Collection Manual

CLINIC & LABORATORY SKILLS

TROPICAL MEDICINE

Presented at The Grade VI

Student of Medical Faculty Hasanuddin University

MEDICAL FACULTY
HASANUDDIN UNIVERSITY
2010

CONTENTS
1. Preface:
2. List authors
3. Order
4. 1st Manual Anamnesis of patches on the skin
patient
Learning objectives
Description of activities
Step of activities
Examples of patient status
Checklist
5. 2nd Manual Physical examination of patches on the skin patients
Learning objectives
Description of activities
Step of activities
Examples of patient status
Checklist
6. 3rd Manual Skin Scratch
Learning objectives
Description of activities
Step of activities
Examples of patient status
Checklist
7. 4th Manual Skin Liquid Smear
Learning objectives
Description of activities
Step of activities
Examples of patient status
Checklist
8. 5th Manual Peripheral Blood Smear
Learning objectives
Description of activities
Step of activities
Examples of patient status
Checklist
9. 6th Manual Feces Smear
Learning objectives
Description of activities
Step of activities
Examples of patient status
Checklist

PREFACE
Manual collection of clinical and laboratory skills is given to the students who take a
course in Tropical Medicine in the sixth semester and the instructors who accompany
students on these skill activities. General instructional purposes

and specific

instructional objectives are presented in each module intended for students and
instructors to know the learning objectives of each manual in order to achieve the
expected minimum competencies.

Description of activities to be conducted at each skills training is equipped with time

allocation, so that the use of 90 minutes for each exercise can be used as efficiently as
possible. Step of activities is a step by step activity that should not be exchanged one
another so that the consistency of the flow of skills is chieftained.

Each manual is equipped with work sheet so students can record the activities which
are undertaken during the skills training, instructors are expected to check this work
sheet at the end of activities. Students Attendance in the skill training will be
equipped with assessment column.

Some things related to activities such as orderliness, schedule of activities, division of

space, and instructor's name are also attached to this set of manual skills.

This manual collection is still far from perfection, a construction criticism is needed
very much

Makassar, April 1th

2010

Tropical Medicine

Editor
1 st Manual
Anamnesis patient patches on the skin
Editor: Sri Vitayani & Sitti Wahyuni
2nd Manual
Anamnesis patient patches on the skin
Editor: Sri Vitayani & Sitti Wahyuni
3rd Manual
Scratch Skin
Editor: Muh. Nasrum Massi, Baedah Madjid
& A.R. Sultan
4thManual
Skin fluid smear
Editor: Muh. Nasrum Massi, Firdaus Hamid & Baedah Madjid
5th Manual
Peripheral blood smear
Editor: Sitti Wahyuni
6th Manual
Faeces smear
Editor: Sitti Wahyuni

RULE OF CLINICAL SKILLS & LABORATORIUM

Students who follow this activity are required:
1. Reading the manual skills of the previous clinical and laboratory.
2. Attending on time.
3. Can prove his identity during the exercise took place (the entire face visible)
4. Wearing a lab coat and appropriate signage absenteeism
5. Neatly dressed and polite.
6. Actively participate in skills training activities.
7. Do not do activities that have not relation with skills training activities.
8. Do not put other items on the table except manual labor and skills training
materials
9. No damage to materials and skills training tools. Any damage must be
replaced within a maximum period of one week.
10. Leaving skills training room in neat and clean condition.
11. The above rules are applied since entering the corridor of an integrated
laboratory skills lab at the first and second floors.

MANUAL 1
ANAMNESIS SKILL
PATIENTS WITH MAJOR COMPLAINTS IN PATCHES ON THE SKIN

LEARNING OBJECTIVES
General Instructional Objectives
At the end of the exercise of these skills, students are expected to do anamnesis that
led to the diagnosis of tropical diseases in patients with major symptoms of patches
on the skin.
Specific Instructional Objectives
1. Capable and skilled to communication with patients
2. Capable and skilled to foster a sense of connection and provide a sense of
empathy.
3. Capable and skilled to get information about patches on the skin is experienced
by patients.
4. Capable and skilled to conduct guided anamnesis that lead to the diagnosis of
tropical diseases with major complaints of patches on the skin
5. Capable and skilled to provide information to patients regarding further action
will be carried out based on the anamnesis has been collected.
6. Capable and skilled to make a resume of all information obtained in the
anamnesis with the chief complaint of patches on the skin.
INDICATIONS
Patients with symptoms of patches on the skin with suspect :
- Leprosy
- Bacterial infection of non leprosy
- Fungal infections
- Viral infection
- Parasitic infection
- Non-specific skin disorders
MATERIALS AND TOOLS
- Desk
- Chair of patient
- Chair of doctor
- Status Book of patients with anamnesis sheet.

ACTIVITY DESCRIPTION
Activity
l. Introduction

Time
5 minutes

2.
Demonstration

20 minutes

3. Practice role 55 minute

playing with s
feedback

Brainstormig
and
Discussion
Total time

Description
Introduction
- The instructor explained about the objectives of
these skills
- The instructor show materials and tools for these
Skills
1. A student acts as patients
2. Mentor shows how to get information about the
patches on the skin experienced by patients
3. Mentor shows how to do anamnesis that lead to
diagnosis of tropical diseases with a chief complaint
of patches on the skin.
4. Mentor shows how to inform to the patient regarding
further action will be done based on the results of
anamnesis have been collected.
5. Mentor shows how to create resumes from all
information obtained in the anamnesis with the chief
complaint of patches on the skin
6. Students are required to ask about the things which
are not clear related to the these skills activities

1. Students are divided into pairs, one of them acts as a

doctor and another one has a role as a patient
2. Person who acts as the doctor performed the following
activities: get information about the patches on the skin
experienced by the patient, performing anamnesis that
lead to the diagnosis of tropical disease with a chief
complaint of patches on the skin, inform the patient
about further action to be performed based on
anamnesis results have been collected and make a
resume of all information obtained in the anamnesis
with the chief complaint of patches on the skin
3. Role exchange
4. Mentor rounds among students and does a supervision
5. Mentor corrects the things which are not perfect

10 minutes Students are given the opportunity to put opinions about

the activities undertaken
90 minutes

STEP OF ACTIVITY
NO. Activities undertaken
Preparation of patients
1
Please let the patient came into the room.
2
Greet patients and their families with great familiarity.
3
Introduce yourself while shaking the patients hand.
4
Please let the patients and their families to sit down.
5
Show empathy for patients.
Provide general information on the patient or family about the anamnesis you are going to do,
6
objectives and benefits to the patient anamnesis.
Provide assurance to patients and their families about the confidentiality of all information
7
obtained on the anamnesis.
Tell us about the patients rights to the patient or his family, for example the right to refuse to
8
answer questions which he considers one does not need to answer.
General Anamnesis
9
Ask patient's personal data: name, age, address, and occupation
Ask what is causing the patient comes to the doctor (chief complaint).
10
For heteroanamnesis, ask the patient relationship with the people who accompany them
introduction.
Guided anamnesis
Ask any skin abnormalities began to appear, whether arising lost, settled, where a location
11
initially and then where they appear.
12
Ask whether or not accompanied by fever
13 Ask whether or not accompanied by itching.
14 Ask if there are patches on the skin with an insect bite or injury (trauma)
15 Ask whether this was accompanied by cramps, patches on the skin or sore. If there is, ask:
- When these things begin to happen, whether or not happen suddenly.
- Nature of pain or cramping: mild, moderate, severe; intermittent or continuous; higher in the
morning, afternoon or evening; attack with a certain interval; only at one place or feels like
ants moving.
- Is there pain bones, artralgia, myalgia, anorexia and malaise.
- Tenderness in the arms and legs.
- Wounds in the palms of the hands or feet
16 Ask whether or not the patient had experienced similar complaints in the past.
17 Ask a history of the same disease in the family or the neighborhood where one lived.
18
19

Ask a history of contact with the victims of the disease with similar symptoms
Ask your medical history has ever been received from a doctor and purchased his own
medicine by a patient without a prescription
Ending anamnesis

20

Explain to patients that this phase is just the beginning phase of a series of checks to know the
patient's illness: and physical examination is still needed to refine the diagnosis.

