Surgery Module (Penerapan 2)

Surgery Module
Author:
Prof. Wahyuni Atmodjo, dr.,P.A.K,Ph.D
Jeremy Sebastian dr.,SpB.,Mkes.
Freda Halim, dr.,SpB.
Contibutors
Dr. Edwin RPL Tobing, dr., SpU

Royman Christian P. Simanjuntak, dr., SpBTKV
Budhi Adhiwijaya, dr. SpBTKV
Harmada Hutajulu, dr., SpB
Anthony Berlim, dr., SpB
Dr. Julius July, dr., SpBS
Harsan, dr., SpBS
Bernard Agung Baskoro, dr., SpB(K)Onk.
Hartono Kartawidjaja, dr., SpBP
John Butar Butar, dr., SpOT
Wibisono, dr., SpOT
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A. COURSE INFO
Surgery Clerkship Course is a 10 weeks course, preceptor based clerkship,
divided into 8 groups of primary preceptor.
The site directors at each teaching site bear the primary responsibility for the
development and maintenance of a program to fulfill the learning objectives of the
Externships in Medicine. The coordinator is responsible for organizing the tutorials and
seminars and encouraging faculty members to take the expected approach toward
student involvement in seminars and tutorials. Since there are differences in student
responsibilities for Surgery, directors will also reinforce at the beginning of each period,
with the attending physician (preceptor) and RMOs, the objectives to be met by the
students assigned to their ward team. Each student is part of a medical team usually
consisting of one or two RMOs, assistants, and a preceptor.
Students attend morning work rounds each day and participate in attending
rounds as scheduled. Students also work 1 night in maximum of 3 duty schedules. The
preceptor has the primary responsibility for educating students assigned to the ward
team. The immediate day-to-day supervisor for students is the assistant. All of the
physician-teachers with whom the student has contact are expected to serve as positive
role models.
Students are expected to do a work-up (complete medical records) with a
minimum of ten patients during the rotation (1 case every week). More cases may be
assigned. Students should attempt to complete their history taking and physical
examinations within 60 minutes.
Student specific seminar

Case Presentation
One student is expected to make and present two case presentations (one in
General Surgery, and the other depend on the schedule). The selected case
chosen from the write up cases. Student complete a written material consist of
minimal 10 pages with detail of history and clinical finding, simple basic theory
related to the case and a constructive discussion. Student will present in 15-20
minutes and discuss with preceptor and other students for another 45 minutes.
Bedside Teaching
Students and preceptor will have dedicated and protected 90 minutes (1.5 hour)
of Bedside teaching activities. Students should prepare them-self for the case and
let the preceptor knows which patient is taken as bedside teaching patient.
Student should be able to take a comprehensive history, good physical
examination, established provisional and differential diagnosis, plan treatment
and educate patient and their family. Each student will have at least 20 times bed
site teaching with different preceptor.
The preceptor uses the one-minute preceptor’s method consisting several steps:
1. Get a commitment
2. Probe for supporting evidence
3. Reinforce what was done well
4. Give guidance about errors and omissions
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5. Teach a general principle
6. Conclusion
Step 1: Get a commitment

A question such as ‘what happen with this patient?’, ‘what other diagnose would
you consider in this setting?’, ‘do you think the patient needs to be hospitalized?’
will help the student either to commit with a diagnosis or to plan treatment
option, rather than simply going along with the preceptor’s plan.
Step 2: Probe for supporting evidence

Explore the students thought processes. Question such as, ‘were there any other
alternatives have you considered?’, ‘what are the factors in the history and
physical examination that support your diagnosis?’, ‘why do you think the
patient should be hospitalized?’, ‘why do you feel it is important to do that part of
the physical examination in this situation?’ will be a helpful method to build
student’s critical thinking. Question that rely on rote memory such as, ‘what is
the differential diagnosis for retrosternal chest pain?’ don’t aid clinical reasoning.
Step 3: Reinforce what was done well

In order for student to improve, they must be made aware of what they did well.
The simple statement ‘that was a good presentation’ is not sufficient. Comment
should include specific behaviors that demonstrated knowledge skills or
attitudes valued by the preceptor, ‘your diagnosis of ‘probable pneumonia’ was
well supported by your history and physical. You clearly integrated the patient’s
history and your physical findings in making that assessment’. With a few
sentences, preceptor was expected to reinforce positive behaviors and skills and
increase the likelihood that they will be incorporated into further clinical
encounters.
Step 4: Give guidance about errors and omissions

Just as important for the student to hear what they have done well, it is
important to tell them the areas that need an improvement. This step also fosters
continuing growth and improved performance by identifying areas of relative
weakness. In framing comments it is helpful to avoid extreme terms such as `bad'
or “poor”. Expression such as “not best” or “it is preferred” may carry less of a
negative value judgment while getting the point across. Comments should be
made as specific as possible to the situation identifying specific behaviors that
could be improved upon in the future. The comments are specific to the situation
and also include guidance on alternative actions or behaviors to guide further
efforts. It is important to reflect here that a balance between positive and
constructive criticism is important.
Step 5: Teach a general principle

One of the key but challenging tasks for the student is to take information and
data gained from an individual learning situation and to accurately and correctly
generalize it to other situations. There may be a tendency to over generalize – to
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conclude that all patients in a similar clinical situation may behave in the same
way or require the exact same treatment. On the other hand, the student may be
unable to identify an important general principle that can be applied effectively
in the future. Brief teaching specifically focused to the encounter can be very
effective. Even if you do not have a specific medical fact to share, information on
strategies for searching for additional information or facilitating admission to the
hospital can be very useful to the learner.
Step 6: Conclusion
This final step serves the very important function of ending the teaching
interaction and defining what the role of the student will be in the next events. It
is sometimes easy for a teaching encounter to last much longer than anticipated
with negative effects on the remainder of the patient care schedule. The
preceptor must be aware of time and cannot rely on the student to limit or cut off
the interaction. The roles of the learner and preceptor after the teaching
encounter may need definition. In some cases you may wish to be the observer
while the learner performs the physical or reviews the treatment plan with the
patient. In another instance you may wish to go in and confirm physical findings
and then review the case with the patient yourself. Explaining to the learner
what the next steps will be and what their role is will facilitate the care of the
patient and the functioning of the learner.
Feedback
Since ongoing feedback is fundamental to a successful educational relationship,
students should feel free to ask about their progress. Feedback from faculty and
residents to students is extremely important in providing the opportunity to
improve clinical performance. During the Externships in Medicine, students will
be expected to initiate meetings at mid-rotation, first with their supervising
resident (if assigned) and then with their attending physician, to discuss both
strengths and areas needing improvement. The content of this feedback is
outlined in the Evaluation forms for this course.
A similar process should occur at the end of the rotation so that the student,
resident and faculty can discuss the student’s progress relative to the mid-
rotation assessment and the Course Objectives. These student-initiated sessions
should make the feedback process more efficient, effective, and palatable for the
faculty and residents; and equally important, promote student self-assessment
through analysis of specific examples of their own performance
Student’s general Roles, Responsibilities, Obligations and Activities

a. Hours of working day.
Students are expected to work 8 hours every day from 07.00 – 16.00
(includes 1 hour meal break) Monday to Saturday
Students are expected to complete their daily work before leaving and to
attend Academic or teaching activities which may extend beyond 16.00
hours.
Night duty will be from 16.00 hours to 07.00 hours on weekdays
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Weekend duty will be from 07.00 hours to 07.00 hours on weekends
(divided in 2 shifts)
Students must standby in the Emergency every night/holiday duty. Students
may leave on permission from the RMO on duty or the preceptor.
If the student leave without permission from the RMO on duty or the
preceptor, there will be consequence
add 2 more night shift (arranged by the Clerkship Coordinator)
failed to fulfill the consequence = one week of rotation + Rotational OSCE
in the next surgery rotation.
failed again = repeat 1 full rotation.
Students will be on duty a maximum of one night/weekend in three (1 in 3
duty schedules)
b. Students are allowed 1 hour for meals.
c. Students must attend all patient care and academic activities.
Students must attend all activities on time. If students will be late, they must
notify the preceptor. Repeated lateness is not acceptable. Continued lateness
after warning, may result in failure of the rotation. Students are required to
notify the supervisor if they will be late or unable to attend. Any lateness
more than 15 minutes without permission before will be treat as ABSENT
(including on morning report)
d. Students must complete all rotations as scheduled.
e. Students must complete all reports and presentation to be able to attend the exit
OSCE.
f. Students must already do the ward rounds individually or by team before the
preceptor and write their SOAP in the students follow up sheets (yellow paper) in
the patient’s chart.
g. Students must complete the “must do” and “must see” list accordingly.
h. Students must always give the performance and clinical skills sheet every time they
finished a presentation/BST/performing a clinical skill.
i. Students must report to the duty RMO every time they do the night/holiday duty.
There will be ward and emergency station, and each of the student only take care of
the surgical patient.
j. There are Ward Rounds with the general surgeon every Wednesday 9.00, and every
clerkship must do oral presentation for each patients they responsible.
k. Morning Report for clerkship is on Tuesday 07.00 O’Clock.
l. Students must collect the morning report book every Tuesday morning (before the
morning report starts). The book will be written every day by a student after
completing a night/holiday duty.
m. All students wishing a leave or withdrawal from a rotation must receive permission
and written approval from the Clerkship Coordinator.
n. Leave or absent ≥ 3 days will not allowed to take the OSCE examination
o. Leave or absent ≥ 6 days the student must repeat one full rotation
p. Students will discuss all significant matters with the preceptor.
q. There will be a primary healthcare visit every Saturday at 8.00 am to Puskesmas
Balaraja.
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Schedule Per Day
Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday
06.00 Follow up Follow Follow up Follow up Follow up Follow up
- up
07.00
07.00 Laporan jaga Laporan Laporan Laporan Laporan Start
- pagi (Tim jaga pagi jaga pagi jaga pagi jaga pagi Jaga
09.00 Bedah Saraf) (Bedah (Tim Bedah (Tim (Tim Pagi
Umum) Saraf) Bedah Bedah (Ganti
Saraf) Saraf) shift pkl
19.00)
09.00 Visite Besar BST Puskes
- Koasisten Kegiatan mas
10.00 dengan
preceptor
10.00 Kegiatan Kegiatan Kegiatan Kegiatan Kegiatan Kegiatan
- dengan dengan dengan dengan dengan dengan
12.00 preceptor(OPD preceptor preceptor preceptor preceptor preceptor
/ OT) (OPD/ (OPD/ OT) (OPD/ (OPD/ OT)
OT) OT)
12.00 Istirahat dan Istirahat Istirahat Istirahat Istirahat Istirahat dan
- persiapan dan dan dan dan persiapan untuk jaga
13.00 untuk jaga persiapa persiapan persiapan persiapan
n untuk untuk jaga untuk untuk jaga
jaga jaga
13.00 Kegiatan Kegiatan Mengikuti Kegiatan Kegiatan Kegiatan dengan
- dengan dengan Siang Kllinik dengan dengan preceptor
16.00 preceptor(OPD preceptor RSUS preceptor preceptor (OPD/ OT)
/ OT) (OPD/ (OPD/ (OPD/ OT)
OT) OT)
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Expected Competencies
(Based on Standard of Indonesian Medical Doctor Competencies or Standar
Kompetensi Dokter Indonesia - SKDI)
Basic Surgical Knowledges Competencies

