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Block 3.3
ABDOMINAL COMPLAINTS
Sixth Edition
2014
1
Block 3.3 Abdominal Complaints
Student‘s Book
Sixth Edition
Copyright law protects this publication and permission should be obtained from publisher prior to any
prohibited reproduction, storage a retrieval system, or transmission in any form by any means, electronic,
mechanical, photocopying, and recording or likewise
2
TEAM OF BLOCK 3.3
ABDOMINAL COMPLAINTS
YEAR COORDINATOR
dr. R. Detty Siti Nurdiati, MPH, Ph.D, Sp.OG(K)
Department of Obstetrics and Gynecology
BLOCK COORDINATORS
CHAIRMAN
Dr. dr. Eti Nurwening Sholikhah, M.Kes
Department of Pharmacology and Therapy
MEMBERS
dr. Untung Tranggono, MS, PA, Sp.B, Sp.U
Department of Surgery
CONTRIBUTORS
dr. Harijadi, Sp.PA(K)
Dr. dr. Mahardika Agus Wijayanti, DTM&H., M.Kes
dr. Pungky Ardanykusuma, Sp.A(K)
dr. Putut Bayu Purnama, Sp.PD-KGEH
dr. Ahmad Mahmudi, Sp.BA
dr. Nenny Sri Mulyani, Sp.A(K)
dr. Sri Mulatsih, Sp.A(K)
dr. Heru Prasanto, Sp.PD
Prof. dr. Siti Nurdjanah, Sp.PD-KGEH
dr. Hardjo Mulyono, Sp.PK(K)
SECRETARY
Ayu Mega Argi, S.Psi
3
CURRICULUM MAP
COMPETENCE – BASED CURRICULUM 2007
FACULTY OF MEDICINE, UNIVERSITAS GADJAH MADA
Clinical Rotation
Holiday
(6 weeks) (7 weeks) (6 weeks) (6 weeks) Complains
(6 weeks)
V O
X X X X X X
Phase 2: Transition from Theory to Practice
Year 2: Life Cycle
Block 2.1 Block 2.2 Block 2.3 Block 2.4 Block 2.5 Block 2.6
Conception, Safe Childhood Adolescent Adulthood Aging/Elderly
Fetal Growth Motherhood & (6 weeks) (6 weeks) (6 weeks) (6 weeks)
Holiday
X Block Examination
O Progress Test & Clinical Skills Exams
4
PREFACE
The Block 3.3 Book‘s theme is Abdominal Complaints of which the main learning
outcomes are: (1) to apply the principles of biomedicine, clinical aspect, professional behavior
and community health problems concerning abdominal complaints; (2) to compile and record
accurate information relating to the management of abdominal complaints in a professional
manner; (3) to conduct clinical procedure (simulation) according to problems, need and authority
and competence; and (4) to handle health problems of individuals, community and surroundings
in a comprehensive, holistic, sustainable, coordinative and collaborative manner.
5
CONTENTS
WEEK 1
Module 1: Acute Abdominal Pain ................................................................................
Learning unit 1 : Acute Abdominal Pain ......................................................................
Scenario 1: Cramp Abdominal Pain ….........................................................................
Lectures ......................................................................................................................
Practical sessions.........................................................................................................
Basic clinical competences training ……......................................................................
Time allocation ............................................................................................................
WEEK 2
Module 2: Reccurent Abdominal Discomfort ...............................................................
Learning unit 2 : Dyspepsia & Diarrhea ......................................................................
Scenario 2: Reccurent Abdominal Pain ......................................................................
Lectures ......................................................................................................................
Practical sessions.........................................................................................................
Basic clinical competences training ……......................................................................
Time allocation ............................................................................................................
WEEK 3
Module 3: Flank Pain ...................................................................................................
Learning unit 3 : Flank Pain ……...……………….........................................................
Scenario 3: Colicky Pain ……......................................................................................
Lectures ......................................................................................................................
Practical sessions.........................................................................................................
Time allocation ............................................................................................................
WEEK 4
Module 4: Abdominal Lump ………..............................................................................
Learning unit 4 : Abdominal Pain ……………...............………....................................
Scenario 4: Lump After Coughing …….......................................................................
Lectures ......................................................................................................................
Practical sessions.........................................................................................................
Basic clinical competences training ……......................................................................
Time allocation ............................................................................................................
WEEK 5
Module 5: GIT Bleeding …………................................................................................
Learning unit 5 : GIT Bleeding ………………………..…………....................................
Scenario 5: Black Coffee Vomits …….........................................................................
Lectures ......................................................................................................................
Practical sessions.........................................................................................................
Basic clinical competences training ……......................................................................
6
Time allocation ............................................................................................................
PRACTICAL SESSION
Department of Anatomy, Embryology and Anthropology ………………………………
Department of Microbiology ……………………………………………………………….
Department of Pharmacology and Therapy ……………………………………………...
Department of Pathology Anatomy ……………………………………………………….
Department of Clinical Pathology …………………………………………………………
7
OVERVIEW
Block 3.3 is the third block in year 3 phase 3 (Transition from Theory to Practice which
consists of Multisystem Disorders). The block 3.3‘s theme is Abdominal Complaints. There are
five scenarios discussed in this block i.e. (1) Cramp Abdominal Pain (2) Reccurent Abdominal
Pain, (3) Colicky Pain, (4) Lump After Coughing, and (5) Black Coffee Vomits. Various learning
strategies are implemented to support the objective of this teaching and learning process
including lectures, tutorial session as a backbone, self-study in the library, practical session in
the laboratory and skills laboratory practical session. Personal communication between students
and lecturers is also likely. In addition to theories and practical skills mentioned above, students
are provided with some other skills such as effective communication, breaking bad news, being
empathy etc.
Student‘s competence is assessed in the sixth week using Multiple Choice Questions test,
while OSCE (Objective Structured Clinical Examination) is used to assess clinical skills.
Professional behavior is assessed continuously throughout the teaching and learning process.
LEARNING OBJECTIVE
General Objectives
After completing block 3.3, students should be able to:
1. Apply the principles of biomedicine, clinical behavior and community health to problems
concerning abdominal complaint.
2. Compile and record accurate information relating to the management of abdominal
complaint in a professional manner.
3. Conduct clinical procedure (simulation) according to problems, need and authority and
competence.
4. Handle health problems of individuals, community and surroundings in a comprehensive,
holistic, sustainable, coordinative and collaborative manner.
Specific objectives
After completing block 3.3 students should be able to:
1. Explain the principles of basic medical and biomedical science that is related to abdominal
complaint, including pathogenesis, pathophysiology, and other influencing factors, from
molecular to human body (area 3).
2. Utilize clinical reasoning when inquiring current illness history, past medical history, family
history, and social or other history of relevance in a consecutive and efficient manner (area
1, area 2).
3. Conduct physical examination of abdomen in a professional manner that cause minimal pain
and discomfort to the patient, and is in accordance to the patient‘s problems (area 2).
4. Interpret anamnesis data and physical examination, and then formulate it into a diagnosis
and comparative diagnosis (area 4).
6. Identify, select and determine appropriate laboratory examination (area 2).
7. Determine supporting examination to strain illness (area 2).
8. Explain diagnosis based on anamnesis, physical examination, laboratory examination, and
supporting examination by making reference to evidence-based medicine (area 3).
9. Identify and explain various choices of intervention that can be conducted. Select
interventions based on rational/scientific reasoning when handling illness, such as surgery,
pharmacology, diet, exercise, or change of behavior through counseling, and should be
based on principles of quality control, budget control, benefit, and patient condition as well
as patient‘s choice (area 1, area 3, area 4).
10. Develop an effective strategy for controlling and/or terminating source of illness,
pathogenesis points and pathophysiology, as well as determine consequences, and specific
risks (area 3).
11. Select and conduct therapeutic skill, as well as undertake preventive action in accordance to
own authority (area 2).
8
12. Explain changes in physical, biochemical, and physiology processes after medication (area
3).
13. Identify various indicators of successful medication, monitor development, improve and
adjust therapy in a correct manner and according to competence (area 3, area 4).
14. Explain the benefit of diet therapy when handling specific cases (area 3).
15. Explain the purpose of follow up evaluation for handling illness (area 3).
16. Identify, provide reasoning, and explain correct methods of primary, secondary, and tertiary
prevention, when communicating to patient, family members and community (area 4).
17. Identify the role of patient‘s family, patient‘s occupation, and social surrounding as a risk
factor in the emergence of illness and factor that may influence therapy, as well as factor
that may influence prevention of illness (area 4).
18. Keep up to date with the latest scientific findings (area 6).
CENTRAL DICIPLINES
Pathology Anatomy, Pharmacology and Therapy, Internal Medicine, Child Health, Clinical
Pathology, Surgery, Neurology, Physiology
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TOPIC TREE
Appendicitis
Urinary Tract
Pyelonephritis
Hepatocellular Carcinoma
Abdominal
Nephroblastoma
Complaints
Ovarian Carcinoma
Malignant
Neuroblastoma
Lower GIT
Bleeding
Neoplasm Colon Carcinoma
Mass Infection
NAFLD
Hepatomegaly
Abscess
Abdominal
Distension Cyst
10
LEARNING ACTIVITIES
The following learning activities are prepared to guide students to obtain the learning
objectives of this block:
3. Lectures
Lecture is addressed to basic concepts of abdominal complaints. Clinical aspects of
abdominal complaints will be taught to the student in order to enrich their understanding as well
as apply those basic concepts in clinical condition.
During block 3.3 there will be several lectures that are associated with the module topic in
the running week. The students are encouraged to ask questions and explanations of unsolved
problem in tutorial.
Week Title Department Duration
(hour)
1 Overview of block 3.3 Block Coordinator Team 1
Urethral Catheterization Skills Laboratory (Expert) 1
IV line Insertion Skills Laboratory (Expert) 1
Differential diagnosis of acute abdominal Internal Medicine 1
pain
Acute abdominal pain for general Surgery 1
practitioner (Perforated appendicitis, illeus,
intestinal obstruction & pancreatico-
hepatobiliary complaints)
11
Abdominal imaging part 1 Radiology 1
Total lectures of week 1 6
2 Dyspepsia Internal Medicine 1
Drugs for gastrointestinal disorder Pharmacology & Therapy 1
Bacteria causing gastrointestinal infection Microbiology 1
(Salmonella typhi, Helicobacter pylori,
Campylobacter sp, etc)
Viruses causing gastrointestinal infection Microbiology 1
(Rotavirus , Hepatitis A, etc)
Pathology of upper gastrointestinal tract Pathology Anatomy 1
Microbes causing UTI Microbiology 1
Total lectures of week 2 6
3 Biochemical aspect on nephrolitiasis Biochemistry 1
UTI & nephrolitiasis in adult Internal Medicine 1
Surgical indication in management of Surgery 1
urinary stone disease
Surgical management in renal and urinary Surgery 1
tract injury
Clinical aspect of urinary tract stone disease Internal Medicine 1
Analgesics, antibiotics for UTI & neprotoxic Pharmacology and Therapy 1
agents
Renal failure Internal Medicine 1
Glomerulonephritis in children Pediatrics 1
Laboratory examination for renal disease Clinical Pathology 1
(ureum, creatinine, electrolytes, urinalysis)
Glomerulonephritis in adult Internal Medicine 1
Total lectures of week 3 10
4 Hernia Surgery 1
Surgical indication in the management of Surgery 1
abdominal tumor
Abdominal tumor & hepatosplenomegaly in Internal Medicine 1
children and adult (early detection)
Abdominal imaging part 2 Radiology 1
Strangulation (vascular compromized) Surgery 1
Laboratory examination of abdominal Clinical Pathology 1
malignancy
Total lectures of week 4 6
5 Pathology of liver and gallbladder disease Pathology Anatomy 1
Pathology of gastrointestinal disease: Pathology Anatomy 1
inflammation and neoplasm
Inflammatory bowel disease Internal Medicine 1
Hemorrhoid Surgery 1
Sero-immunology of viral hepatitis and Clinical Pathology 1
pancreatitis
Clinical aspect of hepatitis in children Pediatrics 1
Adverse effect of cytostatics Pharmacology and Therapy 1
Urinalysis Clinical Pathology 1
Feedback for ICP Skill Laboratory (Expert) 1
Total lectures of week 5 9
4. Panel discussion
Panel discussion joined several diciplines view related to one topic. After this session,
students are expected to have a comprehensive and complete approach of problems.
12
Week Title Department Duration
(hour)
5 Abdominal complaints - Internal Medicine 2
- Surgery
- Clinical Pathology
- Pathology Anatomy
- Pharmacology and Therapy
5. Practical session
During block 3.3 there will be several practical sessions held by some departments to
develop and enrich students understanding that are associated with the module topic in the
running week.
Week Title Department Duration
(hour)
1 Clinical anatomy of the gastrointestinal Anatomy, Embriology and 2
tracts and hepatobiliary organs Anthropology
2 Isolation & identification of bacteria causing Microbiology 2
gastroenteritis
Spasmolytics Pharmacology and Therapy 2
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ASSESSMENT BLUEPRINT
14
WEEK – 1
MODULE 1: ACUTE ABDOMINAL PAIN
LEARNING UNIT 1: ACUTE ABDOMINAL PAIN
Scenario 1
Cramp Abdominal Pain
A 18-year-old male accompanied by his parents came to primary health care with cramp
abdominal pain. The parents said that two days earlier the pain started from periumbilical. He
had fever, loss of appetite, nausea and vomiting. The patient looked sweaty and painful. When
the doctor pressed his right lower abdomen, he felt severe pain. Laboratory examination
showed leucocyte count 11600 /mm3 and neutrophyles 90%, normal urine analysis. Then the
doctor decided to refer him to the surgeon without any medication.
Lectures
1. Title : Overview of Block 3.3
Department : Block Coordinators Team
Duration : 1 hour
Content : Overview of block 3.3
Practical session
Title : Clinical Anatomy of the Gastrointestinal Tracts and Hepatobiliary
Organs
Department : Anatomy, Embriology and Anthropology
Duration : 2 hours
15
Basic clinical competences training
1. Title : Abdominal Examination for Pathologic Conditions
Department : Skills Laboratory
Duration : 2 hours
2. Title : Urinalysis
Department : Clinical Pathology
Duration : 2 hours
Time allocation
Tutorial : 4 hours
Lecture : 6 hours
Practical session : 2 hours
BCCT : 4 hours
Total hours : 16 Hours
Self study : 32 -44 Hours
References
1. Faculty of Medicine UGM, 2011, Block 3.3 (Abdominal Complaints), Faculty of Medicine
UGM Yogyakarta
2. Rasad, S et al. 2009, Radiologi Diagnostik, edisi kedua, Fakultas Kedokteran Universitas
Indonesia, Indonesia
3. Sutton, D et al. 2003, Textbook of Radiology and Imaging, vol 1, 7th edition, Churchill
Livingstone, USA **
Note:
** = available in the library Faculty of Medicine UGM
16
WEEK – 2
MODULE 2: RECURRENT ABDOMINAL DISCOMFORT
LEARNING UNIT 2: DYSPEPSIA & DIARRHEA
Scenario 2
Reccurent Abdominal Pain
A 58 year old female patient came to the outpatient clinic because she felt pain and discomfort
in the upper abdomen. The pain was usually in the upper central region of the abdomen.
Sometimes pain occurs in the left upper region of the abdomen and in the back, feeling of
fullness or burning in the upper part of the belly. Laboratory examination and upper abdominal
ultrasound were normal.
Lectures
1. Title : Dyspepsia
Department : Internal Medicine
Duration : 1 hour
Content : Management and refferal indication for dyspepsia (smoking as one
of risk factors).
Practical session
1 Title : Isolation and Identification of Bacteria Causing Gastroenteritis
Department : Microbiology
Duration : 2 hours
2 Title : Spasmolytics
17
Department : Pharmacology and Therapy
Duration : 2 hours
Time allocation
Tutorial : 4 hours
Lecture : 6 Hours
Practical session : 4 hours
BCCT : 2 hours
Total hours : 16 hours
Self study : 32 -44 hours
References
1. Brunton, Laurence, 2011, Goodman And Gilmans The Pharmacological Basis of
Therapeutics. 12th edition McGrawHill Medical, New York.
2. Kasper, Dennis L., 2008, Harrison’s Principles of Internal Medicine 17th ed. McGraw Hill New
York.**
3. Katzung, BG 2012, Basic and Clinical Pharmacology, 12th edition, McGraw-Hill Professional,
USA
4. Kumar, Vinay, (eds.) 2010, Robbins and Cotran Pathologic Basis of Disease, 8th ed,
Saunders Elsevier, Philadelphia. **
5. Lullman, Heinz, 2005, Color Atlas of Pharmacology, 3rd edition, Thieme, New York.**
6. Mc.Phee, Stephen, J. 2012, Current Medical Diagnosis and Treatment 41th edition. McGraw-
Hill Medical, New York **
7. Rosai, J 2004, Rosai and Ackerman’s Surgical Pathology, 9th edition, Mosby, USA
Note:
** = available in the library Faculty of Medicine UGM
18
WEEK – 3
MODULE 3: FLANK PAIN
LEARNING UNIT 3: FLANK PAIN
Scenario 3
Colicky Pain
A 36-year-old man suddenly suffered from an excruciating flank pain. Initially, he felt a
mild pain between ribs and hip which then gradually increased in severity. He explained that he
had intermitent pain that usually lasted about 30 minutes and ceased as suddenly as it started.
The patient had difficulty to urinate, felt pain during voiding, and red urine. During the physical
examination on the flank region, the doctor found that there was some tenderness and extent to
the lower quadrant of the abdomen. The doctor, then, asked him to undergo radiography and
laboratory examination. His laboratory examination showed hematuria, proteinuria, leucocyturia,
anorganic crystal and cast were found in urine. The patient asked the doctor whether this
colicky pain caused by renal disorders. The doctor said that there are some differential
diagnosis for this case and asked the patient for further renal function test.
Lectures
1. Title : Biochemical Aspect on Nephrolithiasis
Department : Biochemistry
Duration : 1 hour
Content : Biochemical aspect for patient with nephrolithiasis
19
Content : Sign and symptoms, management of renal failure
Practical sessions
1. Title : Pathology of urinary tract
Department : Pathology Anatomy
Duration : 2 hours
Time allocation
Tutorial : 4 Hours
Lecture : 10 Hours
Practical Session : 4 hours
BCCT : - hours
Total hours : 18 hours
Self study : 30-42 hours
References:
1. Finberg, L and Kleinman, RE 2001, Saunders Manual of Pediatric Practice, 2nd edition,
Saunders, USA
2. Grosfeld, JL et al. 2006, Pediatric Surgery, 6th edition, Elsed, USA
3. Holcomb, GW and Murphy, JP 2009, Ashcraft’s Pediatric Surgery, 5th edition, Saunders,
USA
4. Kasper, Dennis L., 2008, Harrison’s Principles of Internal Medicine 17th ed. McGraw Hill
New York**
5. Mc.Phee, Stephen,J. 2012, Current Medical Diagnosis and Treatment 41th edition. McGraw-
Hill Medical, New York.**
6. Orkin, SH et al. 2009, Oncology of Infacny and Childhood, Saunders, USA
7. Orkin, SH et al. 2009. Nathan and Oski’s Hematology of infancy and childhood, 7th edition,
Sanders, USA.
8. Permono, B, Sutaryo, et al. 2005, Buku Ajar Hematologi-Onkologi Anak, Badan Penerbit
IDAI, Indonesia
9. Perry, MC 2008, Side Effect of Chemotherapy
10. Pizzo, PA and Poplack, DG 2002, Principles and Practice of Pediatric Oncology, 4th
edition, Lippincot Williams & Wilkins, USA
11. Rudolph, AM et al. 2002, Rudolph’s Pediatrics, Vol 2, 20th edition, McGraw-Hill
Professional, USA
20
12. Sherlock, S and Dooley, J 2002, Disease of the Liver and Biliary System, 11th edition,
Wiley-Blackwell Publishing, USA
13. Sills, RH, 2003, Practical Agorithms in Pediatric Hematology and Oncology, Karger AG,
Switzerland
14. Schwartz, MK 2002, Tumor Markers, In: Lewandroski, K (editor) Clinical Chemistry
Laboratory Management and Clinical Correlation, Lippincott Williams and Wilikins,
Philadephia, USA
Note:
** = available in the library Faculty of Medicine UGM
21
WEEK – 4
MODULE 4: ABDOMINAL LUMP
LEARNING UNIT 4: ABDOMINAL PAIN
Scenario 4
A 68 years old man, with history of chronic coughing and difficulty to defecate,
complained that he noticed a gradually increasing bulging at his right groin and often feel
dragging and aching at that site. He came to see his physician. History of trauma and infection
was denied by the patient. On physical examination the doctor notice a globular lump above the
right pubic area which expands on coughing. The doctor manually reducing the lump and
occluded the deep inguinal ring with his thumb and asked the patient to cough. The swelling re
appeared medial to the thumb.
Lectures
1. Title : Hernia
Department : Surgery
Duration : 1 hour
Content : Types, diagnosis and management of hernia
22
Practical sessions
1. Title : Prescription analysis
Department : Pharmacology and Therapy
Duration : 2 hours
Time allocation
Tutorial : 4 hours
Lecture : 6 hours
Practical session : 4 hours
BCCT : 4 hours
Total hours : 18 hours
Self study : 30-42 hours
References
1. Agrawal M, Swartz R, Acute Renal Failure. American Family Physician. 2000: 61: 2077-88)
2. Askcraft KW, Holden TM, Pediatrics Surgery second ed. 1993 WB Saunders Company.
Philadelphia London Toronto Montreal Sydney Tokyo.
3. Brady HR, Singer GG. Acute Renal Failure. Lancet 1995; 346: 1533-40
4. Brunicardi, F.C., Andersen, D.K., Billiar, T.R., Dunn, D.L., Hunter, J.G., Matthews, J.B.,
Ollock, R.E. 2010 Schwartz’s Principles of Surgery 9 th ed. McGraw-Hill Companies, Inc.
Sydney Toronto New York Chicago San Fransisco Lisbon London Madrid Mexico City
Milan New Delhi San Juan Seoul Singapore
5. Doherty, G.M. 2010 Current Diagnosis and Treatment Surgery 13 th ed. The McGrawHill
Companies, Inc. , New York Chicago San Fransico Lisbon
6. Economou SG, Biner S, eziel J, Witt TR 1988 Rush University Review of Surgery WB
Saunders Company
7. Frank DJ, Gearheart JP, Snyder HM 2002 Opeerative Pediatrics Urology Second Ed.
Churchill Livingstone London Edinburgh
8. Glassock, RJ and Brener, BM 1994. The Major Glomerulopathies dalam KJ. Isselbacher; E
Braunwald; JD Wilson, JB Martin, A S Fanci, DL Kasper: Harrison’s Principles of Internal
Medicine 1295-1305.
9. Jarell BE, Carabasi AR, Surgery 2nd ed. 1991, William Wilkins Baltimore Maryland.
10. Kasper, DL, Braunwald, E, Hauser, S, Longo, D, Jameson, L and Fauci, AS 2004,
Harrison’s Principles of Internal Medicine 16th ed. McGraw Hill Companies, USA.
11. Kolegium Ilmu Bedah Indonesia & Komisi Trauma Perhimpunan Dokter Spesialis Bedah
Indonesia Definitive Surgical Trauma Care (DSTC) 2009.
12. Marberger, M. 1991 Stone Surgery Churchill Livingstone London
13. Mayor G, Zingg EJ, 1976 Urologic Surgery Diagnosis Techniques and post Operative
Treatment George Thieme Publishers Stutgart.
14. Rasad S, et al, 2009, Radiologi Diagnostik, edisi kedua, Fakultas Kedokteran Universitas
Indonesia, Indonesia.
23
15. Sutton D, et al, 2003, Textbook of Radiology and Imaging, vol 1, 7th edition, Churchill
Livingstone, USA**
Note:
** = available in the library Faculty of Medicine UGM
24
WEEK – 5
MODULE 5: GIT BLEEDING
LEARNING UNIT 5: GIT BLEEDING
Scenario 5
Black Coffee Vomits
A 50 years old male came to emergency unit with complaint recurrent black vomit like coffee
about 250 mL since 6 hours before get to emergency unit. The patient complained nausea,
bloating, weak, and abdominal discomfort. There were not any history for taking medicine for
rheumatic disease, pain kliier, alcohol and herbal medicine, but there was history of jaundice
when he was 35 years old without antiviral therapy. Physical examination revealed weak,
adequate nutrition, BP 90/70 mmHg, pale conjunctivae, normal sclera, atrophy of temporal
muscle, sphlenomegali, ascites, epigastric tenderness, peristaltic (+), and melena in rectal
toucher.
Lectures
1. Title : Pathology of Liver and Gallbladder Disease
Department : Pathology Anatomy
Duration : 1 hour
Content : Pathology of the liver and gallbladder disease
4. Title : Hemorrhoid
Department : Surgery
Duration : 1 hour
Content : Diagnosis and management of lower abdominal bleeding
25
8. Title : Urinalysis
Department : Clinical Pathology
Duration : 1 hour
Content : Urinalysis
Panel discussion
Title : Abdominal Complaints
Panelis : Department of Internal Medicine, Surgery, Clinical Pathology,
Pathology Anatomy, Pharmacology and Therapy
Duration : 2 hours
Practical session
1. Title : Clinical anatomy of abdominal wall and urinary tracts
Department : Anatomy, Embriology and Anthropology
Duration : 2 hour
Time allocation
Tutorial : 4 hours
Lecture : 9 hours
Panel discuccion : 2 hours
Practical session : 6 hours
Total hours : 21 hours
Self study : 27-39 hours
References:
1. Donahue, I & Montgomery E (eds.) 2005, Gastrointestinal and Liver Pathology, Churchill-
Livingstone, Philadelphia.
2. Fateh, MA and Stieber, P 1996, Sensible Use of Tumor Markers, Roche, Switzerland
3. Hamilton SR & Altonen, LA (eds). 2000, WHO: Pathology and Genetic, Tumors of the
Digestive System. IARC Press. Lyon.
4. Kasper, DL, Braunwald, E, Hauser, S, Longo, D, Jameson, L and Fauci, AS 2004,
Harrison’s Principles of Internal Medicine 16th ed. McGraw Hill Companies, USA
5. Kumar, Vinay, (eds.) 2010, Robbins and Cotran Pathologic Basis of Disease, 8th ed,
Saunders Elsevier, Philadelphia. **
6. Rosai, J 2004, Rosai and Ackerman’s Surgical Pathology, 9th edition, Mosby, USA
7. Rubin E, Gorstein F, Rubin R, Schwarting R, Strayer D (eds.) 2005, Rubin,s Pathology:
Clinicopathologic Foundation of Medicine, 4th ed. pp280-311, Lippincott Williams &
Wilkins, Philadelphia.
