Professional Documents
Culture Documents
Author:
Prof. Wahyuni Atmodjo, dr.,P.A.K,Ph.D
Jeremy Sebastian dr.,SpB.,Mkes.
Freda Halim, dr.,SpB.
Contibutors
Dr. Edwin RPL Tobing, dr., SpU
Royman Christian P. Simanjuntak, dr., SpBTKV
Budhi Adhiwijaya, dr. SpBTKV
Harmada Hutajulu, dr., SpB
Anthony Berlim, dr., SpB
Dr. Julius July, dr., SpBS
Harsan, dr., SpBS
Bernard Agung Baskoro, dr., SpB(K)Onk.
Hartono Kartawidjaja, dr., SpBP
John Butar Butar, dr., SpOT
Wibisono, dr., SpOT
A. COURSE INFO
Surgery Clerkship Course is a 10 weeks course, preceptor based clerkship,
divided into 8 groups of primary preceptor.
The site directors at each teaching site bear the primary responsibility for the
development and maintenance of a program to fulfill the learning objectives of the
Externships in Medicine. The coordinator is responsible for organizing the tutorials and
seminars and encouraging faculty members to take the expected approach toward
student involvement in seminars and tutorials. Since there are differences in student
responsibilities for Surgery, directors will also reinforce at the beginning of each period,
with the attending physician (preceptor) and RMOs, the objectives to be met by the
students assigned to their ward team. Each student is part of a medical team usually
consisting of one or two RMOs, assistants, and a preceptor.
Students attend morning work rounds each day and participate in attending
rounds as scheduled. Students also work 1 night in maximum of 3 duty schedules. The
preceptor has the primary responsibility for educating students assigned to the ward
team. The immediate day-to-day supervisor for students is the assistant. All of the
physician-teachers with whom the student has contact are expected to serve as positive
role models.
Students are expected to do a work-up (complete medical records) with a
minimum of ten patients during the rotation (1 case every week). More cases may be
assigned. Students should attempt to complete their history taking and physical
examinations within 60 minutes.
Student specific seminar
Case Presentation
One student is expected to make and present two case presentations (one in
General Surgery, and the other depend on the schedule). The selected case
chosen from the write up cases. Student complete a written material consist of
minimal 10 pages with detail of history and clinical finding, simple basic theory
related to the case and a constructive discussion. Student will present in 15-20
minutes and discuss with preceptor and other students for another 45 minutes.
Bedside Teaching
Students and preceptor will have dedicated and protected 90 minutes (1.5 hour)
of Bedside teaching activities. Students should prepare them-self for the case and
let the preceptor knows which patient is taken as bedside teaching patient.
Student should be able to take a comprehensive history, good physical
examination, established provisional and differential diagnosis, plan treatment
and educate patient and their family. Each student will have at least 20 times bed
site teaching with different preceptor.
The preceptor uses the one-minute preceptors method consisting several steps:
1. Get a commitment
2. Probe for supporting evidence
3. Reinforce what was done well
4. Give guidance about errors and omissions
conclude that all patients in a similar clinical situation may behave in the same
way or require the exact same treatment. On the other hand, the student may be
unable to identify an important general principle that can be applied effectively
in the future. Brief teaching specifically focused to the encounter can be very
effective. Even if you do not have a specific medical fact to share, information on
strategies for searching for additional information or facilitating admission to the
hospital can be very useful to the learner.
Step 6: Conclusion
This final step serves the very important function of ending the teaching
interaction and defining what the role of the student will be in the next events. It
is sometimes easy for a teaching encounter to last much longer than anticipated
with negative effects on the remainder of the patient care schedule. The
preceptor must be aware of time and cannot rely on the student to limit or cut off
the interaction. The roles of the learner and preceptor after the teaching
encounter may need definition. In some cases you may wish to be the observer
while the learner performs the physical or reviews the treatment plan with the
patient. In another instance you may wish to go in and confirm physical findings
and then review the case with the patient yourself. Explaining to the learner
what the next steps will be and what their role is will facilitate the care of the
patient and the functioning of the learner.
Feedback
Since ongoing feedback is fundamental to a successful educational relationship,
students should feel free to ask about their progress. Feedback from faculty and
residents to students is extremely important in providing the opportunity to
improve clinical performance. During the Externships in Medicine, students will
be expected to initiate meetings at mid-rotation, first with their supervising
resident (if assigned) and then with their attending physician, to discuss both
strengths and areas needing improvement. The content of this feedback is
outlined in the Evaluation forms for this course.
A similar process should occur at the end of the rotation so that the student,
resident and faculty can discuss the students progress relative to the midrotation assessment and the Course Objectives. These student-initiated sessions
should make the feedback process more efficient, effective, and palatable for the
faculty and residents; and equally important, promote student self-assessment
through analysis of specific examples of their own performance
Students general Roles, Responsibilities, Obligations and Activities
a. Hours of working day.