1. Able to explain type of minor surgery
2. Able to explain type of major surgery
3. Able to explain informed concent
4. Able to explain universal precaution and infection prevention
5. Able to explain local anesthesia technique
6. Able to explain maximum dose of local anesthetic agent
7. Able to explain basic surgical skills which include knotting, suturing and instrument
handling.
8. Able to explain the type of suture material for wound suturing, both inside or outside
of the wound.
9. Able to explain the type and purpose of wound suturing technique
10. Able to explain each surgical instrument for minor surgery and its purpose
11. Able to explain wound healing process and factors that influence wound healing
Psychomotor Competencies
1. Demonstrate the process of good informed consent
2. Demonstrate the process of universal precaution and infection prevention
3. Demonstrate the process of applying local anesthetic
4. Demonstrate the process of choosing the appropriate suture material
5. Demonstrate the process of choosing the appropriate surgical instrument for suturing
6. Demonstrate the process of wound suturing, and able to choose the appropriate
suturing technique
7. Demonstrate the process of wound care and management
8. Demonstrate the process of giving medical education to the patient about wound care
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Competencies based on Scope of Subject
Expected level of competencies (according to SKDI)
The Indonesian Standard of Medical Doctor Competencies divide the competencies based
on scope of subject: Level 1 to 4
Level of Competency 1: recognize and explain
Graduated student able to recognize and explain the clinical appearances of a disease and
know how to gain appropriate further information about the disease, as well as
determination of further appropriate referral
Level of Competency 2: diagnosis and referral
Graduated student able to determine the correct clinical diagnosis of a disease and able to
determine the appropriate referral to relevant specialist. Graduated student must be able
to execute the process afterward.
Level of Competency 3: diagnosis, initial management, and referral
3A. Non-emergency case
Graduated student able to manage a disease in non-emergency situation and

able to give initial treatment in order to save life or to avoid worsening of
the disease, or to avoid permanent disability. Graduated student must be
able to determine further correct referral for further appropriate
treatment, and able to execute the process.
3B. Emergency case
Graduated student able to conduct initial emergency treatment and able to give
early therapy to save life or to avoid worsening of the disease, or to avoid
permanent disability. Graduated student must be able to determine
further correct referral for further appropriate treatment, and able to
execute the process.
Level of Competencies 4: diagnosis and complete independent treatment
Graduated student able to completely treat the disease independently. Graduated student
must be able to determine the correct diagnosis based on physical examination,
laboratory findings or simple imaging such as x-ray, appropriately and not overly.
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Competencies based on Clinical Skills
Expected level of clinical skills competencies (SKDI)
According to SKDI, clinical skills competencies are divided to 4 levels, based on the Miller’s
pyramid (knows, knows how, shows, does);
Level of competencies 1: Knows and able to explain
Graduated student must have theoretical knowledges of a medical skill, and able to
explain the procedural skills to friend, colleague, patient, or client about the concept,
theory, principles, and indication, as well as how to do it, the possible complications, etc.
Level of competencies 2: Knows how; had seen or demonstrated

Graduated student must have theoretical knowledge of a medical skill (including concept,
theory, principle, indication, how to do it, complications, etc.). Graduated student had seen
the medical skill or had others demonstrated the medical skill directly applied to patient.
Level of competencies 3: Shows; had performed or applied the skill under

supervision
Graduated student must have theoretical knowledge of a medical skill (including concept,
theory, principle, indication, how to do it, complications, etc.) as well as mastering the
bioethical background and psychosocial impact. Graduated student had seen,
demonstrated, and performed or applied the medical skill to real patient under
supervision, and practice the medical skill to a model or standardized patient.
Level of competencies 4: Does; perform the skill independently
Graduated student can demonstrate his/her ability to perform a medical skill by

mastering the whole theories, principles, indications, procedural steps, complications and
how to deal the complications. Had performed the medical skill under supervision.
4A: Achieved the medical skill after graduation
4B: Achieved the medical skill after internship or obtain the skill by post graduate
course.
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Scope based on competencies (SKDI) and local content (*) Level
according to division,
And clinical skills competencies of competency
Note: red font indicate as possible in national OSCE case
Vascular surgery:
Arterial disease
1. Abdominal Aortic Aneurysm (AAA) 1
2. Aortic dissection 1
3. Peripheral Artery Disease
- Diabetic foot * -
- Thromboangiitis obliterans (Buerger’s disease) 2
- Raynaud’s syndrome 2
- Arterial thrombosis 2
- Arterial embolism 1
- Claudication 2
- Lower extremity ulcer 4A
Venous disease
4. Varicose vein 2
5. Chronic Venous Insufficiency 3A
6. Deep Vein Thrombosis 2
7. Venous embolism 2
8. Thrombophlebitis 3A
Lymphatic disease
9. Lymphangitis 3A
10. Lymphedema 3A
Primary
Secondary (elephantiasis - filariasis)
Vascular anomalies
6. Infantile Hemangioma 2
7. Vascular malformation * -
Venous malformation
Capillary malformation
Lymphatic malformation (limfangioma)
Arteriovenous malformation (AVM)
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List of Clinical Skills:
1. Carotid artery palpation 4A
2. Palpation of peripheral arterial pulses 4A
3. Capillary refill time 4A

4. Detection of bruit 4A
5. Brodie Trendelenburg test 4A
6. Perthes test 3
7. Homan’s test 3
8. Ankle-brachial index 3
9. Doppler ultrasound 2
10. Venous puncture 4A
11. Arterial puncture 3
12. Finger prick 4A
13. Venous cutdown 3
14. Pediatric venous cutdown 3
Cardiothoracic surgery:
Thoracic disease
1 Lung cancer 2
2. Pleural Effusion 2
3. Massive pleural effusion 3B
4. Pneumothorax 3A
5. Tension pneumothorax 3A
6. Atelectasis 2
7. Lung abscess 3A
8. Hematothorax 3B
9. Mediastinal tumor 2
10. Rib fracture (including flail chest) * -
11. Lung contussion * -

12. Thoracic Empyema * -
13. Open thoracic surgery on TB * -
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Cardiac disease
9. Acquired * -
CABG surgery
Valve surgery
Congenital *
Cyanotic: TOF
Non-cyanotic: ASD, VSD, PDA

1. Respiratory inspection 4A
2. Chest inspection 4A
3. Chest auscultation 4A
4. Chest percussion 4A
5. Chest palpation 4A
6. Pleural tap 3
7. Superficial FNAB 2
8. Trans thoracal needle aspiration 2
9. Needle decompression 4A
10. Chest tube insertion 3
11. Water Sealed Drainage (WSD) care 4A
12. Pleural puncture 3
13. Oxygen therapy 4A
Digestive surgery:
Abdominal wall
1. Reponible and irreponible hernia (inguinal, femoral, 2
scrotal)
2. Incarcerated or strangulated hernia 3B
3. Umbilical hernia 3B
Acute abdomen
4. Acute appendicitis 3A
5. Appendicular abscess 3B
6. Peritonitis, due to: 3B
Perforated appendix, typhoid, gastric
Other source of perforation
7. Gastrointestinal bleeding 3B
8. Chole(docho)lithiasis 2
9. Acute Cholecystitis 3B
10. Pancreatitis 2
11. Ileus (bowel obstruction) 2
12. Obstructive jaundice * -
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Colorectal
13. Diverticulosis, diverticulitis 3A
14. Colitis 3A
15. Colorectal cancer 2
16. Rectal, anal prolapsed 3A
17. Hemorrhoids grade 1-2 4A
18. Hemorrhoids grade 3-4 3A
19. (peri)anal abscess 3A
20. Perianal fistula 2
21. Anal fissure 2
Others
22. Amebic liver abscess 3A
23. Tetanus 3B
24. Snake or animal bites * -
25. Hipovolemic shock (bleeding) 3B
26. Trauma abdomen * -

1. Abdominal inspection and palpation 4A
2. Groin inspection and palpation 4A
3. Hernia palpation 4A
4. Psoas sign and obturator’s sign 4A
5. Digital rectal examination 4A
6. Nasogastric tube insertion 4A
7. Endoscopy 2
8. Nasogastric tube suction 4A
9. Colostomy bag replacement 4A
10. Enema 4A
11. Anal swab 4A
12. Gastroscopy 2
13. Proctoscopy 2
14. Ascites sampling 3
15. Abdominal ultrasound 2
Pediatric surgery
1. Intussuception / Invagination 3B
2. Anal Atresia (anorectal malformation) 2
3. Fistula umbilical, omphalocele, gastroschizis 2
4. Billiary Atresia 2
5. Intestinal Atresia 2
6. Esophageal Atresia 2
7. Hirschsprung’s disease 2
8. Hydrocele 2
9. Reponible and ireponible hernia (inguinal, femoral, 2
scrotal)
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10. Incarcerated or strangulated hernia 3B
11. Umbilical Hernia 2
12. Undescended testis 2
13. Phymosis 4A
14. Paraphymosis 4A
15. Cystic hygroma 2
16. Hypospadia 2

