Warung Bebas

Tuesday, 14 December 2010


Three days ago, a man came to Mbah Dukun Bagong, He wanted to consult about his problem. He said, "Mbah, i have a problem, please don't laugh, because my problem about my genital". "Okey, tell your problem!" mbah dukun asked. " Its been 3 months, my scrotum growing big, give me advice, what i have to do", patient reported. "Let me see, mmm, i think you have hydrocele", mbah dukun answered.

What is Hydrocele?
Hydrocele is an excessive accumulation of fluid between the parietal and visceral layers of tunica vaginalis. Normally, fluid inside the cavity that do exist and are in the balance between production and reabsorption by the lymphatic system in the vicinity.
Anatomy of Hydrocele

Hydrocele that occurs in newborns the caused by: (1) the incomplete closure of processus vaginalis resulting in the flow of peritoneal fluid into the processus vaginalis or (2) incomplete lymphatic system in the scrotum in doing hydrocele fluid reabsorption. In adults, hydrocele can occur in idiopathic (primary) and secondary. Secondary cause due to abnormalities found in the testes or epididymis that causes disruption of secretion or reabsorption of fluid systems in the pocket hydrocele. Abnormalities of the testes may be a tumor, infection, or trauma to the testis and epididymis.

Patient complained of a lump in scrotum bag that is not painful. on physical examination found a lump on scrotum sack with cystic consistency and on-ray examination showed translumination. on an infected hydrocele or scrotum skin is very thick, sometimes difficult to perform this examination. so it must be assisted by ultrasound examination.

According to the location of the pockets of testicular hydrocele, the clinical hydroceles are classified into 3 types, namely:
1. Testis Hydrocele
2. Funiculus Hydrocele
3. Communicant Hydrocele
This classification is important because it deals with methods of operation to be performed at the time of making corrections hydrocele.

a. Hydrocele testis (noncomunicating Hydrocele) :
Hydrocele bag as if it surrounds the testes so that testicular testis can not be touched. on anamnesis, the magnitude of the bag hydrocele does not change throughout the day.

b. Hydrocele Funiculus (of the Cord):
hydrocele bag was in funiculus, which is located in the cranial of the testis, so that on palpation of the testes can be touched and are beyond the pockets hydrocele. on anamnesis, the magnitude remains throughout the day.

c. Hydrocele communicant:
there is a relationship between the processus vaginalis with peritoneal cavity so that the processus vaginalis can be filled peritoneal fluid. In namnesis, hydrocele bag size can change, growing larger while crying. on palpation, hydrocele bag separate from the testis and can be inserted into the abdominal cavity.

Type of Hydrocele

How to treat hydrocele?
Hydrocele in infants usually wait until the child reaches the age of 1 year in the hope of the processus vaginalis closes, hydrocele will heal itself, but if the hydrocele is still there or increase in size should be considered for correction.
Measures to cope with hydrocele fluid is with the aspirations and operations. Hydrocele fluid aspiration is not recommended because in addition to the high relapse rate, some time can cause complications in the form of the infection.

Indications for surgery are:
a. blood vessels depressed by a large hydrocele
b. cosmetic indications
c. hydrocele permagna the which felt too heavy and disturbing patients in their activities.

In the congenital hydrocele, inguinal approach was due to hydrocele is often accompanied with inguinal hernia so, at the time of surgery can be done herniografi hydrocele.

In the adult testis hydrocele, conducted Scrotal approach by performing excision and marsupialisation bag in the manner of Winkelman hydrocele or hydrocele applications bag in the way Lord.

In Funiculus hydrocele, hydrocele extirpation performed by in toto

What complications of hydrocele? If left unchecked, big hydrocele easily traumatized and hydrocele can permagna pressing blood vessels leading testicle, causing testicular atrophy.

