Metadata

Student‟s Book
Block 3.3
ABDOMINAL COMPLAINTS
Sixth Edition
2014
Medicine Study Program

Faculty of Medicine
Universitas Gadjah Mada
Yogyakarta
1
Block 3.3 Abdominal Complaints
Student‘s Book
Sixth Edition
© Faculty of Medicine, Universitas Gadjah Mada, November 2014

Printed in Yogyakarta
Published by Faculty of Medicine, Universitas Gadjah Mada
All Rights reserved
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
dr. Tri Wibawa, PhD

Department of Microbiology
dr. Rita Cempaka, Sp.PA

Department of Anatomic Pathology
dr. Ira Puspitawati, Sp.PK

Department of Clinical Pathology
dr. Neneng Ratnasari, Sp.PD-KGEH

Department of Internal Medicine
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
Phase 3: Clinical Rotation - Becoming a Compre

Competent Doctor Exams 2
Year 6 (UKDI: CBT &
OSCE)
Clinical Rotation
Phase 3: Clinical Rotation - Becoming a Competent Doctor

Year 5
Clinical Rotation
Phase 2: Transition from Theory to Practice Phase 3: Clinical Rotation -

Year 4: Emergency & Disaster Becoming a Competent Doctor
Compre Exams 1
Year 4
Block 4.1 Block 4.2 Block 4.3
Emergency Health System Elective
(6 weeks) & Disaster (6 weeks) Clinical Rotation
(6 weeks)
O
X X X
Phase 2: Transition from Theory to Practice
Year 3: Multisystem Disorders
Block 3.1 Block 3.2 Block 3.3 Block 3.4 Block 3.5 Block 3.6
Research Chest Abdominal Limited Neurosensory Life Style
(6 weeks) Complaints Complaints Movement Complaints Related
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
Conception, Safe Childhood Adolescent Adulthood Aging/Elderly
Fetal Growth Motherhood & (6 weeks) (6 weeks) (6 weeks) (6 weeks)
Holiday
& Congenital Neonates

Anomaly (6 weeks)
(6 weeks)
V O
X X X X X X
Phase 1: Foundation of Medicine
Year 1: The Human Body System and Basic Medical Practice
Medical Cardio- Digestive Genito-urinary Nerve, Sense, Basic Medical
Student & Respiratory System System Endocrine Practice
Holiday
Locomotor System (6 weeks) (6 weeks) System (6 weeks)

System (6 weeks) (6 weeks)
(6 weeks)
V O
X X X X X X
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.
This block is part of Competence-based Curriculum applied in Faculty of Medicine,

Universitas Gadjah Mada since 2007. Therefore, integration of content from various disciplines
is reflected.
We believe that the Block Team, Year Coordinator, Curriculum Committee and
Contributors from various disciplines have worked hard to complete the block book on time with
high quality. We highly appreciate all the contributions to make the Block 3.3 run smoothly. We
hope that the students can attain maximum benefit from this block.
Dean of Faculty of Medicine,

5
CONTENTS
BLOCK TEAM ................................................................................................................

CURRICULUM MAP ......................................................................................................
PREFACE .....................................................................................................................
CONTENTS ....................................................................................................................
OVERVIEW ....................................................................................................................
TOPIC TREE .................................................................................................................
LEARNING ACTIVITIES ................................................................................................
ASSESSMENT BLUE PRINT ........................................................................................
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 ......................................................................................................................
Time allocation ............................................................................................................
WEEK 3
Module 3: Flank Pain ...................................................................................................
Learning unit 3 : Flank Pain ……...……………….........................................................
Scenario 3: Colicky Pain ……......................................................................................
Lectures ......................................................................................................................
Time allocation ............................................................................................................
WEEK 4
Module 4: Abdominal Lump ………..............................................................................
Learning unit 4 : Abdominal Pain ……………...............………....................................
Scenario 4: Lump After Coughing …….......................................................................
Lectures ......................................................................................................................
Time allocation ............................................................................................................
WEEK 5
Module 5: GIT Bleeding …………................................................................................
Learning unit 5 : GIT Bleeding ………………………..…………....................................
Scenario 5: Black Coffee Vomits …….........................................................................
Lectures ......................................................................................................................
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 …………………………………………………………
BASIC CLINICAL COMPETENCES TRAINING

Abdominal examination for pathologic condition .....................................................…
Intravenous line insertion ……………………....................………………………………
Urethal catheterization ………………………………..………………………………….
NGT insertion ..............................................................................................................
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
RELATIONSHIP WITH OTHER BLOCKS

Block A.3 (Cardiorespiratory System), A.4 (Genito Urinary System), 2.6 (Elderly), 3.2 (Chest
Complaints), 3.6 (Life Style Related Complaints) and 4.1 (Emergency)
9
TOPIC TREE
Appendicitis
Acute Abdominal GI Tract Pancreatitis

Acute
Pain
Urinary Tract Gastroenteritis
IBS & IBD

Abdominal
Pain Gastritis Dyspepsia

GI Tract
Cholecystitis & Cholelithiasis
Hernia Abdominal Lump

Chronic
/Recurrent
Urolithiasis Colic Pain
Urinary Tract
Pyelonephritis
Hepatocellular Carcinoma
Abdominal
Nephroblastoma
Complaints
Ovarian Carcinoma
Malignant
Neuroblastoma
Lower GIT
Bleeding
Neoplasm Colon Carcinoma
Benign Pancreas Carcinoma
Mass Infection
Splenomegaly (Malaria, Typhoid)

Non-infection
Fecalith (Thalassemia)
Non-neoplasm
Cyst Congestion
NAFLD
Hepatomegaly
Abscess
Abdominal
Distension Cyst
Fluid Ascites Hepatic Cirrhosis Upper GIT Bleeding
10
LEARNING ACTIVITIES
The following learning activities are prepared to guide students to obtain the learning
objectives of this block:
1. Group discussion with tutors

Group discussions are scheduled twice a week. Students should be well prepared so they
can explore the topics discussed with significant depth. Relevant learning resources should be
in hand so they may be referred to during the discussion. In order to achieve the learning
objectives, the ―seven-jump‖ method will be used in the group discussion. Usually, the first
group discussion covers steps 1-5, and the remaining steps are carried out in the second group
discussion within the same scenario.
The seven jumps are:
Step 1. Clarify terms and concepts
Step 2. Define the problem
Step 3. Analyze the problem
Step 4. Make a systematic inventory of the various explanations found in step 3
Step 5. Formulate learning objectives
Step 6. Collect additional information outside the group discussion
Step 7. Synthesize and test acquired information
2. Independent learning (self study)

As an adult learner students are expected to perform independent learning, a skill that is
essential for future career and development. This skill includes discovering their own interests,
searching for more information from available learning resources, understanding the information
by different learning strategies and using various learning activities, assessing their own
learning, and identifying further learning needs. They will never be satisfied to learn merely from
the lecture notes or textbooks. Independent learning is an important feature of the PBL
approach and at some stages; learning will become a never-ending journey without limits.
Students learn independently based on block‘s objectives and scenario‘s objectives,
nevertheless, it can be developed according to references which are already recommended or
the new comparative literature study obtained from internet.
Self study activities include searching related information and performing independent skills
training.
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
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
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
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
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
(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.
(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
3 Pathology of Urinary Tract Pathology Anatomy 2

Renal function test & urinalysis Clinical Pathology 2
4 Prescription analysis Pharmacology and Therapy 2
Pathology of gastrointestinal tract Pathology Anatomy 2
5 Clinical anatomy of abdominal wall and Anatomy, Embriology and 2
urinary tracts Anthropology
Pathology of liver and biliary tract Pathology Anatomy 2
Liver Function Test Clinical Pathology 2
6. Basic Clinical Competences Training

During block 3.3 there will be several basic clinical competences training sessions held by
Skills Laboratory Team to develop student‘s skills that are associated with the module topic in
the running week.
(hour)
1 Abdominal examination for pathologic Skills Laboratory 2
condition
Urinalysis Clinical Pathology 2
2 Intravenous line insertion Skills Laboratory 2
4 Urethal catheterization Skills Laboratory 2
NGT Insertion Skills Laboratory 2
13
ASSESSMENT BLUEPRINT
Methods Activities Percentage Total
MCQs in Block Examination 85 85%
Practical Session Microbiology:

Examination Isolation and identificationn of bacteria 1,5
(Assignment & Post Test) causing gastroenteritis
Anatomy, embriology and antropology:
1. Clinical anatomy of the
gastrointestinal tract and 3,0
hepatobiliary organs
2. Clinical anatomy of abdominal wall
and urinary tracts 15%
Clinical Pathology:
1. Liver function test 3,0
2. Renal function test & urinalysis
Pathology Anatomy:
1. Pathology of liver and biliary tract 4,5
2. Pathology of gastrointestinal tract
3. Pathology of urinary tract
Pharmacology and Therapy:
1. Prescription analysis 3,0
2. Spasmolytics
TOTAL 100%
BLOCK EXAMINATION REQUIREMENTS
To be able to participate in the examination, students must:

1. Attending all tutorial activities. The absence in the tutorial with 3 main reasons maximum are
25% of tutorial meeting on those block and replaced with a special assignment or counseling
session.
2. Attending all lab activities. Absence in practicum with 3 main reasons are replaced by
following inhaal regulated by related section.
3. Attending lectures at least 75%
Absence may be permitted by the 3 main reasons, those are:

1. Sick, as evidenced by letter from doctor,
2. Have (parent, spouse, child, or sibling) passed away,
3. Get assignments from faculty as evidenced by a letter of assignment.
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
2. Title : Urethral Catheterization

Department : Skills Laboratory
Duration : 1 hour
3. Title : IV line Insertion

Duration : 1 hour
4. Title : Differential Diagnosis of Acute Abdominal Pain

Department : Internal Medicine (Gastroentero-hepatology)
Duration : 1 hour
Content : Upper and lower abdominal pain
5. Title : Acute Abdominal Pain for General Practitioner: Perforated

Appendicitis, Ileus, Intestinal Obstruction & Pancreatico-
Hepatobiliary Complaints
Department : Surgery
Duration : 1 hour
Content : Perforated appendicitis, ileus, intestinal obstruction & pancreatico-
hepatobiliary complaints
6. Title : Abdominal Imaging Part 1

Department : Radiology
Duration : 1 hour
Content : Stomach and small bowel, liver and gallbladder, spleen, pancreas,
and adrenal glands.
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
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).
2. Title : Drugs for Gastrointestinal Disorders

Department : Pharmacology and Therapy
Duration : 1 hour
Content : Drugs for gastrointestinal and hepatobiliary disorders
3. Title : Bacteria Causing Gastrointestinal Infections

Department : Microbiology
Duration : 1 hour
Content : Salmonella typhi, Helicobacter pylory, Campylobacter sp, etc
4. Title : Viruses causing gastrointestinal infection

Duration : 1 hour
Content : Rotavirus , Hepatitis A, etc
5. Title : Pathology of Upper Gastrointestinal Tract

Department : Pathology Anatomy
Duration : 1 hour
Content : Pathology of upper gastrointestinal tract
6. Title : Microbes causing UTI

Duration : 1 hour
Content : Bacteria and fungi causing UTI, laboratory diagnosis)
Practical session
1 Title : Isolation and Identification of Bacteria Causing Gastroenteritis
Duration : 2 hours
2 Title : Spasmolytics
17
Duration : 2 hours

Title : Intravenous Line Insertion
Duration : 2 hours
Time allocation
Tutorial : 4 hours
Lecture : 6 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:
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
2. Title : UTI and Nephrolithiasis in Adult

Duration : 1 hour
Content : UTI and nephrolithiasis in adult
3. Title : Surgical Indication in Management of Urinary Stone Disease

Duration : 1 hour
Content : Surgical indication in management of urinary stone disease
4. Title : Surgical Management In Renal And Urinary Tract Injury

Duration : 1 hour
Content : Renal and urinary track injury
5. Title : Clinical Aspect of Urinary Tract Stone Disease

Duration : 1 hour
Content : Management of urinary tract stone disease
6. Title : Analgesics, antibiotics for UTI & neprotoxic agents

Duration : 1 hour
Content : Analgesics, antibiotics for UTI and nephrotoxic agents
7. Title : Renal Failure

Duration : 1 hour
19
Content : Sign and symptoms, management of renal failure
8. Title : Glomerulonephritis in Children

Department : Pediatrics
Duration : 1 hour
Content : Acute and chronic glomerulonephritis in children
9. Title : Laboratory Examination for Renal Disease

Duration : 1 hour
Content : Ureum, creatinine, electrolytes, urinalysis
10. Title : Glomerulonephritis in Adult

Duration : 1 hour
Content : Acute and chronic glomerulonephritis in adult
Practical sessions
1. Title : Pathology of urinary tract
Duration : 2 hours
2. Title : Renal function test & urinalysis

Duration : 2 hours
Time allocation
Tutorial : 4 Hours
Lecture : 10 Hours
Practical Session : 4 hours
BCCT : - 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:
21
WEEK – 4
MODULE 4: ABDOMINAL LUMP
LEARNING UNIT 4: ABDOMINAL PAIN
Scenario 4
Lump after coughing
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
Duration : 1 hour
Content : Types, diagnosis and management of hernia
2. Title : Surgical Indication in the Management of Abdominal Tumor

Duration : 1 hour
Content : Surgery aspect of abdominal tumor
3. Title : Abdominal Tumor and Hepatosplenomegaly in Children and in Adult

(early detection)
Duration : 1 hour
Content : a. Clinical and diagnosis of abdominal tumor in adutl;
b. Epidemiology, pathophysiology, diagnosis, and prognosis of:
 Solid Tumor: hepatoblastoma, rhabdomiosarcoma, NHL,
hodgkin
 Leukemia/ non-solid tumor
4 Title : Abdominal imaging part 2

Duration : 1 hour
Content : Kidney, adrenal glands and ureter, bladder and acute abdomen
5. Title : Strangulation (vascular compromised)

Duration : 1 hour
Content : Intussusceptions, DD : dysentery amoebiasis, volvulus, types of
bleeding: melena, hematochezia.
6. Title : Laboratory Examination of Abdominal Malignancy

Duration : 1 hour
Content : Laboratory examination of abdominal malignancy
22
Practical sessions
1. Title : Prescription analysis
Duration : 2 hours
2. Title : Pathology of gastrointestinal tract

Duration : 2 hours

1. Title : Urethral Catheterization
Duration : 2 hours
2. Title : Nasogatric Tube Insertion (NGT Insertion)

Duration : 2 hours
Time allocation
Tutorial : 4 hours
Lecture : 6 hours
BCCT : 4 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:
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
Duration : 1 hour
Content : Pathology of the liver and gallbladder disease
2. Title : Pathology of Gastrointestinal Disease: Inflammation and Neoplasm

Duration : 1 hour
Content : Pathology aspect of inflammation and neoplasm in gastrointestinal
Tract
3. Title : Inflammatory Bowel Disease

Duration : 1 hour
Content : Ulcerative colitis and Crohn‘s disease
4. Title : Hemorrhoid
Duration : 1 hour
Content : Diagnosis and management of lower abdominal bleeding
5. Title : Sero-immunology of Viral Hepatitis and Pancreatitis

Duration : 1 hour
Content : Sero-immunology of viral hepatitis and pancreatitis
6. Title : Clinical Aspect of Hepatitis in Children

Department : Pediatrics
Duration : 1 hour
Content : Clinical aspect of hepatobiliary in children
7. Title : Adverse Effect of Cytostatics

Duration : 1 hour
Content : Adverse effect of cytostatic
25
8. Title : Urinalysis
Duration : 1 hour
Content : Urinalysis
9. Title : Feedback for ICP

Duration : 1 hour
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
2. Title : Pathology of Liver and Biliary Tract

Duration : 2 hours
3. Title : Liver function test

Duration : 2 hours
Time allocation
Tutorial : 4 hours
Lecture : 9 hours
Panel discuccion : 2 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:
26
Practical Guide
Block 3.3
LABORATORY OF ANATOMY, EMBRIOLOGY &

ANTHROPOLOGY
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.
Laboratory of Anatomy, Embriology & Anthropology

Faculty of Medicine
2014
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.
the table below!
Questions Answer
Identify the organs of the lower digestive tracts, list
Describe the anatomical characteristics of the small
intestine!
Describe the gross structure of the large intestine!
explanation in the blank tables!

