MODUL 1

Skenario 2

High Fever with Back Pain

Mr. S, 30 years old, presented to the primary health care with chief complaint of high
fever since a week ago. The patient also complained bilateral back pain, in which the left side is
more painful, frequent and cloudy urine, and urinated smoothly since 3 days ago.

On physical examination, the patient had fever, tenderness and knock pain in both side
(bilateral) waists, and no suprapubic tenderness. The doctor had though about working diagnose
and recommended laboratory examination. From the urinalysis findings, it was found that the
urine was cloudy, there was blood and bacteria. From routine blood examination, leukocytosis
was found. The doctor gave antibiotic and anti pyretic, also planned to check the urine culture
and bacterial sensitivity tests.

Translate

Demam Tinggi dengan Sakit Punggung

Tn. S, 30 tahun, datang ke Puskesmas dengan keluhan utama demam tinggi sejak
seminggu yang lalu. Pasien juga mengeluhkan nyeri punggung bilateral, di mana sisi kiri lebih
nyeri, urine sering dan keruh, serta buang air kecil lancar sejak 3 hari yang lalu.

Pada pemeriksaan fisik, pasien mengalami demam, nyeri tekan dan nyeri tekan di kedua
sisi (bilateral) pinggang, dan tidak ada nyeri tekan suprapubik. Dokter sudah memikirkan tentang
diagnose kerja dan merekomendasikan pemeriksaan laboratorium. Dari hasil pemeriksaan
urinalisis ditemukan urine keruh, terdapat darah dan bakteri. Dari pemeriksaan darah rutin
ditemukan leukositosis. Dokter memberi antibiotik dan anti piretik, juga berencana memeriksa
kultur urine dan tes sensitivitas bakteri.

Data Tambahan

A. Anamnesis
a. Keluhan Utama: demam tinggi sejak seminggu yang lalu.
b. Keluhan lain: nyeri punggung bilateral, di mana sisi kiri lebih nyeri, urine sering
dan keruh, serta buang air kecil lancar sejak 3 hari yang lalu.
c. Riwayat kebiasaan: -
d. Riwayat keluarga: -
 B. Pemeriksaan fisik:
a. Keadaan umum:
b. Kesadaran umum: Komposmentis kooperatif
c. Tekanan darah (TD):
d. Frekuensi nadi (HR):
e. Frekuensi nafas (RR):
f. Temperatur suhu tubuh:
g. Berat badan (BB):
h. Tinggi badan (TB):
i. Head to toe:

C. Pemeriksaan Penunjang:
a. Hematologi Rutin:
i. Leukosit: Leukositosis (meningkat)
ii. Hb: -
iii. Ht: -
iv. LED: -
v. Trombosit: -
b. Urinalisis Rutin: urin keruh, darah (+), bakteri (+)
i. Eritrosit:
ii. Leukosit:
iii. Nitrit:
iv. pH urine:
v. kultur urine:
c. Analisis darah: Kreatinin, asam urat, Na, K, Ca, hitung jumlah jenis darah, CRP

Terminologi

1. bilateral back pain (nyeri punggung bilateral)

2. suprapubic tenderness (nyeri tekan suprapubik)

Suprapubic Pain is the pain felt in the central lower part of the abdomen, which is below
the umbilicus and just above the pubic bone.
Nyeri Suprapubik adalah nyeri yang dirasakan di bagian tengah bawah perut, yaitu di
bawah umbilikus dan tepat di atas tulang kemaluan.
https://www.epainassist.com/abdominal-pain/what-is-suprapubic-pain-and-how-is-it-
treated

3. urinalysis (urinalisis)
 Is an analysis method to determine substances contained in urine and any abnormalities
in the urine.
Merupakan suatu metode analisa untuk mengetahui zat-zat yang terkandung di dalam
urin serta adanya kelainan-kelainan pada urin.
http://repository.unimus.ac.id/427/3/14.%20BAB%20II.pdf

4. urine culture (kultur urin)

Urine culture is the culture of micro-organisms from urine, the germs that grow will be
identified by testing their sensitivity to antibiotics.
Kultur urine adalah pembiakan mikro organisme dari bahan urine, kuman yang tumbuh
akan diidentifikasi dengan di uji kepekaannya terhadap antibiotik.
https://www.academia.edu/10214331/Bab_xxiii_KULTUR_URIN

5. bacterial sensitivity tests. (tes sensitifitas bakteri)

Bacterial sensitivity test is a method to determine the level of susceptibility of bacteria to
antibacterial substances and to find out pure compounds that have antibacterial activity.
Uji sentifitas bakteri merupakan suatu metode untuk menentukan tingkat kerentanan
bakteri terhadap zat antibakteri dan untuk mengetahui senyawa murni yang memiliki
aktivitas antibakteri. 
https://www.academia.edu/35775691/UJI_SENSITIVITAS_ANTIBIOTIK

6. High fever
Fever is the elevation of an individual's core body temperature above a 'set-point' that is
normally regulated by the body's thermoregulatory center in the hypothalamus. This
increase in the body's 'set point' temperature is often secondary to a pathological process
that involves the release of immunological mediators to trigger the thermoregulatory
center of the hypothalamus to elevate the body's core temperature.
( https://www.ncbi.nlm.nih.gov/books/NBK562334/ )

