Urinary Tract Infection ec

Cystitis
By:
Arya Maheswara Wardhana M, MD
Supervisor:
M. Diana Rahim, MD
PATIENT IDENTITY

Ny. A/45 years old/182353

June 08 2022/22.46
GP : Martinus Toro, MD
 COURSE OF DISEASE

Patient come to emergency room of Guntur hospital with the complains of painful urination since 2
days ago. Painful urination is felt continuously, decreased urination, decreased volume, cloudy yellow
color. Complaints accompanied by lower abdominal pain. Patient denies back pain. Defecate is
normal.
Disease history: urinary tract infection, DM
History of drug use (-)
PHYSICAL EXAMINATION

General Condition : moderately illness

Awareness : Compos Mentis
GCS : 15
Tension : 120/80mmHg
Pulse Rate : 114 x/minute
Respiratory Rate : 20 x/minute
Temperature : 36,0 C
Oxygen Saturation : 99% free air
 PHYSICAL EXAMINATION

Head
Eyes : anemic conjungtiva -/-, icteric sclera -/-
Nose : nostring breathing (-)
Mouth : cyanosis (-)
Neck : lymph node enlargment (-)

Thorax : symmetrical chest movements

Cor : S1 S2 regular, gallop (-), murmur (-)
Pulmo : vesicular breath sounds , crackles -/-, wheezing -/-
PHYSICAL EXAMINATION

Abdomen : flat, soepel, bowel sound (+) normal, tenderness (+) a/r suprapubic,
CVA -/-
Liver : within normal limits
Spleen : within normal limits

Extremities :
warm, CRT <2 seconds, Edema (-)
SUPPORTING EXAMINATION
 LABORATORY EXAMINATION
(June 08 2022)
 Blood chemistry
 Blood routine
-Blood sugar: 114 mg/dL
- Hb : 10,6 gr/dL
-Ureum : 52 mg/dL
- Leukocyte : 20.900/mm3
-Creatinin : 0,77 mg/dL
- Trombocyte : 472.000/mm3
-SGOT : 22 U/L
- Ht : 34,5/mm3
-SGPT : 35 U/L
 Immunology
Rapid antigen Covid-19 : Negative
DIAGNOSE

Urinary Tract Infection ec Cystitis

 MANAGEMENT

 IVFD Nacl 20 dpm

 Inj. Ranitidine 2x1 amp IV
 Urogetix 2x1 PO
 Levofloxacin 1x500mg PO
FOLLOW UP
June 09 2022 June 10 2022 June 11 2022

Urination felt better, painful

Urination felt better, painful reduced. Urination felt better, painful reduced, reduced, Lower abdominal pain
Subjective
Fever (-) Lower abdominal pain (+) (+)

CM
T: 173/96 mmhg
CM N: 86 bpm
CM R: 20 x/m
T: 145/80 mmhg
T: 108/63 mmhg S: 36,1 C
N: 76 bpm SPO2: 98% FA
N: 74 bpm
R: 20 x/m Abdomen: NT (+) ar suprapubic
Objective R: 22 x/m Lab:
S: 36,1 C
S: 36,2 C Hb: 9,2 gr/dl
SPO2: 96% FA Leukosit: 10.800
SPO2: 96% FA
Abdomen: NT (+) ar suprapubic Trombosit: 464.000
Abdomen: NT (+) ar suprapubic Hematokrit: 29,4
Diff count: 1/1/0/70/22/6

Urinary Tract Infection ec cystitis

IVFD Nacl 20 dpm
Inj. Ranitidine 2x1 amp IV
Diagnose and Urogetix 2x1 PO
Planning Levofloxacin 1x500mg PO
Perform abdominal ultrasound
Kesimpulan:
-Tampak Kristal di kedua ginjal
-Cystitis
-USG lain tak
 FOLLOW UP

 June 11 2022
-Patient want to go home by herself
-Sign a statement