SURGICAL ASPECT OF DIABETIC FOOT (diagnosis , sign, symptoms, and management ) / komplikasi diabetes melitus pada kaki dan penanganannya.

DIABETIC FOOT SURGERY TREATMENT

A. Definition

Diabetes Mellitus (DM) is a hereditary metabolic disease that mostly, demham signs of hyperglycemia and glucosuria, accompanied by clinical symptoms or absence of acute or chronic, as a result of the lack of effective insulin in the body, lies in the primary disorder of carbohydrate metabolism that is usually accompanied too fat and protein metabolism disorders. (Askandar, 2000).

Gangrene is the process or condition that is characterized by the presence of dead or necrotic tissue, but a microbiological process of necrosis is caused by infection. (Askandar, 2001).

B. Classification

A. Diabetes Mellitus

a. Type I diabetes mellitus (IDDM)

Patients are very dependent on insulin due to an autoimmune process that attacks the insulin. IDDM is the type of DM-derived (Inherited).

b. Type II diabetes mellitus (NIDDM)

Type of DM is influenced by both heredity and environmental factors. A person has a substantial risk of suffering from NIDDM if their parents are people with DM and adopt the wrong lifestyle.

c. Gestational DM

DM of this type tend to occur in pregnant women and the family members who are also suffering from DM. Risk factor is overweight or obese.

d. Secondary DM

DM is associated with other conditions or syndromes (pancreatitis, hormonal abnormalities, and drugs).

abdominal colic diagnostic and management

Colicky abdominal

INTRODUCTION

Before discussing the pain of colic, will be presented in advance of abdominal pain in general. Abdominal pain resulting from the three channels, namely (Mahadevan, 2005):

• Abdominal viscera
Usually caused by distension of hollow organs or the tension in the capsule of solid organs. A rare cause of ischemia when the network is experiencing congestion atau inflamasi to sensitasion end visceral nerve pain and lower pain threshold. Pain inisering an early manifestation of a disease or discomfort a sense vague until the colic. If the organ is engage affected by peristaltic movements, the pain is often intermittent described as, cramps or colic.

• In this pain, bilateral pain due to nerve fibers, not myelin and entering spinal cord at varying levels, the viscera and abdominal pain is usually felt dull, hard to be localized and felt the middle body. Pain comes from the region of the abdominal viscera are referring origin of the embryonic organ. Foregut structures such as the stomach, duodenum, liver, biliary tract and pancreas produce upper abdominal pain, often perceived as pain epigastric region. Midgut structures such as the jejunum, ileum, appendix, and ascending colon causing pain periumbilikus. While the structure of the hindgut as the transverse colon, genitourinary system kolon desendens and cause lower abdominal pain.


• Abdominal pain parietal (somatic)
Parietal or somatic abdominal pain resulting from ischemia, inflamasiatau tension of the parietal peritoneum. Afferent nerve fibers that transmit pain stimulus bermielinisasi to the dorsal root ganglion and at the same dermatomal of origin of the pain. For this reason Yeri parietal  this is in contrast with visceral pain, can often be painful stimuluslocalized to the homelands. Is perceived to be a sharp pain, like a knife wound and survive; coughing and movement can trigger pain it. These conditions resulted in signs of physical examination can be searched delicate flavor, guarding, rebound pain and stiffness padaabdomen are palpable. Clinical presentation of appendicitis can of pain visceral and somatic. Pain in early appendicitis pain often in the form of periumbilikus (viscera), but localized in the region of the right quadrant bawahketika inflammation spreads to the peritoneum (parietal).

• Referred pain
Referred pain is pain that is felt at a distance from the diseased organ. This pain is produced from neuronal pathways afferent central terbagiyang from different locations. Examples are patients with pneumonia may experience abdominal pain due to neuron T9 distribution divided by the lungs and abdomen. Another example is the epigastric pain associated with myocardial infarction, pain in the shoulder associated with irritation of the diaphragm (eg, splenic rupture), nyeriinfrascapular pool associated with the disease and testicular pain associated with urethral obstruction.


