BUKU PANDUAN MAHASISWA

CLINICAL SKILLS LAB MANUAL

GASTROENTEROHEPATOLOGY SYSTEMFACULTY OF MEDICINE HASANUDDIN UNIVERSITY MAKASSAR2013PREFACEClinical Skills Lab Manual of Gastroenterohepatology System provides explanation and procedur of four main skills that will be trained to the students:

1. Anamnesis (history taking) of chief complaint related to the Gastroenterohepatology System.2. Physical examination and diagnosing skill. After learning these skills, the students are expected to be able to conduct complete anamnesis and physical examination due to the system of gastroenterohepatology sequentially and can distinguish the normal and abnormal condition in this system.

3. Nasogastric tube assembling technique and Rectal Touch which will be performed in audio visual form.4. Skill in reading X-ray photo due to the abnormalities in gastroenterohepatology system.

The manual book in addition to provide the guide in conducting anamnesis systematically, physical examination and other skills, also provides check list for assessing the student and the improvement of students skill. We really gratefull to all contributors who have helped in compiling this manual book. Makassar, August 2012Gastroenterohepatology SystemANAMNESIS AND PHYSICAL EXAMINATION

GASTROENTEROHEPATOLOGY SYSTEMDefinition

Anamnesis (history taking) is a very important initial step before moving on to physical examination procedures. The clues obtained during the anamnesis will aid the health care provider on performing the physical examination and listing the most likely diagnosis. Anamnesis procedure must be done systematically giving a fact that medical histories could sometimes be more useful than physical examination in forming a diagnosis. Many complaints related to gastroenterohepatology system are remanded by the patients when they come to physician. Eventhough many complaints are remanded by the patients, but sometimes the complaints due to abdominal disorder are not related to the digestive tract disorder, so that making the doctor must be patient in conducting anamnesis.

Generally physical examination in gastroenterohepatology are similar to the general physical examination include inspection, palpation, percussion, and auscultation whereas some of the doctor prefer to conduct auscultation firstly before palpation. During physical examination normal and abnormal result like abdominal distention, mass abnormality, the increase or loss of peristaltic sound can be found.

In the other side, diagnostic skill in rectal examination (rectal touche) and nasogastric tube assembling technique are usefull in performing diagnose to the patient with digestive tract disorder. IndicationAnamnesis dan physical examination in gastroenterohepatologi are usefull for :1. Determining diagnose 2. Helping the doctor in conducting the next plan of action for the patient3. Determining the improvement of therapy in patient4. Using as treatment procedure standard for the patient Learning ObjectiveGeneral ObjectiveAfter conducting the skills in this manual, students are expected to be able to conduct anamnesis and physical examination systematically and can distinguish the normal and abnormal condition in Gastroenterohepatology system. Spesific ObjectiveAfter conducting the skills in this manual, students are expected to be able to :

1. Conduct complete anamnesis / history taking

2. Prepare the patient prior to the physical examination3. Perform a systematic Physical Examination include Inspection, Palpation, Percussion and Auscultation

4. Conduct examination based on appropriate procedure 5. Identify and determine the type of sound in the abdomen Instrumen and Tools : Manual book of anamnesis and physical examination

Stethoscope, handscoen (gloves), nasogastric tube Jelly, towel, soap dan wash basin (running water) for hand washing simulation Patient status, ballpoint Audio-visual

Learning Method :1. Demonstration due to manual book 2. Lecture

3. Discusssion4. Active participation (simulation)

5. Evaluation using check list ACTIVITIES DESCRIPTION ActivitiesTime allocatedDescription

1. Introduction5 minutesIntroduction

2. Role play demonstration30 minutes1. Arranging studentss seat2. Instructor demonstrates an example on how to perform a systematic anamnesis. Students are asked to observe

3. Allowing students to ask any questions they have regarding the demonstration. Instructor emphazises all important points.

