“The story of Budi”

Budi, 4 years old brought by his mother to polyclinic RSMP with fever complain. Fever
felt since 6 days ago is not too high. Fever is not followed with cough, raining nose, no pain in
the ear and throat, no nausea and vomiting. Budi’s Mother said, her son complained of low
back pain and reddish urination since 3 days ago. It's been given heat loss but nothing has
changed. It has been given heat-lowering drugs but nothing has changed. Regular bowel
movements.
Childbirth history: Budi was born weigh 3000 grams, term and normal delivery.
Immunization history: complete immunization
History of growth and development: normal
Physical examination:
Awareness: compost mentis
Vital signs: BP 90/60 mmHg, pulse: 100x / minute, RR: 28x / minute, temperature: 380C, BW:
16 kg, BH: 110cm
General physical examination:
Head: eyes: conjunctiva is not anemic, sclera is not icteric
Thorax: symmetrical, absent retraction, heart: normal heart sounds I and II, heart noise (-),
Lungs: normal vesicular, absent crackles.
Abdomen: flat, normal bowel sounds, the liver and spleen are not palpable, abdominal
tenderness is absent, suprapubic tenderness is absent, costovetebral angel tenderness is present.
Inguinal region: no palpable lump, pain (-), enlarged lymph nodes (-).
Extremity: warm

Specific examination of the external genital organs: the prepuce was narrow, could not be
opened. There was residual urine in the prepuce, hyperemic OUE, hyperemic scrotal skin, right
and left testis were palpable in the scrotum.

Laboratory examination
Routine blood: Hb 13g / dl, Leukocytes 25,000 / mm3, platelets 250,000 / mm3
Routine urine:
Macroscopic: reddish color ( gross hematuria) , specific gravity 1.020
Microscopic: erythrocytes 8-10 /lpb, leukocytes 10-20 /lpb, epithelium 10 /lpb, urine cylinder
(+), leukocyte esterase (-), nitrite (+), bacteriuria (+).
2.3. Clarification of Terms
1. Urine : the extratied by the kidneys, stored in the baldder, and excreated thought in the
urethra ( dorland,2015).
2. Scrotum : a bladder containing the testicles and additional organs (Dorland 2017).
3. Testis : One of pair of egg- shaped glands that are normally
located with scrotum, where spermatozoa develop
(Dorland, 2016).
4. Fever : increase in temperature above normal.
5. hyperemic OUE : swelling or excess blood on certain parts of the body (Dorland 2017).
6. prepuce : the fold of covering the glans penis (Dorland, 2016).
7. urine sylinder : the sylinder (cast) is the only element found in a unique urine sediment,
which is the period cylindrical proteins form in the renal tubules and are rinsed into the
urine. the cylinder describes the state of the renal tubules (dorland, 2016).
8. hematuria : blood in urine (Dorland, 2015).

2.4. Problem Identifications

1. Budi, 4 years old brought by his mother to polyclinic RSMP with fever complain. Fever
felt since 6 days ago is not too high. Fever is not followed with cough, raining nose, no
pain in the ear and throat, no nausea and vomiting.
2. Budi’s Mother said, her son complained of low back pain and reddish urination since 3
days ago. It's been given heat loss but nothing has changed. It has been given heat-
lowering drugs but nothing has changed. Regular bowel movements.
3. Childbirth history: Budi was born weigh 3000 grams, term and normal delivery.
Immunization history: complete immunization
History of growth and development: normal
4. Physical examination:

Awareness: compost mentis

Vital signs: BP 90/60 mmHg, pulse: 100x / minute, RR: 28x / minute, temperature:
380C, BW: 16 kg, BH: 110cm
General physical examination:
Head: eyes: conjunctiva is not anemic, sclera is not icteric
 Thorax: symmetrical, absent retraction, heart: normal heart sounds I and II, heart noise
(-), Lungs: normal vesicular, absent crackles.
Abdomen: flat, normal bowel sounds, the liver and spleen are not palpable, abdominal
tenderness is absent, suprapubic tenderness is absent, costovetebral angel tenderness is
present.
Inguinal region: no palpable lump, pain (-), enlarged lymph nodes (-).
Extremity: warm
Specific examination of the external genital organs: the prepuce was narrow, could
not be opened. There was residual urine in the prepuce, hyperemic OUE, hyperemic
scrotal skin, right and left testis were palpable in the scrotum.
5. Laboratory examination

