Medical Check up

Standard Operating Procedure for Diagnosis

1. BMI

Weight (kg)/Height (meter) 2 Classification Recommendation

BMI 25-30 Overweight 1. Low calorie diet

2. Exercise 3x/week, 30
minutes per session

BMI 30-35 Grade I Obesity 1. Low calorie diet

BMI 35-40 Grade II Obesity 2. Exercise 3x/week, 30
BMI > 40 Morbid Obesity minutes per session
3. Review by a Nutritionist
for management of
Obesity

BMI < 18.5 Underweight 1. High Calorie and protein

diet
2. Exercise 3x/week, 30
minutes per session

Kalkulator BMI anak :

 usia < 2th :
http://kms-online.web.id/cek/berat-ideal-telentang.html
 Usia > 2th -19th :
http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childr
ens_bmi.html

or you can use this link:

http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx?CalculatorType=Metric

2. Hypertension

Blood Pressure Systolic Diastolic Recommendation

Normal Blood < 120 mmHg < 80 mmHg
Pressure
Stage1 140 – 159 mmHg 90 – 99 1. Low salt diet
Hypertension mmHg 2. Review by a Physician for
Stage 2 ≥160 mmHg ≥100 mmHg management of
Hypertension Hypertension
*Only one abnormal (systole or diastole) choose the highest one to be the diagnosis
* Berdasarkan standar terbaru JNC 8 Desember 2013, criteria prehypertension
ditiadakan.
3. Myopia, Hyperopia , Presbiopia, and Color blindness

Distance Visual Near Visual Diagnose Recommendation

20/20-25 J1/J1 Normal --
20/ > 25 J1/J1 Myopia Review by an
20/20-25 J1/ >J2 Hyperopia Ophthalmologist
for management
20/ >20- 25 J1/ >J2 Presbyopia
of Refractory
(Person aged over
problem
40 years old )
Dx presbiopia
hanya dibuat jika
pada usia 40th
keatas dan ada
gangguan
pengelihatan
dekat.

CONVERSION OF VISUAL ACUITY TEST

Source: http://www.aop.org.uk/uploads/vision-standards-
2013/visual_acuity_conversion_chart_uk_caa.pdf
http://www.precision-vision.com/index.cfm/feature/9/a--visual-acuity.cfm

NORMAL LIMITS OF VISUAL ACUITY BY AGE

AGE NORMAL LIMITS
6 months to 3 years Ability to fix and follow face, toy or light.
3 to 5 years 20/40 or better; 1 line acuity difference between eyes.
Older than 5 years 20/25 or better; no acuity difference between eyes.
Source: American Academy of Ophthalmology

1. Diagnosis: Partial color blindness

Conclusion: FIT with Partial Color Blindness
Recommendation: Patient is not able to do an activity which requires him/her to
differentiate color.

2. Diagnosis: Monocular Vision Impairment

Conclusion: FIT with Monocular Vision Impairment ( kalau mata yang sebelahnya
normal with or without correction)
Recommendation: Special attention should be given to protecting the monocular eye from
high hazard operations

3. Funduscopy:
- Normal: Clear margin, a/v 2/3, CD 0.3-0.4
- Abnormal ( suspect glaucoma ) : Clear margin, a/v 2/3, CD 0.6-0.8, LC
(+)
- LC (Lamina Cribrosa) +  Suspect Glaucoma
Recommendation: Review by an Ophthalmologist for management of
suspect glaucoma. May require visual field examination (Temporary
UNFIT)

4. Anemia

Definition: WHO criteria for anemia in men and women are Hemoglobin <13 and <12
g/dL, respectively.

Microcytic: MCV is less than normal

Hypochromic: MCH and MCHC is less than normal

Hemoglobin MCV MCH MCHC

Normal M>13, F>12 N N N

Microcytic
Hypochromic M<13, F<12 Low Low Low
Anemia
Macrocytic
M<13, F<12 High N/Low N/Low
Anemia
Anemia for
M<13, F<12 N Low Low
investigation

Note:

 Most common cause of Microcytic Hypochromic anemia is Iron Deficiency.

