MODULE OF SKILL LABORATORY PRACTICE

I. BASIC PRINCIPLES AND THEORIES

Acute abdomen is a terminology that indicates an emergency in the abdomen that could threaten life if
not treated with surgery. Emergencies in the abdomen can be caused due to bleeding, inflammation,
perforation or obstruction of the digestive tract. Inflammation can be primary due to inflammation of
the digestive apparatus as in appendicitis or secondary through a peritoneal digestion due to gastric
perforation, perforation of the Payer's patch in abdominal typhus or perforation due to trauma.
In acute abdomen, whatever the cause, the main symptom that stands out is acute pain in the
abdominal area. Sometimes the main cause is clear as in abdominal trauma in the form of vulnus
abdominis penetrans, but sometimes an acute abdomen diagnosis can only be established after
physical examination and additional examination in the form of laboratory and complete radiological
examination and strict observation period.

Generally, abdominal pain is divided into visceral and parietal components. Visceral pain is transmitted
by C nerve fibers that commonly found in muscle, periosteum, mesentery, peritoneum and viscera.
Most of nociception from abdominal visceral is conveyed by this type of fiber and tends to be
interpreted as dull, cramping, burning sensation, poorly localized. It is also more likely to have greater
variation and duration compared to the somatic pain. Visceral pain is usually perceived to be in the
epigastrium, periumbilical or hypogastrium. It occurs since the visceral organs in the abdomen transmit
sensory afferent stimuli to both side of the spinal cord. Moreover, visceral pain is poorly localized due
to lower number of nerve endings in visceral organ than other organs such as the skin and since the
innervations of viscera is multisegmental.
Parietal pain is conveyed by A-δ fibers, which are abundantly found in the skin and muscle. The
stimuli of this nerve pathway are perceived as the sharp, sudden and well-localized pain mimicking
the pain that follows acute injury. The pain is often aggravated by movement or vibration. Parietal
pain due to inflammation of parietal peritoneum is usually more intense and localized than visceral.
For example, in acute appendicitis, the early pain is periumbilical visceral pain, which is followed by
the localized somatoparietal pain at McBurney’s point produced by inflammatory process of the
parietal peritoneum.
The term of referred pain is defined as the pain felt far from the involved organs. It occurs when there
is a convergence of visceral afferent neurons with parietal afferent neurons from different anatomic
regions on second-order neurons in the spinal cord at the same spinal segment

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.

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When evaluating a patient with acute abdominal pain, the physician should focus on common
conditions that cause abdominal pain as well as on more serious conditions. The location of pain
should drive the evaluation (Table 1). For some diagnoses, such as appendicitis, the location of pain
has a very strong predictive value. A final diagnosis is not usually made at the first outpatient visit;
therefore, it is critical to begin the evaluation by ruling out serious disease (e.g., vascular diseases
such as aortic dissection and mesenteric ischemia) and surgical conditions (e.g., appendicitis,
cholecystitis). Physicians should also consider conditions of the abdominal wall, such as muscle strain
or herpes zoster, because these are often misdiagnosed.

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The initial differential diagnosis can be determined by a delineation of the pain’s location, radiation,
and movement (e.g., appendicitis-associated pain usually moves from the periumbilical area to the
right lower quadrant of the abdomen). After the location is identified, the physician should obtain
general information about onset, duration, severity, and quality of pain and about exacerbating and
remitting factors.

Associated symptoms often allow the physician to further focus the differential diagnosis. For bowel
obstruction, constipation is the symptom with the highest positive predictive value. For appendicitis,
right lower quadrant pain has the highest positive predictive value, although migration from
periumbilical to right lower quadrant pain and fever also suggest appendicitis. Some conditions that
were historically considered useful in diagnosing abdominal pain (e.g., anorexia in patients with
appendicitis) have been found to have little predictive value. Colic (i.e., sharp, localized abdominal
pain that increases, peaks, and subsides) is associated with numerous diseases of hollow viscera. The
mechanism of pain is thought to be smooth muscle contraction proximal to a partial or complete
obstruction (e.g., gallstone, kidney stone, small bowel obstruction). Although colic is associated with
several diseases, the location of colic may help diagnose the cause. The absence of colic is useful for
ruling out diseases such as acute cholecystitis; less than 25 percent of patients with acute cholecystitis
present without right upper quadrant pain or colic. Peptic ulcer disease is often associated with
Helicobacter pylori infection (75 to 95 percent of duodenal ulcers and 65 to 95 percent of gastric
ulcers), although most patients do not know their H. pylori status. In addition, many patients with
ulcer disease and serology findings negative for H. pylori report recent use of nonsteroidal anti-
inflammatory drugs. Other symptoms of peptic ulcer disease include concurrent, episodic gnawing or
burning pain; pain relieved by food; and night time awakening with pain.

