HOLISTIC AND COMPREHENSIVE CASE MANAGEMENT PROTOCOL

A. PATIENT IDENTITY
Full name Jenis kelamin: L / P
Place and date of birth Umur:
Address
Phone number/ Cell phone
Occupation
Religion
Education
Blood type
Drug allergy
MODULE OF INTERNAL MEDICINE
URINARY TRACT INFECTION = INFEKSI SALURAN KEMIH

B. HISTORY TAKING
 Complaint:
1. Fever
2. Pain after urinating / Dysuria terminal
3. Increase frequency
4. Nocturia
5. Supra pubic pain
6. Blood in urine / hematuria
7. Waist Pain

 Keluhan :
1. Demam
2. Nyeri saat di akhir BAK
3. Sering BAK
4. Kencing pada malam hari
5. Nyeri tekan suprapubik

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 6. BAK berdarah
7. Nyeri Pinggang

 Risk factor
1. Female
2. History of diabetes mellitus
3. Poor self-Hygiene
4. Resisting urination
5. Immunocompromised patients
6. Foreign body in urinary tract (catheter)
7. Menopause
8. Sexually active
 Faktor Risiko
1. Wanita
2. Riwayat Diabetes Melitus
3. Higiene pribadi buruk
4. Menahan kencing
5. Pasien dengan gangguan imunitas
6. Benda asing pada saluran kemih (kateter)
7. Menopause
8. Aktif secara seksual

C. PHYSICAL FINDINGS
1. Fever subfebril <38C
2. Tachycardia
3. Gross hematuria  di anamnesis
4. Suprapubic pain
5. Flank pain
PEMERIKSAAN FISIK
1. Demam subfebril <38C
2. Takikardia

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 3. BAK berdarah
4. Nyeri tekan suprapubik
5. Nyeri ketok pinggang belakang

D. SUPPORTING EXAMINATION
1. Complete Blood test
2. Complete urine test
3. Culture bacteria from urine
PEMERIKSAAN PENUNJANG
1. Tes Darah lengkap
2. Tes Urine lengkap/komplit
3. Kultur bakteri dari urin tidak ada di data puskesmas
E. DIAGNOSIS
Clinical Diagnosis
 Diagnosis is based on anamnesis, physical examination, and supporting examination
Diagnosis Klinis
 Diagnosis ditegakkan berdasarkan dari anamnesis, pemeriksaan fisik , dan pemeriksaan
penunjang
Differential Diagnosis:
o Urethritis
o Acute Bacterial Prostatitis
o Acute pyelonephritis
o Benign Prostate Hyperplasia (BPH)
o Appendicitis
Diagnosis Banding :
o Uretritis
o Prostatitis Bakterial Akut
o Pielonefritis akut
o Hiperplasia Prostat Jinak (BPH)
o Apendisitis

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 F. TREATMENT / PENATALAKSANAAN
Non medication
 Drink water at least 2 liter/day
 Keep external genitalia hygiene.

o Minum air putih minimal 2 liter/hari

o Menjaga higienitas genitalia eksterna.

Medication
 Ciprofloxacin 500mg, 2x / day for 7 days

Medicine Name Type quantity/time quantity/day duration

Ciprofloksasin 500mg Oral 1 2 x day 7 days

o Siprofloksasin 500mg, 2x/hari untuk 5-7 hari