Recommendation: Review by a Physician for management of Anemia. May
require Serum Ferritin, Transferrin, TIBC and Occult blood test to confirm or
refute the presence of anemia.

 Most common cause of Macrocytic Anemia is folic acid/B12 deficiency or

Alcohol abuse.

5. Non Alcoholic Steato Hepatitis, Alcoholic Steato Hepatitis and Hepatobilliary

disease
 AST ALT AST:ALT ratio Gamma GT
Normal Normal Normal <1 Normal
Normal or
Suspect Non Elevated (more
elevated more
Alcoholic than 10% from <1 Normal
than 10% of
Steato Hepatitis normal)
normal)
Suspect
Alcoholic Liver Elevated Elevated >2 Elevated
Disease
Elevated (more Elevated (More
Suspect Hepato
than 10% of than 10% of <1 Elevated
Billiary disease
normal) normal)

- Confirmation of diagnosis can only be made by USG abdomen or Liver Biopsy.

- If USG abdomen result is Fatty liver but normal or only slight elevated of Liver
Function test (range 10% from normal value), the diagnose  Non Alcoholic
Fatty Liver Disease
If USG abdomen result is Fatty liver with elevated of Liver Function test, the
Diagnose  NASH

- The serum ALT correlates with body mass index (BMI) and waist circumference,
an abnormal ALT was present in 8.9 percent of obese people.

- Elevated Gamma GT : Suspect Hepato Billiary Disease

- Elevated Alkali Phosphatase : Suspect Billiary Disease

- http://www.aafp.org/afp/1999/0415/p2223.html

- Kalau peningkatan LFT tidak significant dan usg normal, maka diagnosa :
Elevated Liver Function Test (kalau hanya 1 atau 2 item maka di sebutkan
itemnya)for investigation, rekomendasi: Repeat Liver Function Test (sebut item
yg perlu di tes nya )after 3 months

- Kalau Peningkatan Gamma GT secara significant ( 2xnormal) tetapi usg normal

maka diagnosa: Suspect Cholecystitis, rekomendasi : Review by an Internist

- GGT is very sensitive test and many times can be elevated if overweight or has
excess fat in the liver  Kalo ada Peningkatan GGT tidak significant dan Fatty
Liver di USG Non Alcoholic Fatty Liver Disease

Recommendation for Suspect Non Alcoholic Steato Hepatitis

 Require a whole abdominal USG to confirm or refute the presence of Non
Alcoholic Steato Hepatitis.
Recommendation for Non Alcoholic Steato Hepatitis
 Review by a Physician for management of Non Alcoholic Steato Hepatitis

6. Chronic Kidney Disease (setiap ada peningkatan creatine serum, hitung GFR
nya, jika GFR abnormal maka temporary unfit)
Creatinine, an endogenous marker, is most commonly used to estimate GFR, as it does
not require an intravenous infusion.
Estimation Equation: Cockroft-Gault equation

(140 - age) x lean body weight [kg]

CCr (mL/min) = —————————————————————————
Cr [mg/dL] x 72

 Stage 1 disease — Normal GFR (≥90 mL/min per 1.73 m2)

 Stage 2 disease — GFR between 60 to 89 mL/min per 1.73 m2
 Stage 3 disease — GFR between 30 and 59 mL/min per 1.73 m2
 Stage 4 disease — GFR between 15 and 29 mL/min per 1.73 m2
 Stage 5 disease — GFR of less than 15 mL/min per 1.73 m2 or ESRD

Note: CCr (Creatinine Clearance = GFR (Glomerular Filtration Rate)

Diagnosis: Elevated Creatinine Serum Level with GFR = …. Suspect Chronic Kidney
Disease stage …
Recommendation: Review by an Internist/ nephrologists or management of CKD

7. Hyperuricemia
Diagnose:
 Male : > 7.7 mg/dL
 Female: > 6.8 mg/dL

Recommendation:
1. Low purines diet
2. Review by a Physician for management of Hyperuricemia