21

Create a resume of the results of anamnesis

Divide up all the results obtained in a tabulation

22

Create one chief diagnosis and differential diagnosis of the anamnesis result

Student activity sheets

EXAMPLES OF PATIENT STATUS SHEET
No Register:
Name:
Sex:
Age:
Ocupation:
Address:
Date/hour:

ANAMNESIS (relationships with patients .....................................if

heteroanamnesis)
Chief complain :
Guided Anamnesis:

Student activity sheets

Summary:

Diagnosis anamnesis:

CHECKLIST MANUAL 1
ANAMNESIS SKILL
PATIENT WITH MAJOR COMPLAINTS IN PATCHES ON THE SKIN
NO.
Activities which are appraised
Check up Preparation
1
Perform a sense of connection with patients and their families.
2
Make an informed concent to the client and his family.
General anamnesis
3
Exploring the client's personal data: name, age, address & occupation
4
Asking four chief reasons to come to the doctor
Guided anamnesis
5
Exploring the history of the disease based on five chief complaints.
6
Exploring other symptoms that accompany the chief complaints
7
Exploring the history of similar illness in the family or neighborhood environment.
8

Exploring the history of contact with patients with symptoms of patches on the skin

9
Exploring the history of medicine has ever been received / used
Ending the anamnesis and creating a resume
10

Explaining to the client that this phase is just the beginning phase of a series of examinations to be
able to know the illnesses is suffered by patients: and physical examination is still needed to refine
the diagnosis.

11

Composing the results of anamnesis and make its resume.

Note: The above list contains activities will be assessed on the skills test in which the instructor was asked for
giving assessments to students for eleven checklist above (see sheets of student assessment)
Score:
0 if not done
1 if it is done but yet satisfying
2 if satisfactory
Examples of student assessment sheets for the manual first
No
Name
Student
number
1 2 3 4 5 6 7
1
2

Aminah

2007000C4 2
3

Activities
10 11
2

Total
20

3
4
20
Scoring for the first manual
Total value of the lowest 0, highest value 22
Score 0-11: unskilled
Score 12-22: skilled (graduate CSL, this value will still be scored to C,B &A )

MANUAL 2
SKILL OF PHYSICAL EXAMINATION
CHIEF COMPLAINT OF PATIENT WITH PATCHES ON THE SKIN
LEARNING OBJECTIVES
General instructional objectives
At the end of this skills exercise, the students are expected to perform physical
examinations that led to the diagnosis of tropical diseases with chief complaints of
patches on the skin
Specific Instructional objectives
7. Capable and skilled to communicate with patients.
8. Capable and skilled to explain the physical examination will be conducted.
9. Capable and skilled to prepare patients before physical examination.
10. Capable and skilled to assess patient status in general and measuring vital
signs.
11. Capable and skilled inspection done in a systematic physical examination to
diagnose a patient with a chief complaint among other patchess on the skin by
checking:
a. Skin effloresensi.
b. Signs of dryness and cracked skin.
c. Sensitivity on the part of skin lesions
d. Palpability peripheral nerves in a symmetrical right and left, to see the
existence of nerve enlargement, its consistence, there is tenderness and
dysfunction nerve.
12. Capable and skilled to inform results found, required investigation and
treatment plan to patient / family.
13. Capable and skilled to make a resume for patient records

INDICATIONS
Patients with suspect:
1. Leprosy
2. Fungal infection
3. Bacterial infection
4. Viral infection
5. Parasitic infections
6. Non-specific skin disorder

MEDIA AND LEARNING TOOLS

Water flow
Liquid Soap
small towel
Thermometer
Stethoscope
Tensimeter
magnifying glass
Tape measure height and weight
Cotton which is sharpened in one its edge.
Sterile needle immersed in alcohol
Two reactions tubes, each containing hot water and cold water
Video, slides or drawings to show typical clinical signs in some tropical
diseases that give a patches on the skin.
medical and non-medical tpatches can
Status book of the patient to record the results of physical examination
ACTIVITY DESCRIPTION
Activity
1. Introduction

Time
5 minutes

2. Demonstration

15 minutes

Description
Introduction
- The instructor explained the purpose of this skill. Instructors
demonstrate the materials and tools necessary to perform these skills.
7. A student acts as patients.
8. Mentor shows how to prepare patients before physical
examination.
9. Mentor shows how to conduct assessment of patient
status and measuring vital signs.
10. Mentor shows how to conduct examination
systematically to physical diagnosis to the patient with
the chief complaint of patches on the skin such as by
examining:
- Skin effloresensi.
- The signs of dryness and cracked on skin.
- Sensitivity on the part of the skin lesions.
- Peripheral nerves in a symmetrical right and left, to
see the existence of nerves enlargement, its
consistency, there is tenderness and neurological
dysfunction (mentor shows the audiovisual how
examination of peripheral nerves).
11. Mentor shows you how to inform the results
found, investigation

11

required and a treatment plan to patient / family

12. Mentor shows how to create a resume for
patient records
13. Students are required to ask the things which are
unclear in relation to skill activity.
3. Practice role playing 55 minutes
with feedback

6.
7.

8.
9.
10.

4.Brainstorming and
discussion

10 minutes

Total time

90 minutes

Students are divided into some pairs , one

person acts as a doctor and one person
acts as a patient.
Person who acts as the doctor performed the following
activities: explains the physical examination will be done,
prepare the patient before physical examination, assessing
patient status in general, and measuring vital signs, perform
physical examination in a systematic physical examination to
diagnose patients with complaints of the chief patchess on the
skin (skin effloresensi, signs of dryness and cracked skin,
sensitivity on the part of the skin lesions, peripheral nerves are
symmetrical right and left, to see the existence of nerve
enlargement, its consistency, tenderness and neurological
dysfunction), inform results are found, the investigation
required and a treatment plan to patient / family and make a
resume for archives patient
Role exchange
Mentor walk rounds among students and do a supervision
Mentor corrects the things which are not perfect

Students are given the opportunity to put forward opinions about the
activities undertaken.