8. Underwood JCE (ed.) 2004, General and Systemic Pathology, 4th ed, Edinburgh: Churchill
Livingstone.
Note:
** = available in the library Faculty of Medicine UGM
26
Practical Guide
Block 3.3
Authors:
Dr. dr. Djoko Prakosa, PA(K)
dr. M. Mansyur Romi, SU., PA(K)
dr. Dwi Cahyani Ratna Sari, MKes., PA(K)
dr. Santosa Budiharjo, MKes., PA(K)
dr. Ch. Tri Nuryana, MKes.
27
PREFACE
This Anatomy practical sessions support the learning process and content of Block 3.3
(Abdominal complaint) such as enrich knowledge to easier understand the pathogenesis of
diseases and help to build clinical reasoning on abdominal examination skill. There are two
topics of Clinical Anatomy practical sessions, such as 1) Clinical anatomy of the Gastrointestinal
tracts and hepatobiliary organs and 2) Clinical anatomy of the abdominal wall and urinary tracts.
This clinical Anatomy practical sessions are difference to the basic Anatomy practical
sessions that already learned in the first year (Block 1.3 Digestive System). In clinical Anatomy
practical sessions, beside identify the basic Anatomy, furthermore students will learn in relating
to clinical condition, such as congenital anomaly, pathological organ, body area that used in
physical examination, site of surgery intervention, body trauma, etc. The total content of this
clinical Anatomy sessions are summarize both the basic Anatomy, and clinical aspect (relate it
to case in pediatric, internal medicine and surgery).
We hope that after completion the clinical Anatomy practical sessions, students can
increase their capabilities of clinical reasoning in learning the problem and competencies in both
physical examination and procedural skills. For improving this manual of Clinical Anatomy
practical session, we accept any correction and suggestion.
Authors
Djoko Prakosa
M. Mansyur Romi
Dwi cahyani Ratna sari
Santosa Budiharjo
Ch. Tri Nuryana
28
TOPICS
1. Clinical anatomy of the Gastrointestinal tracts and hepatobiliary organs
2. Clinical anatomy of the Abdominal wall and Urinary tracts
REGULATIONS
1. Two practical sessions supervised by the instructor. Students must attend practical session
(100% attendance). If students are unable to accomplish full (100%) attendance, they are not
allowed to attend the laboratory exam
2. If students are unable to attend one or more practical session because of an acceptable
reason, Students must reschedule practical session before the laboratory exam. The
replacement will be arranged regarding to each block's schedule.
3. Pretest in practical session if twice has score less than half of the highest score will be given
an assignment, which must be submitted one day after the practical session, if not yet
submitted, students not allowed follow the practical examination.
4. In each practical session, a test will be carried out which will influence mark professional
behavior. This test will be used as a proof of attendance and may be conducted at the
beginning or at the end of a practical session, if twice the pretest score is not satisfying
(below half of the highest score), students have to do an assignment and should be collected
before the next practical session.
5. The minimum score to pass the practical session examination is 50%. If the students score
less than 50% (<50%), students should take a remedial practical examination. There is only
once remedial practical examination could be taken. If some students have score more than
50% (>50%) and want to take remedial examination, they can take remedial practical
examination with permission.
6. The maximum score of remedial practical examination is 70%, if the score>70% will
convert to 70%, if score<70% will not convert(original score).
7. The Anatomy practical session‘s end score is the best score taken from the main and
remedial practical examination.
8. Further items regarding to practical session regulation will be informed later.
29
Clinical Anatomy of the Gastrointestinal
Tracts and Hepatobiliary Organs
OBJECTIVES
General:
o Be able to identify the structures of Gastroinstestinal tracts and hepatobiliary
organs in order to become easier build clinical reasoning relate to clinical aspect
such as inflammation of digestive tract, congenital anomaly, degenerative
diseases, acute abdomen and surgery intervention
Specific:
o Be able to identify GI tract organs and accessory digestive organs and its basic
functions such as:
- Gross anatomy of the stomach
- Gross anatomy of the small intestine
- Comparison of the three regions of the small intestine
- Gross anatomy of the pancreas
- Gross anatomy of the large intestine
- Comparison of the large intestine regions
- Liver and gall bladder anatomy and blood supply
- Blood vessels, lymphatic structures, and nerve that supply the GI tract
in order to become easier build clinical reasoning relate to clinical aspect such as
inflammation of digestive tract, congenital anomaly, degenerative diseases, acute
abdomen and surgery intervention
Case 1
A 34-year-old male with massive upper gastrointestinal bleeding. Failure to control the bleeding
by conservative measures necessitated an exploration. Haemorrhagic gastritis was found to be
the cause of bleeding. Vagotomy and pyloroplasty was performed with satisfactory results.
Explain structures relate to basic Anatomy of digestive tracts in the abdominal cavity! Fill
the table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Identify the organs of the upper digestive tracts, list
their major functions!
Describe the anatomy of the stomach and discuss
its roles in digestion and absorption!
When a person suffers from chronic gastric ulcers,
the branches of the vagus nerves that serve the
stomach are sometimes cut in attempt to provide
relief. Why might this be an effective treatment?
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!!
Clinical Condition Clinically Oriented Anatomy
Gastritis
Hypertrophic pyloric stenosis
Peptic ulcers
Gastroesophageal reflux disease (GERD)
Heartburn (pyrosis)
Gastroscope
Gastrectomy
30
Vagotomy
Duodenal ulcers
Case 2
A 45-year-old male with a 15-year history of Crohn's disease. During this time, he had
undergone a total of four intestinal reactions, each time having a segment of his inflamed small
intestine removed. In between operations, he was kept on a variety of pharmaceuticals. Since
nothing had been done to address causes, it was only a matter of a few years before another
segment of intestine had to be removed. At the time, his intestines were badly inflamed again,
there was nothing more that could be done surgically, since there was not enough small
intestine left to be able to afford removing any more of it. The patient was badly debilitated,
underweight, weak, depressed and very pale. He had severe diarrhea on an ongoing basis.
Explain structures relate to basic Anatomy of digestive tracts in the abdominal cavity! Fill
the table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Identify the organs of the lower digestive tracts, list
their major functions!
Describe the anatomical characteristics of the small
intestine!
Describe the gross structure of the large intestine!
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!
Case 3
A 57-year-old female with bowel discomforts, and she had been originally diagnosed with
"irritable bowel syndrome" since 18 years ago. Since then, she was seeing a gastroenterologist
for the ulcerative colitis. She had also had a consultation with a medical dietitian. The patient
complained of chronic fatigue, ongoing bloody diarrhea, severe stiffness and pain.
Explain structures relate to basic Anatomy of digestive tracts in the abdominal cavity! Fill
the table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Identify the organs of the lower digestive tracts, list
their major functions!
Describe the gross structure of the large intestine!
31
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!
Case 4
A 3-day-old female neonate was admitted to hospital with abdominal distention an d vomiting.
A radiological barium enema study revealed a caliber change at the midportion of the sigmoid
colon and a histochemical study of the rectal mucosa confirmed a diagnosis of Hirschsprung‘s
disease. After a 4 months of daily bowel irrigation at home, the infant was readmitted for the
operation with a body weight of 8.3 kg.
Explain structures relate to basic Anatomy of digestive tracts in the abdominal cavity! Fill
the table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Identify the organs of the digestive system, list their
major functions!
Describe the embryology of gastrointestinal tracts!
And digestive glands! Mesentery!
Describe the gross structure of the large intestine!
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!!
Case 5
Mr. Willy is admitted to the Emergency Department with the pain shifted to his right lower
quadrant and remain localized at the area halfway between the umbilicus and the right iliac
crest (McBurney‘s point). On arrival at the ED, Mr. W is complaining of nausea, and begins
vomiting. He is assisted to a stretcher, and immediately positions himself on his side with his
legs flexed.
Explain structures relate to basic Anatomy of digestive tracts in the abdominal cavity! Fill
the table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Describe the gross structure of the large intestine!
32
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!!
Case 6
A 70-year-old man was hospitalized for severe intermittent epigastric pain associated with a 10-
kg weight loss over 2 months. Laboratory workup revealed amylase and lipase levels that were
elevated three times above normal, suggesting acute pancreatitis. A chest radiograph showed a
voluminous hiatal hernia, whereas abdominal sonography was unremarkable. Endoscopic
retrograde cholangiopancreatography was performed and showed an obstruction of the main
pancreatic duct between the junction of the pancreatic head and isthmus, suggesting a
neoplastic obstruction at this level.
Explain structures relate to basic Anatomy of digestive tracts in the abdominal cavity! Fill
the table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Describe the structure and functions of the
accessory digestive organs!
Describe the lobes of the liver. What is the porta?
Diagram the duct system from the liver, gallbladder,
and pancreas that empties into the major duodenal
papilla!
Describe the flow of blood to and through he liver!
What effect would a drug that blocks
parasympathetic stimulation of the digestive tract
have on peristaltis?
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!!
33
Clinical Anatomy of the Abdominal Wall and Urinary Tracts
OBJECTIVES
General:
Be able to identify the structures of the abdominal wall and urinary tracts relate to
clinical aspect (ascites, hernia, surgical intervention, referred pain, urolithiasis,
urinary tract infection, congenital anomaly, trauma, urine incontinentia)
Spesific:
Importance of surface anatomy in learning about internal structures:
- Clinical relevant features of the abdomen
- Auscultation sites in the abdominopelvic region
Peritoneum location and function
The primary organs of the urinary system:
- Anatomy of the kidney
- Anatomy and location of the ureters, urinary bladder, and urethras
- Blood vessels and nerves that supply the organs of the urinary tract
Functions performed by the urinary system
relate to clinical aspect (ascites, hernia, surgical intervention, referred pain, urolithiasis,
urinary tract infection, congenital anomaly, trauma, urine incontinentia)
Case 1
A 35-year old man was shifting furniture in preparation for his family‘s move to a new home.
When he strained to pick up a particularly heavy coffee table, he suddenly felt a sharp pain in
his right groin. Later, he noticed that a painful bulge had developed in hid groin which
disappeared when he lay on his back and he finally saw a physician. On examination, the
physician observed a swelling which began about midway between the anterior superior iliac
spine and the midline, progressed medially for about 4 cm, and then turned toward the scrotum.
Taking the history and physical findings into account, the physician made a diagnosis of indirect
inguinal hernia and scheduled him for surgery. The hernia was successfully repaired, and he
was released from the hospital a few days later.
Explain structures relate to basic Anatomy of abdominal wall and urinary tracts. Fill the
table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Describe the regions of ventral abdominal wall!
Describe external projection of visceral organs of
abdominal to the anterior wall!
Mention locus minoris resistance of hernia
Describe the layers of abdominal wall
Describe the inguinal regions! Inguinal canal!
Femoral ring!
Where are visceral peritoneum and parietal
peritoneum found? What is a retroperitoneal
organ?
34
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!!
Case 2
A 50-year-old patient is seen in the emergency room. His chief complaint was flank region pain,
vomiting, and frequent urination.The patient also admits to constipation, nausea, and a fever.
On admission, his BUN is 95, probably reflecting dehydration from 4 days of illness, but his
serum creatinine is 6.8, representing underlying kidney disease. The man promptly undergoes
hemodialysis through a hastily-placed Shiley catheter.
Explain structures relate to basic Anatomy of abdominal wall and urinary tracts. Fill the
table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Where are visceral peritoneum and parietal
peritoneum found? What is a retroperitoneal organ?
Identify the components of the urinary system, and
describe the functions it performs!
Describe the location and structural features of the
kidneys, identify major blood vessels associated with
each kidney, trace the path of blood flow through a
kidney, describe the structure of a nephron!
Describe the renal capsule and the structures that
surround the kidney!
List the structures found at the hilum and in the renal
sinus of a kidney!
Describe the structures and functions of the ureters,
urinary bladder, and urethra!
Discuss the voluntary and involuntary regulation of
urination, and describe the micturition reflex!
35
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!!
Case 3
Seventy-one parents and 40 siblings of 41 index patients with bilateral renal agenesis, bilateral
severe dysgenesis, or agenesis of one kidney and dysgenesis of the other were evaluated by
gray-scale ultrasonography for genitourinary malformations. Nine per cent (10 of 111) had
asymptomatic renal malformations, most often unilateral renal agenesis (4.5 per cent — a
frequency that was significantly higher than the frequency of 0.3 per cent among 682 adults).
Explain structures relate to basic Anatomy of abdominal wall and urinary tracts. Fill the
table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Describe the location and structural features of the
kidneys, identify major blood vessels associated
with each kidney, trace the path of blood flow
through a kidney, describe the structure of a
nephron!
Describe the renal capsule and the structures that
surround the kidney!
List the structures found at the hilum and in the
renal sinus of a kidney!
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!!
36
Case 4
The patient complains of on and off right lower quadrant pain radiating to back. A abdominal
radiograph showed a 1.5-cm lower-pole calculus with unfavorable anatomy, a 1.4-cm
proximalureteral calculus, and a staghorn calculus. The treatment options offered were
extracorporeal shockwave lithotripsy (SWL), ureteral stenting, ureteroscopy (URS),
percutaneous nephrolithotomy (PCNL), and open surgery.
Explain structures relate to basic Anatomy of abdominal wall and urinary tracts. Fill the
table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Identify the components of the urinary system, and
describe the functions it performs!
Describe the location and structural features of the
kidneys, identify major blood vessels associated with
each kidney, trace the path of blood flow through a
kidney, describe the structure of a nephron!
Describe the renal capsule and the structures that
surround the kidney!
List the structures found at the hilum and in the renal
sinus of a kidney!
Describe the structures and functions of the ureters,
urinary bladder, and urethra!
Discuss the voluntary and involuntary regulation of
urination, and describe the micturition reflex!
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!!
Case 5
A 26 year old suffered a fractured pelvis 2.5 years ago, which resulted in a partially ruptured
urethra. The rupture was treated with catheterplacement for just over 3 weeks. Since then, he
has had a weak stream and the usual symtoms (symptoms) of a stricture and was followed up
10 months later with a uroflow and ultrasound for PVR (4.1 ml/s and ~200ml respectivley)-
the stricture was confirmed (3 months later) with a urethroscopy and VCUG (only .5cm long but
very narrow). Ever since then he has been waiting to see the urologist to find out what he plans
to do.
37
Explain structures relate to basic Anatomy of abdominal wall and urinary tracts. Fill the
table below!
Questions Answer
(by explanation, table, figure,
schematic diagram, etc.
Identify the components of the urinary system, and
describe the functions it performs!
Describe the location and structural features of the
kidneys, identify major blood vessels associated
with each kidney, trace the path of blood flow
through a kidney, describe the structure of a
nephron!
Describe the renal capsule and the structures that
surround the kidney!
List the structures found at the hilum and in the
renal sinus of a kidney!
Describe the structures and functions of the
ureters, urinary bladder, and urethra!
Discuss the voluntary and involuntary regulation of
urination, and describe the micturition reflex!
Below many cases relate to clinical Anatomy of the gastrointestinal tracts. Fill
explanation in the blank tables!!
38
Practical Guide
Block 3.3
LABORATORY OF MICROBIOLOGY
Laboratory of Microbiology
Faculty of Medicine
Universitas Gadjah Mada
2014
39
Isolation and Identification of Bacteria
Causing Gastroenteritis
Background
Gastroenteritis or diarrheal disease is still a major cause of morbidity and mortality in
infants and young children especially in developing countries. The causative agents responsible
for the disease could be bacteria, viruses and parasites. It is also possible that factors other
than microorganisms may cause diarrhea such as malabsorbtion and malnutrition.
Bacteria may produce diarrhea by different mechanisms. They colonize and invade the
mucous membrane of intestinal tract. During growth and multiplication they may also produce
exotoxins that act on epithelial cells of the gut (enterotoxin) and result in diarrheal diseases.
Bacteria with invasive property and ability to produce toxins include Enteroinvasive E.
coli (EIEC), enterohemorrhagic E. coli (EHEC), and S. dysenteriae type 1, result in bloody
diarrhea, while Enterotoxigenic E. coli (ETEC) which produce Stable Toxine (ST) and Labile
toxine (LT) caused diarrhea without blood. ETEC is a common cause of ―traveler‘s‖ diarrhea.
Enteropathogenic E. coli (EPPEC) is an important cause of diarrhea in infants, especially in
developing countries. Infections with Vibrio cholerae result in profuse diarrhea because of their
highly potent enterotoxin instead of invasion of mucous membrane.
In contrast, ingestion of enterotoxins alone without infection and invasion of the intestinal
tract can cause diarrhea as in botulism and food poisoning cases due to staphylococcal
enterotoxin produced by many strains of Staphylococcus aureus
Enterobacteriaceae is a family includes many genera : Escherichia, Proteus , Klebsiella;
Serrati,. Enterobacter (their natural habitat is in the intestinal tract of humans and animals, as
normal microbial flora) and Salmonella, Shigella, which are regularly pathogenic to human
Microscopically, the Enterobacteriaceae are short Gram negative rods, that may form
chains. E. coli and most of the other enteric bacteria form circular, convex, smooth colonies with
distinct edges. Klebsiella colonies are large and very mucoid. Differentiation of
Enterobacteriaceae is based on carbohydrate fermentation patterns and the activity of amino
acid decarboxylases and other enzymes. Production of indole from tryptophan is commonly
used in identification.
Isolation of Enterobacteriaceae is usually performed with differential medium such as Mc
Conkey agar. On this agar bacteria can be distinguished into 2 major groups: lactose-fermenting
bacteria which give pink-pigmented colonies and non-lactose fermenting bacteria which give
non-pigmented (transparent-white) colonies. E. coli, Klebsiella sp, Enterobacter sp. and Serratia
sp. are lactose fermenting bacteria whereas Shigella sp., Salmonella sp., Proteus sp., and
Pseudomonas sp. are not. When Salmonella or Shigella sp. are suspected to be the causative
agent the use of Salmonella-Shigella agar, a differential and selective medium, is preferred as it
will show specific colonial appearance of the bacteria (Table 1). Thiosulfate Bile Salts Sucrose
(TCBS) agar is used exclusively for isolation of Vibrio sp. V. cholerae shows yellow colonies,
while V. parahemolytica forms green colonies.
Identification of Enterobacteriaceae is carried out by biochemical characterization using
Kliger Iron Agar (KIA), Semi Solid Sucrose (SSS) agar, Lysine Iron Agar (LIA) and Motility Indol
Ornithin (MIO) medium.
Specimens for isolation and identification of bacteria can be fresh stool, rectal swab,
blood and bone marrow. Specimens that can not be cultured shortly after collection should be
placed in transport medium such as buffered glycerol saline (BGS) or Carry and Blair medium,
or alkaline pepton water (for vibrio).
40
Table 1. Colonial characteristics of Enterobacteriaceae group on Salmonella-Shigella agar
Bacteria Colonies characteristics
Non-lactose fermenting:
Salmonella sp Transparent colonies usually with black
centers
Shigella sp Transparent colonies
Proteus sp. and Citrobacter sp Transparent colonies with grey-black centers
Lactose-fermenting : Pink-red colonies
41
Materials and Equipments
Sterile cotton buds
Mc Conkey agar
Salmonella-Shigella agar
TCBS agar
Kliger Iron Agar
Semi Solid Sucrose agar
Lysine Iron Agar
Motility Indol Ornithin medium
Transport medium
Kovacs reagent
Selenite Cystein (SC)
Alkaline pepton water
Procedure
1. Streak the specimen with cotton bud on Mc Conkey, SS or TCBS agar, following by
streaking the specimen using ose
2. Put the cotton bud into enrichment medium (SC, Kaufmann or alkaline pepton for
Salmonella, Shigella and Vibrio respectively)
3. Incubate at 37°C for 18-24 hours
4. Examine colonies on the agar. Note the characteristics of colonies
5. Take the suspected colonies and grow them in KIA, SSS, LIA and MIO
6. Incubate at 37°C for 18-24 hours
7. Examine bacterial growth in KIA, SSS, LIA and MIO. Note the changes in slant and butt
areas of these media
8. Streak the appropriate agar with cotton bud from enrichment medium (this is done if there
no suspected colonies from first culture)
9. Incubate at 37°C for 18-24 hours
10. Examine bacterial growth in KIA, SSS, LIA and MIO. Note the changes in slant and butt
areas of these media
11. Add on drop of Kovacs reagent into MIO to detect indole production. Positive result will
show red ring on the surface of the medium.
12. Match biochemical test result with available chart for species determination of the isolated
bacteria (see Table 2)
Continue step 8 to 12 if necessary.
ASSESSMENT
Student will be evaluated for his/her final score. The points for evaluation should include:
1. Pre test ( will be held just before commencing practical class)
2. Performance and activity during laboratory work
3. Score of laboratory class examination
REFERENCES
- Jawetz E, Melnick JL, Adelberg EA. 2007. Review of Medical Microbiology. 25th ed. Los
Altos : Lange Medical Publication
- Tortora GJ, Fungke BR, Case CJ, 2013. Microbiology: An Introduction 11th ed. Pearson
Education, Inc., Boston, USA
42
Appendix
The composition of Media used for isolation and identification Enterobacteriaceae are
(gram/Liter):
1. Mc Conkey Agar
Casein pepton 17
Meat pepton 3
Lactose 10
Bile Salt 1.5
NaCl 5
Neutral red 0.03
Agar 13.5
2. KIA medium
Pepton 20
Maat extract 3
Yeast extract 3
Lactose 10
Dextrose 1
NaCl 5
Ferri Amonium Citrat 0.5
Sodium thiosulfat 0.5
Agar 15
Phenol red 0.025
Aquadest 1 litre
3. LIA medium
Pepton 15
Yeast extract 3
Dextrose 1
L-lysine 10
Ferri Ammonium Citrate 0.5
Sodium thiosulfat 0.04
Brom cresol purple
Agar 15
Aquades 1 litre
4. SSS medium
Sucrose 10
Pepton 10
Gelatin 80
NaCl 5
Aquadest 1 litre
5. MIO
Pancreatic digest of casein 14
Pancreatic digest of gelatin 5
Yeast extract 3
Dextrose 1.5
L-ornithine monochlorida 5
Brom cresol purple 0.02
Aquadest 1 litre
43
Table.2
Biochemical characterization of Enterobacteriaceae
KIA SSS LIA MIO Acetat Urea
Slant Butt H2S React Mot Slant Butt H2S React Mot Indol Note :
Salmonella typhi K A +/0 K + K K/N +/0 A + 0 0 0 A : Acid 0 : negative
Salmonella paratyphi A K AG 0/+ K + K A 0/+ K + 0 0 0 K : Alkaline N : Neutral
D : Delayed G : Gas
Salmonella enteritidis K AG 0/+ K + K K/N + K + 0 + 0
+ : positive X : not necessary
Salmonella gallinorus K A + K 0 K K/N 0 A 0 0 + 0
Salmonella pullosum K AG + K 0 K K/N + K 0 0 + 0
Shigella dysenteriae K A 0 K 0 K A 0 A 0 0 0 0
Shigella flexneri K A 0 K/D 0 K A 0 A 0 D 0 0
Shigella boydii K A 0 K 0 K A 0 A 0 D 0 0
Shigella sonnei K AG 0 K/D 0 K A 0 A 0 + 0 0
Escherichia coli A/K AG 0 K/D + K K/D - K/D + + + 0
Edwardsiella tarda K AG + 0 + K K/N +/0 K + + K 0
Arizona K AG + 0 + K K/N +/0 K + D X 0
Citrobacter K/A AG + 0 0 K A/AG +/0 K + D X +/0
Klebsiella AG A 0 K/A 0 K K/d 0 A 0 0 X 0/+
Enterobacter A/K AG 0 A/D + K K/N 0 K + 0/+ X +/0
Serratia K/A A 0 K + K/N K/N 0 K + 0/+ X X
Pseudomonas K NO 0 K + K K/N 0 N + D X X
Aeromonas hidrophil K A 0 A + K A 0 A + D X X
Proteus vulgaris A/K AG 0 A + R A 0/+ A + +/0 X +
Proteus mirabilis K/A AG + K/D + R A 0/+ K + +/0 X +
Proteus morgagni K A/D + K + K/R A 0 K + +/0 X +
Providencia rettgeri K A 0 K/D + R A 0 A + +/0 X +
Vibrio cholera K A 0 A + K N 0 A + + X X
Vibrio NAG (sp) K A 0 D + K N 0 K + + X X
Vibrio parahaemolytica K A 0 K + K N 0 K + + X X
44
Department of Microbiology
Laboratory Class
Block 3.3 : Abdominal Complain
Klebsiella pneumoniae
Salmonella typhi
Shigella sp.
Vibrio
BLOK 3.3
PHARMACOLOGY & THERAPY
Contributors:
Dra.Tri Murini, MSi.,Apt.
dr.Rul Afiyah Syarif,M.Kes
Prof.Dr.Mae Sri Hartati Wahyuningsih,MSi.,Apt.
dr. Yolanda Dyah Kartika, MSc
SPASMOLYTICS
Contributors:
dr. Setyo Purwono, M.Kes.
dr. Woro Rukmi Pratiwi, M.Kes., SpPD.
46
PRACTICAL GUIDE
DEPARTMENT OF PHARMACOLOGY AND THERAPY
1. The laboratory work begins on time as the time mentioned on the schedule.
2. The student must arrive on time. There will be a pre-test for ten minutes before the
laboratory work begins.
3. The student who comes before 5 minutes late will not get a pre-test mark, but the
student still allow to do the laboratory work. This student has to get remedial pretest (with
maximal score 6).
4. The student who comes 15 minutes late or more is not allowed to do the laboratory
work. This student has to get INHAL.
5. The student must wear laboratory coat when enter the laboratory.
6. The student must dress properly. Sandals, slippers or thongs are prohibited.
7. Whenever the student will do the laboratory work, he or she must bring the work plan
which is written on the available form (the form is available in the Administration Office of
Pharmacology and Therapy Department, Medicine Faculty, Universitas Gadjah Mada one
day before the laboratory work at the latest). If he or she doesn‘t bring workplan, he or she
is not allowed to do the laboratory work.
8. At the laboratory work, each group will get a check-list of the laboratory equipment based
on the available equipment and material.
9. Before and after the laboratory work, the student must examine the completeness of the
equipment and material based on the check-list.
10. After the laboratory work, the student must clean up the equipment and return it to the place
properly.
11. After the laboratory work, the check-list must be signed by the instructor as the verification
that the equipment is in a good condition.
12. The student must take care of the equipment well.
13. If there is damaged equipment caused by the student (for example: broken thermometer),
the student must replace it one week after the laboratory work at the latest.