8. Serology Hepatitis

Interpretation of the Hepatitis B

Tests Results Interpretation Recommendation
HBsAg negative
anti-HBc negative Susceptible
anti-HBs negative
HBsAg negative Immune due to natural
anti-HBc positive infection
 anti-HBs positive
HBsAg negative * See Immunity Status of
Immune due to hepatitis B Hepatitis B below
anti-HBc negative
vaccination*
anti-HBs positive
HBsAg positive Review by a
anti-HBc positive Hepatologist/internist for
Acutely infected management of Acute
IgM anti-HBc positive
Hepatitis B infection
anti-HBs negative
HBsAg positive Review bay an
anti-HBc positive Hepatologist for
Chronically infected management of Chronic
IgM anti-HBc negative
hepatitis B infection
anti-HBs negative
HBsAg negative Four interpretations possible• -
anti-HBc positive Diagnose : Suspect false
anti-HBs negative positive anti-HBc

 Antibody response (anti-HBs) can be measured quantitatively or qualitatively. A

protective antibody response is reported quantitatively as 10 or more
milliinternational units (>=10 mIU/mL) or qualitatively as positive. Post-
vaccination testing should be completed 1-2 months after the third vaccine dose
for results to be meaningful.

• Four Interpretations:
1. Might be recovering from acute HBV infection.
2. Might be distantly immune and test not sensitive enough to detect very low level of
anti-HBs in serum.
3. Might be susceptible with a false positive anti-HBc.
4. Might be undetectable level of HBsAg present in the serum and the person is
actually chronically infected.

Positive HBsAg with no other seromarker

Recommendation: Review by a Hepatologist for management of Hepatitis B infection.
Requires HbeAg, anti HbeAg and Ig M anti-HBc test to assess the activity of Hepatitis B
virus.

Immunity Status toward Hepatitis B

Status Anti HBs titre Recommendation
Good immunity towards >100 uIU/ml --
 Hepatitis B infection

Poor Immunity towards

Hepatitis B infection
No Immunity towards
Hepatitis B infection
Recommend a Booster dose
10 – 100 uIU/ml
of Hepatitis B vaccine
Recommend a Complete
course of Hepatitis B
< 10 uIU/ml
vaccine

Note : Pada pasien yg hanya di cek anti HBs saja, baik No immunity ataupun Poor
Immuity pada rekomendasi perlu ditambahkan Require ELISA HBsAg test before the
vaccination

9. Spirometry
Step by step read a spirometry:
1. See FEV1% if normal or high THEN see FVC  result : Normal or Restriction
2. If FEV 1% abnormal THEN see FVC  result : Obstruction alone or Obstruction
with low vital capacity

Obstructive pattern  see FEV 1 % (FEV1/FVC best/measured)

 >75 % : Normal
 65 % – 75 % : Mild obstruction
 50 % -64 % : Moderate obstruction
 < 50 % : Severe obstruction

Recommendation : Review by a Pulmonologist for management of Ventilatory problem

Restrictive pattern  See FVC

 Recommendation:

 Mild Restriction
Ventilatory Function
 Repeat
Spirometry after 6

 Moderate Restriction Ventilatory Function
 Severe Restriction Ventilatory Function
10. Audiometry interpretation
months
 Review by a Pulmonologist for
Management of ventilatory
problem
 Review by a Pulmonologist for
Management of ventilatory
problem

1. Sum of frequency of air conduction on 500, 1000, 2000, 4000

2. Divided the total by 4

Severity of Hearing Loss:

0 -25 : Normal
26 - 40 : Mild
41 - 55 : Moderate
56 - 70 : Moderate-Severe
71 - 90 : Severe
>90 : Profound

