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Study Guide The Urinary System and Disorder Block ~ CURRICULUM ~ Aims: 1. 2. 3. 4. 5. Comprehend the biologic function of urogenital system to pathological process of urinary system disorders. Apply and interpret special studies in diagnosis urogenital system disorders, including laboratory and imaging examination. Diagnose and manage patient with common urogenital system disorders Diagnose and refer special patient with urogenital system disorders Plan patient, family, and community education about urogenital system disorders Learning Outcome 1. 2. 3. 4. 5. 6. Describe the functional structure of urigenital system and its general clinical implications. Comprehend the pathological basis underlying the symptoms and signs of urogenital system disorders. Recognize the potential uses of common diagnostic and therapeutic procedure in urogenital system disorders. Manage urogenital system disorders: 1. Diagnose and manage independently uncomplicated urinary tract infection, including uncomplicated pyelonephritis. 2. Diagnose and manage independently phymosis and paraphymosis. 3. Diagnose, give initial treatment, and refer some urogenital system disorders such as acute and chronic glomerulonephritis, renal colic, kidney rupture, bladder rupture, urethra rupture, acute kidney injury, chronic kidney disease, acute tubular necrosis, prostatitis, and priapismus. 4. Diagnose and refer some urogenital system disorders such as, horse shoe kidney, kidney tumor, nephrotic syndrome, symptomatic polycystic kidney, epydidimitis, urothelial carcinoma, benign prostate hyperplasia, and prostate cancer, common penile tumor, hipospadia, and epispadia. Manage secondary hypertension Diagnose and refer secondary hypertension, especially renal hypertension Implement patient education in the prevention and early detection of common urinary system disorders. Curriculum content 1. 2. 3. 4. 5. 6. 7. 8. 9. Functional structure of urogenital system Pathological basis of urogenital system disorders Symptom and sign of urogenital system disorders Physical examination, laboratory investigation and imaging studies in urogenital system disorders Interpret and utilize results of Physical examination, laboratory investigation and imaging studies Rational drug use in urogenital system disorders Management of urogenital system disorders Clinical procedure in urogenital system disorders Communicate and apply basic principle in the prevention, and rehabilitation of urogenital system disorders Udayana University Faculty of Medicine, DME 1|P age Study Guide The Urinary System and Disorder Block ~ PLANNERS TEAM ~ NO 1 2 3 4 5 6 7 8 9 10 11 12 NAME DR. dr. A A Gde Oka, Sp.U (Coordinator) dr. I Wayan Juli Sumadi, Sp.PA (Secretary) Prof. dr. K. Tirtayasa, MS, AIF dr. I A Ika Wahyuniari, M.Kes Prof. DR. dr. Mangku Karmaya, M.Repro Prof. DR. dr. K. Suwitra, SpPD (KGH) dr. Made Adi Tarini, Sp.MK DR. dr. Wiradewi Lestari, Sp.PK dr. IGAP Nilawati, Sp.A(K) dr. I Gst Ayu Artini, M.Sc dr. Gede Wirya Kusuma Duarsa, Sp.U dr. Sri Laksminingsih, Sp.Rad DEPARTMENT Urology Pathology Physiology Histology Anatomy Internal Medicine Microbiology Clinical Pathology Pediatric Pharmacology Urology Radiology ~ LECTURERS ~ NO 1 2 3 4 5 6 7 8 9 10 11 12 13 14 NAME DEPARTMENT Prof. DR. dr. K. Suwitra, SpPD (KGH) Internal Medicine Prof. dr. K. Tirtayasa, MS, AIF Physiology dr. I A Putri Wirawati, Sp.PK Clinical Pathology dr. G A P Nilawati, Sp.A Pediatric Prof. DR. dr. N. Mangku Karmaya, Anatomy M.Repro dr. A A Gde Oka, Sp.U Urology dr. Jodhi Sidarta L, SpPD (KGH) Internal Medicine dr. Ni Wayan Winarti, Sp.PA Pathology Anatomy dr. G. Wirya K Duarsa, SpU, M.Kes Urology dr. I Wayan Sugiritama, M.Kes Histology dr. I Gst Ayu Artini, M.Sc Pharmacology dr. A A Wiradewi Lestari, Sp.PK Clinical Pathology dr. Sri Laksminingsih, Sp.Rad Radiology dr. Made Adi Tarini, Sp.MK Microbiology Udayana University Faculty of Medicine, DME 2|P age Study Guide The Urinary System and Disorder Block ~ FACILITATORS ~ Regular Class (Class A) No Name 2 dr. Ida Bagus Wirakusuma, MOH dr. Kadek Agus Heryana, Sp.An 3 dr. Ketut Agus Somia, Sp.PD-KPTI 1 4 5 6 7 dr. Ketut Rai Purnami, Sp.PD dr. Komang Andi Dwi Saputra , Sp.THT-KL dr. I Kadek Swastika , M Kes dr. Kumara Tini, Sp.S Group A1 A2 A3 A4 A5 A6 A7 8 dr. Made Agus Hendrayana , M.Ked A8 9 dr. Luh Putu Ratna Sundari, M.Biomed A9 10 dr. I Gusti Ayu Artini , M.Sc A10 Venue (2rd floor) Departement Phone Public Health 08124696647 Anasthesi 081338568883 Interna 08123989353 2nd floor: R.2.12 Interna 0818350703 2nd floor: R.2.13 ENT Parasitology 081338701828/ 081338701878 08124649002 2nd floor: R.2.14 2nd floor: R.2.15 Neurology 081238701081 2nd floor: R.2.16 Microbiology 081339158241 2nd floor: R.2.20 Fisiology 0361-7860532 2nd floor: R.2.21 Pharmacology 08123650481 2nd floor: R.2.22 Departement Phone Fisiology 081337761299 Interna 08123814688 2nd floor: R.2.09 2nd floor: R.2.11 English Class (Class B) No 1 2 3 4 Name dr. I Dewa Ayu Inten Dwi Primayanti, M.Biomed dr. Made Ratna Saraswati, Sp.PD-KEMD-FINASIM dr. Made Sudarmaja, M.Kes dr. Made Widhi Asih, Sp.Rad Group B1 B2 B3 B4 5 dr. I G A Sri Darmayani, Sp.OG B5 6 dr. Putu Ayu Asri Damayanti , M Kes B6 7 dr. Ni Kadek Mulyantari , Sp PK B7 8 9 10 dr. I Wayan Niryana, Sp.BS, M. Kes. dr. Ni Luh Putu Ratih Vibriyanti Karna, Sp.KK dr. Ni Made Adi Tarini, Sp.MK Udayana University Faculty of Medicine, DME B8 B9 B10 Venue (2rd floor) 2nd floor: R.2.09 2nd floor: R.2.11 2nd floor: R.2.12 Parasitology 08123953945 Radiology 081916442626 2nd floor: R.2.13 DME 081338644411 2nd floor: R.2.14 Parasitology 085338565783 2nd floor: R.2.15 Clinical Pathology 08123647413 2nd floor: R.2.16 Surgery 08179201958 Dermatology 081337808844 2nd floor: R.2.20 2nd floor: R.2.21 Microbiology 081338675344 2nd floor: R.2.22 3|P age Study Guide The Urinary System and Disorder Block ~ TIME TABLE ~ REGULAR CLASS DAY/DATE TIME I 08.00-09.00 08-05-2015 08.00-10.00 10.00-11.00 11.00-12.30 12.30-13.00 13.00-14.00 14.00-15.00 II 11-05-2015 08.00-09.00 09.00-10.00 10.00-11.00 11.00-12.30 III 12-05-2015 V 18-05-2015 Break Practical Session (Anatomy): Group A6-A10 Plenary Mangku Karmaya Mangku Karmaya Sugiritama Practical Session (Histology): Group A1-A5 SGD 2 Histology Lab Discussio n room Histology Lab Sugiritama 3.02 3.02 Sugiritama Tirtayasa Discussio n Room 3.02 3.02 Facilitators Discussio n Room - Facilitators 14.00-15.00 08.00-09.00 Plenary The function of the urinary system: 10. Urine formation 11. Urine micturition Individual Learning SGD 3 09.00-10.30 10.30-12.00 Student Project Break Plenary session The kidney as water, electrolyte and acid-base balance controller Individual Learning SGD 4 12.00-13.00 Student Project 13.00-14.00 14.00-15.00 08.00-09.00 Break Plenary session Pathogenesis of Glomerular and Tubulointerstitial Injury Individual Learning SGD 5 09.00-10.30 10.30-12.00 Anatomy Lab Discussio n room Anatomy Lab 3.02 PIC Mangku Karmaya Mangku Karmaya Facilitators 3.02 Break Practical Session (Anatomy): Group A6-A10 12.00-13.00 13.00-14.00 14.00-15.00 08.00-09.00 VENUE 3.02 Microscopic Anatomy of The Urinary System Individual Learning 12.30-13.00 13.00-14.00 09.00-10.30 10.30-12.00 IV 13-05-2015 ACTIVITY Macroscopic Anatomy of The Urinary System Individual Learning Practical Session (Anatomy): Group A1-A5 SGD 1 Udayana University Faculty of Medicine, DME - 3.02 3.02 Discussio - Facilitators Sugiritama Tirtayasa Tirtayasa Tirtayasa Winarti Facilitators 4|P age Study Guide The Urinary System and Disorder Block VI 19-05-2015 VII 20-05-2015 VIII 21-05-2015 IX 23-05-2015 X 25-05-2015 12.00-13.00 13.00-14.00 14.00-15.00 08.00-09.00 Student Project Break Plenary session Urinary System Disorders in Children: - Nephrotic syndrome - PSAGN - UTI in Children 09.00-10.30 10.30-12.00 Individual Learning SGD 6 12.00-13.00 Student Project 13.00-14.00 14.00-15.00 08.00-09.00 09.00-10.30 10.30-12.00 Break Plenary session Uncomplicated and complicated Urinary tract infection Individual Learning SGD 7 12.00-13.00 13.00-14.00 14.00-15.00 Student Project Break Plenary session 08.00-09.00 09.00-10.30 10.30-12.00 Urolithiasis (with and without colic); Urethral Stricture Individual Learning SGD 8 12.00-13.00 Student Project 13.00-14.00 14.00-15.00 08.00-09.00 09.00-10.30 10.30-12.00 Break Plenary session Common Neoplasm in Urinary System: Renal tumors, bladder tumors. Individual Learning SGD 9 12.00-13.00 Student Project 13.00-14.00 14.00-15.00 08.00-09.00 Break Plenary session Urinary tract trauma (rupture of the kidney and urinary tract) Individual Learning 09.00-10.30 Udayana University Faculty of Medicine, DME n Room 3.02 3.02 Discussio n Room 3.02 3.02 Discussio n Room 3.02 3.02 Discussio n Room 3.02 3.02 Discussio n Room 3.02 3.02 - Winarti Nilawati Facilitators Nilawati Suwitra and Team Facilitators Suwitra and Team AA Gde Oka Facilitators AA Gde Oka AA Gde Oka Facilitators AA Gde Oka AA Gde Oka - 5|P age Study Guide The Urinary System and Disorder Block XI 26-05-2015 XII 27-05-2015 XIII 28-05-2015 10.30-12.00 SGD 10 12.00-13.00 13.00-15.00 14.00-15.00 08.00-09.00 Student Project Presentation 1 (Horse Shoe Kidney) Break Plenary Acute Kidney Injury 09.00-10.30 10.30-12.00 Individual Learning SGD 11 12.00-13.00 13.00-14.00 14.00-15.00 Student Project Presentation 2 (Symptomatic Polycystic Kidney) Break Plenary session 08.00-09.00 Chronic Kidney Disease 09.00-10.30 10.30-12.00 Individual Learning SGD 12 12.00-13.00 13.00-14.00 14.00-15.00 Student Project Presentation 3 (Hemodialysis) Break Plenary session 08.00-09.00 Renal hypertension 3.02 Suwitra and Team Suwitra and Team Jodi SL 09.00-10.30 10.30-11.30 Individual Learning Drug Use in Renal Disorders: Diuretics; Urinary Antiseptic SGD 13 3.02 Artini 11.30-13.00 XIV 29-05-2015 XV 01-06-2015 13.00-14.00 14.00-15.00 08.00-09.00 Break Plenary session Common Prostate Disorders: Prostatitis, BPH, Prostate Cancer 09.00-10.30 10.30-12.00 Individual Learning SGD 14 12.00-13.00 Student Project Presentation 4 (Urodinamic examination and Uroflowmetry) Break Plenary session Common penile disorders: Epispadia, hypospadia, phimosis, paraphimosis, 13.00-14.00 14.00-15.00 08.00-09.00 Udayana University Faculty of Medicine, DME Discussio n Room 3.02 3.02 3.02 Discussio n Room 3.02 3.02 3.02 Discussio n Room 3.02 3.02 Discussio n Room 3.02 3.02 Facilitators AA Gde Oka AA Gde Oka Suwitra and Team Facilitators Suwitra and Team Suwitra and Team Suwitra and Team Facilitators Facilitators Jodi SL, Artini G. Wirya K. Duarsa Discussio n Room 3.02 Facilitators 3.02 Artini G. Wirya K. Duarsa AA Gde Oka 6|P age Study Guide The Urinary System and Disorder Block 09.00-10.30 10.30-12.00 12.00-13.00 13.00-14.00 14.00-15.00 XVI 03-06-2015 08.00-09.00 3.02 11.00-12.00 12.00-14.00 Urethral catheterization, Clear intermittent catheterization, suprapubic punctie (Lecture & Demonstration) Break Skills Training 14.00-15.00 Free Training 08.00-09.00 Urinalysis 09.00-10.00 10.00-11.00 11.00-12.00 12.00-14.00 Individual Learning Urethral Swab, Urine Culture and Sensitivity Test Break Skills Training 14.00-15.00 Free Training 08.00-09.00 11.00-12.00 Circumcision, Prostate Palpation, Bulbocavernosus reflex (Lecture and Demonstration) Individual Learning Student Project Presentation 6 (Urine Cytology) Break 12.00-14.00 Skills Training 14.00-15.00 Free Training 08.00-09.00 BNO and IVP 09.00-10.00 Individual Learning 09.00-10.00 10.00-11.00 XIX 08-06-2015 3.02 3.02 10.00-11.00 XVIII 05-06-2015 Student Project Presentation 5 (Micturating Cystigraphy) Break Plenary session Discussio n Room 3.02 Anamnesis and Physical Examination in Urinary System Disorders (Lecture & Demonstration) Individual Learning 09.00-10.00 XVII 04-06-2015 epididimitis, prostatitis, priapismus and Common tumor of the penis Individual Learning SGD 14 Udayana University Faculty of Medicine, DME - Skills Lab 2nd Floor Skills Lab 2nd Floor 3.02 3.02 Skills Lab 2nd Floor Skills Lab 2nd Floor 3.02 3.02 Facilitators G. Wirya K. Duarsa G. Wirya K. Duarsa Suwitra and Team AA Gde Oka Facilitators Wirawati/Wirade wi Adi Tarini Facilitators G. Wirya K. Duarsa Juli Sumadi Skills Lab 2nd Floor Skills Lab 2nd Floor 3.02 - Facilitators Laksminingsih - 7|P age Study Guide The Urinary System and Disorder Block 10.00-11.00 XX 09-06-2015 11.00-12.00 Student Project Presentation 7 (Pathological aspect of BPH and Prostate Cancer) Break 12.00-14.00 Skills Training 14.00-15.00 Free Training 08.00-09.00 Student Project Presentation 8 (The role of USG in diagnosis Urinary system disorders) Student Project Presentation 9 (The role of CT Scan in diagnosis Urinary system disorders) Individual Learning 09.00-10.00 10.00-11.00 11.00-12.00 12.00-13.00 13.00-15.00 Skills Lab 2nd Floor Skills Lab 2nd Floor 3.02 3.02 - Break Student Project Presentation 10 (Renal Funtion Test (BUN, SC)) Free Training XXI 11-06-2015 XXII 12-06-2015 3.02 3.02 Winarti Facilitators Laksminingsih Laksminingsih Wirawati/Wirade wi Skills Lab 2nd Floor - Computer Room Team Preparation Day 10.00-11.40 Final Examination ENGLISH CLASS DAY/DATE I 08-05-2015 TIME 09.00-10.00 ACTIVITY Macroscopic Anatomy of The Urinary System VENUE 3.02 PIC Mangku Karmaya 10.00-11.00 11.00-12.00 Anatomy Lab Anatomy Lab Discussion room Mangku Karmaya 13.00-14.30 Individual Learning Practical Session (Anatomy): Group B1-B5 Practical Session (Anatomy): Group B6-B10 SGD 1 14.30-15.00 Break 15.00-16.00 Plenary 3.02 Mangku Karmaya 09.00-10.00 Microscopic Anatomy of The Urinary System 3.02 Sugiritama 12.00-13.00 II 11-05-2015 Udayana University Faculty of Medicine, DME - Mangku Karmaya Facilitators - 8|P age Study Guide The Urinary System and Disorder Block III 12-05-2015 10.00-11.00 Individual Learning 11.00-12.00 Practical Session (Histology): Group B1-B5 Histology Lab Sugiritama 12.00-13.00 Practical Session (Histology): Group B6-B10 Histology Lab Sugiritama 13.00-14.30 SGD 2 Facilitators 14.30-15.00 15.00-16.00 09.00-10.00 Break Plenary The function of the urinary system: Urine formation Urine micturition Individual Learning Break SGD 3 Discussion room 3.02 3.02 Discussion Room 3.02 3.02 Facilitators Discussion Room 3.02 3.02 Facilitators Discussion Room Facilitators 10.00-11.30 11.30-12.30 12.30-14.00 IV 13-05-2015 V 18-05-2015 VI 19-05-2015 14.00-15.00 15.00-16.00 09.00-10.00 Student Project Plenary session The kidney as water, electrolyte and acid-base balance controller 10.00-11.30 11.30-12.30 