Morning report

1. MORNING REPORT
D Rose Ward
August, 3rd 2022

2. Patient Identity
• Name : Mr. TS
• Age : 55 years old
• Sex : Female
• Occupation : unemployed
• Education : Senior High School

3. A 55 year-old Woman was admitted to R.D.
Kandou Hospital at D Rose ward on
August, 3th 2022
Chief complaint: the patient entered from
Hepatology polyclinic for a DNA HBV check
plan

4. Present Medical History
• The patient entered from Hepatology Polyclinic for a
DNA HBV check plan.
• Currently, the patient has no complaints.

5. Past Medical History
• Hepatitis B was detected 2 months ago through laboratory examination at
Teling Hospital.
• Hypertension since 1 year ago, consume Bisoprolol 1x2.5 mg, Amlodipine
1x10 mg, Irbesartan 1x300 mg and Furosemide 1x40 mg.
• Hyperuricemia since 2 months ago, consume Alopurinol 1x100 mg PO,
stopped since 2 weeks ago.
• Dyslipidemia since 2 months ago, consume Atorvastatin 1x20 mg PO,
stopped since 2 weeks ago
• Kidney disorders since April 2022.
• Malaria and DHF April 2022.

6. Family History
• None experienced the same illness

7. Physical Examination
• GC: Moderate ill . Sens : CM
• Vital sign : BP: 193/76 mmHg, PR 88 x/m, RR 20 x/m, T
36.6 oC SpO2 98% room air
• Head : conj. Anemic (+), scl. Icteric(-)
• Neck : JVP distended (-), lymph nodes enlargement (-)
• Thorax :
• Heart :
– Insp : IC not visible
– Palp : IC not palpable
– Perc : left border: ICS V left anterior aksilaris line
right border: ICS IV right parasternalis line
– Ausc : SI-II regular, murmur (-), gallop (-)

8. Physical Examination
• Lung :
Insp : Symmetric
Palp : Stem fremitus R= L
Perc : Sonor
Ausc : Vesicular +/+, ronchi -/-, wheezing -/-
• Abdomen
Insp : Flat
Ausc : Normal bowel sound
Palp : Tender, no liver & spleen enlargement, Epigastric pain (-)
Perc : Timpanic, shifting dullness (-)
• Extr : warm, CRT <2 secs, edema -/-
• RT : not evaluated

9. CHEST RADIOGRAPH

11. RONTGEN INTERPRETATION
Rontgen components Interpretation
Identity, Name, Diagnosis Same
Side Marker (right/left) Correct
Film Type
(AP/PA/Lateral/Erect)
Posteroanterior (PA)
Film Quality:
• Adequate Inspiration?
• Thoracal vertebrae?
• Clavicula and Sternum
symetric in middle
Adequate
Adequate
Symetric
Tube/Cable Yes
Cor + CTR Enlargement 61% shape and size
Pulmo (Trachea position,
bronchi, hilar, vascular
pattern, infiltrate, cavity,
fibrosis, nodul, Pleural
thickening
Perihilar haziness in both lungs

12. RONTGEN INTERPRETATION
Rontgen components Interpretation
Soft tissue and Bone
• Neck, supraclavicula,
axilla, chest, mammae,
upper abdomen, gastric
gas, shoulder joint,
scapula, clavicula,
vertebrae, costae, and
sternum
Normal
Diaphragma Normal
Mediastinum (Shape,
diapraghm height, free air,
tenting, elevation,
Flattening)
Normal
Sinus phrenicocostalis right and left blunt
CONCLUSION : cardiomegaly, early lung edema, bilateral minimal pleural effusion

13. Lab Result
29/6/2022
• Anti HCV non reactive
• Anti HIV non reactive
• HbsAg reactive
6/7/2022
• WBC 6.3
• Erythrocyte 3.01
• Hemoglobin 8.7
• Hematokrit 25.1
• platelet 176
• Ureum Serum 107
• Creatinine Serum 4.3
• eGFR 12
25/7/2022
• HbeAg negative

14. Fibroscan (03-08-2022)
• SO/F3-F4

15. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
1. Hepatitis B Monitoring vital sign/8 hours
Check HBV DNA
Diagnostic

17. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
2. CKD 5 ND ec HNS Monitoring vital sign/8 hours
Monitoring urine output/24 hours
Report nephrology division
Diagnostic

21. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
3. CHF fc II-III ec HHD Report to cardiology division Diagnostic

26. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
4. hypertension Monitoring vital sign / 8 hours
Irbesartan 300 mg/24 hours PO
Amlodipin 10 mg/24 hours PO
Bisoprolol 2.5 mg/24 hours PO
Furosemide 40 mg/24 hours PO
BP < 140/90 mmHg

31. Care Plan
no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
5. Dyslipidemia Simvastatin 20 mg/24 hours PO LDL <150 mg/dl

33. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
6. Hyperuricemia Alopurinol 100 mg/24 hours PO Uric acid <6
Care Plan

37. Conclusion
• Has been reported the case of a 55-year-old woman who
was admitted to R. D. Kandou Hospital at D Rose Ward
with the chief complaint of the patient entered from Poly
Hepatology for a DNA HBV check plan. After a thorough
history-taking, physical examination, and laboratory-
radiology workup, patient was diagnosed with Hepatitis
B, CKD 5 ND ec HNS, CHF FC II-III ec HHD, Hypertension,
Dyslipidemia Hyperuricemia and Anemia ec chronic
disease

38. Prognosis
• Ad vitam: dubia ad bonam
• Ad functionam: dubia ad bonam
• Ad sanationam: dubia ad bonam