Type of hearing loss

 Conductive hearing loss  Bone (</>) : Normal
Air (x/o) : Abnormal ( >25)
Gap : Yes (≥10db)
 Sensory Neural hearing loss  Bone : Abnormal ( >25)
Air : Abnormal (>25)
Gap : No (coincide/at least almost coincide)
 Mixed hearing loss  Bone : Abnormal ( >25)
Air : Abnormal (>25)
Gap : Yes (≥10db)
  Cara melihat Gap : Lihat gap antara bone dan air di 2 frekwensi yang berdekatan (
mis: frek 500 dan 1000, 1000 dan 500, 1000 dan 2000, 2000 dan 1000, 2000 dan
4000, 4000 dan 2000)
 Recommendation : Review by an ENT specialist for management of Hearing
problem
 Jika gangguan nya hanya penurunan pendengaran di frekuensi tinggi maka
rekomendasinya : Avoid working in noise area or use ear protection while
working in noise area and conduct Audiometry test regularly once a year

11. Arterial Blood Gas

Before enterprate the result please ensure that is an arterial blood

by see O2 saturation > 88 %

pH paCO2 HCO3
Respiratory Acidosis
 Acute < 7.35 > 45 Normal
 Partly Compensated < 7.35 >45 > 26
 Compensated Normal >45 > 26
Respiratory Alkalosis
 Acute >7.45 <35 Normal

 Partly Compensated
 Compensated >7.45 <35 <22
Normal <35 <22
Metabolic Acidosis
 Acute <7.35 Normal <22
 Partly Compensated <7.35 <35 <22
 Compensated Normal <35 <22
Metabolic Alkalosis
 Acute >7.45 Normal >26
 Partly Compensated >7.35 >45 >26
 Compensated Normal >45 >26
Note: Jika tidak terdapat kelainan yg bermakna sampai timbul klinis atau kalau ph > 7.7
atau dibawah 7.1 (lethal/berat) dan liat elektrolit serum serta penyakit yg di punya pasien.
Maka tidak perlu di diagnosis tetapi tetap di jabarkan kelainannya di lab exam. Kalau
bermakna baru di tulis didiagnosis.
Diagnosis : Acid Base Imbalance suspect……………………
Recommendation: Review by a Physician/Internist/Pulmonologist (according to the cause
of acid base disorder) for management of …(one of acid base disorder)

12. Glucose Screening

Diagnosis: Impaired fasting glucose (IFG)— Fasting plasma glucose between 100 and
125 mg/dL (5.6 to 6.9 mmol/L)

Recommendation: Require a 2 hours Post Prandial Glucose and HbA1c level to confirm
or refute the presence of Diabetes Mellitus

Impaired glucose tolerance (IGT) — Two-hour plasma glucose value during a 75 g oral
glucose tolerance test between 140 and 199 mg/dL (7.8 to 11.0 mmol/L).

Diagnose: Diabetes mellitus —

o Fasting Plasma Glucose at or above 126 mg/dL (7.0 mmol/L),
o A1C ≥6.5 percent, or
o A random (or "casual") plasma glucose concentration ≥200mg/dL
(11.1 mmol/L) in the presence of symptoms

Recommendation:
1. Low Fat, Protein, carbohydrate, Sugar on diets
2. Increase fiber and vegetable intake
3. Exercise daily at least 30 minutes per day (approximately 150 minutes per week)
4. Encourage Omega 3 intake. Change of cooking oil either to canola oil or olive oil
or other oils containing high amounts of HDL cholesterol
5. Review by a Physician for management of Diabetes Mellitus. Patient requires a 2
hour post prandial glucose and HbA1c level test

13. Hypercholesterolemia/Dyslipidemia/Hypertrigliceridemia
Diagnosis:
Dyslipidemia: ↑TC/LDL+ ↑TG
Hypercholesterolemia: ↑TC/LDL (wo/↑ TG)
Hypertrigliceridemia : ↑TG

Recommendation for Hypercholesterolemia/Dyslipidemia/Hypertriglyceridemia

1. Low calorie diet
2. Exercise 3x/week, 30 minutes per session
3. Change cooking oil to those containing high amounts of mono and
polyunsaturated fatty acid like canola or olive oil

