Diagnose and manage independently uncomplicated urinary tract infection, Diagnose and refer some urogenital system disorders such as, horse shoe

~ CURRICULUM ~ Aims: 1. Comprehend the biologic function of urogenital system to pathological process of urinary system disorders. 2. Apply and interpret special studies in diagnosis urogenital system disorders, including laboratory and imaging examination. 3. Diagnose and manage patient with common urogenital system disorders 4. Diagnose and refer special patient with urogenital system disorders 5. Plan patient, family, and community education about urogenital system disorders Learning Outcome 1. Describe the functional structure of urigenital system and its general clinical implications. 2. Comprehend the pathological basis underlying the symptoms and signs of urogenital system disorders. 3. Recognize the potential uses of common diagnostic and therapeutic procedure in urogenital system disorders. 4. 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. 5. Manage secondary hypertension Diagnose and refer secondary hypertension, especially renal hypertension 6. Implement patient education in the prevention and early detection of common urinary system disorders. Curriculum content 1. Functional structure of urogenital system 2. Pathological basis of urogenital system disorders 3. Symptom and sign of urogenital system disorders 4. Physical examination, laboratory investigation and imaging studies in urogenital system disorders 5. Interpret and utilize results of Physical examination, laboratory investigation and imaging studies 6. Rational drug use in urogenital system disorders 7. Management of urogenital system disorders 8. Clinical procedure in urogenital system disorders 9. Communicate and apply basic principle in the prevention, and rehabilitation of urogenital system disorders Udayana University Faculty of Medicine, DME 1 | P a g e ~ PLANNERS TEAM ~ N O NAME DEPARTMENT 1 DR. dr. A A Gde Oka, Sp.U Coordinator Urology 2 dr. I Wayan Juli Sumadi, Sp.PA Secretary Pathology 3 Prof. dr. K. Tirtayasa, MS, AIF Physiology 4 dr. I A Ika Wahyuniari, M.Kes Histology 5 Prof. DR. dr. Mangku Karmaya, M.Repro Anatomy 6 Prof. DR. dr. K. Suwitra, SpPD KGH Internal Medicine 7 dr. Made Adi Tarini, Sp.MK Microbiology 8 DR. dr. Wiradewi Lestari, Sp.PK Clinical Pathology 9 dr. IGAP Nilawati, Sp.AK Pediatric 10 dr. I Gst Ayu Artini, M.Sc Pharmacology 11 dr. Gede Wirya Kusuma Duarsa, Sp.U Urology 12 dr. Sri Laksminingsih, Sp.Rad Radiology ~ LECTURERS ~ NO NAME DEPARTMENT 1 Prof. DR. dr. K. Suwitra, SpPD KGH Internal Medicine 2 Prof. dr. K. Tirtayasa, MS, AIF Physiology 3 dr. I A Putri Wirawati, Sp.PK Clinical Pathology 4 dr. G A P Nilawati, Sp.A Pediatric 5 Prof. DR. dr. N. Mangku Karmaya, M.Repro Anatomy 6 dr. A A Gde Oka, Sp.U Urology 7 dr. Jodhi Sidarta L, SpPD KGH Internal Medicine 8 dr. Ni Wayan Winarti, Sp.PA Pathology Anatomy 9 dr. G. Wirya K Duarsa, SpU, M.Kes Urology 10 dr. I Wayan Sugiritama, M.Kes Histology 11 dr. I Gst Ayu Artini, M.Sc Pharmacology 12 dr. A A Wiradewi Lestari, Sp.PK Clinical Pathology 13 dr. Sri Laksminingsih, Sp.Rad Radiology 14 dr. Made Adi Tarini, Sp.MK Microbiology Udayana University Faculty of Medicine, DME 2 | P a g e ~ FACILITATORS ~ Regular Class Class A No Name Group Departement Phone Venue 2 rd floor 1 dr. Ida Bagus Wirakusuma, MOH A1 Public Health 08124696647 2nd floor: R.2.09 2 dr. Kadek Agus Heryana, Sp.An A2 Anasthesi 081338568883 2nd floor: R.2.11 3 dr. Ketut Agus Somia, Sp.PD- KPTI A3 Interna 08123989353 2nd floor: R.2.12 4 dr. Ketut Rai Purnami, Sp.PD A4 Interna 0818350703 2nd floor: R.2.13 5 dr. Komang Andi Dwi Saputra , Sp.THT-KL A5 ENT 081338701828 081338701878 2nd floor: R.2.14 6 dr. I Kadek Swastika , M Kes A6 Parasitology 08124649002 2nd floor: R.2.15 7 dr. Kumara Tini, Sp.S A7 Neurology 081238701081 2nd floor: R.2.16 8 dr. Made Agus Hendrayana , M.Ked A8 Microbiology 081339158241 2nd floor: R.2.20 9 dr. Luh Putu Ratna Sundari, M.Biomed A9 Fisiology 0361-7860532 2nd floor: R.2.21 10 dr. I Gusti Ayu Artini , M.Sc A10 Pharmacology 08123650481 2nd floor: R.2.22 English Class Class B No Name Group Departement Phone Venue 2 rd floor 1 dr. I Dewa Ayu Inten Dwi Primayanti, M.Biomed B1 Fisiology 081337761299 2nd floor: R.2.09 2 dr. Made Ratna Saraswati, Sp.PD-KEMD-FINASIM B2 Interna 08123814688 2nd floor: R.2.11 3 dr. Made Sudarmaja, M.Kes B3 Parasitology 08123953945 2nd floor: R.2.12 4 dr. Made Widhi Asih, Sp.Rad B4 Radiology 081916442626 2nd floor: R.2.13 5 dr. I G A Sri Darmayani, Sp.OG B5 DME 081338644411 2nd floor: R.2.14 6 dr. Putu Ayu Asri Damayanti , M Kes B6 Parasitology 085338565783 2nd floor: R.2.15 Udayana University Faculty of Medicine, DME 3 | P a g e 7 dr. Ni Kadek Mulyantari , Sp PK B7 Clinical Pathology 08123647413 2nd floor: R.2.16 8 dr. I Wayan Niryana, Sp.BS, M. Kes. B8 Surgery 08179201958 2nd floor: R.2.20 9 dr. Ni Luh Putu Ratih Vibriyanti Karna, Sp.KK B9 Dermatology 081337808844 2nd floor: R.2.21 10 dr. Ni Made Adi Tarini, Sp.MK B10 Microbiology 081338675344 2nd floor: R.2.22 ~ TIME TABLE ~ REGULAR CLASS DAYDATE TIME ACTIVITY VENUE PIC I 08-05-2015 08.00-09.00 Macroscopic Anatomy of The Urinary System 3.02 Mangku Karmaya 08.00-10.00 Individual Learning - - 10.00-11.00 Practical Session Anatomy: Group A1-A5 Anatomy Lab Mangku Karmaya 11.00-12.30 SGD 1 Discussio n room Facilitators 12.30-13.00 Break - - 13.00-14.00 Practical Session Anatomy: Group A6-A10 Anatomy Lab Mangku Karmaya 14.00-15.00 Plenary 3.02 Mangku Karmaya II 11-05-2015 08.00-09.00 Microscopic Anatomy of The Urinary System 3.02 Sugiritama 09.00-10.00 Individual Learning - - 10.00-11.00 Practical Session Histology: Group A1-A5 Histology Lab Sugiritama 11.00-12.30 SGD 2 Discussio n room Facilitators 12.30-13.00 Break - - 13.00-14.00 Practical Session Anatomy: Group A6-A10 Histology Lab Sugiritama 14.00-15.00 Plenary 3.02 Sugiritama III 12-05-2015 08.00-09.00 The function of the urinary system: 7. Urine formation 8. Urine micturition 3.02 Tirtayasa 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 3 Discussio n Room Facilitators 12.00-13.00 Student Project - - 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 Tirtayasa IV 13-05-2015 08.00-09.00 The kidney as water, electrolyte and acid-base balance controller 3.02 Tirtayasa 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 4 Discussio Facilitators Udayana University Faculty of Medicine, DME 4 | P a g e n Room 12.00-13.00 Student Project - - 