1. History taking from third party, or older 4A
children, or anxious parents
2. General pediatric physical examination 4A
3. Congenital malformation observation 4A
4. Pediatric peripheral IV cannulation 4A
5. Pediatric intubation 3
6. Oropharynx tube insertion 2
7. Intraosseus cannulation 2
8. Circumcision 4A
9. Airway, breathing management 3
10. Emergency rehidration 4A
Plastic surgery
1. Cleft lip and Palate 2
2. Angina ludwig 3A
3. Lacerated wound 4A
4. Perforated, penetrated wound 3B
5. Maxillofacial trauma * -
6. Peritonsillar abscess 3A
7. Hidradenitis supurativa, carbuncle 4
8. Ingrowing toenails 4
9. Ganglion cyst 4
10. Lipoma 4A
11. Burn, 1st and 2nd degree 4A
12. Burn, 3rd degree 3B
13. Burn, chemical 3B
14. Burn, electrical 3B

1. Infiltration anesthesia 4A
2. Local nerve block 4A
3. Topical anesthesia 4A
4. Wound suturing 4A
5. Suture removal 4A
6. Analgesic administration 4A
7. Incision and drainage of abscee 4A
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8. Excision of benign skin tumor 4A
9. Wound care 4A
10. Rozerplasy 4A
11. Bandaging 4A
Urology
1. Benign Prostatic Hyperplasia 2
2. Urethral rupture 3B
3. Bladder rupture 3B
4. Kidney rupture 3B
5. Torsion of Testis 3B
6. Urethral stricture 3A
7. Varicocele 2
8. Hydrocele 2
9. Urinary stone disease or urinary calculi 3A
10. Priapism 3B
11. Renal colic 3A
12. Asymptomatic urinary tract stone disease 3A
13. Urinary tract infection 4A

1. Bimanual kidney examination 4A
2. Costovertebral angle tenderness 4A
examination
3. Bladder palpation 4A
4. Prostate palpation 4A
5. Bulbocavernous reflex 3
6. Uroflowmetry 1
7. Plain abdomen and IVP x-ray 3
interpretation
8. Urethral catheterization 4A
9. Clean intermitten catheterization 3
10. Suprapubic puncture 3
11. Circumcision 4A
12. Penis, scrotum inspection and palpation 4A
13. Scrotum transilumination test 4A
Surgical Oncology
Breast disease
1. Breast cancer 2
2. Phyllodes tumor 1
3. Fibroadenoma of the breast 2
4. Mastitis 4A
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5. Breast abscess 2
6. Paget’s disease of the breast 1
7. Cracked nipple 4A
8. Inverted nipple 4A
Thyroid disease
9. Goitre 3A
10. Thyroid adenoma 2
11. Thyroid cancer 2
Skin disease
12. Nevus pigmentosus 2
13. Malignant melanoma 1
14. Squamous cell carcinoma 2
15. Basal cell carcinoma 2
Others
16. Non-Hodgkin’s lymphoma 1
17. Hodgkin’s lymphoma 1
18. Other soft tissue tumors: fibrosarcoma, 1
rhabdomyosarcoma, leimyosarcoma
19. Branchial cyst and fistula 2
20. Tumor lidah * -
21. Tumor rongga / dasar mulut * -
22. Lymphadenopathy 3A
23. Lymphadenitis 4A
1. Self-Breast examination education 4A

2. Lymph node examination 4A
Orthopaedic surgery
Trauma
1. Open fracture, close fracture 3B
2. Clavicle fracture 3A
3. Pathologic fracture 2
4. Fracture and disclocation of vertebrae 2
5. Extremity disclocation 2
6. Join trauma 3A
7. Achilles rupture 3A
8. Degenerative
9. Osteoarthritis 3A
10. Osteoporosis 3A
11. Spondilitis 2
12. Others
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13. Primary and secondary bone tumor 2
14. Osteomyelitis 3B
15. Congenital malformation 2
16. Carpal tunnel syndrome 3A
17. Tarsal tunnel syndrome 3A

1. Inspection of gait, extremities, vertebral, 4A
scapulae, pevic, neck
2. Palpation of extremities, vertebral, 4A
scapulae, pelvic, neck
3. Range of Motion examination 4A
4. Shoulder girdle test 4A
5. Join function test 4A
6. Leg discrapency examination 4A
7. Close fracture reposition 3
8. Fracture stabilisation 4A
9. Reduction of dislocation 3
10. Application of Dressing 4A
11. Join aspiration 2
12. Splinter removal 3
Neurosurgery
Trauma
1. Epidural hematoma 2
2. Subdural Hematoma 2
3. Spinal cord injury 2
4. Complete spinal transection 3B
(compression)
Others
5. Hydrocephalus 2
6. Hernia of Nucleus Pulposus (HNP) 3A
7. Spondylitis TB 3A

1. Glasgow Coma Scale examination 4A
(Unconsious)
2. Vertebral inspection, percussion, and 4A
palpation
3. Skull x-ray interpretation 4A
4. Vertebral x-ray interpretation 4A
5. Head CT-Scan and interpretation 2
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List of general Clinical Skills:
1. Skin test 4A
2. Blood test examination 4A
3. Plain x-ray interpretation 4A
4. Contrast x-ray interpretation 3
5. Minor surgery prep: a and antiseptic, 4A
local anesthesia
6. Observer or assistant in major surgery: 4A
Scrubbing, Gowning, Gloving
7. Patient transport 4A
8. Basic life support 4A
9. Mask ventilation 4A
10. Intubation 3
11. Fluid resuscitation 4A
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A. MINOR PROCEDURES
A. Wound Dressing
1. Washes hands and applies clean gloves.
2. Loosen edges of tape of the old dressing. Stabilizes the skin with one hand while
pulling the tape in the opposite direction.
3. Beginning at the edges of the dressing, lifts the dressing toward the center of the
wound.
4. If the dressing sticks, moistens it with 0.9% normal saline before completely
removing it.
5. Observed removed dressing for drainage, especially noting amount, color and
odor (if any) of drainage.
6. Disposes of soiled dressing and gloves in a biohazard bag. Removes gloves and
performs hand hygiene.
7. Opens sterile dressing supplies and sterile gloves using sterile technique.
Recognizes and verbalizes action if contamination occurs.
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8. Applies sterile normal saline from bottle or prefilled syringe onto sterile gauze or
cotton balls using sterile technique
9. Wear sterile gloves without
contaminating or recognizing
contamination
a. Grasped folded edge of
cuff of one glove.
b. Lifted glove above
wrapper and away from
body.
c. Slid opposite hand into
glove. Did not adjust
cuff or fingers at this
time or let ungloved
hand touch outside of
glove.
d. Picked up second glove
by sliding sterile gloved
fingers under cuff edge.
Keeps gloved thumb off
cuff of second glove.
e. Slid fingers of opposite
hand into glove. Let go
of edge when hand in
glove.
f. Adjusted for comfort
and fit.
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10. Uses sterile cotton balls or gauze to cleanse wound: “Clean to dirty” and “top to
bottom”
a. Cleans incision line first going from top to bottom
b. Cleans along each side of incision with a separate cotton ball, going from
top to bottom.
11. Picks up new sterile dressing and places over center of wound.
12. Places large sterile ABD dressing over the wound dressing.
13. Secures edges of dressing to skin with tape.
14. Places date, time, and initials on dressing.
15. Removes gloves and performs hand hygiene.
16. Maintained principles of sterile field eg., anything below the waist is unsterile,
sterile field always in field of vision (do not turn back toward sterile field), keep
sterile gloved hands above the waist, no reaching across sterile field, do not use
wet or damaged package of sterile supplies, cannot touch an unsterile object
with sterile gloves, etc
22
B. Sutures (Single Suture)
Material
Sterile fenestrated drape
Needle holder
Surgical scissors
Surgical tweezers (forceps)
Anatomical tweezers (forceps)
1 reabsorbable suture with a sharp rounded needle for suturing deeper layers
Non-reabsorbable suture with a sharp needle for suturing the skin
Sterile gauze pads 10x10cm
Disinfectants
Local anaesthetic
Bandage materials
Bandage scissors
Procedure
1. Ask the patient to lie down and tell them what you are about to do.
2. Ask the patient about allergies to iodine or local anaesthetics.
3. Adjust the lightning.
4. Disinfects the edges of the wound and the surrounding areas.
5. Put on sterile gloves.
6. Cover the wound with a sterile fenestrated drape.
7. Administer infiltration anaesthesia or guided anaesthesia using the Oberst
method; wait until the anaesthesia takes effect.
8. Place the atraumatic needle in the small portion of the jaws of the needle holder,
approximately halfway along the needle holder.
9. Hold the surgical tweezers in a pencil grip in one hand. In the other, hand take
the needle holder.
23
10. Using the tweezers, grip the edge of the wound furthest from you; to minimize
tissue damage, the side of the tweezers with one tooth should be placed in the
wound margin and the side with two teeth should be placed in the skin.
11. Position the needle perpendicularly on the skin approximately 0.5 cm from the
wound margin and insert through the skin.
12. With a supinating hand motion, bring the needle through the wound margin in
an arc, similar to the curve of the needle. For wounds that do not extend beyond
the cutis and have no tension in the wound margins, proceed directly to step 17.
13. Open the needle holder and refasten it to the portion of the needle entering in
the wound.
14. Pull the needle through the skin and out of the wound in a curved path.
15. Reposition the needle in the correct position in the needle holder.
16. Pull the thread through the skin, leaving a sufficient amount to be tied later
(about 2 cm if tying with the needle holder or at least 10 cm if tying by hand).
17. Using the tweezers, grip the edge of the wound closest to you and turn the
wound margin outward.
24
18. With a curving motion, insert the needle into the wound margin bringing it as
deep along the wound bed as possible, and continue through until the needle
point appears through the skin.
19. Open the needle holder when it is adjacent to the wound margin and use it to
grip the needle again on the outer side of the skin.
20. Pull the needle in a curved path through the tissue using the tweezers to fixate
the exiting point of the needle in the wound.
21. Using thumb and forefinger, grip the needle securely and open the needle holder.
25
22. Tie the thread in a knot with the aid of needle holder.
26
C. Male Catheter Insertion
General Objectives
Students will be able to :