Recommendation for Hypercholesterolemia/Dyslipidemia if other risk factors like age

> 55 for males/>50 for females, smoking, overweight/obesity, Hypertension etc
present
1. Low calorie diet
2. Exercise 3x/week, 30 minutes per session
3. Change cooking oil to those containing high amounts of mono and
polyunsaturated fatty acid like canola or olive oil.
4. Review by a Physician for management of Dyslipidemia/Hypercholesterolemia
Framingham Risk Score

Estimate of 10-Year Risk for Men

Framingham Point Scores by Age Group

Age Points
20-34 -9
35-39 -4
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 11
70-74 12
75-79 13

Framingham Point Scores by Age Group and Total Cholesterol

Total Cholesterol Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
<160 0 0 0 0 0
160-199 4 3 2 1 0
200-239 7 5 3 1 0
240-279 9 6 4 2 1
280+ 11 8 5 3 1

Framingham Point Scores by Age and Smoking Status

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0
Smoker 8 5 3 1 1

Framingham Point Scores by HDL Level

HDL Points
 60+ -1
50-59 0
40-49 1
<40 2

Framingham Point Scores by Systolic Blood Pressure and Treatment

Status
Systolic BP If Untreated If Treated
<120 0 0
120-129 0 1
130-139 1 2
140-159 1 2
160+ 2 3

10-Year Risk by Total Framingham Point Scores

Point Total 10-Year Risk
<0 < 1%
0 1%
1 1%
2 1%
3 1%
4 1%
5 2%
6 2%
7 3%
8 4%
9 5%
10 6%
11 8%
12 10%
13 12%
14 16%
15 20%
16 25%
17 or more 30%
 Estimate of 10-Year Risk for Women

Framingham Point Scores by Age Group

Age Points
20-34 -7
35-39 -3
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 12
70-74 14
75-79 16

Framingham Point Scores by Age Group and Total Cholesterol

Total Cholesterol Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
<160 0 0 0 0 0
160-199 4 3 2 1 1
200-239 8 6 4 2 1
240-279 11 8 5 3 2
280+ 13 10 7 4 2

Framingham Point Scores by Age and Smoking Status

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0
Smoker 9 7 4 2 1

Framingham Point Scores by HDL Level

HDL Points
60+ -1
50-59 0
40-49 1
 <40 2

Framingham Point Scores by Systolic Blood Pressure and Treatment

Status
Systolic BP If Untreated If Treated
<120 0 0
120-129 1 3
130-139 2 4
140-159 3 5
160+ 4 6

10-Year Risk by Total Framingham Point Scores

Point Total 10-Year Risk
<9 < 1%
9 1%
10 1%
11 1%
12 1%
13 2%
14 2%
15 3%
16 4%
17 5%
18 6%
19 8%
20 11%
21 14%
22 17%
23 22%
24 27%
25 or more 30%

Framingham Calculator Link : http://www.globalrph.com/10_year_risk.htm

14. Imaging :

Chest X-Ray

o Specific process in the lung

  Recommendation: Review by a physician for further management of chest x ray
abnormality. Patient requires a 3 sputum fast acid basilli (microscopic) and
PCR Tuberculosis

o Cardiomegaly :
UNFIT
 Recommendation: Review by a Cardiologist for further management of
Cardiomegaly may require Echocardiogram.

o Suspect Bronchopneumonia wo/ Symptom or Abnormal PF :

 Diagnose: -
 Recommendation : -

o Elongation aorta : (no need to diagnosed)

 Recommend: -

o Elongation aorta + Hypertension :

 Diagnosis: Suspect Hypertensive Heart Disease
 Recommendation: Require an Echocardiography to confirm or refute the
presence of Hypertensive Heart Disease

USG:
o Prostate calcified tidak perlu dimasukan dalam diagnosa kecuali ada gejala
o Nephrocalcinosis di masukkan ke diagnosis tapi tidak perlu rekomendasi

15. Treadmill
o Positive Ischemic Response on Stress test  Review by a Cardiologist for
further management of Positive Ischemic Response, may require MSCT-Scan or
cardiac catheterization as indication

16.Ketonuria : kalau cuma keton aja yg positive tdk perlu di diagnosa dan di
rekomendasi
Ketonuria is a sign seen in diabetes mellitus that is out of control. Diabetics prone to
ketonuria need to monitor their urine for signs of ketone buildup that could lead to life-
threatening symptoms unless promptly treated. Ketonuria can also develop as a result of
fasting, dieting, starvation and eating disorders.

