Professional Documents
Culture Documents
A. PATIENT IDENTITY
Full name Jenis kelamin: L / P
Place and date of birth Umur:
Address
Phone number/ Cell phone
Occupation
Religion
Education
Blood type
Drug allergy
MODULE OF INTERNAL MEDICINE
URINARY TRACT INFECTION = INFEKSI SALURAN KEMIH
B. HISTORY TAKING
Complaint:
1. Fever
2. Pain after urinating / Dysuria terminal
3. Increase frequency
4. Nocturia
5. Supra pubic pain
6. Blood in urine / hematuria
7. Waist Pain
Keluhan :
1. Demam
2. Nyeri saat di akhir BAK
3. Sering BAK
4. Kencing pada malam hari
5. Nyeri tekan suprapubik
1
6. BAK berdarah
7. Nyeri Pinggang
Risk factor
1. Female
2. History of diabetes mellitus
3. Poor self-Hygiene
4. Resisting urination
5. Immunocompromised patients
6. Foreign body in urinary tract (catheter)
7. Menopause
8. Sexually active
Faktor Risiko
1. Wanita
2. Riwayat Diabetes Melitus
3. Higiene pribadi buruk
4. Menahan kencing
5. Pasien dengan gangguan imunitas
6. Benda asing pada saluran kemih (kateter)
7. Menopause
8. Aktif secara seksual
C. PHYSICAL FINDINGS
1. Fever subfebril <38C
2. Tachycardia
3. Gross hematuria di anamnesis
4. Suprapubic pain
5. Flank pain
PEMERIKSAAN FISIK
1. Demam subfebril <38C
2. Takikardia
2
3. BAK berdarah
4. Nyeri tekan suprapubik
5. Nyeri ketok pinggang belakang
D. SUPPORTING EXAMINATION
1. Complete Blood test
2. Complete urine test
3. Culture bacteria from urine
PEMERIKSAAN PENUNJANG
1. Tes Darah lengkap
2. Tes Urine lengkap/komplit
3. Kultur bakteri dari urin tidak ada di data puskesmas
E. DIAGNOSIS
Clinical Diagnosis
Diagnosis is based on anamnesis, physical examination, and supporting examination
Diagnosis Klinis
Diagnosis ditegakkan berdasarkan dari anamnesis, pemeriksaan fisik , dan pemeriksaan
penunjang
Differential Diagnosis:
o Urethritis
o Acute Bacterial Prostatitis
o Acute pyelonephritis
o Benign Prostate Hyperplasia (BPH)
o Appendicitis
Diagnosis Banding :
o Uretritis
o Prostatitis Bakterial Akut
o Pielonefritis akut
o Hiperplasia Prostat Jinak (BPH)
o Apendisitis
3
F. TREATMENT / PENATALAKSANAAN
Non medication
Drink water at least 2 liter/day
Keep external genitalia hygiene.
Medication
Ciprofloxacin 500mg, 2x / day for 7 days