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    Kementerian Kesihatan Malaysia Surat Rujukan KK Tanglin: Sitting

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    Nur Zalili
    1) The patient, a 53-year-old female, is referred to the urology clinic for persistent microscopic hematuria requiring further investigation. 2) Laboratory tests show mild hydronephrosis and left hydroureter but no nephrolithiasis. Microalbumin is abnormal. 3) The patient is prescribed simvastatin and losartan for lipid and blood pressure management during the urology clinic investigation and follow up.

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    Kementerian Kesihatan Malaysia Surat Rujukan KK Tanglin: Sitting

    Uploaded by

    Nur Zalili
    40 views3 pages
    1) The patient, a 53-year-old female, is referred to the urology clinic for persistent microscopic hematuria requiring further investigation. 2) Laboratory tests show mild hydronephrosis and left hydroureter but no nephrolithiasis. Microalbumin is abnormal. 3) The patient is prescribed simvastatin and losartan for lipid and blood pressure management during the urology clinic investigation and follow up.

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    1) The patient, a 53-year-old female, is referred to the urology clinic for persistent microscopic hematuria requiring further investigation. 2) Laboratory tests show mild hydronephrosis and left hydroureter but no nephrolithiasis. Microalbumin is abnormal. 3) The patient is prescribed simvastatin and losartan for lipid and blood pressure management during the urology clinic investigation and follow up.

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    Download as pdf or txt
    40 views3 pages

    Kementerian Kesihatan Malaysia Surat Rujukan KK Tanglin: Sitting

    Uploaded by

    Nur Zalili
    1) The patient, a 53-year-old female, is referred to the urology clinic for persistent microscopic hematuria requiring further investigation. 2) Laboratory tests show mild hydronephrosis and left hydroureter but no nephrolithiasis. Microalbumin is abnormal. 3) The patient is prescribed simvastatin and losartan for lipid and blood pressure management during the urology clinic investigation and follow up.

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    KEMENTERIAN

    KESIHATAN MALAYSIA
    SURAT RUJUKAN
    KK Tanglin

    Kepada : Urology CLinic HKL Designation/Jabatan : Pakar (Hospital)

    Tarikh Rujukan : 21-02-2023 Segera Tidak Segera

    Nama Pesakit : CHUNG LU LU No. Pendaftaran : 5179361

    Umur : 53 Yr(s) 2 Mth(s) 12 Day(s) Jantina : Female No. Kad Pengenalan : 691209075106

    dear dr, thank you for seeing this pt


    referring this pt for persisnt microscopic hematuria for futher investigation

    UL HPT

    MDD under private GP f/up on Escitalopram 10mg ON

    Come for TCA

    comply on meds

    no sob or chest pain


    no failure sx

    deny any hematuria / dysuria


    deny any hx renal stone / renal operation previously

    usg KUB 12/12/22: Bilateral mild hydronephrosis with left proximal hydroureter , no sonographic evidence of nephrolithiasis
    RK : BPL 9.6cm, PT : 1.5cm
    LK: BPL 9.8cm, PT : 1.6cm

    Vital Signs
    Captured : 21-02-2023 08:22 AM
    Sitting
    BP : 134 / 96 mmHg
    Pulse Rate : 94 bpm
    Pulse Pressure : 38 mmHg
    Temperature : 36 °C
    Oxygen Saturation : 99 %

    Anthropometry
    Captured : 21-02-2023 08:22 AM
    Weight : 58 kg
    Height : 156 cm
    BMI : 23.83 kg/m 2
    Body Surface Area : 1.59 m 2

    Lab Test Result

    FBS (Fasting Blood Sugar)


    Result Details:
    Fasting Blood Sugar: 5.7 Unit: mmol/L, Range: 3.5 - 6.0, Flag: , Remarks:
    Remarks:
    Reported By: NORFIZA MD NOOR

    RP with eGFR
    Result Details:
    Lipemia: 0 Unit: , Range: , Flag: , Remarks:
    Icterus: 0 Unit: , Range: , Flag: , Remarks:
    Hemolysis: 0 Unit: , Range: , Flag: , Remarks:
    Urea: 4.7 Unit: mmol/L, Range: 1.7 - 8.3, Flag: , Remarks:
    Sodium: 142 Unit: mmol/L, Range: 135 - 145, Flag: , Remarks:
    Potassium: 4.5 Unit: mmol/L, Range: 3.5 - 5.0, Flag: , Remarks:
    Chloride: 103 Unit: mmol/L, Range: 95 - 110, Flag: , Remarks:
    Creatinine: 56 Unit: umol/L, Range: 44 - 80, Flag: , Remarks:
    eGFR: 98 Unit: ml/min/1.73m2, Range: , Flag: , Remarks:
    Remarks:
    Reported By: NORFIZA MD NOOR

    Uric Acid
    Result Details:
    Uric Acid: 293 Unit: umol/L, Range: 142 - 339, Flag: , Remarks:
    Remarks:
    Reported By: NORFIZA MD NOOR

    LFT (Liver Function Test)


    Result Details:
    Lipemia: 0 Unit: , Range: , Flag: , Remarks:
    Icterus: 0 Unit: , Range: , Flag: , Remarks:
    Hemolysis: 0 Unit: , Range: , Flag: , Remarks:
    Total Protein: 77 Unit: g/L, Range: 66 - 87, Flag: , Remarks:
    Albumin: 45 Unit: g/L, Range: 35 - 50, Flag: , Remarks:
    Alkaline Phosphatase: 81 Unit: U/L, Range: 35 - 105, Flag: , Remarks:
    Alanine Transaminase: 22 Unit: U/L, Range: < 31, Flag: , Remarks:
    Total Bilirubin: 8 Unit: umol/L, Range: 5 - 17, Flag: , Remarks:
    Remarks:
    Reported By: NORFIZA MD NOOR

