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
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, rigorschill, 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. Upper- tract 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.
Task
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Lecture 7: Urinary Tract Infection:
Uncomplicated and Complicated
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 cfuml. Plain abdominal
photo BNOBOF 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?
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.
Learning Task 8
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Lecture 8: Urinary Calculi Urolithiasis and Urethral Stricture
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 straddlesaddle 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?
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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Lecture 9: Common Neoplasm in Urinary System: Renal
tumors, bladder tumors.
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 prostate-
specific 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?
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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Lecture 10: Urinary tract trauma
Rupture of the kidney and urinary tract
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 hospitalWhat 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?
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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Lecture 11 12: Acute Kidney Injury Chronic Kidney Diseases
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 12476 mmHg and his pulse was 82 beats per minute while he was
supine and 12674 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 mgdl today and it was 1,0 mgdl a week ago. Other blood laboratory findings include the following: WBC count 11.000ml; sodium 142 mmolL;
potassium 4,2 mmolL; and blood urea nitrogen 34 mgdl. His urine showed a sodium level of 54 mmolL and creatinine level of 39 mgdl. The urinalysis with dipstick testing showed +1
protein; the microscopic analysis showed 5-10 leucocytesHPFhigh power field. And an occasional leucocytes cast. Kidney ultrasound showed no hydronephrosis.
Learning Task
1. 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?
2. Explain the pathophysiology
3. 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 mgdl and his creatinine level was 1,5 mgdl base line creatinine level, 1.0 mgdl.
Learning Task
1. 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?
2. Explain the pathophysiology 3. 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 14888 mmHg, and pulse rate is 85 beatsmin. She has + 2 pedal edema. Laboratory tests show a serum creatinine level of 0,7 mgdl and BUN level of 32
mgdl. 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 14488 mmHg
d. Glycosylated hemoglobin level of 7.5 . Explain your answer
5. Describe the management of chronic kidney disease according to the classstage
6. Explain the rational management for the patient above
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 13: Renal Hypertension
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=180100 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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Lecture 14: Drug use in renal disorders
Diuretics Urinary antiseptics
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 injurydisease
and the type of renal injurydisease 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?
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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Lecture 1516 Prostate Male Penile Disorders
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 12080, pulse 88xminutes, 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?
SELF ASSESSMENT 3 The function of the urinary system
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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 11.
Follow up for outpatient PSAGN 12.
Clinical and laboratory evaluation 13.
When is the symptom and laboratory resolves 14.
Prognosis of PSAGN?
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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?
SELF ASSESSMENT 11 Acute kidney injury
1. Explain about acute kidney disease and its classification 2. Explain about the RIFLE criteria
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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. Mention several drugs that potentially induce renal disease 2. Mention the possible mechanisms of drug-induced renal disease
3. Mention pharmacokinetic and pharmacodynamic changes possibly occur in renal disease.
4. What are the basic concepts of dosage adjustment in patient with renal disease? 5. How is the mechanism of action for each type of diuretics?
6. What is the effect of each class of diuretics in acid base balance and serum potassium level?
7. Why spironolactone would not cause potassium wasting? 8. What other adverse effects might occur in diuretic treatment?
9. Mention some clinical indications of diuretics. 10. Mention types of urinary antiseptics.
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11. How is the mechanism of urinary antiseptic action? 12. What are the adverse effects of each type of urinary antiseptic?
SELF ASSESSMENT 1516
1. What is the definition of phimosis and paraphimosis, priapismus and peyronie
disease? 2.
What is the definition and the management of urethral stricture? 3.
What is the complication of the long term phimosis and poor hygiene of the male external genital?
4. What is the definition and aetiology of hypospadia?
5. What is the caused and complication than can be caused by balanopostitis?
6. What is the correlation between phymosis and penile cancer?
7. 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, ureumBUN, 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.
Anamnesis and Physical Examination in Urinary System and Male Genital System Disorders
Learning task
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Title :
Anamnesis and physical examination in lower urinary tract disorders Objective
: Student can do structured anamnesis and physical examination in
lower urinary tract disorders Competency
bold letter :
1. Anamnesis skill