Routine blood: Hb 13g / dl, Leukocytes 25,000 / mm3, platelets 250,000 / mm3
Routine urine:
Macroscopic: reddish color ( gross hematuria) , specific gravity 1.020
Microscopic: erythrocytes 8-10 /lpb, leukocytes 10-20 /lpb, epithelium 10 /lpb, urine
cylinder (+), leukocyte esterase (-), nitrite (+), bacteriuria (+).

2.5. Problem Priority

Number 1 : Budi, 4 years old brought by his mother to polyclinic RSMP with fever complain.
Fever felt since 6 days ago is not too high. Fever is not followed with cough, raining nose, no
pain in the ear and throat, no nausea and vomiting.
Reason : because, it is the main complain in this case. So, if it’s not treat it well will cause
other complication.
2.6. Problem Analysis
1. Budi, 4 years old brought by his mother to polyclinic RSMP with fever complain. Fever
felt since 6 days ago is not too high. Fever is not followed with cough, raining nose, no
pain in the ear and throat, no nausea and vomiting.
a. what is the anatomy (urinary track & genitalia maskulina) and physiology (miksi) ?

b. What is the meaning Budi, 4 years old brought by his mother to polyclinic RSMP
with fever complain. Fever felt since 6 days ago is not too high. Fever is not
followed with cough, raining nose, no pain in the ear and throat, no nausea and
vomiting ?
 c. What is the relationship between age and gender in this case ?
UTI is a disease that is relatively common in children. The incidence of UTI
depends on age and sex. The prevalence of UTI in neonates ranged from 0.1% to
1%, and increased to 14% in neonates with fever, and 5.3% in infants. In
asymptomatic infants, bacteriuria is present in 0.3 to 0.4%. The risk of UTI in
children before puberty is 3-5% in girls and 1-2% in boys. In children with fever
less than 2 years of age, the prevalence of UTI is 3-5% (IDAI, 2011).

Ikatan Dokter Anak Indonesia (IDAI). 2011. Unit Kerja Koordinasi (UKK). Nefrologi, Jakarta.
 d. How is the pathophysiology fever in this case ?

Risk factors: age and sex + not circumcised → bad hygiene → accumulation
of dirt on the glans penis + accumulation of smegma → possible infection of
the glans penis and prepuce → scar tissue forming on the preputial orificium
→ preputium adhere to the glans penis → phimosis → parts orificium
urethra externum narrows → inhibits urine output → urine retention and
urine remains accumulate in the prepuce (urine as an ideal medium for
bacterial growth) → bacteria multiply and spread → infection asending to
the bladder (vesica urinaria) → urinary tract infection → a reaction occurs
inflammation →stimulates endogenous pyrogens to release pro-
inflammatory mediators (IL-1, IL-6, TNF-α, and IFN) → arachidonic acid
release → converted by COX-1 and COX-2 to prostaglandin E2 → increased
thermostart in the thermoregulatory center in the hypothalamus → increase
body temperature → fever (Tusino & Widyaningsih, 2018).
Tusino,A. Widyaningsih N. Karakteristik Infeksi Saluran Kemih pada Anak usia 0-12 tahun di
RS X Kebumen Jawa Tengah. Jurnal Biomediaka. 2017.

e. What is the etiology in this case ?

f. What is the classification of fever in this case ?