    FLP (Fasting Lipid Profile)


    Result Details:
    Lipemia: 0 Unit: , Range: , Flag: , Remarks:
    Icterus: 0 Unit: , Range: , Flag: , Remarks:
    Hemolysis: 0 Unit: , Range: , Flag: , Remarks:
    Total Cholesterol: 4.3 Unit: mmol/L, Range: 5.7 - 6.7, Flag: L, Remarks:
    Triglyceride: 0.9 Unit: mmol/L, Range: 1.7 - 2.3, Flag: L, Remarks:
    HDL Cholesterol: 1.6 Unit: mmol/L, Range: 0.9 - 1.4, Flag: H, Remarks:
    LDL Cholesterol: 2.3 Unit: mmol/L, Range: 3.9 - 4.9, Flag: L, Remarks:
    HDL / Total CHOL Ratio: 37.2 Unit: %, Range: > 25, Flag: , Remarks:
    Sample Appearance: CLEAR Unit: %, Range: , Flag: , Remarks:
    Remarks:
    Reported By: NORFIZA MD NOOR

    Urine Microalbumin
    Result Details:
    Ur Albumin Dipstix: Nil Unit: , Range: , Flag: , Remarks:
    Albumin: 30 Unit: mg/L, Range: , Flag: , Remarks:
    Creatinine: 100 Unit: mg/dL, Range: , Flag: , Remarks:
    A:C: 30-300 Unit: mg/g, Range: , Flag: , Remarks:
    master: abnormal Unit: mg/g, Range: , Flag: , Remarks:
    Remarks:
    Reported By: MOHD ZAFIMAN HAFNY

    UFEME
    Result Details:
    Ur Specific Gravity: 1.020 Unit: , Range: , Flag: , Remarks:
    Urine pH: 5.0 Unit: , Range: , Flag: , Remarks:
    Leucocyte: 2+ Unit: , Range: , Flag: , Remarks:
    Ur Nitrite: Negative Unit: , Range: , Flag: , Remarks:
    Ur Protein: Negative Unit: , Range: , Flag: , Remarks:
    Ur Glucose: Negative Unit: , Range: , Flag: , Remarks:
    Ur Ketones: Negative Unit: , Range: , Flag: , Remarks:
    Ur Urobilinogen: Normal Unit: , Range: , Flag: , Remarks:
    Ur Bilirubin: Negative Unit: , Range: , Flag: , Remarks:
    Ur Blood: 2+ Unit: , Range: , Flag: , Remarks:
    Color: Pale Yellow Unit: , Range: , Flag: , Remarks:
    Appearance: Clear Unit: , Range: , Flag: , Remarks:
    Pus Cells: 23 Unit: /uL, Range: 0 - 6, Flag: H, Remarks:
    RBC: 10 Unit: /uL, Range: 0 - 3, Flag: H, Remarks:
    Epithelial Cells: 5 Unit: /uL, Range: 0 - 5, Flag: , Remarks:
    Casts: not seen Unit: /uL, Range: , Flag: , Remarks:
    Crystals: not seen Unit: /uL, Range: , Flag: , Remarks:
    Bacteria: not seen Unit: /uL, Range: , Flag: , Remarks:
    Others: nil Unit: /uL, Range: , Flag: , Remarks:
    Remarks:
    Reported By: MOHD ZAFIMAN HAFNY

    FLP (Fasting Lipid Profile)


    Result Details:
    Lipemia: 9 Unit: , Range: , Flag: , Remarks:
    Icterus: 1 Unit: , Range: , Flag: , Remarks:
    Hemolysis: 0 Unit: , Range: , Flag: , Remarks:
    Total Cholesterol: 4.0 Unit: mmol/L, Range: 5.7 - 6.7, Flag: L, Remarks:
    Triglyceride: 0.8 Unit: mmol/L, Range: 1.7 - 2.3, Flag: L, Remarks:
    HDL Cholesterol: 1.9 Unit: mmol/L, Range: 0.9 - 1.4, Flag: H, Remarks:
    LDL Cholesterol: 1.7 Unit: mmol/L, Range: 3.9 - 4.9, Flag: L, Remarks:
    HDL / Total CHOL Ratio: 47.5 Unit: %, Range: > 25, Flag: , Remarks:
    Sample Appearance: CLEAR Unit: %, Range: , Flag: , Remarks:
    Remarks:
    Reported By: NORFIZA MD NOOR

    Prescription Order
    Generic Drug Name: Simvastatin 40 mg Tablet
    Drug Status: Approved
    Dosage: 20 mg
    Frequency: ON - Setiap malam
    For 7 Month (s) started on 21-02-2023
    Checked with MIMS: No

    Generic Drug Name: Losartan 50 mg Tablet


    Drug Status: Approved
    Dosage: 25 mg
    Frequency: OD - 1 Kali Sehari
    For 7 Month (s) started on 21-02-2023
    Checked with MIMS: No

    kindly please review this pt and do the needful, thank you

    Tujuan Rujukan : for futher investigation

    Daripada : NCD

    Nama : DR NUR HIDAYAH BINTI ABD RAHMAN

    Tempat Bertugas : KK Tanglin

    Tandatangan :

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