Insert indwelling urinary catheter using sterile technique in male patient
Remove indwelling urinary catheter properly
Definition
Urinary Catheterization is an introduction of a catheter through urethra into the bladder, with
the purpose(s) :
To relieve urine retention
To empty the bladder before, during and after surgery and before certain diagnostic
examinations.
To decompress the abdomen
To monitor urine output precisely, hence monitoring the peripheral circulation
To measure the precise amount of post-void residual urine in the bladder.
To insert medicine to the bladder ( Intravesical chemotherapy )
To get sterile specimen of the urine when other means are not possible
Risk for Catheterization
Infection
Trauma of the urethra ( especially for male urinary catheterization )
Equipments:
Sterile Equipments :
1. Sterile Catheter
Catheter are available from 8 to 24 french:
- Size 8 fr is used for infants and young children
- Size 16 fr is commonly used for adult
2. Sterile Gloves ( 1 pair )
3. Cleansing swabs
4. Cleansing Solution
5. Sterile drapes
6. Local anesthetic contained lubricant ( jelly)
7. Syrine 10 mL 1 pc
8. Sterile aquadest
9. Sterile container for aquadest
10. Sterile container for all sterile equipments
11. Sterile urine bag
27
Non sterile equipments:
1. Non sterile gloves
2. Adhesive tape
3. Scissors
Supporting equipment:
1. Trash bin
2. Penlight or stand lamp
3. Bed
4. Urine container ( if urine examination is needed )
5. Medical record
Process of Urinary Catheterization
Preparations:
1. Determine the need of indwelling urinary catheterization for the patient

2. Introduce yourself to the patient
3. Explain the procedure and the possible complications, obtain (oral) consent from
the patient ( or for pediatric patient, from the family)
4. Collect all the sterile, non sterile, supporting the equipments
5. Positioning the patient and set up the room privacy
Procedure:
1. Put all the sterile equipments in the sterile area

2. Put the sterile gloves
3. Check for the balloon of the foley catheter, is it inflating properly and no leak on the
balloon.
28
4. Desinfect the genital area and the surroundings in the circular fashion
5. Stand in the right side of the patient

6. Pull the penis upward with the left hand, put the local anesthetic contained sterile
lubricant(jelly) to the urethra, and insert the jelly to the urethra.
7. Insert the catheter into the urethra until it reaches the distal tip of the catheter. If it
is difficult, told the patient to inhale.Sometimes we need to add more jelly if the
insertion is difficult.
29
8. Hold the penis and catheter with the left hand while we insert the sterile aquabidest
10-15cc to inflate the balloon therefore we fixate the catheter.
9. Connect the catheter with urine bag and observe the urine production. If urine
sample is needed to be taken to the laboratory, take it from the first production
10. Secure the catheter using adhesive tapes.

11. Secure the urine bag lower than the patient’s body.
Things to do after the procedure:

1. Write in the medical record, size of the urine catheter and the amount of the
aquabidest used for fixation, the urine production: colour and amount.
2. Told the patient how to take care the urine bag and when to change it.
30
C. MODULES
1. Acute Abdominal Pain at Right Lower Quadrant

Purpose:
o To facilitate process of teaching/learning Clinical Reasoning for acute abdominal
pain at right lower quadrant.
Symptom:
o Acute right lower abdominal pain
Case:
o A 22 years old female patient who presents with 1 day of acute right lower
abdominal pain (real patient/prepared paper case/role-play). Periodically
during history taking, the preceptor will explore the student’s inquiry process
and hypothesis development. The real patient will be examined and the
preceptor will explore the student’s hypothesis generation
Learning objectives:
a. Review the abdominal quadrant and pathogenesis of referred pain in the
abdomen
b. List at least three conditions which cause acute right lower abdominal pain in
female and male patients
c. Develop the features of the illness script for acute appendicitis
d. Develop hypothesis generation and diagnostic reasoning process for acute
appendicitis
e. Differentiate among 3 conditions on a clinical basis
f. Describe the identifying clinical features of each condition
g. Describe management plan for the primary disease consideration
Diagnostic Reasoning for Acute Appendicitis

Taking the history
o Periodically during patient history or role-play for history taking, the preceptor
will check the inquiry process by asking questions while the student is obtaining
data for an illness script.
o Questions explored for hypothesis:
What information do you want?
Why did you ask the question?
What are you thinking of as a hypothesis?
What question might you ask next and why?
What are you thinking of as a differential diagnosis and why?
Doing the physical exam

o Based on the information from the history. What are you looking for?
Framework for clinical reasoning:

1. What specific information do you need? Why?
2. Review the abdominal quadrant and pathologic process of referred pain in the
abdomen.
31
3. What diseases might affect the abdominal right lower quadrant in male and
female?
4. What other symptoms that you want to ask to these patients?
5. How will you differentiate these 3 conditions on history?
6. What will you look for on PE ( or if a patient) what are the factors from
examination?
7. What investigations that you order-and what do you expect to find which will
support your diagnosis?
8. Remember to consider the Alvarado Score in Acute Appendicitis patient ,it all
includes the symptoms, signs and laboratory findings.
9. What is the most possible complication of the disease?
10. What is the natural history of the disease?
32
Case Based Discussion (CBD ) : Pursue discussion of alternate diseases
Possible Diseases for acute right lower abdominal pain
o For Female Patients
a. Acute appendicitis
b. Ruptured ectopic pregnancy
c. Torsion of the ovarian cyst
d. Pelvic Inflammatory disease
e. Renal/ Ureter colic due to ureterolithiasis
f. Infection of the urinary tract
o For Male Patients

a. Acute appendicitis
b. Renal/Ureter Colic due to ureterolithiasis
c. Infection of the urinary tract
Information and Take home points : Principles and Concepts

Acute right lower abdominal pain and acute appendicitis:
Diagnosis of acute appendicitis: Alvarado score of minimum 7-8
In most patients, problems in urinary tract (renal/ureter colic and infection of
the urinary tract) should be sought (asked in history taking, assessed in physical
examination). In female patients, problems in obgyn should be sought (asked in
history taking, assessed in physical examination, proven with laboratory test (for
instance pregnancy test)).
33
o Distinguishing Features of Illnesses
Distinguishing features of considered Differential Diagnosis:
o Acute appendicitis as the primary disease
a) commonly associated with migratory/ referred pain at the epigastric
region ( visceral pain)
b) accompanied symptoms are nausea and vomiting, anorexia, and fever
c) tenderness and rebound tenderness of right lower quadrant are found in
the physical examination
d) leukocytosis and shift to the left in differential count is usually found
o Ruptured ectopic pregnancy

a) Should be thought in all sexually active female patient, especially in acute
right lower abdominal pain with anemia
b) Last menstrual cycle should be asked, and history of vaginal bleeding
usually positive
c) Signs of pregnancy usually found ( engorgement of the breast, darkening
areola mammae, darkening linea alba, mild cervix)
d) Pregnancy test should be tested in all suspicion of ruptured ectopic
pregnancy
o Torsion of the ovarian cyst

a. The patient complained of irregular menstrual cycles
b. History of chronic lower abdominal pain
c. Abdominal mass sometimes palpable in the lower abdominal quadrant
o Pelvic Inflammatory disease

a. The patient complained of foul, vaginal discharge
b. Signs of infections might be positive ( fever, leukocytosis, shift to the left)
c. The pain usually blunt, and concentrated in the lower abdominal pain, not
necessarily in the right side
o Renal/ Ureter colic due to ureterolithiasis

a. The pain started at the right back and it radiates to the right lower
abdominal region
b. The pain is intermittent, while the pain of acute appendicitis is constant
c. History of passing stone, and other changes in micturitions such as
hematuria, dysuria might be positive
d. CVA percussion test is positive
34
o Infection of the urinary tract
a. dysuria and cloudy urine usually prominent
b. could be accompanied with passing stone and hematuria
c. The pain is concentrated in the suprapubic, not in the right side of the
right lower abdomen
For Male Patients

o Acute appendicitis, same as above
o Renal/Ureter Colic due to ureterolithiasis, same as above
o Infection of the urinary tract, same as above
Management Options
For study guide purposes, you may list management options and reasons for
choosing them.
1. Principle : Since the disease is caused by acute obstruction of the appendix
lumen and it will progress to rupture of the appendix, then the treatment is
removal of the appendix via operation (appendectomy)
2. Treatment options
a. Open appendectomy, good exposure but bad cosmetic appearance, longer
length of stay in the hospital.
b. Laparoscopic appendectomy, good cosmetic appearance with shorter
length of stay in the hospital.
Stimulating SDL
References
1) Schwartz Principles of Surgery, 9 edition.
2) Schein, Common Senses of Abdominal Surgery 2006
35
2. Reducible Lump at Inguinal
Purpose:
o To facilitate process of teaching/learning Clinical Reasoning for Reducible lump
at inguinal (lateral/medial inguinal hernia)
Symptom:
o reducible lump at right/left inguinal
Case:
o A 60 years old male patient who presents with 1 year of reducible lump at
right/left inguinal (real patient/prepared paper case/role-play). Periodically
and hypothesis development.
o The real patient will be examined and the preceptor will explore the student’s
hypothesis generation
1. Review the anatomy of the abdomen and inguinal, also pathogenesis of inguinal
hernia in childhood and adult
2. List at least three conditions which has symptom of lump in inguinal region each
in female and male adult patients
3. Develop the features of the illness script for inguinal hernia, including the risk
factors of inguinal hernia in childhood and adult patient.
4. Develop hypothesis generation and diagnostic reasoning process for inguinal
hernia
5. Be able to differentiate between the 3 conditions on a clinical basis and to
describe the identifying clinical features of each
6. Provide a management plan for the primary disease consideration
Diagnostic Reasoning for Inguinal Hernia