Students are expected to work 8 hours every day from 07.00 16.00
(includes 1 hour meal break) Monday to Saturday
Students are expected to complete their daily work before leaving and to
attend Academic or teaching activities which may extend beyond 16.00
hours. They have to report by phone or meet in personal to the week s
preceptor at least one day before the rotation.
p.
q.
Monday
Follow up
Tuesday
Follow
up
Wednesday
Follow up
Thursday
Follow up
Friday
Follow up
Laporan jaga
pagi (Tim
Bedah Saraf)
Laporan
jaga pagi
(Bedah
Umum)
Laporan
jaga pagi
(Tim Bedah
Saraf)
Laporan
jaga pagi
(Tim
Bedah
Saraf)
Laporan
jaga pagi
(Tim
Bedah
Saraf)
09.00
10.00
Visite Besar
Koasisten
10.00
12.00
Kegiatan
dengan
preceptor(OPD
/ OT)
12.00
13.00
Istirahat dan
persiapan
untuk jaga
13.00
16.00
Kegiatan
dengan
preceptor(OPD
/ OT)
Kegiatan
dengan
preceptor
(OPD/
OT)
Istirahat
dan
persiapa
n untuk
jaga
Kegiatan
dengan
preceptor
(OPD/
OT)
Kegiatan
dengan
preceptor
(OPD/ OT)
Istirahat
dan
persiapan
untuk jaga
Mengikuti
Siang Kllinik
RSUS
Kegiatan
dengan
preceptor
(OPD/
OT)
Istirahat
dan
persiapan
untuk
jaga
Kegiatan
dengan
preceptor
(OPD/
OT)
Kegiatan
dengan
preceptor
(OPD/ OT)
Saturday
Follow up
Sunday
Start
Jaga
Pagi
(Ganti
shift pkl
19.00)
BST
Kegiatan
dengan
preceptor
Kegiatan
dengan
preceptor
Puskes
mas
Istirahat
dan
persiapan
untuk jaga
Istirahat dan
persiapan untuk jaga
Kegiatan
dengan
preceptor
(OPD/ OT)
Kegiatan dengan
preceptor
(OPD/ OT)
Expected Competencies
(Based on Standard of Indonesian Medical Doctor Competencies or Standar
Kompetensi Dokter Indonesia - SKDI)
Basic Surgical Knowledges Competencies
1. Able to explain type of minor surgery
2. Able to explain type of major surgery
3. Able to explain informed concent
4. Able to explain universal precaution and infection prevention
5. Able to explain local anesthesia technique
6. Able to explain maximum dose of local anesthetic agent
7. Able to explain basic surgical skills which include knotting, suturing and instrument
handling.
8. Able to explain the type of suture material for wound suturing, both inside or outside
of the wound.
9. Able to explain the type and purpose of wound suturing technique
10. Able to explain each surgical instrument for minor surgery and its purpose
11. Able to explain wound healing process and factors that influence wound healing
Psychomotor Competencies
1. Demonstrate the process of good informed consent
2. Demonstrate the process of universal precaution and infection prevention
3. Demonstrate the process of applying local anesthetic
4. Demonstrate the process of choosing the appropriate suture material
5. Demonstrate the process of choosing the appropriate surgical instrument for suturing
6. Demonstrate the process of wound suturing, and able to choose the appropriate
suturing technique
7. Demonstrate the process of wound care and management
8. Demonstrate the process of giving medical education to the patient about wound care
10
11
Level
of competency
2
2
2
1
2
4A
Venous disease
4. Varicose vein
5. Chronic Venous Insufficiency
6. Deep Vein Thrombosis
7. Venous embolism
8. Thrombophlebitis
2
3A
2
2
3A
Lymphatic disease
9. Lymphangitis
10. Lymphedema
Primary
Secondary (elephantiasis - filariasis)
Vascular anomalies
6. Infantile Hemangioma
7. Vascular malformation *
Venous malformation
Capillary malformation
Lymphatic malformation (limfangioma)
Arteriovenous malformation (AVM)
12
1
1
3A
3A
2
-
4A
4A
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
4A
4A
4A
3
3
3
2
4A
3
4A
3
3
Cardiothoracic surgery:
Thoracic disease
1
Lung cancer
2.
Pleural Effusion
3.
Massive pleural effusion
4.
Pneumothorax
5.
Tension pneumothorax
6.
Atelectasis
7.
Lung abscess
8.
Hematothorax
9.
Mediastinal tumor
10. Rib fracture (including flail chest) *
11.
12.
13.
Lung contussion *
Thoracic Empyema *
Open thoracic surgery on TB *
13
2
2
3B
3A
3A
2
3A
3B
2
-
Cardiac disease
9.