Symptoms in patients with abdominal pain that are suggestive of surgical or emergent conditions
include fever, protracted vomiting, syncope or presyncope, and evidence of gastrointestinal blood
loss.

The patient’s general appearance and vital signs can help narrow the differential diagnosis. Patients
with peritonitis tend to lie very still, whereas those with renal colic seem unable to stay still. Fever
suggests infection; however, its absence does not rule it out, especially in patients who are older or

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immunocompromised. Tachycardia and orthostatic hypotension suggest hypovolemia. The location of
pain guides the remainder of the physical examination.

Physicians should pay close attention to the cardiac and lung examinations in patients with upper
abdominal pain because they could suggest pneumonia or cardiac ischemia. There are several
specialized manoeuvres that evaluate for signs associated with causes of abdominal pain. When
present, some signs are highly predictive of certain diseases. These include Carnett’s sign (i.e.,
increased pain when a supine patient tenses the abdominal wall by lifting the head and shoulders off
the examination table) in patients with abdominal wall pain;

Murphy’s sign (tenderness and guarding in the right hypochondrium exacerbated by inspiration) in
patients with cholecystitis (although it is only present in 65 percent of adults with cholecystitis and is
particularly unreliable in older patients); and the psoas sign in patients with appendicitis.

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Other signs such as rigidity and rebound tenderness are nonspecific. Rectal and pelvic examinations
are recommended in patients with lower abdominal and pelvic pain. A rectal examination may reveal
faecal impaction, a palpable mass, or occult blood in the stool. Tenderness and fullness on the right
side of the rectum suggest a retrocecal appendix. A pelvic examination may reveal vaginal discharge,
which can indicate vaginitis. The presence of cervical motion tenderness and peritoneal signs increase
the likelihood of ectopic pregnancy or other gynaecologic complications, such as salpingitis or a tubo-
ovarian abscess.

Examination of the abdomen may reveal diminished bowel sounds and localized tenderness in the
right lower quadrant. With the progression of inflammation, abdominal muscle spasm may progress
from voluntary in response to pain to involuntary guarding. Rebound tenderness may also develop.
Signs of peritoneal irritation are often present but are not specific for appendicitis. Psoas sign is
elicited by having the patient lie on his or her left side while the right thigh is flexed backward.

Pain may indicate an inflamed appendix overlying the psoas muscle. Rovsing’s sign is pain referred to
the right lower quadrant when the left lower quadrant is palpated. A positive obturator sign is pain
that is elicited in a supine patient by internally and externally rotating the flexed right hip.

Tanda Gray Turner dan Cullen menyampaikan pesan yang sama, yaitu adanya perdarahan
intraperitoneal atau retroperitoneal. Tanda Cullen digambarkan sebagai edema superfisial dengan
memar di jaringan lemak subkutan di sekitar daerah peri-umbilikalis. Area ekimosis di sisi kanan
sesuai dengan tanda Grey-Turner. Tanda Gray Turner mengacu pada ekimosis panggul dan dapat
terjadi bersamaan dengan tanda Cullen, terutama pada pasien dengan perdarahan retroperitoneal. Jalur
umum yang menyebabkan terjadinya ekimosis subkutan ini adalah perdarahan retroperitoneal diikuti
dengan pelacakan darah dari retroperitoneum melalui defek pada fasia transversalis ke otot dinding
perut dan kemudian ke jaringan subkutan periumbilikal..

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Periumbilical ecchymosis (Cullen’s Sign) Gray Turner’s Sign

With Cullen’s sign, blood diffuses from the retroperitoneum along the gastrohepatic and falciform
ligaments to the umbilicus. With Grey Turner’s sign, blood diffuses from the posterior pararenal
space to the lateral edge of the quadratus lumborum muscle. These signs may be found in 1-3% of all
cases of acute pancreatitis and are not specific, as they have been described in a wide variety of
situations including rectus sheath haematoma, splenic rupture, perforated ulcer, intra-abdominal
cancer, ruptured ectopic pregnancy, and complications of anticoagulation.