Taking the history
Periodically during patient history or role-play for history taking, the preceptor
data for an illness script, as these questions explore the process of hypothesis
development :
36
o What information do you want?
o Why did you ask the question?
o What are you thinking of as a hypothesis?
o What question might you ask next and why?
o What are you thinking of as a differential diagnosis and why?

o Based on the information from the history- What are you looking for?
o How to differentiate the lateral and medial inguinal hernia in physical
examination-perform 3 finger tests.
Framework for clinical reasoning

o What specific information will you want in this patient? Why?
o Let’s review the abdomen and inguinal anatomy and review the pathologic
process of reducible lump at inguinal in childhood and adult.
o What diseases might have symptoms of lump at inguinal in male and female
patients?
o What other symptoms that you want to ask to these patients?
o What risk factors do you want to ask in the adult patient?
o How will you differentiate these 3 conditions on history?
o What will you look for on PE (or if a patient) what are the factors from
examination?
o What investigations that you order-and what do you expect to find which will
o What is the most possible complication of the disease?
o What is the natural history of the disease?
Case Based Discussion (CBD ) : Pursue discussion of alternate diseases
Possible Diseases for acute inguinal pain
For Female Patients
1. Femoral Hernia
2. Inguinal Hernia (Lateral/Medial)
3. Enlargement of inguinal lymph nodes
For Male Patients

1. Inguinal Hernia ( Lateral/Medial)
2. Enlargement of inguinal lymph nodes
3. Testicular tumor
4. Orchitis
Information and Take home points: Principles and Concepts

Reducible lump at inguinal region and inguinal hernia:
Diagnosis of responsible lateral inguinal hernia: Reducible lump at inguinal
region, sometimes it reaches the scrotal region. No disturbances of bowel
passage. At PE, the lump is found in the lateral side of superficial epigastria
artery, in the 3 finger test the lump came from the lateral side.
37
Diagnosis of responsible medial inguinal hernia: Reducible lump at inguinal
region, it never reaches the scrotal region. No disturbances of bowel passage. At
PE, the lump is found in the medial side of superficial epigastric artery, in the 3
finger test the lump comes from the medial side.
In most male patients, Lower Urinary Tract Syndrome (LUTS) should be sought
(asked in history taking, enlargement of prostate was assessed in physical
examination). History of chronic cough and repetitive heavy weight lifting should
be asked.
In female patients, the lump should be assessed if it is below (femoral hernia) or
upper(inguinal hernia) the inguinal ligament. It should be asked in history
taking, assessed in physical examination.
Distinguishing Features of Illnesses

1. Responsible Inguinal hernia as the primary disease
a. The most prominent symptom is reducible lump
b. Bowel passage is not altered. How to differentiate responsible and
incarcerated inguinal hernia: If the lump is irreducible and the bowel
passage is altered then the patient is in incarcerated inguinal hernia, not
responsible inguinal hernia.
c. Differentiate the medial and inguinal? Medial inguinal hernia never
reaches the scrotal region. Lateral inguinal hernia often reaches the
scrotal region. If the lump came from the lateral side of the 3 finger test,
and then it is lateral inguinal hernia. If the lump came from the medial
side of 3 finger test then it is medial inguinal hernia.
d. Risk Factors of inguinal hernia in adult such as LUTS, chronic cough and
history of repetitive heavy weight lifting should be asked. In Physical
examination should be sought proof of pulmonary disease and
enlargement of prostate.
2. Femoral Hernia
a. Location of the lump should be asked whether it came from below
(femoral hernia ) or upper (inguinal hernia)
b. Femoral hernia is seldom found in reponible condition.
c. Risk factors of femoral hernia should be asked as multipara (give birth to
more than 5 children)
3. Enlargement of inguinal lymph node

a. The lump is constant, it didn’t enlarge with straining or cough
b. Symptoms of infection ( fever, malaise, leukocytosis) might be positive
c. Signs of inflammation of the lump are positive ( tumor, calor, rubor, dolor
and function laesa)
For Male Patients

1. Inguinal Hernia ( Lateral/Medial) : as listed above
2. Enlargement of inguinal lymph nodes : as listed above
38
3. Testicular tumor
a. The lump didn’t enlarge with straining
b. symptoms of chronic malignant disease might be appear ( chronic fatigue,
weight loss, anemia)
4. Orchitis
a. acute, sharp pain at testicular region
b. symptoms of infection might be positive ( fever, malaise, leukocytosis)
c. symptoms of urinary tract infection might be positive ( polakisuria,
dysuria, hematuria)
d. Signs of infection at the testicular region might be positive ( tumor calor
rubor dolor)
Management Options
For study guide purposes, you may list management options and reasons for choosing
them
1. Principle: Since the disease is caused by the weakness of the abdominal muscles
due to constant straining causing the opening of inguinal canal, therefore the
definitive treatment of reponible inguinal hernia is to ligate the hernia sac
(herniotomy) and enhance the strength of abdominal muscle surround the
hernia sac with mesh (hernioplasty). The procedure of herniotomy accompanied
with hernioplasty is called herniorhaphy.
2. Treatment options
o open herniotomy + insertion of mesh, acceptable cosmetic appearance
o Laparoscopic herniotomy and insertion of mesh, good cosmetic
appearance
References
1. Schwartz Principles of Surgery, 9 edition.
2. Schein, Common Senses of Abdominal Surgery 2006
3. Breast Lump
Purpose:
To facilitate process of teaching/learning Clinical Reasoning for breast lump.
Symptom:
palpable breast lump
Case:
A 42 years old female patient who presents with 1 month of palpable lump at her
right/left/bilateral breast (real patient/prepared paper case/role-play).
Periodically during history taking, the preceptor will explore the student’s
inquiry process and hypothesis development.
The real patient will be examined and the preceptor will explore the student’s
39
1. Review the anatomy of the breast and axilla
2. List at least three conditions which cause palpable lump at the breast
3. Develop the features of the illness script for palpable breast lump
4. Develop hypothesis generation and diagnostic reasoning process for malignant
breast tumor
Diagnostic Reasoning for Breast Lump

Taking the history
data for an illness script,.
Questions explored for hypothesis:

Based on the information from the history- What are you looking for?
Framework clinical reasoning

What specific information will you want in this patient? Why?
Let’s review the anatomy of the breast and axilla
What diseases might present with palpable breast lump?
What other symptoms that you want to ask to these patients?
40
How will you differentiate these 3 conditions on history?
What will you look for on PE (or if a patient) what are the factors from
examination?
What investigations that you order-and what do you expect to find which will
What is the most possible complication of the disease?
What is the natural history of the disease?
Case Based Discussion (CbD ) : Pursue discussion of alternate diseases

Possible Diseases for malignant breast tumor
1. Malignant breast tumor
2. Benign breast tumor
3. Fat necrosis
Malignant breast tumor:
Diagnosis of malignant breast tumor:
Palpable breast tumor with signs and symptoms of malignancy

1. Malignant breast tumor as the primary disease
Age>35 y.o.
No pain and no signs of inflammation
Local changes: chronic ulcer at the breast skin, orange’s skin like
appearance, dimpling of the breast skin, nipple retraction, nipple
discharge.
Palpable lymph node at the axilla, supra and infraclavicular, also
parasternal region
Signs of metastases: dyspnea, early satiety, chronic back pain, chronic
pain at the leg, headache, palpable lymph node at the contralateral axilla.
All of the signs of metastases should be proven with radiologic/ biopsy
examination.
Positive Risk factors: positive family history (sisters or mother), prolong
usage of hormonal contraceptive medications (>10 years), late bearing
child (>20 years after menarche), no breastfeeding.
At the mammography: opaque lesion with stellate form. USG: sold lesion
with unclear border.
FNAB/open biopsy : malignant cells are positive
2. Benign breast lump
o usually <35 years old
o enlarged and painful right before menstrual cycle
o no signs of local changes at the breast
o Mammography/USG : opaque lesion with clear border
3. Fat necrosis at the breast
o History of trauma before (+)
41
o Rapid enlarging lump
o Biopsy : no malignant cell
Management Options
a. Principle: Since the lump is caused by uncontrolled hyperproliferation of the cell
and it will progress to spread of the malignant cell to the distant tissues
(metastases) unless it is taken, then the treatment is removal of the tumor via
operation, also for the biopsy purpose. If it is proven to be malignant then
mastectomy is indicated.
b. Treatment options
o FNAB continued with modified radical mastectomy
o open biopsy examined for frozen section continued with modified
radical mastectomy
Stimulating SDL
References
1. Schwartz Principles of Surgery, 9ed. 2010
2. Sabel, E. Essentials of Breast Surgery. 2009
4. Meatal Bleeding
Purpose:
To facilitate process of teaching/learning Clinical Reasoning for Meatal Bleeding.
Symptom:
Meatal bleeding
Case:
A 22 years old male patient who presents with history of 2 hours of meatal
bleeding with history of pelvic/lower abdominal trauma. (Real patient/prepared
paper case/role-play). Periodically during history taking, the preceptor will
explore the student’s inquiry process and hypothesis development.
1. Review the anatomy of the urinary tract and pelvic region.
2. List at least 1 condition which cause meatal bleeding
3. Develop the features of the illness script for meatal bleeding
4. Develop hypothesis generation and diagnostic reasoning process for urethral
rupture
5. Be able to differentiate between the complete or partial urethral rupture on a
clinical basis and to describe the identifying clinical features of each
Diagnostic Reasoning for Urethral Rupture

Taking the history
42
development :
1. What information do you want?
2. Why did you ask the question?
3. What are you thinking of as a hypothesis?
4. What question might you ask next and why?
5. What are you thinking of as a differential diagnosis and why?