12.30-14.00 Individual Learning Break SGD 4 14.00-15.00 15.00-16.00 09.00-10.00 Student Project Plenary session Pathogenesis of Glomerular and Tubulointerstitial Injury 10.00-11.30 11.30-12.30 12.30-14.00 Individual Learning Break SGD 5 14.00-15.00 15.00-16.00 09.00-10.00 Student Project Plenary session Urinary System Disorders in Children: - Nephrotic syndrome - PSAGN Udayana University Faculty of Medicine, DME - 3.02 3.02 - Sugiritama Tirtayasa Tirtayasa Tirtayasa Tirtayasa Winarti Winarti Nilawati 9|P age Study Guide The Urinary System and Disorder Block - UTI in children VII 20-05-2015 VIII 21-05-2015 10.00-11.30 11.30-12.30 12.30-14.00 Individual Learning Break SGD 6 14.00-15.00 15.00-16.00 09.00-10.00 10.00-11.30 11.30-12.30 12.30-14.00 Student Project Plenary session Uncomplicated and complicated Urinary tract infection Individual Learning Break SGD 7 14.00-15.00 15.00-16.00 Student Project Plenary session 3.02 09.00-10.00 Urolithiasis (with and without colic), urethral stricture Individual Learning Break SGD 8 3.02 10.00-11.30 11.30-12.30 12.30-14.00 IX 23-05-2015 14.00-15.00 15.00-16.00 09.00-10.00 10.00-11.30 11.30-12.30 12.30-14.00 X 25-05-2015 14.00-15.00 15.00-16.00 09.00-10.00 11.00-12.30 12.30-14.00 Student Project Plenary session Urinary tract trauma (rupture of the kidney and urinary tract) Student Project Presentation 1 (Horse Shoe Kidney) Individual Learning SGD 10 14.00-15.00 15.00-16.00 09.00-10.00 10.00-11.00 Break Plenary session Acute Kidney Injury Student Project Presentation 10.00-11.00 XI 26-05-2015 Student Project Plenary session Common Tumors in Urinary System: Renal cancer, bladder cancer Individual Learning Break SGD 9 Udayana University Faculty of Medicine, DME Discussion Room 3.02 3.02 Discussion Room Facilitators Suarta/Nilawati Suwitra and team Facilitators Suwitra/AA Gde Oka AA Gde Oka Discussion Room 3.02 3.02 Facilitators Discussion Room Facilitators AA Gde Oka AA Gde Oka 3.02 3.02 AA Gde Oka AA Gde Oka 3.02 AA Gde Oka Discussion Room 3.02 3.02 3.02 Facilitators AA Gde Oka Suwitra and team Suwitra and Team 10 | P a g e Study Guide The Urinary System and Disorder Block XII 27-05-2015 XIII 28-05-2015 11.00-12.30 2 (Symptomatic Polycystic Kidney) Individual Learning 12.30-14.00 SGD 11 14.00-15.00 15.00-16.00 09.00-10.00 10.00-11.00 11.00-12.30 12.30-14.00 Break Plenary session Chronic Kidney Disease Student Project Presentation 3 (Hemoadialysis) Individual Learning SGD 12 14.00-15.00 15.00-16.00 09.00-10.00 Break Plenary session Renal Hypertension 10.00-11.00 11.00-12.30 Individual Learning Drug Use in Urinary System Disorders: Diuretics; Urinary Antiseptic SGD 13 12.30-14.00 XIV 29-05-2015 XV 01-06-2015 14.00-15.00 15.00-16.00 09.00-10.00 Break Plenary session Common prostate disorders: Prostatitis, BPH, Prostate Cancer 10.00-11.00 11.00-12.30 12.30-14.00 Student Project Presentation 4 (Urodinamic examination and Uroflowmetry) Individual Learning SGD 14 14.00-15.00 15.00-16.00 Break Plenary session 09.00-10.00 Common penile disorders: Epispadia, hypospadia, phimosis, paraphimosis, epididimitis, prostatitis, priapismus and Common tumor of the penis Student Project Presentation 5 (Micturating Cystigraphy) Individual Learning SGD 14 10.00-11.00 11.00-12.30 12.30-14.00 Udayana University Faculty of Medicine, DME Discussion Room 3.02 3.02 3.02 Discussion Room 3.02 3.02 - Discussion Room 3.02 3.02 3.02 Facilitators Suwitra and team Suwitra and team Suwitra and Team Facilitators Suwitra and team Jodi SL Artini Facilitators Jodi SL, Artini G. Wirya K. Duarsa AA Gde Oka Discussion Room Facilitators 3.02 G. Wirya K. Duarsa G. Wirya K. Duarsa 3.02 G. Wirya K. Duarsa Facilitators Discussion Room 11 | P a g e Study Guide The Urinary System and Disorder Block XVI 03-06-2015 14.00-15.00 15.00-16.00 Break Plenary session 3.02 09.00-10.00 3.02 3.02 AA Gde Oka 12.00-13.00 13.00-15.00 Anamnesis and Physical Examination in Urinary System Disorders (Lecture & Demonstration) Individual Learning Urethral catheterization, Clear intermittent catheterization, suprapubic punctie (Lecture & Demonstration) Break Skills Training G. Wirya K. Duarsa Suwitra and Team 15.00-16.00 Free Training 09.00-10.00 Urinalysis 10.00-11.00 11.00-12.00 12.00-13.00 13.00-15.00 Individual Learning Urethral Swab, Urine Culture and Sensitivity Test Break Skills Training 15.00-16.00 Free Training 09.00-10.00 12.00-13.00 13.00-15.00 Circumcision, Prostate Palpation, Bulbocavernosus reflex (Lecture and Demonstration) Individual Learning Student Project Presentation 6 (Urine Cytology) Break Skills Training 15.00-16.00 Free Training 09.00-10.00 10.00-11.00 11.00-12.00 12.00-13.00 13.00-15.00 BNO and IVP Individual Learning Student Project Presentation 7 (Pathological aspect of BPH and Prostate Cancer) Break Skills Training 15.00-16.00 Free Training 09.00-10.00 10.00-11.00 Individual Learning Student Project Presentation 8 (The role of USG in 10.00-11.00 11.00-12.00 XVII 04-06-2015 XVIII 05-06-2015 10.00-11.00 11.00-12.00 XIX 08-06-2015 XX 09-06-2015 Udayana University Faculty of Medicine, DME Skills Lab 2nd Floor Skills Lab 2nd Floor 3.02 3.02 Skills Lab 2nd Floor Skills Lab 2nd Floor 3.02 3.02 Skills Lab 2nd Floor Skills Lab 2nd Floor 3.02 3.02 Skills Lab 2nd Floor Skills Lab 2nd Floor 3.02 Facilitators Wirawati/Wiradew i Adi Tarini Facilitators G. Wirya K. Duarsa Juli Sumadi Facilitators Laksminingsih Winarti Facilitators Laksminingsih 12 | P a g e Study Guide The Urinary System and Disorder Block 11.00-12.00 12.00-13.00 13.00-14.00 14.00-16.00 diagnosis Urinary system disorders) Student Project Presentation 9 (The role of CT Scan in diagnosis Urinary system disorders) Break Student Project Presentation 10 (Renal Funtion Test (BUN, SC)) Free Training 3.02 Laksminingsih 3.02 Wirawati/Wiradew i Skills Lab 2nd Floor PREPARATION DAY XXII 11-06-2015 XXI 12-06-2015 - FINAL EXAMINATION ~ STUDENT PROJECT ~ No 1 2 3 4 5 6 7 Group A1, B1 A2, B2 A3, B3 A4, B4 A5, B5 A6, B6 A7, B7 8 A8, B8 9 A9, B9 10 A10, B10 Topic PIC AA Gde Oka Suwitra and Team Suwitra and Team AA GdeOka AA GdeOka Juli Sumadi Winarti Horse Shoe Kidney Symptomatic Polycystic Kidney Hemodialysis Urodinamic examination and Uroflowmetry Micturating cystigraphy Urine Cytology Pathological aspect of BPH and Prostatic Carcinoma The role of USG in diagnosis Urinary system Sri Laksminingsih disorders The role of CT Scan in diagnosis Urinary system Sri Laksminingsih disorders Renal Function Test (BUN, SC) Wirawati/Wiradewi ~ ASSESSMENT METHOD ~ Assessment will be carried out on June 12, 2014. There will be 100 questions consisting mostly of Multiple Choice Questions (MCQ) and some other types of questions. The minimal passing score for the assessment is 70. Other than the examination score, your performance and attitude during group discussions and your study project will be considered in the calculation of your average final score. Udayana University Faculty of Medicine, DME 13 | P a g e Study Guide The Urinary System and Disorder Block ~ LEARNING PROGRAMS ~ Lecture 1 - 2: Macroscopic and Microscopic Structure the Urinary System ABSTRACTS The urinary system (urinary tract) consists of two kidneys, two ureters, a urinary bladder, and the urethra. The kidney is subdivided into cortex and medulla. The kidney is made up by subunits called uriniferous tubule. The uriniferous tubule consists of the nephron and the collecting tubule that is functional unit of the kidney. It modifies the fluid passing through it to form urine. Beside its’ excretion function, kidney also involve in controlling blood pressure. This function is provided by juxtaglomerular apparatus, which consists of juxtaglomerular cell, extraglomerular mesangial cell and macula densa cell. This complex secretes hormones and contains receptors that can modify vasoconstriction and vasodilatation of blood vessels. Urine enters the renal pelvis, a structure that connects the kidney with ureter. The ureters that consist of mucosa, muscular coat, and fibrous outer coat deliver urine from the kidneys to urinary bladder. The urinary bladder is an essentially organ for storing urine until it is ready to be voided. It’s wall consists of mucosa, lined by transitional epithelium that is thin in full bladder, but thicker when contracted. Urine will be excreted from urinary bladder through the urethra. The urethra of male and female have different structure. In male the urethra is divided into three parts, urethra pars prostatica, urethra pars membranasea and urethra pars cavernosa. In female, the urethra is shorter and covered by transitional epithelium and stratified squamous epithelium. SGD 1 Macroscopic Anatomy of Urinary System Trigger Case A 30 years old man came to the doctor with flank pain since 2 days. One week before he fell while he was riding a bike and he didn’t feel any flank pain. His friends suggested that he have to see the doctor, they afraid there is something wrong in his kidney. His friends also suggest drinking much water. After drinking much water, the frequency of urination is increasing and he has very clear urine. He never feels any pain when urinate. On physical examination, the doctor didn’t find any disturbance either on his kidney or urinary tract. The patient asks the doctor to explain about: where is the kidney taking place, why the frequency of urination and urine volume increasing if we drink much water? If you as a doctor, please explain to the patient. Learning Task: 1. Explain the location of urinary system in the abdominal region and its vasculature and innervations! 2. Draw the anatomical structure of urinary tract! 3. Draw the vasculature and innervations of urinary tract! Udayana University Faculty of Medicine, DME 14 | P a g e Study Guide The Urinary System and Disorder Block SGD 2 Microscopic Anatomy of Urinary System Trigger Case 1 A male patient came to the doctor with complaint of generalized swelling, especially around his eyes, feet, and hands. From examination there were albuminuria and hipoalbunemia. After complete examination, the doctor diagnosed the patient with nephrotic syndrome which damage glomeruli. Learning Task 1. Differentiate the microscopic structure of cortex and medulla of the kidney! 2. Explain the structure of the functional unit of the kidney! Explain about the structures that participate in filtrating process! 3. Explain the microscopic structure of the juxtaglomerular apparatus and its function! 4. Why in the case above, albumin is present in the urine? Trigger case 2 A 60 years old man complained with abdominal colic and uncontinuous flow of urination. From abdominal ultrasonography (USG), the doctor found stone in urinary bladder. After urinalysis, there are bloods in urine (hematuria). Learning task 1. Explain the microscopic structure of ureter! Which structure is mainly involved in passing down urine from kidney to urinary bladder? Why urine could not regurgitate from the bladder back into ureters? 2. Explain the microscopic structure of urinary bladder! Why urine does not pass into the underlying lamina propria? Lecture 3-4: The Function of Urinary System The kidneys perform their most important functions by filtering the plasma and removing substances from the filtrate at variable rate, depending on the need of the body. Ultimately, the kidneys “clear” unwanted substances from the filtrate (and therefore from the blood) by excreting them in the urine while returning substances that are needed back to the blood. All process in urine formation takes place in the nephrons as the functional unit of the kidneys. A nephron consists of glomerulus, Bowman’s capsule, proximal tubule, loop of Henle descending limb, loop of Henle ascending limb, distal tubule. Some distal tubules of nephrons empty their product into cortical and medullary collecting tubules and then to collecting duct and all collecting ducts empty into to renal pelvis. Each kidney in the human contain about 1 million nephrons, each of it capable to forming urine. The glomerular filtrates (water, ion, nitrogen waste and organic solute) along the proximal tubule are reabsorbed into the interstitial space and blood. The components of reabsorbed filtrate are water, glucose and protein. In the loop of Henle descending limb, the filtrate is less dilute due to high permeability of tubule cell to water. So the water reabsorbed more in this part of tubule. Meanwhile the filtrate is more diluted due to more NaCl and no water is reabsorbed at ascending limb of Udayana University Faculty of Medicine, DME 15 | P a g e Study Guide The Urinary System and Disorder Block loop of Henle. Concentrated filtrate is also resulted from the counter-current exchange of vasa recta in the renal medulla. Along the distal tubule, the filtrate is more concentrated due to more reabsorption than secretion process. It is also influenced by anti diuretic hormone (ADH) and aldosteron hormone. The rate of reabsorption or secretion at distal tubule depends upon the body internal environment to maintain homeostasis. Urine as the last result of all process of filtrate (through filtration, reabsorption and secretion) along the renal tubules, then empty into renal pelvis. Through the right and left ureter the urine is collected in the bladder. Muscle contraction of the bladder push out the urine through the urethra. The glomerular filtrates (water, ion, nitrogen waste and organic solute) along the proximal tubule are reabsorbed into the interstitial space and blood. The components of reabsorbed filtrate are water, glucose and protein. In the loop of Henle descending limb, the filtrate is less dilute due to high permeability of tubule cell to water. So the water reabsorbed more in this part of tubule. Meanwhile the filtrate is more diluted due to more NaCl and no water is reabsorbed at ascending limb of loop of Henle. Concentrated filtrate is also resulted from the counter-current exchange of vasa recta in the renal medulla. Along the distal tubule, the filtrate is more concentrated due to more reabsorption than secretion process. It is also influenced by anti diuretic hormone (ADH) and aldosteron hormone. The rate of reabsorption or secretion at distal tubule depends upon the body internal environment to maintain homeostasis. The result of all process is urine. Through the right and left ureter the urine is collected in the bladder. Muscle contraction of the bladder push out the urine through the urethra. Learning Task: SGD 3 The function of urinary system: urine formation and micturition process Learning Tasks: 1. Explain that the glomerular filtration rate (GFR) of kidneys depend on the variability of some forces 2. Explain how the autoregulation of glomerular filtration rate and renal blood flow 3. Explain the process and related substances such as water and electrolytes that take place along the proximal tubule of nephron 4. Explain the process and related substances such as water and electrolytes that take place along the loop of Henle of nephron 5. Explain the process and related substances such as water and electrolytes that take place along the distal tubule of nephron 6. Explain the process and related substances such as water and electrolytes that take place along the collective tubule of nephron 7. Normally the urine cannot backflow from bladder to ureter. Please describe the rule of muscles of ureter in urine flow 8. What nerves are involved in micturition and describe the mechanism and rule of bladder muscles, sphincter and nerves that involved in urination process. Udayana University Faculty of Medicine, DME 16 | P a g e Study Guide The Urinary System and Disorder Block SDG 4 The Kidneys as water, electrolyte and acid-base balance controller Learning Tasks 1. Explain the concept of countercurrent multiplier system and countercurrent exchange 2. Explain the osmoreceptor- anti diuretic hormone feedback system 3. Explain the process in kidneys to conserve the fluid osmolarity and sodium concentration of body fluid 4. Explain the potassium excretion and potassium concentration in the extracellular fluid that is controlled by kidneys 5. What are the causes of acidity of body fluid? 