Mini Clinical Evaluation Exercise (CEX)

Penguji : ______________________________________ Tanggal :___________________

Residen : __________________________________________ R-1 R-2 R-3

Permasalahan pasien / Diagnosis : Blighted Ovum

Setting : Rawat jalan Rawat Inap UGD lainnya

Identitas Pasien : Usia :43th Jenis Kelamin :Perempuan Pasien baru Follow Up

Kompleksitas : Ringan Sedang Berat

Fokus : Anamnesis Diagnosis Terapi Konseling

1. Membangun hubungan yang baik antara dokter dengan pasien

1 2 3 I 4 5 6 I 7 8 9
Unsatisfactory Satisfactory Superior

2. Keterampilan penggalian riwayat penyakit pasien (O not observed)

1 2 3 I 4 5 6 I 7 8 9
Unsatisfactory Satisfactory Superior

3. Keterampilan pemeriksaan klinis (O not observed)

1 2 3 I 4 5 6 I 7 8 9
Unsatisfactory Satisfactory Superior

4. Profesionalisme
1 2 3 I 4 5 6 I 7 8 9
Unsatisfactory Satisfactory Superior

5. Diagnosis
1 2 3 I 4 5 6 I 7 8 9
Unsatisfactory Satisfactory Superior

6. Keterampilan Konseling
1 2 3 I 4 5 6 I 7 8 9
Unsatisfactory Satisfactory Superior

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 7. Sistematis
1 2 3 I 4 5 6 I 7 8 9
Unsatisfactory Satisfactory Superior

8. Overall Clinical Competence

1 2 3 I 4 5 6 I 7 8 9
Unsatisfactory Satisfactory Superior

Waktu Mini CEX Observasi _____menit Feedback______menit

Kepuasan penguji dalam mini cex

Low 1 2 3 4 5 6 7 8 9 High

Kepuasan residen dalam mini cex

Low 1 2 3 4 5 6 7 8 9 High

Catatan :

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Tanda Tangan Residen Tanda Tangan Penguji

Medical Record P1 Family Medicine

2
Clinic Note

Encounter Date : 3 november 2016

Subjective :

Chief Complaint :

A female patient aged 43 years, entered hospital emergency department Sekadau on 3

november 2016, with complaints of vaginal bleeding since 5 hours ago before entering the
hospital.Suicide Risk Screening : -
History of Present Illness :

- Patients complain of vaginal bleeding since 2 days ago. since 5 hours before
admission blood coming out excessively filled 3 pads
- No history of passing tissue or clot like material
- Abdominal cramps (+)
- the patient get massage on the stomach since three days ago before admission
- LMP : 23- 08-2016
- No history of fever and leukorrhea
- menstrual history: menarche age of 13 years, a history of irregular menstruation,
duration of 5-7 days, 2-3 times change the bandage, no history of menstrual pain

Active Problem List :

1. Patients using birth control implant
2. There is no previous operating history
3. There is no prior history of psychological disorders
4. There was no history of trauma / accident earlier

Diagnosis : Code ICD : O02.0

 Blighted ovum

Past Surgical History : -

Procedures in hospital Dates

 Abdominal ultrasound 3-11-2016

 Blood test 3-11-2016
 curettage 4-11-2016

Family History :

- No history of heart disease, lung, liver, kidney, diabetes, hypertension, allergies

Problem Relation Age onset

 -
3
  -
 -

Current Outpatien Prescriptions

Medication Sig Dispense Refill

 IVFD RL + Oksitosin in manum medicine

 Cefadroxil 1x/day 1 g (iv)
 Metergin 3x/day 1 tablet

Allergies

Allergen reaction

 -

Previous history

 No history of heart disease, lung, liver, kidney, diabetes, hypertension, allergies

 History taking ulcer medication five days before entering the hospital. Yet patients do
not remember the name of the medicine.