Acquired *
CABG surgery
Valve surgery
Congenital *
Cyanotic: TOF
Non-cyanotic: ASD, VSD, PDA
14
4A
4A
4A
4A
4A
3
2
2
4A
3
4A
3
4A
2
3B
3B
3A
3B
3B
3B
2
3B
2
2
-
Colorectal
13. Diverticulosis, diverticulitis
14. Colitis
15. Colorectal cancer
16. Rectal, anal prolapsed
17. Hemorrhoids grade 1-2
18. Hemorrhoids grade 3-4
19. (peri)anal abscess
20. Perianal fistula
21. Anal fissure
3A
3A
2
3A
4A
3A
3A
2
2
Others
22. Amebic liver abscess
23. Tetanus
24. Snake or animal bites *
25. Hipovolemic shock (bleeding)
26. Trauma abdomen *
3A
3B
3B
-
4A
4A
4A
4A
4A
4A
2
4A
4A
4A
4A
2
2
3
2
Pediatric surgery
1.
Intussuception / Invagination
2.
Anal Atresia (anorectal malformation)
3.
Fistula umbilical, omphalocele, gastroschizis
4.
Billiary Atresia
5.
Intestinal Atresia
6.
Esophageal Atresia
7.
Hirschsprungs disease
8.
Hydrocele
9.
Reponible and ireponible hernia (inguinal, femoral,
scrotal)
15
3B
2
2
2
2
2
2
2
2
10.
11.
12.
13.
14.
15.
16.
3B
2
2
4A
4A
2
2
4A
4A
4A
4A
3
2
2
4A
3
4A
Plastic surgery
1. Cleft lip and Palate
2. Angina ludwig
3. Lacerated wound
4. Perforated, penetrated wound
5. Maxillofacial trauma *
6. Peritonsillar abscess
7. Hidradenitis supurativa, carbuncle
8. Ingrowing toenails
9. Ganglion cyst
10. Lipoma
11. Burn, 1st and 2nd degree
12. Burn, 3rd degree
13. Burn, chemical
14. Burn, electrical
2
3A
4A
3B
3A
4
4
4
4A
4A
3B
3B
3B
4A
4A
4A
4A
4A
4A
4A
16
8.
9.
10.
11.
Urology
1. Benign Prostatic Hyperplasia
2. Urethral rupture
3. Bladder rupture
4. Kidney rupture
5. Torsion of Testis
6. Urethral stricture
7. Varicocele
8. Hydrocele
9. Urinary stone disease or urinary calculi
10. Priapism
11. Renal colic
12. Asymptomatic urinary tract stone disease
13. Urinary tract infection
List of Clinical Skills:
1. Bimanual kidney examination
2. Costovertebral angle tenderness
examination
3. Bladder palpation
4. Prostate palpation
5. Bulbocavernous reflex
6. Uroflowmetry
7. Plain abdomen and IVP x-ray
interpretation
8. Urethral catheterization
9. Clean intermitten catheterization
10. Suprapubic puncture
11. Circumcision
12. Penis, scrotum inspection and palpation
13. Scrotum transilumination test
Surgical Oncology
Breast disease
1. Breast cancer
2. Phyllodes tumor
3. Fibroadenoma of the breast
4. Mastitis
17
4A
4A
4A
4A
2
3B
3B
3B
3B
3A
2
2
3A
3B
3A
3A
4A
4A
4A
4A
4A
3
1
3
4A
3
3
4A
4A
4A
2
1
2
4A
5.
6.
7.
8.
Breast abscess
Pagets disease of the breast
Cracked nipple
Inverted nipple
Thyroid disease
9. Goitre
10. Thyroid adenoma
11. Thyroid cancer
Skin disease
12. Nevus pigmentosus
13. Malignant melanoma
14. Squamous cell carcinoma
15. Basal cell carcinoma
Others
16. Non-Hodgkins lymphoma
17. Hodgkins lymphoma
18. Other soft tissue tumors: fibrosarcoma,
rhabdomyosarcoma, leimyosarcoma
19. Branchial cyst and fistula
20. Tumor lidah *
21. Tumor rongga / dasar mulut *
22. Lymphadenopathy
23. Lymphadenitis
2
1
4A
4A
3A
2
2
2
1
2
2
1
1
1
2
3A
4A
Orthopaedic surgery
Trauma
1. Open fracture, close fracture
2. Clavicle fracture
3. Pathologic fracture
4. Fracture and disclocation of vertebrae
5. Extremity disclocation
6. Join trauma
7. Achilles rupture
8. Degenerative
9. Osteoarthritis
10. Osteoporosis
11. Spondilitis
12. Others
18
4A
4A
3B
3A
2
2
2
3A
3A
3A
3A
2
13.
14.
15.
16.
17.