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 Tirtayasa V 18-05-2015 08.00-09.00 Pathogenesis of Glomerular and Tubulointerstitial Injury 3.02 Winarti 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 5 Discussio n Room Facilitators 12.00-13.00 Student Project - - 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 Winarti VI 19-05-2015 08.00-09.00 Urinary System Disorders in Children: - Nephrotic syndrome - PSAGN - UTI in Children 3.02 Nilawati 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 6 Discussio n Room Facilitators 12.00-13.00 Student Project - - 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 Nilawati VII 20-05-2015 08.00-09.00 Uncomplicated and complicated Urinary tract infection 3.02 Suwitra and Team 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 7 Discussio n Room Facilitators 12.00-13.00 Student Project - - 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 Suwitra and Team VIII 21-05-2015 08.00-09.00 Urolithiasis with and without colic; Urethral Stricture 3.02 AA Gde Oka 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 8 Discussio n Room Facilitators 12.00-13.00 Student Project - - 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 AA Gde Oka IX 23-05-2015 08.00-09.00 Common Neoplasm in Urinary System: Renal tumors, bladder tumors. 3.02 AA Gde Oka 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 9 Discussio n Room Facilitators Udayana University Faculty of Medicine, DME 5 | P a g e 12.00-13.00 Student Project - - 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 AA Gde Oka X 25-05-2015 08.00-09.00 Urinary tract trauma rupture of the kidney and urinary tract 3.02 AA Gde Oka 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 10 Discussio n Room Facilitators 12.00-13.00 Student Project Presentation 1 Horse Shoe Kidney 3.02 AA Gde Oka 13.00-15.00 Break - - 14.00-15.00 Plenary 3.02 AA Gde Oka XI 26-05-2015 08.00-09.00 Acute Kidney Injury 3.02 Suwitra and Team 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 11 Discussio n Room Facilitators 12.00-13.00 Student Project Presentation 2 Symptomatic Polycystic Kidney 3.02 Suwitra and Team 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 Suwitra and Team XII 27-05-2015 08.00-09.00 Chronic Kidney Disease 3.02 Suwitra and Team 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 12 Discussio n Room Facilitators 12.00-13.00 Student Project Presentation 3 Hemodialysis 3.02 Suwitra and Team 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 Suwitra and Team XIII 28-05-2015 08.00-09.00 Renal hypertension 3.02 Jodi SL 09.00-10.30 Individual Learning - - 10.30-11.30 Drug Use in Renal Disorders: Diuretics; Urinary Antiseptic 3.02 Artini 11.30-13.00 SGD 13 Discussio n Room Facilitators 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 Jodi SL, Artini XIV 29-05-2015 08.00-09.00 Common Prostate Disorders: Prostatitis, BPH, Prostate Cancer 3.02 G. Wirya K. Duarsa 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 14 Discussio n Room Facilitators Udayana University Faculty of Medicine, DME 6 | P a g e 12.00-13.00 Student Project Presentation 4 Urodinamic examination and Uroflowmetry 3.02 AA Gde Oka 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 Artini XV 01-06-2015 08.00-09.00 Common