Ileal diverticulum (Meckel diverticulum)
Ileostomy
Inflammatory bowel disease (IBD):
- Crohn disease (regional enteritis)
- Ulcerative colitis
Diverticulitis
Diverticulosis
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.
the table below!
Questions Answer
Identify the organs of the lower digestive tracts, list
31
explanation in the blank tables!

Colitis
Colectomy
Colostomy
Hemorrhoids
Stenosis ani
Atresia ani
Colorectal cancer
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.
the table below!
Questions Answer
Identify the organs of the digestive system, list their
major functions!
Describe the embryology of gastrointestinal tracts!
And digestive glands! Mesentery!

Hirschprung disease (megacolon)
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.
the table below!
Questions Answer
32

Appendicitis
Appendectomy
Visceral referred pain (cholecystitis, appendicitis)
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.
the table below!
Questions Answer
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?

Hiatal hernia
Pancreatitis
Hepatitis
Hepatomegaly
Hepatic cirrhosis
Portal hypertension
Splenomegaly
Cholecystitis
Cholelithiasis
Cholecystectomy
Visceral referred pain (cholecystitis, appendicitis)
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
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

Abdominal surgical incisions
Abdominal hernias
Inguinal hernia
Peritonitis
Peritoneal adhesions
Adhesiotomy
Ascites
Abdominal paracentesis
Laparotomy
Intraperitoneal injection
Peritoneal dialysis
Visceral referred pain
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.
table below!
Questions Answer
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

Nephroptosis
Glomerulonephritis
Pyelonephritis
Polycystic kidney disease
Renal failure
Kidney transplantation
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).
table below!
Questions Answer
kidneys, identify major blood vessels associated
with each kidney, trace the path of blood flow
through a kidney, describe the structure of a
nephron!
List the structures found at the hilum and in the
renal sinus of a kidney!

Congenital anomalies:
- Bifid renal pelvis and ureter
- Retrocaval ureter
- Horseshoe kidney
- Ectopic pelvic kidney
Kidney transplantation
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.
table below!
Questions Answer
kidneys, identify major blood vessels associated with
each kidney, trace the path of blood flow through a
kidney, describe the structure of a nephron!
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!

Nephroptosis
Glomerulonephritis
Pyelonephritis
Polycystic kidney disease
Nephrolithiasis
Ureterolithiasis
Vesicolithiasis
Lithotripsy (ESWL)
Ureteral stenting
Ureteroscopy (URS)
Percutaneous nephrolithotomy (PCNL)
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
table below!
Questions Answer
kidneys, identify major blood vessels associated
with each kidney, trace the path of blood flow
through a kidney, describe the structure of a
nephron!
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!

Cystitis
Suprapubic cystotomy
Cystoscopy
Incontinence:
- Stress incontinence
- True incontinence
- Urge incontinence
- Overflow incontinence
38
Practical Guide
Block 3.3
LABORATORY OF MICROBIOLOGY
Laboratory of Microbiology
Faculty of Medicine
2014
39
Isolation and Identification of Bacteria
Causing Gastroenteritis
Objective: To determine causative agent of 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
Figure 1. Lactose fermenting Enterobacteriaceae on M •Mc Conkey agar
Figure 2. Non lactose fermenting Enterobacteriaceae on McConkey agar
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
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)
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
Title : Isolation and Identification of Bacteria Causing Gastroenteritis

Signature:
Date :
Name :
Student Number : Instructor :
Group :
I. Bacteria identification based on colonies II. Identification

appearance and biochemical properties (Provided)
Klebsiella pneumoniae
KIA SSS LIA MIO KIA SSS LIA MIO
Salmonella typhi
KIA SSS LIA MIO

KIA SSS LIA MIO
KIA SSS LIA MIO

KIA SSS LIA MIO
Eschericia coli
KIA SSS LIA MIO
KIA SSS LIA MIO

KIA SSS LIA MIO
Shigella sp.
KIA SSS LIA MIO
KIA SSS LIA MIO
Vibrio
KIA SSS LIA MIO
KIA SSS LIA MIO

45
KIA SSS LIA MIO

PRACTICAL GUIDE
BLOK 3.3
PHARMACOLOGY & THERAPY
PRESCRIPTION ANALYSIS: ABDOMINAL

COMPLAINT PRESCRIPTION
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.
DEPARTEMENT OF PHARMACOLOGY & THERAPY

FACULTY OF MEDICINE
UNIVERSITAS GADJAH MADA
2014
46
PRACTICAL GUIDE
DEPARTMENT OF PHARMACOLOGY AND THERAPY
RULE AND REGULATION OF LABORATORY WORK
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.
TOOL AND MATERIAL

- Samples of doctor‘s prescription
- LCD projector
- Computer
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:
Ingredients The name of active Effects/Functions

medicinal agent
Remedium Cardinale
(principal drugs)
Remedium Adjuvant
(adjuvant)
Corrigens
Constituents/vehicle
3. Official form (present/none)

If there is official form, explain composition and effects of the medicine
4. Special form (present/none)
If there is special form, explain the content and effect of the medicine
5. Narcotic drugs (present/none)
Name :
Write the drugs in a prescription.
49
B. 1 Dosage regimen (dosage, route of administration, frequency, time of administration,
and duration of treatment)
2. Drug Interaction (present/none)
C. Pharmaceutical dosage form selected by the doctor

(Explain specification of available dosage form, advantages and disadvantages of the
pharmaceutical dosage form)
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
dr. Mrichi Mary

SIP : 007/2000
Home: Pratice site :

Jl.Angsa 20 Jl.Anggrek 70
Yogyakarta Yogyakarta
Yogyakarta, 10 Juni 2011
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 :
dr. Mrichi Mary

SIP : 007/2000
Home: Pratice site :

Jl.Angsa 20 Jl.Anggrek 70
Yogyakarta Yogyakarta
Yogyakarta, 10 Juni 2011
R/. Tab. Ranitidine mg 150 No X

S.1.d.d.Tab.II. hs.
________________________
Pro : Ny.Nila
Age : 40 years old
Location : Medical Pharmacy Department, Medical Faculty Gadjah Mada University

Duration : 1 x 120 minutes
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
ISFI, 2010. ISO Indonesia (Informasi Spesialite Obat Indonesia)
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
a. The purpose of the experiment:

Understand effects of spasmolytics.
b. Probandus: rabbit or rat
c. Equipments:
1. Organ bath
2. Kymograph
d. Materials & Drugs:

1. Thyrode solution
2. Acetylcholine: 10-4 M, 10-5 M, 10-6 M
3. Atropine suphate: 10-7 M,10-8 M
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
LABORATORY OF PATHOLOGY ANATOMY
Laboratory of Pathology Anatomy

Faculty of Medicine
2014
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.
By learning pathological features of the topics, the students are expected to

understand the patholophysiology of the clinical symptoms, and finally they are able to
correlate between the changes of histologic structure with the arising abdominal
complaint.
Topics of practical work:

I. Pathology of urinary tract
1. Chronic pyelonephritis
2. Renal cell carcinoma
3. Transitional cell carcinoma
II. Pathology of gastrointestinal tract
1. Obliterans appendicitis
2. Chronic diverticulitis
3. Crohn‘s disease
4. Signet ring cell carcinoma of the stomach
5. Adenocarcinoma of the large bowel
III. Pathology of liver and biliary tract

1. Chronic cholecystitis
2. Chronic hepatitis
3. Hepatocellular carcinoma
4. Hepatic cirrhosis.
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.
2. Renal cell carcinoma
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.
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.
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.
A tissue, 15x10x7 cm. On cut section, there was solid and papillary, white-brownish
mass, with areas of necrosis, haemorrhage and invasion.
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
Appendicitis obliterans is characterized by progressive obliteration of the lumen of the

appendix. Appendicitis obliterans may be due to the following causes alone or in
combination: (1) destruction of the mucous membrane by ulceration; (2) infiltration,
thickening, and contraction of the muscular coat; (3) prolonged cicatricial contraction of
exudates upon its serous covering. All cases of appendicitis obliterans are necessarily
chronic
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:
A 48 year-old man with persistent abdominal pain, fever, and chronic diarrhea.
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
A 40 year-old male suffered from fever, crampy abdominal pain, and diarrhea since a
month ago.
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.
Crohn‘s disease appears as a chronic inflammatory process. The microscopic hallmark

of the Chron‘s disease is transmural nodular lymphoid aggregates, accompanied by
proliferative changes of the muscularis mucosae and nerves in the submucosal and
myenteric plexuses. Discrete, non caseating granulomas, mostly in the submucosa, may
be present. These granulomas consist of local aggregates of epitheloid cells, vaguely
limited by a rim of lymphocytes. Multinucleated giant cells may be present.
59
4. Signet ring cell carcinoma of the stomach
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.
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.
5. Adenocarcinoma of the larga bowel

Background:
Malignant tumor of epithelial origin in large bowel, predominately located at rectosigmant
area. There are different clinical manifestation of left and right side carcinoma of the
bowel.
A 70 year 0ld man with history of change of bowel habits since 5 years ago and
complaints of melena and abdominal discomfort since 2 months ago. Colonoscopy in 15
cm from wall region showed a solid, ulcerated and infiltrated mass in mucosa of
rectosigmoid
Sessile polypoid & ulcerated of mucosa 3 cm in diameters.
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
Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones,

in the gallbladder), with choleliths most commonly blocking the cystic duct directly. This
leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut
organisms, predominantly E. coli and Bacteroides species.
Chronic cholecystitis may be a sequel to repeated bouts of mild to severe acute

cholecystitis, but in many instances it develops in apparent absence of antecedent
attacks. Since it is associated with cholelithiasis in more than 90% of cases, the
population of the patients are the same as for cholelithiasis. The symptoms for calculous
chronic cholecystitis are similar to those of the acute form and range for biliary colic to
indolent right upper quadrant pain and epigastric distress.
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.
The degree of inflammatory reaction is variable. In more developed cases, there is

marked subepithelial and subserosal fibrosis, accompanied by mononuclear cell
infiltration. Inflammatory proliferation of the mucosa and fusion of the mucosal folds may
give rise to buried crypts of epithelium within the gallbladder wall.
2. Cronic hepatitis
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
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.
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.
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.
Multinodular hepatomegaly with hard consistency, and ascites in peritotoneoscopy
examination.
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
LABORATORY OF CLINICAL PATHOLOGY
RENAL FUNCTION TEST

Clearance Of Urea And Creatinine Tests
Urea – Diacetyl Monoxim Method
Creatinine - Jaffe's Method
LIVER FUNCTION TEST
Serum Bilirubin Total

Serum Bilirubin Direct
Bilirubin In Urine
Serum ALAT (GPT)
One Step Hepatitis B Surface Antibody Test Strip (Serum/Plasma)
Laboratory of Clinical Pathology

Faculty of Medicine
2014
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.
Principle of the method:

Clearence is defined as the (hypothetical) quantity of blood or plasma completely
cleared of a substance per unit of time. Simple stated, the principle requires the amount of a
substance entering an organ (here, the kidney) must exactly equal the amount leaving it.
Clearance of substances that are filtered exclusively or predominantly by glomeruli but neither
reabsorbed nor secreted by other regions of nephron can used to measure the Glomerular
Filtration Rate.
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 :
UV U = mg/100 ml. urea nitrogen in urine

Cm = ------------- where ; P = mg/100 ml. urea nitrogen in serum
P V = ml. urine excreted per minute
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.
Clearence of creatinine test:
Creatinine is filtered through the glomerulus. Under ordinary circumstances the

clearence of endogenous creatinine approximates the glomerular filtration rate. The clearence
formula is :
UCr V UCr= mg/100 ml. creatinine in urine

CCr = ------------- where ; PCr = mg/100 ml. creatinine in serum
PCr V = ml. urine excreted per minute or
per 24 hours
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.
UCr= mg/100 ml. creatinine in urine

PCr = mg/100 ml. creatinine in
CCr= UCr (mg/dl) x V (ml/24 hour) 1,73
serum
X
V = ml. urine excreted per minute
PCr (mg/dl) x 1440 minutes/24 hours A
or per 24 hours
A= actual body surface area
* For surface area (S.A), see normogram.

Care in the chemical determination of creatinine is essential. False low clearence results
may be observed because of non-creatinne chromogen in plasma such as occurs in some
patients with cardiac disease. As clinical test of glomerular filtration it is superior to the urea
clearence.
Reference Ranges for Creatinine Clearance:

Males: 97 mL/min per 1,73 m2 – 137 mL/min per 1,73 m2.
Females: 88 mL/min per 1,73 m2 – 128 mL/min per 1,73 m2.
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
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 .