19
2
3B
2
3A
3A
4A
4A
4A
4A
4A
4A
3
4A
3
4A
2
3
2
2
2
3B
2
3A
3A
4A
4A
4A
4A
2
20
4A
4A
4A
3
4A
4A
4A
4A
4A
3
4A
A. MINOR PROCEDURES
A. Wound Dressing
1. Washes hands and applies clean gloves.
2. Loosen edges of tape of the old dressing. Stabilizes the skin with one hand while
pulling the tape in the opposite direction.
3. Beginning at the edges of the dressing, lifts the dressing toward the center of the
wound.
4. If the dressing sticks, moistens it with 0.9% normal saline before completely
removing it.
5. Observed removed dressing for drainage, especially noting amount, color and
odor (if any) of drainage.
6. Disposes of soiled dressing and gloves in a biohazard bag. Removes gloves and
performs hand hygiene.
7. Opens sterile dressing supplies and sterile gloves using sterile technique.
Recognizes and verbalizes action if contamination occurs.
21
8. Applies sterile normal saline from bottle or prefilled syringe onto sterile gauze or
cotton balls using sterile technique
9. Wear sterile gloves without
contaminating or recognizing
contamination
a. Grasped folded edge of
cuff of one glove.
b. Lifted glove above
wrapper and away from
body.
c. Slid opposite hand into
glove. Did not adjust
cuff or fingers at this
time or let ungloved
hand touch outside of
glove.
d. Picked up second glove
by sliding sterile gloved
fingers under cuff edge.
Keeps gloved thumb off
cuff of second glove.
e. Slid fingers of opposite
hand into glove. Let go
of edge when hand in
glove.
f. Adjusted for comfort
and fit.
22
10. Uses sterile cotton balls or gauze to cleanse wound: Clean to dirty and top to
bottom
a. Cleans incision line first going from top to bottom
b. Cleans along each side of incision with a separate cotton ball, going from
top to bottom.
11. Picks up new sterile dressing and places over center of wound.
12. Places large sterile ABD dressing over the wound dressing.
13. Secures edges of dressing to skin with tape.
14. Places date, time, and initials on dressing.
15. Removes gloves and performs hand hygiene.
16. Maintained principles of sterile field eg., anything below the waist is unsterile,
sterile field always in field of vision (do not turn back toward sterile field), keep
sterile gloved hands above the waist, no reaching across sterile field, do not use
wet or damaged package of sterile supplies, cannot touch an unsterile object
with sterile gloves, etc
23
9. Hold the surgical tweezers in a pencil grip in one hand. In the other, hand take
the needle holder.
24
10. Using the tweezers, grip the edge of the wound furthest from you; to minimize
tissue damage, the side of the tweezers with one tooth should be placed in the
wound margin and the side with two teeth should be placed in the skin.
11. Position the needle perpendicularly on the skin approximately 0.5 cm from the
wound margin and insert through the skin.
12. With a supinating hand motion, bring the needle through the wound margin in
an arc, similar to the curve of the needle. For wounds that do not extend beyond
the cutis and have no tension in the wound margins, proceed directly to step 17.
13. Open the needle holder and refasten it to the portion of the needle entering in
the wound.
14. Pull the needle through the skin and out of the wound in a curved path.
15. Reposition the needle in the correct position in the needle holder.
16. Pull the thread through the skin, leaving a sufficient amount to be tied later
(about 2 cm if tying with the needle holder or at least 10 cm if tying by hand).
17. Using the tweezers, grip the edge of the wound closest to you and turn the
wound margin outward.
25
18. With a curving motion, insert the needle into the wound margin bringing it as
deep along the wound bed as possible, and continue through until the needle
point appears through the skin.
19. Open the needle holder when it is adjacent to the wound margin and use it to
grip the needle again on the outer side of the skin.
20. Pull the needle in a curved path through the tissue using the tweezers to fixate
the exiting point of the needle in the wound.
21. Using thumb and forefinger, grip the needle securely and open the needle holder.
26
22. Tie the thread in a knot with the aid of needle holder.
27
Infection
Trauma of the urethra ( especially for male urinary catheterization )
Equipments:
Sterile Equipments :
1. Sterile Catheter
Catheter are available from 8 to 24 french:
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
28
Supporting equipment:
1.
2.
3.
4.
5.
Trash bin
Penlight or stand lamp
Bed
Urine container ( if urine examination is needed )
Medical record
3. Check for the balloon of the foley catheter, is it inflating properly and no leak on the
balloon.
29
4. Desinfect the genital area and the surroundings in the circular fashion
7. Insert the catheter into the urethra until it reaches the distal tip of the catheter. If it
is difficult, told the patient to inhale.Sometimes we need to add more jelly if the
insertion is difficult.