1. http://www.urologyhealth.org/common/images/anatomy_Hydrocele.jpg
2. http://www.health.com/health/static/hw/media/medical/hw/h9991527_001.jpg
3. http://www.muamat.com/adpics/4cafdd8db59fe87ef645a0f67.jpg
4. http://img.medscape.com/fullsize/migrated/507/161/un507161.fig1.gif
5. http://www.doh.gov.ph/celf_phil/images/stories/food/a%20-%20hydrocele%201.jpg

Thursday, 9 December 2010

Congenital Talipes Equino Varus (C.T.E.V)

Many people who read this post may have ever seen that picture. However, do you know what's the name of  that abnormality? yes that is called C.T.E.V  (Congenital Talipes Equino Varus) or clobfoot.
Congenital Talipes Equino Varus is congenital defects which marked by combination of abnormality consisting of: forefoot adduction and supination through midtarsal joints, Varus heel through subtalar joint and equinus beyond ankle and foot is deviated to medial if viewed from knee joint.
So what are causes of C.T.E.V? there are many theories, etc: genetic, mechanical, cessation of fetal growth, displasia of muscles causes muscle imbalance, primary defects of talus (caput and column talus deviation to medial and plantar, and the last is rotation of calcaneus to medial at subtalar.

What are symptoms and signs of C.T.E.V?
  1. smaller calves,
  2. frequent rotation of the medial leg,
  3. equinus at the ankle,
  4. location of high heels, sometimes smaller,
  5. varus at the subtalar
  6. adduction and varus at the midtarsal and "forefoot"
In naeonatus (age 24 hours), the diagnosis must be determined whether the physiological shape of the foot (because the current position in the uterus); tests on ankle dorsiflexion, if my toes could touch the tibia crest, this is not CTEV.
Children running slow, if it is running, the form of equinus varus foot, callocity on the lateral or lateral front of the foot.

In neonatus, the diagnosis must be determined whether the physiological shape of the foot (because the current position in the uterus); tests on ankle dorsiflexion, if my toes could touch the tibia crest, this is not CTEV
Children running slow, if it is running, the form of equinus varus foot, callocity on the lateral or lateral front of the foot.

How to treatment of C.T.E.V?
the medical therapy for C.T.E.V are two kinds, they are conservative and surgical treatment. Medical therapy as early as possible, golden periode is 24 hours. if delayed will make therapy is complicated.

1. Conservative
a. manipulation correction, systematically, use Gips (plaster/cast), step by step, without anesthesia
b. Adduction and varus are must be corrected first then equinus
c. PLASTER installation until the above knee, knee flexion of 90 degrees
d. duration of plaster is step by step, until stable.

2. Surgical
a. Recurrance C.T.E.V
b. failed conservative in 3 months
c. late C.T.E.V

 The operative procedure includes: 
(1) Z-lengthening of the heel cord with release of the medial fibers distally; 
(2) capsulorrhaphy of the tibiotalar and fibulotalar joints complete; 
(3) capsulorrhaphy of the deltoid ligament and plantar calcaneonavicular ligament maintaining a small tongue of capsule attached to the tibia; 
(4) capsulorrhaphy of the talonavicular ligaments: 
(5) capsulorrhaphy of the anterior tibiotalar ligament from medial to lateral malleolus. (The talocalcaneal ligament and the posterior compartment to the foot should be avoided.) 
(6) The talus is then rotated laterally in the ankle mortise and the calcaneus with it. If derotation is not complete and if the scaphoid does not glide readily to the lateral side, a second incision is made laterally, opening the calcaneocuboid joint and the cuboid metatarsal joints. The sinus tarsi is entered and the lateral talonavicular and calcaneonavicular ligaments are released, as are the tibulotalar ligaments laterally. This procedure usually allows full external rotation of the talus and the calcaneus as a unit and reestablishes the lateral border of the foot - the calcaneocuboid angle being changed from convex to neutral. The relationship between the talus and the calcaneus is reestablished and the foot is then lined up with the fibula and medial malleolus. 
(7) The anterior tibial tendon is detached from the first metatarsal on the medial side and transferred to the dorsum of the first metatarsal where it is reinserted into soft tissue and periosteum in the infant, or into a hole in the first cuneiform in the older patient. 


Friday, 3 December 2010


Two days ago, a medical student came to Mbah Dukun. She asked about DHF. How to treat DHF?
there's no specific therapy for DHF, just support therapy.

