Anorektum above the venous blood flow through the portal system, whereas that of the anus kesisitem kava flowed through a branch. iliac. This distribution is important in understanding how the spread of malignancy and infection as well as the formation of hemorrhoids. Lymphatic system drain its contents from the rectum through the vessels along the vascular hemoroidalis limf superior to the lymph nodes paraaorta through the internal iliac lymph nodes, whereas limf derived from the anal canal flowing towards the inguinal glands.

Hemorodalis superior artery is a direct continuation. inferior mesenteric. The artery divides into two main branches of the left and right. The right branch forked again. The location of the last three branches may be able to explain where the typical is hemorrhoids in two pieces in each quarter of the right and a left diseperenpat. Artery is a branch of the anterior medial hemoroidalis a. whereas the internal iliac artery is a branch of the inferior hemoroidalis a. The internal pudendal.

Superior vena hemoroidalis from hemoroidalis internus plexus and runs into the cranial direction v. and so on through the inferior mesenteric v. splenic to the portal vein. Venous pressure was not berkatup to determine the pressure inside the abdominal cavity. Venous blood draining into the inferior hemoroidalis v. and v into the internal pudendal. sisitem internal iliac artery and vena cava. V magnification. hemoroidalis hemorrhoids can lead to complaints.

The anus is the hole which is a hole out of the anal canal. Anus oval with antero posterior diameter of the lead length and is located on the midline of the perineum, at a place called the anal triangle, which lies between the perineal body in front and behind the os cocygeus.

Picture : Anatomy anorectum

KORNEL ( PRINCE OF SUMEDANG ) , PEOPLE'S DEFENDER

Today, 300 years ago, exactly  March 12nd,1811, the Dutch East Indies governor general's Daendels Wilem Herman ordered to make the road from Anyer (the western tip of Java island to the eastern end of Java, Panarukan (about 1000 kilometers). As it happens slowdown in a hilly rock (rock) 9 KM before the City Sumedang. road works delayed because the rock is a difficult and steep. Many people have told Sumedang that forced labor (corvee labor) like a serf in place and they were many who died from disease and hunger. Seeing a state that Prince Regent Kusumah  Dinata not have the heart to the people miserable. So on that date the prince, met  Daendels .. Daendels : welcome greeted the prince and princes How are you? said, thrusting his right hand, but the prince did not immediately welcome Sumedang even the prince held out his left hand. Daendels was shocked the first time there is a native who dared to insult and humiliate him ....... but it was too late because the prince Sumedang is expert wisdom, the power of knowledge is above average. The prince instantly control of the subconscious mind so that a Governor-General Daendels directly Sumedang genuflection before the prince, as well as direct sugested / rules Daendels , and said  Daendels Sumedang people are dying because of your ambition, sir, make it a good way but if you were successful please pay attention to their workers. Please give good food and equipment. Daendels not challenge the power of the prince's eye, he can only say: iiiiya prince, yes sir prince . Then the prince went on sugestion: And why do I remember the master Daendels thrusting his left hand to shake hands with you, because your right hand Keris (traditional   -sword) when I hold the master did not want to follow my advice then now it will tear the body  lord. Conversely, if the Daendels would turn to treat workers well then I'll make your way suport . Baa  yes prince ..... only that which can be spoken Daendels.  Daendels so stunned and silent as are the guards and soldiers of the Company. After a while princes go home , Daendels awakened, and said: Where was the prince? Prince was great and brave. If he wants to be my advisor I will give the rank of COLONEL. since that time the prince was called PANGERAN KORNEL Since then ordered Daendels good workers instead of food and equipment plus the number of workers from other regions so that the path in the rock Prince can be penetrated and resolved quickly.

 Since when is the rock and the rock cliff called CADAS PANGERAN. If you pass in the west end of Princes Rock will see the monument there are two people who again shook the left-hand one  (Kornel) the other one  robe shook his right hand (Daendels). Me as the next generation / progeny Prince Kornel still maintain that the science of science :kasumedangan: ...... maybe later I will write in this blog to preserve to future generations. Unfortunately this special event escaped historians. In western Java is not a major war, while making way for the governor-general Daendels . Daendels can be controlled by the wise. many residents in western Java. west java area almost equal to the area netherland. Many people of western Java smart, wise and prudent, but the authors note, from administration to administration began to exclud west Javanese people in our government so often unstable and easily swayed because of the clever, wise and prudent that in fact many in the west Java is not included in an optimal and proportional. On the other hand too many western Java which has become a leader, both local and national level do not remember the little people, they're so selfish, forget the culture of origin and greedy, selfish and his group.If you remember the history of Majapahit was also difficult to control in West Java event Bubat Pitaloka tale princess. History also records  Sultan Agung can attack Batavia together with   western Java people,,,,,,,, if you want to get ahead do not forget the good people of western Java. This suggestion ..... trust me sir