penile disorders: Epispadia, hypospadia, phimosis, paraphimosis, epididimitis, prostatitis, priapismus and Common tumor of the penis G. Wirya K. Duarsa 09.00-10.30 Individual Learning - - 10.30-12.00 SGD 14 Discussio n Room Facilitators 12.00-13.00 Student Project Presentation 5 Micturating Cystigraphy 3.02 G. Wirya K. Duarsa 13.00-14.00 Break - - 14.00-15.00 Plenary session 3.02 G. Wirya K. Duarsa XVI 03-06-2015 08.00-09.00 Anamnesis and Physical Examination in Urinary System Disorders Lecture Demonstration 3.02 Suwitra and Team 09.00-10.00 Individual Learning - - 10.00-11.00 Urethral catheterization, Clear intermittent catheterization, suprapubic punctie Lecture Demonstration 3.02 AA Gde Oka 11.00-12.00 Break - 12.00-14.00 Skills Training Skills Lab 2 nd Floor Facilitators 14.00-15.00 Free Training Skills Lab 2 nd Floor - XVII 04-06-2015 08.00-09.00 Urinalysis 3.02 WirawatiWirade wi 09.00-10.00 Individual Learning - - 10.00-11.00 Urethral Swab, Urine Culture and Sensitivity Test 3.02 Adi Tarini 11.00-12.00 Break - 12.00-14.00 Skills Training Skills Lab 2 nd Floor Facilitators 14.00-15.00 Free Training Skills Lab 2 nd Floor - XVIII 05-06-2015 08.00-09.00 Circumcision, Prostate Palpation, Bulbocavernosus reflex Lecture and Demonstration 3.02 G. Wirya K. Duarsa 09.00-10.00 Individual Learning - - 10.00-11.00 Student Project Presentation 6 Urine Cytology 3.02 Juli Sumadi 11.00-12.00 Break - Udayana University Faculty of Medicine, DME 7 | P a g e 12.00-14.00 Skills Training Skills Lab 2 nd Floor Facilitators 14.00-15.00 Free Training Skills Lab 2 nd Floor - XIX 08-06-2015 08.00-09.00 BNO and IVP 3.02 Laksminingsih 09.00-10.00 Individual Learning - - 10.00-11.00 Student Project Presentation 7 Pathological aspect of BPH and Prostate Cancer 3.02 Winarti 11.00-12.00 Break - - 12.00-14.00 Skills Training Skills Lab 2 nd Floor Facilitators 14.00-15.00 Free Training Skills Lab 2 nd Floor - XX 09-06-2015 08.00-09.00 Student Project Presentation 8 The role of USG in diagnosis Urinary system disorders 3.02 Laksminingsih 09.00-10.00 Student Project Presentation 9 The role of CT Scan in diagnosis Urinary system disorders 3.02 Laksminingsih 10.00-11.00 Individual Learning - - 11.00-12.00 Break - - 12.00-13.00 Student Project Presentation 10 Renal Funtion Test BUN, SC 3.02 WirawatiWirade wi 13.00-15.00 Free Training Skills Lab 2 nd Floor - XXI 11-06-2015 Preparation Day XXII 12-06-2015 10.00-11.40 Final Examination Computer Room Team ENGLISH CLASS DAYDATE TIME ACTIVITY VENUE PIC I 08-05-2015 09.00- 10.00 Macroscopic Anatomy of The Urinary System 3.02 Mangku Karmaya 10.00- 11.00 Individual Learning - - 11.00- 12.00 Practical Session Anatomy: Group B1-B5 Anatomy Lab Mangku Karmaya 12.00- 13.00 Practical Session Anatomy: Group B6-B10 Anatomy Lab Mangku Karmaya 13.00- 14.30 SGD 1 Discussion room Facilitators Udayana University Faculty of Medicine, DME 8 | P a g e 14.30- 15.00 Break - - 15.00- 16.00 Plenary 3.02 Mangku Karmaya II 11-05-2015 09.00- 10.00 Microscopic Anatomy of The Urinary System 3.02 Sugiritama 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 Discussion room Facilitators 14.30- 15.00 Break - - 15.00- 16.00 Plenary 3.02 Sugiritama III 12-05-2015 09.00- 10.00 The function of the urinary system: Urine formation Urine micturition 3.02 Tirtayasa 10.00- 11.30 Individual Learning - - 11.30- 12.30 Break - - 12.30- 14.00 SGD 3 Discussion Room Facilitators 14.00- 15.00 Student Project - - 15.00- 16.00 Plenary session 3.02 Tirtayasa IV 13-05-2015 09.00- 10.00 The kidney as water, electrolyte and acid-base balance controller 3.02 Tirtayasa 10.00- 11.30 Individual Learning - - 11.30- 12.30 Break - - 12.30- 14.00 SGD 4 Discussion Room Facilitators 14.00- 15.00 Student Project - - 15.00- 16.00 Plenary session 3.02 Tirtayasa Udayana University Faculty of Medicine, DME 9 | P a g e V 18-05-2015 09.00- 10.00 Pathogenesis of Glomerular and Tubulointerstitial Injury 3.02 Winarti 10.00- 11.30 Individual Learning - - 11.30- 12.30 Break - - 12.30- 14.00 SGD 5 Discussion Room Facilitators 14.00- 15.00 Student Project - - 15.00- 16.00 Plenary session 3.02 Winarti VI 19-05-2015 09.00- 10.00 Urinary System Disorders in Children: - Nephrotic syndrome - PSAGN - UTI in children 3.02 Nilawati 10.00- 11.30 Individual Learning - - 11.30- 12.30 Break - - 12.30- 14.00 SGD 6 Discussion Room Facilitators 14.00- 15.00 Student Project - - 15.00- 16.00 Plenary session 3.02 SuartaNilawati VII 20-05-2015 09.00- 10.00 Uncomplicated and complicated Urinary tract infection 3.02 Suwitra and team 10.00- 11.30 Individual Learning - - 11.30- 12.30 Break - - 12.30- 14.00 SGD 7 Discussion Room Facilitators 14.00- 15.00 Student Project - - 15.00- 16.00 Plenary session 3.02 SuwitraAA Gde Oka VIII 21-05-2015 09.00- 10.00 Urolithiasis with and without colic, urethral stricture 3.02 AA Gde Oka 10.00- 11.30 Individual Learning - - 11.30- 12.30 Break - - 12.30- 14.00 SGD 8 Discussion Room Facilitators 14.00- 15.00 Student Project - - 15.00- Plenary session 3.02 AA Gde Oka Udayana University Faculty of Medicine, DME 10 | P a g e 16.00 IX 23-05-2015 09.00- 10.00 Common Tumors in Urinary System: Renal cancer, bladder cancer 3.02 AA Gde Oka 10.00- 11.30 Individual Learning - - 11.30- 12.30 Break - - 12.30- 14.00 SGD 9 Discussion Room Facilitators 14.00- 15.00 Student Project - - 15.00- 16.00 Plenary session 3.02 AA Gde Oka X 25-05-2015 09.00- 10.00 Urinary tract trauma rupture of the kidney and urinary tract 3.02 AA Gde Oka 10.00- 11.00 Student Project Presentation 1 Horse Shoe Kidney 3.02 AA Gde Oka 11.00- 12.30 Individual Learning - - 12.30- 14.00 SGD 10 Discussion Room Facilitators 14.00- 15.00 Break - - 15.00- 16.00 Plenary session 3.02 AA Gde Oka XI 26-05-2015 09.00- 10.00 Acute Kidney Injury 3.02 Suwitra and team 10.00- 11.00 Student Project Presentation 2 Symptomatic Polycystic Kidney 3.02 Suwitra and Team 11.00- 12.30 Individual Learning - - 12.30- 14.00 SGD 11 Discussion Room Facilitators 14.00- 15.00 Break - - 15.00- 16.00 Plenary session 3.02 Suwitra and team XII 27-05-2015 09.00- 10.00 Chronic Kidney Disease 3.02 Suwitra and team 10.00- 11.00 Student Project Presentation 3 Hemoadialysis 3.02 Suwitra and Team 11.00- 12.30 Individual Learning - - 12.30- 14.00 SGD 12 Discussion Room Facilitators 14.00- 15.00 Break - - 15.00- 16.00 Plenary session 3.02 Suwitra and team Udayana University Faculty of Medicine, DME 11 | P a g e XIII 28-05-2015 09.00- 10.00 Renal Hypertension 3.02 Jodi SL 10.00- 11.00 Individual Learning - - 11.00- 