DHF or DENGUE HEMORRHAGIC FEVER is acute infection which caused by dengue virus with clinical manifestasions are fever, myalgia, athralgia  be accompanied by leukopenia, rash, lymphodenopathy, thrombocytopenia and diatesis haemorrhagic, also haemoconcentration (increasing hematocryt). in Indonesia it called "DEMAM BERDARAH"

What is cause of DHF?
DHF is caused by virus included in Genus Flavivirus, family Flaviviridae. There are 4 serotypes virus, DEN-1, DEN-2, DEN-3, and DEN-4, which all of them can cause Dengue Fever and DHF. In Indonesia, DEN-3 is more commonly found. 

when your patient come. you have to diagnostic this patient by anamnestic. You can use heteroanamnestic or autoanamnestic.
Dengue Fever is acute fever between 2-7 days and be accompanied with two or more clinical manifestations:
* Headache
* Retro-orbital pain
* Myalgia/athralgia
* Rash
* bleeding manifestations (petechie or positif tourniquet test)
* Leukopenia

Dengue Haemorrhagic Fever by WHO criteria 1997
* acute Fever between 2-7 days, biphasic
* minimal there is one of bleeding manifestations, following:
   1. Positive tourniquet test
   2. Petechie, echimosis, or purpura
   3. Mucous Bleeding (epistaxis, gumm bleeding or another site)
   4. Hematemesis and melena
* Thrombocytopenia < 100.000/
* There is minimal one of sign of plasma leakage, following:
   1. Increasing hematocryt >20%, compared by age and sex
   2. Decreasing Hematocryt >20%, after get rehydration and compared by hematocryt before rehydration
   3. Pleura Effusion, ascites or hypoproteinemia.

DSS (Dengue Shock Syndrome) : 
all criteria WHO be accompanied failed of circulation with manifestations are: pulse weak and rapidly, tension drop (<20 mmHg), hypotension by age standard, cold, and anxious.


Classified this patient

a. Dengue Fever    : fever 2-7 days with 2 or more signs : headache, retro-orbital pain, myalgia, athralgia,  Leukopenia, thrombocytopenia but no plasma leakage.
b. DHF grade I     :   fever 2-7 days with 2 or more signs : headache, retro-orbital pain, myalgia, athralgia,  Leukopenia, thrombocytopenia < 100.000, positive tourniquet test and plasma leakage.
c. DHF grade II    :  fever 2-7 days with 2 or more signs : headache, retro-orbital pain, myalgia, athralgia,  Leukopenia, thrombocytopenia < 100.000, positive tourniquet test, plasma leakage, spontaneous bleeding.
d. DHF grade III  :    Fever 2-7 days with 2 or more signs : headache, retro-orbital pain, myalgia, athralgia,  Leukopenia, thrombocytopenia < 100.000, positive tourniquet test, plasma leakage, spontaneous bleeding.failed circulation, cold and anxiety
e. DHF grade IV :     Fever 2-7 days with 2 or more signs : headache, retro-orbital pain, myalgia, athralgia, Leukopenia, thrombocytopenia < 100.000, positive tourniquet test, plasma leakage, spontaneous bleeding.failed circulation, cold and anxiety, tension and pulse can't measured.


1. Protocol 1
Treatment suspect DHF without shock for adult
someone who is suffering from DHF suspected in the emergency room, examination of Hb, HCT and platelets, if:
a. Hb, HCT, and platelets, normal or decreased between 100.000-150.000, patients can be discharged with the recommendation or outpatient controls within the next 24 hours (examination of Hb, HCT, and platelets) or when the patient's condition deteriorated quickly returned to the emergency room.
b. Hb, HCT normal but platelets <100,000 recommended for hospitalized
c. Hb, HCT and platelets increased to normal or down is also recommended for hospitalized

give crystaloid (ringer lactat or NaCL 0.9%) use formula 
1500 + (20 x (weight kg - 20))
example: patient's weight 60 kg --> 1500 + (20 x (60-20)) = 2300 ml/day
if 1 flash RL contain 500 cc so need 4-5 flashes per day,
so 4-5 flashes for 24 hours, 1 flashes need 4-5 hours, ok, assumptions 4 hours, so 500 cc need 4 hours. 1 hour for 125 cc, one minute 125 cc/60 minute ---> 20 cc/minute
if use macro infus set (1cc= 20 drops/minute),so for this case 40 drops/minute
if use micro infus set (1cc=60 drops/minute), so for this casa 120 drops/minute

After rehydration check Hb, Hct and trombocyt every 24 hours
* if  Hct increases10-20% and trombocyt < 100.000, continue protocol 1 but monitor Hb, Hct and thrombocyt every 12 hours.
* if Hb, Hct increasing >20% and trombocyt < 100.000,change protocol to protocol for Hct increases > 20%.

