CASE REPORT

RS Tebet

Identitas
Nama Usia Alamat : Ny. T.P : 52 tahun : Jl. Monumen Pancasila sakti Rt 013/Rw 09. Cipayung TTL : Sigaol, 12 Juli 1957 Agama : Kristen Suku : Batak Pekerjaan : Guru Hari/tgl masuk : Kamis, 22 Oktober 2009 (01.00WIB)

ANAMNESIS
Tanggal/jam : 22 Oktober 2009. 01.00
Diambil dari : Autoanamnesis

KELUHAN UTAMA
Pinggang kanan terasa nyeri sejak 3

hari SMRS.

3 hari SMRS
Perut bagian bawah terasa tidak nyaman. Nyeri saat BAK,ke

Riwayat Penyakit Sekarang

1 hari SMRS, pasien mengeluh nyeri pinggang

kanan. Nyeri dirasakan terus-menerus, menjalar ke perut bagian kanan bawah. Nyeri pinggang kiri tidak dirasakan. Rasa nyeri deperti ditusuk 1 kali namun rasa sakitnya melebihi sakit saat melahirkan. Perubahan posisi tidak mengurangi rasa nyerinya. Sesak nafas muncul saat timbul nyeri. Demam (+), menggigil, mual (+), muntah (+), muntah berisi makanan, darah (-), lendir (-). Muntah sebanyak 1 gelas aqua. Tidak ada batuk, pilek. BAB, BAK lancar.

 3 hari SMRS,

 Alergi: makanan (thn.2008).

Pasien tidak tahu jenis makanannya. Merokok: disangkal Alkohol & obat-obatan: disangkal

RIWAYAT PENYAKIT DAHULU

Childhood illnesses: (-)
Adult illness:

Medical: Thn 2004, pasien mengeluh sakit pinggang kanan. Pinggang kanan terasa panas, BAK normal. lalu berobat di poliklinik, dan di USG. Hasil USG normal. Tifus abdominalis (thn 2006), Disentri (thn 2004), DBD (thn 1996, RS UKI). Tekanan darah tinggi (-), DM (-), Asma (-), Sakit ginjal (-).

 Surgical: (-)

Ob/gyn: G5P5, proses kelahiran normal

pervaginam. 5 anak lahir hidup. Menarche umur 14 tahun. Haid terakhir 1 tahun yll. Psychiatrics (-) Kesehatan: Imunisasi: pasien tidak ingat. Screening test: PAP smear, pasien tidak ingat

RIWAYAT PENYAKIT KELUARGA

Ayah: meninggal th 1980, Ca di leher. Ibu

: 108 thn (meninggal thn. 2006), riwayat sakit maag (+) Saudara: perempuan, 60 thn. Asam urat (+). Dalam keluarga tidak ada riwayat diabetes, tuberkulosis, penyakit jantung atau ginjal.

RIWAYAT PERSONAL & SOSIAL

Lahir dan dibesarkan di Sigaol. Tamat D II

pendidikan keguruan. Bekerja sebagai Guru sampai sekarang. Menikah dan memiliki 5 anak. 24th, 22th, 19th, 18th, 13 th. Olahraga (-), riwayat makanan sehari 3 kali, 3-4 piring per hari. Variasi nasi, daging, sayur (-), buah. Nafsu makan tidak ada penurunan. Riwayat minum sedikit, kadang 1 gelas per hari. Sering menahan BAK sampai terasa sakit.

REVIEW OF SYSTEM
General : BB 61 kg, TB 150 cm. pre obese
Keringat malam (+) Kepala

: tak Mata : tak Telinga :gangguan pendengaran (+) Hidung :tak Mulut :tak Tenggorokan : rasa kering (+) Leher : tak

 Dada

:sesak nafas (+) Abdomen : lambung/usus :

Rasa kembung (+), Mual (+), muntah (+), muntah darah

(-), sukar menelan (+), nyeri perut kolik (+), perut membesar (+).

Saluran kemih/ alat kelamin: disuria (+) Saraf/otot : sukar mengingat (th 2009)

Ekstremitas

: nyeri sendi (+) kaki kiri

PEMERIKSAAN JASMANI
KU : TSS
Kesadaran : compos mentis TD : 110/80 mmHg FN : 76x/mnt RR : 24x/mnt S

: 36.8C Mata : CA-/-, SI -/ Leher : KGB ttm, JVP 5-2 cm

 Thoraks :
pergerakan dinding dada simetris, VF

ka=ki, sonor ka=ki, BND Vesikuler, rh-/-, wh-/-. BJ I=II, normal. Murmur (-), gallop (-) Abdomen Perut tampak buncit. BU(+), supel. NTE (+), NK CVA (+) ka. Asites (-). Timpani. Ekstremitas : akral hangat, oedem (-), turgor cukup.