6. What can you define the body in acidosis or alkalosis condition 7. Explain some buffers system in the body and what are their function 8. Explain the renal correction of acidosis condition and alkalosis condition. Lecture 5: Pathogenesis of Glomerular and Tubulo-Interstitial Injury Pathogenesis of Glomerular Injury Glomerular diseases constitute some of the major problems in nephrology. The glomeruli may be injured by a variety of facilitatorstors and in the course of a number of systemic diseases. Some systemic diseases often affect glomeruli and causing glomerulopathy, termed secondary glomerulonephritis. It’s different with primary glomerulonephritis in which the kidney is the predominant organ involved. Although we know little of etiologic agent and triggering events, it is clear that immune mechanisms, both humoral and cell-mediated immune reactions, underlie most forms of primary glomerulonephritis and many of the secondary glomerular disorders. Two form of antibody-associated injury have been established: 1). Injury by antibodies reacting in situ within the glomerulus, either with insoluble fixed (intrinsic) glomerular antigens or with molecules planted within the glomerulus, and 2). Injury results from deposition of circulating antigen-antibody complexes in the glomerulus. In addition, there is experimental evidence that cytotoxic antibodies directed against glomerular cell components may cause glomerular injury. These pathways are not mutually exclusive and all may contribute to injury. Injuries induced by these immune responses will lead the activation of many cells and mediators, resulting in functional and structural alteration of the glomeruli, followed by alteration of tubulointerstitial components. Pathogenesis of Tubular/Interstitial Injury Most forms of tubular injury also involve the interstitium; therefore, diseases affecting these two components are discussed together. Two major forms of this process are: 1). Ischemic or toxic tubular injury, leading to Acute Tubular Necrosis (ATN) and acute renal failure, and 2). Tubulointerstitial nephritis. In this lecture, we stress on ATN and certain tubulointerstitial nephritides. ATN is a clinicopathologic entity characterized morphologically by destruction of tubular epithelial cells and clinically by acute diminution or loss of renal function. It can be caused by a variety of conditions, including ischemia, toxin, acute tubulointerstitial nephritis, Udayana University Faculty of Medicine, DME 17 | P a g e Study Guide The Urinary System and Disorder Block urinary obstruction, etc. Based on its etiopathogenesis, the ATN can be grouped into two patterns, i.e. ischemic ATN and nephrotoxic ATN. Tubulointerstitial nephritis characterized histologically by inflammation of tubules and interstitium. Pyelonephritis is the most common type of tubulointerstitial nephritis, commonly caused by infection. Toxins and drugs are other important causes. It can produce renal injury in at least three ways: 1). Trigger an interstitial immunologic reaction, exemplified by the acute hypersensitivity nephritis induced by such drugs as methicillin, 2). Those may also cause acute renal failure, and 3). Cause subtle but cumulative injury to tubules that take years to become manifest, resulting in chronic renal insufficiency. SGD 5 Pathogenesis of glomerular and tubulo/interstitial injury Trigger Case 1 A 50 year old man has suffered from nephrotic syndrome since 3 months ago. Renal biopsy revealed diffuse capillary wall thickening by light microscopy. Immunoflurescence examination showed diffuse granular IgG and C3 deposits, located subepithelium (electron microscopy). No evidence of underlying systemic disease. This patient was diagnosed getting membranous glomerulopathy. Learning Task 1. Mention classification of primary glomerular diseases! 2. Mention some diseases commonly induce glomerular injury (secondary glomerulopathy)! 3. Explain the pathogenesis of human membranous glomerulopathy! 4. Explain the differences between in situ immune complex deposition and circulating immune complex deposition! 5. Mention one best known type of glomerular disease which induced by circulating immune complex deposition! 6. Describe four major tissue reactions found in glomerulopathy! Trigger Case 2 A 60 year old man suffers from cardiac infarction and has been admitted since a week ago. Yesterday the nurse noted his urine production decreased, 250mL/24 hours. This oligouria is continuing until this day. Laboratory examination revealed increase of serum urea nitrogen and creatinin. Learning Task 1. Discuss the mechanism responsible for oligouric state in this patient! 2. Explain about pathogenesis of acute kidney injury (AKI)! 3. What is the difference between AKI and tubulo-interstitial nephritis? 4. Mention some causes of tubule-interstitial nephritis! Udayana University Faculty of Medicine, DME 18 | P a g e Study Guide The Urinary System and Disorder Block Lecture 6: Common Kidney Diseases in Children (Acute Poststreptococcal Glomerulonephritis and Nephrotic Syndrome), UTI in Children Post Streptoccocal Acute Glomerulonephritis Hematuria defined as the excretion in urine of abnormal amounts of red blood cells (RBCs). The presence of at least 5 RBCs in the urine was considered abnormal. It occurs with a prevalence of 0.5-2.0% among school aged children. The child who exhibits gross hematuria needs prompt evaluation. The urinalysis should be repeated in the child who has the combination of microscopic hematuria, without proteinuria, normal blood pressure, and normal renal function. If the hematuria persist, further evaluation is appropriate. Acute glomerulonephritis (AGN) is a syndrome characterized by the abrupt onset of macroscopic hematuria and edema. The majority of instances of AGN appear to be postinfectious, and a number of bacterial and viral infections have been etiologically incriminated. The most common recognized clinical picture follows group A, -hemolytic streptococcus infections. So the term used in this report is poststreptococcal acute glomerulonephritis (PSAGN). Only certain nephritogenic strains of streptococci have been associated with PSAGN. The more common sporadic variety of PSAGN usually follows type 12 streptococcal infection of the pharynx. Epidemics of the disorder have been linked to several strains causing either throat or skin infections. PSAGN predominantly affects children between the ages of 2 and 10 years, with a slight predominance of males. Typically, children with PSAGN present with sudden onset of painless gross hematuria, and some edema is usually present. Hypertension is a common feature of PSAGN and may lead to hypertensive encephalopathy. The laboratory findings of PSAGN include increased of ASTO titre and decreased serum complement C3. Urinalysis in most scenarios shows hematuria, proteinuria, and abnormal sediment including erythrocyte cast. In adult from 15% to 30% of patients with PSAGN had been reported to progress to a chronic state while estimation in children have generally ranged from approximately 5% to 10%. The chronicity of PSAGN can be predicted if the microscopic hematuria, proteinuria, and a low serum complement C3 level are present for a period exceeding than six months after initial onset of illness. It is prudent to follow the patients with PSAGN until the proteinuria normalizes and microhematuria has disappeared in the urinalysis. Nephrotic Syndrome Nephrotic syndrome is primarily a pediatric disorder and is 15 times more common in children than adults. The incidence is 2-3/100,000 children per year, and the vast majority of affected children will have steroid sensitive with minimal change disease. The characteristic features of nephritic syndrome are heavy proteinuria (> 40 mg/m2/hour in children), hypoalbuminemia (< 2.5 g/dL), edema, and hyperlipidemia. Most children (90 %) with nephrotic syndrome have a form of the idiopathic nephritic syndrome. The causes of idiopathic nephritic syndrome include minimal change disease Udayana University Faculty of Medicine, DME 19 | P a g e Study Guide The Urinary System and Disorder Block (85%), mesangial proliferation (5%), and focal segmental glomerulosclerosis (10%). The remaining 10% of children with nephrotic syndrome have secondary nephritic syndrome related to glomerular diseases such as membranous nephropathy or membranoproliferative glomerulonephritis. The underlying abnormality in nephritic syndrome is an increase permeability of the glomerular capillary wall, which leads to massive proteinurioa and hypoalbuminemia. The cause of the increase permeability is not yet fully understood. Although the mechanism of edema formation in nephrotic syndrome is incompletely understood, it seems likely that, in most instances, urinary protein loss lead to hypoalbuminemia, which lead to decrease in the plasma oncotic pressure and transudation of fluid from the intravascular compartment to the interstitial space. The diagnoses of nephrotic syndrome based on clinical manifestation that usually present with edema which initially noted around the eyes and in the lower extremities. With the time, the edema became generalized with the development of ascites, pleural effusions, and genital edema. Anorexia, irritability, abdominal pain, and diarrhea are common; hypertension and gross hematuria are uncommon. The urinalysis reveals 3+ or 4+ proteinuria; microscpic hematuria may be present in 20% of children. Urinary protein exceeds > 40 mg/m2/hour in children. The serum albumin level is generally less than 2.5 g/dL and the serum cholesterol and triglyceride levels are elevated. C3 and C4 levels are normal. Treatment of children with the first episode of nephrotic syndrome and mild to moderate edema may be managed as outpatient. Children with onset of nephrotic syndrome between 1 and 8 year of age are likely to have steroid responsive minimal change disease; therefore, steroid therapy may be initiated without renal biopsy. The majority of children with steroid-responsive nephritic syndrome have repeated relapses, which generally decreased in frequency as the child grows older. SGD 6 Common Kidney Diseases in Children Trigger Case 1 Three years old boy was admitted to the outpatient clinic with swollen on both eyelids and followed on both legs. No symptom like this previously. Urination was decreased with cloudy yellow color since swelling was begun. Make the diagnosis, treatment and education for this patient. Learning Task: 1. What are the diagnosis and differential diagnosis for this case? 2. Explain the characteristic features of Nephrotic syndrome? 3. Explain edema mechanism for this case? 4. Describe the laboratory investigation to diagnosed Nephrotic Syndrome? 5. Explain techniques of proteinuria examination 6. Provide initial management of nephrotic syndrome 7. Comprehend the complication of nephrotic syndrome Trigger Case 2 A 12-year-old female present with three days history of the red urine and puffiness of her face. The patient was having fever and sore throat in previous 2 week. Examination reveals minimal puffiness with pitting edema of the lower limbs. Her blood pressure is140/100 mmHg with pulse 88 bpm. Chest, cardiovascular and abdominal examination are normal. Udayana University Faculty of Medicine, DME 20 | P a g e Study Guide The Urinary System and Disorder Block Learning Task: 1. Diagnosis and differential diagnosis for this case? 2. Describe characteristic features of PSAGN 3. Describe the laboratory investigation to diagnose PSAGN 4. Explain the mechanism of hypertension in PSAGN and it complication? 