Colicky abdominal pain

DEFINITION

Colicky abdominal pain is a pain in the form of intermittent severe attacks that can be localized and felt like a sharp feeling. The mechanism of this pain is due to either partial or total obstruction of hollow organs which contain smooth muscle tissue or organ involved is influenced peristalsis.
Classification of colicky abdominal
Classification based on etiology of some of them:

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PERMENKES / PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 2052/MENKES/PER/X/2011 TENTANG IZIN PRAKTIK DAN PELAKSANAAN PRAKTIK KEDOKTERAN ,

TELAH dilakukan revisi terhadap Peraturan Menteri Kesehatan Nomor 512/Menkes/Per/IV/2007; saya downloadkan dari situs resmi DEPKES , mudah mudahan berguna untuk sejawat sekalian.


PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA
NOMOR 2052/MENKES/PER/X/2011
TENTANG
IZIN PRAKTIK DAN PELAKSANAAN PRAKTIK KEDOKTERAN
DENGAN RAHMAT TUHAN YANG MAHA ESA
MENTERI KESEHATAN REPUBLIK INDONESIA,
Menimbang : a. bahwa sebagai pelaksanaan Pasal 38 ayat (3) dan Pasal 43 Undang-Undang Nomor 29 Tahun 2004 tentang Praktik Kedokteran, telah ditetapkan Peraturan Menteri Kesehatan Nomor 512/Menkes/Per/IV/2007 tentang Izin Praktik dan Pelaksanaan Praktik Kedokteran;
b. bahwa untuk memenuhi perkembangan dan kebutuhan hukum, perlu dilakukan revisi terhadap Peraturan Menteri Kesehatan Nomor 512/Menkes/Per/IV/2007;
c. bahwa berdasarkan pertimbangan sebagaimana dimaksud dalam huruf a dan huruf b, perlu menetapkan Peraturan Menteri Kesehatan tentang Izin Praktik dan Pelaksanaan Praktik Kedokteran;
Mengingat : 1. Undang-Undang Nomor 29 Tahun 2004 tentang Praktik Kedokteran (Lembaran Negara Republik Indonesia Tahun 2004 Nomor 116, Tambahan Lembaran Negara Republik Indonesia Nomor 4431);
2. Undang-Undang Nomor 32 Tahun 2004 tentang Pemerintahan Daerah (Lembaran Negara Republik Indonesia Tahun 2004 Nomor 125, Tambahan Lembaran Negara Republik Indonesia Nomor 4437) sebagaimana telah terakhir dengan Undang-Undang Nomor 12 Tahun 2008 (Lembaran Negara Republik Indonesia Tahun 2008 Nomor 59, Tambahan Lembaran Negara Republik Indonesia Nomor 4844);
3. Undang-Undang Nomor 36 Tahun 2009 tentang Kesehatan (Lembaran Negara Republik Indonesia Tahun 2009 Nomor 144, Tambahan Lembaran Negara Republik Indonesia Nomor 5063);
4. Undang–Undang Nomor 44 Tahun 2009 tentang Rumah Sakit (Lembaran Negara Republik Indonesia Tahun 2009 Nomor 153, Tambahan Lembaran Negara Republik Indonesia Nomor 5072);
5. Peraturan Pemerintah Nomor 32 Tahun 1996 tentang Tenaga Kesehatan (Lembaran Negara Republik Indonesia Tahun 1996 Nomor 49, Tambahan Lembaran Negara Republik Indonesia Nomor 3637);
6.  Peraturan Pemerintah Nomor 38 Tahun 2007 tentang Pembagian Urusan Pemerintahan Antara Pemerintah, Pemerintahan Daerah Provinsi Dan Pemerintahan Daerah Kabupaten/Kota (Lembaran Negara Republik Indonesia Tahun 2007 Nomor 82, Tambahan Lembaran Negara Republik Indonesia Nomor 4737);
7.  Peraturan Menteri Kesehatan Nomor 1231/Menkes/ Per/XI/2007 tentang Penugasan Khusus Sumberdaya Manusia Kesehatan;
8. Peraturan Menteri Kesehatan Nomor 299/Menkes/ Per/II/2010 tentang Penyelenggaraan Program Internsip Dan Penempatan Dokter Pasca Internsip;
9. Peraturan Menteri Kesehatan Nomor 317/Menkes/ Per/III/2010 tentang Pendayagunaan Tenaga Kesehatan Warga Negara Asing Di Indonesia;
10. Peraturan Menteri Kesehatan Nomor 1144/Menkes/ Per/VIII/2010 tentang Organisasi dan Tata Kerja Kementerian Kesehatan (Berita Negara Republik Indonesia Tahun 2010 Nomor 585);
MEMUTUSKAN :
Menetapkan:  PERATURAN MENTERI KESEHATAN TENTANG IZIN PRAKTIK DAN PELAKSANAAN PRAKTIK KEDOKTERAN.
BAB I
KETENTUAN UMUM
Pasal 1
Dalam Peraturan Menteri ini yang dimaksud dengan:
1. Praktik kedokteran adalah rangkaian kegiatan yang dilakukan oleh dokter dan dokter gigi terhadap pasien dalam melaksanakan upaya kesehatan.
2. Dokter dan Dokter Gigi adalah lulusan pendidikan kedokteran atau kedokteran gigi baik di dalam maupun di luar negeri yang diakui oleh Pemerintah Republik Indonesia sesuai dengan peraturan perundangundangan.
3. Dokter dengan kewenangan tambahan adalah dokter dan dokter gigi dengan kewenangan klinis tambahan yang diperoleh melalui pendidikan dan pelatihan yang diakui organisasi profesi untuk melakukan praktik kedokteran tertentu secara mandiri.

