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Refleksi Kasus

Oleh: Siti Nashria Rusdhy 12476/KU Pembimbing: dr. I.G. Made Parwata, Sp.PD

Bagian Ilmu Penyakit Dalam FK UGM-RSU Banyumas

Identitas Pasien
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Nama : S. Jenis kelamin : Laki-laki Umur : 80 th Pekerjaan : Petani Alamat : 4/1, Jatilawang, Banyumas No. RM : 590395 Pembayaran : JAMKESMAS Masuk RS : 4 Oktober 2011

Anamnesis

Keluhan utama:

BAK sedikit dan sakit

Keluar darah saat BAK (-). Os merasa penuh di daerah perut bagian bawah. BAB lancar. Os berobat ke Puskesmas dan dikatakan memiliki batu ginjal. Os sering merasa anyang-anyangan. Os sering merasa ingin BAK tapi kencingnya sedikit-sedikit saja. Dengan minum obat dari Puskesmas pegel-pegel meredah. Os dipasang DC di IGD dan disuruh ke Poli Penyakit Dalam. Os mengeluhkan nyeri saat pipis dan nyeri pinggang kiri dan anyang-anyangan.   . HMRS Os merasa kesakitan sekali. +Sehari SMRS Os dibawa ke IGD Banyumas karena Os ingin BAK tapi BAK sakit dan hanya keluar sedikit. Os merasa pegel-pegel di bagian pinggang kiri atas.  Riwayat Penyakit Sekarang: +2 bulan SMRS Os mulai terasa sakit saat BAK.

penyakit jantung dan DM di keluarga disangkal.  Riwayat Penyakit Keluarga:   Riwayat penyakit serupa di keluarga disangkal. Riwayat DM disangkal Riwayat penyakit jantung disangkal. Riwayat Penyakit Dahulu:     Riwayat tekanan darah tinggi disangkal. Riwayat asma disangkal. . Riwayat tekanan darah tinggi.  Riwayat Pribadi:  Os adalah seorang bapak yang tinggal serumah dengan istrinya.

nyeri. nyeri pinggang kiri Saraf : tidak ada keluhan Extremitas : edema (-) . darah (-). nyeri dada(-) Paru : sesak (-) Abdomen : BAB lancar Genitourinary : urin tidak lancar.Anamnesis sistem             Kepala : sedikit pusing (+) Mata : penglihatan kabur (-) Hidung : pilek (-) Mulut : lidah kotor (-). anyenganyengan. lidah tremor (-) Telinga : tidak ada keluhan Leher : tidak ada keluhan Jantung : rasa berdebar-debar (-).

compos mentis. gizi cukup Vital signs:      BP RR N T : 140/90 mmHg : 24 x/mnt : 90 x/mnt : 37.Pemeriksaan Fisik  KU: sedang.0ºC .

 Kepala : CA ( -/.). lymphadenopathy (-)  I P    P A : simmetris. retraksi intercostal (-) . wheeze(-/-) . SI ( -/-). RBB (-/-). ketinggalan gerak (-) : pengembangan dada simmetris. pendarahan gusi (-)  Leher Paru  : JVP tidak meningkat. tactile fremitus ka=ki : sonor : suara vesikuler (+/+).

peristaltik : Tympani : Nyeri tekan suprapubis (+). Jantung:  I  P  P  A Abdomen:  I  A  P  P : IC terlihat : IC teraba di SIC V LMCS : Cardiomegali (-) : Suara 1 suara 2 murni. Hepatomegaly (-). bekas operasi (-). reguler. luka(-) : BU (+) N. splenomegaly (-) Nyeri ketok ginjal kiri (+)  Ekstremitas:  Edema -|-|- . bising (-)  : Bentuk simmetris.

Assessment  Suspek ISK e.c retensi urin e.c suspek BPH dd batu saluran kemih .

Plan        Cek Darah Rutin. Elektrolit darah Cek Urin Rutin BNO-IVP USG IVFD RL 20 tpm Tab Scopamin 2x1 Urogetix 2x1 . Fungsi Ginjal.