12

STEP OF ACTIVITIESS
No.
1
2
3
4
5
6
7
8
9

10
11
12
13

14

15

16

Activities undertaken
Preparation of patients
Explains the physical examination will be conducted, its purpose and benefits
Giving assurance to patients and their families about the confidentiality of all information obtained
on the physical examination.
Explaining about the rights of patients or their families, for example concerning the right to refuse
to be examined.
Please the patient to put off all the clothes and make sure the patient gets good light during the
physical examination.
Standing on the right side of patient.
Assessment of overall patient status and vital signs
View and record the general condition of patients: mild pain, moderate pain or severe pain.
Determine the nutritional status: height and weight measurement (in accordance with the manual to
determine the status of a nutrient).
Measure and assess patient vital signs: blood pressure, pulse, respiration and temperature.
Look at the entire patient body from top to toe:
- whether there is thinning of scalp hair and eyebrows.
- whether there lagophthalmia in the eyelid.
- whether the patient's nose dropped (sadle nose).
- areas where patchess are located
Check there is any enlargement of the liver, edema of the legs, wounds in the legs
Examination of patches on the skin
Where these patchess location are
Look at the effloresence type: erythema, hypopigmentation, hyperpigmentation, vesicles nodules,
blister, macular papules, squama, urtika, ulceration, crusting
If the entire surface of lesions is flat, note whether the skin surface is dry or wet, and the presence of
fine hair.
Sensitivity test
Using a sharpened tip of cotton:
- Touch the skin of normal patients with a sharpened tip of the cotton, and a little bent.
Allow the patient to see what and where you do it.
- Ask the patient to see to another direction and do the touch with cotton at first on a normal
region, and in the regions are alternating patches. Ask whether or not the patient felt the
touch.
- Ask patients to showed part of her body touched. Record whether or not in accordance with
section which is touched.
- Take the assessment test results of the touches.
Doing lightly puncture with the tip of the needle:
- Do the same test with lightly puncture by using a sterile needle, firstly on
normal skin area. Allow the patient to see what and where you do it.
- Close the patients eye and do lightly puncture in normal area first , then in
alternating patches area.
- Do the assessment results of puncture tests.
Using hot and cold tubes:
- Do the same test using two tubes where each using two tube contain cold
and warm water. Doing first at normal skin area and ask for the patient to
see what and where you do it

13

close the patients eyes and put alternating both tubes to normal area first,
then at patches area.
- Doing result assessment of tube test you have done.
Examination of peripheral nerves
17

N. Auricularis magnum:
Ask the patient to turn his face into the direction opposite from the side which
will be checked, while looking toward the shoulder.
- Keep a notice whether visible or absence of enlargement of N. Auricular
magnum.
- If the enlargement of the nerve is not visible, do remain palpation by maintaining
a position like that, scan the area with palpability upper neck of the patient,
from craniolateral to caudomedial direction.
- Feel the presence or absence of this nerve thickening.

18

Inspection N. Radialis:
- Ask the patient to bend his arm so as to form an angle of 60 C at the elbow.
- Calm the patient down and instruct him to relax his muscles.
- Touch and trace the lateral third of the upper arm area roughly between meeting
area. Triceps brachii caput longum and lateral.
- Feel the presence or absence of this nerve enlargement. Look at the expression
on the patient to know the sensitivity of this nerve

19

Inspection N. Ulnaris:
- Hold the bottom of the right arm of patient with your right hand.
- Put elbows slightly bent so that the patient's arm will be relaxed.
- Use the index finger and middle finger left hand to search while touching N.
ulnaris in nervi ulnaris sulcus (indentation between the bones bulge elbow and a
small bulge in the medial = medial epicondylus)
- Feel whether or not there is nerve enlargement.
- Give a little light pressure on N. Ulnar while tracing it to top direction smoothly,
see the expression whether or not looks pain.

20

.Inspection N. Medianus
- Ask for the patient to clench his hands (not too tight), while slightly difleksikan.
- Scan the area between the tendo m. Palmaris longus tendon and m. Flexor carpi
radialis longus with your fingertips.
- Feel if there is enlargement. While touchinglook at the patients expression

14

21

Inspection N. Peroneus communis (lateral popliteal nerve)

- Have the patient sit on the edge of the bed with legs dangling relaxed.
- Sit in front of the patient with a right hand checks the left foot of the patient and
left hand checks the right foot of the patients.
- Put middle finger and your index finger on the outside of the mid-calf patients.
- Touch slowly upward until it finds a lump of bone, (caput fibula).
- After that Touch peroneus nerve approximately 1 cm from the lump into bones
the rear top.
- Rolling the nerve with mild pressure to the left and right are interchangeably.
- Feel the absence of enlargement.
- While touching look at the expression of the patient.
- Patients were asked to sit idly dangling.
- Touch N. Posterior tibial artery at the bottom of the rear side of ankle deep.
- Feel the absence of enlargement.
- While touching look at the expression of the patient.

22

Mapping neural disorders:

Make a picture in the paper that has been provided, all found in nerve abnormalities.

23

Examination of nerve function impairment:

- Inspect the patient's eyelids to see any disruption of motor N. Facialis
-Check the feet to see the motor and sensory disturbances.

24

25
26
27
28
29
30

31

Helping the patient to wake up, to put on clothing and to allow one to re-sit.
Informing results found, investigation and treatment plan
Explain to the patient's family about the patient's examination results found.
Explain that for a definite diagnosis some supporting investigation are required.
Explain about the disease diagnosis, treatment plan, prognosis and complications.
Doing counseling by explaining about the disease (according to diagnosis), especially the one about
the success of therapy.
Explain the rules of treatment and make sure the patient or his preface to comply with a rule that will
be receiving treatment.
Say goodbye to the patient by giving hope to patients
Creating a resume for patient records
Write your resume in its entirety (the anamnesis, physical examination, a
temporary treatment given and the requested investigation) as
patient records.

15

Student activity sheets

EXAMPLES OF PATIENT STATUS

No Register:
Name:
Sex:
Age:
Occupation:
Address:
Date / hour: /

ANAMNESIS (the relationship with the patient.......................... if

heteroanamnesis)
The main complaint:
The guided Anamnesis:
Resume:
GENERAL CONDITIONS:
Vital signs: Blood pressure......mmHg; Nadi....../min, Respiratory:.... minutes;
Temperature.......oC
General conditions: pain mild / moderate / heavy
Nutritional status: height.......cm; weight.......kg; nutrition less/better/more
PHYSICAL EXAMINATION:
1.

Skin patches:
Effloresensi Type:
Surface:

Student activities sheets

2. Sensitivity test
Cotton test:
Needle puncture test:
Test tube:
3. Nerve circumstances:
Thickening N. Auricularis magnum:
Thickening N. Radialis:
Thickening N. Ulnaris:
Thickening N. Medianus:
Thickening N. Peroneus communis (lateral popliteal nerve):

16

Map of neurological disorders:

Nerve facialis

Nefrve medianus

Nerve auricularis
magnus

Nerve radialis

Nerve peroneus
Nerve tiabialis

Disfunction of nerve :

Summary :
Student activity sheets

Diagnosis:

Differential diagnosis :

Management: Th/

Editional examination :