Reagents :
All chemical must be analar grade.
(a) Ferric chloride 5%
Dissolve 5.0 g ferric chloride hexahydrate in 100 ml of distilled water. Add 1.0 ml H 2SO4
and mix. Store in brown bottle at room temperature (25-35oC). Stable for 6 months.
(b) Mixed acid reagent

Add slowly 100 ml of Conc. H2SO4 and orthophosphoric acid to 500 ml distilled water
taken in a 1-litre flat-bottom conocal flask kept in an icecold water bath. Mix well and add
7.5 ml of Ferric chloride 5% reagent. Mix and store in a brown bottle at room
temperature (25-35oC).Stable for 6 months.
(c) Stock colour reagent-A (DAM 2.5%)

Dissolve 2.5 g diacetyl monoxim in distilled water and make the volume up 100 ml in a
volumetric flask. Store in brown bottle room temperature (25-30oC).Stable for 6 months
(d) Stock colour reagent-B (TSC 0.25%)

Dissolve 0.250 g thiosemicarbozide in distilled water and make the volume up 100 ml in
a volumetric flask. Store in brown bottle room temperature (25-35oC).Stable for 6 months
(e) Reagent DAM-TSC

Mix 2.0 ml of stock colour reagent A with 1.0 ml of stock colour reagent B and 30 ml of
mixed acid reagent and make up to 20 ml with distilled water. Store in brown bottle room
temperature (25 – 35oC). Stable for 6 months.
(f) Stock urea standard

Weigh 0.300 g of analytical-grade urea and dissolve in 50 ml with distilled water. Use a
100 ml of volumetric flask for preparing this and add 1.0 ml H2SO4. Store in brown bottle
room temperature (25 – 35oC). Stable for 6 months.
(g) Working standard 30 mg/dl

Dilute 3.0 ml of stock urea standard to 100 ml with distilled water. Store in brawn bottle
room temperature (25 – 35oC). Stable for 6 months.
Equipments:
1. Tubes
2. Sentrifuge
66
3. Pipette
4. Spectrophotometer
Specimen types, collection and storage

Serum or urine is the specimen of choice. Store serum for no longer than 8 hours at
room temperature (25 – 35oC) and 7 days at 2 – 8oC. For a longer duration, store in the
freezer. If the samples show evidence of bacterial contamination, do not use these for urea
estimation. Plasma could also be used for urea estimation
Procedure
Pipette the following into appropriately labeled 13 x 100 nm tubes
Blank Standard Test

Distilled water (ml) 0.5 0.5 0.5
Serum (ml) / Urine 1/100 (ml) - - 0.05
Working standard (ml) - 0.05 -
Reagent DAM-TSC (ml) - 7.5 7.5
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.
Calculation and calibration graph

Concentration of Urea :
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.
 CREATININE - JAFFE'S METHOD
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.

Reagents
All chemicals must be analar grade.
(a) Reagent picric acid 0.04 M
Into 500 ml of distilled water taken in a 500 ml breaker add 9.3 g of picric acid to
dissolve, then titrated with NaOH 0.1 and indicator phenolphthalein, dissolve to 0.04 M.
(b) Reagent Na OH 0.75 N

Dissolve 30 g Na OH in a final volume of 500 ml distilled water. Sable for 6 months at
room temperature (25 – 35oC)
(c) Reagent H2SO4 2/3 N

Dissolve 18 g H2SO4 in a final volume of 1,000 ml distilled water
(d) Reagent Na-Tungstate 5%

Dissolve 50 g Na2WO4, H2SO4 in 500 ml distilled water and final volume of 1,000 ml
(e) Working standard reagent

Dissolve 2 ml of creatinine standard in 100 ml distilled water. Stable for 6 months at 2 –
8oC.
(f) Stock creatinine standard 100 mg/dl

Dissolve 100 g of pure creatinine in 0.1 M HCL and make up to 100 ml with 0.1 M HCL
in a volumetric flask. Stable for 6 months at 2 – 8oC.
Equipment
1. Tubes
2. Sentrifuge
3. Pipette
4. Spectrophotometer
Specimen type, collection and storage

Serum or urine can be used avoid using haemolysed or lipaemic samples. Serum stable
for 12 hours at room temperature (25 – 35oC), one week at 2 – 8oC and for 3 months at – 20oC.
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.
Blanko Standard Test

Aquadest (ml) 2.0 1.5 -
Working reagent (ml) - 0.5 -
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.
Calculation and calibration graph
Absorbance of test
Craetinine in the test = ---------------------------------------------------- X 4 mg/dl
Absorbance of standard
Reference range and clinical interpretation

Population Plasma, serum, urine Jaffe Method
Adult Male Plasma or serum 0,9-1,3 mg/dl
Adult Female Plasma or serum 0,6-1,1 mg/dl
Child Plasma or serum 0,3-0,7 mg/dl
AdultMale Urine 24 hours 800-2000 mg/dl
Adult Female Urine 24 hours 600-1800 mg/dl
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%.
 LIVER FUNCTION TEST
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.
Storage Instructions and Reagent Stability

The reagents are stable up to the end of the indicated month of expiry, if stored at 2 - 8 ºC and
contamination is avoided. Do not freeze the reagents!
Reagent 2 must be protected from light.
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]
Neonates 24 h < 8.8 < 150

2nd day 1.3 – 11.3 22 – 193
3rd day 0.7 – 12.7 12 – 217
4th – 6th day 0.1 – 12.6 1.7 – 216
Children >1 month 0.2 – 1.0 3.4 – 17
Adults 0.1 – 1.2 1.7 – 21
Each laboratory should check if the reference ranges are transferable to its own patient
population and determine own reference ranges if necessary.
 SERUM BILIRUBIN DIRECT
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.
R2: 2,4-Dichlorophenyl-diazonium salt 0.09 mmol/L

HCl 130 mmol/L
EDTA-Na2 0.02 mmol/L
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
Blank Sample or calibrator

Sample or calibrator - 100 L
Dist. Water 100 L -
Reagent 1 1000 L 1000 L
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.
A = [(A2 – A1) sample or calibrator] - [(A2 – A1) blank]
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 is a breakdown product of hemoglobin. Free, unconjugated bilirubin is extremely apolar

and nearly insoluble in water, thus forming a complex with albumin for the transport in the blood
from the spleen to the liver. In the liver, bilirubin is conjugated with glucoronic acid and the
resulting water soluble bilirubin glucoronides are excreted via the bile ducts.
Hyperbilirubinemia can be caused by increased bilirubin production due to hemolysis (pre-

hepatic jaundice), by parenchymal damages of the liver (intra-hepatic jaundice) or by occlusion
of bile ducts (post-hepatic jaundice). A chronic congenital (predominantly unconjugated)
hyperbilirubinemia called Gilbert's syndrome is quite frequent in the population. High levels of
total bilirubin are observed in 60-70 % of neonates due to an increased postpartal breakdown of
erythrocytes and because of the delayed function of enzymes for bilirubin degradation. Common
bilirubin methods detect either total bilirubin or direct bilirubin. Determinations of direct bilirubin
measure mainly conjugated, water soluble bilirubin. Unconjugated bilirubin can therefore be
estimated as the difference between total bilirubin and direct bilirubin
 BILIRUBIN IN URINE
Method: Harrison spot test (Fouchet‟s Test)
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:
Free INSOLUBLE and

Glucuronide Glucuronide
Bilirubin LESS REACTIVE
On standing – oxydation:
GREEN and
Glucuronide Glucuronide BILIVERDIN
NON REACTIVE
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.
 ALAT (GPT) SERUM
Method
Optimized UV-test according to IFCC (International Federation of Clinical Chemistry and

Laboratory Medicine).
Principle
L-Alanine + 2-Oxoglutarate L-Glutamate + Pyruvate

+
Pyruvate + NADH + H D-Lactate + NAD+
Addition of pyridoxal-5-phosphate (P-5-P) stabilizes the transaminases and avoids falsely low
values in samples containing insufficient endogenous P-5-P, e.g. from patients with myocardial
infarction, liver disease and intensive care patients.
Reagents
R1: TRIS pH 7.15 100 mmol/l

L-Alanine 500 mmol/l
LDH (lactate dehydrogenase ≥ 1700 U/l
R2: 2-Oxoglutarate 15 mmol/l
NADH 0.18 mmol/l
Pyridoxal-5-Phosphate FS
Good buffer pH 9.6 0.7 mmol/l
Pyridoxal-5-Phosphate 0.09 mmol/l
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
Serum, heparin plasma or EDTA plasma.

Loss of activity within 3 days.
at 2 – 8 ºC < 10 %
at 15 – 25 ºC < 17 %
Stability: at – 20 ºC at least 3 months.
Discard contaminated specimens.
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
Alanine Aminotransferase (ALAT/ALT), formerly called Glutamic Pyruvic Transaminase (GPT) is

the most important representatives of a group of enzymes, the aminotransferases or
transaminases, which catalyze the conversion of -keto acids into amino acids by transfer of
amino groups. As a liver specific enzyme ALAT is only significantly elevated in hepatobiliary
diseases. The ASAT/ALAT ratio is used for differential diagnosis in liver diseases. While ratios <
1 indicate mild liver damage, ratios >1 are associated with severe, often chronic liver diseases.
 ONE STEP
HEPATITIS B SURFACE ANTIBODY
TEST STRIP (SERUM/PLASMA)
Method: rapid chromatographic immunoassay
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.
Specimen collection and preparation

1. The HBsAb One Step Hepatitis B Surface Antibody Test Strip (Serum/Plasma) can be
performed using eiter serum or plasma
2. Separate the serum or plasma from blood as soon as possible to avoid hemolysis. Only
clear, non-hemolyzed specimen can be used.
3. Testing should be performed immediately after the specimen have been collected. Do
not leave the specimens at room temperature for prolonged periods. Specimens may be
stored at 2-80C for up to 3 days. For long terms storage, specimens should be kept
below -20oC.
4. Bring specimens to room temperature prior to testing. Frozen specimens must be
completely thawed and mixed well prior to testing. Specimens should not be frozen and
thawed repeatedly.
5. If specimens are to be shipped, they should be packed in compliance with federal, state
or local regulations for the transportation of etiologic agents.
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.
Limitations of the test

1. The HBsAb One Step Hepatitis B Surface Antibody Test Strip (Serum/Plasma) is for in
the vitro diagnostic use only. This test should be use for the detection of antibody to
HBsAg in serum or plasma specimen.
2. The HBsAb One Step Hepatitis B Surface Antibody Test Strip (Serum/plasma) cannot
detect less than 10 mIU/mL of HBsAb in specimen.
3. As With all diagnostic tests, all results must be considered with other clinical information
available to the physician.
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
PEMERIKSAAN FISIK ABDOMEN

(PATOLOGIS)
BLOK 3.3
Laboratorium Keterampilan Medis

Fakultas Kedokteran
Yogyakarta
2014
78
(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:
Arum Tri Wahyuningsih Suharyanto

Asisten Tim Materi Skills Lab Karyawan Bagian Ilmu Penyakit Dalam
Fakultas Kedokteran UGM Fakultas Kedokteran UGM
Indra Sari Kusuma Harahap Noviarina Kurniawati

Asisten Tim Materi Skills Lab Koordinator Learning Resources Skills Lab
Staf Bagian Neurologi Fakultas Kedokteran Universitas Gadjah Mada
ACKNOWLEDGEMENT:
Wasilah Rohmah
Guru besar Emeritus Ilmu Penyakit Dalam
Spesialis Penyakit Dalam – Konsultan Geriatri
Bagian Ilmu Penyakit Dalam
Desain program pendidikan ditinjau oleh
Martiana Suciningtyas
Koordinator Tahun III untuk Pelatihan Keterampilan Medik
79
Naskah ini merupakan perbaikan dari naskah
Counseling and Physical Examination of the Abdomen yang diterbitkan pada tahun 2005
Terima kasih yang sebesar-besarnya kepada para kontributor :
Prof.DR.dr.Wasilah R, Sp.PD. Ger.(K)

dr. Yanri W, Sp.PD, Ph.D
dr. Santosa Budihardjo, M.Kes., PA(K)
80
KATA PENGANTAR
Tahun ke 3 pendidikan di FK UGM Prodi Pendidikan Dokter sudah memasuki ―disease

perspective” yang merupakan kelanjutan dari spiral Pendidikan Dokter tahun-tahun
sebelumnya; oleh karenanya tahun ini merupakan “inti” dari baik buruknya seorang Klinisi.
Tugas utama dokter adalah membuat diagnosis, sehingga ketrampilan dalam Prosedur
Diagnosis merupakan syarat mutlak untuk menjadi Klinisi yang ideal. Untuk itu Klinisi harus
mempunyai “hard skill” meliputi: Biological science, Attitude, Skills dan Knowledge -
sedangkan “soft skill” yang harus dimiliki meliputi: Humane, Sympathetic, Systematic,
Observant, Use reason & logic, Respect information, His/her approach is confident-gentle and
competent dan alumni FKUGM juga harus mempunyai Roh Nasionalisme Ke-Gadjah Mada-an.
Topik dalam buku materi ini adalah salah satu topik yang berada di bawah topik utama:
Pemeriksaan Fisik Umum yang akan dipelajari secara berkelanjutan di setiap blok selama masa
pendidikan di S1. Ketrampilan yang ada dalam buku materi ini didasarkan pada Kurikulum
Berbasis Kompetensi 2007. Topik-topik yang termasuk dalam Pemeriksaan Fisik Umum tahun
ke-3 adalah sebagai berikut:
No. Topik Blok

1. Pengumpulan Data Antropometri 3.1
(Research)
2. Pemeriksaan Fisik Dada; Paru dan Jantung 3.2

(Patologis) (Chest Complaint)
3. Pemeriksaan Abdomen 3.3

(Patologis) (Abdominal Complaint)
4. Encounter to Simulated Patient 1 3.5

(Neuro-sensory Complaint)
5. Encounter to Simulated Patient 2 3.6
(Life-style related
Complaint)
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
81
Tingkat Kompetensi
Tingkat kemampuan yang diharapkan dicapai pada akhir pendidikan dokter

 Tingkat Kemampuan 1
Dapat mengenali dan menempatkan gambaran-gambaran klinik sesuai penyakit ini
ketika membaca literatur. Dalam korespondensi, ia dapat mengenal gambaran klinik
ini, dan tahubagaimana mendapatkan informasi lebih lanjut. Level ini
mengindikasikan overview level. Bila menghadapi pasien dengan gambaran klinik
ini dan menduga penyakitnya, Dokter segera merujuk.
Mampu membuat diagnosis klinik berdasarkan pemeriksaan fisik dan
pemeriksaanpemeriksaantambahan yang diminta oleh dokter (misalnya :
pemeriksaan laboratoriumsederhana atau X-ray). Dokter mampu merujuk pasien
secepatnya ke spesialis yang relevan dan mampu menindaklanjuti sesudahnya
3a. Mampu membuat diagnosis klinik berdasarkan pemeriksaan fisik dan
pemeriksaan-pemeriksaan tambahan yang diminta oleh dokter (misalnya
:pemeriksaan laboratorium sederhana atau X-ray). Dokter dapat memutuskan
dan memberi terapi pendahuluan, serta merujuk ke spesialis yang relevan
(bukan kasus gawat darurat).
3b. Mampu membuat diagnosis klinik berdasarkan pemeriksaan fisik dan
pemeriksaanpemeriksaan tambahan yang diminta oleh dokter (misalnya :
pemeriksaan laboratorium sederhana atau X-ray). Dokter dapat memutuskan
dan memberi terapi pendahuluan, serta merujuk ke spesialis yang relevan
(kasus gawat darurat).
Mampu membuat diagnosis klinik berdasarkan pemeriksaan fisik dan
pemeriksaanpemeriksaan tambahan yang diminta oleh dokter (misalnya :
pemeriksaan laboratorium sederhana atau X-ray). Dokter dapat memutuskan dan
mampu menangani problem itu secara mandiri hingga tuntas
Physical Examination Level of expected ability