32 Uric acid : 3.Pemeriksaan penunjang -1 Darah Rutin      Kimia Darah         Hb AL AT HCT : : 8.06 : 102 : 38.8 Crea : 1.97 Na : 139 K : 4.1 Cl : 104  HbsAg : (-) .7 % GOT : 28 GPT : 13 Urea : 42.

berat jenis 1.Pemeriksaan penunjang -2Urinalisa Rutin  Phisis:  kuning. jernih. pH 5.015   Sedimen:  Eritrosit  Leukosit  Silinder  Epitel  Kristal : banyak : 1-3/LPB ::+ : Ca oxalat Kimia:  Protein : +/ Glucose : Keton : Bilirubin : Urobilinogen :  Darah : +3  Nitrit : Leukosit esterase : + .

USG .

Prostat membesar terukur 5.1 cm  Kesan:   Cystitis Prostate hypertrophy . tak tampak batu.Hasil USG   Vesica urinaria: dinding menebal dan irreguler.5 cm x 4.

BNO-IVP .

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dengan gambaran nephrolithiasis multipel Anatomi dan fungsi ren dan ureter dextra normal VU baik .Hasil IVP    Non-visualised fungsi exkresi ren sinistra sampai menit 60.

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ISK/UTI   ISK adalah istilah umum yang menunjukkan keberadaan nikroorganisme (MO) dalam urin Significant bacteriuria menunjukkan pertumbuhan MO murni >105 colony forming units (cfu/ml) pada biakan urin   Dapat menyebabkan bakteriuria asimtomatik Atau bakteriuria bermakna simtomatik .

Presentasi Klinis ISK Bawah Perempuan  Sistitis  Sindrom uretra akut Laki-laki  Sistitis  Prostatitis  Epidimidis  Uretritis Presentasi Klinis ISK Atas •Pielonefritis Akut •Pielonefritis Kronik .

etc. fecal incontinence. chlamydia. outlet obstruction  Evaluation: Urinalysis. urine culture.UTIs in Males   Cystitis is an infection of the lower urinary tract. recent urologic surgery. catheterization. cognitive impairment. by culture or DNA probe) . Risk factors/causes:  BPH. infection of the prostate or kidney. urinary incontinence. usually resulting from a single gram-negative enteric bacteria. STD testing (gonorrhea. urinary tract instrumentation. anal intercourse. immunocompromised host.

35% of women will suffer from an UTI at least once in their life  Etiology        Escherichia coli (80% of infections) Klebsiella Enterobacter Proteus Pseudomonas (pasca kateterisasi) Serratia Streptococcus faecalis and Staphylococcus sp.000 men aged 21-50 years 25 . . Incidence     Increases with age Uncommon in men <50 years of age 8 infections/10.

g. Commonly Associated Conditions       Acute bacterial pyelonephritis Chronic bacterial pyelonephritis Urethritis Prostatitis Prostatic hypertrophy Prostate cancer  Differential Diagnosis    Anatomic or functional pathology Urethritis Infections in other sites of the genitourinary tract (e.. epididymis) .

fever) present with concomitant pyelonephritis or prostatitis.Diagnosis HISTORY      PHYSICAL EXAM       Urinary frequency Urinary urgency Dysuria Hesitancy Slow urinary stream Dribbling of urine Nocturia Suprapubic discomfort Low back pain Hematuria Systemic symptoms (chills. .

95% specificity) nitrate (35-85% sensitivity. other agents).Lab    Pyuria Bacteriuria Urine dipstick   leukocyte esterase (75-90% sensitivity. Klebsiella. Pseudomonas. coli. 70% specificity) 10 high-power colonies of pathogens (or counts >100.000 bacteria/mL of urine) confirm diagnosis (E.  Urine culture:  .

Imaging    Renal imaging procedures untuk investigasi faktor predisposisi ISK: Ultrasonogram Radiografi    Foto polos perut Pielografi IV/ IVP Micturating cystogram .

contour. orientation. Several films are used to evaluate the collecting system (intrarenal collecting system and ureter) beginning at our institution with a KUB obtained 5 minutes after contrast injection. . and radiographic density.IVP    Intravenously injected iodinated contrast is excreted primarily by glomerular filtration in the kidney. the contrast bolus is filtered by the glomeruli and fills the nephron. IVU captures this sequential "opacification" on radiographs Within 1 to 3 minutes after injection. Evaluation of the kidneys during the nephrographic phase is often enhanced with tomograms (nephrotomograms)  The kidneys should be evaluated for their position. size. opacifying the urinary tract as it progresses from the kidney through the ureter and to the bladder. this phase of contrast opacification is called the nephrogram.  Contrast begins filling the intrarenal collecting system including the calyces and renal pelvis pyelographic phase. resulting in intense opacification of the renal parenchyma.