4. Conducting physical examination on maenequin or probandus 5. Students are given opportunity to observe and ask anything that needs to be clarified. Instructor will provide them with answers

3. Practicing the role play100 minutes1. Students are divided into pairs

2. Each couple will perform the role play, one person will act as a physician and the other will play the patient3. Students are given a specific topic or chief complaint that will be explored by the assesor.

4. . Instructor will supervise all the student activities using check list

5. Each student is expected to practice at least once during the day sessions.

4. Brain Storming / Discussion15 minutes1. Brain storming/discussion: students are given the opportunity to raise any issues that they might have including any difficulties during the sessions. Students are also allowed to mention any good things that they have experienced in the class. Students are also asked their impression of being a patient. What could be done by the doctor to make the patient feeling more comfortable.

2. Instructor concludes the session by providing answers and feedback to any points that need clarification.

Total time allocated150 minutes

LEARNING GUIDEGASTROENTEROHEPATOLOGY SYSTEM

NO.CLINICAL STEPSCASE

A. ANAMNESIS CHIEF COMPLAINT 123

1.Welcome the patient, standing up and shaking patients hands. Introduce yourself in a warm, friendly manner

2.Allowing the patient to has a comfortable sit in front of the doctor

3.Give a positive response to build up a good relationship with your patient, ensure comfort and privacy

4.Asking patient identity: name, age, address, and occupation

5.Asking patients chief complaint (intestinal disorder with vomiting and diarrhea) and obtaining a comprehensive history of present illness from the patient

Asking :

Onset and duration of intestinal disorder with vomiting and diarrhea

The shape, color and amount of intestinal disorder with vomiting and diarrhea : clots, spotted, blood red, wine-coloured or coffee-like coloured

The other symptom due to: epigastric pain, or epigastric discomfort, abdominal pain, distention sensation in the abdomen, nose bleeding (ephistaxis), melena

6.Obtain past medical history focusing on any illnesses that are likely to be in conjunction with the present complaints like cirrhosis, cancer, coagulopathy, history of ulcer peptic operation

History of habits : alcoholism, NSAID or medicinal herbs consumption, corrosive drinking

Family history: History of illness prior to bleeding

7.Obtain history of past illness that related to the health condition

B. PHYSICAL EXAMINATION 123

1. Inspection

1.Asking the patient to lay down in supine position with light source in the backside of physician whether the light can illuminates feet to head, or whole abdomen

2.The physician has to be at right side of the patient, and the physicians head is higher than patients abdomen

3.Examine hair, conjunctiva, sclera and skin

4.Inspect or observe the abdomen contour, scars, venous congestion, peristaltic movement or mass in several minutes

5.Observe abdominal distention: obesity, ascites, pregnancy, mass, or neoplasm/ malignancy sign.

Auscultation

1.Ask the patient to relax and breathe

2.Put the diaphragma of the stethoscope on the mid abdomen and focus on listening to sounds in the abdomen

3.Listen to the intestine noisy

4.Determine the intestine noisy: normal or abnormal (normal frequency: 5-12x/minutes

5.Place the stethoscope on the four quadrants of abdomen

6.Conducting auscultation :

Peristaltic sound can be heard underneath the umbilical, above the suprapubic, or other part of the abdomen

To hear thundering/tumultuous sound from hepatic rub in the upper and right side of umbilical

To hear abdominal aortic murmur approximately 5 cm below the xhypoideal processus or in epigastric area

Auscultate Bruit sound of pancreatic carcinoma in the left side of epigastric and also sphlenic friction rub in the lateral abdomen

7.If peristaltic sound can not be heard in 1 minute, keep auscultating for 5 more minutes

8.Note down the auscultation result

Palpation

1.The physicians hand must be warm or suitable with the room/ body temperature

2.Ask the patient to flex their knee and breathe normally by open mouth

3.Communicate with the patient during palpation

4.Apply a gentle palpation:

Placing the palmar surface with adduction position of fingers on the abdomen and palpate gently the abdominal wall into 1 cm depth The abdomen wall must be avoided from nail fingers of the physician

5.

