MORNING REPORT

CASE

7th October, 2011

PATIENT’S IDENTITY
Name : AM
Age : 47 yo
Gender : Female
Ethnicity : Balinese
Religion : Hinduism
Address : Kuta
MR : 01.51.29.73
Tc : 16.05
ANAMNESIS

 Chief complain :
pain in the right waist
 Present history :

 Patient complained of pain in the right waist

since 3 days BATH. The pain feel vanish but
may emerge again, the pain feel like pricked
by needle. And it made patient couldnt do her
daily activities.
 She also complained of fever since 3 days
BATH. The fever was continous, it didn’t get
better by the consumption of antipiretic. Chills
(+)
 She also complain of a tea like color urine
since 3 days BATH.
 History of pain when urinate, history of
decrease in volume of urine was denied by the
patient.
 Past illness history
 History of pain in the right waist like this before
was denied by the patient.
 History of an abnormalities in kidney before was
denied by the patient.
 Family history :
 None of the family member had the same
complained as the patient
 History of HT and DM was denied

 Social History :
 Alcohol consumption and smoking was denied.
 PHYSICAL EXAMINATION

General appearance : Moderately ill

Level of consciousness : CM

Vital Sign:
 BP : 120/80 mmHg
 RR : 20 x/min
 PR : 92 x/min
 tax : 38,1°C
Eyes : conj. Pale (-/-); icterus (-/-);
Rp +/+ isocoric, oedema palp. (-/-)

ENT : Tonsils T1/T1; pharyngeal hyperemia (-);

tongue normal; lip cyanosis (-)

Neck : JVP RP + 2 cmH2O;

lymph node enlargement (-)
Thorax : Simetris, retraction (-)
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion :
UB : ICS II
LB : at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 single regular, murmur (-)

Po
Inspection : Symetric (static and dinamic)
Palpation : VF N/ N
Percussion : sonor/sonor
Auscultation : Vesikular + / + , Rh -/-, wh -/-
Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tympani, knock pain in right CVA
(+)
Palpation : Tenderness on palpation (-); liver
& spleen not palpable
Ballotement (-/-)

Extremities: Warm +/+; edema -/-

+/+ -/-
 Complete blood count
Parameter Result Unit Remarks Reference range
WBC 26,40 103/μL H 4,5 – 11,00
-Ne 86,10% 22,70 103/μL H 47,00 – 80,00
-Ly 4,40% 1,20 103/μL 13,0 – 40,0
-Mo 9,40% 2,50 103/μL 2,00 – 10,00
-Eo 0,00% 0,00 103/μL 0,00 – 5,00
-Ba 0,10% 0,00 103/μL 0,0 0 – 2,00
RBC 4,06 106/μL 4,00 – 5,20
HGB 12,20 g/dL 12,00 – 16,00
HCT 35,40 % L 41,00 – 55,00
MCV 87,30 fL 80,00 – 100,00
MCH 31,20 pg 26,00 – 34,00
MCHC 36,00 g/dL 31,00 – 36,00
RDW 12,70 % 11,60 – 14,90
PLT 154,00 103/μL 150,0 – 440,0
MPV 8,10 fL 6,80 – 10,00
 Blood Chemistry Panel

Parameter Result Unit Remarks Reference range

SGOT 44,43 U/L 11,00 – 33,00
SGPT 33,06 U/L 11,00 – 50,00
BUN 10,90 mg/dL H 10,00 – 23,00
Creatinine 0,84 mg/dL H 0,50 – 1,20
Random blood 90,56 mg/dL H 70,00 – 140,00
glucose
 Urinalysis
Parameter Result Unit Remarks Reference range

pH 6,00 - 5–8
Leucocyte 500,00 Leu/uL +3 Negative
Nitrite Neg - Neg Negative
Protein 25,00 mg/dL +1 Negative
Glucose Norm mg/dL Normal
Ketone Neg mg/dL Neg Negative
Urobilinogen 1,00 mg/dL +1 1 mg/dl
Bilirubin 3,00 mg/dL +2 Negative
Erytrocyte 50,00 ery/uL +3 Negative
Spesific Gravity 1,02 - 1,005 – 1,020