SILENT FEATURE
Pasien perempuan, 52th, pre obese, tampak sakit sedang.

Datang dengan keluhan nyeri pinggang kanan sejak 3 hari SMRS. 3 hari SMRS, perut bagian bawah terasa tidak nyaman. BAK terasa nyeri, tidak lampias. Warna keruh, Mendapat obat tetapi tidak ada perubahan. Nyeri terus-menerus, menjalar ke perut bagian bawah. Nyeri seperti ditusuk. perubahan posisi tidak mengurangi nyeri. Minum obat tidak ada perubahan. Rasa sakit melebihi saat melahirkan. Sesak nafas muncul saat timbul nyeri. Demam (+), menggigil, mual (+), muntah (+), muntah berisi makanan, darah (-), lendir (-). 1 gelas aqua. batuk, pilek (-). BAB, BAK lancar.

 Alergi: makanan. Merokok (-), Alkohol &

obat-obatan (-). Thn 2004 sakit pinggang kanan (+). Pinggang kanan terasa panas, BAK normal. di USG. Hasil normal. Hipertensi (-), DM (-), Asma (-), Sakit ginjal (-). Haid terakhir 1 th yll. Dalam keluarga tidak ada riwayat diabetes, tuberkulosis, penyakit jantung atau ginjal.

 TB 150 cm. BB 61 kg. pre obese (IMT 27.11). BBI 45 kg KU : TSS Kesadaran : compos mentis TD : 110/80 mmHg FN : 76x/mnt RR : 24x/mnt S

: 36.8C Mata : CA-/-, SI -/ Leher : KGB ttm, JVP 5-2 cm

 Thoraks : pergerakan dinding dada simetris, VF ka=ki, sonor ka=ki, BND Vesikuler, rh-/-, wh-/-. BJ I=II, normal. Murmur (-), gallop (-) Abdomen Perut tampak buncit. BU(+), supel. NTE (+), NK CVA (+) ka. Asites (-). Timpani. Ekstremitas : akral hangat, oedem (-), turgor cukup.

 DD/: Pielonephritis dextra akut Nephrolithiasis dextra Abses ginjal dextra Dyspepsia uninvestigated appendicitis

Rule in
PNA dextra Nephrolithiasis dextra Abses ginjal dextra

Rule out
-

+ + +

 D/

Pielonephritis dextra akut Nephrolithiasis dextra

Abses ginjal dextra

PEMERIKSAAN PENUNJANG
DPL
Urinalisis, kultur urin Foto thoraks PA USG abdomen Ureum, kreatinin GDS

Terapi
Rawat inap
Cairan

IVFD Asering + Narfoz 1 amp/24 jam Diet 1700 kkal Ceftriaxone 1x2 g Buscopan 1 amp, IV

Pemeriksaan laboratorium
Hb : 13.8 g/dl
Leukosit

asam urat : 3.62mg%

Faal hati: SGPT : 66 U/L SGOT : 41 U/L GDS 339 mg/dl

: 10.40 ribu/ul LED : 30 mm/jam Eritrosit : 4.56 ribu/ul Trombosit : 218.000/ul Ht : 39.3% Hitung jenis : 1/1/0/76/19/3 Kreatinin : 0.81 mg/dl

URINALISIS
Warna : kuning Kejernihan

Keton

: agak : 5.00 : 1.025 :: +3 :: 0.2

keruh PH BJ Protein Reduksi Bilirubin Urobilinogen

: trace Blood : Leukosit : Nitrit : Mikroskopis urin

Leukosit : 25-30/LPB Eritrosit : 3-4 Silinder Sel epitel 2-3

Bakteri +
Kristal Jamur , trichomonas -

 FOTO TORAKS:
Cor dan pulmo dbn

Foto polos abdomen & IVP:

OA lumbal. Soft tissue baik.

Fungsi kedua ginjal normal. Tidak tampak kelainan radiologi BNO-IVP.

USG ABDOMEN
Saat pemeriksaan ditemukan :

hepatomegali, dilatasi minimal CBD, asites minimal. Spleen, pancreas, ren dextra et sinistra, VU, uterus tidak ditemukan kelainan.

TINJAUAN PUSTAKA
Harrisons 17ed. Vol II
Current medical diagnosis &

treatment.2009

TINJAUAN PUSTAKA
Urinary tract Infections, Pyelonephritis Definitions
Acute infections of the urinary tract fall into two general

anatomic categories: lower tract infection (urethritis and cystitis) and upper tract infection (acute pyelonephritis, prostatitis, and intrarenal and perinephric abscesses). Infections at various sites may occur together or independently and may either be asymptomatic or present as one of the clinical syndromes described in this chapter. Infections of the urethra and bladder are often considered superficial (or mucosal) infections, while prostatitis, pyelonephritis, and renal suppuration signify tissue invasion.