17

EXAMINATION REFERENCE OF LEPROSY SUSPECT PATIENTS

A. Basic diagnosis of leprosy (leprosy)
Leprosy or leprosy diagnosis can only be enforced if found in one of the cardinal
sign (major symptoms).
The main symptoms of leprosy are:
1. Numbness of skin lesions
Abnormalities of the skin in leprosy can be in the shape of patches of
hypopigmentation or reddish (eritrematous), which was numb. May be less flavor
(hipestesi) or do not feel at all (anesthesia).
2. Significant thickening of nerve is followed by nerve function impairment
Thickening of the nerve occurs as a result of peripheral nerve inflammation
(peripheral neuritis).
Neuritis in leprosy can be accompanied with or without a
neurological dysfunction.
Functions nerve disorders that can occur:
a. Sensory dysfunction: anesthesia / hipestesi,
b. Motor dysfunction: parese or paralise,
c. autonomic function disorders: dry skin, cracking, edema, etc..
Neuritis in leprosy can be symptomatic pain, but sometimes there is no pain,
known as
silent neuritis.
3. Positive acid resistant bacillus
Examination materials to notice a smear taken from a liquid preparation made by
direct
skin (skin smear). This material is usually taken from the ear lobe or from
the active part (edge) of a lesion on the skin. Sometimes the material was taken
with a skin or nerve biopsy.
B. Diagnosis
For the diagnosis of leprosy was found in a person must be at least one of the
cardinal sign above. If one cardinal sign is not found, it should only be diagnosed
as a suspected leprosy = leprosy. Such patients should be observed and
reexamined after 3-6 months until the diagnosis of leprosy can be enforced or
removed.
C. Clinical symptoms
a. Early Signs of Leprosy Disease (leprosy)
1. Skin disorders
Changes in skin color such as white spot like white blotches,
Can be infiltrates shape
Can be nodules shape
2. Nerve Disorders Edge
Real nerve enlargement accompanied by numbness, and / or muscle
weakness in areas that are supplied (eyes, hands, feet), or sometimes in the
form of tender.
b. Signs of Leprosy Disease (Leprosy) Continue.
If untreated leprosy early is not medicated or found lately, it will be found
a more severe clinical symptoms.
18

1. Skin disorders
The number of patches on the skin grow much, much thicker and red
spots. The skin becomes more dry.
2. Nerve Disorders
Thickened nerves with nerve function impairment, and tenderness, may
occur on one or more peripheral nerves. Therefore, peripheral nerve
function is disrupted, the skin is numb when taxable collision will cause
wounds (ulcers on the palms of the hands or feet), dry skin can crack.
Further disruption muscles moving the fingers and toes (kiting / clawing).
Symptoms continued: Nose to collapse, gynecomasty madarosis and
lagophthalmus. \
PHYSICAL EXAMINATION OF LEPROSY SUSPECTED PATIENTS
Doing an examination in a room that gets enough sunlight lighting.
Examination must be done systematically in which the patient sits facing the
examiner. Beginyour examination from head to toe, then the rear body start from
neck, shoulders, rear body, arms and legs.
Examination of skin on the entire surface of the client body by paying attention to
the client privacy.
Inspection numb
Inspection of anesthesia (numbness), or sensitivity testing using the following:
- Cotton and patients were asked for indicating the direction of movement of
cotton.
- Pick a light sterile needle to determine the pain experienced by patients.
- Hot and cold reaction Tubes to determine the response to temperature.
- Compare between one lesion with other lesions.
Sensitivity test conducted alternately in the area of normal skin and skin
lesions
Make sure the patient does not see the area is touched or punctured.
Sensitivity test used to assess how much nerve damage that occurs in
patients. While the enlargement of the nerve test to assess how much of the
peripheral nerve fibers involved and damaged in the disease. Both these tests are
often performed in patients suspected of leprosy. Ballpoin or bike bars, can be used
to assess peripheral nerve disorders based on its nerves area.
Examination of peripheral nerve enlargement
Peripheral nerve examination should be conducted systematically and carried out on
the right
limb and left.
Feeling nervous or palpation should be conducted in such a way that does not hurt
patient or not a good impression on patients. Fingernail examiner should not be long.

19

In this examination the patient should be in calm condition with attenuated muscle.
Find a place that will be examined peripheral nerves. Then rubbed and Taste
referred to the enlargement of peripheral nerves.
Check as many as possible peripheral nerves are frequently involved in leprosy.
Make the picture on the paper has been provided.
1. Inspection N.Auricular magnus
In addition to the palpability, in most cases, the enlargement N. Auricular magnus
can be found by inspection.
2. Inspection N.Radialis
Is the most difficult Nerve to be touched because it was not superficial palpable as
other nerves that are often involved in leprosy. To feel it browse the lateral third of
the upper arm about a meeting between regional m. Tricep brachii caput longum and
lateral.
3. Inspection N. Ulnaris
This nerve is difficult to touch from the outside, because it required proficiency of
the examiner to be able to feel it.
4. N. Median Inspection
This nerves is rather difficult to Palpated because lie between the deep and two
tendon (M.Palmaris longus and M.Flexor carpi radialis longus).
To be able to distinguish easily the thickened / enlarged nerve, it is required a
normal nerve palpation experience on healthy people.
CHECKLIST MANUAL 2
PHYSICAL EXAMINATION SYSTEMATIC
COMPLAINTS OF PATIENTS WITH SKIN SPOT ON
NO.
1
2
3
4
5
6
7
8
9
10

Activities that are considered

Preparatory examination
Do connect with patients and their families feel.
Take through the informed concent to patients and their families.
Assessment of general condition and skin
Perform thorough skin examination.
Examination of other organs such as eyes, nose and heart patients.
Verifying the existence of thinning hair and eyebrows.
Examination of skin patches
Location and type of effloresensi.
How is lesions surface: dry, wet, presence or absence of fine hair.
Sensitivity test
With a cotton tip
With the tip of the needle
With tube

20

MANUAL 3
SKILLS OF TAKING, MAKING AND CHECKING WET PREPARATION
AND PREPARING SKIN SCRATCH DELIVERY
LEARNING OBJECTIVES
General instructional objectives
After completing this training, students are expected to perform retrieval and
delivery of skin scratch properly, correctly and efficiently.
Specific instructional objectives
After doing the exercises these skills, students are expected to be able to:
1. Do preparation of patients correctly
2. Prepare equipment / materials correctly
3. Make good relation with patients
4. Give inform concent to patients correctly.
5. conduct regular hand washing and asepsis correctly
6. Install sterile gloves correctly, and release them after the work is completed.
7. Perform capture of the scratch skin correctly
8. Make preparation and delivery of skin scratch correctly
INDICATIONS
Patients with skin lesions which is suspected to suffer dermatomikosis.
TOOLS AND MATERIALS REQUIRED
Flow water
Spiritus Lights
Liquid Soap
Paper sterile Petri dish or is a minimum size 10
x 10 cm
Antiseptic solution
small towel or tissue in a folded state.
Cotton
Sterile gloves
Scalpel (knife handles size
2 pcs Lisol solution containing 5%
No.3 and the blade no. 15)
Medical trash
Alkohol70%
Non-medical trash
REFERENCE
Scratch up ward with a slope of 30 - 45 using a sterile scalpel.
Locations scraped the edge of the lesion which is part of the most active
part and covered with scales.
TOOLS AND MATERIALS ARE REQUIRED FOR MAKING &
EXAMINING DIRECT BLOOD SMEAR OF SKIN SCRATCH
Flow water
Inoculated Needles
Liquid Soap
10% KOH solution
Antiseptic solution
Pipette
Small towel or tissue
Fold the paper sterile / sterile petri dish
Cotton
Binocular microscope
70% Alcohol
2 pcs khlorin0 basin containing solution 5%
Lights spiritus
Cover glass
Glass Objects
permanent markers
Medical trash
Non-medical trash
22

ACTIVITY DESCRIPTION
ACTIVITY
1.Introduction
2. Demonstration

Time
5 minutes
20 minutes

DESCRIPTION
Introduction
1. Organize students seated position
2. Two instructors give examples how to retrieve, create
and examining wet preparat (blood smear), and
preparing skin scratch delivery. Students pay attention /
watched a demonstration by using learning manual.
3. Give opportunities for students to ask questions and
instructors give explanations about important aspects

3. Practice role playing 55 minutes

with feedback

2. Students are divided into pairs. An Instructor is needed

to observe every step taken by each spouse.
3. Simultaneously, each pair of practices take steps to
capture and scratch delivery skin preparation
4. Instructors around between pairs of students who are
doing practice to conduct supervision and use a
checklist to assess student work.
5. If there are errors instructor, immediately work
procedures shows again pass up the right way.
6. Instructors provide questions and feedback back to each
pair

4. discussion

10 minutes

1. Brainstorming / Discussion: Which one is easy? Which

one is difficult? Ask about students feelings at the time
of scratching the skin. What can be done by doctor to
patient feel more comfortable?
2. Instructors make conclusions by answering the last
question and clarify things are still not understood.