14. Every student must write laboratory work systematically based on the regulation.
15. The laboratory work report must be submitted 5 days (deadline) after the laboratory work at
the latest. It must be attached with a temporary report which is signed by the instructor. If
the report is submitted after the deadline, the student will include as ‗report is not
submitted‘, and the student is scored 0 to work report.
16. The grade of the report is determined by the tidiness, systematization, and the content of
the report.
17. Minimal score for pretest is 6. If pretest not reach this minimally score student has to get
remedial pretest at the same laboratory work session.
18. Total grade of the laboratory work consists of pre-test (25%) laboratory work report (25%)
and laboratory work examination (50%).
19. If student geT INHAL, she/he must submit and ajust the schedule of inhal to the
pharmacology and therapy laboratory. The cost needed to carry out inhal is disbursed by
the student.
47
PRESCRIPTION ANALYSIS:
ABDOMINAL COMPLAINT PRESCRIPTION
AIM:
After doing the activity it is expected that student‘s knowledge about prescription writing
increases and student are able to think critically to any prescription which they read and
analyze.
RESUME OF THEORY
Until now it is still found that a prescription is illegible and not written completely. Health
Ministerial Regulation No 26/1981 article 10 regulates that a prescription must be written legibly
and comprehensively. Minister of Health Decree No 280/1981 article 2 regulates that a
prescription must contain
– name, address and practice license number of doctor (Doctor‘s identity)
– date when a prescription written (Superscription)
– name/composition and amount or strength of the drug (Inscription)
– R/.(an abbreviation for Recipe) symbol on the left side of the prescription form
(Superscription)
– Signature/Initial/Initials
– Patient‘s name (or patient‘s identity consisting of name, age, body weight)
Besides those, a complete prescription also contains subscription (the direction to the
pharmacist, usually consisting of a short sentence such as ―make a cream‖, ―dispense 10
capcules‖) and signatura (the direction to the patients).
Therefore, it is necessary to provide the student how to write a good prescription by
giving some samples of doctor‘s prescription to be read and analyzed. After doing it, it is
expected that they will write a complete, right, and rational prescription in the future.
PROCEDURE
Method
Students are divided into some groups (3-4 persons/group). One week before this
session, each group will receive assignments to be prepared for this session. The assignment is
a doctor‘s prescription to be analyzed by using the following criteria below. The students have to
make a repot of the assignment and submit it at least one day before the practical work at
12.00. On D-day the student present and discuss it with other groups.
48
FORM OF PRESCRIPTION ANALYSIS
A. Completeness of a prescription
Complete Right/legible Explanation
(yes/no) (yes/no)
Doctor‘s Identity
Superscription R1/.
R2/.
R3/.
etc.
Inscription R1/.
R2/.
R3/.
etc.
Subscription R1/.
R2/.
R3/.
etc.
Signa (Signatura) R1/.
R2/.
R3/.
etc.
Doctor‘s signature R1/.
R2/.
R3/.
etc.
Patient‘s Identity
B. Prescription form
1. Type of prescriptions
R1/.
R2/.
R3/. etc.
2. Magistral form (present/none)
If there is magistral form, explain using the criteria:
49
B. 1 Dosage regimen (dosage, route of administration, frequency, time of administration,
and duration of treatment)
2. Drug Interaction (present/none)
D. Diagnose
Base on the medicines written in the prescription, what is/are the possibility of patient‘s
diagnose?
E. 1. Conclusion and advice (advices which have to be given to the patient relating to the
disease)
2. Write the right and rational prescribing in a prescription form.
After the students analyze and make a report about the prescriptions, on D-Day they present
and discuss them with other groups.
Each group presents:
1. Original doctor‘s prescription
2. The calculation of drug doses for this patient
3. The right and rational prescribing according to their opinion
50
Example of prescription which have to be presented:
1. Look at the original doctor‘s prescription below
R/. Ranitidine No X
S.1.d.d.a.c
________________________
Pro : Ny.Nila
Age : 40 years old
2. In that prescription, not only inscription and subscription are incomplete but also
signatura. The inscription doesn‘t contain the strength of ranitidine, subscription doesn‘t
carry the kind of pharmaceutical and signatura there is no amount of the drug which has
to be taken in once. From references, it is known that there are many pharmaceutical
dosage forms of ranitidine, such as tablet, film-coated tablet and injection. Each tablet
and each film coated tablet contains 150 mg of ranitidine whereas each ml injection
contains 25 mg (available in ampoule, 2 ml/ampoule). The usual adult dose of ranitidine
by mouth is 300 mg once daily or 150 mg twice daily. The usual dose by intramuscular
or intravenous injection is 50 mg which may be repeated every 6-8 hours. Foods does
not significantly impair absorption of ranitidine
So, inscription, subscription, and signatura are complete if the doctor add the strength,
the kind of pharmaceutical dosage form and amount of the drug which has to be taken
in once.
51
The right and rational prescribing for Ny.Nila is :
Pro : Ny.Nila
Age : 40 years old
REPORT
The students have to submit the report to laboratory of Medical Pharmacy one day before the
practical work.
EVALUATION
Presentation and report
REFERENCES
Anonim, Daftar Obat Esensial Nasional 2008. Depkes RI
Hoover, J.E., 2002, Remington’s Pharmaceutical Sciences, Ed.15th, Mack Publishing Company,
Pennsylvania
Sri Suharmi, 2002, Resep Dokter dan Proses Preskripsi yang Benar dan Rasional, Bagian
Farmasi Kedokteran Fakultas Kedokteran UGM, Yogyakarta.
52
SPASMOLYTICS
INTRODUCTION
Intestinal wall is developed from mucous layer, submucous, circulair muscle and
longitudinal muscle. Tone and peristaltic are controlled by autonomic nervous system.
Parasymphatetic fibres synapting on two ganglion, Aurbach ganglion between two kinds of
muscle and Meissners ganglion in submucous layer. Symphatetic fibres innervating intestine
muscle by mengelilingi blood vessels that come into muscle. Stimulation of symphatetic nervous
system increase tone and peristaltic. Overload stimulation produces spasm.
Drugs that have relaxing muscle effect are called antispasmodic or spasmolitic. There are
two kinds of spasmolitic, as first group is drugs acting directly on intestine muscle (e.g. alverin,
meberverin) and the other group is drugs acting on muscarinic receptor (e.g. atropine sulfate,
atropine, scopolamine, propanthelin and dicyclomine as muscarinic antagonist).
In this experiment, effect of atropine sulfas as anti spasmodic is showed by increasing
acetylcholine concentration is required to reach 50 % of maximum contraction.
EXPERIMENT
c. Equipments:
1. Organ bath
2. Kymograph
e. Procedure:
1. Before the experiment, the animal is fasted and watered ad libitum for 12 hours.
2. The animal is sacrified, open the abdomen and remove its ileum into the beaker
containing tyrode solution.
3. Ileum is removed into a petri disk, cut up in strips about 2 cm length and clean of the fat.
4. Both of ileum end are fixed and suspended into organbath containing tyrode solution .
5. Link to kymograph.
6. Record normal contraction.
7. Add acetylcholine with increasing concentration and make log concentration vs %
contraction curve.
8. Then, ileum is washed in tyrode solution until normal contraction is showed.
9. Add atropine sulfate 10-8M and allow for 30 second.
10. Add acetylcholine with increasing concentration and make log concentration vs %
contraction curve.
11. Repeat no 9 and 10 with atropine sulfate 10-7M.
12. Spasmolytic effects of atropine sulfate is showed by compare:
- Concentration of acetylcholine is required to reach 50% contraction, between before
and after adding atropine sulfate curve.
- Contraction is resulted by adding a concentration of acetylcholine, between before
and after adding atropine sulfate curve.
53
Increasing concentration of Acetylcholine (Ach)
No Volume of Ach which is added in 20 Final concentration of Ach in organ
mL of Tyrode solution in organ bath bath
1 0.2 mL of Ach 10-6 M 10-8 M
2 0.4 mL of Ach 10-6 M 10-7.5 M
3 0.14 mL of Ach 10-5 M 10-7 M
4 0.4 mL of Ach 10-5 M 10-6.5 M
-4
5 0.14 mL of Ach 10 M 10-6 M
6 0.4 mL of Ach 10-4 M 10-5.5 M
REFERENCES
1. Goodman, AG, Goodman LS, Rall TW, Murrad F, 2007, Goodman and Gilman‘s the
Pharmacological Basis of Therapeutics, Macmillan Publishing Company, New York, USA.
2. Lullman H, Mohr K, Ziegler A, Bieger D, 2000, Colour Atlas of Pharmacology, 2nd ed.
Thieme Stuttgart, New York, 2000
3. Vogel, HG (Ed), 2002, Drug Discovery and Evaluation Pharmacology Assays, 2nd ed.,
Springer-Verlag, Berlin
54
Practical Guide
Block 3.3
55
INTRODUCTION
In this section, the students will be introduced to the non neoplastic and
neoplastic lesions of gastrointestinal tract, liver and urinary tract, which frequently cause
abdominal complaints. This section covers the inflammation process, such as chronic
pyelonephritis, obliterans appendicitis, chronic diverticulitis, Crohn‟s disease,
chronic cholecystitis, chronic hepatitis, and hepatis cirrhosis; and neoplastic
lesion, including renal cell carcinoma, transitional cell carcinoma, signet ring cell
carcinoma of the stomach, adenocarcinoma of the large bowel, and carcinoma.
Each lesion begins with short information and a brief description of its clinical
findings and the morphologic features which are described in moderate detail, both in
gross (macroscopic) and microscopic features.
The students may learn the practical work materials from computers and/or from
gross collections as well as histologic slides provided by the department. There are
gross and microscopic photographs of each organ/lesion in the computers. The
photomicrographs are taken in low and high magnification of the same field to give the
students more detail features. The students are able to view microscopic feature of
each case from the slides directly and compare it with the photographs using the
microscopic.
56
I. PATHOLOGI OF URINARY TRACT
1. Chonic pyelonephritis
Clinical information:
A 45-year-old male has suffered from hypertension since five years ago. He was
admitted to the hospital with fever, back pain, frequent pyuria, bacteriuria. Later renal
failure developed. Pyelogram test showed asymmetrically contracted right kidney, with
coarse scar, blunting and deformity of the caliceal system. Surgical operation of the right
kidney was carried out.
Macroscopic appearance:
A kidney tissue 8x8x5 cm, appears contracted, irregularly scarred, and has irregular
granular surface, especially in the upper and lower pole. The parenchyma is atrophic
and replaced by fat tissue.
Microscopic appearance:
The microscopic changes involve predominantly tubules and interstitium. The tubules
showed atrophy in some areas and hypertrophy in others, with atropy of the lining
epithelium. Many of dilated tubules contain pink to blue, glassy-appearing casts known
as colloid casts the suggest the appearance of thyroid tissue, hence the descriptive term
thyroidization is given.
There are varying degrees of chronic interstitial inflammation (lymphocytes, plasma cells
and netrophils) and fibrosis in the cortex and medulla. Glomeruli appear normal except
for periglomerular fibrosis. Vascular changes similar to those of hyaline or proliferative
arteriosclerosis that frequently associated with hypertension might be found be around
the glomerulus.
Clinical information
A 60 year male, suffered from hematuria, fever, flank pain, pale, fatigue, and anorexia,
was admitted to the hospital. Laboratory tests showed polycthemia with erythrocytosis. A
selective arteriogram of the left kidney demonstrated a mass with increased and
irregularly branching vessels. Surgical operation of the left kidney was carried out.
Macroscopic appearance:
A Kidney tissue, 20x15x8 cm in size. On cut section, a solid, white-yellowish mass was
found, protrudes from the renal cortex, with some haemorrhage and necrosis areas. At
the periphery of the tumor, the normal parenchyma is compressed, forming a
pseudocapsule.
Microscopic appearance:
The specimen cosists of epithelial tumor forming tubular, solid, and papillary pattern,
invades to the surrounding tissue. Tumor composed of atypical and polymorphic clear
cells or lipid laden cells, with distinct cytoplasmic membranes, abundant cytoplasm and
eccentric nuclei. Many abnormal with some cluster of histiocytes and inflammatory cells
are present. There are markedly vascularized scanty stroma between cells, with some
clusters of histiocytes and inflammatory cells.
57
3. Transitional Cell Carcinoma of the Bladder
Clinical information.
A 55 year old male suffered from painless hematuria since 2 weeks ago. He looks pale
and anemic. On cystoscopic examination, there was a tumor in the trigone of the
bladder, appear as papillary and plaque like ulcer. The total cystectomy was done by the
surgeon.
Macroscopic appearance:
A tissue, 15x10x7 cm. On cut section, there was solid and papillary, white-brownish
mass, with areas of necrosis, haemorrhage and invasion.
Microscopic appearance:
The specimen consists of transitional epithelial tumor, which show varying degress of
nuclear atypia and pleomorphism, and invade the sub-mucosal or muscular layers.
Tumors are characterized by persistence of the papillary configuration. The epithelium is
15 to 20 cells thick of more. The number mitoses varies.
58
II. PATHOLOGY OF GASTROINTESTINAL TRACT
1. Obliterans Appendicitis
Microscopic appearance:
The lumen of the appendix is filled by granulation and fibrous tissue and the glands are
few in number and indistinct. The wall of the appendix is densely infiltrated by chronic
inflammatory cells.
2. Chronic Diverticulitis:
Clinical information:
A 48 year-old man with persistent abdominal pain, fever, and chronic diarrhea.
Microscopic appearance:
The specimen consists of a colon tissue with flask-like structure/flask-like out pouching
that extends from the lumen through the muscle layer. The base of the diverticulum is
formed by serosal connective tissue. There are a lot of chronic inflammatory cells i.e.
lymphocytes, leucocytes, plasma cells and histiocytes, and some blood vessels
dilatation.
3. Crohn‟s Disease
Clinical information:
A 40 year-old male suffered from fever, crampy abdominal pain, and diarrhea since a
month ago.
Macroscopic appearance:
The bowel appear thickened and edematous, as does the adjacent mesentery.
Mesenteric lymph nodes are frequently enlarged, firm, and matted together. The
intestinal lumen is narrowed by edema, and by combination of edema and fibrosis in
long-standing disease. Nodular swelling, fibrosis, and ulcereated of the mucosa lead to
―cobblestone‖ appearance.
Microscopic appearance:
59
4. Signet ring cell carcinoma of the stomach
Clinical information:
A 60 year-old female suffered from severe gastric pain, nausea, vomitus, loss of appetite
and anemia since 3 months ago. Endoscopic examination showed diffuse, flatted,
infiltrative mass along the major curve of the stomach, with some necrotic, ulcerative and
hemorrhage areas. The patient was admitted to the hospital, and operation was carried
out. The specimen was sent to the Department of Pathology.
Microscopic appearance:
The specimen consists of gastric tissue with diffuse epithelial tumor, invasion into the
serous layer. The cells are atypi, polymorphic with hyperchromatism nuclei. The
abundant cytoplasm is filled with mucinous material. There are many cells that contain
abundant mucinous material, and expanded the nucleus to the one side, forming the so-
called signed-ring cell. Many abnormal mitotic cells can be found.
Macroscopic appearance:
Sessile polypoid & ulcerated of mucosa 3 cm in diameters.
Microscopic appearance:
The specimen shows ephitelial malignant tumor with solid, tubular and papillary
appearances. Tumor cells infiltrated to serous layer of large intestine wall. The cells
show atypic, polymorphic with hyperchromatism of nuclei and there are many
pathological mitosis cells. .
60
III. PATHOLOGY OF LIVER & BILIARY TRACT
1. Chronic cholescystitis
Macroscopic appearance:
The morphologic changes in chronic cholecystitis are extremely variable and sometimes
minimal. The wall has an opaque gray-white appearance and may be less flexible than
normal. In the uncomplicated case, the lumen contains fairly clear, green-yellow, mucoid
bile and usually stone.
Microscopic appearance:
2. Cronic hepatitis
Clinical information:
A 22 year-old boy was admitted to the hospital because of moderate fever for 2 weeks,
fatigue, lost of appetite, and icteric. Clinical examination revealed the liver slightly
enlarged and soft pain in palpation. Needle biopsy with Menghini needle was done, and
the tissue was sent to the laboratory of pathology.
Microscopical appearance:
In chronic hepatitis obvious portal tract lesions can be found, characterized by variable
infiltration of the portal tracts by lymphocytes, plasma cells, and macrophages. The
expanded portal tracts often display mild-to-severe proliferation of bile ductules, which
represents a non-specific response to chronic liver injury.
There is also a periportal chronic inflammatory infiltrate creates an irregular border
between the portal tracts and the lobular parenchyma (piecemeal necrosis). This lesion
is essentially periportal ad refers to focal destruction of the limiting plate of hepatocytes.
3. Hepatocellular carcinoma
Background :
Hepatocellular carcinoma is a malignant epithelial tumor of hepatocytis origin. Eighty
percents of hepatocellular carcinoma was found in cirrhotic liver.
61
Clinical information:
A 50 year-old male was admitted to the hospital with the chief complaint of abdominal
enlargement and icteric, since 3 months ago. Clinical examination showed ascites,
anemia and hepatomegaly with some solid multinoduler masses in the liver. He had a
story of hepatitis B infection when he was 20 years old. The clinician took a biopsy of the
mass and sent the speciment to the laboratory of pathology.
Microscopic appearance:
The speciment consists of liver tissue with nests and diffuse epithelial tumor. The tumor
cells infiltrate to surrounding tissue. Tumor cells are large in size, atypic, polymorphic,
rounded, oval to polygonal cells, with hyperchromatism nuclei and abundant eosinophilic
cytoplasm. Quite a lot of cell mitoses can be found. Some tumor cells contain of bile
pigment.
4. Hepatic Cirrhosis
Background:
Terminal stage of fibrosis process of the lever, with nodular regeneration.
Clinical information:
A 45 year old male suffered from severe fatigue, fever, anemic and icteric since 2
months ago. He has history of hepatitis B infection when he was 15 year old, and
worsening until now.
Microscopic appearance:
Multinodular hepatomegaly with hard consistency, and ascites in peritotoneoscopy
examination.
Microscopic appearance:
The specimen show liver tissue with high grade fibrosis of perilobular and intralobular,
forming variable formation pseudolobuli. The liver cells in the pseudolobuli show different
size and many regenerated liver cells with dilatation of sinusoids.
There are a few cells with compensatory hyperthrophy with large nuclei and abundant
eosinophilic cytoplasm, and some cells show double nuclei.
The Portal areas, fibrotic septa and parenchymal nodules, show infiltration of
lymphocytes.
62
Practical Guide
Block 3.3
63
CLEARANCE OF UREA AND CREATININE TESTS
Learning Objectives:
1. Students understand the principle of urea and creatinine clearance
2. Students able to calculate urea and creatinine clearance.
3. Students understand the clinical application and interpretation the result of Urea
Mesurements.
Urea Clearance:
The concentration of urea in glomerular filtrate is equal to that of the blood producing the
filtrate. Some urea is reabsorbed by tubules, thus urea clearance equals ml. of blood which
contain the amount of urea removed per minute in the urine.
It has been empirically shown that with a rapid flow of urine (2 ml, or more per minute)
the excretion of urea is at a maximum, hence is called ―maximum clearence‖ (Cm). It normally
ranges from 64 – 99 ml., the mean for an average adult being 75 ml. of blood cleared per
minute. The formula is :
If urine flow is slow (1.9 ml. or less per minute), urea excretion is disproportionately less than
above. The range is 41 – 65 ml. per minute; the mean for an average adult, 54 ml. of blood per
minute. This is ―standard clearence‖ (Cs), and any value below 40 ml, is abnormal. The formula
is :
U√V
Cs = ---------------
P
Specimen:
- 24 hours urine collection
- Serum/plasma
Procedure :
1. Twenty-four hour endogenous urea clearence
The entire volume of urine excreted over a period of 24 hours is collected
A blood specimen is abtained during the forenoon of day of the test
Urea concentrations are measured in urine and plasma or serum, and the volume of urine is
measured for use in the formula above.
2. Determine volume and the urea nitrogen content of each specimen (U)
3. Determine urea nitrogen content of plasma/serum (P)
64
Interpretation:
Normal values result unless disease has destroyed over 50% of renal parenchyma. In
the presence of renal insufficiency, there is direct relationship between the anatomical
destruction of renal parenchyma and clearence test value. In normal persons, urea clearence
may be affected by protein intake; Cm is increased by caffeine, small dose of epinephrine, or an
ordinary meal. Cm is decreased by posterior pituitary hormone or large doses of epinephrine.
Procedure :
Twenty-four hour endogenous creatinine clearence
The entire volume of urine excreted over a period of 24 hours is collected
Creatinine concentrations are measured in urine and plasma or serum, and the volume of urine
is measured for use in the formula above.
Creatinine concentrations of plasma and urine and the urine volume are determined for
calculation of the clearence.
Normal value for men and women corrected to 1.73 sq. M. Body surfage area range from 140 to
180 L/24 hrs. (100 to 125 ml/min). To correct clearence to standard 1.73 sq.M. Body surfage
are.
Clinical Applications:
Calculation of creatinine clearance has become the standard laboratory method to determine
GFR. This value is derived by mathematically relating the serum creatinine concentration to the
urine creatinine concentration excreted during period of time usually 24 hours.
65
UREA – DIACETYL MONOXIM METHOD
Learning Objectives:
1. Students understand the principle of Urea Measurement.
2. Students able to perform Urea examination
3. Students understand the clinical application and interpretation the result of Urea
Mesurements.
Method
Diacetyl Monoxime Methods
Principle
Urea reacts directly with diacetyl monoxim under strong acidic conditions togive yellow
condensation product. The reaction is intensified by the presence of ferric ions and
thiosemicarbazide. The intense red color is measured at 520 nm/yellow green filter .
Equipments:
1. Tubes
2. Sentrifuge
66
3. Pipette
4. Spectrophotometer
Procedure
Pipette the following into appropriately labeled 13 x 100 nm tubes
Mix all tubes well keep them in a boiling waterbath for 20 minutes at 100 oC. Remove from
waterbath and cool the for 15 minutes. Set the spectrophotometer/filter photometer to zero with
balnk at 520 nm/yellow green filter and measure the absorbance of the other tubes.
Absorbance of test
Urea in test
= X 30 mg/dl (serum / Urine)
sample
Absorbance of standards
Reference range
Serum / plasma Urea …………………………… 15 – 40 mg/dl
Clinical Applications:
An elevated concentration of urea in the blood called azotemia. Very high plasma urea
concentration accompanied by renal failure called uremia or the uremic syndrome. Conditions
causing increased plasma urea are classified according to cause into three main categories:
prerenal, renal and postrenal. Pre renal azotemia is caused by reduced renal blood flow. The
amount of protein of protein metabolism also induces pre renal change in blood urea
concentration. A high protein diet or increased protein catabolism also induces pre renal change
in blood urea concentration. Decreased renal function causes an increase in plasma urea
concentration.
Learning Objectives
1. Students understand the principle of Creatinine Measurement.
2. Students able to perform creatinine examination
3. Students understand the clinical application and interpretation the result of Creatinine
Mesurements.
Methods
Jaffe‘s Method
67
Principle of the method
Creatinine present of serum or urine directly reacts with acid picrate resulting in the
formation of red colour, the intensity of which is measured at 500 nm / green filter. Protein
interference is eliminated using sodium laurylsulphate. A second absorbance reading after
acidifying with 30% acetic acid corrects for non-specific chromogens in the samples.
This reaction is non specific and subject to positive interference by a large number of
compounds including acetoacetate, acetone, ascorbate, glucose and pyruvte.
Two approaches have been developed to increase the specificity of assay method for
creatine: A kinetic Jaffe Method and Enzymatic Methods.
Equipment
1. Tubes
2. Sentrifuge
3. Pipette
4. Spectrophotometer
Procedure
The protocol of the procedure is described below
Prepare sample serum/plasma by sentrifugating blood 2000 rpm for 10 minutes :
0.5 ml serum / plasma, 0,5 ml aquadest, 0,5 ml Na-tungstate 5%, 0,5 ml H2SO4 2/3 N and filter
pipette the following into appropriately 18 x 150mm labeled tubes.
68
Filtrate serum / Urine (ml) - - 1.0
Picric acid 0.04 M (ml) 0.5 0.5 0.5
Na OH 0.75 N (ml) 0.5 0.5 0.5
Leave at room temperature (25 – 35oC) for 15 minute. Set the spectrophotometer / filter
photometer to zero with blank at 500 nm/green filter and measure the absorbance of the other
tubes.
Absorbance of test
Craetinine in the test = ---------------------------------------------------- X 4 mg/dl
Absorbance of standard
Clinical Application:
Elevated creatinine concentration is associated with abnormal renal function, especially it
relates to glomerular function. Plasma concentration of creatinine is inversely proportional to
clearance of cretinine. Therefore, when plasma creatinine concentration is elevated GFR
clearance is decreseced indicating renal damage.
Plasma creatinine is a relativey insensitive marker and may not be measurably increased until
renal function has deteriorated more than 50%.
Learning Objectives:
1. To know the principle and method of serum Bilirubin Total and Bilirubin Direct, Urine
Bilirubin, SGPT and HBs Ag test
2. To know preparation of the specimens of serum Bilirubin Total and Bilirubin Direct, Urine
Bilirubin, SGPT and HBs Ag test
3. To understand the procedure of serum Bilirubin Total and Bilirubin Direct, Urine Bilirubin,
SGPT and HBs Ag test
4. Able to interprete serum Bilirubin Total and Bilirubin Direct, Urine Bilirubin, SGPT and
HBs Ag test results in order to diagnosis, suggested to determine liver function, as well
as to diffferentiate obstructive jaundice from nonobstructive or medical type of jaundice
and many other variations of jaundice, assesment of hepatocellular inflamation,
destruction and to variable degree of biliary obstruction.
69
SERUM BILIRUBIN TOTAL
Method
Photometric test using 2,4-dichloroaniline (DCA)
Principle
Direct bilirubin in presence of diazotized 2,4-dichloroaniline forms a red colored azocompound
in acidic solution.
Reagents
R1: Phosphate buffer 40 mmol/L
NaCl 9 g/L
Detergents, stabilizers.
R2: 2,4-Dichlorophenyl-diazonium salt 1 mmol/L
HCl 30 mmol/L
Detergents.
Specimen
Serum or heparin plasma.
It is very important to store the sample protected from light.
Stability: 1 day at 15 – 25 ºC 3 months at – 20 ºC
7 days at 2 – 8 ºC If frozen immediately
Freeze only once.