5. Provide initial management for this case 6. List the complication of PSAGN Lecture 7: Urinary Tract Infection: Uncomplicated and Complicated Urinary tract infection (UTI): a documented episode of significant bacteriuria (i.e. an infection with a colony count of > 100,000 organisms per ml) that may affect the upper urinary tract (pyelonephritis, renal abscess) or lower urinary tract (cystitis), or both. UTI is a very common condition in general practice (usually E. coli). Ascending infection (most UTI) is caused in this way (bacteria from gastrointestinal tract colonize lower urinary tract). Haematogenous spread is an infrequent cause of UTI (seen in intravenous drug users, bacterial endocarditis and tuberculosis). Clinical features of Upper urinary tract infection are fever, rigors/chill, flank pain, malaise, anorexia, costovertebral angle and abdominal tenderness; and lower urinary tract infection are dysuria, frequency, urgency, suprapubic pain, haematuria, scrotal pain (epididymo-orchitis) or perineal pain (prostates). Principles of management are to treat the infection with an appropriate antibiotic based on urine culture results and deal with any underlying cause (e.g. relieve obstruction). High fluid intake should be encouraged and potassium citrate may relieve dysuria. Uppertract UTIs, epididymo-orchitis and prostatitis require intravenous antibiotic therapy. Agents commonly used: gentamicin, cephalosporin or co-trimoxazole. Cystitis and uncomplicated lower UTIs can be managed with oral antibiotics. Agents commonly used are trimethroprim, ampicillin, nitrofurantoin, and cephalosporin. An abscess will require drainage either radiologically or surgically. If there is a poor response to treatment, consider unusual urinary infections: tuberculosis (sterile pyuria), candiduria, schistosomiasis, C. trachomatis, N. gonorrhoeae. The complications of urinary tract infection are bacteraemia and septic shock, chronic and xanthogranulomatous pyelonephritis, renal and perinephric abscesses. Learning task 7 Case 1 Seventy years old man referred from primary health care with recurrent lower urinary tract symptoms (LUTS) since 5 years. He had history of antibiotic treatment, and passed urethral stone 10 years ago. Urinalysis revealed Leucocyturia, erythrocyturia, and bacteriuria. Udayana University Faculty of Medicine, DME 21 | P a g e Study Guide The Urinary System and Disorder Block Task If you a doctor in small city (in Indonesia, type B hospital) and not so far from top referral hospital (type A Hospital): 1. What is the need to be complete diagnosed? 2. What is the proper medical treatment 3. When should you refer the patient to referred hospital (type A hospital)? Case 2 A 40 years-old man has been suffering current lower abdominal pain during urination since 1 year. Cloudy urine and sometime the urine colours were red. On digital rectal examination (DRE) do not fine any pathology. The result of laboratory test are: BUN and SC in normal limit (10.0 mg%, and 0.5 mg%), urinalysis revealed erythrocyturia, leucocyturia, and bacteriuria with significant urine culture (E. Coli count 100, 000 cfu/ml). Plain abdominal photo (BNO/BOF) result saw radio opaque picture 20 mm in size at pelvic cavity. 1. What is possible diagnosis? 2. Give some example treatment, if you are a doctor in primary health care practice! 3. What are possible treatments to do at referred hospital? Lecture 8: Urinary Calculi (Urolithiasis) and Urethral Stricture Urolithiasis is a frequent clinical problem. The calculi may be form at any level in the urinary tract, can be bilateral, but frequently unilateral. The favored sites for their formation are within the renal calyces and pelvis, and in the bladder. There are four main types of calculi: (1) Calcium containing calculi, (2) Struvite calculi, (3) Uric acid stone, and (4) Cystine stone. An organic matrix of mucoprotein is present in all calculi. Although there are many causes for initiation and propagation of stone, the most important determinant is an increased urinary concentration of the stone constituents, such that it exceeds their solubility in urine (supersaturation). A low urine volume in some metabolically normal patients may also favor supersaturation. Clinical features of urolithiasis: calyceal stones may be asymptomatic; staghorn calculi present with loin pain and upper tract UTI; ureteric colic: severe colicky pain radiating from the loin to title groin and into the testes or labia associated with gross or microscopic haematuria; bladder calculi present with sudden interruption of urinary stream, perineal pain and pain at the tip of the penis. The management including pain relief for ureteric colic; pethidine, Voltarol, high fluid intake, 80% of ureteric stones pass spontaneously: stones < 4 mm in diameter almost always pass; stones > 6 mm almost never. Indications for intervention: kidney stones: symptomatic, obstruction, staghorn; ureteric stones: failure to pass, large stone, obstruction, infection; bladder: all stones. Udayana University Faculty of Medicine, DME 22 | P a g e Study Guide The Urinary System and Disorder Block Learning Task 8 Case 1 A 50 years-old woman has been getting colicky pain since 2 hours. On the physical examination he has right flank mass and pain full during palpation and percussion. Leucocyturia, erythrocyturia and bacteriuria in urin analysis. Learning Task If you a doctor in small city (in Indonesia, type B hospital) and not so far from general hospital (type A hospital): 1. What are differential diagnoses of this case? 2. Whatare the radiologic examination need to definitive diagnose? 3. Whatare the initial management of this case? 4. When are you going to referral a patient to referred hospital (RS type A)? Case 2 Forty years old man referred from primary health care with lower urinary tract symptoms (LUTS) since 5 years. He had history of antibiotic treatment, and passed urethral stone 10 years ago. Urinalysis revealed leucocyturia, erythrocyturia and bacteriuria. Learning Task If you a doctor in small city (in Indonesia, type B hospital) and not so far from general hospital (type A hospital): 1. What are differential diagnoses of this case? 2. Whatare the radiologic examination need to definitive diagnose? 3. Whatare the initial management of this case? 4. When are you going to referral a patient to referred hospital (RS type A)? Case 3 Twenty years old man referred from primary health care with lower urinary tract symptoms (LUTS) since 2 years. He had history straddle/saddle injury 3 years ago. Learning Task If you a doctor in small (in Indonesia, type B hospital) and not so far from general hospital (type A hospital): 1. What are differential diagnoses of this case? 2. Whatare the radiologic examination need to definitive diagnose? 3. When are you going to referral a patient to referred hospital (RS type A)? Lecture 9: Common Neoplasm in Urinary System: Renal tumors, bladder tumors. Because of the diverse connotations of the term, it is necessary to define BPH as microscopic BPH, macroscopic BPH, or clinical BPH. Microscopic BPH represents histologic evidence of cellular proliferation of the prostate. Macroscopic BPH refers to enlargement of the prostate resulting from microscopic BPH. Clinical BPH represents the LUTS, bladder dysfunction, hematuria, and urinary tract infection (UTI) resulting from macroscopic BPH. Abrams (1994) has suggested using the more clinically descriptive terms benign prostatic enlargement (BPE), BOO, and LUTS to replace BPH. Udayana University Faculty of Medicine, DME 23 | P a g e Study Guide The Urinary System and Disorder Block The histologic diagnosis of prostate cancer is made, in the majority of cases, by prostate needle biopsy. Prostate cancer rarely causes symptoms until it is advanced. Thus, suspicion of prostate cancer resulting in a recommendation for pros-tatic biopsy is most often raised by abnormalities found on digital rectal examination (DRE) or by serum prostatespecific antigen (PSA) elevations. Although there is controversy regarding the benefits of early diagnosis, it has been demonstrated that an early diagnosis of prostate cancer is best achieved using a combination of DRE and PSA. Transrectal ultrasound (TRUS)-guided, systematic needle biopsy is the most reliable method, at present, to ensure accurate sampling of prostatic tissue in men considered at high risk for harboring prostatic cancer on the basis of DRE and PSA findings. Both benign and malignant tumors occur in the kidney. The benign tumors rarely cause clinical problems while malignant tumors are of great importance clinically and deserve considerable emphasis. The common malignant tumors of the kidney are Renal Cell Carcinoma (RCC), Wilm tumor and urothelial carcinoma of renal pelvis. RCC occurs most often in older individual, usually in the sixth and seventh decade of life. Morphologically, RCC is divided into four major types, i.e. clear cell carcinoma, papillary carcinoma, chromophobe renal carcinoma and Bellini duct carcinoma. Wilmtumor usually occur in children. Urothelial carcinoma originates from urothelium of the pelvis, and it often clinically apparent within a relatively short time because they lie between the pelvis and by fragmentation produce noticeable hematuria Learning Task 9 Case 1 Seventy years old man was referred from primary health care with left flank mass since 2 years. He had no history of haematuria, and febrile. Urinalysis revealed leucocyturia, erythrocyturia and bacteriuria. Learning Task If you a doctor in small (in Indonesia, type B hospital) and not so far from general hospital (type A hospital): 1. What are differential diagnoses of this case? 2. Whatare the radiologic examination need to definitive diagnose? 3. When are you going to referral a patient to referred hospital (RS type A)? Case 2 Seven years old boy was reffered from primary health care with left flank mass since 1 year. He had no history haematuria, and febrile. Urinalysis revealed leucocyturia, erythrocyturia and bacteriuria. Learning Task If you a doctor in small (in Indonesia, type B hospital) and not so far from general hospital (type A hospital): 1. What are differential diagnoses of this case? 2. Whatare the radiologic examination need to definitive diagnose? 3. When are you going to referral a patient to referred hospital (RS type A)? Case 3 Sixty years old man was referred from primary health care with painless gross haematuria since 2 years. He had history of antibiotic treatment, and did not found any stone on plain abdominal X ray and ultrasound examination. Udayana University Faculty of Medicine, DME 24 | P a g e Study Guide The Urinary System and Disorder Block Learning Task If you a doctor in small (in Indonesia, type B hospital) and not so far from general hospital (type A hospital): 1. What are differential diagnoses of this case? 2. Whatare the radiologic examination need to definitive diagnose? 3. When are you going to referral a patient to referred hospital (RS type A)? Lecture 10: Urinary tract trauma (Rupture of the kidney and urinary tract) Of all injuries to the genitourinary system, injuries to the kidney from external trauma are the most common. It is essential to obtain as many details of the injury as possible; for example, depending on whether the cause is blunt or penetrating trauma, the approach to evaluation and management is quite different. Blunt renal injuries most often come from motor vehicle accidents, falls from heights, and assaults. Perhaps the most important information to obtain in the history of the injury is the extent of deceleration involved. Rapid deceleration can cause vascular damage to the renal vessels, resulting in renal artery thrombosis, renal vein disruption, or renal pedicle avulsion. In high-velocity-impact trauma, multiple-organ injury is likely to be associated. Penetrating renal injuries most often come from gunshot and stab wounds. The gunshot to the upper abdomen or lower chest should alert the physician to renal injury; of all patients sustaining renal trauma in a large reported series, renal gunshot wounds occurred in approximately 4.0% (McAninch et al, 1993 ). Important factors in assessing a gunshot wound initially are weapon characteristics and bullet ballistics. Ureteral injuries after external violence are rare, occurring in less than 4% of cases of penetrating trauma and less than 1% of cases of blunt trauma. During wartime in the past century, 3% to 15% of urologic injuries have involved the ureter, with an average of 5% over reports from World War II up to modern conflicts. In the nonmilitary setting, a similar incidence of ureteral injuries is caused by civilian gunshot injuries. These patients often have significant associated injuries and a devastating degree of mortality that approaches one third. Associated visceral injury is common, predominantly small (39% to 65%) and large (28% to 33%) bowel perforation. Significant percentages (10% to 28%) of patients with ureteral injuries also have associated renal injuries. A smaller percentage (5%) has associated bladder injuries. Ureteral injuries can occur after a multitude of surgical procedures but largely result from surgeries in the pelvis (such as hysterectomy) and retroperitoneum (such as major vascular replacement). One report, which reviewed 13 previously published studies, concluded that hysterectomy was responsible for the majority (54%) of surgical ureteral injuries. Next most common was colorectal surgery (14%), followed by pelvic surgery such as ovarian tumor removal and transabdominal urethropexy (8%), and followed lastly by abdominal vascular surgery (6%). One series reported that repeat cesarean section can also result in a large number of ureteral injuries, in this case up to 23% of the reported ureteral injuries at one hospital (Ghali et al, 1999 ). The total incidence of ureteral injury after gynecologic surgery is reported to be between 0.5% and 1.5%, and after abdominoperineal colon resection it ranges from 0.3% to 5.7%. Open urologic procedures, because they often occur in proximity to the ureters, were also responsible for a significant number (21%) of reported ureteral injuries in one series. Udayana University Faculty of Medicine, DME 25 | P a g e Study Guide The Urinary System and Disorder Block The urinary bladder is generally protected from external trauma because of its deep location in the bony pelvis. Most blunt bladder injuries are the result of rapid-deceleration motor vehicle crashes, but they also occur with falls, crush injuries, assault, and blows to the lower abdomen. Whereas disruption of the bony pelvis tends to tear the bladder at its fascial attachments, bone fragments can also directly lacerate the organ. Bladder laceration may also arise from penetrating trauma or various iatrogenic surgical complications and may occur spontaneously in patients with altered sensorium, such as those who are intoxicated or have neuropathic disease. Learning task 11 Case 1 Twenty years old man reffered from primary health care with gross haematuria and history of fall from manggo tree 5 meters in high, 4 hours before hospitalize. Bruise and palpable pain on left side flank. Learning Task If you a doctor in small (in Indonesia, type B hospital) and not so far from general hospital (type A hospital) 1. What are differential diagnoses of this case? 2. What are the radiologic examinations need to definitive diagnose? 