PROBLEM BASED LEARNING

Module 1
Tutor: dr. Arni Isnaini Arfah, M.kes
By: Group 12

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Mar’atun Sholehah (11020160178)
Fitri Alfiah Zahrah (11020170017)
Utari Zainal Abidin (11020170038)
Rizki Handayani (11020170061)
Miftahul Jannah (11020170071)
Selfy Eltry Elvira (11020170096)
Oryza Camilia S. (11020170107)
Adibah Afriastini W. (11020170133)
Novita Angriani (11020170169)
Andi Muh. Taufik H. (11020170176)
 Key Word
A girl, 10 years old
01
chief complaint:
02 micturition pain and too often to urinate.

Acompanied by
03 fever and waist pain.

Urinalysis
04 • protein +1/-,
• leukocyte +2/+3,
• Leukocytes sediment 10-20.
 Question
1. What is the anatomic structure that being
impaired based on the scenario?
2. Explain the mechanism of urine production!
3. Explaine the patomecanism of the symptoms
based on the scenario!
4. What is the interpretation of urinalysis based on
the scenario?
5. How to diagnose the disease on the scenario
6. What is the differential diagnosis based on the
scenario?
7. What is the treatment of the disease based on
the scenario?
8. What is the Islamic perspective based on the
scenario?
1. RENAL ANATOMY
Macroscopic
1. RENAL ANATOMY
Microscopic
2. URINE PRODUCTION MECHANISM
 3. The Patomecanism of the symptoms based on the scenario
Mikroorganism

Into the urinary tract

ureter bladder kidney

antigen antibody Waist pain

reaction inflammation

increase in body Tissue swelling terminal nerve stretch from

temperature the sensation of pain

Obstuction of the
fever urinary tract intraluminar pressure ↑

secretion pattern Pain when smooth muscle

disorders urination peristalsis ↑
 4. Interpretation Of Urinalysis

Protein
• Normal protein excretion Usually does not exceed 150 mg / 24 hours or 10 mg / dl of urine. More than 10 mg /
dlified as proteinuria.
• Moderate proteinuria (500-4000 mg / 24 hours) can be given with acute or chronic glomerulonephritis, toxicity
(aminoglycoside chemicals, chemical toxicity), multiple myeloma, heart disease, skin infections, infectious
diseases, preeclampsia.
• High proteinuria (more than 4000 mg / 24 hours) can be used with nephrotic analysis, acute or chronic
glomerulonephritis, lupus nephritis, amyloid disease.
 4. Interpretation Of Urinalysis

Leukocytes
Leukocytes up to 4 or 5 per LPK are generally still considered normal. An increase in the number of leukocytes in
the urine (leukosituria or pyuria) is cystitis, pyelonephritis, or acute glomerulonephritis. Leukosituria can also be
found in febrile, dehydration, stress, leukemia without infection or inflammation, because the speed of leukocyte
excretion increases which may be caused by changes in glomerular membrane permeability or changes in
leukocyte motility. In conditions of low urine specific gravity, leukocytes are found in cell form. The glitter is a
PMN leukocyte which shows Brown's grain movement in the cytoplasm. At pH the alkaline pH of leukocytes is
difficult to group.
5. Steps to diagnose the disease on the scenario

Anamnesis Physical examination Laboratory Examination Radiology Examination

• Patient identity • Vital Signs • Blood Checking • Cystography
• • Urinalysis
Main complaint • Nutritional status • Uretrography
• Kidney Function Examination
• Disease History • Kidney examination • RetrogradPyelography
• Stone Analysis
• Family History • Bladder inspection • Urine Culture (RPG)
• Environmental History • Costovertebral angel • Urine Cytology Examination • MRI
• Medication History • Anatomical Pathology Examination
• Ultrasound
 6. Differential Diagnosis
a. Urinary Tract Infection

DEFINITION Urinary tract infection (UTI) is a condition of germ growth in the urinary tract that
reaches a significant amount (meaning bacteriuria) with or without clinical symptoms.

