MR 6 Oktober HNP, Hipertensi
description
Transcript of MR 6 Oktober HNP, Hipertensi
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