 Escherichia coli causes ~80% of acute infections (both

cystitis and pyelonephritis) in patients without catheters, urologic abnormalities, or calculi. Other gram-negative rods, especially Proteus and Klebsiella spp. and occasionally Enterobacter spp., account for a smaller proportion of uncomplicated infections.

 Symptoms of acute pyelonephritis generally develop rapidly over a few hours or a day and include fever, shaking chills, nausea, vomiting,

abdominal pain, and diarrhea. Symptoms of cystitis are sometimes present. Besides fever, tachycardia, and generalized muscle tenderness, physical examination generally reveals marked tenderness on deep pressure in one or both costovertebral angles or on deep abdominal palpation. The range of illness severity is broad. Some patients have mild disease; in others, signs and symptoms of gram-negative sepsis predominate.

 Most patients have significant leukocytosis

and bacteria detectable in Gram-stained unspun urine. Leukocyte casts are present in the urine of some patients, and the detection of these casts is pathognomonic. Hematuria may be demonstrated during the acute phase of the disease; if it persists after acute manifestations of infection have subsided, a stone, a tumor, or tuberculosis should be considered.

 Except in individuals with papillary necrosis, abscess formation, or urinary obstruction, the manifestations of acute pyelonephritis usually respond to appropriate therapy within 4872 h.

However, despite the absence of symptoms, bacteriuria or pyuria may persist. In severe pyelonephritis, fever subsides more slowly and may not disappear for several days, even after appropriate antibiotic treatment has been instituted. Persistence of fever or of symptoms and signs beyond 72 h suggests the need for urologic imaging.

ESSENTIAL OF DIAGNOSIS
PNA fever Flank pain Irritative voiding symptoms Positive urine culture Nephrolithiasis Flank pain Naussea , vomitting Identification of noncontrast CT

Acute pyelonephritis
an infectious inflammatory disease

involving the kidney parenchyma and renal pelvis. Gram (-) : the most causative agents, including E. Coli, Proteus, Klebsiella, Enterobacter dan Pseudomonas. The infections usually ascends from the lower urinary tract.

Clinical findings:
Symptoms:
fever, flank pain, shaking chills, and irritative voiding symptoms (urgency, frequency, dysuria). Associated nausea and vomiting, and diarrhea are common. Signs include fever and tachycardia. Costovertebral angle tenderness is usually pronounced.

LABORATORY FINDINGS
CBC : leukosytosis, a left shift. Urinalysis : pyuria, bacteriuria, and varying degrees of hematuria. White cell casts may be seen. Urine culture : heavy growth of offending agent, and blood culture may also be (+).

IMAGING
In complicated pyelonephritis, renal

ultrasound may show hidronephrosis from a stone or other source of obstruction.

TREATMENT

Intravenous: Ampicillin, 1 g/6hour, Gentamycin 1 mg/kg/8hr. Oral: Ciprofloxacin, 750 mg, every 12 hours Trimethropin-Sulfamethoxazole, 160/800 mg, every 12 hours
- duration 21 days-

Clinical findings:
Symptoms: and signs:

Colic. Pain usually occurs suddenly and may awaken patients from sleep. It is localized to the flank, ussualy severe, and may be associated with nausea and vomitting. Patients are constantly moving-in sharp contrast to those with acute abdomen. The pain may occur episodically and may radiate anteriorly over the abdomen

LABORATORY FINDINGS
Urinalysis : Microscopic/ gross hematuria (90%). However, if microhematuria (-), doesnt exclude urinary stones. PH (N:5.85) : <5.5 uric acid/ cystine stone. Both radioluscent.
> 7.2 struvite infections stone (radioopaque)

IMAGING
a plain film of the abdomen and

renal ultrasound examination will diagnose most stones.

Perinephric and Renal Abscesses

perinephric abscesses : hematogenous in origin, usually complicating prolonged bacteremia, with S. aureus most commonly recovered. Now, in contrast, >75% of perinephric and renal abscesses arise from a urinary tract infection. Infection ascends from the bladder to the kidney, with pyelonephritis occurring prior to abscess development.. Of the risk factors that have been associated with the development of perinephric abscesses, the most important is concomitant nephrolithiasis obstructing urinary flow. Of patients with perinephric abscess, 20 60% have renal stones. Other structural abnormalities of the urinary tract, prior urologic surgery, trauma, and diabetes mellitus have also been identified as risk factors.

 The organisms most frequently encountered in

perinephric and renal abscesses are E. coli, Proteus spp., and Klebsiella spp. E. coli, the aerobic species most commonly found in the colonic flora, seems to have unique virulence properties in the urinary tract, including factors promoting adherence to uroepithelial cells.