Conducting the deeper palpation: Put the fingers tip into abdomen wall when conducting deeper palpation in about 4-5 cm pressure and try to find the structure under the abdomen

6.Pay attention to the patients expression during palpation

7.Palpate the abdomen in the left quadrant :

Goal: Finding palpable spleen (by Schuffner or Hackett method) and left kidney

Normal : No palpable mass

Perform bimanual palpation. The right hand is put into behind the left rib border on midaxillae line, and left hand is placed below the chest so that fingers bent over under the ribs

Ask the patient to take a deep breath, and when patient inhale deeply, put the right hand deeply into the back of ribs border and raised it, and the left hand raised the back chest

Conduct this skill frequently conform to inspiration rhytm and placing right hand in a various position

8.Palpate the abdomen in the right quadrant :

Goal : Finding palpable liver, right kidney

Put right hand with adduction fingers into below border of rib which volar surface contacted to the surface of abdomen. Sensation tactile will be felt by tip fingers

Left hand supination is placed under the right chest

While inhale deeply, the right hand moving up and put it into at the end of inspiration and in concormity with inspiration, left hand elevating the chest

9.The patients head should be elevated using pillow if pain manifest directly when abdomen palpation performed

10. Blumberg sign--(rebound tenderness): compress the abdominal wall gently and slowly by using the finger tip and then rapidly released. It is called Rovsing's sign--pain in right lower quadrant with palpation of left lower quadrant Psoas sign--pain on extension of right thigh (retroperitoneal retrocecal appendix) Dunphy's sign--increased pain with coughing

11.If the masses are found in abdomen; assess the location, size, consistency, rubberiness, mobility and pulsation

palpation methods spleen palpation

Percussion

1.Percuss the four abdominal quadrant

2.Percuss the liver upper border in the right midclavicule line, start from the second right ICS (intercostal spase) II, percussion is done from upward into downward

3.Resonance sound in the chest become dullness when the examiner percuss the liver and then dullness sound will be changed to thympanic sound when percussion is done on the large intestine

4.Determine the location and the size of liver

C. ASCITES EXAMINATION123

1.Puddle sign :

Ask the patient to lie prone for 5 minutes and then, to rise upon elbows and knees as shown in the figure below.

The middle portion of the abdomen will become dependent and pendulous. Apply stethoscope to this dependent portion of the abdomen and flick the near flank region with finger. Move stethoscope away from yourself (the examiner). Sound loudness increases at the farther edge of puddle. This augmentation of sound intensity is indicative ofAscites. This test is able to detect as little as 140 mL of fluid. Clinical manifestations ofAscitesusually become evident after 500 mL of fluid accumulation. Puddle sign has a sensitivity of 50 % and specificity of 70%.

2. Shifting dullness

Percuss abdomen from the medial side to the lateral side, determine the edge of thympanic and dullness sound Ask the patient to lay down in lateral position Ascites sign will be positive if thympanic sound is changed to dullness in the same location in the abdomen. Shifting dullness has a sensitivity of 90% and specificity of 60%.

Supine position Lateral position

3.Fluid Wave (undulation test) :

Have the patient lying supine. The patient or an assistant places one or both hands (ulnar surface of hand downward) in a wedge-like position into the patient's mid abdomen, applying with slight pressure. The examiner places the fingertips of one hand along one flank, and with the other hand firmly gives a sharp tap along the opposite flank. Positive test: The examiner is able to detect "a shock wave" of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.

NASOGASTRIC TUBE ASSEMBLING TECHNIQUE (NGT)

Introduction

Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric tube, NGT) through the nose, past the throat, and down into the stomach for many purposes. It is important for medical student to know how to assembling NGT and know the NGT inserted into the right place.

Indication1. Gastric Decompression

Allow drainage contents of the stomach in case of small bowel obstruction, peritonitis and pancreatitis.

Relief of symptoms and bowel rest in the setting of small-bowel obstruction Allow gastric lavage in case of Upper Gastrointestinal Bleeding.