7. Cloudy urine
Normal urine is clear and has a straw-yellow color. When the urine does not have its
characteristic clear appearance, it is often referred to as cloudy, turbid, or foamy urine.
Cloudy or foamy urine may occur occasionally due to mild dehydration; when it occurs
in the absence of symptoms and goes away rapidly, it is usually of little consequence.
Certain conditions can cause excess protein or crystalline substances in the urine, causing
it to persistently appear cloudy or foamy. Infections anywhere in the urinary tract (UTIs),
including the bladder or urethra, in both men and women, can cause blood and pus to
appear in the urine, giving it a cloudy appearance.
Rumusan Masalah

1. Why Mr. S had high fever since a week ago?

Inflammatory response initiated cytokines released systemical, so causing fever, malaise,
nausea/vomiting.
Calgaryguide.ucalgary.ca/wp-content/uploads/2014/09/Upper-Urinary-Tract-Infection-
UUTI.jpg

Febrile response is mediated by endogenous pyrogens (cytokines) in response to

exogenous pyrogens, primarily micro-organisms such as bacteria or their direct products
(toxins). These endogenous pyrogens act on thermo-sensitive neurons in the
hypothalamus, which ultimately upgrade the set point via prostaglandins. The body reacts
by increasing the heat production and decreasing the heat loss until the body temperature
reaches this elevated set point.
Fever, in contrast to hyperthermia, will not climb up relentlessly because of an effective
central control of the hypothalamic centre. Cytokines play a pivotal role in the immune
response by activation of the B cells and T-lymphocytes. The production of fever
simultaneously with lymphocyte activation constitutes the clearest and strongest evidence
in favour of the protective role of fever. The protective processes of the immune response
are optimal at high temperature (around 39.5 °C).

2. Why he complained bilateral back pain and in the left side is more painful?
Inflammatory response initiated Inflammation of renal capsule and parenchyma and
cause the flank pain and costovertebral angel tenderness.
Calgaryguide.ucalgary.ca/wp-content/uploads/2014/09/Upper-Urinary-Tract-Infection-
UUTI.jpg

3. Why his urine frequent and cloudy urine, and urinated smoothly since 3 days ago?
Cloudy urine often is a result of precipitated phosphate crystals in alkaline urine, but
pyuria also can be the cause. Pyuria is defined as the presence of 10 or more white cells
per cubic millimeter in a urine specimen, 3 or more white cells per high-power field of
unspun urine, a positive result on Gram’s staining of an unspun urine specimen, or a
urinary dipstick test that is positive for leukocyte esterase. Pyuria can cause the urine to
look cloudy or as if it contains pus.

The presence of pyuria often occurs in a urinary tract infection (UTI). In rare cases, it can
be a sign of a complicated UTI or sepsis.
Sterile pyuria is a form of pyuria that occurs without a detected presence of bacteria. In
these cases, it may be related to non-detected bacteria, a virus or other germ type, or
some other underlying medical condition.
 4. What is the meaning of his physical examination?

5. What is the meaning of his laboratory examination?

The finding of white blood cells (leucocytes) in urine (pyuria) is the most reliable
indicator of infection (> 10 WBC / hpf in rotating specimens) is 95% sensitive but much
less specific for UTI.
Examination of hematuria and protein in urine has low specificity and sensitivity in the
diagnosis of UTI (Corwin, 2009).

Temuan sel darah putih (leukosit) dalam urin (piuria) adalah indikator yang paling dapat
diandalkan infeksi (> 10 WBC / hpf pada spesimen berputar) adalah 95% sensitif tapi
jauh kurang spesifik untuk ISK.
Pemeriksaan hematuria dan protein dalam urin memiliki spesifitas dan sensitifitas yang
rendah dalam diagnosis ISK (Corwin, 2009)

6. Why doctor gave antibiotic and anti pyretic, and also planned to check the urine culture
and bacterial sensitivity tests?
Antibiotics are the mainstay of therapy for UTIs. Antipyretic administration also aims to
treat the patient's fever. The results of culture tests and sensitivity tests are very helpful in
choosing the right antibiotic. The effectiveness of antibiotic therapy in UTI can be seen
from the decrease in the urine leukocyte count in addition to the results of culturing
bacteria from the urine after therapy and improvement in the clinical status of the patient.

Antibiotik merupakan terapi utama pada ISK. Pemberian antipiretik juga bertujuan untuk
menangani demam pasien. Hasil uji kultur dan tes sensitivitas sangat membantu dalam
pemilihan antibiotika yang tepat. Efektivitas terapi antibiotika pada ISK dapat dilihat dari
penurunan angka leukosit urin disamping hasil pembiakan bakteri dari urin setelah terapi
dan perbaikan status klinis pasien.
https://www.academia.edu/33565748/TUTORIAL_KLINIK_ISK_BAGIAN_ATAS_PIE
LONEFRITIS_AKUT

7. What is Mr. S diagnose?

Pielonefritis Akut / ISK?

Learning Issues

1. Seperti biasa