Assay Procedure
Measurement Against reagent blank
Blank Sample or calibrator
Sample or calibrator - 25 L
Dist. Water 25 L -
Reagent 1 1000 L 1000 L
Mix, incubate for 5 min. at 37 ºC or 10 min. at 20 – 25 ºC, read absorbance A1, then add:
Reagent 2 250 L 250 L
Mix, incubate for 5 min. at 37 ºC or 10 min. at 20 – 25 ºC, read absorbance A2.
A = [(A2 – A1) sample or calibrator] - [(A2 – A1) blank]
Wavelength 546 nm, (540 – 560 nm)
Temperature 20 – 25 ºC / 37 ºC
Calculation
With calibrator.
Bilirubin [mg / dl] =
Conversion factor
Bilirubin [mg / dl] x 17.1 = Bilirubin [mol /L]
Specificity / Interferences
No interference was observed by ascorbic acid up to 30 mg/dL, hemoglobin up to 500 mg/dL
and lipemia up to 2000 mg/dL, triglycerides when measured using a triglyceride concentrate and
up to 1000 mg/dL. triglycerides when measured using Intralipid.
70
Reference Range [mg / dl] [mol /L]
Method
Photometric test using 2,4-dichloroaniline (DCA)
Principle
Direct bilirubin in presence of diazotized 2,4-dichloroaniline forms a red colored azocompound
in acidic solution.
Reagents
R1: EDTA-Na2 0.07 mmol/L
NaCl 6.6 g/L
Sulfamic acid.
Specimen
Serum or heparin plasma.
It is very important to store the sample protected from light.
Stability: 2 days at 15 – 25 ºC In case of immediate freezing.
7 days at 2 – 8 ºC Freeze only once.
3 months at – 20 ºC
Assay Procedure
Wavelength 546 nm, (540 – 560 nm)
Temperature 20 – 25 ºC / 37 ºC
Measurement Against reagent blank
Mix, incubate for 3 - 5 min. at 20 – 25 ºC / 37 ºC, read absorbance A1, then add:
Reagent 2 250 L 250 L
Mix, incubate for 5 min. at 37 ºC, or 10 min. at 20 – 25 ºC, then read absorbance A2.
71
Calculation
With calibrator.
Bilirubin [mg / dl] =
Conversion factor
Bilirubin [mg / dl] x 17.1 = Bilirubin [mol /L]
Specificity / Interferences
No interference was observed by ascorbic acid up to 30 mg/dL and lipemia up to 1000 mg/dL
triglycerides. Interference by hemoglobin occurs starting at hemoglobin concentrations of 50
mg/dL.
Clinical Correlation
BILIRUBIN IN URINE
Procedure
1. Place 10 ml acidified urine in a test tube.
2. Add 5 ml 10% barium chloride solution.
3. Shake and filter.
4. To the residual precipitate on the filter paper, add l drop of reagent made follows:
Trichloroacetic acid 25 gm
10% ferric chloride solution 10 mL
distilled water 100 mL
5. When bilirubin is present, a green or blue-green color develops.
Bilirubin is an unstable compound and disappears from urine on standing, especially if exposed
to light. It is very important that urine be tested for bilirubin as soon after excretion as Possible.
(Figure)
Bilirubin in urine
SOLUBLE
Glucuronide BILIRUBIN Glucuronide And REACTIVE
72
On standing – hydrolysis:
Reference values
Bilirubin present in urine is approximately 0,02mg/dL, reflecting the normally low blood levels of
conjugated bilirubin. This amount is undetected by routine semi-quantitative techniques, and is
interpreted as a negative result.
Clinical correlation
Bilirubin excretion in the urine will reach significant levels in any disease process that increases
the amount of conjugated bilirubin in the bloodstream. In some liver diseases due to infectious
or hepatotoxicagents, liver cells are unable to secrete all of the conjugated bilirubin in the bile,
so that sufficient amounts are returned to the blood to elevate blood levels and cause significant
bilirunuria. Bilirubinuria is an important diagnostic sign of liver disease and a bilirubin test
should be part of every routine urinalysis.
Method
Principle
Reagents
Reagent Preparation
Substrate Start
The reagents are ready-to-use,
For the determlnation with pyridoxal-5-phosphate (p-5-p)
mix 1 part of P-5-P with 100 parts of reagent 1.
73
E.g. 100 l P-5-P + 10 ml R1
Stability after mixing: 6 days at 2-8 ºC
24 hours at 15-25 ºC
Sample Start
(without pyridoxal-5-phosphate)
Mix 4 parts of R1 + 1 part of R2
(e.g 20 ml R1 + 5 ml R2) = monoreagent
Stability: 4 weeks at 2 – 8 ºC
5 days at 15 – 25 ºC
The monoreagent must be protected from light!
Specimen
Assay Procedure
Wavelength 340 nm. Hg 365 nm, Hg 334 nm
Temperature 37 ºC
Measurement
Substrate Start
Sample 100 L
Reagent 1 1000 L
Mix, incubate for 5 min., then add:
Reagent 2 250 L
Mix, read absorbance after 1 min. and start stopwatch . Read absorbance again1, 2 and 3 min
thereafter.
Sample Start
Sample 100 L
Monoreagent 1000 L
Mix, read absorbance after 1 min. and start stopwatch .
Read absorbance again1, 2 and 3 min thereafter.
Calculation
From absorbance readings calculate A/min and multiply by the corresponding factor from table
below:
A/min x factor = ALAT activity [U/l]
Substrate Start Sample Start
340 nm 2143 1745
334 nm 2184 1780
365 nm 3971 3235
Measuring range
The test has been developed to determine ALAT activities which correspond to a maximal
A/min of 0.16 at 340 and 334 nm or 0.08 at 355 nm.
If such value is exeeded the sample should be diluted 1 + 9 with NaCl solution (9 g/l) and results
multiplied by 10.
74
Specificity / lnterferences
No lnterference was observed by ascorbic acid up to 30 mg/dl, bilirubin up to 40 mg/dl,
hemoglobin up to 400 mg/dl and lipemia up to 2,000 mg/dl triglycerides.
Clinical correlation
ONE STEP
HEPATITIS B SURFACE ANTIBODY
TEST STRIP (SERUM/PLASMA)
Principle:
The HbsAb One Step Hepatitis B surface Antibody Test Strip (Serum/Plasma)is a Qualitative,
lateral flow immunoassay for the detection of HBsAb in serum or plasma. The membrane is pro-
coated with HBsAg on the test line region of the strip. During testing, the serum or plasma
specimen reacts with the particle coated with HBsAg. The mixture migrates upward on the
membrane chromatographically by capillary action to react with HBsAg on the membrane and
generate a colored line. The presence of this colored line in the test region indicates a positive
result, while its absence indicates a negative result. To serve as a procedural control, a colored
line will always appear in the control line region indicating that proper volume of specimen has
been added and membrane wicking has occurred.
The HBsAb One Step Hepatitis B Surface Antibody Test Strip (Serum/Plasma) is a rapid test to
qualitative detect the presence of HBsAb in serum or plasma specimen. The test utilizes a
double antigen sandwich system to detect a low as 10mIU/mL of HBsAb in serum or plasma.
Reagents
The test strip contains HBsAg particles and HBsAg coated on the membrane.
75
Materials
Test strips
Package insert
Specimen collection container
Centrifuge (for plasma only)
Timer
Procedur
Allow test strip, serum or plasma specimen, and/or controls to equilibrate to room
temperature (15-30oC) prior to testing.
1. Bring the pouch to room temperature before opening it. Remove the test strip from the
scaled pouch and use it as soon as possible. Best results will be obtained if the assay is
performed within one hour.
2. With arrows pointing toward the serum or plasma specimen, immerse the test strip
vertically in the serum or plasma for at least 10-12 seconds. Do not pass the maximum
line (MAX) on the test strip when immersing the strip. See illustration below.
3. Place the test strip on a non-absorbent flat surface, start the timer and wait for the red
line(s) to appear. The results should be read at 15 minutes.
Note : A low HBsAb concentration might result in a weak line appearing in the test region
(T) after an extended period of time; therefore, do not interpret the result after 20
minutes.
INTERPRETATION OF RESULT
Positive results
Two distinct red lines appear. One line should be in the control region (C) and another
line should be in the test region (T).
Note: The intensity of the red color in the test line region (T) will vary depending on the
concentration of the HBsAb present in the specimen. Therefore, any shade of red in the test
region (T) should be considered positive.
Negative results
One red line appears in the control region (C). No apparent red or pink line appears
in the test region (T).
76
lnvalid results
Control line fails to appear. Insufficient specimen volume or incorrect procedural
techniques are the most likely reasons for control line failure. Review the procedure and repeat
the test with a new test strip. If the problem persists, discontinue using the test kit immediately
and contact your local distributor.
Quality Control
Internal procedural controls included in the test. A red line appearing in the control region (C) is
an internal positive procedural control. It confirms sufficient specimen volume and correct
procedural technique.
Control standards are not supplied with this kit; however, it is recommended that positive control
(containing 10ng/mlHBsAg) and negative controls be tested as a good laboratory practice to
confirm the best procedure and to verity (containing o ng/ml HBsAg)proper test performance.
EXPECTED VALUES
The HBsAb One Step Hepatitis B Surface Antibody Test Strip (Serum/plasma) has been
compared with a leading commercial HBsAb RIA test. The correlation between these two these
two systems is over 99%.
Clinical Correlation
Viral hepatitis is as systemic disease primarily involving the liver. Most cases of acute
viral hepatitis are caused by Hepatitis A virus, Hepatitis B virus (HBV) or Hepatitis C virus. The
complex antigen found on the surface of HBV is called HBsAg. The presence of HBsAg in
serum or plasma is an indication of an active Hepatitis B infection, either acute or chronic. The
antibody to HBsAg. HBsAb, may not become detectable for 3-6 months after acute infection. It
is associated with resolution of the illness. This antibody is recognized as the marker of
immunity to HBV. As a result, vaccination against HBV was introduced to control the morbidity
and mortality associated with the virus. As part of the World Health Organization (WHO)
program the control of hepatitis B, many people especially new born infants, receive
vaccination. The minimum standard titer of HBsAg ia 10 mIU/mL for protective immunity to HBV.
Unfortunately, approximately 5-15% of healthy immuno-competent individuals either does not
exhibit an antibody response to the existing recombinant vaccination or respond poorly.
REFERENCES
1. Lewandrowski Kent, Clinical Chemistry Laboratory Management & Clinical Correlations,
Lippincott Williams & Wilkins, Philadelphia, 2002.
2. Henry John Bernard, Clinical Diagnosis & Management By Laboratory Methods, WB
Saunders
3. Co,1996.
4. Guidelines on Standard Operating Procedures for Clinical Chemistry, World Health
Organization, New Delhi, 2000.
5. Diagnosis Systems International (Diasys) Practical Guidelines, 2012.
6. Roche Diagnostic Systems Practical Guidelines, 2012.
77
BUKU MATERI PELATIHAN KETERAMPILAN MEDIS
PEMERIKSAAN FISIK UMUM
TAHUN 3
78
PEMERIKSAAN FISIK ABDOMEN
(PATOLOGIS)
Koordinator:
Bambang Djarwoto
Spesialis Penyakit Dalam – Konsultan Ginjal-Hipertensi,
Bagian Ilmu Penyakit Dalam
Fakultas Kedokteran Universitas Gadjah Mada
KONTRIBUTOR:
Rizka Humardewayanti Asdie Neneng Ratnasari
Spesialis Penyakit Dalam – Konsultan Spesialis Penyakit Dalam - Konsultan
Penyakit Tropik-Infeksi Gastroentero-hepatologi
Staf Bagian Ilmu Penyakit Dalam Staf Bagian Ilmu Penyakit Dalam
Fakultas Kedokteran UGM Fakultas Kedokteran UGM
Fahmi Indrarti
Spesialis Penyakit Dalam
Staf Bagian Ilmu Penyakit Dalam
Fakultas Kedokteran UGM
KO-KONTRIBUTOR:
ACKNOWLEDGEMENT:
Wasilah Rohmah
Guru besar Emeritus Ilmu Penyakit Dalam
Spesialis Penyakit Dalam – Konsultan Geriatri
Bagian Ilmu Penyakit Dalam
Fakultas Kedokteran Universitas Gadjah Mada
Martiana Suciningtyas
Koordinator Tahun III untuk Pelatihan Keterampilan Medik
Fakultas Kedokteran UGM
79
Naskah ini merupakan perbaikan dari naskah
Counseling and Physical Examination of the Abdomen yang diterbitkan pada tahun 2005
80
KATA PENGANTAR
Sangat penting bagi mahasiwa, untuk menyadari bahwa topik-topik ketrampilan yang
harus dikuasai sudah ada di Standar Kompetensi Dokter Indonesia. Kompetensi hanya akan
tercapai jika tingkat penguasaan Kognitif sampai C6 (evaluasi) A5 (karakterisasi) dan
Psikomotor P5 (naturalisasi). Hanya dengan latihan yang benar, diulang, diulang, dan diulang
berkali-kali akan membawa mahasiswa ke tingkat: Kompeten.
Selamat berlatih!
Yogyakarta, Oktober 2014
Kontributor
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Tingkat Kompetensi
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The spine
inspection at rest 1 2 3 4
inspection in motion 1 2 3 4
percussion for tenderness 1 2 3 4
palpation for tenderness 1 2 3 4
palpation for pain on vertical pressure 1 2 3 4
(eg pressing down on shoulders)
assessment of lumbar flexion 1 2 3 4
Thorax
inspection at rest 1 2 3 4
inspection during respiration 1 2 3 4
palpation of respiratory expansion 1 2 3 4
palpation of tactile fremitus 1 2 3 4
palpation of apex beat 1 2 3 4
percussion of lungs, lung bases, cardiac size 1 2 3 4
auscultation of lungs 1 2 3 4
auscultation of heart 1 2 3 4
inspection of breasts 1 2 3 4
palpation of breasts 1 2 3 4
Abdomen
Abdominal Inspection 1 2 3 4
1 2 3 4
auscultation (bowel, sounds, bruits) 1 2 3 4
percussion (especially liver, Traube‘s area bladder
dullness) 1 2 3 4
palpation (abdominal wall, colon, liver,
spleen, aorta, rigidity) 1 2 3 4
eliciting abdominal tenderness and rebound 1 2 3 4
tenderness 1 2 3 4
eliciting shifting dullness 1 2 3 4
eliciting a fluid thrill
eliciting renal tenderness
Extremities
inspection of skin, nails, muscle tone 1 2 3 4
inspection of joints 1 2 3 4
assessments of capillary pulse 1 2 3 4
assessments of capillary refill 1 2 3 4
palpation of arterial pulses 1 2 3 4
detection of bruits 1 2 3 4
palpation of skin, tendons, joints 1 2 3 4
assessments of range of motion of joints 1 2 3 4
examination of sensory system 1 2 3 4
examination of monitor system 1 2 3 4
eliciting reflexes: knee reflex, ankle reflex, triceps 1 2 3 4
reflex, biceps reflex, plantar response
Therapeutic skills
to advice a patient about life-style 1 2 3 4
to prescribe a diet 1 2 3 4
subcutaneous and intramuscular injection 1 2 3 4
administration of insulin 1 2 3 4
intravenous cannulation 1 2 3 4
mouth to mouth resuscitation 1 2 3 4
cardiac massage 1 2 3 4
initiate resuscitation 1 2 3 4
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nasogastric tube 1 2 3 4
Contraventil needle (needle decompression) 1 2 3 4
WSD 1 2 3 4
Endoscopy 1 2 3 4
bladder catheter 1 2 3 4
renal dialysis 1 2 3 4
sclerotherapy for varicose veins 1 2 3 4
NB: Level of Expected Ability yang harus tercapai pada akhir pendidikan.
Gastrointestinal
Mouth
Candidiasis 4
Mouth ulcers 4
Glossitis 3A
Esophagus
Corrosive lesions of esophageus 3B
Reflux esophaghitis 3A
Acute abdomen
Ileus 3B
Salphingitis 3A
Acute appendicitis 3A
Appendicular abscess 3B
Liver
Fatty liver 4
Hepatitis A 4
Uncomplicated Hepatitis B 4
Amoebic liver abscess 4
Jejunum, ileum
Enteritis
Colon
Irritable bowel syndrome 3A
Necrotizing enterocolistis 3A
Diverticulosis/diverticulitis 3A
Colitis 3A
Rectal,anal prolapsed 3A
Proctitis 3A
Hemorrhoids 3A
Pediatrics
Gastro-esophageal reflux 4
Gastro-enteritis 4
Gastro-enteritis dengan dehidrasi 3B
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Worms 4
Dehydration 3B
Malabsorbsion 3A
Food Intolerance 3A
Peritonotis Tuberculosis 4
Umbilical Hernia 3A
Hepatitis 3A
Cirrhosis of the liver 3A
Food Alergy 4
Nefro-urologi
Acute Glumerulonephritis 3A
Chronic Glumerulonephritis 3A
Renal Colic 3A
Urinary stone diseases or urinary calculi without colic 3A
Urinary tract infection 4
Uncomplicated pyelonephritis 4
Prostatitis 3A
Male genitalia
Hypospadia 3A
Epispadia 3A
Undescended testes/cryptorchidism 3A
Retractile testes 3A
Torsion of testis 3A
Paraphimosis 4
Rupture uretra 4
Rupture kandung kencing 4
Rupture Ginjal 4
Striktura Uretra 4
Priapismus 4
Penyakit peironi 4
Ekstrophia vesicae 4
Vulva
Vulvitis 4
Cyst of bartholin, abcess of bartholin‘s gland 4
Abcess of hair follicle or sebaceous gland 4
Condylomata acuminate 4
Vagina
Vaginitis 4
Bacterial vaginosis 4
Foreign body 4
Cervix
Cervicitis 4
Adnexae
Salpingitis 4
Ovarian cyst 3A
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PEMERIKSAAN FISIK ABDOMEN (PATOLOGIS)
Ilustrasi kasus
Seorang wanita berusia 24 tahun datang ke ruang unit darurat ditemani suaminya
dengan keluhan nyeri kram pada perut. Karena rasa nyeri ini muncul bersamaan
dengan menstruasi, dia beranggapan bahwa nyeri kram tersebut menunjukkan awal
dysmenorrheal yang biasa dia alami. Rasa nyeri ini awalnya menyebar dan sulit
untuk dilokalisir. Rasa nyeri bermula di daerah tengah (periumbilical) dan berpindah
dari wilayah periumbilical ke wilayah kuadran kanan bawah. Dia menderita demam,
kehilangan nafsu makan yang berkembang menjadi mual-mual dan bahkan muntah-
muntah. Hasil pemeriksaan fisik menunjukkan pasien memiliki temperatur yang
tinggi dan detak nadi yang semakin cepat. Sewaktu dilakukan palpasi pada
abdominal, dokter mendeteksi adanya rigiditas terlokalisisr dan nyeri pada abdomen
kanan bawah. Dokter meminta dilakukan penghitungan darah dan merujuk pasien
ke ahli bedah tanpa memberikan medikasi analgesik.
Pertanyaan
1. Apa saja kemungkinan diagnosis pada pasien tersebut?
2. Sebagai dokter umum, apa saja yang harus disiapkan pada pasien ini?
3. Edukasi apa yang dapat diberikan untuk pasien tersebut?
Tujuan Pembelajaran
1. Mengulang kembali langkah-langkah dasar komunikasi dokter-pasien, anamnesis, vital sign,
pemeriksaan fisik abdomen, serta organ lain yang relevan.
2. Mengulang kembali memahami metode dan prosedur dalam menggunakan peralatan yang
diperlukan untuk pemeriksaan abdomen, serta organ lain yang relevan.
3. Mampu memahami dan melaksanakan prosedur diagnostik (anamnesis, pemeriksaan fisik
dan pemeriksaan penunjang).
4. Mampu memberikan terapi dan edukasi sesuai dengan kewenangannya.
5. Mampu menulis resep.
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7. Mahasiswa mampu melakukan pemeriksaan fisik patognomonis, relevan, skrining.
8. Mahasiswa mampu merencanakan pemeriksaan penunjang.
9. Mahasiswa mampu menemukan masalah aktif & pasif dari anamnesis, pemeriksaan fisik
dan pemeriksaan penunjang.
10. Mahasiswa mampu membuat diagnosis klinis – causative/definitive
11. Mahasiswa mampu memberikan terapi non medika mentosa – medikamentosa.
12. Mahasiswa mampu menulis resep.
13. Mahasiswa mampu memberikan edukasi untuk promotif, preventif dan rehabilitative.
Penilaian
Prosedur kerja digunakan sebagai metode pengajaran. Skor minimal pada akhir blok adalah
70.
Latihan Mandiri
Tujuan dari latihan mandiri adalah untuk meningkatkan skor / nilai prosedur pemeriksaan
sampai dengan ≥ 70.
Mempertimbangkan bahwa sesi latihan terbimbing dengan instruktur di tahun ketiga ini amat
terbatas (untuk masing-masing topik hanya 1 kali latihan), maka latihan mandiri sangat
diperlukan.
Salah satu kesempatan latihan mandiri adalah latihan di seting pelayanan primer (Puskesmas
dan LSM) yang telah difasilitasi oleh Skills Lab. Mahasiswa tahun ketiga silakan memanfaatkan
kesempatan tersebut untuk mengoptimalkan latihan keterampilan medik secara terintegrasi di
komunitas (dengan tetap mendapatkan umpan balik dari instruktur skills lab secara periodik).
Program Belajar
1. Pemeriksaan fisik Abdomen terbagi dalam 2 sesi terbimbing dengan instruktur.
2. Mahasiswa telah diberi tugas untuk membuat work plan yang terdiri dari 10 gejala-gejala
yang berbeda, yaitu:
Sesuai dengan kompetensi dokter umum, buatlah algoritme diagnosis & pengelolaan
(edukasi, penulisan resep):
1. Nyeri perut kanan bawah akut (nyeri visceral)
2. Benjolan di inguinal
3. Pembesaran perut/perut membesar
4. Jaundice
5. Muntah darah
6. Nyeri Ulu hati
7. Diare
8. Berak darah
9. Kencing darah
10. Nyeri kolik
Catatan: Setiap mahasiswa hanya wajib membuat work plan dengan 1 symptom saja,
mungkin ada beberapa mahasiswa membuat work plan yang sama karena jumlah
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mahasiswa dalam 1 kelompok lebih banyak daripada jumlah symptoms yang
ditugaskan.
4. Instruktur dimohon untuk menuliskan kasus yang telah dibahas pada saat membimbing
mahasiswa di dalam Berita Acara (ada di dalam daftar hadir mahasiswa / didalam daftar
evaluasi mahasiswa)
5. Work plan mahasiswa mohon dikembalikan lagi kepada mahasiswa supaya dapat
dipakai dalam pertemuan yang berikutnya.
88
3. Penutupan:
- Refleksi, hasil latihan dibandingkan Instruktur 25 menit
dengan checklist / feedback form.
- Penjelasan semua pertanyaan
work plan.
- Penjelasan tugas untuk
meningkatkan keahlian dengan
Belajar Mandiri.
- Mengingatkan para mahasiswa
mengenai pentingnya keahlian
sebagai dasar dari pemeriksaan
fisik yang akan diajarkan pada blok
selanjutnya.
- Feed back dari mahasiswa
mengenai sesi praktek untuk Skill
Lab.
- Doa penutup.
Tabel 2. Instrumen dan alat bantu dalam pemeriksaan tanda vital dan abdomen
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Struktur dan Fisiologi Abdomen
Untuk tujuan deskriptif abdomen dapat dibagi menjadi empat kuadran. Dua garis khayal
bersilangan di pusar dan membagi abdomen menjadi kuadran kanan atas dan kanan bawah,
serta kuadran kiri atas dan kiri bawah. Satu garis ditarik dari sternum ke tulang pubis melalui
pusar. Dengan demikian terbentuklah empat kuadran dan organ perut di dalam tiap kuadran
diperlihatkan dalam Gambar 1.
Cara deskripsi lainnya membagi abdomen menjadi sembilan daerah (Gambar 2):
epigastrium, umbilikus, suprapubis, hipokondrium kanan dan kiri, lumbal kanan dan kiri, inguinal
kanan dan kiri. Dua garis khayal ditarik dengan memperpanjang garis midklavikular sampai ke
pertengahan ligamen inguinal. Garis-garis ini membentuk batas lateral muskulus rektus
abdominus. Dua garis sejajar dibuat tegak lurus dengan garis-garis ini, yaitu satu pada margo
kosta dan lainnya pada spina iliaka anterior superior. Yang lazim dipakai hanya nama tiga
daerah di bagian tengah (epigastrium, umbilikus, dan suprapubis).
Pemeriksa harus menguasai struktur abdomen yang terletak pada tiap daerah. Tabel 3
memuat daftar organ-organ yang ada pada masing-masing dari empat kuadran. Karena ginjal,
duodenum, dan pankreas merupakan organ posterior, kelainan pada organ-organ ini tidak
mungkin teraba pada orang dewasa. Pada anak-anak, di mana otot perutnya belum
berkembang, massa ginjal dapat diraba.
90
Apendiks Kolon desendens: sebagian
Kolon asendens: sebagian Ovarium kiri
Ovarium kanan Tuba falopii kiri
Tuba falopii kanan Ureter kiri
Ureter kanan Korda spermatika kiri
Korda spermatika kanan Uterus (jika membesar)
Uterus (jika membesar) Kandung kemih (jika membesar)
Kandung kemih (jika membesar)
PEMERIKSAAN ABDOMEN
Pada pemeriksaan abdomen pasien harus berbaring lurus di tempat tidur, memakai
bantal di kepala dan perutnya harus terlihat penuh dari sternum sampai lutut. Lengannya
diletakkan di sisi tubuh dan tungkainya lurus. Sehelai handuk atau kain diletakkan di atas
genetalia pasien seperti yang terlihat pada gambar 3.
Pada pemeriksaan selanjutnya, untuk membantu merelaksasi otot-otot perut dapat
diletakkan bantal di bawah lutut pasien atau dengan mengintruksikan pasien menekuk lututnya
(gambar 4). Pemeriksa harus berdiri di sisi kanan penderita. Jika pasien mempunyai keluhan
nyeri perut, adalah penting bahwa daerah yang nyeri diperiksa terakhir. Jika pemeriksa
menyentuh area yang nyerinya maksimal, otot perutnya akan teregang.
