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

TERMINOLOGY
1. 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/ )
Fever ( pyrexia ) is a regulated body temperature above the normal range
occurring as a result of IL-1-mediated elevation of the hypothalamic set point. Once
fever is established, body temperature is regulated, as in health, by a net balance
between heat production and loss.
( Clinical Manual of Fever in Children )
2. Bilateral back pain
3. 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.
4. Tenderness
Tenderness is pain or discomfort when an affected area is touched
5. Knock pain (CVA tenderness)
Costovertebral angle (CVA) tenderness is pain that results from touching the
region inside of the costovertebral angle. The CVA is formed by the 12th rib and
the spine. Assessing for CVA tenderness is part of the abdominal exam, and CVA
tenderness indicates kidney pathology.
6. Suprapubic
The hypogastrium (also called the hypogastric region or suprapubic region) is a
region of the abdomen located below the umbilical region. The pubis bone
constitutes its lower limit. The roots of the word hypogastrium mean "below the
stomach"; the roots of suprapubic mean "above the pubic bone".
7. Urinalysis
A urinalysis is a test of your urine. A urinalysis is used to detect and manage a
wide range of disorders, such as urinary tract infections, kidney disease and
diabetes.
A urinalysis involves checking the appearance, concentration and content of
urine. Abnormal urinalysis results may point to a disease or illness. For example, a
urinary tract infection can make urine look cloudy instead of clear. Increased levels
of protein in urine can be a sign of kidney disease. Unusual urinalysis results often
require more testing to uncover the source of the problem.
8. Leukocytosis
Leukocytosis, a common laboratory finding, is most often due to relatively
benign conditions (infections or inflammatory processes), typically above
11.0x10^9/L.
9. Antibiotic
 Antibiotic is a type of antimicrobial substance that kill, or stop the growth of,
microorganisms, including both bacteria and fungi.
Antibiotics that kill bacteria are called "bactericidal"
Antibiotics that stop the growth of bacteria are called "bacteriostatic"
10. Antipiretic
An antipyretic is a substance that reduces fever. Antipyretics cause the
hypothalamus to override a prostaglandin-induced increase in temperature. The
body then works to lower the temperature, which results in a reduction in fever.
11. Urine Culture
A urine culture is a test that can detect bacteria in your urine. This test can find
and identify the germs that cause a urinary tract infection (UTI). Bacteria, which
typically cause UTIs, can enter the urinary tract through the urethra.
12. Bacterial sensitivity test
Bacterial sensitivity test is a test to find the most effective antibiotic to kill an
infecting microorganism. Infecting microorganisms are organisms such as bacteria
or fungi that invade your body and cause an infection. A sensitivity analysis is a test
that determines the “sensitivity” of bacteria to an antibiotic. It also determines the
ability of the drug to kill the bacteria. The results from the test can help your doctor
determine which drugs are likely to be most effective in treating your infection.

PROBLEM IDENTIFICATION
1. Why did Mr. S complain high fever and back pain?
2. Why did Mr. S complain frequent and cloudy urine?
3. What was the interpretation of physical examination findings (fever, tenderness,
bilateral knock pain, and no suprapubbic tenderness)?
4. What kind of laboratory examination the doctor recommended?
5. What was the interpretation of the urinalysis?
6. Why did the doctor plan to do urine culture and bacterial sensitivity test?
7. Should Mr. S be hospitalized?
ANSWER
1. Why did Mr. S complain high fever and back pain?
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 did Mr. S complain frequent and cloudy urine?

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.

3. What was the interpretation of physical examination findings (fever, tenderness,

bilateral knock pain, and no suprapubbic tenderness)?

4. What kind of laboratory examination the doctor recommended?

Urinalysis and routine blood examination

5. What was the interpretation of the urinalysis?
Blood : Microscopic hematuria. Urologic causes of microscopic hematuria include
tumors, calculi, and infections. Urologic hematuria is distinguished from other
etiologies by the absence of proteinuria, dysmorphic RBCs, and erythrocyte casts.
Even significant hematuria will not elevate the protein concentration to the 2+ to 3+
range on the dipstick test. Up to 20 percent of patients with gross hematuria have
urinary tract malignancy; a full work-up with cystoscopy and upper-tract imaging is
indicated in patients with this condition.24 In patients with asymptomatic
microscopic hematuria (without proteinuria or pyuria), 5 to 22 percent have serious
urologic disease, and 0.5 to 5 percent have a genitourinary malignancy.
Bacteria : The bacteria found is a sign of an bacterial infection that might be in the
kidney, might be from the blood or from another organ in the body such as the
bladder. Later on, if an urine culture is performed, if there are bacterias found, five
bacteria per HPF represents roughly 100,000 colony-forming units (CFU) per mL,
the classic diagnostic criterion for asymptomatic bacteriuria and certainly
compatible with a UTI. In symptomatic patients, a colony count as low as 100 CFU
per mL suggests UTI, and antibiotics should be considered.

6. Why did the doctor plan to do urine culture and bacterial sensitivity test?

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_ATA
S_PIELONEFRITIS_AKUT)

7. Should Mr. S be hospitalized?

??