- Fever with localizing signs
Forms the majority of febrile episodes and associated signs of localized infection
like heat swelling, discharge at ears, nose, skin throat, cough, vomiting diarrhea,
rash
- Fever without localizing signs
Presence of elevated temperature for <1 week, careful history & examination fail
to reveal cause, suggestive of occult cause or prodoromal illness.
- Fever of unknown origin
Presence of elevated temperature for >1 week without localizing signs, infection
may eventually become apperent (Egidio, et al, 2017).
Egidio, et al. 2017. Fever in Children: Pearls and Pitfalls.
2. Budi’s Mother said, her son complained of low back pain and reddish urination since 3
days ago. It's been given heat loss but nothing has changed. It has been given heat-
lowering drugs but nothing has changed. Regular bowel movements.
a. What is the meaning her son complained of low back pain and reddish urination
since 3 days ago ?
The meaning of her son complained of low back pain and reddish urination since 3
days ago is the possibility of Budi having an upper urinary tract infection because it
is characterized by low back pain and reddish urination It is possible that Budi has
an upper urinary tract infection because it is characterized by characteristic back
pain and red urine. This is due to inflammation of the kidneys, which damages the
epithelium and blood vessels, resulting in red urine (Basuki, 2011).

Basuki B. Prunomo, 2011, Dasar-Dasar Urologi, Perpustakaan Nasional RI, Katalog Dalam
Terbitan (KTO) Jakarta.

b. What is the meaning It's been given heat loss but nothing has changed. It has been
given heat-lowering drugs but nothing has changed. Regular bowel movements ?
The meaning of It's been given heat loss but nothing has changed. It has been given
heat-lowering drugs but nothing has changed is because the treatment given does not
address the cause, it only treats the symptoms, because the cause is not resolved, it is
likely that the complaint will still be there (Basuki, 2011).

c. What is the pathophysiology of low back pain and reddish urination ?

Low back pain
risk factors have not been circumcised and poor personal hygiene → accumulation
of smegma in the prepuce and glans penis → adhesions of the prepuce on the glans
penis → phimosis → impaired micturition → residual urine remains in the prepuce
→bacterial colonization →bacteria enter the urinary tract ascending → to kidney
→pyelonephritis → lower back pain
Reddish urination
risk factors have not been circumcised and poor personal hygiene → accumulation
of smegma in the prepuce and glans penis → adhesions of the prepuce on the glans
penis → phimosis → impaired micturition → residual urine remains in the prepuce
 → bacterial colonization → bacteria enter the urinary tract ascending → to kidney
→ pyelonephritis → damaged epithelium and blood vessels → hematuria (reddish
urination).

d. What is the etiologi and risk factor of low back pain ?

e. What is the possible heat-lowering drugs given in this case ?
f. What is the etiology of reddish urination ?

g. What are the classification of urine color ?

h. What is the relation between the main complaint and additional complain ?
The relationship was because the patient low back pain and reddish urination so that
the cause of the fever was suspected to be from the urinary tract infection.

3. Childbirth history: Budi was born weigh 3000 grams, term and normal delivery.
Immunization history: complete immunization
History of growth and development: normal
a. What is the meaning of childbirth history ?
The meaning of childbirth history is that the birth weight is 3000 grams
which is still normal, LBW (low birth weight) only occurs if the baby weighs
less than 2500 grams (Proverewati, 2010).
The labor history also indicates that the complaints that occur in the case are
not caused by embryological or congenital disorders, so that the phimosis
that occurs in the case is most likely formed when Budi has been born (non-
congenital phimosis). This can also rule out the differential diagnosis of
other urinary tract diseases such as the maldensensus testis, ectopic ureter,
testicular torisio, and cryptokimus (Purnomo, 2016).
Proverewati, A. 2010. BBLR (Berat Badan Lahir Rendah). Nuhamedika. Yogyakarta.
Aldy Rochmat, Purnomo. (2016). Analisis Statistik Ekonomi dan Bisnis dengan SPSS.
Yogyakarta: Fadilatama.

b. What is the meaning of immunization history ?

Complete Immunization History, meaning that Budi has immunity to the
invasion of microorganisms that commonly attack children. At the age of 4
years, Budi has already carried out immunizations, especially BCG, DPT,
 Polio, Measles, Hepatitis B, and others according to the immunization
schedule (IDAI, 2014).