Follow the ramework for clinical reasoning
What specific information will you want in this patient? Why?
Let’s review the anatomy of the lower urinary tract and pelvic region.
What diseases might present with meatal bleeding?
How will you differentiate partial or complete urethral rupture?
What wil you look for on PE (or if a patient) what are the factors from
examination?
What is the most possible complication of the disease?

Possible Diseases Complete Urethral Rupture
1. Complete/Partial urethral rupture
Complete urethral rupture:
1. Acute Meatal bleeding with previous history of lower abdominal trauma/ pelvic
trauma
2. Complete inability for micturition with signs of clear urinary retention ( acute,
painful, palpable full bladder)
3. Scrotal Hematoma
4. At Digital Rectal examination : high position prostate

1. Complete urethral rupture
a. Acute Meatal bleeding with previous history of lower abdominal trauma/
pelvic trauma
b. Complete Inability for micturition with signs of clear urinary retention (
acute, painful, palpable full bladder)
c. Scrotal Hematoma
d. At Digital Rectal examination : high position prostate
e. Urethrography bipolar : proof of urethral disruption
43
2. Partial urethral rupture
Same as complete urethral rupture, but the inability for micturition is
incomplete.
Management Options
them
o Principle: Since the inability for micturition is caused by disruption of urethra
and it will progress to urethral stricture if urine catheterization is done to the
patient, then the treatment is including no urine catheterization of whatsoever
indication . Instead, suprapubic cystostomy is recommended, and then bipolar
urethrography could identify the site of urethral rupture. Railroading procedures
for urinary catheterization via bladder is recommended after the site of urethral
rupture is found in bipolar urethrography.
o Step of Treatment :
No urine catheterization
Identifying the site of urethral rupture with bipolar urethrography
Railroading procedures for urinary catheterization via bladder.
Stimulating SDL
References
1. Schwartz Principles of Surgery, 9 edition. 2010
2. Mattox, Trauma, 6th edition.
5. Diffuse Abdominal Pain

Purpose:
to facilitate process of teaching/learning Clinical Reasoning for Diffuse
abdominal pain ( Diffuse peritonitis)
Symptom:
Diffuse abdominal pain
Case:
A 20 years old male patient who presents with 1 day of diffuse abdominal pain.
Since 9 days ago the patient complained of dull pain at the right lower quadrant
accompanied with mild intermittent fever. Suddenly 1 day ago the pain spread
to whole abdomen. (Real patient/prepared paper case/role-play). Periodically
and hypothesis development.
1. Review the anatomy of the abdomen and focused of epigastric region, also
pathologic process of abdominal pain
44
2. List at least three conditions which has symptoms of diffuse abdominal pain,
preceded with right lower abdominal pain.
3. Develop the features of the illness script for diffuse abdominal pain
4. Develop hypothesis generation and diagnostic reasoning process for diffuse
peritonitis due to abdominal typhoid perforation
Diagnostic Reasoning for Diffuse Abdominal Pain

Taking the history
development:
o What are the possible complications happened in this patient and why?

Follow the “framework “ process or Microskills method for clinical reasoning

What specific information dos you want in this patient? Why?
Let’s review the abdomen anatomy and review the pathologic process of diffuse
abdominal pain.
What diseases might have symptoms of diffuse abdominal pain preceeded with
right lower abdominal pain?
What are the possible complications happened in this patient?
How will you differentiate these 3 conditions on history?
What will you look for on PE (or if a patient) what are the factors from
examination?
If you already investigation results (for example: lab results, abdominal photos),
what do you see in the investigations results, and how it help you make the
diagnosis, how do you connect the abnormality to the disease that the patient
has now?
What are the most possible complications of the disease?
45
Possible Diseases for diffuse abdominal pain proceeded with right lower abdominal
pain
1. Diffuse peritonitis due to perforated ileum due to abdominal typhoid perforation
2. Diffuse peritonitis due to perforated appendicitis
3. Diffuse peritonitis due to perforated ileum due to Meckel’s Diverticle perforation

o Diffuse peritonitis due to perforated ileum due to abdominal typhoid
perforation:
o Diagnosis of diffuse peritonitis due to perforated ileum due to abdominal typhoid
perforation: acute and diffuse abdominal pain, preceded with dull right lower
abdominal pain and mild progressive intermittent fever more than 7 days
periode .
o History of disturbances in GI tract (diarrhea, constipation, hematochezia ) could
be positive. In PE the most prominent signs are tense and distended abdomen,
with tenderness, rebound tenderness and muscular rigidity positive all the
abdominal region. Punctum maximum of the pain are in the right lower quadrant
region. The liver dullness is negative. Absent bowel sound.
o The most often possible complications are sepsis and dehydration, and should be
sought in history taking and PE.
o Plain abdominal photos will show free air at the right subdiaphragma, absence of
preperitoneal fat and psoas line. There should be fluid collection intrabdominal
and thickening of bowel wall.
Distinguishing Features of Illnesses in the differential diagnosis:

1. Diffuse peritonitis due to perforated ileum due to abdominal typhoid infection
a. The most prominent symptom is diffuse abdominal pain, with punctum
maximum of pain is right lower abdominal region.
b. History dull right lower abdominal pain and history of mild progressive
intermittent are positive.
c. History of GI tract disturbances (diarrhea, constipation, hematochezia)
might be positive.
d. Signs of peritonitis (distended and tense abdomen, tenderness and
rebound tenderness, also muscular rigidity all over the abdominal region,
absent bowel sound).
e. Free air at the plain abdominal photos
f. Positive Widal test ( titer antibody S. Typhi-H is equal or more than
1/320)
2. Diffuse peritonitis due to perforated appendicitis
a. The most prominent symptom is diffuse abdominal pain, with punctum
maximum of pain is at right lower quadrant. History of migratory pain at
epigastric region before pain at right lower quadrant often found.
46
b. No history of dull abdominal pain accompanied with mild progressive
intermittent fever.
c. No history of GIT disturbances
d. Liver dullness is still positive
e. No free air at the plain abdominal photos.
3. Diffuse peritonitis due to perforated ileum due to Meckel’s Diverticle perforation
a. Seldom condition, more affecting female than male ( 2:1)
b. Previous history of intermittent right lower abdominal pain is positive
since childhood
c. Preceded by sharp pain at the right lower abdominal region for several
days ( diverticulitis)
d. There is free air at the plain abdominal photos.
f. Positive Widal test ( titer antibody S. Typhi-H is equal or more than
1/320)
Management Options
them
a. Principle : Since the disease is caused by inflammation of whole abdominal
peritoneum due to contamination of fecal and purulent materials, therefore the
definitive treatment of diffuse peritonitis is to control the source of infection
(Closure of perforation of ileum, followed by debride all the gastric fecal and
purulent material from the abdominal cavity. This source control achieved by
emergency exploratory laparotomy.
open exploratory laparotomy with wedge excision + closure with primary
suture/ileostomy of ileal perforation
Stimulating SDL
References
1. Schwartz Principles of Surgery, 9 editions.
47
6. Lower Urinary Tract Syndrome ( LUTS )
Purpose:
To facilitate process of teaching/learning Clinical Reasoning for Lower Urinary
Tract Syndrome.
Symptom:
difficulty in micturition
Case:
A 60 years old male patient who presents with 5 years of difficulty in micturition
(real patient/prepared paper case/role-play). Periodically during history taking,
the preceptor will explore the student’s inquiry process and hypothesis
development.
1. Review the urinary tract anatomy and physiology
2. List at least three conditions which cause difficulty in micturition- LUTS
3. Develop the features of the illness script for LUTS
4. Develop hypothesis generation and diagnostic reasoning process for LUTS
48
Teaching Diagnostic Reasoning for Benign Prostatic Hyperplasia
Taking the history

o Periodically during patient history or role-play for history taking, the preceptor
data for an illness script.
o questions explore the process of hypothesis development:
– What information do you want?
– Why did you ask the question?
– What are you thinking of as a hypothesis?
– What question might you ask next and why?
– What are you thinking of as a differential diagnosis and why?

Follow the “framework “process or Microskills method for clinical reasoning

1. What specific information will you want in this patient? Why?
2. Let’s review the anatomy and physiology of the urinary tract ( upper and lower)
3. What diseases might present with difficulty in micturition?
4. What other symptoms that you want to ask to these patients?
5. How will you differentiate these 3 conditions on history?
6. What will you look for on PE (or if a patient) what are the factors from
examination?
7. What investigations that you order-and what do you expect to find which will
8. What is the most possible complication of the disease?
9. What is the natural history of the disease?