Social history

 Marital status Life partner

Spouse name : Mr Ramli
Number of children : 2
 Years of education : primary school

Occupational history

 Housewife

Social history main topics

 Smoking status : -
Quit dates
 Smokeless tobacco
Types
 Alkohol use : -
 Drug uses : -
 Sexual activity
Partners : spouse (husband)
Birth control/protection : contraceptive implant

Other topics concern

 Blood transfusions : -
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  Stress concern : -

Social history narrative

- The 4th kid of 8 children

- Married (one time ), on 1998
- contraceptive implant
- Pregnancy / Abortion / Childbirth: 3/1/2
1. 1999, female, 3000g , term, normal birth, the midwife
2. 2008, female, 3300g, term, normal birth, the midwife
3. Now, abortion

Screening for particular age : age

 -

Review of systems

Objective

Objective :
1. General state = compos mentis
2. GCS = E4M6V5(15)
3. Vital sign =
- Blood pressure : 120/80mmHg
- HR : 88x/minutes
- RR : 18x/minutes
- Term : 36.50C
4. Anthropometry =
- Height : 155cm
- Weight : 50 kg
- IMT : 20.81
- Nutritional state : normoweight
5. General inspection =
- Skin : found no abnormality
- Lymph gland : no palpable lymphadenopathy
- Muscle : eutonus
- Bone : found no abnormality
- joints : found no abnormality
6. systemic examination =
- Head : Normochepal
- Eye : anemic (-), jaundice (-), isokor, Ø 3mm/3mm, light reflex +/+
normal
- Nouse : found no abnormality
- Ear : found no abnormality
- Mouth and teeth : found no abnormality
5
 - Throat : found no abnormality
- Neck : found no abnormality

Thorax Inspection Palpation Percussion Auscultation

Pulmo Normochest, Fremitus left = right Sonor Vesicular, Rh

retraction (-) -/-, Wh -/-

Cor Ictus cordis not Ictus palpable one Heart border Rhythmical,
visible finger medial LMCS is not widened murmur (-)

Abdominal distention (-) Tenderness (-) Timpani Normal bowel

sounds

- Gyn :
I : vaginal bleeding (+)
Bimanual VT : ostium uteri externum closed, left/ right parametrium found no
abnormality
- Ekstremitas : found no abnormality

Upper right Upper left Lower right Lower left

ROM freely in any direction

Tone Eutonus Eutonus Eutonus Eutonus

Trophy Eutropi Eutropi Eutropi Eutropi

Physiological + + + +
reflex

Pathological - - - -
reflex

Sensibility + + + +

Meningeal sign - - - -

Supporting investigation

6
1. Lab

03 Nov 16

Hb 13.6gr/dl

Ht 45.7%

Leukosit 7690/mm3

Trombosit 304000/mm3

Blood type B+

Bleeding Time 2 minutes

Clothing Time 10minutes

HBsAg Non Reactive

Anti HIV Non Reactive

2. Radiologi =

Ultrasound : GS (+), in accordance with the 10 weeks of pregnancy, fetal pole (-).

Diognosis : Blighted Ovum

3. Lainnya =
-

Assessment : blighted ovum

Plan : Kuretage

Staff physician comments : -

Staff involved : an obstetrician and gynecologist, anesthetist, general practitioners, midwives,

and nurses

Evidence Based Medicine

7
 Form Critical Appraisal
Diagnosis Study

Are the result of this diagnostic study valid?

Was there an independent, blind comparison with a reference (“gold”) standard of

diagnosis?
This paper : yes no unclear
Comment
Patients with vaginal bleeding suspected of blighted ovum can only be at a definitive
diagnosis with ultrasound

Was the diagnostic test evaluated in an appropiate spectrum of patients (like those in whom
it would be used in practice)?
This paper : yes no unclear
Comment
In all patients with vaginal bleeding either on the state with or without complications,
ultrasound is a diagnostic tool that can be used

Was the reference standard applied regardless of the diagnostic test result?
This paper : yes no unclear
Comment
On examination with ultrasound, can be fulfilled the patient's diagnosis and the gold
standard examination

Was the test (or cluster of tests) validated in a second, independent group of patients?
This paper : yes no unclear
Comment
Ultrasound scan on vaginal bleeding may be used in patients with other comorbidities

Kesimpulan

Ultrasound is a diagnostic examination (gold standard) to diagnose a blighted ovum.

