MEDICAL REPORT

PATIENT WITH URINARY TRACT INFECTIONS

OLEH :
LUH PUTU RUSMASARI, S.ST (07)

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLTEKKES KEMENKES DENPASAR
JURUSAN KEPERAWATAN
PROGRAM STUDI NERS
TAHUN 2021
 MEDICAL REPORT

SECTION 1: PATIENT’S PARTICULARS

Full name of patient: Mrs. Maria

NRIC/FIN/Passport no. of patient: S2288822x

Age of patient: 32 years old

SECTION 2: DOCTOR’S PARTICULARS

Full name of doctor: Dr. Han

NRIC/FIN/Passport no. of doctor: S9872222Z

MCR no. of doctor: 333333

Hospital / Clinic name and address: Permata Hospital, Denpasar No. 127

Doctor’s qualifications and experience in the area of work:

Dr. Han is An obstetrician-gynecologist or OB-GYN, a doctor who specializes in

women’s healt, has expertise in female reproductive health, pregnancy, and childbirth. 
Dr. Han is is experienced to evaluate and treat a wide variety of conditions such as
abnormal bleeding, pelvic pain, genital itching, urinary incontinence, urinary tract or
vaginal infections, endometriosis, breast disorders, hormonal disorders, and infertility.
Dr Han has trained in major or minor surgery for both inpatient and outpatient
procedures. Examples of these procedures include dilation and curettage, biopsy, tubal
ligation for female sterilization, laser surgery, hysterectomy, or the removal of the
uterus, myomectomy, or the removal of fibroids.
Doctor-patient relationship:

I have been the doctor in charge of Mrs. Maria since she started the pregnancy
program from August 2020. I have seen Mrs.Maria regularly since then, at least once
in three months for her antenatal until post natal care. For purposes of Her medical
report, I examined Mrs. Maria on 30 June 2021.

SECTION 3: PATIENT’S MEDICAL INFORMATION

Patient’s Clinical Hertory :

Mrs. Maria came to the obgyn clinic accompanied by her husband with the main
complaint of experiencing pain when urinating since about 4 days ago. The pain radiates
to the waist and accompanied by decreased urine volume.

Mrs. Maria had a Hertory of section caesaria 2 weeks ago. Mrs Maria is currently living
with her husband and her newborn son. Mrs Maria used to work as a accounting. Her
breastfeeding goes well.

Mrs. Maria has history of medical conditions. She has had urinary tract infections 2
years ago. She doesn’t has medical conditions such as hypertension, asthma, diabetes,
ect.

She was last admitted to the Permata Hospital on 16 June 2021 till 20 June 2021 when
she had premature rupture of membranes and had to do section and had urinary
catheterization. After that, Mrs. Maria was discharged and suggested for follow-up
postnatal treatment. After two week she started to experienced pain during urinating.
She said that she frequentnly toileting with low urin volume.

I did a physical examination and laboratory tests on Mrs. Maria's blood and urine. The
results of the examination showed that Maria had a fever of 38 degrees Celsius. The
pain scale is 5. She has dark yellow urine color with a volume of approximately 100 cc.
Laboratory results show the presence of white blood cells in the urine and increases the
value of WBC in the blood.

Findings from physical examination / mental state examination:

Mrs. Maria was brought to the polyclinic accompanied by her husband. Her mood was
euthymic (i.e. normal, non-depressed and reasonably positive mood).
 She was able to tell that She was in a hospital clinic, identified Her husband, she was able
to tell Her own name and the name of Her husband. She was able to tell correctly what
made her come to hospital.

Basic information
She said that she is 32 years old. She correctly said that she lived with her husband and her
son, and could give the correct address. She also remembered well that two weeks ago she
has discharged from hospital after giving birth.
Simple arithmetic, financial issues
Mrs. Maria was able to perform simple arithmetic such as 4 plus 3, giving 8 as tShe
answer, and could not subtract 7 from 10. SShe could count backwards from 20 to 1.
SShe was also able to recognise notes or coins (She identified a 50-cent coin as 20 cents
and a 10-dollar note as 2 dollars).
Personal welfare/property and affairs related questions
I asked Mrs. Maria if She owned any property. Mrs. Maria said She did. She has
boarding house at Denpasar. I asked Mrs. Maria what the address of her boarding
house and she could remember it well. I asked her how much cost she got from
renting her boarding house and Mrs. Maria can explain it so well.

I asked her wether She knew what medical problems She had. Mrs. Maria just stared
at me and shook Her head. I asked him wether She remembered being in hospital
before. Mrs. Maria nodded. I asked her if She knew what She was in hospital for.
Mrs. Maria also nodded. I asked her if She was taking any medicine at the moment.
Mrs. Maria shook hear head ans said that she didn’t take any medicine at the moment.

Date of physical examination/mental state examination: 30 June 2021

Relevant investigation results:

[Results of complete Blood Examination and complete Urin Examination is attached.]

Diagnose :
1. Urinary Tract Infections
SECTION 4: TREATMENT

Mrs. Maria showed a symtopms of A simple UTI (Urinary Tract Infections), it can be
treated with a short course of antibiotic meds. Pain and the urge to urinate often go away
after a few doses, but Mrs. Maria should still take the full course of the antibiotic to ensure
all the UTI is treated, even if she feel better. Mrs Maria also recommended to plenty of
liquids, especially around the time of a UTI.

Some education and suggestion I give to Mrs Maria to prevent another Urinary Tract
Infections (UTI) in the future :

 Use the bathroom as soon as you feel the urge to urinate. Don’t hold urine in.
 Drink plenty of fluids each day. This will dilute the urine and keep it moving
through the urinary tract, making it more difficult for bacteria to adhere to the
walls of the urethra and bladder.
 Sexual intercourse is associated with recurrent UTIs, especially in younger
women. Urinating after sex may help prevent UTIs. Avoiding the use of
spermicidal foams and jellies, products (such as condoms) containing
spermicides, and barrier methods of birth control (such as diaphragms) may
reduce the frequency of UTIs. Talk to your healthcare practitioner about other
birth control methods that are less likely to cause UTIs.
 Postmenopausal women may benefit from the use of vaginal estrogen gels or
creams.
 In women, UTIs may occur when bacteria from the anus enter the urethra. To
lower the risk of this, be sure to wipe from front to back after a bowel
movement.
 Some people drink cranberry juice or take cranberry supplements to prevent
UTIs, but studies on this have not been conclusive. You may choose to drink
cranberry juice or take cranberry supplements if you find it helpful and it
won't cause harm. However, people with diabetes should avoid sugary drinks.

SECTION 5: DECLARATION

I have read and understood the provisions in sections 3 and 4. I believe in the
correctness of the opinion set out here in.
I understand that in giving this report my duty is to the Court and I confirm that
I have complied with this duty.
Signature: _[Doctor to sign]
Name : Dr Han

Date : 30 June 2021