obtained immediately after release of the device at 15 minutes. which can be caused by stones or tumor. which is evaluated with a KUB. such as mass lesions. Evaluation of the ureteral course is important.  Bolus of contrast material entering the ureters. the ureter should be no more lateral than the tips of the lumbar transverse processes and no more medial than the lumbar pedicles. and often with oblique films. and should be symmetric in size. Bladder is opacified last on the study . Deviations of the normal ureter generally suggest extrinsic diseases. Typically.  the ureter should be inspected for filling defects.

Size ranges 11 .Normal Nephrotomogram size of the kidneys 3-4 lumbar vertebra lengths. symmetry of the nephrograms.14 cm They generally lie with their axes along the psoas muscles with the upper pole slightly more medial than the lower. Alterations in position and orientation of the kidneys may be related to congenital anomalies such as pelvic kidneys or may be secondary to mass effect from an adjacent lesion.    The kidneys are typically located at the level of the upper lumbar spine with the right kidney slightly lower than the left. . and smooth renal contour.

Normal pyelogram  Cup-shaped appearance of the calyces and the relative symmetry of the renal pelvis with no evidence of dilation or mass effect. .

crossing over the sacrum. Due to peristalsis. . the ureter may not be visible in its entirety. and curving laterally in the pelvis before turning medially to insert in the urinary bladder. Note the course of the ureters lateral to the lumbar spine overlying the psoas muscles proximally. Normal KUB showing contrast opacified ureters.

. Normal bladder. as well as its smooth contour. Note the location of the bladder just above the pubic symphysis. No filling defects should be seen.

and to evaluate for mucosal lesions such as transitional cell carcinoma of the upper tracts or papillary necrosis. especially of the collecting system. The IVU can be used to evaluate the urinary tract for congenital anomalies. Has high spatial resolution allowing for subtle lesion detection. less than 50% of renal masses < 3 cm will be detected on an IVU even mass lesions detected are nonspecific and require further evaluation with additional modalities. . it lacks sensitivity and specificity for many disorders   For example. to assess obstruction.Benefits of IVP      Able to assess both function and morphology To evaluate the entire urinary tract. However.

Urolithiasis. KUB shows a right renal calcification .

 KUB shows two dense 1-cm calcifications (arrows) projecting over the mid-portion of the left kidney consistent with nephrolithiasis. .

USG Ren Ren: Length: 13 cm Width : 4 -6 cm Thickness of renal cortex can be 12 mm Renal pelvis: 4 cm in length .

unlike the cortical location of cortical nephrocalcinosis. Renal ultrasound. Strong uniform shadowing posteriorly from the echogenic areas consistent with sound attenuation and suggesting calcification. Calcifications are located in the medullary area of the kidney. Rounded highly echogenic areas throughout the central parenchyma of the kidney. .

CT scan of a patient with nephrolithiasis .

Managemen ISK ISK Bawah  Intake cairan banyak  Antibiotik    80% memberikan respon setelah 48 jam Ampisilin 3 g atau trimetoprim 200mg Bila infeksi menetap: terapi selama 5-10 hari ISK Atas  Pielonefritis akut  Rawat inap  Terapi antibiotik parenteral mininal 48 jam:    Fluorokuinolon Aminoglikosida +/.aminoglikosida .ampisilin Sefalosporin dgn spektrum luas +/.

Bactrim DS. either empirically or based on culture and sensitivity results. Septra DS. usually will treat the most likely pathogens  Complicated or recurrent infection:  Prescribe 14-21 days of antibiotics based on antimicrobial sensitivities with repeat urine check after the treatment .i. others) b.d. 1st infection. For empirical therapy. trimethoprim-sulfamethoxazole DS (SMX-TMP. no risk factors for treatment:   Prescribe 7-10 days of oral antibiotics.Treatment   First Line Acute infection.

General measures     Hydration Analgesia if required Discontinue sexual activity until cured. Patient with indwelling catheters:   If asymptomatic bacterial colonization. no need to treat (sterilization of urine is not possible. . If symptomatic of acute infection. and resistant organisms may take up residence). institute treatment.

Complications    Pyelonephritis Ascending infection Recurrent infection .