Ultrasound scan is a non-invasive examination and not influenced by conditions or
comorbidities in patients.

8
 Evidence Based Medicine
Form Critical Appraisal
Therapy Study
Searching flow :
Source : institute of obstetricians and gynaecologist, royal collage of
physicians of ireland and directorate of quality and clinical care, helath service
executive
Access date : 06-12-2016
Keyword :ultrasound diagnosis of early pregnancy miscarriage
Address :-
Are the results of the trial valid ? (internal validity)
What question did the study ask ?

Patients : woman in aerly pregnancy

Intervention :-

Comparison : None

Outcome(s) : The test show clear result

1a. R-Was the assignment of patients to treatments randomized ?

This paper : Yes (V) No ( ) Unclear ( )

Comment : the assignment of patients to treatments randomized. It is intended that the
research subjects selected objectively, thereby reducing research bias

1b. R- Were the groups similar at the start of the trial ?

This paper : Yes (V) No ( ) Unclear ( )

Comment : the groups similar at the start of the trial. The research sample comes from the
same group were selected based on inclusion and exclusion criteria.

2a. A-Aside from the allocated treatment, were groups treated equally ?

This paper : Yes (V) No ( ) Unclear ( )

Comment : the groups treated equally. In a study to reduce bias, the study group should be
managed in the same way.

2b. A- Were all patients who entered the trial accounted for ? – and were they analysed
in the groups to which they were randomized ?

This paper : Yes (V) No ( ) Unclear ( )

Comment : all patients who entered the trial accounted and they analysed in the groups to

9
which they were randomized.

3. M- Were measures objective or were the patients and clinicians kept “blind” to which
treatment was being received ?

This paper : Yes (V) No ( ) Unclear ( )

Comment : the patients and clinicians kept “blind” to which treatment was being received

4. Kesimpulan : penelitian ini di lakukan dengan cara sampel acak (Randomized) untuk
menghindari bias dalam hasil penelitian. Perlakuan dalam masing-masing pasien percobaan
sama, baik itu untuk pemeriksaan maupun tatalaksana yang memenuhi kriteria inklusi dan
eksklusi.

What were the result ?

1. How large was the treatment effect ?

(tabel 2 x 2 )

Present (case) Absent (control) Total

Intervensi (a) (b)

Placebo (c) (d)

Total

Experimental Event Rate (EER)

Hal ini berarti dalam kelompok yang diberikan intervensi berupa

…………………………………, sebesar ………….. % dari seluruh partisipan mengalami
………………………………
Control Event Rate (CER)

Hal ini berarti dalam kelompok yang diberikan intervensi berupa placebo, sebesar ... % dari

10
seluruh partisipa nmengalami ……………………….

Dari kedua perhitungan di atas, dapat dilihat kalau EER >/< CER, hal ini berarti terapi yang
diberikan ………………… akan …………………………, beberapa perhitungannya nanti
nya akan menjadi Absolute Risk Reduction (ARR), Relative Risk Reduction (RRR), dan
Number Needed to Treat (NNT).

What is the measure ? What does it mean ?

Relative Risk (RR) Dari hasil perhitungan ditemukan bahwa RR

>/< 1, hal ini berarti terapi yang diberikan
………….. akan …………….

Absolute Risk Reduction (ARR) Dari hasil perhitungan, ditemukan bahwa

APR = …. . Hal ini menunjukkan bahwa
terapi yang diberikan ……….. tidak /
memberikan pengaruh terhadap……………
namun hal ini tidak/cukup signifikan,
mengingat nilai ARR yang negative/positif.

Relative Risk Reduction (RRR) Dari hasil perhitungan, ditemukan bahwa

RRR = …. . Hal ini menunjukkan bahwa
terapi yang diberikan ………… tidak /
berpengaruh terhadap …………………..

Number Needed to Treat (NNT) Dari hasil perhitungan, ditemukan bahwa

NTT = …. Hal ini menunjukkan bahwa
tidak/dibutuhkan partisipan yang diterapi
dengan …… .