General Survey
assessment of mental status 1 2 3 4
assessment of apparent state of health 1 2 3 4
assessment of nutritional condition 1 2 3 4
assessment of habitus and posture 1 2 3 4
assessment of respiration 1 2 3 4
palpation of pulse 1 2 3 4
measurement of blood pressure 1 2 3 4
measurement of jugular venous pressure 1 2 3 4
measurement of height and weight 1 2 3 4
inspection and palpation of skin 1 2 3 4
inspection of mucous membranes 1 2 3 4
palpation of lymph nodes 1 2 3 4
Head/neck
inspection of eyes, nose, mouth and throat 1 2 3 4
chvostek‘s sign 1 2 3 4
palpation of salivary glands 1 2 3 4
throat swab 1 2 3 4
palpation of thyroid gland 1 2 3 4
palpation of trachea 1 2 3 4
palpation of carotic arteria 1 2 3 4
82
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
83
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
Stomach and duodenum

Gastric/duodenal ulcer 3B
Gastrointestinal bleeding 3B
Gastroenteritis 4
Liver
Fatty liver 4
Hepatitis A 4
Uncomplicated Hepatitis B 4
Amoebic liver abscess 4
Gall bladder, bile duct and pancreas

Acute cholecystitis 3A
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
84
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
85
PEMERIKSAAN FISIK ABDOMEN (PATOLOGIS)
TUJUAN UMUM KETERAMPILAN MEDIS TAHUN KE-3

1. Mahasiswa mampu membina komunikasi dan interaksi dokter-pasien
2. Mahasiwa mampu menentukan diagnosis banding dari permasalahan pasien
3. Mahasiswa mampu merencanakan pengobatan yang rasional
4. Mahasiswa mampu menegosiasikan rencana manajemen (CARE PLAN) dengan pasien
dengan mempertimbangkan biososiokultural (keterlibatan keluarga, penggunaan
pengobatan tradisional, tanggapan dan perilaku non verbal pasien)
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.
Hasil Pembelajaran yang Diharapkan

Mahasiswa diharapkan menjadi kompeten dalam Prosedur diagnostik kelainan abdomen.
1. Mahasiswa mampu mengelola paripurna penyakit abdomen sesuai etiologi penyakit:
- Kelainan congenital
- Kelainan aquisita / dapatan (trauma, infeksi, kelainan degenerasi, malignansi dan
autoimun).
2. Mahasiswa mampu berkomunikasi dokter-pasien yang optimal sejak awal pertemuan
hingga akhir.
3. Mahasiswa mampu menemukan keluhan utama.
4. Mahasiswa mampu membuat konsep diagnosis banding.
5. Mahasiswa mampu anamnesis
6. Mahasiswa mampu cuci tangan secara lege artis sebelum dan sesudah pemeriksaan.
86
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.
Hubungan dengan Ketrampilan Lain

Untuk melakukan ketrampilan pemeriksaan fisik dalam Blok 3.3, mahasiswa harus mampu
melakukan pemeriksaan fisik dasar seperti pada Blok 1.1; 1.2 dan 1.3; memahami anatomi
serta fisiologi abdomen.
Ketrampilan dalam Blok 3.3 diperlukan untuk mempelajari ketrampilan klinis lanjut pada
Blok 4.1 (Keadaan Darurat).
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
87
mahasiswa dalam 1 kelompok lebih banyak daripada jumlah symptoms yang
ditugaskan.
3. Dua sesi terbimbing dengan instruktur dibagi sebagai berikut:

a. Pertemuan pertama: instruktur membimbing mahasiswa menggunakan 3-5 kasus
berdasarkan workplan yang telah dibuat
b. Pertemuan kedua: instruktur membimbing mahasiswa menggunakan 3-5 kasus
berdasarkan work plan yang belum dibahas dalam pertemuan sebelumnya.
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.
Tabel 1. Aktifitas Pembelajaran
No. Isi Yang Terlibat Keterangan

1. Pembukaan:
- Berdoa. Instruktur 15 menit
- Penjelasan dan persiapan bahan Mahasiswa
- Skenario dan pretest. Bahan:
•Alkohol
- Tujuan pembelajaran.
•Stetoskop (stetoskop
- Simulasi yang dilakukan oleh
latihan dan stetoskop
beberapa mahasiswa (dilakukan
tunggal)
oleh mahasiswa yang telah
mempersiapkan diri mereka sendiri
atau dipilih oleh instruktur)
- Komentar dari instruktur dan
mahasiswa
2. Kegiatan Utama:
- Sesi Praktek. Tiap kelompok terdiri Mahasiswa 80 menit
dari ± 3-4 mahasiswa, yang terbimbing
berperan sebagai pasien, dokter, Checklist/feedback form
penilai (setiap mahasiswa harus
bergabung dalam simulasi). Peran
sebagai dokter, pasien dan penilai
dilakukan secara bergantian.
- Latihan dengan 1-2 Kasus yang
sudah disiapkan sebagai
workplan untuk tiap kelompok.
- Pemeriksaan performa abdomen
- Tanggapan langsung dari para
mahasiswa.
- Diskusi: Seluruh pertanyaan pada
rencana kerja ditujukan langsung
pada instruktur.
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.
Alat dan Bahan

Alat dan bahan yang diperlukan untuk pemeriksaan abdomen ada pada tabel 2.
Tabel 2. Instrumen dan alat bantu dalam pemeriksaan tanda vital dan abdomen
• Termometer air raksa Oral, axilla, rectal

• Termometer Elektrik Digital
• Termometer Inframerah
• Sphygmomanometer - Mercury
- Jarum
- Digital
- Bed Side Monitor
• Denyut - Manual (jam tangan dengan JARUM
DETIK)
- Elektrik/digital
 Alkohol Cuci tangan
• Tempat pemeriksaan Meja periksa, meja peralatan, dan
tempat tidur
• Stetoskop
• Lampu Senter Pena
• Pensil dan kertas
• Pengukur berat/tinggi badan
• Jubah Pemeriksaan
• Kain penutup
• Sarung tangan disposable
89
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.
Gambar 1. Empat kuadran abdomen Gambar 2. Sembilan kuadran abdomen

Sumber : Swartz M.H. Textbook of Physical Sumber : Swartz M.H. Textbook of Physical
th th
Diagnosis, History and Examination. 5 edition. Diagnosis, History and Examination. 5 edition.
Philadelphia. WB Saunders Company. 2010. Philadelphia. WB Saunders Company. 2010.
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.
Tabel 3. Struktur abdomen menurut empat kuadran

Kanan Kiri
Atas
Hati Hati: lobus kiri
Kandung empedu Limpa
Pilorus Lambung
Duodenum Pankreas: korpus
Pankreas: kaput Adrenal kiri
Adrenal kanan Ginjal kiri: kutub atas
Ginjal kanan: kutub atas Fleksura lienika
Fleksura hepatika Kolon desendens: sebagian
Kolon asendens: sebagian Kolon transversum: sebagian
Kolon transversum: sebagian
Bawah
Ginjal kanan : kutub bawah Ginjal kiri: kutub bawah
Sekum Kolon sigmoid
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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.
Gambar 3. Posisi saat pemeriksaan abdomen: Gambar 4. Merelaksasikan otot abdomen;

Pasien berbaring, abdomen terpapar penuh pasien berbaring dengan lutut ditekuk
dari sternum sampai inguinal Sumber : Swartz M.H. Textbook of Physical
Sumber : Swartz M.H. Textbook of Physical Diagnosis, History and Examination. 5th edition.
Diagnosis, History and Examination. 5th edition. Philadelphia. WB Saunders Company. 2010
Philadelphia. WB Saunders Company. 2010
Pemeriksaan fisik abdomen meliputi:

o Inspeksi
o Auskultasi
o Perkusi
o Palpasi
o Pemeriksaan dubur
o Teknik khusus
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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.
Gambar 5. Palmar eritema Gambar 6. Jaundice

Sumber:http://www.graphicshunt.com/health/images/ Sumber:http://www.patient.co.uk/doctor/Jaundice.ht
palmar_erythema-2073.htm m
Gambar 7. Clubbing finger pada Sirosis

Bilier Primer
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
Gambar 10. Asites dengan Hernia

Umbilikalis
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
Gambar 15. Pola Vena Abdomen Gambar 16. Asites
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.
Gambar 18. Scratch test
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.
Perkusi kandung kemih dan atau uterus

Apabila pada perkusi menunjukkan bunyi redup pada daerah suprapubik maka
menunjukkan kandung kemih penuh atau suatu pembesaran uterus pada pasien wanita.
Lakukan pula perkusi untuk menentukan tingginya kandung kemih atau uterus di atas simfisis
osis pubis.
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
96
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.
Gambar 19. Pemeriksaan Asites dengan Fluid Wave Technique
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 Kandung Kemih

Apabila pada perkusi menunjukkan bunyi redup pada daerah suprapubik maka
palpasilah pada daerah itu akan menunjukkan kandung kemih penuh atau suatu pembesaran
uterus pada pasien wanita. Secara normal kandung kemih tidak dapat dipalpasi kecuali
mengalami distensi di atas simphisis osis pubis. Pada palpasi kubah kandung kemih yang
terdistensi akan teraba halus dan bundar dan kadang-kadang lunak. Nilailah apakah ada nyeri
tekan. Lakukan pula perkusi untuk mengecek area redupnya dan menentukan tingginya
kandung kemih diatas simfisis osis pubis.
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.
Gambar 20. Palpasi Aorta Abdominalis
Pemeriksaan Untuk Menilai Kemungkinan Cholecystitis akut

Jika didapatkan nyeri atau nyeri tekanan pada kuadran kanan atas, salah satu yang
diagnosis bandingnya adalah cholecystitis akut, lakukanlah pemeriksaan Murphy’s sign.
Tempatkanlah ujung jari di bawah lengkung kosta kanan di sebelah lateral batas muskulus
rectus abdominis menyeberang dengan lengkung kosta. Suruhlah pasien untuk menarik nafas
dalam. Kadang-kadang selama palpasi nyeri timbul selama inspirasi dan pasien secara tiba-tiba
menghentikan usaha inspirasi ini. Hal ini disebut dengan tanda Murphy positive, dan mengarah
kepada kolesistitis akut. Pada waktu inspirasi, kandung empedu yang meradang turun
menyentuh tangan yang melakukan palapasi, timbul nyeri, sehingga pernafasan berhenti
(Gambar 21).
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Gambar 21. Palpasi Kandung Kemih
Pemeriksaan untuk kemungkinan Appendicitis

1. Pertama, tanyailah pasien dan minta menunjukkan dimana rasa sakit awalnya muncul
dan sekarang ini nyeri dirasakan dimana. Setelah itu mintalah pasien untuk batuk, untuk
menilai apakah nyeri tersebut dicetuskan oleh batuk dan dimanakah nyeri tersebut
muncul. Nyeri appendicitis secara klasik dimulai dari sekitar umbilicus dan kemudian
menetap di kuadran kanan bawah, dan nyeri tersebut bertambah bila batuk.
2. Carilah secara cermat daerah nyeri tekan. Nyeri tekan di lobus kanan bawah dapat
mengindikasikan appendicitis, meskipun dapat pula disebabkan yang lain.
3. Rasakan apakah ada rigiditas otot.
4. Lakukanlah pemeriksaan atau test “rebound tenderness” pada daerah nyeri tekan
tadi. (Gambar 22). Rebound tenderness menunjukkan adanya inflamasi peritoneum
yang salah satunya disebabkan oleh appendicitis.
Gambar 22. Rebound tenderness (appendisitis)
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.
Gambar 24. Obturator sign
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.
Gambar 26. Hernia Inguinalis
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).
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Gambar 27. Prolaps Hemoroid Interna
Gambar 28. Fissura ani anterior
Gambar 29. Polip fibrovaskuler anal Gambar 30. Perianal abses
Pemeriksaan Urogenital Eksterna

Pemeriksaan ini merupakan hal yang penting meski agak sensitif karena itu harus
mendapat ijin dari pasien apalagi bila dokter dan pasien berbeda jenis kelaminnya dan harus
ada indikasi pemeriksaannya. Bila ditemukan adanya kelainan genital pada perempuan dapat
dikonsulkan ke dokter kulit kelamin atau dokter kandungan. Yang perlu diperhatikan tentu
semua kelainan bawaan, penyakit seksual dan lainnya dari genetalia eksterna.
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
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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.
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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
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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
1. Apa yang dimaksud asterixis?

