MORNING REPORT

C3

A 62 year-old woman was admitted to R.D. Kandou Hospital at C3 ward on 6th October, 2015

With main complaint:Right flank pain

Patient’s identityName : Mrs MLAge : 62 yrsSex : FemaleOccupation : HousewifeEducation : Senior High SchoolEthnicity : MinahasaReligion : Christian

Present Medical History•Right flank pain experienced since 2 weeks b.a to the hospital. •Pain radiating into the regio gluteal and right leg. Prickling pain and cramps in the right leg•History of heavy lifting (+).•History of trauma (fail) when chillhood.•Fever (-), pain when urinating (-).•Defecating as usual.

Past Medical History

• History of hypertension about 10 years take captopril but not regurally

• History of Diabetes, heart, liver, kidney, high cholesterol, uric acid was denied.

Family History

• None experienced the same illness

History of allergy :Unknown

History of immunization :Unknown

Habit history :Alkoholism (-) Smoking (-)

General anamnesis ( review of system )General : Right flank painSkin : -Head and neck : -Eye : -Ear : -Nose : -Mouth and throat: -Respiratory : -Chest : -Heart : -

Abdomen : -Genitalia : -Kidney : -Hematology : -Endocrine : -Musculosceletal : Pain radiating into the gluteal and right legNeurology : -Psychology : -

Physical Examination• GC: Moderately ill . Sens : CM• ER :BP: 150/90 mmHg, PR 68 x/m, RR 20x/m T 36.4 C• BW 65 kg, BH 168 cm, BMI 23.3 kg/m2• Head : conj. anemic (-), scl. icteric(-)• Neck : JVP 5+0 cmH20• Thorax :• Heart :– Insp : IC not visible– Palp : IC palpable– Perc : left border: ICS V Axillaris sinistra

right border: ICS IV parasternalis dextra– Ausc : SI-II regular, murmur (-), gallop (-)

Physical examination• Lung : Insp : Symmetric R = L

Palp : stem fremitus R = LPerc : sonor +/+Ausc : vesicular, ronchi -/-, wheezing -/-

• Back Insp : Symmetric R = LPalp : stem fremitus R = LPerc : sonor +/+Ausc : vesicular, ronchi -/-, wheezing -/-

• Abd :IInsp : FlatPalp : Soft, tenderness (-)

Perc : Tympanic, shifting dullness (-) Ausc : Bowel sound (+) normal

Back Abdmen Reg Lumbal : Tenderness on the regio lumbal

• Waist : Pain on CVA exam (-/-)• Extr : warm, edema (-/-)

• Straight Leg Raising (SLR) test (+) pain

Genital : urinating now clearly

Rectum : normal

Neurology : normal

Problem ListNo CM : 131917 Age : 63 y.o 1.Main complain:•Right flank pain

2. Anamnesis: •Pain radiating into the buttocks and right leg. Prickling pain and cramps in the right leg•History of heavy lifting (+).•History of hypertension

3. Physical examination:•GC: moderately ill . Sens : CM

•BP: 150/90mmHg

•Back Abdomen Reg Lumbal : Tenderness on the regio lumbal

• Extr : Straight Leg Raising (SLR) test (+) pain

Working Diagnosis

• LBP ec susp HNP Lumbal dd PNA dextra dd nefrolitiasis dextra

• Hypertension stg I

Plan

• Check Hb,Leuko,trombosit• Ureum, creatinine,uric acid, Na,K,Cl• Check urinalysis• X-foto lumbosacral • USG Abdomen• MRI Lumbal

Lab Result9/08/2015

• Leucocyte 5904• Erythrocyte 4.40x106

• Hb 13.4

• Ht 40.8

• Platelet 242• RBS 107• Ureum 16• Creatinine 0.7• Na 141• Kalium 3.5• Cl 103

Urinalisis•pH 7•BJ 1.005•Leu -•Nit –•Bil –•Glu –•Prot -•Blood/eritrosit •Ket –

X-photo Thoracolumbal

• Skoliosis• Narrow

Discus gap L4L5

Chest X Ray

Interpretation of RadiologyRontgen components Interpretation

Identity Same as the patient

KV enough

Symmetric yes

Diaphragma normal

MediastinumSinus Costophrenicus

Normalsharp

Sinus Cardiophrenicus sharp

Bone intact

Cor + CTR 52%

Pulmonary Parenchyme Infiltrat (-)

CONCLUSION : Cardiomegali

ECG

Interpretation of ECGECG componentsid Interpretation Value

Rhythm Sinus rhythm Sinus Rhythm

Speed / HR (times/mnt) 64x/min 1500/R-R’

Axis Normal Normal / RAD / LAD

Morphology P wave 0,06 sec Lead II : Duration ≤0.10”, Height ≤2.5”

PR Interval 0,16 sec 0,12” – 0,20”

QRS complex duration 0,08 sec 0,05” – 0,11”``

ST segmen Isoelectric Normal / Elevated / Depressed

T wave Normal Normal / abnormal

QT Interval 0,36 sec cQT = QT interval / vR-R’ Interval

U wave Absent Appear / not appear

CONCLUSION : Sinus Rhtym HR 64x/m

No Problem List Plan Dx Plan Tx Plan Education Plan Monitoring

1 → LBP ec Susp HNP Lumbal

•Right flank pain•Pain radiating into the gluteal and right leg. •Prickling pain and cramps in the right leg•History of heavy lifting (+).•History of trauma (fail) when chillhood.

Back Abdomen Reg Lumbal : Tenderness on the regio lumbal

Extr : Straight Leg Raising (SLR) test (+) pain

X-foto Thoracolumbal : Skoliosis, Narrow discus gap L4L5

•MRI Lumbal

•USG Abdomen

•Complete urinalisis

Ketorolac inj 3x1

Consult to neurology and rehabilitation medic

Consult to orthopedi

•Educate about condition of the patient

•Educate sleep on a firm mattres

•Educate to not work with heavy lifting

•Pain monitoring

No Problem List Plan Dx Plan Tx Plan Education Plan Monitoring4 →Hypertension st.

1

•History of hypertension since 10 years ago, taking captopril but not regurally

Foto thorax : Cardiomegali

BP: 150/90mmHg,

•Urinalisis

•Profil lipid

•Ureum,creatinin

•Na, K, Cl

•ECG

•Echocardiography

•Check for another target organ damage:•1.Eye ophtalmologist•2.Nerve neurology•3.Nutrition nutritionist

Amlodipin 5 mg 1-0-0

•Exercise based on ability

•Educate the patient to check up regularly

•Educate to patient to take antihypertension drugs regurally

•Vital sign monitoring

•Ureum/creatinine, control

•Urinalysis

Thank You