30
8. Hold the penis and catheter with the left hand while we insert the sterile aquabidest
10-15cc to inflate the balloon therefore we fixate the catheter.
9. Connect the catheter with urine bag and observe the urine production. If urine
sample is needed to be taken to the laboratory, take it from the first production
31
C. MODULES
1. Acute Abdominal Pain at Right Lower Quadrant
Purpose:
o To facilitate process of teaching/learning Clinical Reasoning for acute abdominal
pain at right lower quadrant.
Symptom:
o Acute right lower abdominal pain
Case:
o A 22 years old female patient who presents with 1 day of acute right lower
abdominal pain (real patient/prepared paper case/role-play). Periodically
during history taking, the preceptor will explore the students inquiry process
and hypothesis development. The real patient will be examined and the
preceptor will explore the students hypothesis generation
Learning objectives:
a. Review the abdominal quadrant and pathogenesis of referred pain in the
abdomen
b. List at least three conditions which cause acute right lower abdominal pain in
female and male patients
c. Develop the features of the illness script for acute appendicitis
d. Develop hypothesis generation and diagnostic reasoning process for acute
appendicitis
e. Differentiate among 3 conditions on a clinical basis
f. Describe the identifying clinical features of each condition
g. Describe management plan for the primary disease consideration
Diagnostic Reasoning for Acute Appendicitis
Taking the history
o Periodically during patient history or role-play for history taking, the preceptor
will check the inquiry process by asking questions while the student is obtaining
data for an illness script.
o Questions explored for hypothesis:
What information do you want?
Why did you ask the question?
What are you thinking of as a hypothesis?
What question might you ask next and why?
What are you thinking of as a differential diagnosis and why?
Doing the physical exam
o Based on the information from the history. What are you looking for?
Framework for clinical reasoning:
1. What specific information do you need? Why?
2. Review the abdominal quadrant and pathologic process of referred pain in the
abdomen.
32
3. What diseases might affect the abdominal right lower quadrant in male and
female?
4. What other symptoms that you want to ask to these patients?
5. How will you differentiate these 3 conditions on history?
6. What will you look for on PE ( or if a patient) what are the factors from
examination?
7. What investigations that you order-and what do you expect to find which will
support your diagnosis?
8. Remember to consider the Alvarado Score in Acute Appendicitis patient ,it all
includes the symptoms, signs and laboratory findings.
9. What is the most possible complication of the disease?
10. What is the natural history of the disease?
33
34
35
Stimulating SDL
References
1) Schwartz Principles of Surgery, 9 edition.
2) Schein, Common Senses of Abdominal Surgery 2006
36
Learning objectives:
1. Review the anatomy of the abdomen and inguinal, also pathogenesis of inguinal
hernia in childhood and adult
2. List at least three conditions which has symptom of lump in inguinal region each
in female and male adult patients
3. Develop the features of the illness script for inguinal hernia, including the risk
factors of inguinal hernia in childhood and adult patient.
4. Develop hypothesis generation and diagnostic reasoning process for inguinal
hernia
5. Be able to differentiate between the 3 conditions on a clinical basis and to
describe the identifying clinical features of each
6. Provide a management plan for the primary disease consideration
Diagnostic Reasoning for Inguinal Hernia
Taking the history
Periodically during patient history or role-play for history taking, the preceptor
will check the inquiry process by asking questions while the student is obtaining
data for an illness script, as these questions explore the process of hypothesis
development :
37
o
o
o
o
o
1.
2.
3.
4.
38
39
3. Testicular tumor
a. The lump didnt enlarge with straining
b. symptoms of chronic malignant disease might be appear ( chronic fatigue,
weight loss, anemia)
4. Orchitis
a. acute, sharp pain at testicular region
b. symptoms of infection might be positive ( fever, malaise, leukocytosis)
c. symptoms of urinary tract infection might be positive ( polakisuria,
dysuria, hematuria)
d. Signs of infection at the testicular region might be positive ( tumor calor
rubor dolor)
Management Options
For study guide purposes, you may list management options and reasons for choosing
them
1. Principle: Since the disease is caused by the weakness of the abdominal muscles
due to constant straining causing the opening of inguinal canal, therefore the
definitive treatment of reponible inguinal hernia is to ligate the hernia sac
(herniotomy) and enhance the strength of abdominal muscle surround the
hernia sac with mesh (hernioplasty). The procedure of herniotomy accompanied
with hernioplasty is called herniorhaphy.
2. Treatment options
o open herniotomy + insertion of mesh, acceptable cosmetic appearance
o Laparoscopic herniotomy and insertion of mesh, good cosmetic
appearance
References
1. Schwartz Principles of Surgery, 9 edition.
2. Schein, Common Senses of Abdominal Surgery 2006
3. Breast Lump
Purpose:
To facilitate process of teaching/learning Clinical Reasoning for breast lump.