4. Surat Izin Praktik, selanjutnya disingkat SIP adalah bukti tertulisyang diberikan dinas kesehatan kabupaten/kota kepada dokter dan dokter gigi yang akan menjalankan praktik kedokteran setelah memenuhi persyaratan.
5. Surat Tugas adalah bukti tertulis yang diberikan dinas kesehatan provinsi kepada dokter atau dokter gigi dalam rangka pelaksanaan praktik kedokteran pada fasilitas pelayanan kesehatan tertentu.
6. Surat Tanda Registrasi, selanjutnya disingkat STR adalah bukti tertulis yang diberikan oleh Konsil Kedokteran Indonesia kepada dokter dan dokter gigi yang telah diregistrasi.
7. Fasilitas pelayanan kesehatan adalah tempat penyelenggaraan upaya pelayanan kesehatan yang dapat digunakan untuk praktik kedokteran atau kedokteran gigi.
8. Pelayanan kedokteran adalah pelayanan kesehatan yang diberikan oleh dokter dan dokter gigi sesuai dengan kompetensi dan kewenangannya yang dapat berupa pelayanan promotif, preventif, diagnostik, konsultatif, kuratif, atau rehabilitatif.
9. Standar pelayanan adalah pedoman yang harus diikuti oleh dokter atau dokter gigi dalam menyelenggarakan praktik kedokteran.
10. Standar profesi adalah batasan kemampuan (knowledge, skill and professional attitude) minimal yang harus dikuasai oleh seorang dokter atau dokter gigi untuk dapat melakukan kegiatan profesionalnya pada masyarakat secara mandiri yang dibuat oleh organisasi profesi.
11. Standar prosedur operasional adalah suatu perangkat instruksi/langkah-langkah yang dibakukan untuk menyelesaikan suatu proses kerja rutin tertentu yang memberikan langkah yang benar dan terbaik berdasarkan konsensus bersama untuk melaksanakan berbagai kegiatan dan fungsi pelayanan yang dibuat oleh fasilitas pelayanan kesehatan berdasarkan standar profesi.
12. Organisasi profesi adalah Ikatan Dokter Indonesia untuk dokter dan Persatuan Dokter Gigi Indonesia untuk dokter gigi.
13. Konsil Kedokteran Indonesia, selanjutnya disingkat KKI adalah suatu badan otonom, mandiri, non struktural, dan bersifat independen yang terdiri atas Konsil Kedokteran dan Konsil Kedokteran Gigi.
14. Majelis Kehormatan Disiplin Kedokteran Indonesia, selanjutnya disingkat MKDKI adalah lembaga yang berwenang untuk menentukan ada tidaknya kesalahan yang dilakukan dokter dan dokter gigi dalam penerapan disiplin ilmu kedokteran dan kedokteran gigi, dan menetapkan sanksi.
15. Menteri adalah menteri yang menyelenggarakan urusan pemerintahan di bidang kesehatan.