3. What is the initial management of this case? 4. When are you going to referral a patient to referred hospital (RS type A)? Case 2 A 22 years-old man has been suffering from urethral bloody discharge and pain on lower abdominal region since he had motor cycle accident 5 hours ago. On physical examination found that he has bruising and mass lower abdominal region area. Learning Task If you a doctor in small (in Indonesia, type B hospital) and not so far from general hospital (type A hospital)What are differential diagnosis of this case? 5. What are the radiologic examinations need to definitive diagnose? 6. What is the initial management of this case? 7. When are you going to referral a patient to referred hospital (RS type A)? Lecture 11 & 12: Acute Kidney Injury & Chronic Kidney Diseases The syndrome of acute renal failure (ARF) is defined as a reduction of glomerular filtration rate (GFR) that is often reversible. The syndrome may occur in three clinical settings: (1) as an adaptive response to severe volume depletion and hypotensiuon with structurally ang functionally intact nephrons, (2) in response to cytotoxic insults to the kidney when both renal structure and function are abnormal, and (3) when the passage of urine is blocked. Thus ARF may be classified as prerenal, intrinsic, or postrenal. Chronic kidney disease (CKD) is characterized by a progressive course with ongoing loss of kidney function. Once the glomerulous filtration rate (GFR) falls below about half of normal, kidney function tends to decline even if the initial insult of kidney has been Udayana University Faculty of Medicine, DME 26 | P a g e Study Guide The Urinary System and Disorder Block eliminated. This phenomenon has been defined as progression of CKD and typically moves through phases from initial diminution of renal reserve to mild, moderate, and severe reduction of GFR, then kidney failure ultimately requiring renal replacement therapy (end stage renal disease). Learning Task 11 Case 1 36 year old man is admitted for an increased serum creatinine level. He has been taking intravenous antibiotics at home for the past 2 weeks for osteomyelitis caused by Staphylococcus aureus. He reports no change in his urine output. On physical examination, his blood pressure was 124/76 mmHg and his pulse was 82 beats per minute while he was supine and 126/74 mmHg 86 beats per minute while he was standing. He has a diffuse red maculopapular rash on his trunk and limbs. The remainder of the examination is normal. His serum creatinine level is 2,4 mg/dl today and it was 1,0 mg/dl a week ago. Other blood laboratory findings include the following: WBC count 11.000/ml; sodium 142 mmol/L; potassium 4,2 mmol/L; and blood urea nitrogen 34 mg/dl. His urine showed a sodium level of 54 mmol/L and creatinine level of 39 mg/dl. The urinalysis with dipstick testing showed +1 protein; the microscopic analysis showed 5-10 leucocytes/HPF(high power field). And an occasional leucocytes cast. Kidney ultrasound showed no hydronephrosis. Learning Task 1. 2. 3. What is the most likely diagnosis for this patient’s AKI? Give your reason! a. AKI (acute kidney injury) as a result of acute interstitial nephritis b. Chronic kidney diseases as a result of diabetes c. AKI as a result of acute tubular necrosis (ATN) d. AKI as a result of prostate diseases Explain your answer! What kind of abnormality findings was found in the patient supports your conclusion? Explain the pathophysiology! Explain the management for this patient! Case 2 79 year old white man comes to emergency unit with the symptom: not being able to urinate this day. He recently saw his primary care physician for an upper respiratory infection, and began taking diphenhydramine (anti-histamine) for relief the nasal congestion. He reports a history that is significant for benign prostatic hyperplasia (BPH) and hypertension. A Foley catheter was placed, with the return of 1200 ml of urine. Urinalysis was within normal limit. His blood urea nitrogen (BUN) level was 21 mg/dl and his creatinine level was 1,5 mg/dl (base line creatinine level, 1.0 mg/dl). Learning Task 1. 2. 3. What is the most likely diagnosis for this patient? a. Pre renal as a result of hypovolemia b. Intra renal as a result of ATN c. Intra renal as a result of acute interstitial nephritis d. Post renal as a result of obstruction Explain your answer! What kind of abnormality findings was found in the patient supports your conclusion? Explain the pathophysiology! Explain the management for this patient! Udayana University Faculty of Medicine, DME 27 | P a g e Study Guide The Urinary System and Disorder Block Learning task 12 Trigger Case A 63-year-old African-American woman with type 2 diabetes mellitus and hypertension for last 17 years is seen in the clinic for worsening feet edema. Her history reveals that she underwent laser surgery for diabetic retinopathy. Her medications include metoprolol (50 mg twice daily), hydrochlorothiazide (25 mg daily), and insulin. On physical examination her blood pressure is 148/88 mmHg, and pulse rate is 85 beats/min. She has (+) 2 pedal edema. Laboratory tests show a serum creatinine level of 0,7 mg/dl and BUN level of 32 mg/dl. The glycosylated hemoglobin level is 7,5 %. Urine testing shows +4 proteins by dipstick. Learning Task 1. Describe the classification of chronic kidney disease! 2. Which of the following statements is true? a. This patient does not have CKD (chronic kidney disease) b. This patient has stage 1 CKD c. This patient has stage 2 CKD d. This patient has stage 3 CKD Explain your answer! What kind of abnormality findings was found in the patient that supports your conclusion? 3. Explain the pathophysiology! 4. Which of the following facilitatorstors is not likely to increase the progression of CKD for this patient? a. Female gender b. (+) 4 proteinuria c. Blood pressure of 144/88 mmHg d. Glycosylated hemoglobin level of 7.5 %. Explain your answer! 5. Describe the management of chronic kidney disease according to the class/stage! 6. Explain the rational management for the patient above! Lecture 13: Renal Hypertension Renovascular hypertension is the most common cause of secondary hypertension in the United States. Renovascular hypertension is an elevation of blood pressure due to activation of the renin-angiotensin system in the setting of renal artery occlusive diseases. The diagnosis of renovascular hypertension can be made only if blood pressure improves following intervention, thereby making renovascular hypertension a retrospective diagnosis. The presence of anatomic renal artery stenosis is not synonymous with renovascular hypertension. Progressive and occlusive renovascular disease may lead to impaired kidney function, termed “ischemic nephropathy”. Learning Task 13: 1. Describe the pathophysiology of Renovascular hypertension 2. Explain the type of endocrine hypertension 3. Describe the principle management for the patient with secondary hypertension Udayana University Faculty of Medicine, DME 28 | P a g e Study Guide The Urinary System and Disorder Block Lecture 14: Drug use in renal disorders Diuretics Urinary antiseptics Kidney performs a number of essential functions in the body including clearance of waste product, drug or other substances, control of volume status, maintenance of electrolyte and acid base balance. Renal impairment (disorders) frequently alters the pharmacokinetic and pharmacodynamic of certain drugs. Absorption, bioavailability, protein binding, distribution volume and clearance (metabolism) of several drugs can be affected, as well as pharmacodynamic processes. Alterations in pharmacokinetic and pharmacodynamic of drugs in renal disorders (diseases) potentially cause increased risk of adverse drug reaction. In addition, multiple medical problems in patient with kidney disease frequently result in polypharmacy and consequently increased drug interaction. Careful attention should also be taken for drug use in renal disease. Many drugs potentially cause drug-induced renal disease, thus their uses in renal impairment should be avoided or the dosage should be adjusted. Drug-induced renal disease may result from immunological or non immunological process, and may affect pre renal, renal or post renal. Dosage adjustment in renal disorders commonly required for drugs which eliminated mainly by renal excretion or drugs with narrow safety margin. Diuretic is group of drugs that increase the secretion of urine (water, electrolytes and waste products) by the kidney. Diuretics inhibit renal sodium reabsorption by several mechanisms. Each type of diuretic acts upon a single anatomic segment of the nephron, which has a distinctive transport function. There are several types of diuretics available recently, carbonic anhydrase inhibitors, loop diuretics, thiazides, potassium sparing diuretics, and osmotic diuretics. Urinary antiseptics are oral drugs that are rapidly excreted into the urine and act there to suppress bacteriuria. Types of urinary antiseptic available are nitrofurantoin, nalidixic acid and methenamine. SELF-DIRECTED LEARNING Basic knowledge must be known: 1. The role of kidney on drug disposition 2. The pharmacokinetic and pharmacodynamic changes of drugs in renal disorders 3. Types of drug-induced renal disease and the pathophysiological mechanism 4. Drug dosage adjustment in renal disorders 5. Mechanism of action, clinical indication, adverse effects of several types of diuretics 6. Types of urinary antiseptics, the mechanism of action and adverse effects Learning Task 14 SCENARIO 1 A 38 years old man was admitted to emergency unit due to bloody urine and flank pain since last week. Patient had history of hypertension since 4 years. Physical examination revealed BP=180/100 mmHg, edema (+) in both lower extremities, anemia (+), t =38˚C. Laboratory result revealed WBC= 13.0; Hb= 8.5; BUN= 201; SC= 16.4. Doctor decided to give several drugs to manage patient’s disease. One of the medications planned to be given was antibiotic. Udayana University Faculty of Medicine, DME 29 | P a g e Study Guide The Urinary System and Disorder Block TASK 1 1. From the scenario above, what is the most appropriate antibiotic for this patient? Explain the reason. 2. What are the principal factors should be considered before giving antibiotic treatment for patient with chronic kidney disease? 3. If patient required any analgesic medication, what analgesic would be the safest one? 4. Mention types of antibiotic and analgesic that potentially induced renal injury/disease and the type of renal injury/disease might be resulted from it. 5. Mention the basic concepts of drug dosage adjustment in chronic kidney disease SCENARIO 2 A 40 years old man was admitted to emergency unit due to swelling on both legs since 2 weeks before. After complete physical and laboratory examination patient was diagnosed as having chronic kidney disease. Doctor decided to give furosemide for relieving the oedema. After several days of furosemide treatment, patient was suffered from hypokalemia. TASK 2 1. How does furosemide exert its action? 2. When used chronically, what adverse effects would possibly occur? 3. How was the possible mechanism of hypokalemia result from furosemide treatment? 4. What is the effect of concurrent NSAID treatment in patient receiving furosemide? Lecture 15&16 Prostate & Male Penile Disorders Disorder of male genital system include penis (malformation, inflammation, neoplasm), scrotum, testis (cryptorchidism, inflammation, neoplasma), epididymis, prostate (prostatitis, BPH, carcinoma) and sexual transmitted diseases. Malformations of the penis are hypospadia, epispadia, priapism, peyronie disease. Hypospadia is more common than epispadia. These malformations may result in lower urinary tract problem and failure to impregnate women. Inflammatory condition of the penis that unrelated to STDs is called balanitis and posthitis. In phimosis, where prepuce cannot be retracted, smegma is deposited between glans penis and prepuce. Therefore most cases of phimosis accompanied by balanoosthitis. When phimosis is forcibly retracted it may result in paraphimosis. In this condition, the circulation to the glans penis may be strangulated by the stenotic prepuce. This may cause congestion, swelling and pain. In severe case, urinary retention may occur. Carcinoma of the penis is the most neoplasm occurs in the penis. Some predisposition factors are pimosis, BXO and chronic irritation. It is believed that smegma and infection of HPV (type 16 & 18) have an important role in the occurrence of carcinoma of the penis. Microscopically carcinoma of the penis is squamous cell carcinoma. Learning Task 15 Man 68 years old come with lower abdominal pain and unable to void since one day ago. He suffered from Lower urinary tract symptoms since 6 months ago. 1. What is the possible diagnosis of this patient? 2. What are the anamnesis, signs, symptoms and examination to support the diagnosis? 3. What is your planning to complete the diagnosis? 4. What is your planning treatment of this patient? Udayana University Faculty of Medicine, DME 30 | P a g e Study Guide The Urinary System and Disorder Block Learning Task 16 A 34- years- old man, came with complaint of unable to void since 2 days ago. He also complains of weak urinary flow and terminal dribbling since last 2 months. He had history of urethral discharge due to sexual transmitted diseases. No complaint on erectile capability. He has a good general condition, composmentis, normal blood pressure 120/80, pulse 88x/minutes, uncircumcised, narrow MUE. Normal scrotal finding, right testicle normal. Questions: 1. What is the possible diagnosis of this patient? 2. What are the anamnesis, signs, symptoms and examination to support the diagnosis? 3. What is your planning to complete the diagnosis? 4. What is your planning treatment of this patient? Questions: 5. What is the most possible diagnose of your patients? 6. If you are in doubt, the best diagnostic tool that you propose? 7. What is the treatment of your patient? SELF ASSESSMENT SELF ASSESSMENT 1 (Macroscopic structure of the Urinary system) 1. Drawing and describe the topography of kidneys 2. Drawing and describe the vascularisations of kidneys 3. Drawing and describe the innervations of kidneys 4. Drawing the profile of uriniferous tubules 5. Drawing the anatomical structure of urinary tract 6. Drawing the vasculature and innervations of urinary tract SELF ASSESSMENT 2 (Microscopic structure of the urinary system) 1. Explain the kidney disorders in relation with it’s microscopic structure! 