2. Administer of fluids, medicine and Nutrition Patient who can not swallow because of many factors. Aspiration of gastric content from recent ingestion of toxic material Bowel irrigation Administration of medication Feeding3. Diagnostic Purposes

Identification of the esophagus and stomach on a chest radiograph.

Helping diagnosis by Analyze of gastric contentContra indication NG tube placement should not be considered in the following patients: 1. Maxillo facial disorders and Basal Skull Fracture2. Oesophageal tumours3. Oesophageal varices and stricturesComplication

Complication may occur from NG tube placement

1. Nasal Irritation, Sinusitis, Epistaksis, Rhinorrhea, Fistula esofagotracheal2. Aspiration pneumonia3. Hypoxia, Cyanosis or respiratory arrest caused by tracheal intubationLearning ObjectiveGeneral Objective After conducting the skills in this manual, students are expected to be able to conduct the procedure for insertion of Nasogastric tube. Spesific Objective After conducting the skills in this manual, students are expected to be able to :

1. Know indication and contraindication of insertion nasogastric tube.2. Prepare instrumen and tools prior insertion of nasogastric tube.3. Conduct insertion of nasogastric tube based on appropriate procedure.Instrumen and Tools :1. Manual book of NGT assembling technique.

2. Stethoscope, handscoen (gloves), nasogastric tube3. Jelly, towel, soap dan wash basin (running water) for hand washing simulation4. Audio-visual

Learning Methods :1. Demonstration due to manual book 2. Lecture 3. Discusssion4. Active participation (simulation)5. Evaluation using check list

Instrumen and Tools

1. Nasogastric tube Adult : NGT size 16-18F

Pediatric - in pediatric patients, the correct tube size varies with the patient's age. To find the correct size, add 16 to the patient's age in years and then divide by 2 (eg, [8 y + 16]/2 = 12F)

2. Cylocain jelly or K-Y jelly

3. Stethoscope

4. Disposable syringe 10 cc5. Handscoen ( Gloves)6. Non-allergenic tape 7. Curved Basin

8. Suction

ACTIVITIES DESCRIPTION

ActivitiesTime allocatedDescription

1. Introduction5 minutesIntroduction

2. Demonstration by instructor30 minutes1. Arranging studentss seat2. Instructor demonstrates an example on how to perform insertion of NGT and DRE.3. Students are asked to observe.4. Allowing students to ask any questions they have regarding the demonstration. Instructor emphazises all important points.

5. Students are given opportunity to observe and ask anything that needs to be clarified. Instructor will provide them with answers

3. Practicing the Technique100 minutes1. Students are performing insertion of NGT and Digital Rectal Examination.2. Instructor will supervise all the student activities using check list

3. Each student is expected to practice at least once during the day sessions.

4. Brain Storming / Discussion15 minutes1. Brain storming/discussion: students are given the opportunity to raise any issues that they might have including any difficulties during the sessions. 2. Instructor concludes the session by providing answers and feedback to any points that need clarification.

Total time allocated150 minutes

Procedures1. Give Informed Consent to the patientsa. Explain indication of NGT insertion for the patient.b. Explain NGT insertion procedure.c. Ensure patient is in agreement with the procedure and that verbal/informed consent is gained2. Preparing instrument and tools for NGT insertion

Picture 1. Instruments and tools for NGT insertion

3. Wash hands with soap and water, put on gloves.4. Assist adult patient to sit in supported, confortable upright position (55-600 angle) in the bed ( High fowler position). 5. If the patient is unconscious, lie down in supine position or left lateral decubitus or right lateral decubitus, with the head bent to the front .6. Measuring the length of tube required by measuring from the nose to the ear lobe then from ear to xyphodeal processus and mark this length.

