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

Patients identity
Name
Age
Sex
Occupation
Education
Ethnicity
Religion

:
:
:
:

Mrs ML
62 yrs
Female
Housewife
: Senior High School
: Minahasa
: 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 pain
Skin
:Head and neck : Eye
:Ear
:Nose
:Mouth and throat: Respiratory : Chest
:Heart
:-

Abdomen
Genitalia
:Kidney
:Hematology : Endocrine
Musculosceletal
gluteal and right
Neurology
Psychology

:-

:: Pain radiating into the

leg
::-

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 :
Palp
Perc
Ausc
Back
Palp
Perc
Ausc

Insp
:
:
:
Insp
:
:
:

: Symmetric R = L
stem fremitus R = L
sonor +/+
vesicular, ronchi -/-, wheezing -/: Symmetric R = L
stem fremitus R = L
sonor +/+
vesicular, ronchi -/-, wheezing -/-

Abd :
IInsp
: Flat
Palp
: 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 List
No CM : 131917
y.o
1.Main complain:

Age : 63

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 Result
9/08/2015

Leucocyte
Erythrocyte
Hb
Ht
Platelet
RBS
Ureum
Creatinine
Na
Kalium
Cl

5904
4.40x106
13.4
40.8
242
107
16
0.7
141
3.5
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 Radiology
Rontgen
components

Interpretation

Identity

Same as the patient

KV

enough

Symmetric

yes

Diaphragma

normal

Mediastinum
Sinus Costophrenicus

Normal
sharp

Sinus Cardiophrenicus sharp

Bone

intact

Cor + CTR

52%

Pulmonary
Parenchyme

Infiltrat (-)

CONCLUSION : Cardiomegali

ECG

Interpretation of ECG
ECG componentsid

Interpretatio
n

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

N
o
1

Problem List
LBP ec Susp
HNP Lumbal

Plan Dx

Plan Tx

MRI Lumbal

Ketorolac inj
3x1

USG
Abdomen

Right flank pain

Pain radiating
into the gluteal
Complete
and right leg.
urinalisis
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

Consult to
neurology and
rehabilitation
medic
Consult to
orthopedi

Plan
Education
Educate
about
condition of
the patient
Educate
sleep on a
firm mattres
Educate to
not work with
heavy lifting

Plan
Monitoring
Pain
monitoring

N
o

Problem List

Hypertension
st. 1

Plan Dx
Urinalisis
Profil lipid

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

Ureum,creati
nin
Na, K, Cl
ECG

Foto thorax :
Cardiomegali

Echocardiogr
aphy

BP: 150/90mmHg,
Check for
another
target organ
damage:
1.Eye
ophtalmologi
st
2.Nerve
neurology
3.Nutrition
nutritionist

Plan Tx
Amlodipin 5
mg 1-0-0

Plan
Education
Exercise
based on
ability
Educate the
patient to
check up
regularly
Educate to
patient to take
antihypertensi
on drugs
regurally

Plan
Monitoring
Vital sign
monitoring
Ureum/creatinin
e, control
Urinalysis

Thank You