2. How is the relation between Bowman’s capsule and glomerulus? 3. Differentiate afferent and efferent glomerular arteriole! 4. Explain the epithelium of proximal tubule, Henle’s loop, and distal tubule! 5. What is filtration barrier in renal corpuscle! 6. Explain about podocyte, mesangial cells and its function! 7. Explain about two types of nephron and cell types composing the thin limbs of Henle’s loop? 8. Explain three regions of collecting tubules! 9. What is renal interstitium? 10. Explain the urinary tract disorders in relation with it’s microscopic structure! 11. The structure that separates transitional epithelial from underlying lamina propria is…. 12. The structure of fibrous outer coat of ureter at its proximal and distal terminal is… 13. The function of plaque regions of the transitional epithelial cell plasmalemma is….. 14. What is the microscopic structure of the triangular region of the bladder? 15. Explain the two layers of lamina propria of the bladder! 16. What is gland of Littre? Udayana University Faculty of Medicine, DME 31 | P a g e Study Guide The Urinary System and Disorder Block SELF ASSESSMENT 3 (The function of the urinary system) 1. Explain the pressures that involved in filtration process 2. Describe the myogenic response in autoregulation of GFR 3. Describe the tubulo-glomerular feedback in autoregulation of GFR 4. Describe the hormonal and autonomic nerve factor in autoregulation 5. Describe the process of water, electrolyte and other solute along the proximal, loop of Henle, distal and collective tubules of nephrons 6. Describe the rule of muscles of ureter in urine flow 7. Describe the rule of muscles of bladder and sphincter internal and external of urethrae 8. Describe the nerve that involved in micturition process 9. Describe the counter-current concept in relation to maintain the difference of tissues osmolarity between cortex and medulla of kidneys 10. Explain the rule of anti diuretic hormone (ADH) in kidneys to maintain the body fluid balance 11. Explain the aldosterone hormone to maintain the electrolytes balance 12. Explain the mechanism of water and electrolytes excretion that influenced by diuretic drug 13. Describe the mechanism for producing concentrated and dilute urine excretion 14. Describe what is the meaning of acidosis condition and alkalosis condition 15. Describe the buffers and their function in the body 16. Describe the renal correction in acidosis and alkalosis condition SELF ASSESSMENT 5 (Pathogenesis of the glomerular and tubulointerstitial injury) State whether the statement is true or false! 1. Goodpasture syndrome is characterized by membranous glomerulonephritis induced by circulating antigen-antibody complex deposition within glomeruli. 2. Glomerular disease associated with immune response to streptococcal infection is commonly showed acute diffuse glomerulonephritis. 3. Podocytes alteration in minimal change disease can be detected by histomorphology examination. 4. The distribution of tubular necrosis in ischemic ATN and nephrotoxic ATN is similar. 5. Acute hypersensitivity nephritis induced by methicillin usually associated by subtle and cumulative injury to tubules. SELF ASSESSMENT 6 Common kidney diseases in children 1. Assessment for proteinuria 2. Describe the term of remission, relapse, steroid dependent and steroid resistant in nephrotic syndrome 3. What is the most form of Nephrotic syndrome in children? 4. Explain the monitoring for the hospitalized patient with Nephrotic Syndrome? 5. Is it possible to give furosemide for edema in Nephrotic Syndrome? Explain your answer. 6. Explain the time and percentage of response for steroid therapy in Nephrotic Syndrome? 7. Describe differentiation of glomerular and extra glomerular hematuria. 8. List the source of infection and bacterial strain in PSAGN 9. Pathophysiology of APSGN 10. Monitoring for inpatient PSAGN Udayana University Faculty of Medicine, DME 32 | P a g e Study Guide The Urinary System and Disorder Block 11. 12. 13. 14. Follow up for outpatient PSAGN Clinical and laboratory evaluation When is the symptom and laboratory resolves Prognosis of PSAGN? SELF ASSESSMENT 7 (Complicated and Uncomplicated Urinary tract infection) 1. How to do a complete anamnesis (history talking) by fundamental four and secrete seven in complicated UTI? 2. How to do a complete diagnosis (primary, scondary and complication) by history talking, physical, X ray and ultrasound) in complicated UTI? 3. How to do the proper medical management in complicated UTI? 4. How to do the education in complicated UTI, if a patien is going to reffered hospital and surgical management? SELF ASSESSMENT 8 (Urolithiasis and urethral stricture) Self Assessment Urolithiasis 1. How to do a complete anamnesis (history talking) by fundamental four and secrete seven in renal, ureteral, bladder and urethral stone? 2. How to do a complete diagnosis (primary, secondary and complication) by history talking, physical, X ray and ultrasound examination in renal, ureteral, bladder and urethral stone? 3. How to do initial management in renal, ureteral, bladder and urethral stone? 4. How to do education in renal, ureteral, bladder and urethral stone, if a patient going to do to referred hospital and surgical management? Self Assessment Urethral stricture 1. How to do a complete anamnesis (history talking) by fundamental four and secrete seven in urethral stricture? 2. How to do a complete diagnosis (primary, secondary and complication) by history talking, physical, X ray examinations) in urethral stricture? 3. How to do education in urethral stricture, if a patient going to do to referred hospital and surgical management? SELF ASSESSMENT 9 (Common neoplasm of the urinary tract and related structure) 1. How to do a complete anamnesis (history talking) by fundamental four and secrete seven in kidney and bladder neoplasma? 2. How to do a complete diagnosis (primary, secondary and complication) by history talking, physical, X ray examinations) in kidney and bladder neoplasma? 3. How to do education in kidney and bladder neoplasma, if a patient going to do to referred hospital and surgical management? SELF ASSESSMENT 10 (Urinary tract Trauma) 1. How to do a complete anamnesis (history talking) by fundamental four and secrete seven in renal, ureteral, bladder and urethral trauma? 2. How to do a complete diagnosis (primary, secondary and complication) by history talking, physical, X ray and ultrasound examination in renal, ureteral, bladder and urethral trauma? 3. How to do initial management in renal, ureteral, bladder and urethral stone? 4. How to do education in renal, ureteral, bladder and urethral trauma, if a patient going to do to referred hospital and surgical management? Udayana University Faculty of Medicine, DME 33 | P a g e Study Guide The Urinary System and Disorder Block SELF ASSESSMENT 11 (Acute kidney injury) 1. Explain about acute kidney disease and its classification! 2. Explain about the RIFLE criteria! 3. Explain the pathophysiology of acute kidney disease due to gastroenteritis with dehidration? 4. Explain the management of acute kidney disease? 5. Can you describe the compication of acute kidney injury? SELF ASSESSMENT 12 (Chronic kidney disease) 1. Describe the classification of Chronic Kidney disease 2. Explain the pathophysiology of hypertension in cronic kidney disease? 3. Explain the pathophysiology of anemia in cronic kidney disease? 4. Describe the management of Chronic Kidney disease according to the classification SELF ASSESSMENT 13 Secondary hypertension Secondary Hypertension 1. In a patient with bilateral renal artery stenosis, drugs that inhibit ACE inhibitors or that block angiotensin receptors can have a negative impact of renal function. Which renal function can be made worse? A. The ability to secrete renin B. The ability to concentrate urine C. Glucose-reabsorbing ability D. Glomerular filtration 2. Which of the following clinical symptoms and signs is not seen in patient with primary hyperaldosterinism A. Edema of the angkles B. Weakness of the muscle C. Systolic blood pressure of more than 180 mmHg D. Muscle cramps 3. A physician is practicing in a third world region with no radiology or nuclear medicine support and a laboratory that can only measure blood counts, electrolytes and simple blood chemistries. A young patient with hypertension who has no family history of hypertension presents to the clinic. Which of the following tests would the physician request to investigate the possibility that the patient has primary hyperaldosteronism? A. Serum sodium concentration B. Serum and 24-hour urine potassium C. 24-hour urine sodium and creatinine D. Urine sodium concentration and pH SELF ASSESSMENT 14 1. 2. 3. 4. 5. 6. Mention several drugs that potentially induce renal disease Mention the possible mechanisms of drug-induced renal disease Mention pharmacokinetic and pharmacodynamic changes possibly occur in renal disease. What are the basic concepts of dosage adjustment in patient with renal disease? How is the mechanism of action for each type of diuretics? What is the effect of each class of diuretics in acid base balance and serum potassium level? Udayana University Faculty of Medicine, DME 34 | P a g e Study Guide The Urinary System and Disorder Block 7. 8. 9. 10. 11. 12. Why spironolactone would not cause potassium wasting? What other adverse effects might occur in diuretic treatment? Mention some clinical indications of diuretics. Mention types of urinary antiseptics. How is the mechanism of urinary antiseptic action? What are the adverse effects of each type of urinary antiseptic? SELF ASSESSMENT 15&16 1. 2. 3. 4. 5. 6. 7. What is the definition of phimosis and paraphimosis, priapismus and peyronie disease? What is the definition and the management of urethral stricture? What is the complication of the long term phimosis and poor hygiene of the male external genital? What is the definition and aetiology of hypospadia? What is the caused and complication than can be caused by balanopostitis? What is the correlation between phymosis and penile cancer? How is the management of penile cancer? BASIC CLINICAL SKILLS In general, patients with kidney diseases usually come with non specific symptom. They usually come with hematuria, foamy urine, abnormality of the urine volume (poliuria, oligouria, anuria), or disturbance in micturition process. Another symptom also not infrequently, such as edema, fatigue, pale, nausea and vomiting. Edema starts from face and spread to all of the body. They also come with flank pain (renal colic and ureter colic). The patient with severe kidney destruction may come with shortness of the breath as the result of lung edema or acidosis. Sign that frequently seen in kidney diseases including anemia, hypertension, and edema. If a patient come to seek the treatment with nausea, vomiting, fatigue, hypertension and edema always think that the most possibility is chronic kidney diseases. Renal colic is a severe pain at right or left lumbal region and referred to genital region. Also accompanied by percussion pain at costovertebral angle. Test for kidney patient include routine laboratory test, imaging, and biopsy. Laboratory test, including, routine hematology, urinalysis, ureum/BUN, creatinine, electrolyte (K, Na), uric acid serum, urine volume, in special scenario, blood gas analysis, total protein and albumin, calsium, anorganik phosphate maybe required. Another examination should be done based on their indication. Clearence creatinine test is important in measuring glomerular filtration rate. Imaging examination including BNO, IVP, Ultrasonography, CT Scan and, retrograde pielography. Urine cytology and renal biopsy can be done based on indication. One of the necessary laboratory examination is the examination of the microbiology laboratory. To be able to produce accurate data from the microbiological examination, the specimen quality is a factor that must be considered. A good quality specimen is needed to assist in establishing a reliable diagnosis. Improper management of specimens, both in terms of collection, storage, or transportation, can lead to failure in finding the cause of microorganisms. Interpretation of result culture and susceptibility testing must be tailored according to the patient at risk and the specimen type submitted. There are three things that should be considered in cases of urinary tract infections are the colony count of microorganisms growing in culture, measurement of pyuria and presence or absence of symptoms (dysuria and frequency). Knowledge of the normal flora in the area genetalia are also required similarly with microorganisms that are often the causes of urinary tract infections are very helpful in determining the culture of an agent causing the infection or merely contamination only. Udayana University Faculty of Medicine, DME 35 | P a g e Study Guide The Urinary System and Disorder Block Anamnesis and Physical Examination in Urinary System and Male Genital System Disorders Learning task Title Objective : : Competency (bold letter) : Instruction for the students : Anamnesis and physical examination in lower urinary tract disorders Student can do structured anamnesis and physical examination in lower urinary tract disorders 1. Anamnesis skill 2. Physical examination skill 3. Skill in clinical procedure or interprate data from laboratory finding and/or imaging to making a diagnosis or diferensial diagnosis 4. Management 5. Patient education and communication 6. Profesional behaviour Clinical scenario 1: A-25-year old man come to the primary health care service with pain during urination. Clinical Scenario 2: A-40-year old man come to the primary health care service with fever and flank pain. Clinical scenario 3: Two years old boy came with complaint of left scrotal enlargement since he was born For each clinical scenario: Do the role play, one student as a doctor and one student as a patient Task: 1. Do the anamnesis and physical examination! 