MORNING REPORT

C1
A 61 year-old male was admitted to R.D. Kandou
Hospital at C1 ward on 25 February 2018

With main complaint:

Abdominal pain
 Patient’s identity
Name : Mr HS
Age : 61 yrs
Sex : Male
Occupation : Entrepreneur
Education : Senior High School
Ethnicity : Minahasa
Religion : Christian
 Present Medical History
• Patient came with pain in his abdomen since 5 day b.a.
the pain didn’t radiate and tend to happen all day long at
the epigastric region. Patient also felt nauseous and
losing his appetite to eat, and also vomit since 5 days
before admission, for 1-2 times per day, consist of food
and liquid that the patient took, for 100-200 ml per
vomit.
• Patient deny any black tarry stool, blood vomiting, fever,
and complaint in defecating and urinating.
 Past Medical History
• Patient also told that he just knew his disease
unexpectedly on 2018 January, and started to take
hepatitis B drug routinely since 2018 April until now.
Patient deny any hepatitis risk factor such as changing
sexual partner, blood transfusion, or using needle from
the other -> patient took propranolol, lansoprazole, and
entecavir
• History of diabetes, hyperuricemia, and hypertension
denied by the patient
 Family History
• None experienced the same illness
 Comprehensive geriatric assessment
• Functional: independent , can do daily
activities on his own
• Cognitive: patient can remember date, day,
month, and country
• Nutrition: patient can eat and swallow
• Psychoafective: no depression or manic
• Polypharmacy: routinely take some
medication
 ADL

Mengendalikan rangsang BAB 2

Mengendalikan rangsang BAK 2
Membersihkan diri (seka,sisir,skt gigi) 1
P(g)n WC[in/out,lepas/pakai celana,siram] 2
Makan 2
Transfer 3
Mobilisasi = ambulasi 3
Mengenakan pakaian 2
Naik turun anak tangga 2
Mandi 1

20 : Mandiri
12-19 : Ketergantungan ringan
9-11 : Ketergantungan sedang
5- 8 : Ketergantungan berat
0- 4 : Ketergantungan total
 Mini Mental State Examination (MMSE)

MMSE

ORIENTASI [thn,bln,tgl,hari,musim,negara,
propinsi,kota,RS,ruang apa] 10
REGISTRASI [3 obyek, sebut ulang] 3
ATENSI+KALKULASI [100-7/mesra] 5
RECALL [sebut ulang 3 obyek] 3
BAHASA ; EKSEKUTIF
Tunjuk 2 benda 2
‘Tanpa, bila, dan atau tetapi’ 1
‘Ambil kertas dgn tangan kanan,
lipat dua, letakkan di meja. 3
Read and do it: MOHON PEJAMKAN
MATA IBU/BPK 1
Tulis 1 kalimat 1
Gambar 2 buah segi-5 1
Mini Nutritional Assessment (MNA)

11
Norton Risk Scale

4
4
4
4
4
History of allergy :
Unknown

History of immunization :
Unknown

Habit history :
Alkoholism (+) 1 glass since 30 years ago, only
once or twice a week
Smoking (-)
 Physical Examination
• GC: Severe ill . Sens : CM
• C1 :BP: 110/80mmHg, PR 82x/m, RR 18x/m, T 36.7 ºC spo2
97%
• ER :BP: 120/70mmHg, PR 88x/m, RR 20x/m, T 36.8 C spo2
97%
• BW 50 kg, BH 155 cm, BMI 20,8 kg/m2
• Head : conj. anemic (-), scl. icteric(-)
• Neck : JVP 5+0 cmH20, lymph nodes enlargement (-)
• Thorax :
• Heart :
– Insp : IC not visible
– Palp : IC palpable
– Perc : left border: ICS V midclavicularis sinistra
right border: ICS IV parasternalis dextra
– Ausc : SI-II regular, murmur (-), gallop (-)
 Physical examination
• Lung : Insp : Symmetric R = L
Palp : stem fremitus R = L
Perc : sonor +/+
Ausc : vesicular + /+ , ronchi -/-,
wheezing -/-
• Abd :
Insp : Convex, spider naevi (-)
Palp : H/L don’t palpated, pain on epigastrium (+)
Perc : Shifting dullness (+)
Ausc : Bowel sound (+)

• Waist : Pain on CVA exam (-/-)

• Extr : warm, eritema palmaris (-), edema (-/-), tophi -/-,
CRT < 2”
Genital : not evaluated (no complain)