EPIDEMIOLOGY Generally, asymptomatic UTI (Covert Bacteriuria) is more common than symptomatic
UTI. Asymptomatic UTI in male infants (neonates) 1-3.7% and 0.13-2.1% in female
infants. UTIs in the neonatal period are more common in male infants than female
infants. Whereas in adulthood women are more likely to suffer from UTIs than men.

ETIOLOGY The bacteria that cause most UTIs are Escherichia coli group O, both symptomatic
and asymptomatic bacteriuria, following Klebsiella, Enterobacter, Proteus,
Pseudomonas aeroginosa, Enterococcus, Staphylococcus, Shigella, Salmonella.
Other causes of organisms are Protoplast, viruses, fungi and protozoa.
PATHOGENESIS Germs enter the urinary tract through 3 pathways:
1. Through the blood (hematogenous)
2. Percontinuitatum, namely through tissue from the external genitalia and perineum
(especially in girls) through the urethra to the bladder and finally to the kidney.
3. Lymphogene, which is through the channel or flow of lymph.
Routine urine analysis, microscopic examination of fresh, no-rotating urine, urine
SUPPORTING culture, and the number of germs / mL of urine are standard protocols for the UTI
EXAMINATION diagnosis approach. The collection and collection of urine, temperature, and
transportation techniques for urine samples must be in accordance with the
recommended protocol.
MANAGEMENT 1. Lower urinary tract infection (UTI)
High fluid intake, adequate antibiotics, and if necessary symptomatic therapy for urine
alkalinization:
• Ampicillin 3 grams, Trimetropin 200 mg
2. Upper Urinary Tract Infection (UTI)
Maintain hydration status, and parenteral antibiotic therapy for at least 48 hours.
Three alternative antibiotic IV therapies as initial therapy for 48 - 72 hours before
microorganisms are known as the cause:
• Fluoroquinolones
• Amyglycosides with or without ampicillin
Broad-spectrum cephalosforin with or without amyglycosides.
 6. Differential Diagnosis
b. Urolithiasis

DEFINITION Urolithiasis (ureteric) is a pathological state because of the hard times such as stone
formed along the urinary tract and can cause pain, bleeding, or infection of the
urethral
EPIDEMIOLOGY In Indonesia the stone disease of the urinary tract still occupies the largest portion of
the number of patients in urological clinics. The prevalence of stone diseases is
estimated at 13% in adult males and 7% in adult females. Four in five patients were
males, while the peak age was the third to fourth decade
ETIOLOGY The ureters stone generally comes from a kidney stone that descends into the
ureters. An peristaltic movement of the ureters tries to push the stones into the distal,
thus creating a strong contraction. Stones can form throughout the urinary tract,
especially in places that often experience obstructions of the urine flow (urinary
stasis). The other factors that cause ureteric stones, namely:
1. The existence of supersaturation of stone-forming substances.
2. The presence of factors that cause crystallization of the substance
3. The existence of a crystalline substance is gathered together so one
PATHOGENESIS The mechanism of stone formation in the urinary tract or known as urolithiasis has not
known for certain. However there are several factors predisposition to the occurrence
of stone, among others :

Increased concentrations of urine solution

resulting from less fluid intake and also the Supersaturation of urine elements such
increase of organic substances due to as calcium, phosphate, oxalat, and other
urinary tract infections or urine stasis factors supporting the formation of stones
presents nests for stone formation

The old immobilisation will cause the movement of calcium to the

bones to be hampered. Increased serum calcium will add to the
fluid to be excreted. If the incoming fluid is not adequate then the
buildup or deposition is increasing and the deposition is
increasingly complex so that the stone occurs