2. How orecise was the estimate of the treatment effect ?

95% Confident Interval (CI)

1. Kesimpulan
11
Will the results help me in caring for my patient ? (external validity/ applicability)

12
 Evidence Based Medicine
Form Critical Appraisal
Harm Study

Searching flow

Source : institute of obstetricians and gynaecologist, royal collage of physicians of

ireland and directorate of quality and clinical care, helath service executive
Acces date : 6-12-2016

Keyword : ultrasound diagnosis of early pregnancy miscarriage

Address :

Are the result of thi trial valid? IInternal Validity

What question did the study ask? whether ultrasound can be used as a diagnostic tool in the
early trimester of pregnancy

Are the result of this harm study valid? The result of this harm study could be valid IF the
subject of research, the methods and the purpose of the research can be achieved during the
process

Were there clearly defined groups of patients, similar in all important ways other
than exposure to the treatment or other cause?

This paper: Yes √ No □ Unclear □

Comment: there clearly defined groups of patients, similar in all important ways other than
exposure to the treatment or other cause

Who were the cases and control:

Case : patients who have a disease or outcome of interest

Control : patients who do not have the disease or outcome

What is definition of the exposure:

Exposure : risk factor that may be associated with either an increased or a decreased
occurrence of disease or other specified health outcome, and may relate to the environment
or inborn or inherited characteristics

Is the subject’s characteristics similar between cases and control: yes it is.

13
Were treatments/exposure and clinical outcomes measured in the same ways in both
groups (Was the assessment of outcomes either objective or blinded to exposure)?

This paper: Yes √ No □ Unclear □

Comment:

What is definition of the exposure and outcomes:

exposure : risk factor that may be associated with either an increased or a decreased
occurrence of disease or other specified health outcome, and may relate to the environment
or inborn or inherited characteristics

The outcome of a study is a broad term for any defined disease, state of health, health-related
event or death. In some studies, there may be multiple outcomes

How the exposure and outcome were determined:

The exposures and outcomes of interest are specific to study hypotheses and should always
be clearly defined before the study starts. The exposure of interest in one study may be the
outcome in another. For example, smoking is clearly the exposure of interest in a study that
examines whether smokers are more likely to develop lung cancer than non-smokers, but
would be the outcome in a study examining the effectiveness of an anti-smoking intervention
programme in reducing the frequency of smoking in a certain population

What the follow-up the study patients sufficiently long and complete?

This paper: Yes √ No □ Unclear □

Comment: the follow up had been done every time in which we needed appropiate and
thrustworthy research result.

Do the results some “diagnostic tests for causation”?

This paper: Yes √ No □ Unclear □

Comment:

It is clear that the exposure preceded the onset of the outcome: yes, the exposure preced the
onset because it can affect on how longthe patient need to be treated

Is there dose-response gradient: No, there’re no dose independent gradient because in this
case the subject using antibiotics with proper usen in dose and amount of consume.

Is there positive evidence from a “dechallenge-rechallenge” study: no, there’re no evidence

because there’re no shown different symptom in dechallenge and rechallenge study.

14
Is the association constant from study to study: yes, the association with previous studies is
constantly show the same result.

Does the association make biological sense: yes, the association make biological sense
especially in the farmakokinetic of the drugs imbued in patient.

Are the valid results from this harm study important?

What is the magnitude of the association between the exposure and outcome?

Has high magnitude especially the effect of the outcome to the patient.

Adverse outcome Totals

Present (Case) Absent

(control)

Exposed to the (a) (b) (a+b)

Treatment (c) (d) (c+d)

Totals (a+c) (b=d) (a+b+c+d)

Realtive Risk (RR) What doest it mean?

Dalam studi ini didapatkan RR > 1 maka

exposuee yang diberikan (rosiglitazone) akan
meningkatkan resiko kematian ataupun
dibawa ke rumah sakit Karen gagal jantung
atau infark miokrad. Kemungkinan partisipan
yang mendapatkan exposure (rosiglitazone)
akan mendapatkan resiko 0.25 kali lebih
tinggi daripada yang tidak diberi exposure
(tetapi diberi pioglitazole)

Odds Ratio (OR) What does it mean?