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A. INSPEKSI ABDOMEN
Inspeksi abdomen adalah memeriksa abdomen dengan cara mengamati/
memandang/melihat dan membandingkan secara cermat keadaan abdomen. Pemeriksa harus
melatih dirinya untuk melihat tubuh dengan menggunakan suatu pendekatan sistematik. Ketika
melakukan anamnesis, pemeriksa sudah harus memperhatikan hal-hal tertentu mengenai
pasien yang mungkin dapat membantu menegakkan diagnosis. Coba buka kembali buku materi
skills lab blok 1.3 mengenai pemeriksaan umum yang berkaitan dengan kelainan di abdomen.
Inspeksi abdomen meliputi kontur dinding abdomen yang ditentukan oleh volume
jaringan subkutan, perkembangan otot-ototnya, dan adanya distorsi jaringan parut. Diperhatikan
pula bentuk abdomennya apakah rounded, protuberan, datar atau scaphoid. Abdomen yang
scaphoid mungkin berkaitan dengan kakeksia, sedang abdomen protuberan dapat disebabkan
oleh distensi usus oleh gas, asites, pembesaran organ atau obesitas. Jaringan parut dari bekas
operasi sebelumnya dapat menyebabkan distorsi dari kontur.
Umbilikus dinilai untuk menilai apakah ada penonjolan atau indentasi. Umumnya
umbilicus normal biasanya mengadakan indentasi tetapi sama rata dengan dinding abdomen
atau agak menonjol. Umbilikus yang tereversi sering menjadi tanda peningkatan tekanan
abdominal, biasanya karena asites atau massa yang besar. Suatu hernia umbilical juga
dapat menyebabkan eversi umbilicus. Adakah nodul-nodul seperti nodul Sister Mary Joseph’s
yang merupakan nodul metastatik adenocarcinoma lambung.
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Gambar 8. Penurunan Turgor Kulit pada
Dehidrasi Berat Gambar 9. Nodul Sister Mary Joseph’s
Selain itu kulit abdomen harus dilihat apakah ada jaringan parut bekas pembedahan
atau trauma serta dicatat dimana lokasi jaringan parut tersebut berada. Tanda-tanda kulit
seperti perubahan warna, lesi local, dan pola vena, seperti stria perak atau putih atau ―tanda
garukan‖ yang merupakan tanda peregangan kulit yang terjadi pada orang-orang dengan
pertambahan berat badan yang cepat, stria berwarna agak kebiruan atau kehitaman dapat
dilihat pada orang hamil, stria ungu-merah muda merupakan tanda klasik akibat kelebihan
adrenokortikal. Apakah ada tanda Gray yaitu perdarahan / ekimosis yang masif dapat terjadi
pada daerah abdomen atau pinggul yang dapat terjadi pada pankreatitis atau strangulasi usus,
atau apakah ada tanda Cullen yaitu kebiru-biruan yang disebabkan oleh hemoperitoneum.
Pola vena abdomen biasanya hampir tidak dapat dilihat atau samar, tidak jelas dan
retikuler, jika dapat dilihat drainase dua pertiga bawah abdomen terjadi ke arah bawah. Jika ada
sumbatan pada vena cava, vena superficial mungkin berdilatasi dan drainase vena terjadi ke
arah cephal. Pada pasien dengan hipertensi portal dilatasi vena kelihatan menyebar dari
umbilicus, ini disebabkan oleh aliran membalik melalui vena kolateral di dalam ligamentum
falsiformis, dan pola aliran ini disebut dengan caput medusae. Jika vena superfisialis
mengalami distensi periksalah arah drainasenya. Inspeksi adanya hernia dilakukan pada
pasien dengan posisi berbaring ditempat tidur, dan pasien diminta untuk batuk,
sementara pemeriksa memeriksa daerah inguinal, umbilical dan femoral.
Gambar 11. Periumbilical Purpura (Tanda Gambar 12. Tanda Grey Turner
Cullen)
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Gambar 13. Dilatasi Vena Dinding Abdomen Gambar 14. Rose Spot
Pada orang kurus dapat dilihat hantaran pulsasi aorta pada epigastrium atau
periumbilikalis. Amati pula pergerakan peristaltik dan naik turunnya dinding abdomen pada
waktu pergerakan pernafasan. Pergerakan abdomen sewaktu istirahat pada posisi terlentang
adalah minimal.
B. AUSKULTASI ABDOMEN
Lakukan auskultasi abdomen sebelum melakukan perkusi atau palpasi, karena
manuver-manuver ini dapat mengganggu frekuensi suara usus. Auskultasi bunyi usus
dapat didengarkan dengan diafragma stetoskop dengan menekan secara lembut terhadap kulit
dan dapat dinilai pada setiap kuadran. Bunyi usus normal terdiri dari clicks and gurgles, timbul
kira-kira tiap 5-10 detik dan bernada tinggi atau sekitar 5-34 kali permenit. Hitunglah berapa kali
terdengar bunyi usus dalam 1 menitnya dengan cara meletakkan diafragma stetoskop diatas
mid-abdomen. Pada keadaan normal, suara peristaltik usus kadang-kadang dapat didengar
walaupun tidak menggunakan stetoskop, terutama pada keadaan lapar. Dengan bertambahnya
isi usus, peristaltik menjadi lebih aktif, aktivitas usus bertambah saat post-prandial dan bunyi
usus menjadi lebih sering. Pada waktu istirahat bunyi usus menjadi lebih jarang.
Jika ada obstruksi usus, suara peristaltik dapat meningkat, lebih lagi pada saat timbul
rasa sakit yang bersifat kolik dan mungkin akan timbul arus ―denting‖ bernada tinggi yang
disebut dengan borborigmi (atau stomach growling). Suara gurgle yang diperpanjang yang
berkaitan dengan hiperperistaltik, sering dijumpai pada obstruksi usus akut dini. Jika setelah 2
menit tidak terdengar bunyi usus, dapat dibuat pernyataan tidak ada bunyi usus. Tidak adanya
bunyi usus mengarah pada ileus paralitik yang disebabkan iritasi peritoneum difus. Keadaan ini
juga dapat terjadi pada tahap lanjut dari obstruksi usus dimana usus menjadi sangat melambat
dan atoni. Pada ileus obstruksi kadang terdengar suara peristaltik dengan nada yang tinggi dan
suara logam (metallic sound).
Suatu succussion splash mungkin ditemukan pada abdomen yang distensi sebagai
akibat adanya gas dan cairan didalam suatu organ yang mengalami obstruksi, dengan cara
meletakkan stetoskop diatas abdomen pasien sambil mengguncang pasien dari sisi ke sisi.
Adanya bunyi percikan biasanya menunjukkan adanya distensi lambung atau kolon.
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Gambar 17. Succusion splash
Auskultasi juga berguna untuk menentukan adanya bruit. Tiap kuadran harus diperiksa
untuk mengetahui adanya bruit ini terutama pada aorta, arteri iliaca, dan arteri renalis. Suara
murmur sistolik atau diastolic mungkin dapat didengar pada auskultasi abdomen. Bruit sistolik
dapat didengar pada aneurisma aorta atau pada pembesaran hepar karena hepatoma. Bruit
dengan komponen sistolik dan diastolic menunjukkan adanya turbulensi aliran darah akibat
oklusi parsial arteri atau insufisiensi arteri. Jika pasien memiliki tekanan darah tinggi, cari
apakah ada bruit di epigastrium dan masing-masing di kuadran atas, dan lanjutkan pada daerah
sudut costovertebralis pada posisi pasien duduk. Bising vena (venous hum) yang kadang-
kadang disertai dengan terabanya getaran (thrill) dapat didengar diantara umbilicus dan
epigastrium. Pada keadaan fistula arteriovenosa intra-abdominal kadang-kadang dapat
didengar suara murmur.
Selain itu dapat pula digunakan untuk menilai ada tidaknya gesekan friksi peritoneal
yang menunjukkan adanya peradangan. Selama gerakan pernafasan, suatu gesekan friksi
mungkin terdengar di kuadran atas kanan atau kiri jika ada kelainan hepar atau limpa, seperti
tumor hepar, infeksi gonococcal disekitar hepar dan infark limpa.
C. PERKUSI ABDOMEN
Perkusi dipakai untuk memperlihatkan adanya distensi gas, cairan atau massa padat.
Pada pemeriksaan normal biasanya hanya ukuran dan lokasi hepar dan limpa yang dapat
ditentukan. Sebagian pemeriksa lebih suka melakukan palpasi sebelum perkusi, terutama jika
pasien mengeluh nyeri perut. Perkusi abdomen, dilakukan dengan posisi pasien berbaring
terlentang, dilakukan perkusi 13 titik, seperti yang telah dipelajari pada blok 1.3 sebelumnya.
Perkusi abdomen sangat membantu dalam menentukan apakah rongga abdomen berisi lebih
banyak cairan atau udara serta distribusinya udara di dalam abdomen. Selain itu perkusi
berguna untuk menentukan ukuran hepar dan limpa.
Timpani merupakan bunyi perkusi yang paling sering ditemukan pada abdomen. Ini
disebabkan oleh adanya gas didalam lambung, usus kecil dan kolon, kecuali di daerah hepar
suara perkusinya adalah pekak. Hilangnya sama sekali daerah pekak hepar dan bertambahnya
bunyi timpani di seluruh abdomen harus dipikirkan akan kemungkinan adanya udara bebas
dalam rongga perut, misal pada perforasi usus. Daerah suprapubis mungkin redup pada perkusi
jika kandung kemih distensi atau pada wanita jika uterusnya membesar. Terdapat suatu
keadaan yang disebut dengan fenomena papan catur (chessboard phenomenon) dimana
pada perkusi dinding perut ditemukan bunyi timpani dan redup yang berpindah-pindah, sering
ditemukan pada peritonitis tuberkulosa.
Perkusi hepar
Lakukan perkusi hepar seperti yang telah dipelajari pada blok 1.3. Distensi kolon pada
kuadran kanan dapat mengaburkan redup hepar bagian bawah, oleh karena itu pemeriksa
dapat menaksir terlalu rendah ukuran hepar. Jika pada perkusi ditemukan redup hepar lebih
dari 12 cm pada garis midclavicula kanan, atau jika tepinya teraba lebih dari 2 cm di bawah
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margo kosta kanan tanpa pengembangan paru yang berlebihan maka dicurigai hepar ini
membesar. Redup hepar ini berkurang bila hepar ini mengecil (misal pada sirosis hepar) atau
terdapat udara bebas di atas diafragma sebagai akibat perforated hollow viscus. Batas atas
redup hepar mungkin dapat turun ke bawah akibat rendahnya diafragma pada penderita
penyakit paru obstrusi menahun (PPOK).
Jika pemeriksa mendapat kesulitan dalam menentukan batas bawah hati, scratch test
merupakan pemeriksaan tambahan yang bermanfaat. Difragma stetoskop ditempatkan pada
hepar tepat di atas tepi iga pada garis mid clavicula. Satu jari tangan mengadakan garukan
dengan lembut pada kulit secara zigzag berlanjut ke cephal di sepanjang garis mid-clavicula
menuju kuadran kanan atas. Bila jari tangan penggaruk menyilang tepi hepar, maka bunyi
dihantarkan lebih jelas melalui organ padat.
Perkusi Limpa
Meskipun daerah limpa sulit untuk diperkusi, penentuan ukuran limpa harus diusahakan.
Ruang Traube adalah daerah gelembung udara lambung pada kuadran atas kiri. Tepat
disebelah lateral ruang Traube ada daerah redup yang berkaitan dengan adanya limpa. Daerah
ini kira-kira terletak pada iga ke sepuluh disebelah posterior garis mid-aksila. Ingat dan kalau
perlu buka kembali buku petunjuk skills lab blok 1.3 bagaimana cara memperkusi limpa.
Pemeriksaan Ascites
Dalam keadaan adanya cairan bebas didalam rongga abdomen, perkusi di atas dinding
perut mungkin timpani dan disampingnya redup. Lakukanlah perkusi mulai dari umbilikus ke
lateral hingga ditemukan batas timpani dan redup pada posisi pasien berbaring telentang. Batas
timpani ada di atas batas redup, ini disebabkan gas dalam usus yang terapung di atas puncak
asites. Dengan memiringkan pasien ke satu sisi suara redup ini akan berpindah (shifting
dullness), pada posisi yang lebih rendah, daerah disekitar umbilikus yang mula-mula timpani
sekadang akan menjadi redup. Pemeriksaan ini sangat patognomonis dan lebih dapat
dipercaya dari pada memeriksa adanya gelombang cairan, memiliki sensitivitas 83% dan
spesifisitas 56%. Adanya redup bilateral pada perkusi pinggang merupakan tanda yang paling
sensitif untuk adanya asites dengan sensitivitasnya 94% sedang spesifisitasnya hanya 29%.
Selain ini ada beberapa teknik lain untuk memeriksa adanya cairan bebas didalam
rongga abdomen (asites), yaitu:
Cara pemeriksaan gelombang cairan (fluid wave). Cara ini dilakukan pada pasien
dengan asites yang cukup banyak dan perut yang agak tegang. Pasien dalam keadaan
berbaring telentang dengan tangan asisten atau tangan pasien sendiri diletakkan di bagian
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tengah abdomen dengan sedikit penekanan. Penekanan dinding abdomen ini akan
menghentikan transmisi impuls oleh jaringan adiposa subkutan dan mencegah gerakan yang
diteruskan melalui dinding abdomen. Tangan pemeriksa diletakkan pada satu sisi sedang
tangan lainnya mengetuk-ngetuk dinding perut atau pinggang pada sisi yang lain. Adanya
gelombang cairan mempunyai sensitivitas hanya 50% dan spesifitasnya 82%. Hasil positif palsu
dapat terjadi pada pasien yang terlalu gemuk dan hasil negatif palsu dapat terjadi jika asitesnya
sedikit sampai sedang.
Untuk cairan yang lebih sedikit dan meragukan dapat dilakukan pemeriksaan dengan
posisi pasien terkurap dan menungging (knee-chest position). Setelah beberapa saat,
perkusi daerah perut yang terendah, jika terdapat cairan akan didengar bunyi redup. Pada
posisi tegak maka perkusi redup akan didengarkan pada bagian bawah.
Pemeriksaan yang lain adalah puddle sign yaitu posisi pasien tetap pada knee-chest
position dan dengan menggunakan stetoskop yang diletakkan pada bagian perut terbawah
didengarkan perbedaan suara yang ditimbulkan karena ketukan jari-jari pada sisi perut
sedangkan stetoskop digeserkan melalui perut tersebut ke sisi yang lainnya. Ketukan
diteruskan pada posisi yang terfiksir. Pengurangan intensitas bunyi secara mendadak yang
dihasilkan dari ketukan jari tangan ketika stetoskop bergerak di atas cairan yang tergenang
dianggap tanda positif. Jika dirasakan perubahan ini, proses ini diulang pada tempat
seberangnya untuk menentukan margo/batasnya.
D. PALPASI ABDOMEN
Untuk mempermudah palpasi hepar abdomen diperlukan dinding usus yang lemas
dengan cara posisi pasien berbaring telentang, kaki ditekuk sehingga membuat sudut 45o-60o.
Palpasi abdomen dilakukan 2 kali yaitu palpasi ringan atau superficialis palpation dan palpasi
dalam atau deep palpation.
Palpasi ringan dipakai untuk menemukan nyeri tekan dan daerah spasme otot atau
rigiditas dan beberapa organ dan massa superfisial. Seluruh abdomen harus dipalpasi secara
sistematis, dengan menggunakan bagian rata tangan atau bantalan jari tangan, bukan dengan
ujung jari. Jari-jari tangan harus disatukan dan hindari gerakan menusuk secara tiba-tiba.
Tangan harus diangkat dari satu daerah ke daerah yang lain, bukannya digeserkan diatas
dinding perut. Palpasi ini dengan menekan ke arah dalam tidak lebih dari 1 cm sambil mencari
dan menilai adanya nyeri tekan, massa kutan atau subkutan. Setiap kuadran harus dilakukan
palpasi ringan.
Untuk memonitor respon palpasi abdomen, pemeriksa harus mengamati wajah
pasien secara terus menerus selama pemeriksaan, karena banyak pasien tidak
memperlihatkan ekspresi nyeri secara verbal tetapi menunjukkan rasa tidak enak/nyaman
dengan perubahan wajah. Teknik ini sudah dipelajari pada blok 1.3. Coba ingat kembali.
Selama ekspirasi, muskulus rektus biasanya rileks dan lunak. Jika ada sedikit perubahan
dikatakan bahwa ada rigiditas (rigiditas adalah spasme involunter otot-otot perut dan
menunjukkan iritasi peritoneum). Rigiditas mungkin difus seperti pada peritonitis atau setempat,
seperti diatas apendiks atau kandung empedu yang meradang. Pada pasien yang mengeluh
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nyeri perut, palpasi harus dilakukan dengan hati-hati dan palpasi dilakukan dari tempat yang
jauh dari keluhan, meninggalkan palpasi dalam pada tempat yang bersangkutan untuk
pemeriksaan yang terakhir.
Palpasi dalam diperlukan untuk menentukan ukuran organ dan adanya massa
abdomen, lokasinya, ukurannya, bentuknya, konsistensinya, ada nyeri tidak dan mobilitasnya
terhadap respirasi atau jaringan sekitarnya. Pada palpasi dalam bagian datar tangan kanan
diletakkan di atas abdomen dan tangan kiri diletakkan di atas tangan kanan. Ujung jari tangan
kiri memberi tekanan, sedang tangan kanan mengindera setiap rangsang taktil. Tekanan
kepada abdomen harus diberikan dengan ringan tetapi terus menerus. Selama palpasi dalam,
pasien harus disuruh untuk bernafas perlahan-lahan melalui mulutnya dan meletakkan kedua
lengannya pada sisi tubuhnya. Meminta pasien untuk membuka mulutnya selama bernafas
dapat membantu relaksasi otot secara umum. Tangan yang melalukan palpasi harus hangat,
sebab tangan yang dingin dapat menimbulkan spasme otot volunter yang disebut dengan
guarding. Mengajak pasien bercakap-cakap sering membantu merelaksasi otot-otot perutnya.
Sebelum melakukan palpasi pada pasien dengan nyeri perut atau nyeri tekan, suruh
pasiennya batuk, ini untuk menilai apakah batuk mencetuskan nyeri. Kemudian lakukan palpasi
secara gentle dengan menggunakan satu jari untuk mendapatkan daerah yang nyeri. Pasien
dengan nyeri perut harus ditentukan apakah ada nyeri lepas (rebound tenderness).
Nyeri lepas adalah tanda iritasi peritoneum dan dapat dibangkitkan dengan mempalpasi
dalam-dalam dan perlahan-lahan di daerah perut menjauhi daerah yang diduga mengalami
peradangan setempat. Tangan yang melakukan palpasi kemudian diangkat dengan cepat.
Tanyailah pasien dan lihat ekspresi wajah pasien mana yang lebih sakit, saat saya tekan
(sambil melakukan penekanan) atau saat saya lepas (sambil melepaskan tekanan). Sensasi
nyeri pada sisi peradangan yang terjadi ketika tekanan dilepaskan disebut nyeri lepas.
Palpasi Hepar
Untuk mempermudah palpasi hepar diperlukan dinding usus yang lemas dengan cara
posisi pasien berbaring telentang, kaki ditekuk sehingga membuat sudut 45o-60o. Palpasi
dikerjakan dengan menggunakan sisi palmar radial jari tangan (bukan ujung jari) dengan posisi
ibu jari terlipat di bawah palmar manus. Lebih tegas lagi bila arah jari membentuk sudut 45o
dengan garis median. Ujung jari terletak pada bagian lateral musculus rectus abdominalis dan
kemudian pada garis median untuk memeriksa hepar lobus sinistra, sementara tangan kiri
pemeriksa diletakkan dibawah tubuh pasien paralel dan menyokong iga ke-11 dan 12 kanan,
disebelah lateral muskulus paraspinosus.
Pasien diminta relaks dan menarik nafas panjang, pada saat ekspirasi maksimal jari
ditekan ke bawah kemudian pada awal inspirasi jari bergerak ke kranial dalam arah parabolik,
sehingga diharapkan bila hepar membesar akan terjadi sentuhan antara jari pemeriksa dengan
hepar pada saat inspirasi maksimal.
Palpasi dimulai dari regio iliaka kanan menuju ke tepi lengkung iga kanan. Dinding
abdomen ditekan ke bawah dengan arah dorsal dan kranial sehingga akan dapat menyentuh
tepi anterior hepar. Gerakan ini dilakukan berulang-ulang dan posisinya digeser 1-2 jari ke arah
lengkung iga. Penekanan dilakukan pada saat pasien sedang inspirasi. Pada inspirasi, hepar
terpalpasi sekitar 3 cm di atas lengkung iga kosta kanan pada garis midclavicula. Beberapa
orang bernafas lebih dengan menggunakan dadanya (pernafasan dada), dibandingkan dengan
abdomennya. Akan sangat membantu bila melatih pasien terlebih dahulu untuk bernafas
dengan abdomennya, pada saat melakukan palpasi hepar, limpa dan ginjal.
Bila pada palpasi dapat meraba adanya pembesaran hepar, maka harus didiskripsikan sebagai
berikut:
Berapa cm lebar redup hepar di bawah lengkung iga kanan atau di bawah processus
xyphoideus?
Bagaimana keadaan tepi hati? Misalnya tajam pada hepatitis akut atau tumpul pada
tumor hepar.
Bagaimanakah konsistensinya? Apakah kenyal (konsistensi normal) atau keras (pada
tumor hepar)?
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Bagaimanakan permukaannya? Pada tumor hepar permukaan teraba berbenjol, dan
Apakah ada nyeri tekan? Hal ini dapat terjadi pada kelainan seperti abses hepar atau
tumor hepar. Pada abses hepar dapat pula dirasakan adanya fluktuasi.
Pada keadaan normal hati tidak akan terpalpasi kecuali pada beberapa kasus misal dengan
tubuh yang kurus. Terabanya hepar 1-2 jari di bawah lengkung iga harus dikonfirmasi apakah
hal tersebut memang suatu pembesaran hepar atau karena adanya perubahan letak diafragma
misal pada emfisema paru.
Teknik lain untuk palpasi hepar dikenal dengan metode ”kaitan”/ hooking technique,
terutama jika pasien obese. Pemeriksa berdiri didekat kepala pasien dan meletakkan kedua
tangan bersama-sama di bawah margo/lengkung kosta kanan dan daerah redup. Pemeriksa
menekan ke dalam dan keatas dan mengait di sekitar tepi hepar ketika pasien disuruh menarik
nafas dalam-dalam.
Untuk menilai adanya pembesaran lobus kiri hepar dapat dilakukan palpasi pada garis
tengah abdomen ke arah epigastrium. Batas atas sesuai dengan pemeriksaan perkusi batas
paru hepar (normal sela iga 6). Pada beberapa keadaan patologis misal emfisema paru, batas
ini akan lebih rendah sehingga besar hepar yang normal dapat teraba tepinya pada waktu
palpasi.
Nyeri tekan hepar diperiksa dengan meletakkan telapak tangan kiri diatas kuadran akan
atas dan dengan lembut mengetuknya dengan permukaan ulnar kepalan tinju tangan kanan.
Proses peradangan yang menyerang hepar atau kandung empedu akan menyebabkan nyeri
tekanan pada palpasi dengan tinju ini.
Kadang-kadang selama palpasi nyeri timbul selama inspirasi dan pasien secara tiba-tiba
menghentikan usaha inspirasi ini. Hal ini disebut dengan tanda Murphy, dan mengarah kepada
kolesistitis akut. Pada waktu inspirasi kandung empedu yang meradang turun menyentuh
tangan yang melakukan palpasi, timbul nyeri, sehingga pernafasan berhenti.
Palpasi Limpa
Teknik palpasi limpa tidak berbeda dengan palpasi hepar dan telah dipelajari pada blok
1.3. Pada keadaan normal limpa tidak teraba. Limpa membesar mulai dari bawah lengkung iga
kiri, melewati umbilikus sampai regio iliaka kanan. Seperti halnya hepar, limpa juga bergerak
sesuai inspirasi. Palpasi dimulai dari regio iliaka kanan melewati umbilikus di garis tengah
abdomen, menuju ke lengkung iga.
Pembesaran limpa diukur dengan menggunakan garis Schuffner yaitu garis yang
dimulai dari titik dilengkung iga kiri menuju ke umbilicus dan diteruskan sampai spina iliaka
anterior superior (SIAS) kanan. Garis tersebut dibagi menjadi 8 bagian yang sama. Untuk
meyakinkan bahwa yang teraba itu adalah limpa, harus diusahakan meraba incisura lienalisnya.
Palpasi limpa juga dipermudah dengan memiringkan pasien 45o ke arah kanan (ke arah
pemeriksa). Pembesaran limpa dapat disebabkan oleh hiperplasia, kongesti, infeksi atau
infiltrasi oleh tumor atau unsur leukemoid. Setelah tepi bawah limpa teraba maka didiskripsikan
sebagai berikut:
Berapa jauh dari lengkung iga kiri pada garis Schuffner? (SI sampai SVIII)
Bagaimana konsistensinya? Apakah kenyal (splenomegali karena hipertensi portal) atau
keras (seperti pada malaria).
Palpasi Ginjal
Ginjal terletak pada daerah retroperitoneal sehingga pemeriksaan harus dengan cara
bimanual. Tangan kiri diletakkan pada pinggang bagian belakang dan tangan kanan pada
dinding abdomen di ventralnya. Teknik ini sudah dipelajari di blok 1.3. Pembesaran ginjal
(akibat adanya tumor atau hidronefrosis) akan teraba diantara kedua tangan tersebut.
Fenomena ini dinamakan ballotement positif. Pada keadaan normal ballotement negatif.
Untuk menyingkirkan kemungkinan nyeri tekan ginjal, maka untuk pemeriksaan ini
pasien harus dalam posisi duduk. Pemeriksa mengepalkan tinjunya menggunakan tangan
kanan dengan lembut memukul tangan pemeriksa yang satunya yang diletakkan daerah di atas
sudut kostovertebral dikedua sisi. Pasien dengan pielonefritis biasanya merasakan nyeri hebat
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bahkan pada perkusi ringan di daerah ini. Jika mencurigai adanya pielonefritis, pakailah
tekanan dengan jari-jari saja.
Palpasi Aorta
Palpasi dalam pada garis tengah dekat umbilikus memungkinkan kejelasan margo aorta
pada orang yang kurus atau orang dengan dinding abdomen yang sangat kendur. Dengan
menggunakan kedua tangan, lakukan penekanan yang dalam pada salah satu sisi aorta dan
dapat diperkirakan dimensi lateral. Pada orang berusia > 50 tahun ke atas lebar aorta tidak
lebih dari 3 cm (sekitar 2,5 cm). Pengukuran ini tidak termasuk ketebalan dinding abdomen.