2. Apa yang dimaksud dengan fetor hepaticus?
3. Temuan fisik lain apakah yang dapat ditemukan pada pasien dengan hipertensi porta?
4. Apa yang dimaksud dengan tanda Murphy?
5. Seberapa akurat tanda Murphy dapat memprediksi cholecystitis?
6. Apakah peran terkini dari tanda Murphy pada evaluasi cholecystitis akut?
7. Seberapa efektif pemeriksaan abdomen dalam penilaian limpa?
8. Apakah terdapat kontraindikasi pada palpasi limpa?
9. Apa yang dapat dipelajari/didapatkan dari palpasi limpa?
10. Bagaimana cara terbaik untuk mempalpasi limpa?
B. Identifikasi penyakit-penyakit dengan level kompetensi 4, 3B, 3A dari buku

Standard Kompetensi Dokter Indonesia (SKDI) tahun 2006
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
C. Pelajari etio-patologi penyakit dari sembilan gejala yang harus dikuasai

1. Penyakit kongenital
2. Penyakit akuisita / dapatan, meliputi :
a. Trauma
b. Infeksi dan inflamasi
c. Neoplasma dan penyakit degeneratif
d. Penyakit metabolik
e. Imunologik atau penyakit autoimun
109
FEEDBACK FORM
No Aspek yang dinilai Feedback
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)
Skala Rating Global untuk Interaksi Dokter-Pasien

No. Keterampilan Landasan ilmiah dan keterangan Skala
1 2 3 4 5
Tidak Di bawah Sesuai Melebihi Sempurna
sesuai harapan harapan harapan
harapan
1. SALAM Kemampuan membina hubungan
Membina dan baik (melalui kemampuan
mepertahankan mendengarkan, kemampuan
hubungan yang baik merespon dengan baik, empati,
dengan pasien selama komunikasi interpersonal dan
seluruh konsultasi membuat pasien nyaman)
2. AJAK BICARA Kemampuan membina hubungan
Eksplorasi problem baik dan mengekplorasi masalah
pasien dan pasien kemudian menyimpulkannya
menyimpulkan (melalui kemampuan eksplorasi,
masalah pengumpulan data, pengambilan
riwayat, alloanamnesis, penilaian
dan penyimpulan)
3. DISKUSIKAN Kemampuan membina hubungan
Edukasi dan konseling baik, mengekplorasi masalah
pasien pasien, menyimpulkan masalah dan
menyusun langkah kerja/ rencana
serta menegosiasikannya dengan
pasien dan atau keluarganya
(melalui edukasi dan konseling
dalam kemitraan sejajar)
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 5: Menunjukkan rasa hormat dan norma minimal + kurang dari 20% kesalahan
Yogyakarta, ............................................
Observer
...................................................................
111
SKILLS TRAINING MATERIAL BOOK
LIFE SUPPORT SKILLS YEAR III
INTRAVENOUS LINE INSERTION

BLOCK 3.3
Skills Laboratory
Faculty of Medicine
Yogyakarta
2014
112
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
Santosa Budiharjo
Department of Anatomy, Embryology, and Anthropology
Fajar Waskito
Department of Dermato-Venereology
Angela Nurini Agni

Department of Ophthalmology
Co-Contributor:
Yulia Wardhani
Assistant of Content Development Team for Skills Training
Indra Sari Kusuma Harahap

Assistant of Material Development Team for Skills Training
Staff of Neurology Department
Noviarina Kurniawati
Coordinator of Learning Resources for Skills Training
Educational Design Reviewed by

Martiana Suciningtyas
Year III Coordinator for Clinical Skills Training
Faculty of Medicine
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:
No. Skills Training Topic Block

1. Electrocardiography I 3.2
(Chest Complaint)
2. Intravenous Line Insertion 3.3

(Abdominal Complaint)
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
A. General Objectives of Skills Training Year III

1. Students are able to make and maintain doctor-patient interaction
2. Students are able to determine differential diagnosis from patient‘s problems
3. Students are able to plan a rational medication
4. Students are able to negotiate CARE PLAN with patient by considering biosociocultural
aspects (the involvement of family, use of traditional remedy, and patient‘s perception
and behavior)
B. General Objectives of IV Line Insertion

1. The medical student should be skillful in inserting intravenous line correctly.
2. The medical student should be able to choose the correct fluid according to patient‘s
condition.
3. The medical student should be able to measure and evaluate the drip of IV line.
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
demonstrated to them or they had applied several times under supervision.
 Level of Competence 4: Able to perform independently
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.
Therapeutic Skill Level of Expected Ability

Venous Cannulation 1 2 3 4
Therapeutic Skills of the child Level of Expected Ability

Insertion of cannula (peripheral vein) 1 2 3 4
Insertion of cannula (central venous) 1 2 3 4
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:
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.
How to conduct intravenous line insertion in correct way?

I. INTRODUCTION
Therapeutic skills training in this block consist of inserting a peripheral venous

catheter/cannulae (PVC). Most patients admitted to hospital receive some form of
intravenous therapy via numerous routes. These may be either central or peripheral venous
or arterial catheters (also called cannulae).
Intravenous infusion is performed for various indications: to maintain the daily fluid
requirements, to replace lost fluids, or to administer medication (as a vehicle, mostly for
antibiotics). Because the intravenous infusion provides direct access to the blood stream, it
may involve many hazards. It provides an optimum entry for infectious organisms, allows
foreign materials including air to access blood stream (emboli), can cause bleeding, and
both the equipment and the solution can irritate the body-tissue. It is the responsibility to
protect the patients from those dangers.
The care of critically ill patients requires one or more pipelines to the vascular
system, for both monitoring and intervention. This skills training presents some guidelines
for the insertion of vascular catheters, including a brief description of the common
percutaneous access routes. The labor of vascular cannulation is a skill learned at the
bedside.
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
Veins of the hand
The dorsal venous network of

the hand is a network of veins
formed by the dorsal metacarpal
veins. It is found on the back of the
hand and gives rise to veins such
as the cephalic and basilic veins.
The basilic vein runs along the
ulnar aspect of the forearm and
upper arm. The cephalic vein runs
along the radial aspect of forearm
and upper arm.
Figure 1. Veins on the dorsum of the hand

(Bourgery)
Source: Gray (2000). Anatomy of the Human Body.
Figure 2. Veins on the dorsum of the hand

Source: Skills Laboratory Manual. 2007. Vena Puncture &
Insertion of Intravenous Infusion.
118
Veins of the upper limb
The antecubital fossa is the

triangular area on the front side
ofthe elbow joint of the arm. It
contains the antecubital veins
which are the cephalic, basilic, the
median cubital veins. The
accessory cephalic vein arises
either from a small tributory plexus
on the back of the forearm or from
the ulnar side of the dorsal venous
network; it joins the cephalic. The
basilic vein is located on the ulnar
side and the median cubital vein,
in front of the elbow joint. The
median antebrachial veins arise
from the ulnar side of the front of
the forearm and ends in the basilic
vein. The cephalic vein is a
superficial vein in the upper limb. It
communicates with the median
Figure 3. Superficial veins of the upper extremity
cubital vein at the elbow.
Scalp Veins
The frontal vein begins on the

forehead. It communicates with the
frontal branches of the superficial
temporal vein on the side of the
head. The posterior auricular
vein begins upon the side of the
head, and communicates with the
tributaries of the occipital vein and
superficial temporal veins.
Figure 4. Veins of the head and neck

119
Veins of the foot
Peripheral veins of the foot include

he small saphenous vein, the great
saphenous vein and the dorsal
venous arch. The small and large
saphenous veins are relatively
large veins of the leg. The small
Great saphenous vein is on the posterior
saphenous aspect of the leg and arises from
vein the smallest toe to merge with the
dorsal venous arch of the foot,
which attaches to the great
Dorsal
saphenous vein. The great
venous
network
saphenous vein courses laterally
to lie on the anterior surface of
thethigh.
Figure 5. The great saphenous vein and its

tributaries
III. INDICATION ANS CONTRAINDICATION
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.
Cleansing the Skin

Skin must be clean, that is, free of soil, and dust and organic material prior to
applying the antiseptic. Agents that reduce skin micro flora are called antiseptics,
whereas agents that reduce the micro flora on inanimate object are called
disinfectants. Common antiseptic agents are alcohol and iodine, both of which have a
broad spectrum of antimicrobial activity. The skin should be prepared for at least 30
seconds and allowed to air dry before catheter insertion to reduce the pain of
veinpuncture.
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.
B. CATHETER INSERTION DEVICES

Vascular catheters are composed of plastic polymers impregnated with barium or
tungsten salts to enhance radio-opacity. Catheter for short-term cannulation (days)
are usually made of polyurethane; catheter used for long-term venous access (weeks
to months) are composed of a more flexible and less thrombogenic derivative of
silicone.
Over The Needle Catheter

A catheter over needle device is shown in figure 6. The advantage of a
catheter-over-needle device is the ability to cannulate vessels in a simple one-step
procedure. The disadvantage is the tendency for the catheter tip become frayed as it
passess through the skin and soft tissues, and to subsequently damage the vascular
endothelium and promote phlebitis and thrombosis. To minimize this risk, the
catheter-over-needle device is usually reserved for cannulation of superficial vessels.
Figure 6. A Catheter-over-needle device
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.
Figure 8 & 9. Butterfly catheter and technique of inserting a butterfly needle.

Source: taken from www.nu-careproduct.co.uk
Figure 10. Scalp vein needle in an infant

Source: Marino, P. L., 1998. The ICU Book Volume 1. Second Edition.
William & Wilkins. Baltimore, Maryland
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:
Table 1. Recommendation by different organizations on the use of

specific catheter gauges
Size Gauge UK Recommendations BD recommendations
12 G Major resuscitative procedures -
requiring rapid transfusions:
13 G mainly used in theatres
14 G High volume transfusions ; mainly Used in theatres or emergency
in operative procedures for rapid transfusion of blood or
viscous fluids
16 G High volume transfusions ; mainly Used in theatres or emergency
in operative procedures for rapid transfusion of blood or
viscous fluids
17 G IV fluid therapy and blood Blood transfusions, rapid
transfusions infusion of large volumes of
viscous liquids
18 G IV fluid therapy and blood Blood transfusions, parenteral
transfusions nutrition, stem cell harvesting
and cell separation, large
volumes of fluids
20 G Blood transfusions, medication Blood transfusions, large
and IV fluid therapy volumes of fluid
22 G Medication ; Pediatric patients Blood transfusions, most
medications and fluids
24 G Medication ; Pediatric patients Medications, short term
infusions, fragile veins, children
24 G (N) - Neonatal
* Spaces left blank are not addressed in respective organization‘s recommendations.
UK = United Kingdom Expert Panel; BD = Becton Dickinson
C. INTRAVENOUS RESUSCITATION FLUID

Critically ill patients frequently demonstrate evidence of inadequate tissue perfusion
manifested by anaerobic metabolism and lactic acidosis. The primary resuscitation goal
in such patients is to restore tissue perfusion / cellular oxygenation and maintain end
organ function through volume resuscitation. Choice of resuscitation fluid depends on
the cause of the deficit.
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.
Table 2. Intravenous Fluid Composition

Fluid Glucose Na Cl Lactate Osmolarity
(g/L) (mEq/L) (mEq/L) (mEq/L) (mOsm/kg)
D5W 50 0 0 0 252
RL 0 130 109 28 273
D5W/RL 50 130 109 28 525
0.9% NaCl 0 154 154 0 308
6% HES 0 154 154 0 310
5% Albumin 0 154 154 0 310
25% Albumin 0 154 154 0 310
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.
VI. PUNCTURE SITE AND DIRECTION

The puncture site and the direction of needle insertion must be correct. In selecting
a vein to be punctured, we have to consider:
1. The size and visibility of the vein
2. Besides we have to consider the location has limited movement and does not disturb
patient‘s activity. By choice, select the patient‘s non-dominant arm and the most distal
site for initial cannulation, subsequent cannulation should be in sites proximal to the
initial cannulation
3. Choose the straight vein (without or with minimal branches)
4. Most distal part from the heart
5. Avoid choosing on joint proximal site from the elbow. In adults, infusion is usually
conducted at the superficial veins of the upper or lower extremities; while in infant, it is
usually performed in the head or frontal area. The safest veins to be punctured on the
dorsal and ventral surfaces of the upper extremities: v.cephalica, v. antebrachii
intermedius, v. basilica, and v. metacarpal dorsalis
6. Veins in lower extremities should not be used routinely in adults due to increased risk of
embolism and thrombophlebitis
7. Avoid bruised, painful or infected skin and if possible avoid areas of flexion as this may
compromise flow and the increased catheter movement increases the risk of infection
as well as the discomfort for the patient.
8. Avoid cannulation of an arm of a patient who has had a mastectomy node dissection or
radiotherapy or who has, or is due to have a fistula. If this is unavoidable, seek medical
opinion.
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
Figure 11. Fixation method

Source: Skills Laboratory Manual. 2007. Vena Puncture & Insertion of Intravenous Infusion.
VIII. PROCEDURAL INSTRUCTION FOR INTRAVENOUS INFUSION

1) Equipment to set up an intravenous infusion
- Infusion set/infusion tubing
- 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
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.
Figure 12. Pierce the skin (hold at a 15 to 30 degree angle)

- 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
- 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.
4) How to adjust the flow rate

The specific amount of fluid to be administered over a certain period will define
the number of drops per minute. You can calculate the rate of flow yourself, based on
the number of drops per millimeter administered by the equipment you are using. You
can use this formula:
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:
25 x 4 = 100 ml per hour
Some brands of infusion sets have a default number of droplets/ml as follows:

Table 3. Infusion Set
BRAND ADULTS CHILDREN
NAME
Abbos Venopak (13 – 15) drops/ml Micro drip (60) drop/ml
Blood administration set (10)
Baxter Plexitron (10) drop/ml Minimeter (50) drop/ml
Lutter Saftiset (20) drop/ml Blood Saftiset (60) drop/ml
administration set (12)
drop/ml
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)
5) Care of Intravenous Cannulae

- Documentation, as in all aspects of healthcare, is an essential factor in the care of
peripheral cannulae.
- The insertion site should be observed for signs of phlebitis or infection.
- Cannulae should be flushed with 0.9% sodium chloride at least daily to ensure
patency, and pre and post drug administration
- Loose or contaminated dressings should be replaced. Using an aseptic procedure
the area should be cleaned with sodium chloride 0.9%, then disinfected with an
alcohol wipe and allowed to dry prior to application of the new dressing.
- Prophylactic antimicrobial creams should not be used on insertion sites
- Peripheral cannulae should be removed or re-sited every 72-96 hours to minimize
the risk of phlebitis.
6) Possible complications of intravenous infusion:

- Micro-organism/pyrogenic substance contamination (infection, systemically or
locally)
- Phlebitis
- Hematoma
- Extravasation
- Overload
- Nerve fiber injury
- Air emboli
- Thrombus
Bottle and its

outflow
Infuse
Drip chamber
stand (with micro or
macro-drip)
Secondary Regulator
(roller &
clamp)
Figure 14. Intravenous line

Source: Skills Laboratory Manual. 2007. Vena Puncture & Insertion of Intravenous Infusion.
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
2. Wash hands with alcohol 70% -

glyserine.
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).
7. 7. 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.
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.
11. 11. 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.
132
12.
12. Check if there are some air bubles,

left within the tube.
13.
13. Hang the infuse bottle at the

infusion stand.
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.
15. 15. 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
133
16.
16. Open the cap of abbocath
17. 17. 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.
18. 18. Wait until the first ‗flashback‘ blood fill

in the needle ‗flashback‘ space.
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.
21. Open the regulator and let the

infusion fluid flow through the tube.
22.
22. Regulate the outflows. For the

maintenance of the outflows, use 20
drops per minutes.
23. 23. After the infusion is sufficient,

perform fixation and cover the
wound with alcohol or iodine-tincture
soaked cotton wool.
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 produce 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, essentially all of the trials over the past 20
years involving fluid choice have compared alternatives to LR.
Table 3. Classes Of Shock By ATLS® Designation*
Class 1 Class 2 Class 3 Class 4

Blood loss, % < 15% 15%-30% 30%-40% > 40%
Heart rate, beats per < 100 > 100 > 120 > 140
minutepressure, mm Hg Normal
Blood Normal Decreased Decreased
Pulse pressure Normal or Decreased Decreased Decreased
Respiratory rate, increased
14-20 20-30 30-40 > 35
breathsstatus
Mental per minute Slightly anxious Mildly anxious Anxious, Confused,
confused lethargic
*See the text, page 6, for a discussion of the utility of these criteria.
137
Clinical Pathway For Resuscitation In Hemorrhagic Shock
Patient in hemorrhagic shock
 Stanch bleeding
 Minimize time-consuming prehospital
interventions (Class II)
Rapid transport to facility where the

patient can receive definitive care
 Initiate massive transfusion protocol

with rapid procurement of blood
products in fixed PR BC:FPP:Platelet
ratio (Class II) (See text, page 14, for
protocols)
 Also consider:
- Fluid warmer (Class III)
- Cell saver/autotransfuser (Class II)
Blood products immediately