Ikatan Dokter Anak Indonesia (IDAI). 2014. Unit Kerja Koordinasi (UKK). Nefrologi, Jakarta.

c. Wha is the meaning of history of growth and development ?

4. Physical examination:

Awareness: compost mentis

Vital signs: BP 90/60 mmHg, pulse: 100x / minute, RR: 28x / minute, temperature:
380C, BW: 16 kg, BH: 110cm
General physical examination:
Head: eyes: conjunctiva is not anemic, sclera is not icteric
Thorax: symmetrical, absent retraction, heart: normal heart sounds I and II, heart noise
(-), Lungs: normal vesicular, absent crackles.
Abdomen: flat, normal bowel sounds, the liver and spleen are not palpable, abdominal
tenderness is absent, suprapubic tenderness is absent, costovetebral angel tenderness is
present.
Inguinal region: no palpable lump, pain (-), enlarged lymph nodes (-).
Extremity: warm
Specific examination of the external genital organs: the prepuce was narrow, could
not be opened. There was residual urine in the prepuce, hyperemic OUE, hyperemic
scrotal skin, right and left testis were palpable in the scrotum.
a. What is the interpretation of physical examination ?
Awareness: compost mentis : normal
Vital signs: BP 90/60 mmHg,
pulse: 100x / minute :normal
RR: 28x / minute : normal
temperature: 380C : febris
BW: 16 kg, BH: 110cm : normal
Normal TTV in Preschool ages (4-5 tahun) :
• Pulse : 80-140x/minutes
• RR: 22-34x/minutes
 • Vital signs : 80-100 mmHg

b. How is the abnormal mechanism of physical examination ?

Fever
Natural adhesion of the prepuce and glans penis → phimosis + no circumcision and bad
hygiene → Smegma → Separates the prepuce and glans penis → Prepuce stays sticky →
Disturbed micturition → Residual urine is left in the prepuce → Bacterial colonization →
Balanopostitis → Ascending infection → Pielonefritis → Systemic infection → Fever
(Price, 2013).

c. What is the interpretation of general physical examination ?

Head: eyes: conjunctiva is not anemic, sclera Normal
is not icteric

Thorax: symmetrical, absent retraction, Normal

heart: normal heart sounds I and II, heart
noise (-), Lungs: normal vesicular, absent
crackles.

Abdomen: flat, normal bowel sounds, the CVA + (abnormal characteristic of

liver and spleen are not palpable, abdominal pyelonefritis).
tenderness is absent, suprapubic tenderness
is absent, costovetebral angel tenderness is
present.

Inguinal region: no palpable lump, pain (-), Normal

enlarged lymph nodes (-).

Extremity: warm Normal

d. What is the abnormal mechanism of General physical examination ?

Costovertebral tenderness
 risk factors have not been circumcised and poor personal hygiene → accumulation of
smegma in the prepuce and glans penis → adhesions of the prepuce on the glans penis
→ phimosis → impaired micturition → residual urine remains in the prepuce
→bacterial colonization →bacteria enter the urinary tract ascending → to kidney
→pyelonephritis → stimulus saraf aferen → cva + (price, 2013).

Price, Silvia Anderson. 2013. Pathophysiology: Clinical Concepts of Disease Processes.

Edition 6. Jakarta: EGC.

e. What is the interpretation of Specific examination of the external genital organs ?

f. What is the abnormal mechanism Specific examination of the external genital
organs ?
g. What is the examination technique used to check for costo vertebrae pain ?
5. Laboratory examination