Digital rectal examination consists of visual inspection of the perianal skin, digital palpation of the
rectum, assessment of neuromuscular function of the perineum and examination of gloves. Digital
rectal examination provides access to several structures and allows doctor to identify several disease
processes related to the rectum, anus, prostate, seminal vesicles, bladder, and perineum. In women,
this examination performed with pelvic examination.
Rectal examination may reveal right rectal tenderness or an inflammatory mass. Women require
pelvic examination to identify possible gynaecologic sources of their pain. With perforation,
abdominal pain, tenderness, and guarding may be more pronounced and diffuse.

The rectum begins at the termination of the sigmoid colon about 12 cm from the anal verge (Figure 97
.1) . Two muscle bundles, known as the internal and external anal sphincters, participate in defecation
. The internal anal sphincter is an enlargement of the circular smooth muscle of the colon and
functions involuntarily . The external anal sphincter consists of striated muscle bands under the
voluntary control of the puborectalis muscle . The rectum has the same innervation as the bladder ; the
hypogastric nerves innervate the internal anal sphincter, and the internal pudendal nerve (S,-Sq)
operates the external anal sphincter. Because of the common innervation, dysuria is a common
complaint associated with rectal disorders .
An important landmark both anatomically and clinically is the pectinate line where the anus and
rectum merge, approximately 3 to 4 cm from the skin . It serves as a demarcation for venous and
lymphatic drainage and for the nerve supply. Above the pectinate line, the veins drain into the portal
and caval systems, sympathetic nerves are present (pain is absent), and lymph drains to the superior
rectal and iliac nodes . Below the pectinate line, the veins drain into the canal system alone,
innervation is through somatic nerves (pain is present), and lymph drains into the inguinal nodes.
The rectum functions to permit defecation in a voluntary fashion. Peristalsis propels the stool from the
sigmoid colon into the rectum. Increased intraluminal pressure causes involuntary relaxation of the
internal anal sphincter followed by reflex contraction of the external anal sphincter, preventing
incontinence while providing awareness of imminent defecation. The external anal sphincter then
relaxes in a voluntary fashion, expelling the faeces. Studies suggest that the evacuative process is
facilitated by larger faecal bulk, providing an impetus for encouraging patients to consume diets high
in fiber and bulk.

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Digital Rectal Examination Indications:
• As a part of complete physical examination and is often included in urology,
gynecology, gastrointestinal, and neurological examinations.
• Disease processes that can be investigated by digital rectal examination include:
• Hemorrhoids
• Prostatitis
• Prostate cancer
• Benign prostatic hyperplasia
• Anal-rectal cancer
• Anal condyloma
• Constipation
• Fecal incontinence
• Anal fissures
• Inflammatory bowel disease, including ulcerative colitis and Crohn's disease
• Neurological deficits

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Anatomical Position :

The buttocks are spread apart, and the anus, posterior perineum, and gluteal folds are visually
inspected to identify pathologic conditions such as condyloma, external hemorrhoids, abrasions,
decubitus ulcers, abscesses or cellulitis, and, occasionally, malignancies (eg, melanoma and anal or
rectal carcinoma).

The nondominant hand is then placed on the patient’s anterior pelvic bone to provide countertraction
while the dominant hand, with the help of generous lubrication, slowly advances only the index finger
through the sphincter and into the rectum. After a few seconds, the sphincter should relax slightly, at
which point the digit is advanced further (see the image below). Note should be made of sphincter
tone, which can be lax or absent in neurologic diseases. Palpation of the internal structures then
proceeds in a systematic fashion.

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Palpation begins at the apex of the prostate and progresses toward the base to determine the size of the
gland and assess its consistency, which, in a normal gland, resembles that of the thenar eminence
when the thumb and little finger are opposed. Prostate cancer typically feels like a harder nodule, and
an abscess is typically fluctuant. In acute prostatitis, the gland can be quite tender, which can be a
diagnostic finding; however, care should be taken not to manipulate the prostate vigorously, because
of the risk of bloodstream infection.