Clinical Manifestation • Pain

• Hematuria
• Infections
• Fever
• Tachycardia and cold sweat out
Diagnosis Supporting examination:
• BNO
• IVP
• ULTRASOUND
• Laboratory examinations: routine blood, blood chemistry, urinalysis and urine culture
Management • Corticosteroids: : Prednisolone (econopred, pediapred, Delta-Cortef, Deflazacort).
The adult dose is 25 mg of mouth for 5-10 days
• Calcium antagonists (Calsium Channel Blockers): nifedipine 30 mg slow release
over 5-10 days
• Alpha Adrenergic Blockers (α Blockers): Tamsulosin 0.4 mg peroral
• Extracorporeal Shock Wave Lithotripsy (ESWL)
• Ureteroscopy (URS)
Complication Blockage: Due to stone fragments
-Infections: Due to the elimination of stone particles or bacteria due to obstruction
-Deterioration of renal function: due to prolonged obstruction before treatment and
removal of kidney stones
Prevention -Avoid dehydration by drinking enough
-Diet to reduce the level of substances component of stone forming
-Enough activity
-Medicamentose Administration
Prognosis In general, the prognosis of patients with urolithiasis (ureteric stones) is good.
 6. Differential Diagnosis
b. Pelvic Inflamatory Disease

DEFINITION Pelvic Inflammatory Disease is a inflamatory disease of genital tract of a

woman, including endometritis, salphingitis, abses tuboovaria and pelvic
peritonitis.
EPIDEMIOLOGY The case of Pelvic inflamatory disease mostly found in woman, 15-24 years old whom
sexualy active. There almost 250.000 woman are being hospitalized per year and
100.000 patient got surgical procedure because of PID an the rest of it is an
ambulatory patient.
ETIOLOGY Sexual transmitted disease is one of the cause of PID. Bacteria in sexual transmitted
disease, such as chlamydia and ghonoroe is an example of bacteria that could cause
infection in cervix uteri.
risk factors : miscarriage, abortion, frequent sexual partner changes, unprotected sex,
history of pelvic inflammation and previous sexually transmitted infections, And the
use of IUD contraceptive
PATHOGENESIS PID is usually started by cervicitis. This is followed by changes in the condition of the
microbes in the vagina and cervix. Resulting in bacterial vaginosis Pathogens (both
initial and BV) will ascend to the upper genital tract.

Clinical Manifestation • Symptoms vary greatly, depending on location, intensity, and endurance.
• Lower abdominal pain / tension
• Fever
• Urinary disorders
• Cervical shake
• Pain in adnexa
• Excessive vaginal discharge
• Pelvic mass on ultrasound examination Clinical diagnosis of PRP has a positive
predictive value of 65-90% compared to laparoscopy.
SUPPORTING • Laboratorium: Blood leukocytes, ESR, CRP, Gram staining, Culture
EXAMINATION • Ultrasound
• Laparoscopy: Purulent fluid from fimbrae

Management • Antibiotic: metronidazole, ofloxacin, doxycycline, or ceftriaxone to treat bacterial

infections, for at least 14 days.
• accompanied by giving pain relievers, such as ibuprofen and paracetamol
• The surgical procedure is done if an abscess has appeared on an infected organ by
performeing opening the abdomen (laparotomy) or by minimally invasive surgery
(laparoscopy), to remove or drain the abscess and cut the scar tissue.

Prognosis Patients who are treated appropriately show a good prognosis

However, if not resolved can cause long-term complications, namely chronic low back
pain, infertility, and ectopic pregnancy.
 7. Initial
Non- Pharmacology
Therapy
Drink plenty of
Pharmacology water 01
Eating real fruit juice or
• Atibiotics such as fresh fruits and vegetables
ciprofloxacin (250 mg in 02 that contain lots of water,
one tablet)
much rest
• Acetaminophen or 03
paracetamol such as Take care of personal
tylenol, panadol, and hygiene
04
others (400 mg in one
Give a 45 mg vitamin C
tablet)
supplement every day. 05
.

06
 8. Islamic Perspective
a. Urinary Tract Infection

Translate: Indeed, Allah is good, loves goodness, that Allah is clean, loves
cleanliness, He is Glorious who loves glory, He is Beautiful, loves beauty,
therefore clean your places (H.R Tirmidzi)
THANK
YOU