TUGAS LC

CASE 35

KELOMPOK
TAUFIK RIZAL
NUR MUHAMMAD SYAFEI
MUHAMMAD GHIFAR RAMADHAN
NUUR HIDAYAH
PRIMA RIZKI

UNIVERSITAS MALAHAYATI
KEMILING ANDAR LAMPUNG, LAMPUNG

CASE 35
A 56 years old man comes in for routine health maintenance visit. He is saw to your practice and
has no specific complaints today. He has hypertension for which he takes hydrochlorothiazide,
and he occasionally takes an aspirin because someone told him that it was good for him. He has
no other significant medical history. He does not smoke cigarettes, occasionally drinks alcohol,
and does not exercise. His father died of a heart attack at age 60 years and his mother died at age
72 years of cancer. He has two younger sisters who are in good health. On examination, his
blood pressure is 130/80 mmHg and his pulse is 75 bpm. He is 6 ft tall and weight 200 lb. his
complete physical examination is normal. You order a fasting lipid panel, which subsequently
return with the following result. Total cholesterol 242 mg/dl, triglycerides 138 mg/dl, highdensity lipoprotein (HDL) cholesterol 48 Mg/dl, and low-density lipoprotein (LDL) cholesterol
155 mg/dl

TALKING NOTES
SURNAME : NONE
FIRST NAMES : NONE
AGE
: 56
MARITAL STATUS : MARRIED
OCCUPATOIN : NONE
PRESENT COMPLAINT : no specific complaints today
O/E
General Condition, 6 ft tall, 200 lb
ENT
NAD
RS
NAD
CVS
Pulse : 75, Blood Preasure : 130/80
GIS
NAD
GUS
NAD
CNS
NAD
IMMEDIATE PAST HISTORY
No significant medical history
POINT OF NOTE
His father died cause heart attack
His mother died cause cancer
DIAGNOSIS
Hypertension

KEYWORD

A 56 years old man

no specific complaints today
He has hypertension
he takes hydroc
he occasionally takes an aspirin
He has no other significant medical history.
He does not smoke cigarettes
occasionally drinks alcohol
does not exercise
His father died of a heart attack
and his mother died cause cancer
his blood pressure is 130/80 mmHg
his pulse is 75 bpm
He is 6 ft tall
complete physical examination is normal

LEARNNG ISSUE