Kemudahan merasakan pulsasi aorta bervariasi sesuai dengan ketebalan dinding abdomen dan
diameter anteroposterior abdomen.
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Gambar 21. Palpasi Kandung Kemih
5. Lakukan pemeriksaan test Rovsing sign dan radiasi / penjalaran nyeri dari test
‖rebound tenderness‘. Tekanlah secara ―gentle‖ pada kuadran kiri bawah kemudian
lepas dengan cepat dan mendadak. Nyeri yang dirasakan pada kuadran kanan bawah
ketika daerah kiri bawah ditekan disebut dengan Rovsing sign positive. Nyeri yang
dirasakan pada kuadran kanan bawah ketika tekanan dilepaskan disebut dengan
rebound tenderness radiation positive.
6. Lakukan pemeriksaan Psoas sign (Gambar 23). Tempatkan tangan pada lutut kanan
pasien dan mintalah pasien mengangkat kakinya melawan tangan anda. Atau mintalah
pasien untuk miring ke sisi kiri, suruhlah pasien untuk mengangkat kaki kanannya lurus
ke atas dengan bertumpu pada pangkal paha. Fleksi kaki pada pangkal paha akan
menyebabkan kontraksi dari muskulus psoas. Adanya nyeri abdomen akibat manuver ini
disebut dengan psoas sign positive, menunjukkan adanya iritasi muskulus psoas yang
diakibatkan oleh radang appendix.
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Gambar 23. Illiopsoas sign
7. Lakukan juga maneuver obturator sign (Gambar 24). Fleksikan kaki kanan pasien 90o
pada pangkal paha dengan lutut ditekuk. Pegang kaki pasien di atas lutut dan di atas
pergelangan kaki. Rotasikan kaki ke dalam dan medial. Nyeri pada daerah hipogastrik
kanan disebut dengan obturator sign positive, menunjukkan adanya iritasi muskulus
obturator.
8. Carilah daerah hiperestesi kulit dengan mencubit kulit secara gentle menggunakan ibu
jari dan jari telunjuk. Secara normal perasat ini tidak menyebabkan nyeri.
9. Lakukan pemeriksaan rectal. Perasat ini tidak hanya dapat membantu membedakan
antara appendix yang normal dan appendiks yang meradang, tetapi juga membantu
apakah yang meradang betul-betul appendix di dalam rongga. Adanya nyeri pada
daerah kanan pada pemeriksaan rectal mungkin dapat pula disebabkan inflamasi dari
jaringan adnexa atau vesicular seminalis.
Pemeriksaan Inguinal
Daerah inguinal ditempati oleh spermatic cord, kelenjar getah bening inguinal dan arteri
femoralis. Pembengkakan pada daerah inguinal dapat disebabkan oleh hernia inguinalis atau
hernia femoralis atau limfadenopati (Gambar 25 dan 26). Pada fase embrional seorang laki-laki,
testis dan spermatic cord turun dari rongga abdomen ke dalam skrotum melalui kanalis
inguinalis. Proses penurunan ini meninggalkan saluran yang bila tidak tertutup akan dapat
menyebabkan hernia dikemudian hari. Kanalis inguinalis berjalan ke bawah dari lateral ke
medial melalui anulus inguinalis interna ke anulus inguinalis eksterna di atas dan sejajar dengan
ligamentum inguinalis sehingga ligamentum tersebut menjadi dasar kanalis inguinalis. Anulus
inguinalis interna terletak pada titik percabangan antara ligamentum inguinalis dan arteri
femoralis. Arteri femoralis berjalan dari kranial ke kaudal pada titik tengah antara spina iliaka
anterior superior dan simfisis osis pubis masuk ke dalam femoral sheath, selain arteri femoralis
didalam femoral sheath juga terdapat vena femoralis dan kanalis femoralis. Kanalis femoralis
ditutup oleh jaringan lemak dan kelenjar getah bening dan merupakan jalan terbentuknya hernia
femoralis.
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Hernia inguinalis akan tampak sebagai benjolan di daerah inguinal atau didalam
skrotum bila tekanan intraabdominal meninggi. Massa itu akan hilang spontan bila pasien
berbaring, oleh sebab itu pemeriksaan untuk mencari hernia sebaiknya dilakukan dalam posisi
pasien berdiri. Untuk melakukan palpasi kanalis inguinalis, terutama bila ada keluhan hernia
inguinalis, letakkan ujung jari pemeriksa di bawah skrotum lalu mengikuti spermatic cord naik
keatas dan menembus anulus inguinalis eksterna. Lima sentimeter di atas anulus ini terletak
anulus inguinalis interna. Bila ujung jari telah mencapai anulus inguinalis interna, pasien di
suruh mengejan atau batuk. Bila ada masa yang mendorong maka berarti terdapat hernia.
Gambar 25. Hernia Inguinalis direct; Hernia Inguinalis indirect an Hernia femoralis
Untuk membedakan hernia inguinalis dengan hernia femoralis dilihat dari letak hernia
tersebut dengan pubic tubercle, bila hernia terletak di atas dan medial dari pubic tubercle
merupakan hernia inginalis sedang jika terletak di bawah dan lateral terhadap pubic tubercle
merupakan hernia femoralis.
Pemeriksaan Perineum
Pemeriksaan abdomen akan lengkap dengan pemeriksaan perineum dan colok dubur.
Untuk pemeriksaan ini penting dijelaskan terlebih dahulu pada pasien tentang tujuan dan
manfaatnya. Pasien pada berbaring pada posisi lateral dekubitus kiri atau posisi Sims dengan
kedua lutut terlipat ke arah dada. Pemeriksaan menggunakan sarung tangan. Dengan
penerangan cahaya yang adekuat, pantat kanan pasien ditarik keatas dengan menggunakan
tangan kiri pemeriksa sehingga kita dapat melakukan inspeksi perineum dengan baik. Adanya
hemoroid eksterna atau interna yang prolaps, fisura ani, jaringan parut, perianal tags,
dermatitis, keganasan, ulkus ataupun tumor dapat dinilai dengan baik (Gambar 27-30).
103
Gambar 27. Prolaps Hemoroid Interna
Gambar 28. Fissura ani anterior
Genetalia Laki-laki
Lakukan inspeksi secara seksama, perhatikan pertumbuhan rambut pubes yang
kadang-kadang dapat mencapai umbilikus. Perhatikan lubang penis, terutama bila ada keluhan
retentio urin. Bila pasien mengeluh nyeri waktu ereksi, perhatikan kemungkinan ada hipospadia.
Tanda-tanda peradangan pada glans penis juga harus diperhatikan. Kalau perlu lakukan
pengurutan penis untuk melihat adanya urethral discharge. Pada pasien yang tidak sirkumsisi,
preputium harus dibuka untuk melihat adanya smegma atau peradangan. Skrotum dan testis
juga harus diperiksa dengan seksama, apakah ada pembesaran atau tidak. Dalam keadaan
normal terstis kiri dapat lebih besar dibandingkan dengan testis kanan. Perhatikan terhadap
kemungkinan adanya varikokel, hidrokel dan hernia. Varikokel merupakan pelebaran vena-
vena pleksus pampiniformis biasanya pada bagian kiri tanpa adanya keluhan yang berarti.
Pada Hidrokel -penimbunan cairan pada tunika vaginalis testis - biasanya kulit teraba
agak tegang, mengkilat, tidak nyeri dan teraba fluktuasi. Bila diberi sinar dengan cara
meletakkan senter pada skrotum maka akan nampak sinar tersebut menembus lapisan cairan
tersebut (diafonoskopi/transluminasi positif). Pada hernia, karena di dalam skrotum didapatkan
massa padat yang berasal dari rongga abdomen, maka bila diberi sinar, sinar tidak akan
menembus massa skrotum (diafonoskopi negatif). Testis yang membesar lunak serta nyeri
merupakan tanda adanya orchitis virus, bila konsistensinya keras dan tidak nyeri hati-hati
104
kemungkinan sifilis atau tumor. Pada tumor permukaan testis biasanya tidak rata. Pada palpasi
juga harus dicari epididimitis. Pada epididimitis tuberkulosis akan teraba epididimis seperti
manik-manik. Pada palpasi daerah inguinal, dicari benjolan yang mungkin merupakan kelenjar
getah bening, hernia dan testis yang tidak turun, atau limfogranuloma inguinal. Denyut arteri
femoralis juga harus dipalpasi dan dinilai apakah normal atau tidak. Demikian juga daerah
suprapubik harus dipalpasi, terutama pada retensio urin untuk melihat adakah pembesaran
kandung kemih.
Genetalia Perempuan
Bila dianggap perlu, pemeriksaan genitalis perempuan harus disertai dokter atau perawat
atau dokter muda perempuan. Perhatikan pertumbuhan rambut pada mons veneris, klitoris,
labia mayora dan labia minora. Pisahkan labia mayora dengan ibu jari dan jari telunjuk tangan
kanan. Usakan mencari kelenjar bartolini, dalam keadaan normal kelenjar ini tidak teraba.
Pembesaran kelenjar bartolini akan teraba di posterolateral labia mayora, biasanya disebabkan
infeksi atau abses. Pisahkan kedua labia minora sehingga introitus vagina dan uretra akan
tampak. Perhatikan vulva dengan seksama, apakah ada ulkus atau lekoplakia. Perhatikan juga
cairan vagina, apakah normal atau berlebih, berbau busuk atau tidak. Kemudian dengan kedua
labia masih dipisahkan oleh jari telunjuk dan jari tengah, pasien diminta untuk meluruskan
kedua tungkainya, perhatikan adanya penonjolan (bulging) pada dinding vagina yang mungkin
disebabkan oleh sistokel atau rektokel.
Pemeriksaan Anorektal
Pada inspeksi diperhatikan kelainan anus, misalnya adanya hemoroid eksterna, keganasan dan
lain-lain. Bila perlu dan ada indikasinya lakukan pemeriksaan colok dubur (rectal toucher).
Adapun cara pemeriksaan rectal adalah sebagai berikut:
Posisi pasien dapat dilakukan dengan pasien berbaring terlentang; berbaring pada sisi kiri
tubuh atau berdiri, membungkuk pada meja pemeriksaan. Posisi litotomi (pasien terlentang
dengan kedua lutut difleksikan) yang dimodifikasikan dipakai kalau pasien sulit berdiri atau
kalau pemeriksaan anus secara rinci tidak diperlukan. Pemeriksa menjulurkan tangan kanannya
di bawah paha kanan pasien. Jari telunjuk di dalam rektum dipakai bersama dengan tangan kiri
pemeriksa yang diletakkan di abdomen (Gambar 31).
Posisi miring ke lateral kiri / posisi sims dipakai pada wanita atau pada pasien yang sangat
lemah dan harus terpaku pada tempat tidur. Dalam posisi ini tungkai kanan atas harus
difleksikan sedangkan tungkai kiri bawah setengah diekstensikan.
Posisi berdiri merupakan posisi yang paling banyak dipakai dan dengan posisi ini dapat
dilakukan inspeksi menyeluruh pada anus dan palpasi pada rektum. Pasien disuruh berdiri
membungkuk dengan bahu dan siku disokong di atas tempat tidur atau meja pemeriksa.
Tangan kanan pemeriksa dengan memakai sarung tangan memeriksa anus dan jaringan
sekitarnya sementara tangan kiri dengan hati-hati merentangkan pantat. Jika mencurigai
adanya infeksi, kedua tangan pemeriksa harus memakai sarung tangan.
Pasien diberi tahu bahwa pemeriksan rektum akan segera dilakukan. Pemeriksa harus
memberitahukan pasien bahwa lubrikan yang memberikan sensasi dingin akan dipakai dan ini
akan diikuti dengan sensasi akan buang air besar, pasien harus diberikan jaminan bawha
sebenarnya ia tidak akan buang air besar. Pasien diminta mengejan untuk menginspeksi anus
untuk melihat adanya hemoroid atau fisura.
105
Gambar 31. Pemeriksaan rektal
Sumber : http://en.wikipedia.org/wiki/Rectal_examination
Oleskan jari telunjuk tangan kanan yang telah memakai sarung tangan dengan jeli atau
vaselin dan juga dioleskan pada anus pasien, sementara tangan kiri diletakkan pada pantat
pasien untuk merentangkan pantat pasien. Pasien disuruh tarik nafas dalam, dan pada saat ini
letakkan bagian palmar ujung jari telunjuk kanan pada tepi anus dan secara perlahan tekan
agak memutar sehingga jari tangan masuk ke dalam lumen anus, saat sfingter ani mengendur.
Sfingter ani harus menutup dengan sempurna disekitar jari pemeriksa. Masukkan lebih dalam
secara perlahan–lahan sambil menilai apakah ada spasme anus (misal pada fisura ani) dan
tonus sfingter ani harus dinilai. Jari harus dimasukkan sejauh mungkin ke dalam rektum
meskipun 10 cm merupakan batas eksplorasi jari yang mungkin dilakukan. Tangan kiri
pemeriksa dapat dipindahkan ke pantat kiri pasien sementara jari telunjuk kanan memeriksa
rektum. Dinding rektum dipalpasi untuk melihat adanya polip, massa tumor dan ada tidaknya
rak blumer, hemoroid interna beserta derajatnya, rasa nyeri, mukosa yang teraba ireguler,
pembesaran prostat pada laki-laki atau penekanan dinding anterior oleh vagina/rahim pada
perempuan. Pada waktu jari telunjuk sudah dikeluarkan dari anus, perhatikan pada sarung
tangan apakah terdapat perdarahan baik darah merah atau hitam (melena), lendir ataupun
bentuk feses yang menempel pada sarung tangan
106
REFERENSI
1. Ferry, F. Ferry’s Color Atlas and Text of Clinical Medicine. 1st edition. Saunders Elsevier,
Philadelphia. 2009.
2. Adams Diagnosik Fisik. Burnside-Mc Glynn. EGC. 1995.
3. Bickley L.S. dan Szilagyi P.G. Chapter 7, The Thorax and Lungs. In: Bickley L.S. dan
Szilagyi P.G. Bates’ Guide to Physical Examination and History Taking. 9th edition. Lippicott
Williams & Wilkins. 2010.
4. David Mattingly & Charles Seward. Bedside Diagnosis. Edisi 13. Gadjah Mada University
Press. Yogyakarta. 1989.
5. Delp & Manning: Major Diagnosis Fisik. EGC. 1996.
6. Henry M. Seidel; Jane W. Ball; Joyce E. Dains & G. William Benedict. Mosby’s Guide to
Physical Examination. 6th edition.Canada. Elsevier.2010.
7. Janice Willms & Henry Schneiderman: Diagnosis Fisik. Buku Saku.EGC. 1996.
8. Marcellus Simadibrata K. Pemeriksaan Abdomen, Urogenital dan Anorektal. dalam: Buku
Ajar Ilmu Penyakit dalam Jilid I Edisi IV. Editor: Aru W. Sudoyo; Bambang Setyohadi; Idrus
Alwi; Marcellus Simadibrata K dan Siti Setiati. Pusat Penerbitan Departemen Ilmu Penyakit
dalam FKUI. Jakarta. 2010.
9. Morton P.G. et al. Chapter 13, Gastrointestintal System. Dalam: Morton P.G. et al. Health
Assessment in Nursing. Pennsylvania. Springhouse Corporation. 1989.
10. Nicholas J. Talley & Simon O‘Connor. Pemeriksaan Klinis. Pedoman Diagnosis Fisik. Alih
bahasa: Dr. Wendra Ali. Binarupa Aksara. Jakarta. 1994.
11. Owen Epstein dkk: Clinical Examination Third Ed. 2003.
12. Richard F. LeBlond, Richard L. DeGowin & Donald D. Brown: DeGowin’s Diagnostic
Examination. 2004.
13. Rumende C.M. Pemeriksaan Fisis Dada dan Paru. Dalam: Sudoyo A.W. Dasar-dasar Ilmu
Penyakit Dalam. Edisi keempat. Jakarta. Pusat Penerbitan, Departermen Ilmu Penyakit
Dalam Fakultas Kedokteran Universitas Indonesia. 2010.
14. Simeon Margolis: John Hopkins Symptoms & Remedies.2005.
15. Skills Lab. Lab. Ketrampilan Medik FK UGM. Yogyakarta. 2005-2008.
16. Sundaru dkk. Buku Ajar Ilmu Penyakit Dalam. BP FKUI jilid 1-2. Jakarta. 2010.
17. Swartz M.H. Chapter 16, The Abdomen. In: Swartz M.H. Textbook of Physical Diagnosis,
History and Examination. 5th edition. USA: W.B.Saunders Company. 2010.
107
A. SELF-ASSESSMENT
Ada sembilan gejala penyakit yang harus dikuasai oleh mahasiswa, yaitu :
1. Nyeri perut kanan bawah akut
2. Benjolan di inguinale
3. Distensi abdomen
4. Ikterik
5. Muntah darah
6. Nyeri ulu hari
7. Diare dan Berak darah
8. Kencing darah
108
Lakukan identifikasi terhadap sembilan gejala tersebut, meliputi :
- Anamnesis
- Konsep hipotesis
- Pemeriksaan fisik (kenali tanda-tanda patogenomonisnya)
- Pemeriksaan penunjang
- Diagnosis banding
- Terapi
- Prognosis
- Edukasi
109
FEEDBACK FORM
PEMERIKSAAN FISIK ABDOMEN
Abdomen
1 Mengucapkan salam pembuka (selamat pagi/siang/sore)
dan memperkenalkan diri.
2 Mempersilahkan penderita telentang dan menjelaskan apa
yang akan dilakukan.
3 Meminta penderita untuk membuka baju daerah dada dan
perut. Berusaha membuat penderita siap diperiksa (santai)
dengan menekuk lutut dan mengajak berbicara.
4 Berdiri di sebelah kanan penderita.
5 Meminta penderita untuk memberikan respons terhadap
pemeriksaan.
6 Cuci tangan sebelum melakukan pemeriksaan.
INSPEKSI:
7 Melakukan inspeksi seluruh lapangan Perut penderita
dengan teknik yang benar.
AUSKULTASI:
8 Melakukan auskultasi sebelum perkusi dan palpasi.
9 Melakukan auskultasi peristaltik usus (satu tempat).
10 Melakukan auskultasi kelainan vaskular pada Perut
(7 tempat).
PERKUSI :
11 Melakukan perkusi sebagai orientasi pada ke empat
kuadran Perut (13 tempat).
12 Perkusi harus menghasilkan suara timpani.
13 Melakukan perkusi untuk menentukan batas hepar pada
garis midklavikula dari arah kaudal.
14 Mengukur daerah redup hepar pada daerah midklavikula
kanan.
15 Melakukan perkusi lien pada daerah perkusi.
PALPASI :
16 Menghangatkan tangan terlebih dahulu kemudian
melakukan palpasi superfisial seluruh lapangan perut.
17 Melakukan pemeriksaan untuk nyeri tekan dan nyeri lepas
tekan.
18 Melakukan pemeriksaan untuk mengetahui adanya asites
(undulasi dan pekak beralih).
19 Melakukan pemeriksaan palpasi hepar dengan menilai
permukaan, tepi dan perabaan hepar.
20 Melakukan palpasi lien.
21 Melakukan palpasi ginjal kanan dan kiri.
22 Memberitahu pasien bahwa pemeriksaan PERUT sudah
selesai.
23 Cuci tangan setelah melakukan pemeriksaan.
24 Memberikan informasi resume hasil pemeriksaan dan
mengucapkan terima kasih.
110
Skala Rating Global untuk Perilaku Profesional
No. Keterampilan Landasan ilmiah dan keterangan Skala
1 2 3 4 5
Tidak Di Sesuai Melebihi Sempurna
sesuai bawah harapan harapan
harapan harapan
1. Menunjukkan Berhadapan dengan diri sendiri (ketika
kepercayaan diri mahasiswa mampu bersikap secara
dalam melakukan profesional tanpa menunjukkan keadaan
keterampilan di depan dirinya sendiri saat itu, misal sedang cemas,
pasien sedih, memikirkan sesuatu yang lain)
2. Etika (Menghormati Berhadapan dengan pasien (ketika
pasien, nilai-nilai lokal mahasiswa mampu bersikap secara
dan norma) profesional tanpa menunjukkan asumsi-
asumsinya terhadap pasien)
3. Kesalahan minimal Berhadapan dengan diri sendiri, pasien dan
tugas-tugasnya (ketika mahasiswa mampu
bersikap secara profesional berhubungan
dengan orang dihadapannya dan
mengerjakan tugasnya tanpa kesalahan)
Penjelasan:
Skala 1: Tidak menunjukkan rasa hormat dan norma + lebih dari 80 % kesalahan
Skala 2: Menunjukkan rasa hormat dan norma minimal + 60%-80% kesalahan
Skala 3: Menunjukkan rasa hormat dan norma minimal + 40%-60% kesalahan
Skala 4: Menunjukkan rasa hormat dan norma minimal + 20%-40% kesalahan
Skala 5: Menunjukkan rasa hormat dan norma minimal + kurang dari 20% kesalahan
Yogyakarta, ............................................
Observer
...................................................................
111
SKILLS TRAINING MATERIAL BOOK
LIFE SUPPORT SKILLS YEAR III
Skills Laboratory
Faculty of Medicine
Universitas Gadjah Mada
Yogyakarta
2014
112
INTRAVENOUS LINE INSERTION
BLOCK 3.3
Contributor:
Bambang Suryono S
Departement of Anesthesiology and Reanimation
Faculty of Medicine Universitas Gadjah Mada
Yunita Widyastuti
Departement of Anesthesiology and Reanimation
Faculty of Medicine Universitas Gadjah Mada
Santosa Budiharjo
Department of Anatomy, Embryology, and Anthropology
Faculty of Medicine Universitas Gadjah Mada
Fajar Waskito
Department of Dermato-Venereology
Faculty of Medicine Universitas Gadjah Mada
Co-Contributor:
Yulia Wardhani
Assistant of Content Development Team for Skills Training
Faculty of Medicine Universitas Gadjah Mada
Noviarina Kurniawati
Coordinator of Learning Resources for Skills Training
Faculty of Medicine Universitas Gadjah Mada
113
PREFACE
Medical school students should study and practice several clinical skills as preparation
for entering clinical rotation prior to becoming a certified doctor. Currently, the medical
profession compels medical students to be competent in clinical skills before they directly deal
with real patients experiencing real life medical cases. For this reason, clinical skills are trained
as early as possible. This clinical skills laboratory provides opportunity for students to study and
practice the clinical skills on their own.
The topic of this manual is one of the clinical skills topics that constitute the main topic of
Life Support, which will be studied continually in blocks throughout undergraduate studies. The
skill included in this book is based on Competence-Based-Curriculum of 2007. Topics covered
in Life Support, which will be studied in Year III, are as listed as follows:
3. Electrocardiography II 3.6
(Life Style Related
Complaint)
It is important for students to recognize that all topics, including those listed above, are
interrelated. Therefore, students are expected to categorize the topics based on the main topics,
so that continuity from one topic to another can be achieved. We hope that in the future, this
manual for clinical skills training can be useful for students to improve their skills, especially in
physical examination; and for instructors who are involved in providing the trainings.
Contributor
114
LESSON PLAN FOR IV LINE INSERTION
C. Level of Competence
Level of Competence for Clinical Skills :
The following is the division of competence level according to Miller Pyramid:
Level of Competence 1: Understanding and Explaining
The graduates of medical school possess theoretical knowledge concerning these skills,
so that they are able to explain concepts, theories, principles or indications, performing
procedures, emerging complications and others to their colleagues.
Level of Competence 2: Having seen or Having been demonstrated
The graduates of medical school possess theoretical knowledge concerning this skill
(concepts, theories, principles or indications, performing procedures, complications and
others). Besides, during their study, they had seen this skill or this skill had been
demonstrated to them.
Level of Competence 3: Having done or Having applied under Supervision
The graduates of medical school possess theoretical knowledge concerning this skill
(concepts, theories, principles or indications, performing procedures, complications and
others). Besides, during their study, they had seen this skill or this skill had been
demonstrated to them or they had applied several times under supervision.
Level of Competence 4: Able to perform independently
The graduates of medical school possess theoretical knowledge concerning this skill
(concepts, theories, principles or indications, performing procedures, complications and
others). Besides, during their study, they had seen this skill or this skill had been
demonstrated to them and they had applied several times under supervision; in addition,
they possess experience to use and apply this skill in the context of doctor practices
independently.
115
D. Activities
First session:
Time Activity Students Instructor Materials
5 minutes Introduction and Listen and Explain and Workplan
collecting Submitting the Collecting
assignment assignment assignment
10 Practicing IV line Practicing Observing and - Infusion tubing
minutes insertion problem - Infusion fluid
identified - Sterile infuse
needle
10 Demonstration by Observe & Demonstrating,
- Clean Gloves
minutes instructor discuss discussing
- Cotton in a sterile
5 x 10 Exercise Performing and Observing and container
minutes observing each giving feedback - Cotton wool soaked
other in alcohol
(one by one) - Tincture of iodine
or 10% povidone
iodine solution
- Tapes, scissor, and
bandage
- Kidney bowl
- Infusion stand
- Plastic drape
- Arm board (if
necessary)
- Tourniquet
- Sharps Container
20 Case discussion Discuss Explaining Scenario
minutes (Diarrhea in adult
and child)
5 minutes Evaluation and Asking and Explaining Feedback form
Closing Giving Comment
Second session:
Time Activity Students Instructor Materials
10 Introduction & Identify problem Explain -
minutes Reflection
10 Demonstration Observe and demonstration
minutes discuss
5 x 10 Exercise Performing and Observing and
minutes observing each giving feedback
other (one by one)
20 Case discussion Discuss Explain Scenario
minutes (Hemorrhagic Shock
& Dengue Shock
Syndrome)
5 minutes Evaluation Asking, giving Explaining and Feedback form
comments closing session
116
Illustration Case
You are a doctor on duty in ER. A-18-year-old man is having traffic accident. He
comes to ER in shock due to bleeding. The patient is conscious but looks pale. You
are performing fluid resuscitation and bleeding control.
II. ANATOMY
Peripheral venous cannulation is performed on a number of vessels including the
superficial veins of the dorsum of the hand; veins in the antecubital fossa (cephalic and
basilic veins); the dorsum of the foot; and in newborns and small infants, the scalp. Veins
used to access the central circulation include vessels such as the internal jugular; external
jugular; subclavian and femoral veins. In the adult population, the femoral vein is the largest
vessel most commonly used for rapid volume infusion in an emergency situation such as
cardiac and respiratory arrest, and shock. This is because the femoral vein is easily
identified, easy to apply pressure if needed, and does not hinder resuscitation efforts. In
neonates, infants and children during an emergency, any venous access can be
challenging. If it cannot be accessed quickly the intraosseous route is recommended
117
ACCESS ROUTE TO THE PERIPHERAL VEINS
118
Veins of the upper limb
Scalp Veins
119
Veins of the foot
Indication
The goal of intravenous therapy is correction or prevention of fluid and electrolyte
disturbances. It can provide maintenance fluids to support hydration, and serve as a route
for administering medications such as antibiotics and enteral therapy.
