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.
15. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
1. Hepatitis B Monitoring vital sign/8 hours
Check HBV DNA
Diagnostic
16.
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
18.
19.
20.
21. no Problem list Pharmacological and Non
Pharmacological Intervention
Output and Outcome
3. CHF fc II-III ec HHD Report to cardiology division Diagnostic
22.
23.
24.
25.
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
27.
28.
29.
30.
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
32.
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
34.
35.
36.
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