Total time

90 minutes

23

LEARNING GUIDE

SKILLS OF TAKING, MAKING AND CHECKING WET PREFARAT, AND PREPARING

DELIVERY OF SKIN SCRATCH

NO.
STEP / ACTIVITY
PATIENT PREPARATION
1.
Greet clients or their families friendly and introduce yourself, and ask their conditon.
2.
Please clients and their families to sit
3.
Give general information on the client or his family about making scratch, purpose and the benefit to
the client circumstances.
4.
Give assurance to the client or his family about the security checks performed
5.

Give assurance to the client or his family about the confidentiality required by the client

6.

Explain to the client about the rights of clients or their families, for example the right to refuse taking
skin scratch.
Ask your client's willingness to oral examination of skin scratch

7.

PREPARATION OF MAKING SKIN SCRATCH

8.
Prepare all the necessary tools and materials on a table near the patient
9.
Write the register number / patient data on the back of the glass objects, petri dish or on the outside of
the sterile paper folds.
10.
Ask the patient to sit or lie down (depending on the location of specimen collection)
11.
Wash your hands regularly
12.
Put sterile gloves
MAKING SKIN SCRATCH
13.
Check the location of specimens well
14.
Do disinfection of the skin defect with alcohol 70% starting from the middle of an abnormal area in a
circle to the edge of the skin disorder that would be scratched.
15.
Take a new alcohol cotton and do skin disinfection in the area around the lesion started from the
outside to the inside.
16.
Making scratch with a sterile scalpel lesion edges upward with a slope of 30 - 45
17.
Open the folded paper cup or lid
18.
Knock scalpel at the base of the Petri dish or on the surface of sterile paper that had been prepared
until all the scales and the flake of skin scratch falls on the surface of paper or a petri dish .
19.

Insert a scalpel which has been used in the basin contains 50-10% lisol

MAKE AND CHECK WET TABLET FROM SKIN SCRATCH

20.
Put one glass flat objects with Register number / patient data on the back.
21.
Drop 1-2 drops of 10% KOH solution
22.
Dampen the tip of the needle inoculation with KOH solution and then take one or more bits of skin on
the bottom plate dish, and insert in KOH solution on the surface of glass objects
23.

Cover a glass cover on the liquid droplets with caution, so that no air between the glass objects and
glass cover.

24

24.
25.

Fit horizontally on the microscope table.

27.

Close the microscope diaphragm as small as possible and derive the microscope condenser (if any) as
low as possible.
Look under the microscope with an objective lens 10 times. Rotate macrometer to obtain a clear
image.
Find the object by looking at the edge of the liquid droplets.

28.
29.

After finding the object, change the object lens to 45 times magnification.
Record what you see: epithelial skin, spores, hyphae.

26.

AFTER WORK OUT

30.
Wipe the desk with a cloth dampened with a solution of 50-10% lisol
31.
Take inventory and write this directly in a bowl lisol
32.
Wash hands who still wear gloves with a solution of 5% lisol
33.

Open up the gloves and throw into medical trash.

34.
35.

Do wash your hands asepsis.

Say thank you and goodbye to patients with good wishes recovery soon

PREPARATION SKIN SCRATCH DELIVERY

36.
Check the security of the skin scratch: stick cap with a folded paper tape Sello.
37.

38.

Write the introduction of the skin scratch delivery for laboratory containing:
Personal data of patients,
Examination request: microscopic or / and culture
An explanation of the local use of anti-fungal or other drugs: what drugs are
used and when to stop.
The folding of paper inserted in an envelope and sent in room temperature together with a letter
envelope of introduction to the laboratory.

Student activity sheets

EXAMPLES OF SKIN SCRATCH EXAMINATION SHEET RESULTS

No:
Date:
Name:
Sex:
Age:
Address:
Occupation:
The main complaints:

The result of skin scratch examination:

25

Student activity sheets

EXAMPLE REFERENCE GAZETTE

Dr. Sanusi Perangin Angin
Praktice permission No. 1234567
Practice address: Kebangkitan street no. 27
Telephone No.: 0411-275634

Makassar,
Designation:
At........................

In Sincerely,
Sent patient's skin scratch:
Name:
Sex:
Age:
Address:
Occupation:
The main complaints:

Thank you,

Dr. Sanusi Perangin Angin

26

CHECK LIST
TAKE, MAKE AND CHECK WET PREPARAT AND PREPARE SKIN
SCRATCH DELIVERY
Instructions

: Put an (V) in the appropriate box.

Give Score : (0) if not done, (1) if it is done but still not satisfactory, (2) if
satisfactory
NO.
ASSESSED ASPECTS
PREPARATION
1. Capable of connecting with patients and their families feel.
2.
3.
4.
5.
6.

SCORE
1
2

Able to give informed concent well.

Able to prepare the patient for retrieval and examination of
skin sctrach
Able to adjust lighting
Prepare all the necessary tools
Perform routine hand washing and wear gloves correctly

MAKE & CHECK SKIN SCTRACH

7. Conduct any skin sctrach
8. Saving the skin sctrach on the right folded paper
9. Doing the manufacture of wet preparat skin sctrach
10. Checking the wet prefarat in the microscope correctly

MAKING OUT AFTER SKIN SCTRACH

11. Conducting medical garbage disposal properly
12. Perform cleaning and disinfeksi job field correctly
13. Making a delivery preparation examination material
correctly.
14. Separate well with the Patients .

Commment / Summary :

Recommendation:

Instructor Signature ..........................................

Date:..

27

MANUAL 4
SKILLS OF TAKING AND MAKING SKIN SMEAR PREFARAT

LEARNING OBJECTIVES
General Instruction Objectives
After having this training, students are expected to be able to perform skin fluid intake and
make prefarat skin liquid (skin smears) well, correct and efficient.
Specific Instructional Objectives
After doing these exercises skills, students are expected to be able to:
1. Prepare equipment / materials properly.
2. Make sense of connection with the patient and or family well.
3. Make inform concent to patients and / or their families properly.
4. Conduct regular hand washing and asepsis correctly.
5. Wearing sterile gloves correctly, and put it out after the work is completed.
6. Perform skin fluid intake.
7. Making and store prefarat liquid of the skin (skin smears) correctly.
8. Prepare a prefarat skin liquid delivery properly.

TOOLS AND MATERIALS REQUIRED

Water flow

70% Alcohol

Liquid soap

Lights spiritus

Antiseptic solution to clean

Objects glass

Small towel or tissue

The basin contains a 5% solution Lisol

Cotton

Plasters

scalpel (knife handle No.3 and blade no.15)

medical trash
non-medical trash

28
28

INDICATIONS
Patients who have anaestesi skin patches (numbness) or with enlargement of one
peripheral nerves.