Peripheral venous cannulation is the preferred method of vascular access in most
non-emergent situations. Venous cannulation to access the central circulation, as in
femoral vein cannulation, provides a more stable and reliable route of venous access than
peripheral cannulation. This route is commonly used when peripheral veins are
inaccessible and when longer term venous access is required There are numerous other
indications for femoral vein cannulation, which include rapid infusion of fluid during
resuscitation; frequent blood sampling for diagnostic purposes; temporary/acute
hemodyalisis; administration of potent vasoactive drugs; infusion of irritating or hypertonic
solutions; infusion of incompatible medications through a multilumen catheter;
hyperalimentation; hemodynamic monitoring such as for central venous pressure readings;
and transvenous cardiac pacing In the case of resuscitation, central venous access is
preferred over peripheral access due to the relatively large bore catheters that can be
inserted in these vessels which facilitate rapid fluid administration.
Contraindication
Contraindications for peripheral vein cannulation are related to local site selection.
Sites distal to previous venipuncture sites, sclerosed or hardened cordlike veins, infiltrate
site or phlebotic vessels, bruised areas and area of venous valves or bifurcation should be
avoided. Fragile dorsal veins in older adults and vessels in an extremity with compromised
circulation should not be used (e.g. in cases of mastectomy, dialysis graft or paralysis). In
the paediatric population, veins are fragile and so extra attention to sites that can be easily
disturbed by movement should be avoided.
120
IV. PREPARING FOR VASCULAR CANNULATION
A. STERILITY AND SELF-PROTECTION
The discussion of sterility below covers the sterility process, equipment
sterility, and the materials used for the sterility process.
Process sterility is conducted by doing the aseptic procedures, while
equipment sterility refers to efforts to maintain the sterility of the puncture site, the
needle, and the gloves. The materials used for sterility process includes antiseptic
agents such as tincture of iodine, 70% alcohol, etc.
Hand Washing
Hand washing remains the corner stone of infection prevention and control.
Hand hygiene reduces the transmission of micro-organisms. It includes hand
washing, maintaining hand health, avoiding nail polish, artificial nails or jewelry and
keeping nails trimmed and clean. The fingernail area can harbor considerable flora
and other micro-organisms.
Hair removal
Shaving is not recommended for hair removal because it abrades the skin and
promotes bacterial colonization. If hair removal is necessary, the hair can be clipped.
121
Source: Marino, P. L., 1998. The ICU Book Volume 1. Second Edition.
William & Wilkins. Baltimore, Maryland
Bevel
Figure 7. Bevel
Source: www.ersdnetwork18.org
Butterfly needles
Butterfly (scalp vein) needle is a short needle attached to plastic stabilizers at
90 degrees. It is used for IV access of small veins of adults and children. Usual gauge
is 25 to 22 lengths (as shown in figure 8).
Butterfly (scalp vein) needle are useful for short term intravenous infusion in
adults and for both long and short term use in children. They are also useful for
phlebotomy in uncooperative patients, especially children, because the flexible
connecting tubing prevents dislodgement of the needle when the patient moves.
122
Catheter Size
The gauge system was developed for wires and needles, and has been
adopted for catheters. In general, the shortest and smallest gauge catheter should be
used to prevent damage to the intima of the vein and to ensure the minimum of
vascular complication. To aid choice, assess the type of use required from the
Peripheral Venous Cannulation:
1. Crystalloids
Crystalloid is a substance in solution that can pass through a semi permeable
membrane, and be crystallized. It has low molecular weight, approximately less than
8000 Dalton. Crystalloids are freely permeable to the vascular membrane and are
therefore distributed mainly in the interstitial and/or intercellular compartment. Only
25% of the infused crystalloid solution remains in the intravascular space, whereas
75% extravasates into the interstitium.
Crystalloids may be classified as hypotonic, isotonic, or hypertonic. For
purposes of resuscitation, only the isotonic and hypertonic fluids are of use.
a. Hypotonic fluid (such as 5% dextrose in water and ½ Normal Saline), even less
remains in the vasculature and thus is not used for resuscitation
123
b. Isotonic fluids, both 0.9% saline and RL are equally effective; RL may be
preferred in hemorrhagic shock because it somewhat minimizes acidosis. For
patients with acute brain injury and hemorrhagic shock, 0.9% saline is preferred.
c. Hypertonic fluids (such as 3%, 6%, or 7.5% Normal Saline) are largely
experimental and not commonly used in everyday resuscitation.
Crystalloids have the advantage of being inexpensive and readily available.
They resuscitate both the intravascular and interstitial space, and promote urinary
output. Disadvantages include edema formation in patients with capillary
permeability and the need for increased volumes to achieve equivalent resuscitation
to colloids.
2. Colloid
Colloids may be divided into protein and non-protein colloids. The molecular
weight of colloid is more than 8000 Dalton.
a. The protein colloids include human serum albumin (5% and 25%) and gelatin
solutions (Plasmagel, Haemacell, Gellifundol). Albumin has the advantage of
remaining intravascular longer than the crystalloids; less volume is therefore
required. Albumin is expensive (65 times that of an equivalent volume of
crystalloid) and does not restore the interstitial space. It can cause anaphylaxis in
rare circumstances.
b. The non-protein colloids include the starches (6% hetastarch, 10% pentastarch)
and the dextrans (dextran-40 in normal saline, dextran-70 in 5% dextrose in
water). They have been found to be equivalent to albumin as a resuscitation fluid.
Their primary drawbacks are their expense (13 times that of crystalloid), a dose-
related coagulopathy (greatest with hetastarch), and occasional anaphylaxis
(greatest with the dextrans). There have also been reports that these starch
molecules may adversely affect renal function by causing tubular injury. Non-
protein colloids can also interfere with antigen detection during cross matching of
blood products. Newer preparations are on the horizon which may alleviate some
of the above concerns.
3. Blood
Blood typically is given as packed RBCs, which should be cross-matched, but
in an urgent situation, 1 to 2 units of type O Rh-negative blood are an acceptable
alternative. When > 1 to 2 units are transfused (e.g., in major trauma), blood is
warmed to 37° C. Patients receiving > 8 to 10 units may require replacement of
clotting factors with infusion of fresh frozen plasma or cryoprecipitate and platelet
transfusion.
4. Blood Product
Blood products are defined as any therapeutic substances derived from
human blood, including whole blood, labile blood components and plasma-derived
medicinal products.
124
V. GENERAL ASPECTS
Some aspects must be carefully considered to be able to perform a safe and
comfortable intravenous cannulation.
1. Sterilization and self-protection. The aim of sterilization is to prevent infectious
organisms from causing an infection at the puncture site, which can cause phlebitis,
bacteraemia, and sepsis. Many things should be considered:
1) Hands must be decontaminated prior to and after the insertion of, and before all
manipulations of a device, preferably with antiseptic soap.
2) The skin must be disinfected prior to the insertion of a PVC
3) All equipment must be sterile prior to first use
4) An aseptic technique must be adopted during the insertion and maintenance of a
PVC or associated device
5) A fresh pair of non-sterile gloves must be worn when manipulating any PVC or
associated device
6) Blood contaminated and/or sharp items must be disposed of in a sharps bin,
which must be taken to the point of use
2. The puncture site and the puncture direction must be correct.
3. Fixation. Fixation must be done to prevent the movement of the infusion cannulae or
needle. A failure in the fixation will increase the risk of a puncture injury to the inner wall
of the vein, which can cause hematoma and thrombosis.
4. The flow speed of the fluid into or out of the vein. If we want to withdraw blood from the
vein, the container must be placed relatively inferior to the body. However, if we want to
do an IV infusion, the bottle must be positioned superior to the body. The speed of the
flow can be regulated according to the patient‘s need. It must be kept in mind that every
type or brand of infusion-set has its own characteristics in regard of the volume of its
droplets. So we have to read carefully the instruction on the package.
5. Air emboli. To prevent the air emboli to the blood stream, we can expel the air from the
syringe camber by draw syringe's plunger directed to the needle. And also connect
firmly between needle and syringe.
125
VII. FIXATION/TYPE OF DRESSING
The cannulae as well as the needle must be securely fixed, so it is steady and cannot
be easily withdrawn (Figure 11).
Either gauze or transparent semi-permeable dressings are suitable. However as the
insertion site of the cannulae must be visually inspected at least daily. If at any time a
dressing becomes loose or moist, it must be replaced after cleaning the site using an
aseptic technique, sterile sodium chloride 0.9% and an alcohol wipe
Bandages should not be used to cover peripheral cannulae; however exceptions
include: paediatric patients, neonates and patients who are likely to dislodge the cannulae,
i.e. confused patients. If a bandage has been used, it should be removed at least daily, in
order to inspect the insertion site
2) Patient‟s preparation
- Inform the patient about the procedure and the aim of the procedure, and also the
risks. The usual method of consent is verbal, however the patient‘s decision
whether or not to agree must be based on adequate/accurate information.
- Make the patient‘s position comfortable
- Free the infusion site from clothing
- Check access for signs of infection (redness, swelling, tenderness or abnormal
drainage), bruising and prior needle sites.
3) Procedural instruction
- After finishing the preparation steps, take the equipment to the bedside
- Wash hands.
- Place the plastic drape under the extremity on which you are going to perform the
infusion.
- Remove the infuse set from the package. Check the spike and the tube in a
straight line. Close the regulator.
126
- Open the outflow infusion bottle, pierce the outflow with a spike after open its
protector; hold the bottle with left hand, which the position of the bottle lower than
the spike. Use your right hand to spike the outflow, and connect the infusion
tube/infusion set to the bottle.
- Hang the infuse bottle at the infusion stand.
- Fill half of the drip chamber with infuse solution.
- Open the needle cover, let the infusion fluid fill the tube by opening the switch,
until there is no air bubble left within the tube. Note: Fill the solution, turn the tube
as you make latter U, then close the needle and push the air that still on the tube
to the drip chamber.
- Use the gloves both of your hand
- Put the tourniquet on proximal side of the vena puncture location (10-20 cm from
punctured vein) to encourage venous distension, assess and select the vein
- Identify the vein and choose the easiest one. Place the part of body that
contents the vein lower than heart.
- Clean the area around the selected vein with an alcohol swab in a circular
outward direction and allow to ‗air dry‘ for a further 30 seconds. Thorough cleaning
and complete drying is vital to ensure removal of skin bacteria.
- Do not re-palpate the vein or touch the surrounding cleaned skin following
disinfection
- Open the cap of abbocath
- Stabilize the vein by applying manual traction on the skin and then pierce the
intravenous needle with the bevel facing upward. Insert the cannulae at the
selected angle (15 – 30 degrees) according to the depth of the vein.
- Wait until the first ‗flashback‘ blood fill in the needle ‗flashback‘ space.
- Positioning the cannulae and needle by decreasing the selected angle between
cannulae and skin. Then push the cannulae smoothly to confirm that the needle
inserted into the vein lumen. Push the nylon part of needle into the vein
meanwhile pull the stainless part of needle smoothly. Then you will see the
second ‗flashback‘ blood fill in through cannulae shaft.
- Note : to prevent the loss of blood from opened cannulae, please compress the
vein which is close to the cannulae tip by giving direct compression before you
pull out the needle from the nylon.
- Put on cannulae to the infusion bottle.
- Put off the torniquet.
- Open the regulator and let the infusion fluid flow through the tube.
- After the infusion is sufficient, perform fixation and cover the wound with alcohol or
iodine-tincture soaked cotton wool, and apply plaster on it.
127
Figure 13. Cannula dressed and tapes in place
Source: www.ersdnetwork18.org
- Regulate the outflows. For the maintenance of the outflows, use 20 drops
per minutes.
- Remove your gloves.
- Dispose of the sharps in a sharps bin.
Drop factor = 60 divided by the number of drops per 1 ml fluid can be administered by
the equipment you are using (w). (Drop factor = 60/w)
For example:
An infusion set which can administer 1 ml of liquid in 15 drops, the drop factor is
60/15 = 4 Therefore the number of fluid administered for a flow rate of 25 drops per
minute is:
If an infusion set does not mention the number of drops per ml, it means that its
drop factor is 4. There are some factors responsible for a failure in intravenous fluid
administration:
1. Failure to insert the needle into the right place (in to the vein)
2. The infusion tube is obstructed (blood clot, etc)
3. The connecting pipe is not patent
128
4. The position of the arm/leg causes obstruction of the infusion needle
5. The infusion needle punches out the vein (extravasations)
Secondary Regulator
(roller &
clamp)
129
IX. SEQUENCE OF INTRAVENOUS INFUSION
1.
Patient Preparation
1. Inform the patient about the
procedure and the aim of the
procedure, and also the risks. Make
the patient‘s position comfortable.
Free the infusion site from clothing.
Check access for signs of infection
(redness, swelling, tenderness or
abnormal drainage), bruising and
prior needle sites.
2.
Self and Tools Preparation
3.
3. Use the gloves both of your hand
4.
4. Prepare for the instruments needed
for inserting IV line, such as : Infusion
fluid, Sterile infuse needle (abbocath):
No. 18G-24G for infusion or No.16G-
20G for blood transfusion, clean
gloves, cotton in a sterile container,
cotton wool soaked in alcohol, tincture
of iodine or 10% povidone iodine
solution, tapes, scissor, and bandage,
kidney bowl, infusion stand, plastic
drape, arm board (if necessary),
Tourniquet, Sharps Container.
130
5.
Procedural instruction :
5. Remove the infuse set from the
package. Check the spike and the tube in
a straight line
6 (a).
6 (a, b). Open the outflow infusion bottle
and open the protector of spike.
(b).
131
8.
8. Hang the infuse bottle at the infusion
stand. Fill half of the drip chamber with
infuse solution.
9.
9. Close the regulator
10.
10. Open the needle cover.
132
12.
13.
14.
14. Put the tourniquet on proximal side of
the vena puncture location (10-20 cm
from punctured vein) to encourage
venous distension, assess and select the
vein. Identify the vein and choose the
easiest one. Place the part of body that
contents the vein lower than heart.
133
16.
16. Open the cap of abbocath
19.
19. Positioning the cannulae and needle
by decreasing the selected angle
between cannulae and skin. Then push
the cannulae smoothly to confirm that
the needle inserted into the vein lumen.
Push the nylon part of needle into the
vein meanwhile pull the stainless part of
needle smoothly. Then you will see the
second ‗flashback‘ blood fill in through
cannulae shaft.
134
20. 20. To prevent the loss of blood from
opened cannulae, please compress the
vein which is close to the cannulae tip by
giving direct compression before you
pull out the needle from the nylon.
Put on cannulae to the infusion bottle.
Put off the torniquet
21.
22.
135
24 (a).
24. (a,b,c). Apply laster and perform
fixation on the wound.
(b).
(c).
136
Which Fluid Is Best For Resuscitation?
Tremblay et al stated that ―the optimal fluid for resuscitation would combine the volume
expansion
and oxygen-carrying capacity of blood, without the need for crossmatching or the risk of
disease trans-
mission. In addition, it would restore and maintain the normal composition and distribution of
body fluid compartments. Taking this one step further, the ideal fluid would combine all of
those things with positive immunologic and coagulation effects, and be durable, portable,
and cheap. None of the fluid options currently available comes close to this ideal. Standard
trauma resuscitation as defined by the ATLS® course includes infusion of LR solution.
Lactated Ringer was created in the 1930s by Hart- mann in an attempt to make Ringer
solution pro- duce a beneficial effect on acidosis. Lactate is metab- olized in the liver,
producing either pyruvate or CO2 and H2O. In either case, there is release of hydroxide,
which is rapidly converted to bicarbonate, thus offering a physiologic buffer against acidosis.
Given that this represents standard therapy, essen- tially all of the trials over the past 20
years involving fluid choice have compared alternatives to LR.
137
Clinical Pathway For Resuscitation In Hemorrhagic Shock
Stanch bleeding
Minimize time-consuming prehospital
interventions (Class II)
Head injury?
NO YES
Abbreviations: FFP, fresh frozen plasma; ICU, intensive care unit; LR, lactated Ringer solution; PRBC, packed red blood cell; SBP,
systolic blood pres- sure.
138
Figure 14. Intravenous Catheter size 22G Figure 15. Intravenous Catheter size
20G
Figure 16. Intravenous Catheter size 18G Figure 17. Intravenous Catheter size
24G
Figure 18. Intravenous Catheter size 16G Figure 18. Intravenous Catheter size
14G
139
CLINICAL REASONING
CASE 1:
A 24 year old man comes to an emergency unit at night complaining diarrhea since 2 days
earlier. Frequency of defecation is ± 8 times/day, average volume ± ½ glass, no visible mucus
or blood in stool. Patient feels nauseous, lack of appetite, and has vomited twice. Body
temperature increases at second day. Last urine was at the morning with low volume and thick
appearance.
Vital sign examination finds fully conscious patient, blood pressure 90/60 mmHg, pulse 130
times/minute, temperature 38ºC, and breathing 24 times/minute, body weight 60 kg. Physical
examination finds dry oral mucus, hoarseness, decrease in skin turgor, cold extremities, and
patient feels thirsty.
Based on the condition, doctor concludes patient‘s dehydration score (using Daldiyono method)
is 7.
Questions:
You are doctor on duty at the emergency unit who are going to conduct fluid resuscitation to the
patient.
1. How much fluid does patient need based on clinical condition above (according to Daldiyono
method)?
2. What size of venous catheter (cannulae) will you use?
3. What type of fluid will you give?
4. How will you conduct fluid resuscitation to patient? (How much is the flow rate and how long
will it be given?)
5. What type of clinical condition will you observe during fluid resuscitation?
6. Other than Daldiyono method, what method will you use to assess patient‘s need of fluid?
Guideline:
Below are some guidelines you may use for answering the questions:
1. Daldiyono‘s dehydration score:
Skor Daldiyono
- Thirsty/Vomit 1
- Systolic Blood Pressure 60-90 mmHg 1
- Systolic Blood Pressure < 60 mmHg 2
- Pulse > 120 x/minutes 1
- Apatic 1
- Somnolen, sopor atau come 2
- Respiration Rate > 30 x/minutes 1
- Facies cholerica 2
- Vox cholerica 2
- Decrease in skin turgor 1
- Washer woman‘s hand 1
- Cold Extremities 1
- Cyanotic 2
- Age 50-60 year old -1
- Age > 60 year old -2
140
If score < 3 and shock (-) oral resuscitation
If score > 3 and shock (+) intravenous resuscitation
3. Fluid Resuscitation
First 2 hours (initial re-hydration)
Give fluid according to dehydration level to achieve optimal re-hydration as soon as
possible.
Next 1 hour
Fluid resuscitation is given based on amount of fluid loss at 2 hours of initial phase.
Next hour
Fluid resuscitation is given based on fluid loss through stool, urine and insensible water
loss (to maintain daily fluid requirement for adult)
CASE 2:
An 11 months old female infant is brought to a clinic by her mother at morning. Her mother
complains that she has been suffering from diarrhea since three days earlier. Average
frequency of defecation is ± 10 times/day, average volume of each defecation is ± ¼ glass. The
mother said she had diluted stool, no visible mucus or blood. Patient vomited three times. Last
urine was at evening the day before having thick yellow appearance.
Vital sign examination shows anxiety, blood pressure (not measured), pulse 140 times/minute,
deep breathing frequency 30 times/minute, axilla temperature 38ºC, body weight 10 kg.
Physical examination finds sunken eyes, sunken fontanel, dry eyes, dry oral mucus, patient
refused breastfeeding or bottled milk, skin turgor at abdomen wall very slow.
Questions:
You are doctor on duty at the clinic going to conduct fluid resuscitation to the infant.
1. How will you assess dehydration level on children?
2. After assessment, how much fluid does the infant need for re-hydration?
3. What size of venous catheter (cannulae) will you use?
4. What type of fluid will you give?
5. How will you conduct fluid resuscitation to the patient? (how fast is flow rate and how long
will it be given?)
6. What kind of clinical condition will you observe during fluid resuscitation?
Guideline:
Below are aspects you may use as guidelines to answer questions above:
1. Assessment of infant dehydration level
141
Table of Dehydration Degree Assessment
Assessment A B C
1. See
Read table of dehydration level assessment from right column to left column (C to A).
Conclusion of patient‘s dehydration level is determined by 1 key symptom (given star sign)
plus minimal 1 other symptom (1 symptom minimal0 at the same column.
4. Therapeutic Plan
Therapy A
If oralit is given at home, show to the mother the amount of oralit that is given
every time after the child defecates and oralit is given for two days
Age Amount Of Oralit Given Amount Of Oralit Provided
For Every Defecation At Home
<1 year 50-100 ml 400 ml/day (2 sachets)
1-4 years 100-200 ml 600-800 ml/day (3-4
sachets)
>5 years 200-300 ml 800-1000 ml/day (4-5
sachet)
Adult 300-400 ml 1200-2800 ml/day
142
- If diarrhea continues after oralit is finished, tell the mother to give another liquid as
explained in the first method or go back to the health worker to get additional oralit
Therapy B
PLAN OF THERAPY B
FOR THE THERAPY OF MILD/MODERATE DEHYDRATION
If the childs weight is unknown and or to make it easy at field, give oralit according to the
table below
Age <1 year 1 – 4 years > 5 years Adult
Amount of 300 ml 600 ml 1200 ml 2400 ml
ORALIT
Therapy C
Start to give IV liquid immediately, when the patient is able to drink, give oralit. When
starting to give IV liquid, give 100 ml/kg BW using Ringer Lactate (or normal liquid when
ringer lactate is not available) divided as follows:
- Reassess the patient every 1-2 hours. If the optimal rehydration has not been achieved,
faster the flow rate.
- Also give oralit (5ml/kg BW/hour) if the child can drink
- After 6 hours (infant) and 3 hours (child) reassess the patient using table of dehydration
degree assessment and then choose the correct therapeutic plan.
CASE 3:
A 35 year old woman comes to an emergency unit caused by accident.
In admission, patient looks weak and confuse. Vital sign examination finds blood pressure 95/50
mmHg, pulse 130 times/minute, temperature 35.6ºC, and breathing 28 times/minute.
Physical examination finds deformity on left thigh, large hematoma and decrease in vesicular
sounds on the right chest. The x-ray examination finds fracture on the left femur and right
hematothorax.
Questions:
You are doctor on duty at the emergency unit who are going to conduct fluid resuscitation to the
patient.
1. Based on patient‘s clinical condition, can you estimate the volume of blood loss? (define the
classification of hemorrhagic shock)
2. What type of fluid will you give?
143
3. How will you conduct fluid resuscitation to the patient? (How much fluid does patient need
based on clinical condition above? how fast is flow rate? and how long will it be given?)
CASE 4:
A 2-years-old female child is brought to a clinic by her mother. Her mother complains that she
has been suffering from fever since four days earlier. The mother said that she had nose
bleeding and vomited three times this morning. She had no respiratory and abdominal
complains.
In admission, patient looks weak and lethargic. Vital sign examination shows blood pressure
(not measured), pulse is not palpable, deep breathing frequency 30 times/minute, axillary
temperature 38ºC, body weight 16 kg. Physical examination finds positive Rumple Leede Test,
cold extremities and decrease in capillary refill. The blood examination shows Hb 13,5 Hct 41%,
g/dL, leucocyte count 3000/µL, thrombocyte count 70.000/µL.
Based on the above condition, doctor concludes that the patient is suffering from Dengue shock
syndrome.
Question:
You are doctor on duty at the clinic going to conduct fluid resuscitation to the child.
1. What size of venous catheter (cannulae) will you use?
2. What type of fluid will you give?
3. How will you conduct fluid resuscitation to the patient?
- How much fluid does patient need?
- How will you give the resuscitation fluid? (infusion drip? bolus?)
- How fast is flow rate?
- How long will it be given?
4. What kind of clinical condition will you observe during fluid resuscitation?
5. After administering a large amount of RL in the first 30 minutes, there is no improvement in
patient condition. What will you do?
144
FEEDBACK FORM
INTRAVENOUS LINE INSERTION
(The Intravenous Fluid and Regulate 20 drop/minute)
Nama : ………………………………………………………………..
Student No : ………………………………………………………………..
145
Global Rating Scale for Professional Behavior
No Skills Scientific basis and Scale
explanation 1 2 3 4 5
Unexpected Below Meet Exceeding Excellent
expectation expectation expectation
1 Demonstrate confidence Dealing with one-self:
during performing skills (student able to behave
in front of patient professionally without
showing his/her anxiety,
sadness and worries)
2 Ethics (Respect the Dealing with others:
patient, demonstrate (student able to behave
local values and norms) professionally without
showing his/her
assumptions about
patient)
3 Minimal Error Dealing with one-self,
(systematic in others and task: (student
procedures, harmless) able to behave
professionally in dealing
with others and
performing tasks with
minimal error)
Yogyakarta, …………………..
Instructor,
( )
146
REFERENCES
1. Moore, K.L., Arthur, F. D. 2006. Clinically Oriented Anatomy. 5th Edition. Lippincott.
William & Wilkins. United Kingdom.
2. Marino, P. L., 1998. The ICU Book Volume 1. Second Edition. William & Wilkins.
Baltimore, Maryland
3. Elis, JR. Nowlis EA, Benn P. 1996. Modules for Basic Nursing Skills. 6th Ed. Lippincott
Philadelpia
4. Leksana, E. 2004. Terapi Cairan dan Elektrolit. SMF/Bagian Anestesi dan Terapi Intensif
Fakultas Kedokteran Universitas Diponegoro. Semarang.
5. Anonym. Terapi Intra Vena yang Lebih Baik: Cara Pemakaian IV kateter. TERUMO
Hiroshi Tomita. Infus dan Keamanan Sistem Infus. TERUMO.
6. Waskito, F., Budiharjo, S., Agni, A. N. 2007. Skills Laboratory Manual: Vena Puncture &
Insertion of Intravenous Infusion. Block VI. Faculty of Medicine, Universitas Gadjah
Mada. Yogyakarta.
7. Rivera, A. M., Strauss, K. W., Van Zundert, A. A. J., Mortier, E. P. 2007. Matching the
peripheral intravenous catheter to the individual patient. Acta Anæsthesiologica Belgica,
58, 19-25.
8. Tulloh, S., Giligan, J. 2005. Policy for the Insertion and Management of Peripheral
Venous Cannulae (PVC). Middlesbrough and Redcar & Cleveland Primary Care Trust.
