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Ismail Pratama
A. Tenri Luwu
Mutmainnah
Vital Signs
Consciousness : Compos mentis (GCS 15 E4M6V5)
Blood pressure : 100/70 mmHg
Heart rate : 88 x/ min regular
Respiratory rate : 20 x/min
Temperature : 36,9C (axilla)
NRS : 7/10
Head : Normocephal
Face : Normal
Eyes : Isocor pupils, normal light reflex, no icteric sclera, no pale
conjunctiva
Ear : No abnormalities, otorrhea (-)
Nose : No abnormalities, epistaxis (-)
Lips : No abnormalities, cyanosis (-)
Oral cavity : No abnormalities, gingival hypertrophy (-), oral trush (-)
Throat : No abnormalities, pharyngeal hyperemia (-), T1-T1 normal
Neck : JVP R +1 cmH2O, no lymphadenopathy
Lung
Inspection : Symmetrical left and right
Palpation : No mass, normal tactile fremitus
Percussion : Sonor
Auscultation : Vesicular breathing sounds, no ronchi, no wheezing
Heart
Inspection : Ictus cordis unseen
Palpation : Ictus cordis palpable on ICS V linea midclavicula
Percussion : Dull, left heart border 1 finger laterally from left
linea midclavicularis
Auscultation : heart sound I / II regular, no murmur
Abdomen
Inspection : Flat
Auscultation : Bowel peristaltic (+) normal
Palpation : No ascites, no organomegaly
Percussion : Tympani
Gait : Unable to walk
Arm : normal
Leg :
Genu (D) et (S) : kalor (-), dolor (-), rubor (-), crepitation(-),
effusion (-), limited ROM (-)
Spine : Laseque (+)
Ur/ Cr : 39/1,07
WBC : 6300 Chol : 206
Secondary Osteoporosis
An Osteoporosis that caused by an underlying disease, some drugs effect, etc.
Idiopathic Osteoporosis
An osteoporosis that occurred in juvenile, adolescent, or middle ages that caused by
an unknown condition.
Source: Canalis, et.al. Osteoporosis Int 2007 in dr. Faridins Slide
Generally patients are asymptomatic even
with very low bone densities
Hip Fractures
Acute or chronic back pain secondary to
vertebral fractures
Atraumatic or low impact fractures
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Patients who have sustained a vertebral
compression fracture may note progressive
kyphosis with loss of height. They may also
present with an episode of acute back pain
after bending, lifting, or coughing. It should be
noted, however, that two thirds of vertebral
fractures are asymptomatic.
Postmenopausal : dorsal kyphosis or gibbus
(Dowagers hump), loss of height, protuberant
abdomen, paravertebral muscle spasm, thin
skin.
History taking: risk factors
Physical examination: anthropometry, gait, deformity,
and ect
Supporting examination:
Laboratory: complete blood for basic disease
screening, 24 hour urine calcium, kidney function,
liver function, TSH level
Bone biochemistry
Radiology
Densitometry (Gold Standard)
Radiology
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Nutritional Recommendations
Calcium ( >51 and older = 1200mg/d)
Vitamin D supplementation for daily intakes
(based on obtaining a serum level of 20
ng/mL). 400-800 IU for those >70 years.
Other nutrients such as salt, high animal
protein intakes, and caffeine may have modest
effects on calcium excretion or absorption.
Adequate vitamin K status is required for
optimal carboxylation of osteocalcin
PHARMACOLOGY RECOMMENDATION
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