2. Mention your diagnosis dan minimum 1 diferensial diagnosis! Udayana University Faculty of Medicine, DME 36 | P a g e Study Guide The Urinary System and Disorder Block Check List Skills Anamnesi s Pemeriks aan fisik, meliputi Vital sign dan status lokalis 0 Mahasiswa tidak melakukan anamnesis Mahasiswa tidak melakukan pemeriksaan fisik 1 2 3 Mahasiswa melakukan anamnesis, hanya menanyakan tentang keluhan utama saja Mahasiswa melakukan anamnesis, menanyakan Basic 7 dan fundamental 4 tapi tidak lengkap. Mahasiswa melakukan anamnesis, menanyakan Mahasiswa melakukan pemeriksaan fisik, tapi sebelum dan setelah kontak dengan pasien tidak cuci tangan Mahasiswa melakukan cuci tangan sebelum dan setelah kontak dengan pasien dan mahasiswa melakukan dengan tidak lengkap atau tidak benar pemeriksaan fisik berikut: Mahasiswa melakukan cuci tangan sebelum dan setelah kontak dengan pasien dan mahasiswa melakukan dengan lengkap dan benar pemeriksaan fisik berikut: 3 Keluhan utama, basic 7 dan fundamental 4 dengan lengkap. 1. 1. 2. Bob ot Vital sign Pemeriks aan status lokalis: Palpasi bladder 3 Vital sign Pemeriks aan status lokalis: Palpasi bladder Menentuk an diagnosis Mahasiswa tidak bisa membuat diagnosis Mahasiswa membuat diagnosis namun tidak lengkap Mahasiswa membuat diagnosis dengan benar namun tidak bisa membuat diferensial diagnosis Mahasiswa membuat diagnosis dengan benar dan bisa membuat minimal satu diferensial diagnosis yang benar 2 Komunika si edukasi pasien dan perilaku profesion al Mahasiswa tidak melakukan semua hal berikut: Mahasiswa hanya melakukan 1 dari hal berikut: Mahasiswa melakukan 2-3 dari hal berikut: Mahasiswa melakukan semua hal berikut: 1 1. 1. 1. 1. 2. menguca pkan salam, perkenala n Melakuka n kontak mata dengan pasien dan berempati 2. menguca pkan salam, perkenala n Melakuka n kontak mata dengan pasien dan berempati Udayana University Faculty of Medicine, DME 2. menguca pkan salam, perkenala n Melakuka n kontak mata dengan pasien dan berempati 2. menguca pkan salam, perkenala n Melakuka n kontak mata dengan pasien dan berempati 37 | P a g e Sk or Study Guide The Urinary System and Disorder Block 3. 4. menjelas akan dan meminta ijin untuk melakuka n perasat, memperh atikan kenyama nan pasien 3. 4. menjelas akan dan meminta ijin untuk melakuka n perasat, memperh atikan kenyama nan pasien 3. 4. menjelas akan dan meminta ijin untuk melakuka n perasat, memperh atikan kenyama nan pasien 3. 4. menjelas akan dan meminta ijin untuk melakuka n perasat, memperh atikan kenyama nan pasien Total Global Rating Score (lingkari): tidak lulus, borderline, lulus, superior Urethral Catheterization Learning task Title Objective : : Competency (bold letter) : Instruction for the students : Urethral Catheterization Student is competent to perform Urethral Catheterization on maniquine. 1. Anamnesis skill 2. Physical examination skill 3. Skill in clinical procedure or interpret data from laboratory finding and/or imaging to making a diagnosis or differential diagnosis 4. Management 5. Patient education and communication 6. Profesional behaviour Clinical Scenario: A 60 years old male patient, come to Primary Health Care Center with unable to urinate. Instruction: Perform Urethral Catheterization on this patient. Instruction for the facilitators : 1. 2. 3. Facilitator will allow student to perform urinary catheterization on mannequin in sequence. Facilitator must observe and evaluate each of student performance with checklist provided below. Facilitator must give feedback to each student based on their individual performance and also encourage each student to give feedback to their own performance. Udayana University Faculty of Medicine, DME 38 | P a g e Study Guide The Urinary System and Disorder Block CATHETERIZATION CHECK LIST Male No 1 Skills 0 Score 1 2 Introduce your self, explain what you would like to do and obtain concent 2 Hand washing before and afterprocedure 3 Lie the patient comfortably with his legs slightly separated 4 Choose a catheter, open the catheterization pack, pour antiseptic into the reciever and put on gloves 5 Clean the penis throughly, retract the prepuce and clean around the meatus 6 Drape, so that only penis is in sterile field 7 Hold the penis with a gauze swab; squeeze anaesthetic/lubricant jelly into the urethra and occlude it with pressure from the gauze 8 Advance the catheter tip from its sleeve and introduce to urethra, Advance the catheter using a “no touch technique”, or with sterile forceps, until the end arm of the catheter is up to the meatus 9 Inflate the baloon: inject about 5ml of water and check that it does not cause pain before fully inlating it 10 Attach the bag, gently extend the catheter into position, reposition the prepuce 11 Record the volume of urine in the bag (residual volume) Total Score Total Score Final score = --------------- x 100 = 22 Udayana University Faculty of Medicine, DME 39 | P a g e Study Guide The Urinary System and Disorder Block Female No 1 Skills 0 Score 1 2 Introduce your self, explain what you would like to do and obtain concent 2 Hand washing before and after procedure 3 Lie the patient comfortably with his legs slightly separated 4 Choose a catheter, open the catheterization pack, pour antiseptic into the reciever and put on gloves 5 Clean the vulva 6 Drape, so that only vulva is in sterile field 7 Advance the catheter tip from its sleeve and introduce to urethra, Advance the catheter using a “no touch technique”, or with sterile forceps 8 Inflate the baloon: inject about 5ml of water and check that it does not cause pain before fully inlating it 9 Attach the bag, gently extend the catheter into position, reposition the prepuce 10 Record the volume of urine in the bag (residual volume) Total Score Total Score Final score = --------------- x 100 = 20 Udayana University Faculty of Medicine, DME 40 | P a g e Study Guide The Urinary System and Disorder Block Urinalysis Learning Task 1 1. There are 5 urinalysis results provided. Analyze and conclude each of it? 2. Explain correctly and completely the technique of urine collection? Learning task 2 Title : Objective : Competency (bold letter) : Instruction for the students : Anamnesis , physical examination and interpret data from urinalysis in urinary system disorders Student can do structured anamnesis, physical examination and make a right interpretation from urynalisis in lower urinary tract disorders 1. Anamnesis skill 2. Physical examination skill 3. Skill in clinical procedure or interprate data from laboratory finding and/or imaging to make a diagnosis or diferensial diagnosis 4. Making diagnosis and diferential diagnosis 5. Management 6. Patient education and communication 7. Profesional behaviour Clinical scenario: A-25-year old man come to the primary health care service with pain during urination. Do the role play, one student as a doctor and one student as a patient Task: 1. Do the anamnesis and physical examination! 2. Ask the facilitator if you need laboratory examination or imaging! 3. Make a diagnosis from all data that you have collected! Udayana University Faculty of Medicine, DME 41 | P a g e Study Guide The Urinary System and Disorder Block Lembar Check List Aspek yang dinilai Anamnesis 0 1 Mahasiswa tidak melakukan anamnesis Mahasiswa melakukan anamnesis, hanya menanyakan tentang keluhan utama saja Pemeriksaa n fisik Mahasiswa tidak melakukan pemeriksaan fisik Mahasiswa melakukan pemeriksaan fisik, tapi sebelum dan setelah kontak dengan pasien tidak cuci tangan Melakukan interpretasi urinalysis Mahasiswa tidak mampu menginterpretasi dengan benar hasil pemeriksaan urinalysis - Menentuka n diagnosis Mahasiswa tidak bisa membuat diagnosis Mahasiswa membuat diagnosis namun tidak lengkap Komunikasi edukasi pasien dan perilaku profesional Mahasiswa tidak melakukan semua hal berikut: 1. mengucap kan salam, perkenala n 2. Melakuka n kontak mata dengan pasien dan berempati 3. menjelasa kan dan meminta ijin untuk melakuka n perasat, 4. memperha tikan kenyaman an pasien Mahasiswa hanya melakukan 1 dari hal berikut: 1. mengucapk an salam, perkenalan 2. Melakukan kontak mata dengan pasien dan berempati 3. menjelasak an dan meminta ijin untuk melakukan perasat, 4. memperhati kan kenyamana n pasien 2 3 Mahasiswa melakukan anamnesis, menanyakan Basic 7 dan fundamental 4 tapi tidak lengkap. Mahasiswa melakukan cuci tangan sebelum dan setelah kontak dengan pasien dan mahasiswa melakukan dengan tidak lengkap pemeriksaan fisikberikut: 1. Vital sign 2. Pemeriksa an bladder - Mahasiswa melakukan anamnesis, menanyakan Basic 7 dan fundamental 4 dengan lengkap. Mahasiswa melakukan cuci tangan sebelum dan setelah kontak dengan pasien dan mahasiswa melakukan dengan lengkap pemeriksaan fisikberikut: 1. Vital sign 2. Pemeriksa an bladder Mahasiswa mampu menginterpretasi dengan benar hasil pemeriksaan urinalysis Mahasiswa membuat diagnosis dengan benar namun tidak bisa membuat diferensial diagnosis Mahasiswa melakukan 2-3 dari hal berikut: 1. mengucap kan salam, perkenala n 2. Melakuka n kontak mata dengan pasien dan berempati 3. menjelasa kan dan meminta ijin untuk melakuka n perasat, 4. memperha tikan kenyaman an pasien Mahasiswa membuat diagnosis dengan benar dan bisa membuat diferensial diagnosis yang benar Mahasiswa melakukan semua hal berikut: 1. mengucap kan salam, perkenala n 2. Melakuka n kontak mata dengan pasien dan berempati 3. menjelasa kan dan meminta ijin untuk melakuka n perasat, 4. memperha tikan kenyaman an pasien Bob ot 3 3 3 1 1 Total Global Rating Score (lingkari): tidak lulus, borderline, lulus, superior Imaging in Urinary System Disorders Udayana University Faculty of Medicine, DME 42 | P a g e Sko r Study Guide The Urinary System and Disorder Block Learning task 1 Title : Objective : Competency (bold letter) : Instruction for the students : Anamnesis , physical examination and interpret data from abdominal X-ray (BOF/BNO) in urinary system disorders. Student can do structured anamnesis, physical examination and make a right interpretation from BOF/BNO in urinary tract disorders 1. Anamnesis skill 2. Physical examination skill 3. Skill in clinical procedure or interprate data from laboratory finding and/or imaging to make a diagnosis or diferensial diagnosis 4. Making diagnosis and diferential diagnosis 5. Management 6. Patient education and communication 7. Profesional behaviour Clinical scenario: A 40 years-old male patient has been getting colicky pain since 2 hours. Do the role play, one student as a doctor and one student as a patient Task: 1. Do the anamnesis and physical examination! 2. Ask the facilitator if you need laboratory examination or imaging! 3. Make a diagnosis from all data that you have collected! Udayana University Faculty of Medicine, DME 43 | P a g e Study Guide The Urinary System and Disorder Block Lembar Check List Aspek yang dinilai Anamnesis 0 Mahasiswa tidak melakukan anamnesis 1 Mahasiswa melakukan anamnesis, hanya menanyakan tentang keluhan utama saja Mahasiswa melakukan pemeriksaan fisik, tapi sebelum dan setelah kontak dengan pasien tidak cuci tangan Pemeriksaan fisik Mahasiswa tidak melakukan pemeriksaan fisik Melakukan interpretasi urinalysis Mahasiswa tidak mampu menginterpretasi - Menentukan diagnosis Mahasiswa tidak bisa membuat diagnosis Mahasiswa membuat diagnosis namun tidak lengkap Komunikasi edukasi pasien dan perilaku profesional Mahasiswa tidak melakukan semua hal berikut: 1. menguc apkan salam, perkenal an 2. Melakuk an kontak mata dengan pasien dan beremp ati 3. menjela sakan dan meminta ijin untuk melakuk an perasat, 4. memper hatikan kenyam anan pasien Mahasiswa hanya melakukan 1 dari hal berikut: 1. mengucap kan salam, perkenala n 2. Melakuka n kontak mata dengan pasien dan berempati 3. menjelasa kan dan meminta ijin untuk melakuka n perasat, 4. memperha tikan kenyaman an pasien 2 Mahasiswa melakukan anamnesis, menanyakan Basic 7 dan fundamental 4 tapi tidak lengkap. Mahasiswa melakukan cuci tangan sebelum dan setelah kontak dengan pasien dan mahasiswa melakukan dengan tidak lengkap pemeriksaan fisikberikut: 1. Vital sign 2. Pemeriksaan palpasi ginjal dan bladder - Mahasiswa membuat diagnosis dengan benar namun tidak bisa membuat diferensial diagnosis Mahasiswa melakukan 2-3 dari hal berikut: 1. mengucapkan salam, perkenalan 2. Melakukan kontak mata dengan pasien dan berempati 3. menjelasakan dan meminta ijin untuk melakukan perasat, 4. memperhatik an kenyamanan pasien 3 Mahasiswa melakukan anamnesis, menanyakan Basic 7 dan fundamental 4 dengan lengkap. Mahasiswa melakukan cuci tangan sebelum dan setelah kontak dengan pasien dan mahasiswa melakukan dengan lengkap pemeriksaan fisikberikut: 1. Vital sign 2. Pemeriksaan palpasi ginjal dan bladder Mahasiswa mampu menginterpretasi dengan benar foto XRay abdomen (BOF) Mahasiswa membuat diagnosis dengan benar dan bisa membuat diferensial diagnosis yang benar Mahasiswa melakukan semua hal berikut: 1. mengucapkan salam, perkenalan 2. Melakukan kontak mata dengan pasien dan berempati 3. menjelasakan dan meminta ijin untuk melakukan perasat, 4. memperhatikan kenyamanan pasien Total Global Rating Score (lingkari): tidak lulus, borderline, lulus, superior Udayana University Faculty of Medicine, DME 44 | P a g e Bob ot 3 3 3 1 1 Skor Study Guide The Urinary System and Disorder Block Learning task 2 Title : Objective : Competency (bold letter) : Instruction for the students : Anamnesis , physical examination and interpret data from abdominal X-ray (BOF/BNO) in urinary system disorders. Student can do structured anamnesis, physical examination and make a right interpretation from BOF/BNO in urinary tract disorders 1. Anamnesis skill 2. Physical examination skill 3. Skill in clinical procedure or interprate data from laboratory finding and/or imaging to make a diagnosis or diferensial diagnosis 4. Making diagnosis and diferential diagnosis 5. Management 6. Patient education and communication 7. Profesional behaviour Clinical scenario: A 30 years-old male patient has been suffering from tenderness, urgency and interruption during urination since 5 months. Do the role play, one student as a doctor and one student as a patient Task: 1. Do the anamnesis and physical examination 2. Ask the facilitator if you need laboratory examination or imaging! 