15
OR=
Atau memakai calculator pada web:
http://www.hutchon.net/ConfidOR.htm
Number Needed to Harm (NNH)
NNH untuk RCT dan Cohort =
NNH =
Jika Case-control study, rumus NNH
adalah sebagai berikut:
OR < 1 maka NNH =
OR > 1 maka NNH =
Selain rumus di atas, kita bias
mendapatkan NNH dengan menghitung
CER ataupun PEER (patients expected
event rate) terlebih dahulu
PEER = =
Setelah mendapatkan angka PEER,
Odds Ratio merupakan data yang dilaporkan
dalam studiretrospective yang menunjukkan
resiko dari suatu intervensi saat hasil yang
terlihat pada kelompok case daripada
kelompok control.
Apabila OR < 1 maka exposure yang
diberikan memberi efek protectif.
Apabila OR = 1 maka exposure yang
diberikan tidak memberikan perbedaan.
Apabila OR > 1 maka exposure yang
diberikan tidak memberikan efek yang
membahayakan (harm)
What does it mean?
Number Needed to harm merupakan
besarnya partisipan yang diperlukan untuk
memberikan suatu efek bahaya akibat
exposure yang diberikan. Semakin tinggi
NNH semakin tidak berbahaya exposure
tersebut. Dan sebaliknya, semakin sedikit
NNH semakin berbahaya exposure yang
diberikan tersebut.
16
gunakan calculator dari:

http://ktclearinghouse.ca/cebm/practise/ca/
calculato/otonnt

What is the precision of the estimate of the assossiation between exposure and
outcome?

17
 Form Kajian Rumah Sakit
Nama Pasien dan Masalah Kesehatan
Nama Dokter dan Dokter Spesialis Yang Merawat

I. Self assessment
a) Ceritakan masalah pasien SEBELUM tiba dirumah sakit dan alasan rujukan

Format bebas, ditulis rangkuman mengenai dara diri pasien, rangkuman hasil
peggalian riwayat penyakit, riwayat keluarga, rangkuman hasil pemeriksaan dan
laboratorium dan penekanan pada masalah yang memerlukan rujukan ke rumah sakit
(atau sebenarnya tidak memerlukan rujukan). Bagaimana pendapat anda sebagai DLP
dalam rujukan ini.
Bahan kajian : diagnostic holistic dan komprehensif (person centered care, spesific
problem solving, bio psychosocial – cultural background)
Seorang pasien perempuan 43 tahun masuk IGD RSUD Sekadau pada tanggal 3
November 2016 dengan keluhan keluar darah yang banyak dari kemaluan sejak 5 jam
sebelum masuk rumah sakit. Keluhan keluar darah dari kemaluan pertama dirasakan
sejak 2 hari yang lalu, semakin lama semakin banyak memenuhi 3 pembalut sejak 5
jam yang lalu. Riwayat keluar jaringan seperti daging tidak ada. Keluhan disertai
nyeri perut menjalar ke ari-ari. Hasil pemeriksaan fisik didapatkan perdarahan aktif
pervaginam. Hasil pemeriksaan laboratorium dalam nbatas normal. Dan pada
pemeriksaan USG ditemukan adanya blighted ovum.
Kasus blighted ovum merupakan kasus rujukan karena dibutuhkan pemeriksaan USG
untuk diagnosis pasti dan tatalaksana kuretase oleh dokter ahli kandungan

