Professional Documents
Culture Documents
OLEH:
Anggia Pradini
Selvia Ningsih
Wulan Safitri
PEKANBARU
2019
A. CASE
Ny. S age of 58 years came to AA Pekanbaru Hospital with complaints of pain in the
joints are often felt since 3 months ago, feeling pain had been felt since a few years ago,
but Mrs. S ignore it. When it went to the doctor Ny. S is recommended for blood tests
and rongent foot. Rongent Results showed that Ny. S osteoporosis is reinforced by the
results of BMD T-score of -3. Clients experiencing menopause since 6 years ago.
According to her clients do not like to drink milk from a young age and do not like
seafood.
B. ASSESMENT
1. Client identity
Name: Ny. S
Age: 58 Years
Female gender
Occupation: IRT
2. Medical history
Health History Now Ny. S age of 58 years came with complaints of pain in the joints are
often felt since 3 months ago, feeling pain had been felt since a few years ago, but Mrs. S
ignore it. When it went to the doctor Ny. S is recommended for blood tests and rongent
foot. Rongent Results showed that Ny. S osteoporosis is reinforced by the results of BMD
T-score of -3.
3. Formerly Health History
Previous medical history is known that the client never experienced diseases like diabetes
and hypertension and had been treated at the hospital. History of hormonal contraceptive
use
4. Physical examination
Inspection: Clients look humpback (kyphosis), weight loss, changes in gait.
Palpation: Clients feel pain on palpation in the back area.
5. Psychosocial history
Clients are anxious to perform strenuous activities.