(taken from http://www.mrccs.nhs.uk).
9. Boldt, J. 2004. Fluid Choice For Resuscitation Of The Trauma Patient: A Review Of The
Physiological, Pharmacological, And Clinical Evidence. Canadian Journal of Anesthesia
51:5. pp 500-513.
10. Gabriel, C. 2008. Clinical Best Practice Guideline: Peripheral and Femoral Vein
Cannulation. College of Respiratory Therapist of Ontario. (taken from
http://www.crto.on.ca)
11. Anonym. 2006. Self-Cannulation of Vascular Access Procedure. (taken from:
http://www.ersdnetwork18.org)
12. Anonym. 2005. Fluid Resuscitation. Department of Surgical Education, Orlando
Regional Medical Center.
147
BUKU MATERI KETERAMPILAN MEDIK
KETERAMPILAN BEDAH DASAR TAHUN III
KATETERISASI URETRA
BLOK 3.3
148
KATETERISASI URETRA
BLOK 3.3
Kontributor:
Co-Contributor:
149
KATA PENGANTAR
Sangat penting bagi mahasiwa, untuk menyadari bahwa topik-topik yang dicantumkan
tersebut, saling terkait satu dengan lainnya. Oleh sebab itu, mahasiswa diharapkan dapat
mengelompokkan topik-topik tersebut ke dalam topik utamanya, sehingga kontinuitas topik
dapat tercapai. Kami berharap, buku manual pelatihan keterampilan klinik ini dapat bermanfaat
bagi mahasiswa untuk meningkatkan keterampilan mereka, terutama dalam keterampilan
prosedural khusus; dan bagi instruktur yang terlibat di dalamnya.
Kontributor
150
KATETERISASI URETRA
D. Tingkat Kompetensi
Tingkat Kompetensi Clinical Skills:
Pembagian tingkat kompetensi menurut Piramida Miller adalah sebagai berikut:
Kompetensi 1: Memahami dan Menjelaskan
Lulusan pendidikan kedokteran menguasai pengetahuan teoretis tentang skills ini
sehingga mereka mampu menjelaskan konsep, teori, prinsip atau indikasi, prosedur
praktek, komplikasi yang muncul dan lain-lain kepada rekannya.
Kompetensi 2: Telah Melihat atau Telah Diperagakan
Lulusan pendidikan kedokteran menguasai pengetahuan teoretis yang terkait dengan
keterampilan ini (konsep, teori, prinsip atau indikasi, prosedur praktek, komplikasi dan
lain-lain). Selain itu, selama masa pendidikan, mereka pernah melihat skill ini
diperagakan atau skill ini pernah dipraktekkan di depan mereka.
Kompetensi 3: Pernah melakukan atau pernah menerapkan dengan Pengawasan
Lulusan pendidikan kedokteran menguasai pengetahuan teoretis terkait dengan skill ini
(konsep, teori, prinsip atau indikasi, prosedur praktek, komplikasi dll.). Selain itu, selama
masa studi, mereka telah melihat keterampilan ini dilakukan atau keterampilan tersebut
dipertunjukkan di depan mereka atau mereka telah menerapkannya beberapa kali di
bawah pengawasan.
Kompetensi 4: Mampu Mempraktekkan secara Mandiri
Lulusan pendidikan kedokteran menguasai pengetahuan teoretis yang berkaitan dengan
skill ini (konsep, teori, prinsip atau indikasi, prosedur praktek, komplikasi dan lain-lain.)
Selain itu, selama masa studi, mereka telah melihat penerapan skill ini atau skill ini
diperagakan di depan mereka dan mereka telah memperagakannya secara mandiri
dengan pengawasan pihak berwenang. Mereka juga telah memiliki pengalaman untuk
menggunakan dan melaksanakan skill ini dalam konteks praktek dokter secara mandiri.
E. Kegiatan
Waktu Aktivitas Mahasiswa Instruktur Materi
5 menit Perkenalan Mendengarkan Menjelaskan -
5 menit Pengumpulan Mendengarkan Menjelaskan Workplan
tugas dan
mengumpulkan
tugas
15 menit Sesi Trial and Mencoba dan Observasi dan 1. Folley Catheter
Error mengobservasi mempersiapkan Spuit injeksi 10
(2 mahasiswa) feedback cc untuk
15 menit Memberikan Membuat Memberikan lubrikan
feedback pertanyaan feedback Spuit injeksi 20
15 menit Demonstrasi Observasi dan Demonstrasi, cc untuk
Diskusi diskusi memompa
5 x 10 Latihan Melakukan dan Observasi dan balon
menit saling memberikan Akuades steril
mengobservasi feedback Gel/Lubrican
(satu sama lain) 2. Pinset Anatomi
3. Kidney Bowl
4. Kasa steril
5. Plaster
6. Povidon
Iodin/Betadine
7. Gunting
8. Linen steril
berlubang
9. Sarung tangan
bersih
10. Alkohol 70%
11. Sabun dan
air mengalir
12. Container
tempat
instrumen,kassa
dll
15 menit Evaluasi dan Bertanya dan Menjelaskan dan Lembar
penutupan memberikan menutup sesi Feedback
komentar
Seorang kakek berusia 67 tahun datang ke puskesmas tempat anda bertugas dengan keluhan sulit
untuk buang air kecil. Dari anamnesis didapatkan ada riwayat Benigna Prostate Hyperplasia (BPH)
dan pada pemeriksaan fisik terdapat distensi pada regio suprapubik.
Sebagai mahasiswa fakultas kedokteran, anda akan berlatih melakukan kateterisasi uretra.
Prosedur ini harus dikuasai oleh semua tenaga kesehatan termasuk dokter. Laboratorium
Keterampilan Medis memberi kesempatan kepada mahasiswa untuk berlatih melakukan prosedur
tersebut di bawah bimbingan instruktur. Mahasiswa sebaiknya membaca buku petunjuk, yang akan
membantu dalam memahami dan berlatih melakukannya.
I. PENDAHULUAN
Kateterisasi uretra biasa dilakukan baik di rumah sakit, puskesmas maupun praktek
dokter swasta. Intervensi ini diperlukan untuk penegakan diagnosis penyakit maupun
pengobatan. Semua tenaga kesehatan, baik dokter spesialis, dokter umum maupun
perawat harus bisa menggunakan kateter sekaligus cara memasangnya ke dalam kandung
kemih. Pemahaman tentang macam-macam kateter dan alat yang terkait dengannya akan
membantu dokter maupun perawat dalam melaksanakan tugas. Pasien harus memahami
prosedur yang akan dilakukan maupun komplikasi yang bisa terjadi. Mereka juga harus
diberi informasi, kooperatif, toleran, dan nyaman dengan prosedur yang dilakukan.
Instrumentasi retrograd yang kurang tepat di saluran kemih bisa mengakibatkan
luka serius. Larutan sterilisasi, lubrikan larut air dan pembilasan (irigasi) dengan tekanan
rendah bisa menurunkan risiko infeksi. Pemasangan dalam jangka panjang harus disertai
antibiotik yang tepat. Selain itu, posisi pasien juga berperan penting dalam keberhasilan
tindakan ini.
II. PEMBAHASAN
Sebelum melakukan kateterisasi uretra, dokter atau perawat harus memahami alat,
kateter uretra, anatomi kandung kemih dan uretra, retensi urin, pemasangan kateter
urethra menetap (indwelling catheterization), melepas dan mengganti kateter uretra
menetap. Kateterisasi uretra bisa dilakukan oleh dokter maupun perawat terlatih.
A. Kateter Uretra
Kateter uretra (bisa terbuat dari bahan karet, lateks, plastik/polivinilklorida, teflon,
silikon, hidrogel, logam) merupakan pipa berlumen yang digunakan untuk mengalirkan
urin dari kandung kemih. Kateterisasi di indikasikan pada penderita retensi urin, urin
harus di-drain untuk mengukur volume residu urin, mengambil sampel pemeriksaan,
memasukkan obat atau kontras radiografi, dan irigasi kandung kemih. Beberapa jenis
kateter juga dapat berfungsi sebagai nephrostomy tubes. Kateter yang rigid atau
berbahan metal bisa menimbulkan perforasi di bagian uretra posterior (false passage)
sehingga sebaiknya hanya digunakan oleh urolog.
Kateter Coudé sejenis berukuran 16 – 18 Fr sebaiknya tidak digunakan untuk
jangka panjang. Kateter jenis ini berujung kaku dan bisa mengakibatkan ulserasi dan
nekrosis pada dinding kandung kemih, sehingga menyebabkan kolapsnya kandung
kemih. Kateter pendek (berbahan plastik atau metal) berukuran panjang 8 cm digunakan
untuk kateterisasi pada wanita. Kateter untuk laki-laki sebaiknya lembut.
Kateter yang cocok digunakan untuk jangka panjang antara lain kateter Foley.
Kateter Foley merupakan self–retaining balloon catheter yang dirancang oleh Dr.
Frederick Foley di tahun 1920. Ada dua jenis yang beredar di pasaran:
Ukuran kateter umumnya dalam skala Cherriere (Ch) atau French (Fr). Ukuran
standar diameter luar kateter dan sebagian besar instrumen endoskopis didasarkan
pada skala Charriere‘s French (0,33 mm = 1 French [F] atau 1 Charriere [Charr]).
Diameter dalam satuan milimeter diperoleh dengan cara Ch/Fr dibagi 3. Misalnya,
kateter bertuliskan 30 Fr berarti memiliki diameter sekitar 10 mm. Kateter cabang tiga
memiliki saluran lebih sempit untuk drainase urin karena adanya saluran tambahan
untuk irigasi. Kateter cabang tiga yang lebih besar berukuran 22 – 24 Fr diperlukan
untuk lavase kandung kemih dan irigasi jika terdapat debris atau pasien hematuri.
Balon kateter harus dipompa agar mampu menahan ujung kateter dalam
kandung kemih. Volume balon umumnya 3 ml,5 ml, 10 ml dan 30 – 50 ml pada kateter
cabang tiga dirancang untuk digunakan setelah tindakan transuretra lresection
prostatectomy. Balon yang besar lebih mudah menyebabkan spasme kandung kemih
dan kebocoran urin. Penggunaan balon besar dalam jangka panjang bisa menyebabkan
kerusakan pada leher kandung kemih. Volume balon kateter diisi sesuai volume yang
direkomendasikan produsen untuk menghindari pecahnya balon.
C. Uretra
Uretra Pria
Uretra bermula dari orifisum kandung kemih (uretra internal) berukuran sekitar 17
– 25 cm hingga meatus eksternus, lebar rata-rata 8 – 9 mm. Meatus eksternal
merupakan bagian tersempit dari uretra. Fossa navicularis merupakan bagian terbesar
glans uretra. Pembagian anatomi uretra sangat penting secara klinis.
Uretra pria terbagi menjadi bagian posterior (uretra pars prostatica dan pars
membranacea) dan bagian anterior (uretra pars bulbosa dan penile uretra). Colliculus
seminalis dengan duktus seminalis dan kelenjar prostat terletak di uretra pars prostatica.
Uretra pars membranacea berisi sphincter eksternal, suatu otot volunter. Pada titik ini,
uretra menembus diafragma urogenital dan difiksasi oleh jaringan ikat padat hingga
bagian bawah symphysis. Fraktur pelvis dapat mengakibatkan kontusio, laserasi atau
transeksi dari uretra. Mukosa uretra dilapisi epithel transisional di bagian posterior
berlanjut menjadi epithel kolumnar kompleks dan epithel squamous. Bagian tersebut
kaya akan suplai darah dan inervasi.
Dalam kondisi flaksid, organ ini berbentuk S, ketika penis ereksi, uretra
berbentuk U atau L. Bentuk uretra yang melengkung (huruf S) dapat diluruskan kembali
dengan traksi penis ringan. Hal ini penting dilakukan ketika memasukkan kateter ke
dalam uretra.
D. Retensi Urin
Retensi urin banyak ditemui di ruang gawat darurat maupun praktek pribadi.
Gangguan ini dapat diakibatkan oleh ketidakmampuan kandung kemih untuk
mengosongkan urin, obstruksi dari bladder outflow, kontraktilitas kandung kemih yang
menurun atau kombinasi keduanya. Retensi urin tidak hanya menyebabkan gangguan
lokal tapi bisa pula merusak fungsi ginjal. Retensi urin kejadiannnya dapat cepat hanya
dalam waktu beberapa jam (Acute Urinary Retention, AUR) atau beberapa bulan atau
tahun (Chronic Urinary Retention, CUR). Keduanya mungkin pula terjadi secara
bersamaan.
Edukasi:
1. Bagaimana cara menjaga kateter?
o Jangan diletakkan di tempat yang lebih tinggi dari kandung kemih
o Kateter jangan tertekuk
o Tidak boleh melepas sambungan antara kateter dan pipa kantong urin
o Tidak boleh membuang urin yang terkumpul tanpa seizin petugas medis
2. Kapan harus menemui dokter?
o Urin tidak keluar
o Warna urin yang keluar abnormal
o Nyeri di area suprapubik dan genital
o Ada tanda-tanda alergi pada daerah pemasangan
3. Kapan kateter bisa dilepas?
o Dalam waktu 2 minggu jika kateter terawat dengan baik
Dengan perawatan yang baik (drainase tertutup rapat, terfiksasi kuat pada paha
atas), kateter Foley bisa tetap terpasang selama 2 – 4 minggu. Pada pasien dengan urin
keruh, terdapat tanda infeksi dan kecenderungan mengalami enkrustasi, kateter harus
diganti sesuai keperluan. Selain itu, perawatan harus dilakukan untuk menghindari
penyumbatan kateter. Asupan cairan harian sebanyak 2000 ml akan membuat aliran
dalam kateter berjalan dengan baik.
Pada penderita gross hematuria, pembekuan darah, atau infeksi, kandung kemih
diirigasi dengan hati-hati sampai isi kandung kemih bersih. Saline steril atau air steril
bisa digunakan sebagai irigan (larutan pembilas)
REFERENSI
1. Alken E.C.M.D. , Sokeland J. M.D., Engel R. M.D., F.A.C.S. 1982. Urology. Guide for
Diagnosis and Therapy. Year Books Medical Publisher,Inc. Chicago.
2. Baskin L.S., Kogan B.A., Ducket J.W.1997. Handbook of Paediatric Urology. Lippincott
3. Bennett M.D. J.V., Brachman M.D. P.S, 1992. Hospital Infection. Third
Edition.Little,Brown.
4. Chaple C.R.., MacDiarmid S.A. 2000. Urodynamics Made Easy. Second Edition.
Churchil Livingstone.
5. Dawson C., Whitfield H. 2001. ABC of Urology. BMJ Publishing Group.
6. Hanno P.M., Malkowicz S.B., Wein A.J. 2001. Clinical Manual of Urology. McGraw-Hill
International Edition.
7. Mumtaz F., Woodhous C.R.J., McAninch J.W.,,Cochlin D.L. 2004. Management of
Urological Emergencies. Taylor & Francis Group.
8. Tonago E.A., McAninch J.W. 2004. Smiths General Urology. Sixteenth Edition.
International Edition.
Penjelasan:
Skala 1: Tidak menunjukkan rasa hormat dan norma + lebih dari 80 % kesalahan
Skala 2: Menunjukkan rasa hormat dan norma minimal + 60%-80% kesalahan
Skala 3: Menunjukkan rasa hormat dan norma minimal + 40%-60% kesalahan
Skala 4: Menunjukkan rasa hormat dan norma minimal + 20%-40% kesalahan
Skala 5: Menunjukkan rasa hormat dan norma minimal + kurang dari 20% kesalahan
Yogyakarta, …………………..
Instruktur,
( )
Nama : ………………………………………………………………………..
No. Mahasiswa : ………………………………………………………………………..
No Penilaian Feedback
1. Menjelaskan dan menginformasikan prosedur pemasangan
kepada pasien (melakukan informed consent)
2. Mempersiapkan semua peralatan yang akan digunakan
pada tempat yang disediakan
3. Memposisikan pasien
Menerapkan Prinsip Aseptik
4. Mencuci tangan
5. Memakai sarung tangan steril
Melakukan Prosedur dengan benar
6. Melepas perban dari glans penis
7. Mengempiskan balon kateter dengan mengeluarkan air dari
balon hingga kosong
8. Menarik kateter uretra secara perlahan dan lembut
9. Meminta pasien menarik napas panjang perlahan atau
mengejan seperti hendak berkemih untuk merelaksasi otot
sphincter
10. Meletakkan kateter dan kantong urin ke dalam wadah
khusus
11. Membereskan semua peralatan
12. Mencuci tangan
Penjelasan:
Skala 1: Tidak menunjukkan rasa hormat dan norma + lebih dari 80 % kesalahan
Skala 2: Menunjukkan rasa hormat dan norma minimal + 60%-80% kesalahan
Skala 3: Menunjukkan rasa hormat dan norma minimal + 40%-60% kesalahan
Skala 4: Menunjukkan rasa hormat dan norma minimal + 20%-40% kesalahan
Skala 5: Menunjukkan rasa hormat dan norma minimal + kurang dari 20% kesalahan
Yogyakarta, …………………..
Instruktur,
( )
Skills Laboratory
Faculty of Medicine
Universitas Gadjah Mada
Yogyakarta
2014
Contributor:
Co-Contributor:
Medical school students should study and practice several clinical skills as preparation
for entering clinical rotation prior to becoming a certified doctor. Currently, the medical
profession compels medical students to be competent in clinical skills before they directly deal
with real patients experiencing real life medical cases. For this reason, clinical skills are trained
as early as possible. This clinical skills laboratory provides opportunity for students to study and
practice the clinical skills on their own.
The topic of this manual is one of the clinical skills topics that constitute the main topic of
Life Support, which will be studied continually in blocks throughout undergraduate studies. The
skill included in this book is based on Competence-Based-Curriculum of 2007. Topics covered
in Life Support, which will be studied in Year III, are as listed as follows:
4. Electrocardiography II 3.6
(Life Style Related
Complaint)
It is important for students to recognize that all topics, including those listed above, are
interrelated. Therefore, students are expected to categorize the topics based on the main topics,
so that continuity from one topic to another can be achieved. We hope that in the future, this
manual for clinical skills training can be useful for students to improve their skills, especially in
physical examination; and for instructors who are involved in providing the trainings.
Contributor
C. Level of Competence
Level of Competence for Clinical Skills :
The following is the division of competence level according to Miller Pyramid:
Level of Competence 1: Understanding and Explaining
The graduates of medical school possess theoretical knowledge concerning these skills,
so that they are able to explain concepts, theories, principles or indications, performing
procedures, emerging complications and others to their colleagues.
Level of Competence 2: Having seen or Having been demonstrated
The graduates of medical school possess theoretical knowledge concerning this skill
(concepts, theories, principles or indications, performing procedures, complications and
others). Besides, during their study, they had seen this skill or this skill had been
demonstrated to them.
Level of Competence 3: Having done or Having applied under Supervision
The graduates of medical school possess theoretical knowledge concerning this skill
(concepts, theories, principles or indications, performing procedures, complications and
others). Besides, during their study, they had seen this skill or this skill had been
demonstrated to them or they had applied several times under supervision.
Level of Competence 4: Able to perform independently
The graduates of medical school possess theoretical knowledge concerning this skill
(concepts, theories, principles or indications, performing procedures, complications and
others). Besides, during their study, they had seen this skill or this skill had been
demonstrated to them and they had applied several times under supervision; in addition,
they possess experience to use and apply this skill in the context of doctor practices
independently.
D. Activities
Time Activity Students Instructor Materials
5 minutes Introduction and Listen and Explain and Workplan
collecting Submitting the Collecting
assignment assignment assignment
10 Practicing NGT Practicing Observing and Non-allergenic
minutes insertion problem tape
identified Protective pad or
10 Demonstration by Observe & Demonstrating, towel
minutes instructor discuss discussing
Safety pin
Cup of water
with
straw
Stethoscope
60 cc Irrigating
syringe
Water soluble
lubricant
NG tube (plastic
or rubber) of
appropriate
size
Suction
What will you conduct as a doctor on duty regarding the patient’s condition?
I. PHARYNGEAL ANATOMY
The nasopharynx extends from the nares superiorly and laterally to the sinuses,
eustachian tubes, and sphenoid sinus and inferiorly to the soft palate. The posterior
oropharynx begins below the soft palate and extends inferiorly to the glottis and
esophageal opening. Notable elements of the nasopharynx are its mucosa, which can be
either enlarged or constricted; the hard palate anteriorly; and the soft palate posteriorly.
Notable structures in the oropharynx include the tongue, salivary glands, and the tonsils.
The glottis represents the termination of the oropharynx and is located anterior to
the esophagus. The anterior mobile leaf-like epiglottis functions to cover the glottis during
swallowing. Inside the glottis lie the false and true vocal cords.
The esophagus is a tubular conduit between the oropharynx and stomach. The
esophagus consists of both striatal (proximal) and smooth (distal) muscle that exhibit
distal-moving peristalsis. It has a moist mucosal surface. The distal esophagus ends in a
smooth muscle sphincter, which normally prevents reflux of gastric fluid into the
esophagus.
III. INDICATIONS
Decompression of the Gastrointestinal Tract
Nasogastric intubation and suction are required to remove enteric secretions and
swallowed air in patients with obstructions of the small bowel or gastric outlet.
Nasogastric intubation may also provide symptomatic relief for patients with severe
pancreatitis and associated ileus; however, routine placement of nasogastric tubes in
patients with mild or moderate symptoms is not indicated, since this may result in
prolonged nausea and vomiting and extended hospitalization. Nasogastric (or
orogastric) intubation and suction may be beneficial in patients undergoing mechanical
ventilation with the use of an endotracheal tube in order to prevent aspiration of gastric
contents.
Avoid or reduce nausea or vomiting after surgery/trauma
Administration of Oral Agents
Oral agents (e.g., activated charcoal or radiographic contrast material) may be
administered through a nasogastric tube in patients unable to tolerate fluids delivered
orally.
Gastrointestinal Hemorrhage
Nasogastric intubation and suctioning may be performed in patients with severe upper
gastrointestinal bleeding in order to provide symptomatic relief and to facilitate
endoscopic visualization of the gastric and duodenal mucosa. In the absence of frank
bloody return, examination of nasogastric aspirates has a suboptimal sensitivity and
specificity and cannot be relied on to confirm or rule out active hemorrhage in patients
with a history of hematemesis or melena.
IV. CONTRAINDICATIONS
Maxillofacial Trauma
Nasogastric intubation should be avoided in patients with substantial maxillofacial
trauma or anterior fossa skull fracture in order to avoid passage of the tube into the
cranial vault through a potentially disrupted cribriform plate.
Esophageal Abnormalities
The risk of esophageal perforation is high among patients with a recent history of
ingestion of caustic substances and those in whom esophageal strictures or diverticula
are present.In most cases, nasogastric intubation may be performed safely in patients
with esophageal varices.
Altered Mental Status and Impaired Defenses
Nasogastric intubation may precipitate vomiting and thus should be avoided in patients
with altered mental status or impaired airway defenses. In such patients, endotracheal
intubation should precede nasogastric intubation if the procedure is indicated.
VII. PREPARATION
Patient
Explain the procedure to the patient, and obtain informed consent. Put the patient in
‗highfowler‘ position, so that the procedure of insertion is easier to perform. Place the
towel at patient‘s chest.
Equipment
To choose the appropriate side of the nose for insertion, first assess the patency and
symmetry of the nares by asking the patient to inhale alternately through each nostril,
noting which side provides superior flow. An otoscope may be used to examine the
passageway directly to identify septal deviation or other anatomical restrictions. Estimate
the proper depth that the tube should be inserted by measuring the distance from the
nostril to the earlobe and then to the xyphoid process. Note the corresponding distance
mark on the tube.
Universal Precaution
Use mask, protective gown and gloves to protect ourselves.
IX. COMPLICATIONS
Minor complications of nasogastric intubation include sinusitis, epistaxis, and sore throat.
Serious complications include esophageal perforation, aspiration, pneumothorax, and,
rarely, intracranial placement.
Hypoxia and cyanosis
Name : ………………………………………………….
Student No : ………………………………………………….
No Aspects Score Feedback
1 2 3
1. Explain the procedure to the patient
2. Position the patient as follows
a. If the patient is awake and alert-in a sitting position in
high-Fowler‘s.
b. If the patient is obtunded or unconscious-head down,
preferably in a left side lying position.
3. Place a protective pad/towel on the patient‘s chest as well as
provide the patient with a basin to minimize contact with
aspirated gastric contents.
4. Using the NG tube as a measuring device determine the length
of the NG tube to be passed by measuring the length from
nose to earlobe earlobe to xiphoid process
5. Add the measurements together and mark this total distance
with a small piece of tape.
6. Inspect both of the patient‘s nostrils for patency. Have the
patient blow nose if able.
7. Lubricate along 10-20 cm of the NG tube liberally with a water
soluble lubricant. Choose the largest patent nostril and begin
to pass the NG tube through the nostril to the nasopharynx;
direct the tube through the nostril aiming down and back.
8. Once in the pharynx instruct the patient to swallow either
mimicking the action or by sipping on small amounts of water.
If awake and alert have the patient place chin to chest to
facilitate easier passage of the tube. Introduce the tube until
the selected mark (indicated by the tape) is reached.
9. During the procedure, check whether the NGT curls in patients
pharynx or mouth using a flashlight.
10. Note the patient response during the procedure
11. Verify NG tube placement in the stomach by two of the
following:
a. Aspirating gastric contents with the irrigation syringe
b. While listening over the epigastrum with a stethoscope
quickly instill a 10-20 cc air bolus with the irrigation
syringe. Air entering the stomach will produce a
―whooshing‖ sound.
c. Place the open end of the NG tube in a cup of water.
Persistent bubbling may indicate that the NG tube has
passed through the larynx.
12. If unable to positively confirm that the NG tube has been
placed is in the stomach the tube must be removed
immediately and re-attempted.
13. Clean the nose using cotton soaked alcohol
14. Secure the NG tube by placing one end of tape on from the
bridge to the tip of the nose and the other end wrapped around
the tube itself
Total score
Explanation:
Scale 1: Unable to demonstrate respect and norms + More than 80 % error
Scale 2: Below observer‘s expectation (demonstrate minimal respect and norms + 60%-80% error)
Scale 3: Meet observer‘s expectation (demonstrate minimal respect and norms + 40%-60% error)
Scale 4: Exceed observer‘s expectation (demonstrate minimal respect and norms + 20%-40% error)
Scale 5: Excellent (demonstrate minimal respect and norms + less than 20% error)
Yogyakarta, …………………..
Instructor,
( )