17. ECG :

 Right and Left Axis :

 Kalau tidak ada keluhan ataupun kelainan pada pemeriksaan fisik maka tidak perlu di
tulis di diagnosa dan di rekomendasi. Cukup di tulis di bagian ECG result aja.

 1st degree AV block  Put in the diagnose but no need recommendation

 Old Myocard Infarct wo/ history of Heart disease

Diagnose: -
Conclusion: FIT

 Complete RBBB + Murmur :

Recommendation: Review by a Cardiologist for management of Heart problem.
Require an Echocardiography to confirm or refute the presence of Heart problem
Conclusion: Temporary UNFIT

 ERP :
In a person without symptoms and without a family history of sudden cardiac death,
should not lead to further investigation or any preventive therapy because the absolute
risk of cardiac arrest in such people is very low ( www.plosmedicine.org)

18. CEA:
Elevated CEA in asymptomatic patient.
Diagnosis : Elevated CEA for investigation
Recommendation: Repeat CEA after 3 month

19. Breast Exam:

Diagnosis : Breast Lump for investigation
Recommendation : Review by a Breast Surgeon for management of Breast lump.
Description for area Mammae: Upper outer quadrant --- Upper inner quadrant
Lower outer quadrant --- Lower inner quadrant

21. Hyperbilirubinemia
1. Jika Total bilirubin serum ↑ tetapi tidak ada bilirubin di urin, lihat Hb nya. Jika Hb
normal maka diagnosa nya hyperbilirubinemia for investigation, conclusion:
FIT, rekomendasi: Review by an Internist for further management of
Hyperbilirubinemia, may require reticulocytes and peripheral blood smear.

2. Jika Total bilirubin serum ↑, bilirubin di urin + maka diagnosanya :

Hyperbilirubinemia and Hyperbilirubinuria for investigation, conclusion :
 Temporary Unfit, rekomendasinya: Review by an Internist for further
management of Hyperbilirubinemia and Hyperbilirubinuria, may require direct
and indirect bilirubin test, anti HAV total, HbsAg, anti HCV, USG whole
abdomen. (liat hasil lab yang sudah ada).

3. Jika Total bilirubin serum normal, walaupun direct/indirect nya tdk normal tdk
perlu didiagnosa.

22. Dental Problems

K : Carries
RG : Radix gangrene
PG : Pulp gangrene
M : Missing
Im : Impacted
Fr : Fracture
Calculus : Karang gigi
Stain : Perubahan warna gigi
Partial Denture : Gigi palsu
F: Filling  No need to be diagnose
Missing tooth on 18, 28, 38, or 48  No need to be diagnosed
Recommendation: Review by a Dentist for management of Dental problems

23. Recommendation for Suspect Urolithiasis

Require a whole abdominal USG to confirm or refute the presence of Urolithiasis. If
present, patient requires a review by an Urologist.

24. Recommendation for G6PD Deficiency

Review by an Internist for management of low G6PD. Patient requires a list of
medication and food that is to be avoided.

25. Widal interpretation

http://nillaaprianinaim.wordpress.com/2011/09/28/120/

Baseline titre of the population must be known before attaching significance to the titres.
The antibody levels of individuals in a population of a given area give the baseline titre.
A titre of 100 or more for O antigen is considered significant and a titre in excess of 200
for H antigens is considered significant.