Possible Diseases Benign prostatic hyperplasia
1. Benign prostatic hyperplasia
2. Vesicolithiasis
3. Urethral stricture
4. Neurogenic Bladder

Benign Prostatic Hyperplasia/ BPH:
Diagnosis of BPH : LUTS, accompanied with:
1. Age>40 y.o.
2. Symptoms of obstruction: Hesitancy and intermittency
3. Symptoms of irritation: Frequency, Nocturia and Urgency
49
4. At physical examination: Enlarged prostate at digital rectal examination. No
signs of stricture at the meatus urethra.
5. Complications: urinary retention, urinary tract infection, hematuria, urinary
stone

1. BPH
o Age>40 y.o.
o Progressive history of LUTS
o Symptoms of obstruction : Hesitancy and intermittency
o symptoms of irritation : Frequency, Nocturia and Urgency
o At physical examination: Enlarged prostate at digital rectal examination.
No signs of stricture at the meatus urethra.
o Complications : urinary retention,urinary tract infection, hematuria,
urinary stone
2. Vesicolithiasis
o History of LUTS is intermittent.
o positive history of passing stone
o the prostate may be enlarged, but not significant of obstruction
o Slight tenderness at suprapubic area.
o USG: opaque nodule at bladder.
o Complications : urinary tract infection, passing stone will cause urethral
stricture
3. Urethral stricture
o History of passing stone or urinary tract trauma or urinary tract
instrumentation before might be positive
o History of LUTS is progressive; the urinary stream is decreased
significantly.
o In physical examination could be found urethral stricture at the external
urethral meatus, normal prostate
o Complications : intermittent UTI
4. Neurogenic Bladder
o Positive history of recurrent, intermittent LUTS
o History of diseases with possibility of neurologic disturbances, i.e.
diabetic mellitus with diabetic neuropathy, neurologic disturbances in
spinal cord injury, cerebrovascular disease with neurologic disturbances.
50
Management Options
them
a. Principle :
BPH is aging process that happened in almost every male patient. The principle
of treatment is to reduce the volume of prostate, could be reached by several
options that discussed below.
Watchful waiting: Usually reserved for those patients with minimal
symptoms (AUA-PSS < 7) from their BPH. No medications, but the patient
have to see their physicians regularly for physical examinations and routine
laboratory tests.
Medications : the principle is to reduce the volume of the prostate, hence
will reduce the signs and symptoms of BPH
o Alpha-adrenergic receptor blockers
o 5-alpha reductase inhibitors
o Herbal medications
Operations: Since the symptoms of obstruction and irritation is caused by
enlargement of prostate ( mechanical problem) and some are intractable
with medications, then for the patient with BPH with several indications
are mandatory for operation:
o BPH patient that presented with LUTS with IPSS Score >19
o BPH patient that presented with LUTS with complications
o BPH Patient with history of twice urinary retention
Stimulating SDL
References
1. Schwartz Principles of Surgery, 9 editions. 2010
2. Smith, Essential of Urology, 2009
51
7. Hypovolemic Shock with Multiple Trauma
Purpose:
To facilitate process of teaching/learning Clinical Reasoning for Hypovolemic
Shock with Multiple Trauma, with possible source of shock is internal bleeding.
Actual diagnosis:
Hypovolemic shock due to intra- abdominal bleeding due to solid organ rupture
due to liver trauma.
Symptom:
Decreased Consciousness
Case:
A 28 years old male patient who presents with history of 1 hour of decreased
consciousness. The patient has history of traffic accident 3 hours before
admissions. (real patient/prepared paper case/role-play). Periodically during
history taking, the preceptor will explore the student’s inquiry process and
hypothesis development.
1. Review the primary survey, the assessment and therapy that done in primary
survey.
2. Review the secondary survey, the assessment and therapy that done in
secondary survey.
3. In concordance with primary and secondary survey, ask the student for history
taking for the multiple trauma patient : Mechanisms of trauma, Injury sustained,
and Degree of Trauma(MIST)
4. Be able to identify possible sources of bleeding ( intraabdominal, skeletal,
intrathoracal,retroperitoneal, and intracranial) on a clinical basis and to describe
the identifying clinical features of each.
5. Develop hypothesis generation and diagnostic reasoning process for
hypovolemic shock with possible source of intra-abdominal bleeding due to solid
organ rupture due to liver trauma.
Teaching Diagnostic Reasoning for Hypovolemic Shock with Multiple Trauma

with intra-abdominal bleeding as the possible source of bleeding
Doing the primary survey and quick history taking

development :
52
o What is important to do with this acute, multiple trauma patient, and
how you will provide quick and live saving management for the
patient?
o What is the main problem in the primary survey in this patient?
o What information do you want from history taking?
Doing the secondary survey

o What is important to do with the secondary survey, and how will you find the
source of bleeding in the secondary survey?
Follow the framework clinical reasoning

o Let’s review the possible source of bleeding, considering the Mechanism of
Trauma, Injury sustained and Degree of Trauma.
o How will you differentiate the possible sources of bleeding?
o What will you look for on PE (or if a patient) what are the factors from
examination?

Possible Diseases Hypovolemic Shock (3rd/4th grade, might be rapid response, transient
response and no response) due to intra-abdominal bleeding due to liver rupture
1. Hypovolemic Shock(3rd/4th grade, might be rapid response, transient response
and no response) due to intra-abdominal bleeding due solid organ rupture due
to liver rupture
and no response) due to intra-abdominal bleeding due to splenic rupture
and no response) due to Pelvic Fracture
and no response) due to intra thoracic bleeding due to lung contusion and
multiple rib fractures
and no response) due to renal trauma
53
Possible disease:
o Hypovolemic Shock (3rd/4th grade, might be rapid response, transient response
to liver rupture
o Clinical diagnosis of this condition is made by :
There is clear hypovolemic Shock with mechanism of trauma: injury at
the right side of the body. Signs of injury sustained is visible at the right
side ( multiple lower rib fractures), hematoma, contusions at the right
upper quadrant of the abdomen. Degree of trauma is visible at open
exploration or at abdominal CT scan, and graded by the AAST (American
Association Surgery of Trauma) Criteria for Abdominal Solid Organ
Rupture.
Distinguishing Features of Illnesses in the differential diagnosis of the Hypovolemic

Shock:
to liver rupture
a. There are clear signs of Hypovolemic Shock
b. Mechanism of trauma: injury at the right side of the body.
c. Signs of injury sustained are visible at the right side: might be
hematoma, contusions, lacerated wounds, multiple lower rib fractures,
at the right upper quadrant of the abdomen.
d. Degree of trauma is visible at open exploration or at abdominal CT scan,
and graded by the AAST (American Association Surgery of Trauma)
Criteria for Abdominal Solid Organ Rupture.
e. Might be increased of Liver Enzymes, but this is not specific.

and no response) due to intra-abdominal bleeding due to splenic rupture
b. Mechanism of trauma: injury at the left side of the body.
c. Signs of injury sustained are visible at the left side: ie hematoma,
contusions, lacerated wounds, multiple lower rib fractures at the left
upper quadrant of the abdomen.
d. Degree of trauma is visible at open exploration or at abdominal CT scan,
and graded by the AAST (American Association Surgery of Trauma)
Criteria for Abdominal Solid Organ Rupture.
3. Hypovolemic Shock (3rd/4th grade, might be rapid response, transient response

and no response) due to Pelvic Fracture
b. Mechanism of trauma: Multiple injury at the lower abdominal, or
history of severe trauma.
54
c. Signs of injury sustained are visible at the pelvic region: i.e. hematoma,
contusions at the lower quadrant of the abdomen. Might be injury to
containing organs at the pelvic regions, for instance urethral ruptures,
perianal trauma, etc.
d. Degree of trauma is visible at open exploration or at pelvic CT scan, and
graded by the AAST (American Association Surgery of Trauma) Criteria
for Pelvic Injury.

and no response) due to intra thoracic bleeding due to lung contusion and
multiple rib fractures
b. Mechanism of trauma: history of severe trauma, especially on chest.
c. Signs of injury sustained are visible at the chest region: i.e. hematoma,
contusions, lacerated wounds, multiple rib fractures at the chest.
d. Degree of trauma could be predicted by inserting thoracic catheter and
see the volume of the blood came out from the thoracic catheter. Degree
of trauma is visible at open exploration or at pelvic CT Scan, and graded
by the AAST (American Association Surgery of Trauma ) Criteria for
Thoracic Trauma
5. Hypovolemic Shock (3rd/4th grade, might be rapid response, transient response

and no response) due to renal trauma
b. Mechanism of trauma: history of severe trauma, especially on chest.
c. Signs of injury sustained are visible at the flank region: ie hematoma,
contusions, lacerated wounds, multiple rib fractures at the ipsilateral
chest.
d. Degree of trauma is visible at open exploration or at Abdominal CT Scan,
and graded by the AAST (American Association Surgery of Trauma )
Criteria for Renal Trauma
Management Options
List management options and reasons for choosing them
Principle :
To identify what grade is the hypovolemic shock (1, 2, 3, and 4). If the
hypovolemic shock is 3rd or 4th grade:
1. Aggressive Fluid Resuscitation and blood replacement
2. Identify source(s) of bleeding. If the bleeding is external, treatment must
include how to stop external bleeding.
3. Identify the response to fluid resuscitation and blood replacement
i. Rapid response
ii. Transient response
iii. No response
55
4. Identify the needs of surgical resuscitation. When the aggressive fluid
resuscitation and blood replacement failed, then the patient needs
surgery resuscitation.
Treatment options
1. Aggressive Fluid Resuscitation and blood replacement ,along with control
of external bleeding
2. Surgical Resuscitation :
o Exploratory laparotomy for intra-abdominal bleeding.
o Pelvic sling, C-clamp for pelvic trauma
o Thoracic tube insertion,
o Exploratory Thoracotomy for intra thoracic bleeding.
o Exploratory laparotomy or renal exploration (retroperitoneal
approach) for renal trauma
Stimulating SDL
References
56
8. Multiple Trauma
Purpose:
• To facilitate process of teaching/learning Clinical Reasoning for Assesment of

patient with multiple trauma
Actual diagnosis:
• Multiple trauma ( with definition of Multiple trauma : condition of a person who

has been subjected to multiple traumatic injuries at 2 or more body regions, It is
defined via an Injury Severity Score ISS >=16 and usually happens after high impact
injury.
Symptom: usually the patients came with symptoms of :
Decreased Consciousness or
Multiple wounds at 2 or more body regions
Case:
A 30 years old male patient who presents with history of falling from 5 stories in
the building project 1 hour before admissions, with history of lucid interval is positive.
Now the patient’s familty is complaining about decreased consciousness, wound at back
and femoral area. (real patient/prepared paper case/role-play).. Periodically during
history taking, the preceptor will explore the student’s inquiry process and hypothesis
development
The patient came with gurgling airway not responding with suction and need
intubation
The patient’s breathing is rapid and shallow breathing. The breath sound is still
equal but there is signs of bruising and crepitation in the left thoracic side. O2 sat is
93%
The skin is pale, cool with BP 80/60 mmHg, HR 120x/m, Urine: no production
after insertion of bladder catheter. No sign of hematuria
The GCS is E3M4V3=10, round pupil but unequal with size 5mm for the right
pupil, 3m for the left pupil. Good light reflexes. Equal motoric and sensoric strength.
57
At secondary survey :
There is deformity at the right mandibular, and much blood clot at the oral
region. There is hematoma at the right temporal.There is bruising and crepitation in the
left thoracic side starting from the 4-6 th thoracic ribs, but normal vesicular breath
sound. Clear abdomen There is lacerated wound at the lumbal area at approximately 3rd
lumbal, base of the wound is subcutaneous fat, irregular edge, size about 3x4x2cm, no
active bleeding. There is lacerated wound and deformity at the left femoral area, with
base of the wound is anterior quadriceps muscle, irregular edge,size about 5x4x3cm,
there is continuous bleeding from the wound.
1. Review the primary survey, the assessment and therapy that done in primary
survey.
2. Review the secondary survey, the assessment and therapy that done in
secondary survey.
3. In concordance with primary and secondary survey, ask the student for history
taking for the multiple trauma patient : Mechanisms of trauma, Injury sustained,
and Degree of Trauma(MIST)
4. Be able to identify possible sources of decreased consciousness ( intracranial or