NO YES
available?
Temporize with small volume Transfer patient

resuscitation using L-type LR
boluses of 250-500 mL until
products are available or
resuscitation goal is met (Class III)
Head injury?
NO YES
Goal of resuscitation: SBP 70- Goal of resuscitation:

90 mm Hg or normal mentation normotension (Class III)
and peripheral pulses (Class III)
Administer tranexamic acid (Class I)

Loading dose 1 g over 10 minutes,
then infusion of 1 g over 8 hours
Definitive bleeding control

NO YES
achieved?
Transfer to operating room or Transfer to ICU

angiography suite
Abbreviations: FFP, fresh frozen plasma; ICU, intensive care unit; LR, lactated Ringer solution; PRBC, packed red blood cell; SBP,
systolic blood pressure.
138
Figure 14. Intravenous Catheter size 22G Figure 15. Intravenous Catheter size
20G
24G
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
2. Equation of fluid requirement according to Daldiyono method
Fluid requirement: Score x 10% x kg BW x 1 liter

15
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?
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
Table interpretation to determine dehydration level:
Assessment A B C
1. See
General Condition Good, Conscious Restless, fretful Languid, or

unconscious
Eye Normal Sunken
Very Sunken and dry
Tear Present Absent
Absent
Mouth and Tongue Wet Dry
Very dry
Thirst Drink commonly *Thirsty, wanting to
No thirsty drink a lot Reluctant to drink or
not able to drink
2. Examine Skin Rebound fast *Rebound slow Rebound very slow
Turgor
3. Degree of Without dehydration Mild/moderate Severe dehydration

Dehydration dehydration If there is a symbol *
If there is a symbol * add 1 or more other
add 1 or more other symbols
symbols
4. Therapy Plan of Therapy A Plan of Therapy B Plan of Therapy C
 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.
3. Determine therapeutic plan

Based on result of dehydration level assessment, use appropriate therapeutic plan diagram:
 Plan A for diarrhea patient without dehydration
 Plan B for diarrhea patient with mild to moderate dehydration
 Plan C for diarrhea patient with severe dehydration
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
- Show to the mother the way how to give oralit

- Give a tea spoon of oralit every 1-2 minutes for under-two child
- Give some gulps from the glass for the older child
- If the child vomits, wait for 10 minutes and then give liquid longer (for example, a tea
spoon every 2-3 minutes)
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
Amount of oralit given in the first three hours:

Oralit given is counted by multiplying patient’s weight (kg) with 75 ml
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
- Give the child more oralit if the child wants it

- Persuade the mother to continue to breastfeed
- For an infant under 6 months of age who does not receive any breast milk, also give
100-200 ml water during this period
 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:
Age Give 1-30 ml/kg in Continue to 70 ml/kg in

Infant < 1 year 1 hour 5 hours
Infant = 1 year ½ hours 2 ½ hours
*Repeat if pulse is still weak or not palpable
- 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)
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.
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
(The Intravenous Fluid and Regulate 20 drop/minute)
Nama : ………………………………………………………………..
Student No : ………………………………………………………………..
No Point of Adjustment Feedback

1. Fully explain the procedure to the patient and obtain verbal
consent, this should be documented in the patient records
Make the patient‘s position comfortable and free the infusion
site from clothing
2. Collect appropriate equipment in clean receiver
3. Wash hands
4. Check the spike and tube, closed the regulator (Remove the
infuse set from the packed firstly)
5. Pierce the outflow with a spike
6. Hang the infuse bottle at the infusion stand and fill half of the
drip chamber with the infuse solution
7. Open the fluid regulator to allow the fluid to fill the tubing to
get rid of air bubbles within the tubing
8. Use the clean gloves both of your hand
9. Identify the vein
10. Put the tourniquet on proximal set
11. 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.
12. 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 15-30 degrees angles (in
sterile approach).
13. Level the device by decreasing the angle between the
cannulae and the skin and advance the cannulae slowly to
ensure entry into the lumen of the vein
14. Push the nylon part of the needle correctly if there is blood fill
the needle chamber
15. Occlude the vein proximal to the end of the cannulae by
applying direct pressure before pulling the needle out of the
nylon part.
16. Attach the cannulae to the infusion tube
17. Release the tourniquet
18. Open the regulator to let the fluid flow
19. Fixate the infusion needle and tape it
20. Adjust the flow rate 20 drop/minute
21. Remove your gloves
22. Dispose of the sharps in a sharps bin.
23. Wash Hand
24. Documentation by writing down the procedure in medical
record
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)
Global Rating Scale for Doctor-Patient Interaction

explanation 1 2 3 4 5
Unexpected Below Meet Exceeding Excellent
1 GREETS Ability to build a good relationship
Building and (through active listening, response
maintaining properly, empathy, interpersonal
adequate communication and putting patient
relationship with at ease)
patients during the
whole consultation
2 INVITES Ability to build a good relationship,
Exploration on explore patient‘s problem and
patient problem summarize it (through exploration,
and summarize data gathering, history taking, allo-
the problem anamnesis, checking and
summarization)
3 DISCUSS Ability to build a good relationship,
Patient education explore patient‘s problem,
and counseling summarize it, formulate working
plan and negotiating it with patient
and family
(through education and counseling)
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,
( )
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
Laboratorium Keterampilan Medik

Fakultas Kedokteran
2014
148
KATETERISASI URETRA
BLOK 3.3
Kontributor:
Prof. dr. H. Prawito Singodimedjo, Sp.B, Sp.U

dr. H. Sungsang Rochadi, Sp.B, Sp.U
dr. H. R. Danarto, Sp.B, Sp.U
dr. H. Trisula Utomo, Sp.B, Sp.U
dr. H. M. Untung Tranggono, MS, Sp.B, Sp.U, PA (K)
dr. Indrawarman, Sp.U
dr. Ahmad Zulfan Hendri, Sp.U
Sub Bagian Urologi, Bagian Bedah
Fakultas Kedokteran UGM/RSUP Dr. Sarjito Yogyakarta
dr. B. Sunoko, SU, Sp.B-KBTV

Sub Bagian Bedah Thorax dan Vaskuler, Bagian Bedah
Fakultas Kedokteran UGM/RSUP Dr. Sarjito Yogyakarta
dr. Santosa Budiharjo, M.Kes, PA (K)

Bagian Anatomi, Embriologi dan Antropologi
Yogyakarta
dr. E. Suryadi, SU, PA, MHPE

Bagian Anatomi, Embriologi dan Antropologi
Yogyakarta
Co-Contributor:
dr. Yulia Wardhani dr. Indra Sari Kusuma Harahap, Ph.D

Asisten Tim Materi Skills Lab Asisten Tim Materi Skills Lab
Fakultas Kedokteran Universitas Gadjah Mada Fakultas Kedokteran Universitas Gadjah Mada
dr. Noviarina Kurniawati

Koordinator Learning Resources Skills Lab
Desain program pendidikan ditinjau oleh
dr. Martiana Suciningtyas, SpF

Koordinator Tahun III untuk Pelatihan Keterampilan Medik
Fakultas Kedokteran
149
KATA PENGANTAR
Mahasiswa fakultas kedokteran harus mempelajari dan melatih beberapa keterampilan

klinik sebagai persiapan memasuki rotasi klinik sebelum menjadi dokter yang sesungguhnya.
Saat ini, pendidikan kedokteran meyakini bahwa mahasiswa harus terampil dalam keterampilan
klinik sebelum mereka berhadapan langsung dengan pasien yang sebenarnya. Oleh sebab itu,
diperlukan pelatihan keterampilan klinik seawal mungkin. Laboratorium keterampilan klinik
memberikan kesempatan bagi mahasiswa untuk mempelajari dan mempraktekkan keterampilan
klinik mereka.
Topik buku ini merupakan salah satu sub topik dari topik utama yaitu Keterampilan
Bedah Dasar yang akan terus dipelajari dalam blok oleh mahasiswa tingkat strata 1.
Keterampilan yang termuat dalam buku ini disusun berdasar pada Kurikulum Berbasis
Kompetensi 2007. Topik-topik yang termasuk dalam Keterampilan Bedah Dasar tahun III
adalah sebagai berikut:
No. Topik Keterampilan Medis Blok

1. Kateterisasi Uretra 3.3
2. Trauma Ortopedi 3.4

(Limited Movement)
3. Bedah Minor 3.4

(Limited Movement)
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
A. Tujuan Umum Skills Training Tahun III

1. Mahasiswa mampu membina komunikasi dan interaksi dokter-pasien
2. Mahasiwa mampu menentukan diagnosis banding dari permasalahan pasien
3. Mahasiswa mampu merencanakan pengobatan yang rasional
4. Mahasiswa mampu menegosiasikan rencana manajemen (CARE PLAN) dengan pasien
dengan mempertimbangkan biososiokultural (keterlibatan keluarga, penggunaan
pengobatan tradisional, tanggapan dan perilaku non verbal pasien)
B. Tujuan Umum Kateterisasi Uretra

Mahasiswa mengetahui instrumentasi yang digunakan dalam keterampilan kateterisasi
uretra, dan mampu melakukan tindakan kateterisasi dengan benar.
C. Tujuan Khusus Kateterisasi Uretra

1. Mempersiapkan pasien, termasuk informed consent, dan memposisikan pasien
2. Mempersiapkan instrumentasi secara aseptik
3. Mencuci tangan dengan metode aseptik
4. Memakai sarung tangan steril dengan metode aseptik
5. Melakukan disinfeksi pada orificium uretra dan penis
6. Menutup penis dengan kain linen steril berlubang
7. Aplikasi lubrikan pada uretra
8. Memasukkan kateter uretra sampai ke vesika urinaria
9. Memompa balon kateter
10. Menentukan posisi kateter pada vesika urinaria
11. Memberikan dressing pada glans penis menggunakan larutan antiseptik
12. Memfiksasi kateter dengan plaster (Velco band)
13. Melepas dan mengganti kateter uretra menetap (indwelling)
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.
Student„s Book – Blok 3.3: Abdominal Complaints

Therapeutic Skills Level of Expected Ability
Uretral catheterization in male 1 2 3 4
Uretral catheterization in female 1 2 3 4
Clean intermitten catheterization 1 2 3 4
(Neuropathic bladder)
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

Kasus Ilustrasi
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.
Lakukan TINDAKAN yang sesuai dengan kondisi pasien.
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:

i) Kateter bercabang dua, satu saluran untuk drainase urin dan saluran yang lebih
kecil untuk memompa balon.
ii) Kateter cabang tiga, saluran ketiga berfungsi sebagai saluran irigasi.
Kateter Foley tersedia dalam berbagai ukuran, volume balon dan desain ujung.
Pilihan kateter menetap lain misalnya Kateter Pezzer dan Malecot yang memiliki ujung
berbentuk mirip jamur.
Gambar 1. Kateter uretra, stylet metal, kateter dan teknik guidewire

untuk insersi kateter
Sumber: Manual Skills Laboratory. 2008. Kateterisasi Uretra. Blok 15.
Fakultas Kedokteran. Universitas Gadjah Mada
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.

Pilihan ukuran kateter tergantung pada pasien dan tujuan penggunaan. Kateter
kaliber besar digunakan untuk mengevakuasi jendalan darah dan debris. Indikasi
pemakaian kateter yang lain digunakan untuk menstabilkan grafts setelah tindakan
open urethroplasties, stenting setelah tindakan insisi endoskopi (uretrotomi interna)
pada striktur uretra, sebagai suprapubik kateterisasi (uretral eksternal?), serta menilai
urin output.
Ujung kateter memiliki perbedaan dalam bentuk dan konfigurasi ujung saluran.
Kateter Coudé memiliki ujung runcing dan agak melengkung. Ujung kateter Robinson
dan Whiestle berbentuk bulat dan berujung lurus. Kateter Pezzer dan Malecot memiliki
ujung runcing dan berbentuk mirip jamur.
B. Kandung Kemih (Vesica Urinaria)

Kandung kemih merupakan organ berongga, yang pada orang dewasa memiliki
kapasitas 400-500 ml. Pada wanita, dinding luar dan kubahnya berbatasan dengan
uterus. Saat kandung kemih penuh, organ ini naik melampaui symphysis dan mudah
dipalpasi dan diperkusi. Jika terjadi overdistensi, misalnya pada pasien dengan retensi
urin akut atau retensi urin kronis, menyebabkan abdomen bagian bawah nampak
menonjol (bulging). Saat kosong, kandung kemih orang dewasa berada di belakang
symphysis pubis. Pada balita dan anak-anak, kandung kemih berada di posisi yang lebih
tinggi.
Median umbilicus ligament memanjang dari umbilicus hingga kandung kemih.
Organ ini merupakan fibrous cord yang menandakan obliterasi dari urachus. Ureter
memasuki kandung kemih secara oblique. Bangunan di antara orifisum ureter kiri dan
kanan disebut interureteric ridge, yang membentuk batas proksimal dari bladder
trigone/trigonum vesicae. Sphincter internal bukan sphincter yang sesungguhnya tetapi
penebalan yang terbentuk dari serabut otot detrusor yang terjalin dan mengumpul.

Gambar 2. Neural control of the lower urinary tract. Ada interaksi ekstensif
dalam spinal cord dan paravesical serta intramural bladder ganglia
(tidak nampak)
Mukosa kandung kemih tersusun dari epithel transisional. Di bawah mukosa

terdapat lapisan submukosa, dan di luar mukosa adalah otot detrusor. Otot detrusor
tersusun dari serabut halus dan terdiri dari 3 lapis utama: longitudinal (memanjang) di
bagian dalam, sirkular di bagian dalam dan longitudinal di bagian luar.
Vaskularisasi kandung kemih berasal dari arteria vesikalis superior dan inferior,
yang merupakan percabangan dari arteria hipogastrica/iliaca interna. Arteria lain yang
menyuplai kandung kemih berasal dari arteria obturator dan arteria glutea inferior. Pada
wanita, cabang arteria vagina dan uterus juga menyuplai kandung kemih. Di sekeliling
kandung kemih terdapat plexus vena yang bermuara ke vena iliaca/hipogastrica.
Inervasi pada dalam kandung kemih melalui sistem saraf otonom dengan tiga
jenis saraf: parasimpatik, simpatik and somatis. Sistem saraf parasimpatik bermula dari
segmen S2 – S4/pelvic nerves, dan melalui pelepasan neurotransmitter acetylcholine
menjadi kontrol motorik dari otot detrusor. Sistem saraf simpatik bermula dari Th 10 – L
2/hypogastric nerves yang muncul dalam jumlah terbanyak menuju trigonum (dasar)
kandung kemih dan leher kandung kemih.
Saraf simpatik merupakan pengontrol motorik utama untuk otot-otot polos prostat
dan uretra. Saraf somatis adalah saraf pudendum yang berperan dalam striated
sphincter mechanism.