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II. LEARNING GUIDE OF ACUTE ABDOMEN
A. HISTORY TAKING
No. Procedure Performance Scale

1 2 3 4
Introduction
1. Greet the patient, and develop a warm and helpful environment
2. Introduce yourself to the patient
Patient Identity
3. Ask the patient politely concerning his/her:
 name
 age
4. Record the gender:
 Male
 Female
6. Ask the marital (perkawinan)status of the patient (especially for
female)
Chief complaint
7. Ask the patient regarding why the patient comes to you.
8. Pain:
 Onset
 Site at onset
 Site at present
 Severity
 Aggravating factors (factor yang memperberat)
 Relieving factors (factor yng memperingan)
 Duration
 Progress
 Type of pain
 Radiation
Other related symptoms
9. Tanyakan kepada pasien tentang gejala yang berhubungan /bersamaan
dari:
9.1. Gastro-intestinal functions:
 Nausea
 Vomiting
 Loss of appetite (nafsu makan hilang)
 Faintness (pingsan)
 Previous indigestion (habitual) (gangguan pencernaan)
 Jaundice
 Bowel habit:
o constipation?
o Diarrhoea?

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 o Colour of the stool?
o Presence or absence of blood and mucus (slime)
9.2. Urinary function:
 Micturition: amount of urine(jumlah urin), lower
abdominal discomfort, colour of urine
9.3. Gynaecological function: (Female)
 Menstrual function
 Delayed or miss period
 Abnormal bleeding or discharge (colour, quantity)
10. Previous history of:
 Previous similar pain
 Previous abdominal surgery
 Previous major illness: incl. fever, abdominal injury/ trauma.
 Drugs
 Allergies
 Abdominal mass

B. PHYSICAL EXAMINATION
No. Procedure Performance Scale
1 2 3 4
Preparation
1. Check all the equipment required and have a good light:
 Examination couch
 Stethoscope
2. Explain the procedure and its goals to the patient.
3. Wash your hands with antiseptic soap.
4. Dry and warm your hands with tissues.
Implementation
A General Examination:
5. General appearance:
 Consciousness
 Affect: distressed? Anxious?
 Immobile
 Move cautiously
 Colour: Pallor? Flushing? Jaundice? Cyanosis?
6. Examine the vital signs:
 Temperature
 Pulse rate
 Blood Pressure
 Respiratory rate
7. Perform other systems examination, including cardio-pulmonary
system.
8. Ask the patient politely to expose his/her abdomen.
B. Abdominal Examination:
Inspection
9. Inspect the movement:
 Respiratory movement
 Visible bowel peristaltic
10. Is there any scar on the skin of the abdomen?

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11. Is there any echymosis ?
12. Is there any abdominal distention?
 Flatus/Gas?
 Fluid?
 Fetus?
13. Is there any rashes and discolouration?
 Cullen’s sign (perdarahan di umbilikal)
 Gray Turner’s sign (perdarahan di samping/flank)
 Ecchymosis of the abdominal wall
14. Is there any masses:
 Tumors?
 Hernial sites?
 Masses with pulsation?
Palpation
15. Ask the patient to locate the site of maximum pain with the tip of a
finger.
16. Dengan menggunakan permukaan palmar jari-jari Anda, palpasi perut
dengan lembut, mulai dari tempat terjauh dari area nyeri maksimum,
bergerak secara bertahap ke arahnya. Saat meraba, lihat ekspresi
wajah pasien, dan cari tanda-tanda:
 Tenderness
 Rebound tenderness ( Blumberg sign)
 Muscle guarding
 Rigidity (akibat inflamasi peritonium)
 Murphy’s sign (nyeri tekan di arcus aorta/hati peradangan
empedu)
 Swelling or masses
 Rovsing’s sign (tekan berlawanan arah nyeri)
 Expansile pulsation
 Hernial orifices
 Scrotum in male
Percussion
17. Tempatkan aspek palmar tangan kiri Anda di perut, dan dengan
lembut perkusi aspek punggungnya dengan ujung jari tengah tangan
kanan, bergerak di sekitar daerah perut:
 Is it tymphanitic?
 Is it Dull? (cairan)
 Is there any shifting dullness?
 Site of liver dullness? And is it disappeared?
Auscultation
18. Using stethoscope, and place it gently on the abdomen, listen to the
bowel sounds and bruit at least for one minute:
 Absent? (peritonitis)
 High pitched and hyperactive? (sesuatu di saluran cerna)
 Metallic sound? (besi yg dipukul/ada sumbatan)
 Vascular bruit?
C. Digital Rectal Examination
Assessment
19. Assess the indications and contraindications of doing DRE to the
patient