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TRAUMATOLOGY SERIES : UPDATED ABDOMINAL TRAUMA AT AGLANCE. (definition, diagnosis, clinical overview, sign, symptom, and management )

ABDOMINAL TRAUMA

CHAPTER I

INTRODUCTION

I. Anatomy of the abdomen

I. 1 Anatomy of the external abdominal

a. Front abdominal

Front abdominal definition is a restricted area in the superior by intermamaria line, in inferior limited by the inguinal ligament and lateral to the pubic symphysis and both anterior axillary line.

b. Waist

Is an area that lies between the anterior axillary line and posterior axillary line, from between the ribs to 6 above, down sampaicrista iliaca. At this location there is a thick wall of the abdominal muscles, as opposed to the thinner wall of muscle on the front, especially tterhadap menjadipelindung stab wounds.

c. Back

This area is located in the back of the posterior axillary line, from the lower end of the scapula to the crista iliaca. As with daerak flank, here back muscles and paraspinal muscles to protect against sharp trauma. (1)

I. 2 Anatomy of the abdomen in

There are three rooms, the peritoneal cavity, retroperitoneal cavity and pelvic cavity. The pelvic cavity contains the parts of the peritoneal cavity or retroperitoneal cavity.

a. Peritoneal cavity

Simply the peritoneal cavity is divided into two parts, the top and bottom. The peritoneal cavity is protected by the bottom of the thoracic wall which includes the diaphragm, liver, spleen, gastric and transverse colon. This section is also called a thoracoabdominal components of the abdomen. At the time of the diaphragm rises up between the ribs IV at full expiration, each rib fracture or penetrating stab wound below the intermamaria can injure organs in the abdomen. The peritoneal cavity contains the small intestine, the colon ascendens and colon descendens, sigmoid colon, and in women, internal reproductive organs.

b. Retroperitoneal cavity

Potential cavity is a cavity behind the peritoneum lining the abdominal wall, and includes the abdominal aorta, inferior vena cava, a large part of duodenoum, pancreas, kidney and ureter and the posterior part of the colon ascendens and colon descendens, and also the retroperitoneal pelvic cavity. Injury to the retroperitoneal organs are difficult to identify because this area is far from the reach of regular physical examinations, and also here in the first injury will not show any signs or symptoms of peritonitis. In addition, the cavity is not included in the sample examined in diagnostic peritoneal lavage (DPL).

c. The pelvic cavity

Pelvic cavity, which is protected by the bones of the pelvis, is actually the bottom of the intraperitoneal cavity, while the bottom of the retroperitoneal cavity. Contained therein rectum, vesica urinary, iliaca vessels, and in women, internal reproductive organs. As with the thoracoabdominal, examination of pelvic organs obstructed by parts of the bones on it. (1)

I. Regio-3 region of the abdomen

The abdomen is divided into nine regions, namely:

1. Epigastrica Regio (right and left)

2. Hipocondria Regio (right and left)

3. Umbilical region (right and left)

4. Region of the lateral (right and left)

5. Pubica Regio (right and left)

6. Inguinal region (right and left)

GENERAL SURGERY SERIES : ROUTINE SCREENING FOR PATIENTS PREOPERATIVE GUIDELINES

Chapter I

INTRODUCTION

I.1. Background

Once we know the importance of routine examination screnning preoperative for smooth operation and to control costs in the hospital. Therefore here I downloaded on the official website of the Ministry of Health  hopefully useful to all colleagues, especially colleagues Surgical and anesthesia. Preoperative routine examination, either on the basis of appropriate clinical indications patient or not, has become part of clinical practice for many years. The purpose of the investigation is to identify conditions unexpected that may require treatment prior to surgery or changes in the management of perioperative surgery or anesthesia; assess previously known diseases, disorders, or medical therapy alternatives that may affect perioperative anesthetic; estimate postoperative complications; as the consideration for the reference next; examination screening. (1)     

