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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
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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
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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.
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~ 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!
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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
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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.
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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,
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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!
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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
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(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.
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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.
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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.
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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.
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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.
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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.
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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
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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!
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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
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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.
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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?
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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?
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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
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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?
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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?
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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.
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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!
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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.
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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
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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
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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!
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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
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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
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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
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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.
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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.
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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
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~ 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)
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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
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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
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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
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