b) Ceritakan masalah pasien pada saat dirawat dirumah sakit

Format bebas, ditulis rangkuman mengenai hasil pemeriksaan dan laboratorium

selama dirumah sakit dan penekanan pada masalah (medis maupun psikososial) yang
pasien temui selama perawatan dirumah sakit (bisa rawat inap maupun rawat jalan di
RS). Bagaimana pendapat anda sebagai DLP dalam perawatan RS ini.
Bahan kajian :
a. Pelayanan berpusat pada pasien dan mengutamakan keselamatan pasien
(patient centered care, patient safety)
b. Kerjasama tim dalam pengelolaan pasien untuk memberikan pelayanan yang
berkualitas (interproffesional collaboration to serve the highest quality of care)
Pasien dirujuk ke rumah sakit untuk dilakukan pemeriksaan lanjutan berupa
pemeriksaan laboratorium dengan seluruh hasil dalam batas normal, dan pemeriksaan
USG sebagai diagnosis pasti. Pada pemeriksaan USG ditemukan adanya blighted
ovum. Untuk itu segera dilakukan tindakan kuretase sebagai tatalaksana definitif
untuk menghentikan perdarahan. Dalam tatalaksana ini dokter ahli kandungan
bekerjasama dengan dokter anastesi dalam melakukan tindakan anastesi dan bidan
dalam perawatan lanjutan pasien dirumah sakit

c) Ceritakan rencana pengelolaan pasien setelah pulang dari rumah sakit dan kembali di
komunitasnya, dimana anada adalah dokter keluarga/dokter layanan primernya di
FTKP tempat ia dan keluarganya terdaftar
18
 Format bebas, ditulis rangkuman mengenai rencana tindak lanjut ketika pasien
dipulangkan. Penekanan pada persiapan kepulangan pasien, penerimaan keluarga
dirumah, rencana medis dan psikososial apa yang diperlukan ketika pasien pulang.
Bagaimana rencana kontrol ulang di rumah sakit, apa yang harus anda diskusikan
dengan dokter spesialis yang merawat di RS maupun kepada perawat atau bidan atau
tenaga kesehatan lain yang akan merawatnya saat kembali ke FTKP. Bagaimana
rencana anda sebagai DLP dalam hal kepulangan RS ini.

Bahan kajian :
a) Kerjasama tim dalam pengelolaan pasien untuk memberikan pelayanan yang
berkualitas (interproffesional collaboration to serve the highest quality of care)
b) Koordinasi dengan nakes di sekunder/tersier maupun di primer
(comprehensive care)

Setelah pasien menyelesaikan perawatan di rumah sakit maka pasien dianjurkan

kontrol ke RS atau FTKP kontrol perawatan selama 1 minggu setelah tindakan. Dalam
hal ini dokter layanan primer perlu mendiskusikan penyakit pasien dengan ahli
kandungan yang menangani di RS dan tindakan kontrol seperti apa yang selanjutnya
dilakukan.

II. Rencana pengelolaan lanjutan atas masalah kesehatan pasien di atas

Setelah pasien pulang dari RS dan bermaksud kontrol kepada anda di FKTP, apa
rencana pengelolaan pasien jangka pendek (3 bulan pertama) dan jangka panjang (lebih
atau sama dengan 1 tahun) yang akan anda komunikasikan kepada pasien. Perlukah
anda lakukan home visit, apa alasannya

Bahan kajian : pelayanan berkelanjutan (continuity of care)

Setelah pasien pulang pasien dianjurkan kontrol pasca tindakan selama 1 minggu
pertama. Kemudian untuk penanganan selanjutnya pasien diberikan penjelasan terkait
kondisi pasien dan penyebab yang mungkin untuk terjadinya blighted ovum. Untuk itu
juga pasien diberikan penyuluhan terkait kesehatan kandungan, pilihan KB, cara
pemakaian KB, dan kemungkinan yang dapat terjadi jika pasien ingin hamil kembali.

Referensi yang saya baca dan telah saya lakukan telaah kritis (terlampir) :

1. Cunningham, F, G., Gant, N. F., Leveno, K. J., et al., 2006. Obstetri William, edisi 23.
New York: The McGraw-Hills Companies, Inc

19
2. Morin, L., Montreal., Hof, VD., Ultrasound Evaluation of First Trimester Pregnancy
Complications. SOGC Clinnical Practice Guidline; 2005; 161: 581-85
3. Knez, J., Ultrasound Imaging in The Management of Bleeding and Pain In Early
Pregnancy. Elsevier: Best Practice and Research Clinical and Gynaecology; 2014; 1-
16

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