Fungsi utama kandung kemih adalah untuk menampung urin dan mengosongkan
secara efisien.
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.
Gambar 3. Top : Hubungan kandung kemih, prostat, vesikula seminalis, penis,

uretra, dan skrotum, Kiri bawah: Irisan transversal dari penis. Struktur bagian atas
yang berpasangan adalah corpora cavernosa. Bagian bawah tunggal. Struktur yang
mengelilingi uretra disebut corpus spongosium. Kanan bawah: Bidang fascial dari
saluran genitourinary bawah.

Uretra Wanita
Uretra wanita jauh lebih pendek daripada uretra laki-laki. Panjang uretra wanita
dewasa sekitar 4 cm dengan diameter 8 mm. Organ ini sedikit melengkung dan terletak
di bawah symphysis pubis dan anterior vagina. Mukosa uretra terdiri dari epitel
squamous di bagian distal dan transisional di tempat lainnya, yang kaya akan kelenjar
mukosa. Di ujung uretra terdapat meatus eksternal yang menuju vestibulum vagina.
Pada wanita yang mengalami obesitas, lokasi meatus eksternal tersembunyi, sehingga
kateterisasi uretra mungkin sulit dilakukan dan harus hati-hati ketika melakukannya.
Gambar 4. Anatomi kandung kemih, uretra, uterus

dan ovarium, vagina, dan rektum
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.
Retensi Urin Akut

Retensi Urin Akut merupakan kondisi kedaruratan urologi yang umum terjadi,
ditandai dengan ketidakmampuan berkemih dan distensi kandung kemih dengan rasa
nyeri dan/atau rasa sangat tidak nyaman di abdomen bagian bawah. Retensi Urin Akut
umumnya berupa ketidakmampuan mengeluarkan urin (tetapi ada rasa ingin berkemih)
disertai rasa nyeri di abdomen bawah.
Hasil perkusi dan palpasi pada perut bagian bawah ditemukan
ketegangan,distensi dan nyeri pada kandung kemih. Pada pasien post laporotomy dan
penderita obesitas, untuk mendeteksi adanya distensi pada kandung kemih mungkin
sulit dilakukan. Pada pasien yang mengalami retensi urin akut, pengosongan kandung
kemih dengan cepat melalui pemasangan kateter uretra harus segera dilakukan kecuali
pada pasien yang pernah mengalami striktur uretra atau traumatic catheter insertion.
Pada kondisi ini, sistostomi/kateter suprapubik harus dipasang. Volume residu urin yang
besar setelah pemasangan kateter akan memastikan hasil diagnosis.

Retensi urin akut jarang tanpa disertai rasa nyeri dan menandakan penyebab
neurologis. Disamping keluhan pada saluran kemih, pasien mungkin mengeluhkan
gangguan fungsi pencernaan dan/atau disfungsi seksual. Beberapa pasien mungkin
mengeluhkan nyeri punggung dan sciatica. Selama pemeriksaan rektal, terdapat
penurunan tonus anal dan gangguan sensorik pada saddle area, hal ini memunculkan
dugaan adanya penyebab neurologis. Konsultasi neurologis atau bedah saraf mungkin
diperlukan, karena penundaan intervensi dapat menghambat pemulihan.
Retensi Urin Kronik

Pasien dengan retensi urin kronik biasanya tidak mengeluhkan rasa nyeri, dan
ditemukan nocturnal enuresis akibat adanya overflow incontinence, dengan keluhan
minimal pada saluran kemih bagian bawah. Retensi urin kronik diklasifikasikan berdasar
penemuan klinik dan urodinamik, sebagai Low Pressure Chronic Urinary Retention
(LPCUR), atau High Pressure Chronic Urinary Retention (HPCUR), meskipun
pembedaan ini tidak terlalu jelas.
Gambaran klinis pada LPCUR sering hanya sedikit gejala dan biasanya
merupakan temuan tidak sengaja selama pemeriksaan abdominal atau pemindaian
ultrasound. LPCUR bukan kondisi kedaruratan urologis dan bisa ditangani secara elektif,
meski penting membedakannya dengan HPCUR. Kandung kemih terdistensi, lunak dan
sulit diraba. Pada pemindaian ultrasound ditemukan ginjal yang normal dengan level
serum kreatinin normal.
Gambaran klinis pada HPCUR yaitu enuresis, kandung kemih yang tegang tanpa
rasa nyeri, hipertensi dan hidronefrosis bilateral. Penderita HPCUR lain menampakkan
gejala gagal ginjal disertai retensi sodium dan air. Selain itu, hipertensi dan gagal
jantung kongestif juga terjadi dengan persentase masing-masing 50% dan 20%.
Pada pemeriksaan fisik ditemukan kandung kemih yang tegang dan terdistensi,
tanpa rasa nyeri, kelebihan cairan dan tanda-tanda uremia. Penderita HPCUR dapat
dijumpai nefropati obstruktif, infeksi saluran kemih atau gross hematuria. Gejala-gejala
ini juga merupakan indikasi bahwa kateterisasi kandung kemih harus segera dilakukan.
E. Pemasangan dan Pelepasan Kateter Uretra Menetap (Indwelling Catheter)

Kateterisasi uretra dilakukan dengan memasukkan kateter uretra ke dalam
kandung kemih melalui orifisum uretra eksterna. Kateterisasi suprapubik langsung
dilakukan dengan memasukkan kateter ke dalam kandung kemih melalui saluran
terbuka pada kandung kemih (sistostomi).
Kateterisasi uretra merupakan tindakan yang mudah dilakukan, cepat dan
langsung. Dokter dan perawat di puskesmas maupun di ruang gawat darurat biasa
melakukan teknik ini. Kateter suprapubik memiliki beberapa keuntungan, terutama jika
dilakukan dalam jangka panjang. Kateter jenis ini kecil kemungkinan menyebabkan
infeksi dan striktur uretra maupun gangguan pada hubungan seksual. Kateter
suprapubik diperlukan ketika kateterisasi uretra gagal atau ada kontraindikasi, misalkan
adanya striktur uretra atau trauma uretra.
Aturan dasar kateterisasi menetap adalah penggunaan teknik sterilisasi. Clean
Intermittent Catheterization (CIC) biasanya dilakukan pada pasien yang mengalami
gangguan neurogenic kandung kemih dengan gejala retensi urin.
Mekanisme ganda otot sphincter menyediakan sawar yang efektif terhadap
infeksi dari luar yang masuk ke saluran kemih steril. Sebaliknya, setiap kateterisasi
berisiko menginduksi masuknya organisme patogen secara retrograd,dan bisa
mengakibatkan komplikasi.

III. TEKNIK KATETERISASI URETRA
A. Pemasangan Kateter Uretra Menetap (Indwelling Catheter)
 Jelaskan dan informasikan prosedur pemasangan kepada pasien
 Atur posisi pasien pada posisi supine yang nyaman
 Persiapkan peralatan di tempat yang mudah dijangkau
 Gunakan teknik aseptik (baik operator maupun pasien)
 Pada laki-laki, pegang penis dengan arah tegak lurus tubuh pasien.
 Pada wanita, buka labium majora
 Untuk laki-laki, masukkan 10 – 15 ml lubrikan (Jel Xylokain) larut air dengan anestesi
lokal ke dalam uretra
 Pada wanita, masukkan 5 ml lubrikan (Jel Xylokain) larut air dengan anestesi lokal
ke dalam uretra
 Masukkan kateter perlahan dan lembut ke dalam uretra, hindari penggunaan tenaga
yang terlalu kuat atau gerakan mendadak
 Pada laki-laki, ketika mencapai sphincter eksterna, atur posisi penis paralel terhadap
tubuh, masukkan perlahan dengan memberi sedikit tekanan lembut. Minta pasien
mengambil napas dalam-dalam atau disuruh mengingat seperti saat kencing dengan
tujuan untuk merelaksasi otot sphincter external
 Pada laki-laki, untuk memastikan bahwa kateter sudah berada di dalam kandung
kemih, kateter harus dimasukkan sampai pangkal.
 Setelah kateter berada dalam kandung kemih, pompa balon kateter dengan volume
yang sesuai dengan akuades dan pasang urine bag/kantung urin, balut glans penis
dengan kasa steril yang diberi povidon iodin.
 Catat volume urin yang keluar/residu.
Kontraindikasi Kateterisasi Uretra:

 Perdarahan Meatal
 Hematoma perineal
 Floating prostate/prostat yang mengapung
Gambar 5. Kateterisasi steril


Gambar 6. Pemasangan kateter uretra dengan forceps (pria)
Gambar 7. Pemasangan kateter uretra (wanita)

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)

Kateter dalam uretra dan kandung kemih merupakan benda asing dalam tubuh.
Bagi pasien, terutama pasien sensitif, alat ini menyebabkan iritasi yang tidak nyaman,
sehingga mungkin memerlukan pereda nyeri atau analgesik untuk mengurangi rasa
tidak nyaman.
B. Kateterisasi Intermittent, Clean Procedure

 Cuci tangan dengan sabun dan air mengalir
 Persiapkan peralatan di tempat tersendiri.
Peralatan yang diperlukan: kateter, lubrikan larut air (KY Jeli), handuk, dan kain
bersih yang direndam sabun dan air
 Jika perlu letakkan kain pelapis di bawah pantat anak untuk menjaga kebersihan
 Sarung tangan tidak harus dipakai. Namun, jika perawat bayi atau rekannya
melakukan pemasangan kateter, mereka mungkin perlu memakai sarung tangan non
steril dari bahan non-karet.
 Bersihkan penis dan perineum dengan sabun lembut dan air. Bagi anak yang belum
disirkumsisi, tarik kulit penutup penis lalu bersihkan kepala penis.
Bagi perempuan, buka labia dan bersihkan dari depan ke belakang.
 Setelah lubrikasi, pegang kateter di dekat bagian ujung, lalu masukkan ke dalam
uretra sampai urin mengalir.
 Jangan dipaksakan. Jika terasa ada sedikit tahanan, putar kateter perlahan
 Letakkan ujung lain kateter dalam wadah atau toilet dan pegang kateter sampai urin
berhenti mengalir.
 Tarik kateter dengan perlahan dan lembut. Kadang masih terdapat urin yang
mengalir keluar.
 Pastikan anak anda kering dan nyaman
 Bersihkan alat kateter dan simpan dalam wadah bersih
 Ukur volune urin, lalu buang dan bersihkan wadah
 Basuh tangan hingga bersih
 Catat pelaksanaan prosedur
Gambar 8. Prosedur Kateterisasi

C. Pelepasan Kateter Uretra Menetap (Indwelling Catheter)

Peralatan, posisi pasien maupun operator sama dengan saat prosedur
pemasangan kateter uretra.
 Keluarkan cairan dari balon kateter sampai sampai kosong dan kateter bisa ditarik
tanpa hambatan
 Lepas perban pada glans penis

 Pada laki-laki, pegang penis lalu regangkan
 Tarik kateter uretra perlahan dan lembut, hindari gerakan mendadak atau kasar
 Taruh kateter dan wadah urin dalam tempat khusus.
 Lakukan prosedur disinfeksi terhadap orifisum uretra eksterna dengan povidon iodin
Gambar 9. Tempat masuknya bakteri penyebab infeksi saluran kemih

akibat penggunaan kateter
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.

OSCE
CHECKLIST INTEGRATED PATIENT MANAGEMENT
(URETHRAL CATHETER INSERTION)
Nama : _______________________________
No.Mahasiswa : _______________________________
NO ASPEK YANG DINILAI SKOR

0 1 2 3
PERSIAPAN
1. Memastikan indikasi dan tidak adanya kontraindikasi pemasangan
kateter pada pasien (kesadaran akan situasi darurat - jika ada)
2. Informasi-persetujuan
- Memeriksa dan mengkonfirmasi identitas pasien
- Menjelaskan prosedur dan risiko
- Diskusikan dengan pasien
- Mendapatkan izin (di atas kertas atau oral)
3. Mempersiapkan dan mengecek alat dan bahan yang dibutuhkan
dalam troli
4. Mempersiapkan pasien
5. Mempersiapkan diri sesuai dengan prinsip general precaution
- mencuci tangan dengan cara aseptik
- mengenakan sarung tangan steril
KEMAMPUAN TEKNIS SELAMA MELAKUKAN PROSEDUR
6. Melakukan prosedur antiseptik pada area genital menggunakan
metode yang tepat
7. Menutupi area genital dengan linen steril berlubang
8. Tangan kiri memegang penis tegak lurus terhadap tubuh/ membuka
labia mayora
9. Memasukkan pelumaslarut air yang mengandung anestesi lokal
pada uretra sebelum memasukkan kateter:
- 10-15 mL pada uretra laki-laki
- 5 mL pada uretra wanita
10. Memasukkan kateter dengan metode yang benar:
- memasukkan kateter tanpa menggunakan dorongan
berlebihan
- memasukkan panjang kateter sampai percabangan kateter
11. Memastikan kateter mencapai kandung kemih yang ditandai
dengan:
- tampak urin mengalir keluar ATAU
- jika urin tidak keluar, dilakukan aspirasi dengan syringe 10 cc
12. Mengembangkan balon kateter menggunakan aquades steril
dengan volume yang sesuai dan menarik kateter sampai balon
terfiksasi pada leher kandung kemih
13. Menghubungkan kateter dengan pipa kantong urin
14. Mengeringkan glans penis dengan kassa steril dan menutup orificum
uretra eksternal menggunakan kassa antiseptik
15. Melepaskan linen steril berlubang
16. Memposisikankateter uretra dan kantong urin pada tempat yang
sesuai
17. Manajemen pasca prosedur yang memadai
- membereskan alat
- mencuci tangan
- mencatat jumlah dan kualitas urin inisial
18. Edukasi yang memadai
PROFESIONALISME
19. Menunjukkan kepercayaan diri sebagai seorang profesional
kesehatan
20. Etika (Hormati pasien, menunjukkan norma lokal & nilai-nilai lokal)
21. Menjaga prinsip aseptik selama melakukan prosedur*
22. Menjaga komunikasi dan hubungan yang baik selama prosedur

Keterangan: Yogyakarta, ……………………………….
Skor 0 = Tidakdilakukan
Skor 1 = Dilakukandenganburuk
Skor 2 = Dilakukandenganbaik
Skor 3 = Sempurna (lengkap) ……………………………...
(Skor Total) OVERALL PERFORMANCE* (CENTANG

Nilai = ------------------------------ x 100% = SALAH SATU)
…………% FAIL PASS
39 BORDERLINE EXCELENT

No Keterampilan Landasan ilmiah dan Skala
keterangan 1 2 3 4 5
harapan
1 Menunjukkan Berhadapan dengan diri sendiri
kepercayaan diri (ketika mahasiswa mampu
dalam melakukan bersikap secara profesional
keterampilan di depan tanpa menunjukkan keadaan
pasien dirinya sendiri saat itu, misal
sedang cemas, sedih,
memikirkan sesuatu yang lain)
2 Etika (Menghormati Berhadapan dengan pasien

pasien, nilai-nilai lokal (ketika mahasiswa mampu
dan norma) bersikap secara profesional
tanpa menunjukkan asumsi-
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)