Symptom:
palpable breast lump
Case:
A 42 years old female patient who presents with 1 month of palpable lump at her
right/left/bilateral breast (real patient/prepared paper case/role-play).
Periodically during history taking, the preceptor will explore the students
inquiry process and hypothesis development.
The real patient will be examined and the preceptor will explore the students
hypothesis generation
40
Learning objectives:
1. Review the anatomy of the breast and axilla
2. List at least three conditions which cause palpable lump at the breast
3. Develop the features of the illness script for palpable breast lump
4. Develop hypothesis generation and diagnostic reasoning process for malignant
breast tumor
5. Be able to differentiate between the 3 conditions on a clinical basis and to
describe the identifying clinical features of each
6. Provide a management plan for the primary disease consideration
Diagnostic Reasoning for Breast Lump
Taking the history
Periodically during patient history or role-play for history taking, the preceptor
will check the inquiry process by asking questions while the student is obtaining
data for an illness script,.
Questions explored for hypothesis:
o What information do you want?
o Why did you ask the question?
o What are you thinking of as a hypothesis?
o What question might you ask next and why?
o What are you thinking of as a differential diagnosis and why?
Doing the physical exam
Based on the information from the history- What are you looking for?
Framework clinical reasoning
What specific information will you want in this patient? Why?
Lets review the anatomy of the breast and axilla
What diseases might present with palpable breast lump?
What other symptoms that you want to ask to these patients?
41
42
4. Meatal Bleeding
Purpose:
To facilitate process of teaching/learning Clinical Reasoning for Meatal Bleeding.
Symptom:
Meatal bleeding
Case:
A 22 years old male patient who presents with history of 2 hours of meatal
bleeding with history of pelvic/lower abdominal trauma. (Real patient/prepared
paper case/role-play). Periodically during history taking, the preceptor will
explore the students inquiry process and hypothesis development.
The real patient will be examined and the preceptor will explore the students
hypothesis generation
Learning objectives:
1. Review the anatomy of the urinary tract and pelvic region.
2. List at least 1 condition which cause meatal bleeding
3. Develop the features of the illness script for meatal bleeding
4. Develop hypothesis generation and diagnostic reasoning process for urethral
rupture
5. Be able to differentiate between the complete or partial urethral rupture on a
clinical basis and to describe the identifying clinical features of each
6. Provide a management plan for the primary disease consideration
Diagnostic Reasoning for Urethral Rupture
Taking the history
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Periodically during patient history or role-play for history taking, the preceptor
will check the inquiry process by asking questions while the student is obtaining
data for an illness script, as these questions explore the process of hypothesis
development :
1. What information do you want?
2. Why did you ask the question?
3. What are you thinking of as a hypothesis?
4. What question might you ask next and why?
5. What are you thinking of as a differential diagnosis and why?
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Stimulating SDL
References
1. Schwartz Principles of Surgery, 9 edition. 2010
2. Mattox, Trauma, 6th edition.
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2. List at least three conditions which has symptoms of diffuse abdominal pain,
preceded with right lower abdominal pain.
3. Develop the features of the illness script for diffuse abdominal pain
4. Develop hypothesis generation and diagnostic reasoning process for diffuse
peritonitis due to abdominal typhoid perforation
5. Be able to differentiate between the 3 conditions on a clinical basis and to
describe the identifying clinical features of each
6. Provide a management plan for the primary disease consideration
Diagnostic Reasoning for Diffuse Abdominal Pain
Taking the history
Periodically during patient history or role-play for history taking, the preceptor
will check the inquiry process by asking questions while the student is obtaining
data for an illness script, as these questions explore the process of hypothesis
development:
o What information do you want?
o Why did you ask the question?
o What are you thinking of as a hypothesis?
o What question might you ask next and why?
o What are you thinking of as a differential diagnosis and why?
o What are the possible complications happened in this patient and why?
Doing the physical exam
Based on the information from the history- What are you looking for?
Follow the framework process or Microskills method for clinical reasoning
What specific information dos you want in this patient? Why?
Lets review the abdomen anatomy and review the pathologic process of diffuse
abdominal pain.
What diseases might have symptoms of diffuse abdominal pain preceeded with
right lower abdominal pain?
What other symptoms that you want to ask to these patients?
What are the possible complications happened in this patient?
How will you differentiate these 3 conditions on history?
What will you look for on PE (or if a patient) what are the factors from
examination?
What investigations that you order-and what do you expect to find which will
support your diagnosis?
If you already investigation results (for example: lab results, abdominal photos),
what do you see in the investigations results, and how it help you make the
diagnosis, how do you connect the abnormality to the disease that the patient
has now?
What are the most possible complications of the disease?
What is the natural history of the disease?
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4.
5.
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Management Options
For study guide purposes, you may list management options and reasons for choosing
them
a.