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20. Ask the patient that he/she has been informed about DRE
Planning
21. Periksa dengan bantuan asisten. Jika memungkinkan pemeriksa harus
memiliki hal yang sama
jenis kelamin dengan pasien. Lakukan pemeriksaan dengan privasi
yang baik.
22. Minta pasien untuk melepas celana dalamnya.
23. Bantu pasien untuk berbaring di tempat tidur dan dalam posisi litotomi
untuk DRE
24. Gunakan senter/lampu berdiri untuk meringankan area bokong
25. Use aprone
26. Wash your hand and use the gloves
27. Bersihkan perianal dengan kain kasa basah
28. Oleskan jeli pelumas pada jari telunjuk kanan.
Performing
29. Kaji posisi pasien apakah sesuai atau tidak
30. Periksa daerah sacrococcygeal dan perianal untuk benjolan, ulkus,
inflamasi, ruam, ekskoriasi, fisura.
31. Sentuh di perianal (hindari refleks vagal) dengan jari tengah dan ibu
jari
32. Masukkan jari telunjuk yang dilumasi ke dalam anus dengan lembut
dengan pasien kekhawatiran.
33. Periksa tonus sfingter dengan lembut ( apakah lemah, kuat, kering,
halus) mukosa rektum secara melingkar ( halus, permukaan granula)
ampula rektum. ( terisi, kosong, kolaps atau tidak)
Catat adanya nodul, ketidakteraturan, atau indurasi Lokasi nyeri yang
ditimbulkan
Massa atau pembengkakan: konsistensi, lokasi, permukaan, fiksasi
terhadap lingkungan.

34. Sapukan jari Anda dengan hati-hati (pukul 12) di atas kelenjar prostat
di bagian anterior tubuh, identifikasi lobus lateral dan sulkus
mediannya diantara mereka. Perhatikan ukuran, bentuk, konsistensi,
identifikasi adanya nodul atau nyeri tekan pada prostat.
35. Inform consent kemudian periksa refleks Bulbocavernosus ( bila ada
kecurigaan syok spinal): wanita, garukan lembut daerah perineum. Pria
: Gosok pennile atau tarik kateter) dengan tangan lain
36. Lakukan palpasi bimanual pada pasien wanita untuk memeriksa uterus,
rongga panggul dan adneksa.
37. Tarik jari telunjuk dengan lembut, amati apakah ada darah,
lendir atau kotoran pada sarung tangan
38. Wipe the anus with paper tissue
39. Remove the gloves and wash your hands.
40. Help the patient to get off the bed and ask the patient to put on his/her
underwear.
41. Say Hamdallah
Write up
42. Write up all significant findings in the medical record.
43. Conclude your diagnosis and differential diagnosis, and order any
necessary special investigations

III. CRITERIA OF PERSONAL PERFORMANCE EVALUATION

SCALE PERFORMANCE ACHIEVEMENT COMMENT
Clin ical Skill Gastrointestinal System 20 2 2 / 2 0 2 3 14
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1 If students are doing the task that only fill less than 35% of LOW
whole items for each step precisely
2 If student are doing the task that only fill 35% - 60% from MILD
whole items for each step precisely
3 If student are doing the task that only fill 60% - 78% from MODERA
whole items for each step precisely TE
4 If student are doing the task that fill at least 80% from whole EXCELLE
items for each step precisely NT

IV. SKILL LABORATORY PRACTICE

ARRANGEMENT SCHEDULE OF
PRACTICE

No. Subject Allocated Time Instructor

1. Brief Description about acute abdomen: 20 minutes 4 persons
a. Definition
b. Epidemiology and etiology
c. Diagnostic approach
d. Basic techniques of history
taking physical examination
e. Special investigations
2. Demonstration of history taking and 20 minutes 4 persons
physical examination of acute abdomen:
a. Clinical scenario using
standardized patient
b. Physical examination:
inspection, palpation,
percussion, and auscultation.
3. Coaching the students while they perform: 120 minutes 4 persons
History taking and physical examination
on
standardized patient.
4. Feedback and evaluation 20 minutes 4 persons

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