Last literature recommends not adequately about assessment of clinical benefit or harm preoperative routine examination. At the time found abnormal or positive results, the percentage of patients who changes in its management varies. (1)

Termination of the word "routine" is unclear and requires clarification. One sense of routine checks are carried out all examinations based on existing regulations, these regulations have never changed by clinicians. In the assessment of a routine examination by the unit preoperative HTA English, understanding the inspection routine is intended for healthy indiviuals, asymptomatic, with no specific clinical indication, to know the condition is not detected by clinical history and physical examination. Based on the understanding that, if a patient found to have specific clinical features with the consideration that examination may be useful, it is defined that the examination The indications are not on the basis of examination routine. (1)

On the other hand has been agreed by the consultant and member of the American Society of Anesthesiologists (ASA) that the examination should not prabedah done routinely. Pre operation examination can be done selectively for optimizing the perioperative implementation. Indication does examination should be based on information gathered from the records medical, anamnesis, physical examination, the type and level of invasive surgery planned and should note. (2)

Several studies have shown that in the absence of clinical indications, the likelihood of finding significant abnormal results on examlaboratory, electrocardiography and chest X-ray small. Abnormal results are procedure is not expected to affect operation. (3)

I.2. problems

From the clinical history and physical examination can be determined from healthy patients who appropriate for surgery, and selecting the examination pre operation necessary. The reason why the doctors still perform
prabedah is chosen well without them believing that history clinical and physical examination are not sensitive and may be a routine pre operation  can protect them from medikolegal issue. Each inspection  pre opertion  to do with good reason so as to bring benefits to patients and avoid side effects potential. The benefits include the execution time of anesthesia or the use of sources that can improve the safety and effectiveness process of anesthesia during and after surgery. Potential side effects can occur, including interventions that can cause injury, uncomfort, delays or expenses that are not comparable with benefits.



     



I.3. purpose

Realization of scientific studies as the basis of government recommendations to establish policies in preparation for elective pre operation so as to reduce the cost of expenses for patients who do not have the disorder.

Chapter II

ASSESSMENT METHODOLOGY

II.1. The literature search strategy

Search articles through Medline, New England Journal of Medicine, British Medical Journal, Anesthesiology, Annals of Internal Medicine, Canadian Journal of Anesthesia, British Journal of Anaesthesia, and BioMedicalCenter Anesthesiology, Surgery, Pediatrics, Anaesthesia, America Journal of Surgery, Journal of Clinical Anesthesia, Academy of Emergency Medicine, Mayo Clinic Proceedings, Anesthesia and Anesthesia, Anesthesia in the last 25 years (1978-2003). Information was also obtained from the guideline include a structured by ASA, American College of Cardiology (ACC), American Heart Association (AHA), National Institute of Clinical Excellence (NICE) and the Institute for Clinical Systems Improvement (ICSI) and the results of HTA studies from several countries, among Another England in 1997 on Routine Preoperative Testing. The keywords used were preoperative evaluation, preoperative examination, preoperative assessment, preoperative testing, guidelines, routine, Electrocardiography (ECG), fasting, chest X-ray, hemostatic screening, urinalysis, pulmonary function tests, laboratory tests, elective surgery, pediatric Patients, Patients elderly.

II.2. Level of Evidence and Level Recommendations

Any literature which gained critical assessment (critical appraisal) based on the rules of evidence based medicine, then the specified level. The recommendations are set to be determined level of recommendation. Level of evidence and the recommendations are classified according to the definition of Scottish Intercollegiate Guidelines Network, originating from the U.S. Agency for Health Care Policy and Research.

Level of evidence:

Ia.  Meta-analysis of randomized controlled trials.

Ib.  At least one randomized controlled trials.

IIa.  At least one non-randomized controlled trials.

IIb.  Cohort studies and / or case-control study

IIIa. Cross-sectional study

IIIb. Case series and case reports

IV.   Consensus and expert opinion

Recommendation:

A. Evidence included in the level he or lb.

B. Evidence included in level IIa or II b

C. Evidence included in level IIIa, IIIb or IV