No. Keterampilan Landasan ilmiah dan Skala
harapan
1 SAPA Kemampuan membina
Membina dan hubungan baik (melalui
mepertahankan kemampuan mendengarkan,
hubungan yang baik kemampuan merespon dengan
dengan pasien selama baik, empati, komunikasi
seluruh konsultasi interpersonal dan membuat
pasien nyaman)

2 AJAK BICARA Kemampuan membina
Eksplorasi problem hubungan baik dan
pasien dan mengekplorasi masalah pasien
menyimpulkan kemudian menyimpulkannya
masalah (melalui kemampuan eksplorasi,
pengumpulan data,
pengambilan riwayat,
alloanamnesis, penilaian dan
penyimpulan)
3 DISKUSIKAN Kemampuan membina

Edukasi dan konseling hubungan baik, mengekplorasi
pasien masalah pasien, menyimpulkan
masalah dan menyusun langkah
kerja/ rencana serta
menegosiasikannya dengan
Penjelasan:
Instruktur,
( )

LEMBAR FEEDBACK
Pelepasan Kateter Uretra (Foley) Menetap, Indwelling Catheter
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

No Keterampilan Landasan ilmiah dan Skala
keterangan 1
Tidak
2
Di
3
Sesuai
4
Melebihi
5
Sempurna
sesuai bawah harapan harapan
harapan harapan
1. Menunjukkan Berhadapan dengan diri sendiri
kepercayaan diri (ketika mahasiswa mampu
dalam melakukan bersikap secara profesional
keterampilan di depan tanpa menunjukkan keadaan
pasien dirinya sendiri saat itu, misal
sedang cemas, sedih,
memikirkan sesuatu yang lain)
2. Etika (Menghormati Berhadapan dengan pasien

pasien, nilai-nilai lokal (ketika mahasiswa mampu
dan norma) bersikap secara profesional
tanpa menunjukkan asumsi-
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)

No. Keterampilan Landasan ilmiah dan Skala
harapan
1. SAPA Kemampuan membina
Membina dan hubungan baik (melalui
mepertahankan kemampuan mendengarkan,
hubungan yang baik kemampuan merespon dengan
dengan pasien selama baik, empati, komunikasi
seluruh konsultasi interpersonal dan membuat
pasien nyaman)
2. AJAK BICARA Kemampuan membina

Eksplorasi problem hubungan baik dan
pasien dan mengekplorasi masalah pasien
menyimpulkan kemudian menyimpulkannya
masalah (melalui kemampuan eksplorasi,
pengumpulan data,
pengambilan riwayat,
alloanamnesis, penilaian dan
penyimpulan)
3. DISKUSIKAN Kemampuan membina

Edukasi dan konseling hubungan baik, mengekplorasi
pasien masalah pasien, menyimpulkan
masalah dan menyusun langkah
kerja/ rencana serta
menegosiasikannya dengan
Penjelasan:
Instruktur,
( )

BASIC CLINICAL COMPETENCES TRAINING MATERIAL BOOK
LIFE SUPPORT SKILLS YEAR III
NASOGASTRIC TUBE INSERTION

BLOCK 3.3
Skills Laboratory
Faculty of Medicine
Yogyakarta
2014

NASOGASTRIC TUBE INSERTION
BLOCK 3.3
Contributor:
dr. Santosa Budiharjo, M.Kes, PA

Department of Anatomy, Embryology, and Anthropology
Co-Contributor:
dr. Yulia Wardhani

Assistant of Content Development Team for Skills Training
dr. Indra Sari Kusuma Harahap, Ph.D

Assistant of Material Development Team for Skills Training
Staff of Neurology Department
dr. Martiana Suciningtyas,SpF

Coordinator of Learning Resources for Skills Training

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:
No. Skills Training Topic Block

1. Electrocardiography I 3.2
(Chest Complaint)
2. Intravenous Line Insertion 3.3

3. Nasogastric Tube Insertion 3.3

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.
Yogyakarta, October 2014
Contributor

LESSON PLAN FOR NASOGASTRIC TUBE INSERTION
A. General Objectives of Skills Training Year III

5. Students are able to make and maintain doctor-patient interaction
6. Students are able to determine differential diagnosis from patient‘s problems
7. Students are able to plan a rational medication
8. Students are able to negotiate CARE PLAN with patient by considering biosociocultural
aspects (the involvement of family, use of traditional remedy, and patient‘s perception
and behavior)
B. General Objectives of Nasogastric Tube Insertion

4. The medical student should be able to identify the indication and contraindication for
inserting nasogastric tube
5. The medical student should be skillful in inserting nasogastric tube correctly.
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
demonstrated to them.
 Level of Competence 3: Having done or Having applied under Supervision
demonstrated to them or they had applied several times under supervision.
 Level of Competence 4: Able to perform independently
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.
Therapeutic Skill Level of Expected Ability

Nasogastric tube insertion 1 2 3 4
D. Activities
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

5 x 15 Exercise Performing and Observing and  Rubber
minutes observing each giving feedback Band
other
(one by one)  Gloves
 Curved
Basin
 Safety pin
 Cup of water
with
straw
 Stethoscope
 60 cc Irrigating
syringe
 Water soluble
lubricant
 NG tube (plastic
or rubber) of
appropriate
size
 Suction
5 minutes Evaluation and Asking and Explaining Feedback form

Closing Giving Comment

Illustration Case
A 56 year-old man complained to have abdominal distension since 3 days ago.

He also complained about having a difficulty in defecation. He was looked pale
and weak.
What will you conduct as a doctor on duty regarding the patient’s condition?
I. PHARYNGEAL ANATOMY
Figure 1. Pharyngeal Anatomy

Source: Bates, Guide to Physical examination 2005
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.
II. NASOGASTRIC TUBE

Nasogastric tube is a tube that is passed through the nose and down through the
nasopharynx and esophagus into the stomach. It is a flexible tube made of rubber or
plastic and it has bidirectional potential.

Figure 2. Nasogastric tube
Source: Skills Laboratory 2010
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.

V. TYPE OF NASOGASTRIC TUBE
a. Salem sump, Levin, Miller-Abbott nasogastric tube for decompression
b. Duo, Dobhoff, Levin nasogastric tube for feeding (gavage)
c. Sengtaken-Blakemore nasogastric tube for compression
d. Levin, Ewald, Salem sumo nasogastric tube for lavage
VI. EQUIPMENT REQUIRED

 Non-allergenic tape
 Protective pad or towel
 Rubber Band
 Gloves
 Curved Basin
 Safety pin
 Cup of water with straw
 Stethoscope
 Clamp/forceps
 Tongue spatula
 Flashlight
 60 cc and 20 cc irrigating syringe
 Water soluble lubricant
 NG tube (plastic or rubber) of appropriate size (14 or 16 Fr)
 Suction
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.
Figure 3. Measuring the depth of insertion

Source: Thompson et al. Nasogastric Intubation. NEJM 2006.

VIII. PROCEDURE
TUBE INSERTION
 Gather your equipment. You will need gloves, a protective gown, and a face shield; a
nasogastric tube; lubricant (viscous lidocaine or surgical jelly); a glass of water and a
straw; an emesis basin; absorbent towels or pads; a catheter-tip (Toomey) syringe; a
stethoscope; adhesive tape; and a suction unit.
 Position the patient so that he or she is sitting upright in the ―sniffing‖ position (neck
flexed and head extended).
 Lubricate the distal end of the nasogastric tube along 10-20 cm.
 Insert it into the nasal cavity, slowly passing it posteriorly along the floor of the nasal
canal. Continue to advance the tube slowly into the posterior oropharynx.
The patient may gag or you may feel resistance as the tube nears the laryngeal
apparatus. If so, temporarily halt the advancement and instruct the patient to sip water
through the straw. Coordinate further advancement of the tube with instructions to the
patient to swallow. As the patient swallows, the epiglottis will cover the trachea and
prevent inadvertent placement of the tube in the trachea. Once the tube is past the
larynx, guide it rapidly to the predetermined depth.
CONFIRMATION OF TUBE PLACEMENT

 If the patient is unable to talk or is in respiratory distress or if respirations can be heard
through the nasogastric tube, tracheal intubation has probably occurred, and the tube
should be immediately removed.
 Proper gastric placement is suggested (though not unequivocally confirmed) by
auscultating borborygmus over the epigastrium as 10-20 cc air is injected into the tube
with the catheter-tip syringe. Then, slowly aspirate the gastric content.
 If there is any question with regard to proper placement, or if agents such as activated
charcoal are to be instilled though the tube, a chest radiograph should be obtained to
confirm placement. Visualization of the descent of the tube below the diaphragm
provides such confirmation.
SECURING THE NASOGASTRIC TUBE AND INITIATING SUCTIONING

 To secure the tube, cut a 7-cm length of 1-in–wide adhesive tape and tear it halfway
down along 3,5 cm its vertical length. Apply the wide end to the patient‘s nose, and
wrap the two ―tails‖ around the tube.
 At this point, the tube can be connected to the suctioning equipment. Intermittent, low
suction should be used for the majority of patients.
 Place the NGT tip to the patient‘s cloth using a tape and secure it with a pin.
Figure 4. Securing the tube

Source: Thompson et al. Nasogastric Intubation. NEJM 2006.

GASTRIC IRRIGATION
 Check the NGT placement
 Inject 30 cc normal saline into the tube
 Clamp the NGT tip for a while and release it
 Attach the syringe to the NGT tip for irrigation and inject normal saline through the tube
slowly
 If there is any resistance, check the tube placement, move the patient to another
position/side
 Aspirate the gastric content slowly and measure the volume
 Connect the tube to the container, if it doesn‘t flow, repeat the irrigation
 Wash your hand
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

FEEDBACK FORM FOR NAGOGASTRIC INTUBATION
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

Global Rating Scale for Professional Behavior
explanation 1
Unexpected
2
Below
3
Meet
4
Exceeding
5
Excellent
1. Demonstrate Dealing with one-self:
confidence during (student able to behave
performing skills in professionally without
front of patient showing his/her anxiety,
sadness and worries)
2. Ethics (Respect the Dealing with others:
patient, demonstrate (student able to behave
local values and professionally without
norms) showing his/her assumptions
about patient)
3. Minimal Error Dealing with one-self, others
(systematic in and task: (student able to
procedures, behave professionally in
harmless) dealing with others and
performing tasks with
minimal error)
Global Rating Scale for Doctor-Patient Interaction

explanation 1
Unexpected
2
Below
3
Meet
4
Exceeding
5
Excellent
4. GREETS Ability to build a good
Building and relationship
maintaining adequate (through active listening,
relationship with response properly, empathy,
patients during the interpersonal communication
whole consultation and putting patient at ease)
5. INVITES Ability to build a good
Exploration on relationship, explore patient‘s
patient problem and problem and summarize it
summarize the (through exploration, data
problem gathering, history taking, allo-
anamnesis, checking and
summarization)
6. DISCUSS Ability to build a good
Patient education relationship, explore patient‘s
and counseling problem, summarize it,
formulate working plan and
negotiating it with patient and
family
(through education and
counseling)
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)
Instructor,
( )

REFERENCES
1. Thomsen, T. W, Shaffer, R. S., Gary S. Setnik, G. S. 2010. Nasogastric Intubation. New

England Journal of Medicine. August 10th 2010. Massachusetts.
2. Bickley, L. S. 2005. Bates: Guide to Physical Examination and Hystory Taking. Ninth Edition.
Lippincott William & Wilkins. Philadephia.

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Student‟s Book

Medicine Study Program

© Faculty of Medicine, Universitas Gadjah Mada, November 2014

dr. Tri Wibawa, PhD

dr. Rita Cempaka, Sp.PA

dr. Ira Puspitawati, Sp.PK

dr. Neneng Ratnasari, Sp.PD-KGEH

Phase 3: Clinical Rotation - Becoming a Compre

Phase 3: Clinical Rotation - Becoming a Competent Doctor

Phase 2: Transition from Theory to Practice Phase 3: Clinical Rotation -

& Congenital Neonates

Locomotor System (6 weeks) (6 weeks) System (6 weeks)

This block is part of Competence-based Curriculum applied in Faculty of Medicine,

Dean of Faculty of Medicine,

BLOCK TEAM ................................................................................................................

BASIC CLINICAL COMPETENCES TRAINING

RELATIONSHIP WITH OTHER BLOCKS

Acute Abdominal GI Tract Pancreatitis

IBS & IBD

Pain Gastritis Dyspepsia

Cholecystitis & Cholelithiasis

Hernia Abdominal Lump

Benign Pancreas Carcinoma

Splenomegaly (Malaria, Typhoid)

Fluid Ascites Hepatic Cirrhosis Upper GIT Bleeding

1. Group discussion with tutors

2. Independent learning (self study)

3 Pathology of Urinary Tract Pathology Anatomy 2

6. Basic Clinical Competences Training

Methods Activities Percentage Total

MCQs in Block Examination 85 85%

Practical Session Microbiology:

BLOCK EXAMINATION REQUIREMENTS

To be able to participate in the examination, students must:

Absence may be permitted by the 3 main reasons, those are:

2. Title : Urethral Catheterization

3. Title : IV line Insertion

4. Title : Differential Diagnosis of Acute Abdominal Pain

5. Title : Acute Abdominal Pain for General Practitioner: Perforated

6. Title : Abdominal Imaging Part 1

2. Title : Drugs for Gastrointestinal Disorders

3. Title : Bacteria Causing Gastrointestinal Infections

4. Title : Viruses causing gastrointestinal infection

5. Title : Pathology of Upper Gastrointestinal Tract

6. Title : Microbes causing UTI

Basic clinical competences training

2. Title : UTI and Nephrolithiasis in Adult

3. Title : Surgical Indication in Management of Urinary Stone Disease

4. Title : Surgical Management In Renal And Urinary Tract Injury

5. Title : Clinical Aspect of Urinary Tract Stone Disease

6. Title : Analgesics, antibiotics for UTI & neprotoxic agents

7. Title : Renal Failure

8. Title : Glomerulonephritis in Children

9. Title : Laboratory Examination for Renal Disease

10. Title : Glomerulonephritis in Adult

2. Title : Renal function test & urinalysis

Lump after coughing

2. Title : Surgical Indication in the Management of Abdominal Tumor

3. Title : Abdominal Tumor and Hepatosplenomegaly in Children and in Adult

4 Title : Abdominal imaging part 2

5. Title : Strangulation (vascular compromised)

6. Title : Laboratory Examination of Abdominal Malignancy

2. Title : Pathology of gastrointestinal tract