2. Protocol 2
For Hct increases > 20%
Increased HCT> 20% indicates that the body fluid deficit of 5%. in these circumstances, early therapy is to give intravenous crystalloid 6-7 cc / kg / hour. then patients are monitored after 3-4 hours of initial rehydration. if there is a marked improvement with a decrease in HCT. pulse frequency decreased, stable blood pressure, urine production increases the amount of fluid infusion reduced be 5 cc / kg / hour. 2 hours later be back and when the condition monitoring equipment showed improvement infusion reduced the number of an advanced 3 cc / kg / hour. if still better then the fluid can be stopped 24-48 hours later.
If after the initial rehydration 6-7/kg/jam earlier, the condition still does not improve, which is marked with HCT and the pulse increased, decreased blood pressure <20 mmHg, urine production declines, then the amount of fluid infusion was increased to 10 cc / kg / hour. 2 hours later, the monitor again and if conditions indicate improvementt then the amount of liquid is reduced to 5 cc / kg / h but if things do not show improvement, the amount of fluid infusion was increased to 15 cc / kg / hour and if the development of the patient's condition worsened and obtained marks shock the patient treated according to protocol treatment of dengue shock syndrome.

4. Protocol 4.
Treatment for DHF with spontaneous Bleeding
spontaneous and massive bleeding in patients with DHF are: uncontrolled epistaxis despite being given a tampon nose, gastrointestinal bleeding (hematemesis and melena or hematochezia), hematuria, brain hemorrhage or bleeding hidden by the amount of bleeding as much as 4-5 ml / kg / hour. in conditions just as this amount and speed of rehydration remain as DHF without shock. Monitor blood pressure, pulse, hb, HCT, urine production, and platelet counts should be repeated every 4-6 hours.
Giving heparin if the clinical and laboratory signs of DIC obtained. transfusion of blood components is given as indicated. FFP given if found deficient clotting factor (prolonged PT and aPTT), PRC is given if the value of Hb <10 g / dl. Platelet transfusions are given only in DHF patients with spontaneous bleeding and massive with amount platelet <100,000 with or without DIC

5. Protocol 5
For DSS 
first give oxygen 2-4 l / min, and then treat shock with rehydration using crystalloid fluids. Do not forget to complete peripheral blood examination, hemostasis, blood gas analyse, electrolytes (Na, K, Cl), Also urea and creatinine.
in the initial phase, give rapidly with crystalloid fluids as much as 10-20 ml / kg and evaluated after 15-30 minutes. if the shock has been resolved which marked with systolic blood pressure 100 mm Hg and pulse pressure over 20 mmHg, pulse frequency of less than 100 x / min with enough volume, warm extremities, and skin is not pale and diuresis from 0.5 to 1 cc / kg / hours. If within 60-120 minutes, the condition remains stable, then the liquid was reduced to 3 ml / kg / hour. if within 24-48 hours after the shock is resolved, and HCT stable vital signs, diuresis enough, then rehydration should stop.
if after the initial phase of rehydration was shock is not resolved, then rehydration crystalloids can be increased to be 20-30 ml / kg, then evaluated after 20-30 minutes. If the situation remains unsolved, then note the value of HCT. if HCT increased mean plasma leakage is still ongoing, so giving a colloidal fluid of choice, but if the HCT value declines, it means there is internal bleeding, then Whole Blood transfusion given 10 ml / kg and can be repeated as needed.
Before the liquid colloid is given, should have known the properties of these fluids. Providing early, rapid drop of 10-20 ml / kg and evaluated after 10-30 minutes. if the condition is still not resolved, then to monitor the adequacy of fluid made central vein catheter installation (PVC), and the provision of colloid can be added up to a maximum of 30 ml / kg with a target of 15-18 cmH2O PVC. If the situation remains unsolved, must be considered and made corrections to the acid-base disorders, electrolyte, hypoglycemia, anemia, DIC, secondary infection. If PVC is on target but the shock is not resolved then it can be given inotropic drugs / vasopressin

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