REFERENCE
Abnormalities of skin disorders in leprosy is usually a skin spot that can be red or whiter
than normal skin (hypopigmentation). This defect usually experienced anesthesia.
Good taking area is skin defect on the ear lobe or lobes nose. Or on the skin in other
places that show signs of leprosy.
Skin incision with a scalpel on the skin defect is only efforted up to the layer of dermis, in
case achieve coating subdermis because there are many blood vessels and nerve fibers in
that area. Blood on the stocks is very difficult to the discovery of acid resistant bacillus.
Leprosy bacillus usually gathered a lot at the ends of sensory nerves in the lining
dermis.

29
28

ACTIVITY DESCRIPTION
Activity
l.Introduction
2. Role playing &
answer question

Time
5 minutes
20 minutes

Description

3. Role playing
practice with
feedback

55 minutes

7. Students are divided into pairs, couples.

An instructor is required to observe every
step is taken by each couples.
8. Simultaneously, each pair practice these
steps taking and making skin liquid
prefarat (skin smear).
9. Instructors walk around between couple
of students who practice to conduct
supervision and use a checklist to assess
students work
10. If there are errors work procedures
instructor shows again pass up the right
ways soon.
11.The instructor gives questions and
feedback to each pair

4. Brainstorming /
Discussion

10 minutes

3. Brainstorming / Discussion: What is

perceived easy? What is difficult?
Asking how the students feel when they
slice skin. What can be done by doctor
so that the patient feels more
comfortable?
4. Instructors make conclusions
by answering the last question
and clarify the things are not yet
understood

Total times

90 minutes

Introduction
4. Organize students seated position
5. Two instructors give example of how to
retrieve and made directly from a liquid
dosage form skin. Students pay attention
to demonstration by using Learning
manual.
6. Give opportunities to students to ask
questions and instructors provide an
explanation about important aspects

30
28

LEARNING GUIDE
SKILL OF TAKING AND MAKING SKIN
SMEAR PREFARAT
NO.
STEPS / ACTIVITIES
PATIENT PREPARATION
1. Greet clients or their families with friendly and introduce yourself, and ask their
condition
2. Please clients and their families to sit
3. Give general information to the client or his family about making the skin
liquid, objectives and benefits for client condition.
4. Give assurance to the client or his family about the security check up
performed.
5. Provide assurance to the client or his family about the confidentiality required
by the client.
6. Explain to the client about the rights of clients or their families, for example
the right to refuse taking action skin liquid
7. Ask your client's willingness orally to take skin fluids
PREPARATION OF TAKING SKIN LIQUID
8. Prepare all the necessary tools and materials on a table near the patient.
9. Wipe the glass objects and write the lab number / patient data on the back of the
glass object
10. Ask the patient to sit in bright locations
11. Wash your hands regularly
12. Wear gloves DDT .
MAKING SKIN SMEAR
13. Choose the area for suspicious skin lesion, for example on the ear lobes or
nostrils
14. Take asepsis action by brushing cotton with alcohol 70% in the area to be used
as place-making, ranging from local to regional play edges.
15. Pinch the area strongly between finger and left thumb, so that the surface of the
skin becomes pale.
16. Make incisions with a sterile scalpel along the 0.5 cm with a depth of 1 2
mm (top layer only reaches the dermis).
17. Rotate the scalpel 90 with curry base side and wound up a kind of pulp tissue
obtained from the epidermis and dermis to be attached to the surface of the
scalpel.
18. Make a smear prefarat, with drops of examination material evenly on the
surface of glass objects.
19. Dry prefarat and then fication with the flame
20. Press the cut wound with cotton and cover it with plaster alcohol
AFTER FINISHING TO MAKING PREPARAT
21. Put off your gloves and throw into medical trash can
22. Do wash hand asepsis.
23. Put a rack of preparations in preparations or wrap the preparations with
tissue paper and put in envelope.
24. Write a letter reference to the laboratory

31
28

Student activity sheets

EXAMPLES OF RESULTS SKIN SMEAR PREFARAT

No

Date

Name

Sex

Age

Address

Occupation

The main complaints :

The result of skin smear examination

32

28

Student activity sheets

EXAMPLE REFERENCE GAZETTE

Dr. Sanusi Perangin Angin

Practice permission no. 1234567
Address practice: Kebangkitan street No. 27
No. Phone: 0411-275634
_______________________________________________________________________
___
Makassar,
Designation:
At..................

Sincerely,
Sent liquid of skin smear ..................

From a patient:
Name
Sex
Age
Address
Occupation
The main complaints

:
:
:
:
:
:

Thank you

Dr. Sanusi Perangin Angin

33
28

CHECKLIST
SKILLS OF TAKING AND MAKING SKIN SMEAR PREFARAT
Instructions: Put an (V) in the appropriate box.
Give Score: (0) if not done, (a) if it is done but still not satisfactory, (2) if satisfactory

NO.
ASSESSED ASPECTS
SCORE
PREPARATION
0
1
2
1. Capable of connecting with patients and their families feel.
2.
Able to give good informed concent.
3.
Able to prepare patients for making skin smear
4.
Able to regulate lighting
5.
Prepare all the necessary equipment
6.
routinely hands properly
MAKING SKIN LIQUID
7.. Determining the location of the specimen and disinfection
8.
Perform specimen collection correctly .
9.
Doing the manufacture of liquid dosage form of skin (skinsmear)
10. Perform decontamination of equipment which has been used
AFTER TAKING
11.
Making a preparation of delivering apus stocks.

Comment / Summary :

Coordinator signature/Instructure .............................

Student Name :

Recommendation :

Date:..

Stambuk number :

34
28

SKILL
DOING PERIPHERAL BLOOD TAKING,
MAKE A PERIPHERAL BLOOD SMEAR, MAKE
GIEMSA STAIN FOR PERIPHERAL BLOOD SMEAR
AND MICROSCOPIC EXAMINATION FOR PERIPHERAL
BLOOD SMEAR

EDITORS:
SITTI WAHYUNI

PRESENTED IN SEMESTER 6
TROPICAL MEDICINE SUBJECT
MEDICAL FACULTY HASANUDDIN UNIVERSITY
2010

28

SKILL
DOING PERIPHERAL BLOOD TAKING,
MAKE A PERIPHERAL BLOOD SMEAR, MAKE
GIEMSA STAIN FOR PERIPHERAL BLOOD SMEAR
AND MICROSCOPIC EXAMINATION FOR PERIPHERAL BLOOD SMEAR
LEARNING OBJECTIVES
General instructional objectives
After completion of this skills training, students are expected to be capable and
skilled bleeding edge, making the peripheral blood smear (thin and thick), made for
Giemsa staining peripheral blood smear and microscopic examination for peripheral
blood smear well and right.

Specific Instructional objectives

After doing the exercises these skills, students:
1. Capable and skilled to give explanations on the patient or family about what will be
done, tools are used, how to do, what are the benefits, and what possible risks & the
right of patients to refuse.
2. Capable and skilled to make a preparation of patients correctly.
3. Capable and skilled bleeding edge by using the Lancet.
4. Capable and skilled to do a thick blood smear.
5. Capable and skilled to do thin blood smear.
6. Capable and skilled to make Giemsa colouring.
7. Capable and skilled to do microscope inspection to identify parasites found on
blood smear prefarat.
8. Capable and skilled to calculate the intensity of Plasmodium infection
9. Capable and skilled to clean laboratory after completion of these skills.
INDICATIONS
1. Patients with suspected malaria fever, dengue infection or infection of filaria
2. Patients with symptoms of lethargic / weak

36
28

DESCRIPTION OF ACTIVITIES
Activities

Time

Description

1. Introduction

10 minutes

Introduction
- Instructor explain about the skill objectives
- Instructor shows material and tools
needed to perform this skill.