12.30 Drug Use in Urinary System Disorders: Diuretics; Urinary Antiseptic - Artini 12.30- 14.00 SGD 13 Discussion Room Facilitators 14.00- 15.00 Break - - 15.00- 16.00 Plenary session 3.02 Jodi SL, Artini XIV 29-05-2015 09.00- 10.00 Common prostate disorders: Prostatitis, BPH, Prostate Cancer 3.02 G. Wirya K. Duarsa 10.00- 11.00 Student Project Presentation 4 Urodinamic examination and Uroflowmetry 3.02 AA Gde Oka 11.00- 12.30 Individual Learning - - 12.30- 14.00 SGD 14 Discussion Room Facilitators 14.00- 15.00 Break - - 15.00- 16.00 Plenary session 3.02 G. Wirya K. Duarsa XV 01-06-2015 09.00- 10.00 Common penile disorders: Epispadia, hypospadia, phimosis, paraphimosis, epididimitis, prostatitis, priapismus and Common tumor of the penis G. Wirya K. Duarsa 10.00- 11.00 Student Project Presentation 5 Micturating Cystigraphy 3.02 G. Wirya K. Duarsa 11.00- 12.30 Individual Learning - - 12.30- 14.00 SGD 14 Discussion Room Facilitators 14.00- 15.00 Break - - 15.00- 16.00 Plenary session 3.02 G. Wirya K. Duarsa XVI 03-06-2015 09.00- 10.00 Anamnesis and Physical Examination in Urinary System Disorders Lecture Demonstration 3.02 Suwitra and Team 10.00- 11.00 Individual Learning - - 11.00- 12.00 Urethral catheterization, Clear intermittent catheterization, suprapubic 3.02 AA Gde Oka Udayana University Faculty of Medicine, DME 12 | P a g e punctie Lecture Demonstration 12.00- 13.00 Break - 13.00- 15.00 Skills Training Skills Lab 2 nd Floor Facilitators 15.00- 16.00 Free Training Skills Lab 2 nd Floor - XVII 04-06-2015 09.00- 10.00 Urinalysis 3.02 WirawatiWiradew i 10.00- 11.00 Individual Learning - - 11.00- 12.00 Urethral Swab, Urine Culture and Sensitivity Test 3.02 Adi Tarini 12.00- 13.00 Break - 13.00- 15.00 Skills Training Skills Lab 2 nd Floor Facilitators 15.00- 16.00 Free Training Skills Lab 2 nd Floor - XVIII 05-06-2015 09.00- 10.00 Circumcision, Prostate Palpation, Bulbocavernosus reflex Lecture and Demonstration 3.02 G. Wirya K. Duarsa 10.00- 11.00 Individual Learning - - 11.00- 12.00 Student Project Presentation 6 Urine Cytology 3.02 Juli Sumadi 12.00- 13.00 Break - 13.00- 15.00 Skills Training Skills Lab 2 nd Floor Facilitators 15.00- 16.00 Free Training Skills Lab 2 nd Floor - XIX 08-06-2015 09.00- 10.00 BNO and IVP 3.02 Laksminingsih 10.00- 11.00 Individual Learning - - 11.00- 12.00 Student Project Presentation 7 Pathological aspect of BPH and Prostate Cancer 3.02 Winarti 12.00- 13.00 Break - - 13.00- 15.00 Skills Training Skills Lab 2 nd Floor Facilitators 15.00- 16.00 Free Training Skills Lab 2 nd Floor - XX 09-06-2015 09.00- 10.00 Individual Learning - - 10.00- 11.00 Student Project Presentation 8 The role of USG in diagnosis Urinary system disorders 3.02 Laksminingsih 11.00- Student Project Presentation 3.02 Laksminingsih Udayana University Faculty of Medicine, DME 13 | P a g e 12.00 9 The role of CT Scan in diagnosis Urinary system disorders 12.00- 13.00 Break - - 13.00- 14.00 Student Project Presentation 10 Renal Funtion Test BUN, SC 3.02 WirawatiWiradew i 14.00- 16.00 Free Training Skills Lab 2 nd Floor - XXII 11-06-2015 PREPARATION DAY XXI 12-06-2015 FINAL EXAMINATION ~ STUDENT PROJECT ~ No Group Topic PIC 1 A1, B1 Horse Shoe Kidney AA Gde Oka 2 A2, B2 Symptomatic Polycystic