26. Urinalysis:
 Cristal Oxalat , Crystal Amorf 1+/2+ without symptoms and other abnormal
finding  Normal Urinalysis
  Hematuria + Proteinuria + RBC cast  Suspect Acute Glomerulonephritis
Acute GN is defined as the sudden onset of hematuria, proteinuria, and red blood cell
(RBC) casts. This clinical picture is often accompanied by hypertension, edema,
azotemia (ie, decreased glomerular filtration rate [GFR]), and renal salt and water
retention. Acute GN can be due to a primary renal disease or to a systemic disease.
Most original research focuses on acute PSGN.

 Bacteria (+) wo/ Leucocyte

o Diagnose: Asymptomatic Bacteriuria
o Recommendation: Repeat Urinalysis

 Bacteria (+), Leucocytes (+)

o Diagnose: UTI, jika tanpa gejala maka Asymptomatic Urinary Tract
Infection
o Recommendation: Review by a Physician for management of UTI

 Proteinuria only
o Recommendation: Repeat urinalysis. If persistence need review by an
Internist.

 Proteinuria plus …
o Proteinuria + Hypertension :
Diagnose: Suspect Hypertensive Nephropathy
Recommendation: Require a Microalbumin test to confirm or refute the
presence of Hypertensive Nephropathy. If presence need review by a
Nephrologists.

o Proteinuria + Diabetes Mellitus :

Diagnose: Suspect Diabetic Nephropathy
Recommendation: Require a Microalbumin test to confirm or refute the
presence of Diabetic Nephropathy. If presence need review by a
Nephrologists.

27. Stool analysis:

 Hematoschezia (blood in stool)
 Recommendation: Require an Occult blood test to confirm or refute the presence
of Hematochezia. If presence need review by a Gastroenterologist.
28.Smokers
20cigarettes/day for 1 year = 1 pack year
Ex: 10 cigarettes/day for 10 years = 5 pack year
Calculation : cigarettes/day x years = …… pack years
20
Recommendation: Stop smoking by a combination of counseling by a General Physician
and Pharmaceutical Support

29. Syphilis Serologic test

http://www.tabletsmanual.com/wiki/read/syphilis
 Positive VDRL and positive FTA-ABS (or TPHA) test confirms the diagnosis of syphilis
 Positive VDRL and negative FTA-ABS (or TPHA) indicate that there is other disease, not
syphilis
 Negative VDRL and positive FTA-ABS (or TPHA) test indicate very early stage syphilis
or healed syphilis or syphilis in the tertiary stage  Dx: Reactive TPHA, Susp Syphilis
infection
 Negative VDRL and negative FTA-ABS (or TPHA) dismiss the diagnosis of syphilis
(there are rare cases where the test is done too early, there may be false negative on both
tests)

30. LDH http://www.medicalhealthtests.com/askquestion/254/what-is-ldh-blood-test.html

High LDH levels can be associated with some conditions such as, strokes, hemolytic
anemia, drug abuse, kidney disease, liver disease, mononucleosis, pancreatic disease, and
muscular dystrophy. It is also important to know when the level of LDH will be elevated
naturally. People who undergo strenuous exercise or have just taken part in a physically
demanding activity may have slightly damaged muscles as the muscles have been
strained to a great extent. This will reflect in a temporary rise in LDH levels, so it is
important rest well prior to any testing.

In fact low levels of LDH indicate that all is normal in the body. In cases where the
numbers are radically low there is still no need to worry. One of the causes of low LDH
levels may be a high intake of vitamin C and this will show up in other blood reports as
well.

31. CPK/CK  Jika hanya CPK/CK yang meningkat tanpa peningkatan LDH
maka kemungkinan besar permasalahannya di otot (muscle injury). Lihat juga hasil
EKGnya.

Pada lab, tetap ditulis abnormal tetapi tidak perlu di diagnosa.