Colour Brown - p.yel p. yellow - yellow

SEDIMEN URINE
Leucocyte Banyak /hpf <6/lp
Erytrocyte 4-6 /hpf <3/lp
Gepeng 3-4 /hpf ---

Others Bactery (+) /hpf ---

Ro. Thorax
 Cor: CTR 48%
 Pulmo: nodul(-), infiltrat (-),
broncovascular pattern
normal
 Left and right sinus pleura
are sharp
 Left and right diafragma is
normal
 Conclusion: Normal
BOF
 Radioopaque stone
appearance (-)
ECG

 Sinus rhytm

 Axis normal

 HR 92 x/min

 ST-T change (-)

 LVH (-)

 Conc. : Normal
ASSESMENT

 PNA dextra ec susp bacterial infection

- septicaemia
PLANNING
 Therapy
 MRS

 IVFD NS 20dpm
 Cefoperazone sulbactam 2 x 1 gr  LOM 
ciprofloxacin 2 x 200 mg (iv)
 Paracetamol 3 x 500 mg
 Pdx
 USG Urologi
 Urine culture / gram / ST

 Blood culture / gram / ST

 Monitoring
 Vital
sign
 Complaints
THANK YOU
INDIKASI MRS PADA PASIEN PNA
 Kegagalan mempertahankan hidrasi normal
 Pasien sakit berat/debilasi
 Terapi antibiotik oral selama rawat jalan gagal
 Diperlukan investigasi lanjutan
 Adanya komorbiditas seperti kehamilan, DM, usia
lanjut
Classification Schema

 Site of Origin
 Cystitis: dysuria, frequency, urgency

 Pyelonephritis: fever, chills, flank pain

 It is very difficult to distinguish the two on the

basis of symptoms and generally not
necessary as the treatment is similar in
clinically uncomplicated infections
Classification Schema

 Anatomic or functional status of urinary tract

 Uncomplicated: occurring in a normal
urinary tract in a healthy individual
 Complicated: occurring in a functionally or
structurally abnormal urinary tract, a host
with a compromised immune system, a host
with diabetes, or infection with a virulent or
resistant strain of bacteria
Diagnosis → Urine culture
Several ways to obtain urine sample:
 Suprapubic aspires → bacteria (+) → UTI

 Midstream urine sample → colony count 10

5 →

UTI
Pathology
 Ascending infection: most UTI is caused in this way
 (bacteria from gastrointestinal tract colonize
lower urinary tract)
 Haematogenous spread: infrequent cause of UTI
 (seen in intravenous drug users, bacterial
endocarditis and tuberculosis)
Risk factors
 Urinary tract obstruction
 Instrumentation of urinary tract
 (e.g. indwelling catheter)

 Diabetes mellitus
 Vesicoureteric reflux
 Immunosuppression
 Pregnancy
 Sexually active women
 Diaphragm, intercourse frequency, estrogen deficiency
EMPIRICAL THERAPY (The Infections Disease
Society Of America)
 Fluoroquinolon
 Aminoglikosida dengan/tanpa ampisilin
 Sefalosporin dengan atau tanpa aminoglikosida
 Consider Imaging (ultrasound)

 Women with febrile infections

 Men
 If urinary tract obstruction is suspected
 Calculi, Diabetes, Previous
instrumentation
 Ureteral stricture

 Persistent symptoms despite treatment

 Rapid recurrence after successful Rx
Diagnosing UTI
 Clinical symptom
 Lab examination:
-blood: leukositosis
-urine: leukosuri/pyuria (leukosit >8 /lp)
hematuria (eritrosit >2 /lp)
 GOLD STANDARD IS URINE CULTURE 
BAKTERIURIA AND COLONY COUNT