Picture 2. Measuring the length of NGT required

7. Lubricate the tip of tube with K-Y jelly

8. Inserting the tube passing the nose, throat, esofagus until reaching the stomach. (advance the tube until reach the point where the tube was measured and marked)9. Confirm the placement of NGT with whoosh test method; a. Placed membran stetoscope on the left epigastric.

b. Aspirate air to the 10 cc syringe

c. Placed 10cc syringe to the NGT.d. The air is injected passing through the tube by vacuum mechanism, it will cause pathognomonic sound (whoosh) that can be heard from stethoscope.e. If the pathognomonic sound was heard, mean the NGT was inserted in the right place. If did not heard the pathognomonic sound pull/inserted NGT and reply the whoosh test till heard the sound.

Picture 3. Whoosh test 10. Secure the NGT to the nostril with appropriate tape.11. Remove hand gloves and throw in medical waste disposal12. Wash hand

Picture 4. NGT FixationReference : 1. Insertion and Confirmation of position of Nasogastric tubes for adults and children. Northern Health and Social Care Trust. June 2010

2. Policy for the insertion of a Naso-gastric tube in Adults. Birmingham East and North NHS. October 2009.

3. Nasogastric Feeding Tube Placement and Management Resource Manual. Salford Royal NHS Foundation. August 2011.

4. Schwartz Manual of Surgery 8th Edition. The MacGraw-Hill companies, New York, 2006

DIGITAL RECTAL EXAMINATION (RECTAL TOUCHER)IntroductionDigital rectal examination (DRE) is examination procedure done by inserting of index finger to the anus and rectum. DRE is a necessary part of a complete physical examination and evaluation. of a patient. This procedure assist physician find abnormality in the perineum, anal, rectum, prostate, bladder and for the evaluation of a variety of diseases and conditions, especially those of gastrointestinal, infectious, and oncologic origin.Before undertaking DRE, abnormalities of the perineal and perianal area should be observed, looking for:

Rectal prolapse (degree, ulceration).

Haemorrhoids (their number, position, grade, prolapsed).

Anal skin tags number, position, condition.

Wounds, dressings, discharge.

Anal lesions (malignancy).

Gaping anus.

Skin conditions, broken areas, pressure sores of all grades.

Bleeding and the colour of the blood.

Faecal matter/ stool consistency.

Foreign bodies. Assess anal sphincter tone and sensation, then evaluate ampulla, mucosa, palpate the rectal wall looking for mass and prostate enlargement.

This procedure may make the patient feel discomfort, obtain informed consent, privacy of the service user must be a priority and considered before performing these procedures.Indication Assessing the rectum and anus is an essential part of a comprehensive physical examination. DRE are indicated for : 1. Lower Gastrointestinal Bleeding

2. Hemorrhoid, rectal prolaps.

3. Ca Recti, anal tumor

4. Ileus Obstruktif and ileus paralitik.

5. Peritonitis.

6. BPH & Ca prostat.

7. etcContraindication There is no absolute contraindication to perform digital rectal examination. Special precautions for Children, patient with prostatitis, Internal Hemorrhoid grade IV .Learning Objective

General Objective

After conducting the skills in this manual, students are expected to be able to conduct Digital Rectal Examination Procedure.

Spesific Objective

After conducting the skills in this manual, students are expected to be able to :

1. Know indication and contraindication of digital rectal examination.2. Prepare instrumen and tools prior digital rectal examination.3. Conduct digital rectal examination based on appropriate procedure.Instrumen and Tools :1. Manual book of digital rectal examination.

2. Handscoen (gloves)3. Towel, soap dan wash basin (running water) for hand washing simulation4. K-Y Jelly5. Audio-visual

Learning Methods :1. Demonstration due to manual book 2. Lecture 3. Discusssion4. Active participation (simulation)5. Evaluation using check list

PROCEDURES1. Give Informed Consent to the patientsa. Explain indication digital rectal examination for the patient.b. Explain digital rectal examination procedure.c. Ensure patient is in agreement with the procedure and that verbal/informed consent is gained2. Preparing instrument and tools for digital rectal examination3. Ensure privacy and dignity and reassure service user at each stage.4. Washing hand and put on gloves.

