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Week III

MODULE OF SKILL LABORATORY PRACTICE

BLOCK : GASTRO-INTESTINAL SYSTEM
TOPIC : CLINICAL EXAM OF SURGICAL DISEASE/
DISORDERS OF THE ACUTE ABDOMEN

I. GENERAL OBJECTIVE
After finishing skill practice of Clinical examination of surgical diseases and disorders of the
abdomen, the student will be able to perform history taking and physical examination of
surgical diseases and disorders of the abdomen correctly.

II. SPECIFIC OBJECTIVES
At the end of skill practices, the student will be able to perform clinical examination of acute
abdomen correctly.

III. SYLLABUS DESCRIPTION

3.1 Sub Module Objective
After finishing skill practice of examination of acute abdomen, the student will be
able to perform history taking and physical examination of acute abdomen correctly.

3.2 Expected Competencies
a. Students perform history taking of acute abdomen. (P5)
b. Students perform physical examination of acute abdomen.(P5)

3.1 Topics
1. History taking of acute abdomen.
2. Physical examination of acute abdomen.

3.2 Methods
a. Presentation
b. Demonstration
c. Coaching
d. Self practices

3.3 Laboratory Facilities
1. Skills Laboratory
2. Clinical Instructors
3. Student Learning guide
4. Instructor guide
5. References
6. Equipment
7. Standardized patient

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3.4 Venue
Skills Laboratory Faculty of Medicine of Universitas Padjadjaran, Bandung, at
A.5.1.1 Building, Jatinangor Campus.

3.5 Organizer
Clinical Skills Program of Gastro-intestinal System, Faculty of Medicine Universitas
Padjadjaran, Dr Hasan Sadikin Hospital.

3.6 Evaluation
a. Skill demonstration
b. Point nodal evaluation
c. OSCE


IV. Equipment arrangement

All equipment required for this topic includes:

1. Multimedia equipment
2. Examination couch
3. Table
4. Chairs
5. Stethoscope
6. Pelvic models
7. Supporting equipment and facilities
1. Water tap with running water
2. Wash basin















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V. LEARNING GUIDE OF ACUTE ABDOMEN

A. HISTORY TAKING

No. Procedure Performance Scale

Comment
1 2 3

Introduction


1. Greet the patient, and develop a warm
and helpful environment

2. Introduce yourself to the patient

Patient Identity


3. Ask the patient politely concerning
his/her:
name
age

4. Record the gender:
Male
Female

5. Ask the marital status of the patient
(especially for female)



Chief complaint


6. Ask the patient regarding why the
patient comes to you.

7. Pain:
Onset
Site at onset
Site at present
Severity
Aggravating factors
Relieving factors
Duration
Progress
Type of pain
Radiation



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Other related symptoms

8. Ask the patient concerning
related/concomitant symptoms of:
9.1.Gastro-intestinal functions:
Nausea
Vomiting
Loss of appetite
Faintness
Previous indigestion (habitual)
Jaundice
Bowel habit:
o Constipation?
o Diarrhoea?
o Color of the stool?
o Presence or absence of
blood and mucus (slime)
9.2.Urinary function:
Micturition: amount of urine,
lower abdominal discomfort,
color of urine
9.3.Gynaecological function: (Female)
Menstrual function
Delayed or miss period
Abnormal bleeding or discharge
(color, quantity)

9. Previous history of :
Previous similar pain
Previous abdominal surgery
Previous major illness: incl.
fever, abdominal injury.
Drugs
Allergies













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B. PHYSICAL EXAMINATION

No. Procedure Performance Scale

Comment
1 2 3

Preparation

1. Check all the equipment required and
have a good light:
Examination couch
Stethoscope

2. Explain the procedure and its goals to the
patient.

3. Wash your hands with antiseptic soap
4. Dry and warm your hands with tissues

Implementation


A General Examination:

5. General appearance:
Consciousness
Mood: distressed? Anxious?
Immobile
Move cautiously
Colour: Pallor? Flushing?
Jaundice? Cyanosis?


6. Examine the vital signs:
Temperature
Pulse rate
Blood Pressure
Respiratory rate


7. Perform other systems examination,
including cardio-pulmonary system.

8. Ask the patient politely to expose his/her
abdomen.


B. Abdominal Examination:


Inspection


9. Inspect the movement:
Respiratory movement
Visible bowel peristaltic

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10. Is there any scar on the skin of the
abdomen?

11. Is there any abdominal distention?
Flatus?
Fluid?
Fetus?

12. Is there any rashes and discoloration?
Cullens sign
Gray Turners sign
Ecchymosis of the abdominal wall

13. Is there any masses:
Tumors?
Hernial sites?
Masses with pulsation?


Auscultation

14. Using stethoscope, and place it gently on
the abdomen, listen to the bowel sounds
and bruit at least for one minute:
Absent?
High pitched and hyperactive?
Metallic sound?
Vascular bruit?


Palpation


15. Ask the patient to locate the site of
maximum pain with the tip of a finger.

16. Using the palmar surface of your fingers,
gently palpate the abdomen, starting from
a site farthest from the area of maximum
pain, move gradually towards it. While
palpating, look to the face expression of
the patient, and look for any signs of :
Tenderness
Rebound tenderness
Muscle guarding
Rigidity
Murphys sign
Rovsings sign
Psoas and Obturators sign
Swelling or masses
Expansile pulsation
Hernial orifices
Scrotum in male

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Percussion

16\7
.
Place the palmar aspect of your left hand
on the abdomen, and gently percuss its
dorsal aspect with the tip of the middle
finger of the right hand, moving all
around the abdominal region:
Is it tymphanitic?
Is it Dull?
Is there any shifting dullness?
Site of liver dullness? and is it
disappeared?


Digital Rectal Examination

18. Put on surgical hand gloves and ask the
patient to expose his/her buttock and anus,
and place the patient in lithotomic
position.

19. Apply lubricating jelly on to the right
index finger.

20. Gently insert your right index finger into
the anus, move toward the anal canal
slowly, and evaluate the followings:
Anal margin: piles?
Mucosal surface of the anal canal
and the ampulla (collapsed?)
Sites of any pain elicited
Masses or swelling: consistency,
location, surface, fixity to the
surroundings.
Bowel contents: consistency of
faeces? Mucus? Blood?

21. Perform bimanual palpation in female
patient to examine the uterus, pelvic
cavity and adnexa.

22. Remove the gloves and wash your hands.
Write up
23. Write up all significant findings in the
medical record.

24. Conclude your diagnosis and differential
diagnosis, and order any necessary special
investigations