2. Demonstration

20 minutes

3. Practice of role
playing with
feedback

60 minutes

4.Brainstorming
and discussion

10 minutes

1. A student acts as patients.

2. Instructors demonstrate how to perform peripheral blood
taking by using the Lancet.
3. Instructors demonstrate how to create thick and thin blood
smear.
4. Instructors demonstrate how to create Giemsa Stain
5. The instructor shows way of microscope examination to
identify parasites found on blood smear preparations.
6. The instructor explains how to calculate the intensity of
infection Plasmodium.
7. Students are required to ask for things are unclear in
connection with the activities of these skills
1. Students were divided into four groups
2. Each group engaged in activities of peripheral blood
taking, make thick and thin blood smear, making Giemsa
Stain for blood smear and microscopic examination for
simultaneous blood smear
3. Mentors walk around among students and do a supervision
4. Mentor corrects things which are not perfect yet
Students are given the opportunity to express opinions about
the activities undertaken

Total time

100
minutes

MATERIALS AND EQUIPMENT

(for each student)
- 2 pieces of glass objects
- Lancet or sterile needles
- Gloves
- Permanent markers/ markers
- Cotton alcohol
- Dry Cotton
- Methanol Solution
- 3% Giemsa solution in phosphate buffer solution (pH 7.2)
- Bottled water containing
- glass objects Rack
- medical trash can
- Oil emersi binocular microscope
- Tissue lens

37
28

STEPS / ACTIVITIES
A

Preparation

Explaining to patients about the purpose of inspection and asked for approval.

Prepare all the necessary tools.

Peripheral blood-making activities

With a marker, write the patient's identity on the first glass objects
224
10/04/84

C
4

How to perform the peripheral blood sampling

Clean the ring finger or middle finger with cotton alcohol, let it dry.

Puncture the clean Finger with sterile Lancet

38
28

Wipe the first drop with sterile dry cotton.

Press the fingers gently until blood came out

In a glass object which has been given an identity, drops blood approximately 1
cm from the left edge of the glass object the size of 3 mm for a thick blood
smear and a drop more of the same dimensions for a thin blood smear of about 1
cm adjacent to the thin trickle of blood

Making a thin blood smear

Place the glass object of blood on the table

10

Tap the blood on the surface of a glass object with the tip of the other glass
objects that has a function as the catalyst so that the blood spread to all the tip of
a glass object

11

Make a 45 degree angle between the object glasses containing the droplets of
blood and glass objects booster.

39
28

12

Push the second glass object towards the front while maintaining a 45 degree
angle and the driving end of the object glass is never separated from the glass
object containing a droplet of blood

A good smear is a smear-shaped tip of the tongue are more narrowed

Let the smear is dry
Reference
Thin blood smear can be used for:
Identification of Plasmodium and the degree of
parasitemia
See cell and the morphology of cells are in blood for
example to view hipokrom microcytic anemia due to
hookworm infestation.
Calculating the platelet count in patients with DHF
E

Making a thick blood smear

13

Place the glass objects that are filled with approximately equal to ,
Take another glass object which has a function as a spreader, and spread out the
blood on an object glass by using sharp angles of the spreader object glass until
approximately

40
28

And let dry

Reference
Thick blood smear can be used for:
Identification of Plasmodium and the degree of
parasitemia/mm3 blood
Identification of filaria

Giemsa staining activity

14

Put a glass object containing a dried blood smear on a glass shelf object

15

Dipping into the thin blood smear methanol solution, be careful not to come
thick blood smear fixed. Allow to dry.
Drop the water above the thick blood smear for hemolysis of erythrocytes, let

16

a few minutes

17

Drops two object glasses with Giemsa solution 3% and let stand for 30
minutes.

18

Flush with running water until clean.

19

After it is clean place in slanting condition and let it dry.

42
28

The identification of parasites on thin blood smear

20

Put binocular microscope on a flat work table

21

Check the cleanliness of the microscope. if it is dirty, clean it with xylol and
wipe lightly with lens tissue

22

Put dawn preparat on the object table.

23

First look at the object with the objective lens 10 until you can see the red
blood Cells clearly.

24

If the object has been focus, drop to preparat with a drop of oil emersi

25

Replace the lens objective lens with 100 times and turn the micrometer to
focus.

26

Find erithrocyt containing schizont, trophozoit, gametocytes at all field of

view, do a zigzag way, record what you get
Identification reference for thin blood smear
Parasite Plasmodium which can be found located within erithrocyt
Plasmodium will appear with a red chromatin and pale bluish
purple-stained cytoplasm.
Normal erithrosit grayed somewhat pale purple
Neuthrophil same color but with a core of dark purple and
have granules in their cytoplasm
Erithrocyt containing Plasmodium will be different in shape
and size.
Wall of normal erythrocytes.
Chromatin from Plasmodium reddish purple with purple-blue
cytoplasm.
Spot of Schiiffher's is seen in erythrocytes containing P. vivax or
P. Ovale
Maurer spots visible on the large rings erythrocytes containing
P.falciparum.
In P.vivax and P.ovale Schuffher's spots can be seen
Preparations declared negative if no plasmodium was found in 100
field of view

28

28

Seeing the thick blood smear (Erythrocyte lysis was so red blood cells did not
appear anymore
Look at the object with the objective lens 10 times.

29

If the object has been focus, drop to the preparat with a drop of oil emersi

30

Replace the lens objective lens with 100 times and turn the micrometer until
the focus of which will show the background looks clean and Plasmodium will
appear with a red chromatin and cytoplasm pale bluish purple

31

Perform inspection at the 100 field of view and take note of what was found

Reference to identify parasites in thick blood smear

Plasmodium will appear with a red chromatin and cytoplasm
pale bluish purple.
In P.vivax and P.ovale Schuffher's spots can be seen
Microfilaria can also appear with thick blood tests 10 x
magnification
Calculating the intensity of infection (parasitemia)
For each field of view (LP) count the amount of leukocyte and Plasmodium
until the amount of leukocyt achieves 200
For example:

43
28

field of
view

Amount
eritrocyt/
field of view

Amount
Plasmodium/
field of view

1
2
3
4
5
6
7
8
9
10
11
Total

23
27
16
17
15
23
15
20
17
15
12
200

0
2
0
1
0
0
0
0
0
1
1
5

After 11 field of view, 200 leukocyt and five Plasmodium are found.
In 1 mm3 blood there are 5000-10000 leukocyt, or taken as many as 8000 the
average
Then the intensity of infection are:
8000 x 5 = 200 parasit/mm3
200
The results stated above there are a number of 200 parasit/mm3 blood

44
28

CHECKLIST

No
1
2
3
4
5
6
7
8

Assesced Aspect
Knowledge of these skills training purposes.
Ability and skills to act in patients asepsis
Ability and skills to do the blood sampling using the Lancet
Ability and skills to make a thin blood smear
Skills Ability to make a thick blood smear.
Ability and skills to make Giemsa staining
Ability and skill to determine the intensity of infection in a thick blood smear.
Ability to answer a question from the examiner