extracranial ( possibility of extracranialpathology that caused decreased of
consciousness: intraabdominal, skeletal, intrathoracal,retroperitoneal ) ) on a
clinical basis and to describe the identifying clinical features of each.
5. Develop hypothesis generation and diagnostic reasoning process for decreased

of consciousness due to hypoxic condition, caused by unclear airway, multiple
fractures at the left thorax, hypovolemic shock due to open femoral fracture,
accompanied with epidural hematoma.
6. Provide a management plan based on ATLS consideration ( ABCDE)
58
Teaching Diagnostic Reasoning for Patient with Multiple Trauma
Doing the primary survey and quick history taking
Periodically during patient history or role-play for history taking, the preceptor will
check the inquiry process by asking questions while the student is obtaining data for an
illness script, as these questions explore the process of hypothesis development :
o What is important to do with this acute, multiple trauma patient, and how you
will provide quick and live saving management for the patient?
o What is the main problem in the primary survey in this patient?
o What information do you want from history taking?
Doing the secondary survey
What is important to do with the secondary survey, and how will you find the
possible cause of hypoxia in the secondary survey?
Follow the framework clinical reasoning
o Let’s review the possible cause of hypoxia, considering the Mechanism of

Trauma, Injury sustained and Degree of Trauma.
o How will you manage the hypoxia at this patient?
59
Possible Diseases Hypovolemic shock(3rd/4th grade, might be rapid response, transient

response and no response) due to suspected open femoral fracture, with epidural
hematoma possibility in the right temporal, suspected thoracic ribs fracture at the level
of 4-6th thoracic ribs,lacerated wound at the lumbal region, with suspected right
mandible fracture
Possible disease:
Hypovolemic shock(3rd/4th grade, might be rapid response, transient response

and no response) due to suspected open femoral fracture, with epidural hematoma
possibility in the right temporal, suspected thoracic ribs fracture at the level of 4-6th
thoracic ribs,lacerated wound at the lumbal region
Clinical diagnosis of this condition is made by :
There is clear sign of hypoxic condition due to multiple trauma due to high
impact injury, with mechanism of trauma: falling from 5 stories. Signs of injury
sustained is as explained in the secondary survey above. Degree of trauma is visible at
thoracic x-ray, Femoral x-ray, Lumbal x-ray,head CT Scan, and intracranial blood
volume could be measured with the head CT scan.
Management Options
List management options and reasons for choosing them
Principle:
1. To identify what grade is the hypoxic condition:
Compromised airway due to blood clot and right mandible fracture

Painful breathing due to left side multiple thoracic ribs fractures
Hypovolemic shock due to open femoral fractures
Epidural hematoma at the right temporal side
2. To identify the needs of surgical resuscitation. When the aggressive fluid

resuscitation and blood replacement failed for the hypovolemic shock, then the
patient needs surgery resuscitation.
Treatment options
60
1. Airway suction, if failed then consider endotracheal intubation, with barton sling
for the right mandible fracture
2. Oxygenation with face mask non rebreathing, ventilation if needed ( as seen in
the clinical condition and blood gas analysis result)
3. Aggressive Fluid Resuscitation and blood replacement ,along with control of
external bleeding ( compression of open femoral fractures with adequate
bandages)
4. Close monitoring of the GCS and pupil size along the resuscitation. If there is sign
of intracranial hypertension, probably burrhole drainage is needed.
5. Surgical Resuscitation :
When there is active bleeding from the femoral artery, probably surgical
control of the bleeding is needed.
When the epidural hematoma is expanding and there is adequate signs of
intracranial hypertension, burrhole drainage or craniotomy is needed.
Stimulating SDL
References
61
D. ASSESMENT
Grading and evaluation

Information from a variety of sources will be compiled in the evaluation and
grading of each student. The hospital coordinator at each site is responsible for
compiling the evaluations and using these evaluations along with the scores on
the examination(s) to assign the final grade. In the event of a disputed grade,
failing grade on any exam or any area of performance that was judged as “below
expectations”, the Course Committee will only assign a final grade after thorough
review of student performance.
The targeted grade distribution will be 10% Outstanding, 75% Excellent and
10% Satisfactory and Fail less than 5%.
Grades will be
– Exceed Requirement,
– Meet Requirement,
– Need Improvement and Fail.
Final Grade
30% of the grade will be based upon clinical activities as evaluated by primary
preceptor, division preceptor, attending, RMO, and nurses (global assessment)
30% of the grade will be based on OSCE
15% of the grade will be based on medical record evaluation
25% of the grade will be based on case presentation
Failure
Failing grades can be assigned based on:
a. Professionalism,
b. Unsatisfactory Clinical Performance or
c. Failure of the written exam(s).
In the event a student fails the OSCE Exam, the student will be allowed to repeat the
exam without repeating the course (assuming clinical performance was
acceptable). Failure to submit the rotation duty (Case Presentation/Refferat) will
result in failing to go through the OSCE. A second failure will require remediation of
the entire clerkship. If a student fails both of the exams will be reviewed on an
individual basis and the student may be asked to remediate the entire clerkship. If
a student’s performance is judged “below expectations” in any area on any final
evaluation, all of the evaluations and any other pertinent information about
student’s performance will be carefully reviewed by the Medicine Clerkship
Committee who will then determine the grade. If a student is assigned a grade of
Fail, he/she must follow the procedures outlined by the Medical School. If a
student’s performance on the clerkship was passing but marginal, further review of
the students overall medical school performance may be recommended.
62
Absence
Each student is assigned to a team and is expected to function as a responsible
member of that team. Any unexcused absence may result in a failing grade.
Absence for any reason but illness or emergency must be approved ahead of time
by the hospital coordinator. An opportunity to make up required work will be
provided when such absences are cumulatively less than one week in length.
Absence for more than two weeks for any reason will automatically result in the
student having to repeat the entire externship. Absences of one to two weeks
will be handled on an individual basis by the hospital coordinator and course
director. Prior approval from the hospital site coordinator is required. If for
some reason, a student misses the OSCE exam, the only option for taking this will
be to wait for the next administration 10 weeks later at the conclusion of the
next clerkship.
Preceptor performance indicator

a. Student’s pre and post test
b. Student’s case presentation
c. Student’s final exam
d. Internal medicine OSCE result
e. UKDI’s Graduation rate of UPH faculty medicine graduate
References
1. Schwartz Principles of Surgery, 9th ed.
4. Smith, Essential of Urology, 2009
5. Sabel, E. Essentials of Breast Surgery. 2009
6. Atlas for Human Anatomy. Sobotta 15th ed. ELSEVIER, URBAN & FISHER
63

Surgery Module (Penerapan 2)

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Surgery Module

Dr. Edwin RPL Tobing, dr., SpU

Student specific seminar

Step 1: Get a commitment

Step 2: Probe for supporting evidence

Step 3: Reinforce what was done well

Step 4: Give guidance about errors and omissions

Step 5: Teach a general principle

Student’s general Roles, Responsibilities, Obligations and Activities

Basic Surgical Knowledges Competencies

Level of Competency 1: recognize and explain

Level of Competency 2: diagnosis and referral

Level of Competency 3: diagnosis, initial management, and referral

3A. Non-emergency case

Graduated student able to manage a disease in non-emergency situation and

3B. Emergency case

Level of Competencies 4: diagnosis and complete independent treatment

Level of competencies 1: Knows and able to explain

Level of competencies 2: Knows how; had seen or demonstrated

Level of competencies 3: Shows; had performed or applied the skill under

Level of competencies 4: Does; perform the skill independently

Graduated student can demonstrate his/her ability to perform a medical skill by

4A: Achieved the medical skill after graduation

Note: red font indicate as possible in national OSCE case

3. Capillary refill time 4A

11. Lung contussion * -

List of Clinical Skills:

List of Clinical Skills:

List of Clinical Skills:

List of Clinical Skills:

List of Clinical Skills:

List of Clinical Skills:

1. Self-Breast examination education 4A

List of Clinical Skills:

List of Clinical Skills:

Students will be able to :

Risk for Catheterization

Process of Urinary Catheterization

1. Determine the need of indwelling urinary catheterization for the patient

1. Put all the sterile equipments in the sterile area

5. Stand in the right side of the patient

10. Secure the catheter using adhesive tapes.

Things to do after the procedure:

1. Acute Abdominal Pain at Right Lower Quadrant

Diagnostic Reasoning for Acute Appendicitis

Doing the physical exam

Framework for clinical reasoning:

o For Male Patients

Information and Take home points : Principles and Concepts

o Ruptured ectopic pregnancy

o Torsion of the ovarian cyst

o Pelvic Inflammatory disease

o Renal/ Ureter colic due to ureterolithiasis

For Male Patients

Diagnostic Reasoning for Inguinal Hernia

Doing the physical exam

Framework for clinical reasoning

For Male Patients

Information and Take home points: Principles and Concepts

Distinguishing Features of Illnesses

3. Enlargement of inguinal lymph node

For Male Patients

Diagnostic Reasoning for Breast Lump

Doing the physical exam