Principle :
BPH is aging process that happened in almost every male patient. The principle
of treatment is to reduce the volume of prostate, could be reached by several
options that discussed below.
b.
Treatment options
Watchful waiting: Usually reserved for those patients with minimal
symptoms (AUA-PSS < 7) from their BPH. No medications, but the patient
have to see their physicians regularly for physical examinations and routine
laboratory tests.
Medications : the principle is to reduce the volume of the prostate, hence
will reduce the signs and symptoms of BPH
o Alpha-adrenergic receptor blockers
o 5-alpha reductase inhibitors
o Herbal medications
Operations: Since the symptoms of obstruction and irritation is caused by
enlargement of prostate ( mechanical problem) and some are intractable
with medications, then for the patient with BPH with several indications
are mandatory for operation:
o BPH patient that presented with LUTS with IPSS Score >19
o BPH patient that presented with LUTS with complications
o BPH Patient with history of twice urinary retention
Stimulating SDL
References
1. Schwartz Principles of Surgery, 9 editions. 2010
2. Smith, Essential of Urology, 2009
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c. Signs of injury sustained are visible at the pelvic region: i.e. hematoma,
contusions at the lower quadrant of the abdomen. Might be injury to
containing organs at the pelvic regions, for instance urethral ruptures,
perianal trauma, etc.
d. Degree of trauma is visible at open exploration or at pelvic CT scan, and
graded by the AAST (American Association Surgery of Trauma) Criteria
for Pelvic Injury.
4.
5.
Management Options
List management options and reasons for choosing them
Principle :
To identify what grade is the hypovolemic shock (1, 2, 3, and 4). If the
hypovolemic shock is 3rd or 4th grade:
1. Aggressive Fluid Resuscitation and blood replacement
2. Identify source(s) of bleeding. If the bleeding is external, treatment must
include how to stop external bleeding.
3. Identify the response to fluid resuscitation and blood replacement
i. Rapid response
ii. Transient response
iii. No response
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Treatment options
1. Aggressive Fluid Resuscitation and blood replacement ,along with control
of external bleeding
2. Surgical Resuscitation :
o Exploratory laparotomy for intra-abdominal bleeding.
o Pelvic sling, C-clamp for pelvic trauma
o Thoracic tube insertion,
o Exploratory Thoracotomy for intra thoracic bleeding.
o Exploratory laparotomy or renal exploration (retroperitoneal
approach) for renal trauma
Stimulating SDL
References
1. Schwartz Principles of Surgery, 9 editions. 2010
2. Mattox, Trauma, 6th edition.
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8. Multiple Trauma
Purpose:
To facilitate process of teaching/learning Clinical Reasoning for Assesment of
patient with multiple trauma
Actual diagnosis:
Multiple trauma ( with definition of Multiple trauma : condition of a person who
has been subjected to multiple traumatic injuries at 2 or more body regions, It is
defined via an Injury Severity Score ISS >=16 and usually happens after high impact
injury.
Decreased Consciousness or
Multiple wounds at 2 or more body regions
Case:
A 30 years old male patient who presents with history of falling from 5 stories in
the building project 1 hour before admissions, with history of lucid interval is positive.
Now the patients familty is complaining about decreased consciousness, wound at back
and femoral area. (real patient/prepared paper case/role-play).. Periodically during
history taking, the preceptor will explore the students inquiry process and hypothesis
development
The patient came with gurgling airway not responding with suction and need
intubation
The patients breathing is rapid and shallow breathing. The breath sound is still
equal but there is signs of bruising and crepitation in the left thoracic side. O2 sat is
93%
The skin is pale, cool with BP 80/60 mmHg, HR 120x/m, Urine: no production
after insertion of bladder catheter. No sign of hematuria
The GCS is E3M4V3=10, round pupil but unequal with size 5mm for the right
pupil, 3m for the left pupil. Good light reflexes. Equal motoric and sensoric strength.
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At secondary survey :
There is deformity at the right mandibular, and much blood clot at the oral
region. There is hematoma at the right temporal.There is bruising and crepitation in the
left thoracic side starting from the 4-6 th thoracic ribs, but normal vesicular breath
sound. Clear abdomen There is lacerated wound at the lumbal area at approximately 3rd
lumbal, base of the wound is subcutaneous fat, irregular edge, size about 3x4x2cm, no
active bleeding. There is lacerated wound and deformity at the left femoral area, with
base of the wound is anterior quadriceps muscle, irregular edge,size about 5x4x3cm,
there is continuous bleeding from the wound.
The real patient will be examined and the preceptor will explore the students
hypothesis generation
Learning objectives:
1. Review the primary survey, the assessment and therapy that done in primary
survey.
2. Review the secondary survey, the assessment and therapy that done in
secondary survey.