Rektum : normal
Rectal touche: TSA strong, blood -, faeces -, ampulla
empty

Melenic stool -

Neurology : normal
 Lab Result
• Leucocyte 11300 Combur
• Erythrocyte 2.4
• Hb 8.4 Leucocyte -
• Ht 23.7 Protein +1
• Platelet 44000 Urobilinogen –
• MCH 35 Bilirubin –
• MCHC 35.4 Blood –
• MCV 98.8 Nitrite –
• Ureum 174 Ketone –
• Creatinine 3.9 Glucose –
• Na 130
• K 5,4 eGFR : 16,8
• Cl 107
 Rontgen INTERPRETATION
Roentgen Componen Interpretation
Identity Same
KV Normal
Symmetric Symmetric
Trachea Middle
Diaphragma Normal
Sinus Costophrenicus sharp
Sinus Cardiophrenicus Sharp
Bone Intact
COR - CTR 8.7/18.7 = 46,5%
Pulmo Parenchym Normal
CONCLUSION : normal
 ECG INTERPRETATION
ECG components Interpretation Value
Rhytm Sinus rhythm Sinus rhytm
Speed / HR (times/mnt) 60x/mnt 1500/R-R’
Axis Normal Normal / RAD / LAD
Morphology P wave Normal Lead II : Duration ≤0.10”, Height ≤2.5”
PR Interval 0.20” 0,12” – 0,20”
Pathologic Q Absent Absent / Present
QRS complex duration 0.10” 0,05” – 0,11”``
QRS complex morphology Normal Q duration <0,04”
QRS complex amplitudo Normal Depth <1/3 R wave
ST segmen Elevated Normal / Elevated / Depressed
T wave Normal Normal / abnormal
QT Interval 0.2” cQT = QT interval / vR-R’ Interval
U wave Not appear Appear / not appear
CONCLUSION : sinus rhtym, HR 75x/m
Score , CPC:
 Assessment
• Decompensated hepatic cirrhosis ec Chronic
hepatitis B
• CKD 4 ec hepatorenal syndrome
• Hepatitis B on treatment
• Anemia ec chronic disease dd renal
• Hyponatremia
• Hyperkalemia
• Pro evaluation thrombocytopenia
 Care Plan

Pharmacology and Non

No Problem List Pharmacology Outcome
Intervention
Spironolactone, furosemide, Disease compensated
1. Hepatic cirrhosis
propranolol, entecavir or controlled
2. CKD st 4 Treat the etiology Creatinine decreased
4. Hyperkalemia Kalitake K < 5.3
5. Hyponatremia Salt diet Na > 135
6. Anemia PRC transfusion Hb > 9
HBsAg -, HbEAg -, HBV
7. Hepatitis B Entecavir
DNA -
8. Thrombocytopenia Blood smear Diagnostic outcome
 Planning Diagnosa
• Billirubin direct, indirect, total
• Albumin, Globulin, Total protein
• Ascites fluid punction and analysis
• PTT, APTT, INR
• HbSAg
• Blood smear
 Pharmacotherapy
• Venflon
• Spironolakton 1x25 mg po
• Furosemide 20 mg 1-0-0 iv
• Propanolol 2x10 mg po
• Folic acid 2x0,4 mg po
• Ranitidine 2 x 50 mg iv
• Metoklopramide 3x10 mg iv
• Kalitake 3x1 sachet po
• Entecavir 1 x 0,5 mg po
• Lactulosa 1x15 ml po
 Non Pharmacotherapy

– Diet sirosis
• low natrium
– Diet for ascites
• Bed rest
• Low natrium 90 mmol or 5.2 g/day
• Check body weight and measure abdominal
circumference everyday
 Conclusion
A 61 year-old male was admitted to R.D. Kandou Hospital at
C1 ward on 25 February 2018, With main complaint:
Nausea and vomiting. After taking anamnesis, physical
examination, and laboratory, patient diagnosed with:
– Decompensated hepatic cirrhosis ec Chronic hepatitis B
– CKD 4 ec hepatorenal syndrome
– Hepatitis B on treatment
– Anemia ec chronic disease dd renal
– Hyponatremia
– Hyperkalemia
– Pro evaluation thrombocytopenia
 Prognosis
• Ad Vitam : Dubia ad malam
• Ad Functionam : Dubia ad malam
• Ad Sanationam : Dubia ad malam
Thank you
Thank You