3. Make a diagnosis from all data that you have collected! Udayana University Faculty of Medicine, DME 45 | P a g e Study Guide The Urinary System and Disorder Block Lembar Check List Aspek yang dinilai Anamnesis 0 1 Mahasiswa tidak melakukan anamnesis Mahasiswa melakukan anamnesis, hanya menanyakan tentang keluhan utama saja Pemeriksaa n fisik Mahasiswa tidak melakukan pemeriksaan fisik Mahasiswa melakukan pemeriksaan fisik, tapi sebelum dan setelah kontak dengan pasien tidak cuci tangan Melakukan interpretasi urinalysis Mahasiswa tidak mampu menginterpretasi - Menentuka n diagnosis Mahasiswa tidak bisa membuat diagnosis Mahasiswa membuat diagnosis namun tidak lengkap Komunikasi edukasi pasien dan perilaku profesional Mahasiswa tidak melakukan semua hal berikut: 1. mengucapk an salam, perkenalan 2. Melakukan kontak mata dengan pasien dan berempati 3. menjelasak an dan meminta ijin untuk melakukan perasat, 4. memperhati kan kenyamana n pasien Mahasiswa hanya melakukan 1 dari hal berikut: 1. mengucap kan salam, perkenala n 2. Melakukan kontak mata dengan pasien dan berempati 3. menjelasa kan dan meminta ijin untuk melakukan perasat, 4. memperha tikan kenyaman an pasien 2 3 Bobot Mahasiswa melakukan anamnesis, menanyakan Basic 7 dan fundamental 4 tapi tidak lengkap. Mahasiswa melakukan cuci tangan sebelum dan setelah kontak dengan pasien dan mahasiswa melakukan dengan tidak lengkap pemeriksaan fisikberikut: 1. Vital sign 2. Pemeriksa an palpasi ginjal dan bladder - Mahasiswa melakukan anamnesis, menanyakan Basic 7 dan fundamental 4 dengan lengkap. Mahasiswa melakukan cuci tangan sebelum dan setelah kontak dengan pasien dan mahasiswa melakukan dengan lengkap pemeriksaan fisikberikut: 1. Vital sign 2. Pemeriksa an palpasi ginjal dan bladder Mahasiswa mampu menginterpretasi dengan benar foto X-Ray abdomen (BOF) 3 Mahasiswa membuat diagnosis dengan benar namun tidak bisa membuat diferensial diagnosis Mahasiswa melakukan 2-3 dari hal berikut: 1. mengucap kan salam, perkenala n 2. Melakukan kontak mata dengan pasien dan berempati 3. menjelasa kan dan meminta ijin untuk melakukan perasat, 4. memperha tikan kenyaman an pasien Mahasiswa membuat diagnosis dengan benar dan bisa membuat diferensial diagnosis yang benar 1 Mahasiswa melakukan semua hal berikut: 1. mengucap kan salam, perkenalan 2. Melakukan kontak mata dengan pasien dan berempati 3. menjelasak an dan meminta ijin untuk melakukan perasat, 4. memperhat ikan kenyaman an pasien 1 3 3 Total Global Rating Score (lingkari): tidak lulus, borderline, lulus, superior Udayana University Faculty of Medicine, DME 46 | P a g e Skor Study Guide The Urinary System and Disorder Block Collection and Interpretation of Culture and Susceptibility Test from Urine Specimen Learning Task Case 1 A 26-year-old woman had performed complete laboratory examination including examination of urine culture. Sometimes she complained dysuria. she is an employee of one of the famous Bank in Bali. Her job required her sitting behind a desk in long period of time. On microscopic examination of urine sediment was found 1-5 leukocytes / LPB, Gram negative rod bacteria. Culture examination found Escherichia coli 1000 CFU / ml. Question: 1. Explain how the urine specimen collection techniques in patient above? 2. Explain how the techniques of storage and transportation of urine specimens? 3. Describe the stages of microbiological examination of urine specimens? 4. How the interpretation of the results obtained by microbiological examination? 5. Explain whether the patient requires antibiotic therapy? Case 2 A 61 years old male patient, complained of pain in the lower abdomen. On physical examination found tenderness in the suprapubic and urethral catheter inserted. He also has been suffering from prostate enlargement and is currently on treatment. Urine specimen was collected in the emergency room for complete examination and urine culture. On microscopic examination of urine sediment found 10-15 leukocytes / LPB, Gram negative rod bacteria. Culture examination found Pseudomonas aeruginosa 100.000 CFU / ml. Questions: 1. Mention the bacteria that cause urinary tract infection based on clinical presentation? 2. Explain whether Pseudomonas aeruginosa in this case is the microorganisms that cause urinary tract infections? 3. Explain how the specimen collection techniques in the above case? 4. Explain whether the patient requires antibiotic therapy? Circumcision Introduksi a. Definisi Tindakan pembuangan dari sebagian atau seluruh prepusium penis dengan tujuan tertentu. b. Ruang lingkup Fimosis merupakan suatu keadaan dimana prepusium tidak dapat ditarik ke belakang (proksimal) atau membuka, dan lubang pada ujung prepusium yang kecil sehingga urin sulit keluar. Maka dari itu fimosis perlu dilakukan tindakan sirkumsisi. Parafimosis merupakan suatu keadaan di mana preputium tidak dapat ditarik ke depan (distal) atau menutup. Glands penis terjepit oleh preputium yang membengkak. Sebelum tindakan sirkumsisi terlebih dahulu dilakukan reduksi, bila gagal dilakukan sirkumsisi. Kebudayaan yang melakukan sirkumsisi untuk alasan kesehatan, tanda peralihan menuju kedewasaan, sebagai tanda identitas budaya. Udayana University Faculty of Medicine, DME 47 | P a g e Study Guide The Urinary System and Disorder Block c. Indikasi operasi Agama & kebudayaan Medik – Phimosis – Paraphimosis – Perlekatan preputium dan gland d. Kontra indikasi operasi: Hipospadia Chordae tanpa hipospadia Striktur urethra Teknik operasi Teknik guillotine Teknik konvensional Persiapan Persiapan operator : o Operator memakai pakaian kamar bedah o Mengenakan topi dan masker o Mencuci tangan dengan antiseptik, seperti savlon, hibiscrub, dan sebagainya o Mengenakan sarung tangan steril. Persiapan pasien : o Rambut di sekitar penis (pubis) dicukur dan dibersihkan dengan air sabun o Pada pasien anak dilakukan pendekatan agar anak tidak cemas dan gelisah o Periksa apakah pasien mempunyai riwayat alergi terhadap obat, penyakit terdahulu atau hal-hal lain yang dianggap perlu. Persiapan peralatan : o Sirkumsisi set o Spuit 10 cc & needle 21G o Jarum jahit jaringan & Catgut plain o Duk steril o Obat anestesi local (lidokain, prokain, bupivakain) o Povidon Iodine o Kasa steril o Plester o Handscoen Teknik guillotine : Persiapan operator, pasien, dan alat. Tindakan asepsis & drapping duk steril berlubang Tindakan Anestesi Bersihkan daerah dalam gland penis dan melepaskan perlekatan prepusium Prepusium dijepit pada arah jam 6 dan 12. Pada cara ini sebaiknya perlekatan preputium telah dilepaskan agar didapatkan hasil yang baik Klem melintang dipasang pada prepusium secara melintang dari sumbu panjang penis. Arah klem miring dengan melebihkan bagian yang sejajar frenulum. Yakinkan bahwa glans penis tidak terjepit Prepusium di bagian proksimal atau distal dari klem melintang di insisi. Insisi dapat dilakukan di sebelah luar klem (distal klem, cara ini yang banyak dipakai, mudah), atau disebelah dalam klem Perdarahan yang terjadi dirawat dengan klem dan ligasi Penjahitan frenulum-kulit. Digunakan arah jahitan benbentuk angka 8 Penjahitan mukosa-kulit di sekeliling penis. Jumlah jahitan disesuaikan dengan kondisi. Udayana University Faculty of Medicine, DME 48 | P a g e Study Guide The Urinary System and Disorder Block Teknik Konvensional : Persiapan operator, pasien, dan alat. Tindakan asepsis & drapping duk steril berlubang Tindakan Anestesi Membuka preputium perlahan-lahan dan bersihkan penis dari smegma menggunakan kasa betadin sampai corona glandis terlihat Kembalikan preputium pada posisi semula Klem preputium pada jam 11, 1 dan jam 6 Gunting preputium pada jam 12 sampai corona gland Lakukan jahit kendali mukosa – kulit pada jam 12 Gunting preputium secara melingkar kanan dan kiri dengan menyisakan frenulum pada klem jam 6 Observasi perdarahan (bila ada perdarahan, klem arteri/vena, ligasi dengan jahitan melingkar) Jahit angka 8 pada frenulum. Lakukan pemotongan frenulum di distal jahitan Kontrol luka dan jahitan, oleskan salep antibiotik di sekeliling luka jahitan Balut luka dengan kasa steril Buka duk dan handscoen, cek alat dan rapikan kembali semua peralatan Pemberian obat dan edukasi pasien Udayana University Faculty of Medicine, DME 49 | P a g e Study Guide The Urinary System and Disorder Block ~ CURRICULUM MAP ~ Smstr Program or curriculum blocks 10 Senior Clerkship 9 Senior Clerkship 8 Senior clerkship 7 6 Medical Emergency (3 weeks) Special Topic: -Travel medicine (2 weeks) Elective Study III (6 weeks) Clinic Orientation (Clerkship) (6 weeks) BCS (1 weeks) The Respiratory System and Disorders (4 weeks) The Cardiovascular System and Disorders (4 weeks) The Urinary System and Disorders (3 weeks) The Reproductive System and Disorders (3 weeks) BCS (1 weeks) Alimentary & hepatobiliary systems & disorders (4 Weeks) BCS (1 weeks) The Endocrine System, Metabolism and Disorders (4 weeks) BCS (1 weeks) Clinical Nutrition and Disorders (2 weeks) BCS (1 weeks) Elective Study II (1 weeks) 5 BCS (1 weeks) BCS (1 weeks) BCS (1 weeks) 4 3 2 Musculoskeletal system & connective tissue disorders (4 weeks) Neuroscience and neurological disorders (4 weeks) Behavior Change and disorders (4 weeks) BCS (1 weeks) Hematologic system & disorders & clinical oncology (4 weeks) BCS (1 weeks) Immune system & disorders (2 weeks) BCS(1 weeks) Infection & infectious diseases (5 weeks) BCS (1 weeks) The skin & hearing system & disorders (3 weeks) BCS (1 weeks) Medical Professionalism (2 weeks) BCS(1 weeks) Evidence-based Medical Practice (2 weeks) BCS (1 weeks) Health System-based Practice (3 weeks) BCS(1 weeks) Community-based practice (4 weeks) - BCS (1 weeks) Studium Generale and Humaniora (3 weeks) Medical communication (3 weeks) BCS (1 weeks) The cell as biochemical machinery (3 weeks) Growth & development (4 weeks) BCS (1 weeks) BCS(1 weeks) BCS: (1 weeks) Special Topic : - Palliative medicine -Compleme ntary & Alternative Medicine - Forensic (3 weeks) Elective Study II (1 weeks) Special Topic - Ergonomi - Geriatri (2 weeks) Elective Study I (2 weeks) The Visual system & disorders (2 weeks) 1 Pendidikan Pancasila & Kewarganegaraan (3 weeks) Udayana University Faculty of Medicine, DME 50 | P a g e Study Guide The Urinary System and Disorder Block Udayana University Faculty of Medicine, DME 51 | P a g e Study Guide The Urinary System and Disorder Block REFERENCES 1. Moore KL, Agur AMR: Essential Clinical Anatomy, 2 nd ed. Philadelphia, Lippincott Williams & Wilkins, 2002. 2. Gartner LP, Hiatt JL. Color Textbook of Histology, International edition. Elsevier. 2007 3. Fawcett DW, Jenish RP : Bloom and Fawcett’s Concise Histology, 2nd ed. London, Arnold, 2002. 4. Guyton A. C and Jhon E. Hall: Textbook of Medical Physiology, 10th ed. Philadelpia, WB Saunders Company, 2000 5. Silverthorn DU. Human Physiology an integrated approach, 2nd edition, Prentice Hall. 2001 6. Mitchell RN, Kumar V, Abbas K, Fausto N. Robbins & Cotran, Pathologic Basis of Disease, 8th edition. New York. , W.B. Sounders Company, 2010 7. Fischbach FT, Dunning MB: A Manual of Laboratory and Diagnostic Tests, 7th ed. Philadelphia, Lippincott Williams & Wilkins, 2004. 8. Behrman RE, Kliegman RM, Jenson HB: Nelson Textbook of Pediatrics, 17th ed. New York, W.B. Sounders Company, 2004 9. Macfarlane MT, et al. : Urology, 4th ed. Lippincott Williams & Wilkins, 2006 10. Friedman AL. Nephrology: Fluids and electrolytes. In: Behrman RE, Kliegman RM, editors. Nelson Essentials of pediatrics. 4th edition. Philadelphia: WB Saunders Co, 2001. 11. Davis ID, Avner ED. Nephrology. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson textbook of pediatrics. 17th edition Philadelphia: WB Saunders Co, 2004. 12. Smiths general Urology, 17th ed, 2008 Udayana University Faculty of Medicine, DME 52 | P a g e Study Guide The Urinary System and Disorder Block INTRODUCTION The curriculum block on Urinary System and Disorder is developed collectively by the academic staff from various departments: Anatomy, Histology, Physiology, Pharmacology, Pathology, Clinical Pathology, Nephrology, Urology, and Pediatric. The number of Urinary System credits is three. This book consists of general information on the learning schedule, block members, facilitatorsilitators, and the core curriculum, such as learning outcomes, learning situation, learning task and self-evaluation. Lecture is only given to emphasize crucial things or objectives of material and to guide the students before discussion. During discussion, students also have to evaluate their learning progress independently (self evaluation). For difficult concepts in discussion and self evaluation, the students are also being asked to discuss several example of scenario. More than half of the learning material should be learned independently and in small group discussion. Curriculum content, study load and teaching-learning are specified in curriculum and study guide, student assessment is carried out mainly by objective test at the end of theme course, and the minimum passing level is set at 70 (70%). A remedial is provided for those who failed, and later they have to re-sit a second summative test. Since the integrated curriculum at Facilitatorsulty of Medicine Udayana University is still in progress, this guide book will also still have some changes in the future. Regarding that, we invite readers to give any positive comments for its development. Planners i Udayana University Faculty of Medicine, DME 53 | P a g e Study Guide The Urinary System and Disorder Block CONTENTS Introduction ……………………………………………………………………………………………………………..………………. i Table of contents ……………………………………………………………………………………………………..………………. ii Curriculum Block Urinary System and Disorders…………………………….................................…………… 1 Planners Team …………………………………………………………………………………………………………..……………... 2 Lecturers ………………………………………………………………………….……………............................................. 2 Facilitators …………………………………………………………………………………………………………………... ………….. 3 Time Table Regular Class …………………………………………………………………………………………….………..…… 4 Time Table English Class …………………………………………………………………………………………….………..……. 8 Student Project ……………………………………………………………………………………………………………………….. 12 Assessment Method …………………………………………………………………………………………………………………. 13 Learning Program ……………………………………………………………………………………………………..…………..….. 14 1. Abstract and Learning task of Lectures ………………………………………………………………………… 14 2. Self assessment …………………………………………………………………………………………………...………. 32 Basic Clinical Skills ………………………………………………………………………………………………………………….. . 36 Curriculum Mapping ………………………………………………………………………………………………………..……….. 50 Block Mapping ………………………………………………………………………………………………………………………….. 51 Reference …………………………………………………………………………………………………………………………..…….. 52 ii Udayana University Faculty of Medicine, DME 54 | P a g e