3. In concordance with primary and secondary survey, ask the student for history
taking for the multiple trauma patient : Mechanisms of trauma, Injury sustained,
and Degree of Trauma(MIST)
4. Be able to identify possible sources of decreased consciousness ( intracranial or
extracranial ( possibility of extracranialpathology that caused decreased of
consciousness: intraabdominal, skeletal, intrathoracal,retroperitoneal ) ) on a
clinical basis and to describe the identifying clinical features of each.
5. Develop hypothesis generation and diagnostic reasoning process for decreased
of consciousness due to hypoxic condition, caused by unclear airway, multiple
fractures at the left thorax, hypovolemic shock due to open femoral fracture,
accompanied with epidural hematoma.
6. Provide a management plan based on ATLS consideration ( ABCDE)
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Treatment options
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1. Airway suction, if failed then consider endotracheal intubation, with barton sling
for the right mandible fracture
2. Oxygenation with face mask non rebreathing, ventilation if needed ( as seen in
the clinical condition and blood gas analysis result)
3. Aggressive Fluid Resuscitation and blood replacement ,along with control of
external bleeding ( compression of open femoral fractures with adequate
bandages)
4. Close monitoring of the GCS and pupil size along the resuscitation. If there is sign
of intracranial hypertension, probably burrhole drainage is needed.
5. Surgical Resuscitation :
When there is active bleeding from the femoral artery, probably surgical
control of the bleeding is needed.
When the epidural hematoma is expanding and there is adequate signs of
intracranial hypertension, burrhole drainage or craniotomy is needed.
Stimulating SDL
References
1. Schwartz Principles of Surgery, 9 editions. 2010
2. Mattox, Trauma, 6th edition.
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D. ASSESMENT
Grading and evaluation
Information from a variety of sources will be compiled in the evaluation and
grading of each student. The hospital coordinator at each site is responsible for
compiling the evaluations and using these evaluations along with the scores on
the examination(s) to assign the final grade. In the event of a disputed grade,
failing grade on any exam or any area of performance that was judged as below
expectations, the Course Committee will only assign a final grade after thorough
review of student performance.
The targeted grade distribution will be 10% Outstanding, 75% Excellent and
10% Satisfactory and Fail less than 5%.
Grades will be
Exceed Requirement,
Meet Requirement,
Need Improvement and Fail.
Final Grade
30% of the grade will be based upon clinical activities as evaluated by primary
preceptor, division preceptor, attending, RMO, and nurses (global assessment)
30% of the grade will be based on OSCE
15% of the grade will be based on medical record evaluation
25% of the grade will be based on case presentation
Failure
Failing grades can be assigned based on:
a. Professionalism,
b. Unsatisfactory Clinical Performance or
c. Failure of the written exam(s).
In the event a student fails the OSCE Exam, the student will be allowed to repeat the
exam without repeating the course (assuming clinical performance was
acceptable).
Failure to submit the rotation duty (Case Presentation/Refferat) and NOT
FULLFILLING THE LOG BOOK will result in failing to go through the OSCE. A second
failure will require remediation of the entire clerkship. If a student fails both of the
exams will be reviewed on an individual basis and the student may be asked to
remediate the entire clerkship. If a students performance is judged below
expectations in any area on any final evaluation, all of the evaluations and any
other pertinent information about students performance will be carefully reviewed
by the Medicine Clerkship Committee who will then determine the grade. If a
student is assigned a grade of Fail, he/she must follow the procedures outlined by
the Medical School. If a students performance on the clerkship was passing but
marginal, further review of the students overall medical school performance may
be recommended.
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Absence
Each student is assigned to a team and is expected to function as a responsible
member of that team. Any unexcused absence may result in a failing grade.
Absence for any reason but illness or emergency must be approved ahead of time
by the hospital coordinator. An opportunity to make up required work will be
provided when such absences are cumulatively less than one week in length.
Absence for more than two weeks for any reason will automatically result in the
student having to repeat the entire externship. Absences of one to two weeks
will be handled on an individual basis by the hospital coordinator and course
director. Prior approval from the hospital site coordinator is required. If for
some reason, a student misses the OSCE exam, the only option for taking this will
be to wait for the next administration 10 weeks later at the conclusion of the
next clerkship.
Preceptor performance indicator
a. Students pre and post test
b. Students case presentation
c. Students final exam
d. OSCE result
e. UKDIs Graduation rate of UPH faculty medicine graduate
References
1. Schwartz Principles of Surgery, 9th ed.
2. Schein, Common Senses of Abdominal Surgery 2006
3. Mattox, Trauma, 6th edition.
4. Smith, Essential of Urology, 2009
5. Sabel, E. Essentials of Breast Surgery. 2009
6. Atlas for Human Anatomy. Sobotta 15th ed. ELSEVIER, URBAN & FISHER
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