Kidney Suwitra and Team 3 A3, B3 Hemodialysis Suwitra and Team 4 A4, B4 Urodinamic examination and Uroflowmetry AA GdeOka 5 A5, B5 Micturating cystigraphy AA GdeOka 6 A6, B6 Urine Cytology Juli Sumadi 7 A7, B7 Pathological aspect of BPH and Prostatic Carcinoma Winarti 8 A8, B8 The role of USG in diagnosis Urinary system disorders Sri Laksminingsih 9 A9, B9 The role of CT Scan in diagnosis Urinary system disorders Sri Laksminingsih 10 A10, B10 Renal Function Test BUN, SC WirawatiWiradewi ~ 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. ~ LEARNING PROGRAMS ~ Udayana University Faculty of Medicine, DME 14 | P a g e 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 SGD 2 Udayana University Faculty of Medicine, DME 15 | P a g e Lecture 1 - 2: Macroscopic and Microscopic Structure the Urinary System 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? 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 loop of Henle. Concentrated filtrate is also resulted from the counter-current exchange of vasa recta in the renal medulla. Udayana University Faculty of Medicine, DME 16 | P a g e Lecture 3-4: The Function of Urinary System 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. SDG 4 The Kidneys as water, electrolyte and acid-base balance controller Learning Tasks Udayana University Faculty of Medicine, DME 17 | P a g e 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. 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 TubularInterstitial 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, 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 Udayana University Faculty of Medicine, DME 18 | P a g e Lecture 5: Pathogenesis of Glomerular and Tubulo-Interstitial Injury 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 tubulointerstitial 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, 250mL24 hours. This oligouria is continuing until this day. Laboratory examination revealed increase of serum urea nitrogen and creatinin. Learning Task 1. Discuss the mechanism responsible for oligouric state in this patient 2. Explain about pathogenesis of acute kidney injury AKI 3. What is the difference between AKI and tubulo-interstitial nephritis? 4. Mention some causes of tubule-interstitial nephritis Udayana University Faculty of Medicine, DME 19 | P a g e 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 2-3100,000 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 mgm 2 hour in children, hypoalbuminemia 2.5 gdL, 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 85, mesangial proliferation 5, and focal segmental glomerulosclerosis 10. The Udayana University Faculty of Medicine, DME 20 | P a g e Lecture 6: Common Kidney Diseases in Children Acute Poststreptococcal Glomerulonephritis and Nephrotic Syndrome, UTI in Children 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 mgm 2 hour in children. The serum albumin level is generally less than 2.5 gdL 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 is140100 mmHg with pulse 88 bpm. Chest, cardiovascular and abdominal examination are normal. Learning Task: Udayana University Faculty of Medicine, DME 21 | P a g e 1. Diagnosis and differential diagnosis for this case? 2. Describe characteristic features of PSAGN