5. The Examiners position : Stand up in the right side of patient

6. Patients position: Lithotomi (Supine, bent 600 on knee and relaxation)7. The examination is started from anal inspection under shiny illumination (if found hemorrhoid grade IV, do not perform DRE).8. Abnormalities such as thrombosed external hemorrhoids, skin tags, rectal prolapse, an obvious fissure, anal warts, or evidence of pruritus ani usually from fecal soiling should be easily appreciated. 9. The patient is asked to strain abdominal muscles just like when defecating for examining the perineal descencus, haemoroid prolaps or other prominent lesions (rectal prolaps and tumor). 10. Observe anal tone when relaxation and volunter contraction.

11. Lubricate the gloved index finger; inform the service user that you are about to perform the procedure, then contacted slowly to the edge of the anal. 12. Press edge of the anal gently until sphincter is opened and the finger can be inserted into the anal directly, asses anal sphincter tone: resistance should be felt.13. Evaluate the rectal ampula, whether normal, collaps or dilatation.14. Palpate the rectal wall, asses wether mucous is smooth or not, evaluate for any mass or prostate.15. Pay attention to the prostate and cervices and also several lesions outside the rectum 16. Evaluate wether any pain when palpating the rectal wall.

17. Remove index finger from the anal.

18. Inspect gloves : any faeces, blood or slime?

19. Remove gloves and Dispose to the medical waste bin.

20. Wash hands21. Record DRE Results, Example Results of DREDRE : Perianal and perineum was not inflamed, no tumor massa, Sfingter ani was tight, smooth mucosa, ampulla was empty, no palpable tumor mass, prostat was unpalpable.

Gloves: No faeses, no blood, no slime.

Reference : 1. Nicholas J. Talley. How to Do and Interpret a Rectal Examination in Gastroenterologi. Am J Gastroenterology 2008;103:820822.

2. Roslyn Davies. Clinical Guidelines for Digital Rectal Examination, Manual Removal of Faeces and Insertion of Suppositories /Enemas for Adult Care only. NHS South Gloucestershire July 2010.

3. Cathy Popadiuk, Madge Pottle, Vernon Curran. Teaching Digital Rectal Examinations to Medical Students: An Evaluation Study of Teaching Methods. Academic medicine, vol. 77, no. 11 / november 2002.

RADIOLOGIC PHOTO ASSESSMENT TECHNIQUE

THE RADIOLOGIC PHOTO ASSESSMENT TECHNIQUE FOR GASTROENTEROHEPATOLOGY1. BNO PHOTO1. Check the patients identity (name/age)2. Check the marker in the assessed photo 3. Put the photo in the light box directly in front of the examiner

4. Assessing the air distribution in the abdomen (existing of obstruction, distribution the air into the distal)

5. Identify herring bone appearance, step ladder appearance, air fluid level appearance, and distension sign in intestines (free air fluid level in subdiaphragm) 6. Pay attention to the left right psoas line and left- right pre peritonid 7. Make a conclusion from the radiologic appearance

2. MD PHOTO (Barium meal)1. Check the patients identity (name/age)2. Check the marker in the assessed photo

3. Put the photo in the light box directly in front of the examiner

4. Assessing patient position according to the contrast position (supine, prone, and erect)

5. Pay attention to the gastric mucous and duodenum (is there any filling defect or additional shadow) 6. Make a conclusion from the radiologic appearance

3. COLON IN LOOP PHOTO (Barium enema)1. Check the patients identity (name/age)2. Check the marker in the assessed photo

3. Put the photo in the light box directly in front of the examiner

4. Assess firstly the patients BNO photo 5. Pay attention to the contrast position.

6. Pay attention to the colon mucous, colon haustra, colon incisura, and the colon space size (is there any filling defect or additional shadow) 7. Make a conclusion from the radiologic appearance

Mark every clinical step using the following scoring categories:

Need to be improved: Steps that are not correctly performed, un-organized chronologically, or for some missed/left over steps

Able: Steps that are performed correctly, chronologically based, but not efficiently conducted

Master: Steps that are performed correctly, chronologically based, and efficiently conducted

Massa feces

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