Routine blood: Hb 13g / dl, Leukocytes 25,000 / mm3, platelets 250,000 / mm3
Routine urine:
Macroscopic: reddish color ( gross hematuria) , specific gravity 1.020
Microscopic: erythrocytes 8-10 /lpb, leukocytes 10-20 /lpb, epithelium 10 /lpb, urine
cylinder (+), leukocyte esterase (-), nitrite (+), bacteriuria (+).
a. What is the interpretation of laboratory examination ?
b. What is the abnormal mechanism of laboratory examination ?
risk factors have not been circumcised and poor personal hygiene → accumulation
of smegma in the prepuce and glans penis → adhesions of the prepuce on the glans
penis → phimosis → impaired micturition → residual urine remains in the prepuce
→ bacterial colonization → bacteria enter the urinary tract ascending → to kidney
→ pyelonephritis → damaged epithelium and blood vessels → hematuria (reddish
urination).
risk factors have not been circumcised and poor personal hygiene → accumulation
of smegma in the prepuce and glans penis → adhesions of the prepuce on the glans
penis → phimosis → impaired micturition → residual urine remains in the prepuce
→bacterial colonization →bacteria enter the urinary tract ascending → to kidney
→pyelonephritis → damaged epitel and blood vessel → hematuria → increase
ephitelium and erytrocyte +
risk factors have not been circumcised and poor personal hygiene → accumulation
of smegma in the prepuce and glans penis → adhesions of the prepuce on the glans
 penis → phimosis → impaired micturition → residual urine remains in the prepuce
→bacterial colonization → leukositosis
risk factors have not been circumcised and poor personal hygiene → accumulation
of smegma in the prepuce and glans penis → adhesions of the prepuce on the glans
penis → phimosis → impaired micturition → residual urine remains in the prepuce
→bacterial colonization → infection urinary tract → luekositosis urine , urine
cylinder + ,nitrit + (because bacteri can changes nitrat to be nitrit) and
bacteriuria (Basuki 2011).

Basuki B. Prunomo, 2011, Dasar-Dasar Urologi, Perpustakaan Nasional RI, Katalog Dalam
Terbitan (KTO) Jakarta.

6. Interpretation : the meaning is Budi has a urinary tract infections are caused by bacteria:
most commonly E.Coli

7. How to diagnose in this case?

8. What is differential diagnose in this case?

9. What is the additional examination in this case?

10. What is the working diagnose in this case?
a. Definition ?
b. Etiology ?

c. Risk factor ?
d. Pathophysiology ?
e. What is the differences between upper and lower urinary track infection ?
An upper urinary tract infection mainly refers to the kidneys and the tubes that lead
from the kidney into the urinary bladder – these tubes are called the ureters. A
urinary infection of the kidney is referred to as pyelonephritis. Symptoms can
include lower back pain that may be severe, nausea, vomiting and a high fever.
A lower urinary tract infection refers to the inflammation and infection of the
bladder and the urethra, which is the tube that leads from the bladder, enabling urine
to exit the body. Women are more prone to lower UTIs than men. Cystitis refers to
inflammation of the bladder and urethritis refers to inflammation of the urethra
(Duane, et al, 2016).
Duane, et al. 2016. Anatomy and Physiology of the Urinary Tract: Relation to Host Defense
and Microbial Infection

11. How to treatment in this case?

12. What is the complication in this case?
UTIs can cause acute kidney failure, bacteremia, sepsis, and meningitis. Complications
of long-term UTIs are kidney scarring, hypertension, kidney failure, complications
during pregnancy such as preeclampsia. Kidney scarring occurs in 8-40% of patients
after experiencing an episode of acute pyelonephritis (IDAI, 2011).

- Inflammation of the glans penis (Balanitis)

- Inflammation of the prepuce (postitis)
- Paraphimosis
- Infertility
- If circumcision is not performed, it can increase the incidence of penile
cancer and chronic infections if accompanied by poor hygiene (McCance, K.
2019).
 13. What is the prognosis in this case?

Quo ad vitam : Dubia ad bonam

Quo ad sanationam : Dubia

Quo ad functionam : Dubia ad bonam

14. SKDU?
4A.
A graduate of general practitioners Able to make clinical diagnosis and manage
the disease independently and completely.

15. What is the Islamic values? (QS. An-nisa 125, hadist riwayat bukhari &
muslim 5 dari fitrah …)

2.7. Conclusion
Budi 4 years old has fever, reddish urine, low back pain, CVA (+), and there was
residual urine in prepuce possible suffering of pielonefritis et causa phimosis.

2.8. Conceptual Framework