Check list above contains the activities which will be assessed on the skills test in
which the instructor was asked for giving assessments to students for twelve checklist
above (see sheets of student assessment)
Score:
0 if not done
1 if it is done but unsatisfying yet
2 if satisfactory
Examples of student assessment sheets for manual 8
No

Name

Stambuk
1

Activities
6
7

Total
8

1
2
6
7
8
9
10
Scoring for the manual 8
Total value of the lowest 0, highest value 16
Value <12 : unskilled
Value > = 12: ski

45
28

SKILL
TABLET MAKING DIRECT FECES,
IDENTIFYING PARASITES CONTAINED
IN THE FECES AND WAY OF PRESERVATION AND
DELIVERY OF FECES SAMPLES

Created by
SITTI
WAHYUNI

PRESENTED IN GRADE 6
TROPICAL MEDICINE SUBJECT
MEDICAL FACULTY HASANUDDIN UNIVERSITY
2010

28

SKILL
TABLET MAKING DIRECT FECES, PARASITES IDENTIFYING
CONTAINED IN FECES AND WAY OF PRESERVATION AND
FECES SAMPLES DELIVERY
LEARNING OBJECTIVES
General instructional objectives
After completion of this skills training, students are expected to be capable and
skilled to make feces direct preparations, identified the parasites found in stool
specimens as well as preserving and delivering specimens of faeces properly and
correctly.
Special Instructional objectives
After doing the exercises these skills, students:
1. Capable and skilled to give explanations to the patient or family about what to do,
tools are used, how to do, what the benefits are, risks and what might happen. And
the right to refuse
2. Capable and skilled in preparing patients correctly.
3. Capable and skilled to prepare equipment / materials properly.
4. Capable and skilled to make smear feces on a glass object
5. Capable and skilled to color feces samples for direct examination.
6. Capable and skilled to identify the parasites contained in stool samples.
7. Capable and skilled to perform preservation of feces samples to be sent to
reference
laboratories.
8. Capable and skilled to clean laboratory after finishing skill exercise.
INDICATIONS
1. Patients with diarrhea.
2. Patients with a dysentery.
3. Patients with gastrointestinal complaints without diarrhea or dysentery.
4. Patients with symptoms of fever complaint or weakness with a suspected infection
of the gastrointestinal tract.

47
28

ACTIVITY DESCRIPTION
Activity

Time

Description

1. Introduction

10
minutes

2. Demonstration

20
minutes

1. Instructors demonstrate how to make preparations

Feces direct.
2. Instructors demonstrate how to identify parasite found
in stool specimens.
3. Instructors demonstrate how to preserve Feces
specimens and how to refer.
4. Students were asked for asking about unclear things
related to this activity

3. Practice of role
playing with
feedback

60
minutes

11.Students were divided into four groups

12. Being supervised by instructors, each group of students
make direct preparations feces, dentify parasites found
on feces specimens and stool specimens preserved for
reference laboratory simultaneously
13. Instructors walk around among students and do a
supervision
14. The instructor corrects the things which are not perfect

4. Disscusion

10
minutes

Students are given the opportunity to express their opinion

about the activities undertaken

Total times

100
minutes

The instructor explained the purpose of this skills

training
Instructors show materials and tools required

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TOOLS AND MATERIALS

1. Gloves
2. glass Object and the glass cover
3. Disinfection solution
4. Pots containing feces
5. Solution and saline solution and Lugol's iodine solution (1% solution)
6. Tissue paper
7. Microscope
8. Wooden applicators
9. Marker pen
10. Pots with a volume of 20 ml of feces that have a tight lid
11. Formalin (formaldehyde) 10%
12. Scotch tape
13. Paper labels
14. Preparat to remove faeces
15. Reference letter
STEP/ACTIVITY

Preparation

Prepare all the necessary tools.

Explaining to patients about the purpose of inspection

Make a direct preparations feces

With a marker, write the patient's identity on a glass object

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10/04/84

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Place the glass objects are flat on the table

Drop a drop of saline solution on the middle left glass and 1 drop of lugol iodine
solution on the right middle of the glass object

Take a little faeces (part slimy) using a wooden applicator, put on drop saline solution, mix
until blended
Note:
- Hard Faeces: take a part that is located outside and inside the specimen.
- Mixed Faeces or blood: taken from the slimy or bloody area
Dilute Faeces: take a section anywhere.

Same as the third step: Take a little faeces, put on lugol iodine drop, mix until evenly
distributed

Close the two drops each with a glass cover

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28

Suction with blotting paper and which is outside the glass cover

10

Put the stocks on the microscope object table, ready for inspection

Identifying parasites which are found on fecal preparations

11

Place the glass object on an objective table under the microscope

12

Lower the condenser and arrange the light through the diaphragm.

13

Look at the object by using an objective lens 10 times, turn macrometer until the
object is visible

14

Clear the focus by turning the micrometer slowly

15

Increase the magnification to 45 times if necessary

16

Perform the systematic examination with zigzag method.

17

Perform identification of parasites:

Protozoa worm eggs and larvae: the form of trophozoites and cysts
amoebae and flagella

Reference

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28

Eggs and larvae of worm in a saline solution and iodine lugol

Worm eggs and larvae can be identified easily in the saline solution. They look
colorless and easily seen with magnification 10 x
Protozoa in saline solution
- Forms of trophozoites and cysts of amoebae and flagellate may be seen
- Cysts look round or oval with a clear wall
- Trophozoit will look round or oval with irreguler wall.
- In fresh faeces (faeces of no more than two hours after being expelled),
trophozoit movement can be seen especially in the flagella.
- At first look at the object with the enlargement of an Ox, to see more clearly a part
of parasites such as the nucleus, chromatoid bodies, sucking discs, spirals
grooves, or filaments of the parasite, increase gradually enlarged.
Protozoa in Lugol Iodine
- Trophozoit or cytoplasm of the cyst will look yellow or brown and the nucleus
will look dark brown.
- In Entamoeba cysts karyosome peripheral chromatin and the position can be seen
(if not visible, not Entamoeba). Peripheral chromatin look pale yellow.
Sometimes the young cysts still contain glycogen, glycogen will look dark brown.
- Cysts and flagella filaments are also visible with iodine staining lugol.
D

Preserve Feces

18

Label the pot with the patient's identity

19

Fill the pot with 10% formalin until the middle of pot

20

With a wooden applicator take feces approximately as much as a teaspoon, put into
pots that are filled with preservatives, stir until feces and its preservative mixed
properly.

Send to a reference laboratory

21

Cover pot well and use masking tape to prevent leakage at the mouth of the pot.

22

Write the introduction of these specimens include: name, age and sex of patients, a
major complaint and the date of delivery

23

Clean the table after the completion of this activity

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CHECK LIST

No.

Aspects assessed

Knowledge of these skills training purposes.

Abilities and skills of doing preparation materials and tools are used
correctly.
Ability and skills to make smear feces on an object glass for immediate

inspection.
Ability & skill to identify the parasites contained in stool samples.

Ability and skills to do the stool sample preservation

Ability & skill to send stool samples to a reference laboratory

check list above contains the activities that will be assessed on the skills test
where the instructor was asked for giving assessments to students for eight
checklist above (see sheets of student assessment)
Score:
0 if not done
1 if it is done but unsatisfying yet
2 if satisfactory
Examples of student assessment sheets for manual 9
No

Name

Stambuk
1

Activities
2
3
4

Total
5

1
2
3
4
5
6
7
Scoring for manual 9
Total value of the lowest 0, highest value 10
Score 0-6: unskilled
Score 60-10: skilled53
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