Rekomendasi : Repeat CPK/CK test after 6 months

High CPK levels may be seen in patients who have:

 Brain injury or stroke

 Convulsions
 Delirium tremens
 Dermatomyositis or polymyositis
 Electric shock
 Heart attack
 Inflammation of the heart muscle (myocarditis)
 Lung tissue death (pulmonary infarction)
 Muscular dystrophies
 Myopathy

Additional conditions may give positive test results:

 Hypothyroidism
 Hyperthyroidism
 Pericarditis following a heart attack
 Rhabdomyolysis

32. Varicose Vein (if in mild/early stage)

Recommendation: Elevation of the affected leg , Avoid prolonged standing or sitting and
Wearing compression stockings for management of Varicose Vein

33. Hydonefrosis and Hydroureter : http://emedicine.medscape.com/article/436259-

treatment

34. Vital Sign For Children :

http://www.sickkids.ca/Nursing/Education-and-learning/Nursing-Student-
Orientation/module-two-clinical-care/vitals/index.html

Vital signs ranges

Respiratory Rate
Heart Rate
Age (respiration Blood Pressure
(beats/min)
s/min)

0-1 month 93-182 26-65 45-80/33-52

1-3 months 120-178 28-55 65-85/35-55

3-6 months 107-197 22-52 70-90/35-65

6-12 months 108-178 22-52 80-100/40-65

1-2 years 90-152 20-50 80-100/40-70

2-3 years 90-152 20-40 80-110/40-80

3-5 years 74-138 20-30 80-115/40-80

5-7 years 65-138 20-26 80-115/40-80

8-10 years 62-130 14-26 85-125/45-85

11-13 years 62-130 14-22 95-135/45-85

14-18 years 62-120 12-22 100-145/50-90

Oral, Rectal & Axillary Temperatures

Assessment of appropriate route of temperature measurement:

Oral
 patients assessed as being developmentally and cognitively appropriate, and who
are not receiving oxygen via mask or hood
 patients who have not had surgery and/or do not have an inflammatory condition
of the mouth
 patients who do not have respiratory difficulties

Rectal
 patients who are beyond the neonatal period
 patients who are unconscious or present difficulty with oral temperature
measurement related to cognitive function
 patients who have not had rectal surgery or other rectal abnormalities
 patients who are not immunocompromised

Axillary
 patients in the neonatal period (<28 days old)
 patients for whom oral and rectal temperatures are contraindicated
Temperature Ranges
*Note:

 There is no single definition of fever

Method Range (°C) Fever* (°C)
 Fever should be interpreted and
managed in the context of the
Oral 36.5 - 37.5 38.0 patient’s age, illness and clinical
picture
Rectal 37.0 - 37.8 38.0
 Premature and small term infants
may not be able to generate an
Axillary 36.1 - 37.1 37.3
elevated temperature in response to
infection

35. Tonsil :
ukuran besarnya tonsil dinyatakan dengan :
· T0 : bila sudah dioperasi
· T1 : ukuran yang normal ada
· T2 : pembesaran tonsil tidak sampai garis tengah
· T3 : pembesaran mencapai garis tengah
· T4 : pembesaran melewati garis tengah

Tonsil enlargement without sign and symptom no need to be diagnosed

35. DRE (Digital Rectal Examination)

Rectal-Anal:
 Normal mucosa feels uniformly smooth and
 pliable to palpate
 Polyps –may be attached by stalk or base
 Masses or irregular shaped nodules
 Areas of unusual hardness
 Abscesses (perirectal sepsis) may be
 indicated by extreme tenderness
 Haemorrhoids (internal or external)  External : Review by a Physician
Recommendation:
1. Increased of fiber and water intake (minimum 2 L/day)
2. Avoid straining during a bowel movement
3. Review by a Surgeon for management of Internal Hemorrhoid if
symptoms appears
Normal prostate:
 About 2.5 cms across
 Prominent median sulcus
 Smooth, rubbery consistency
 Tenderness not usual, but patients should feel the need to urinate

Benign Prostatic hypertrophy (BPH)

 Enlargement of the gland is usually
 Marked protrusion into the rectal lumen
 Smooth with no nodularity
 Median sulcus may be indistinguishable
 Consistency is rubbery, or slightly elastic