MORNING REPORT August 28th 2022

 Duty 1st on Ward: dr. Farma, dr. Muti, dr. Diana

 Duty 1st on ER : dr. Cesar, dr Yusuf
Duty 2nd on Ward : dr. , dr.

Duty 2 nd
on ER : dr.

Duty chief : dr.

DPJP : Dr.dr. Nur Ahmad Tabri,Sp.PD, K-P, Sp.P (K)

 VISI DAN MISI
PROGRAM STUDI PULMONOLOGI DAN
KEDOKTERAN RESPIRASI
VISI

Menjadi pusat Pendidikan, penelitian dan pelayanan

Pulmonologi dan Kedokteran Respirasi yang
menghasilkan lulusan Dokter Spesialis Pulmonologi
yang berjiwa Maritim (Manusiawi, Arif, Religius,
Integritas, Tangguh, Inovatif, dan Mandiri) berkualitas,
professional dan kompeten pada tahun 2023.
 VISI DAN MISI
PROGRAM STUDI PULMONOLOGI DAN
KEDOKTERAN RESPIRASI
MISI

1. Menyelenggarakan Pendidikan berbasis pelayanan dan evidence based di bidang

Pulmonologi dan Kedokteran Respirasi melalui pendekatan budaya MARITIM secara
paripurna dan bermutu
2. Mengembangkan ilmu dan penelitian bidang Pulmonologi dan Kedokteran Respirasi
yang berkualitas
3. Melaksanakan pelayanan medik dan menjadi pusat rujukan Kesehatan Paru dan
Kedokteran Respirasi di Kawasan Timur Indonesia melalui pengembangan sumber daya
manusia, sarana dan prasarana
4. Memegang teguh profesionalisme, etika dan moralitas pada setiap langkah
pengembangan keilmuan dan pelayanan medik
 ANAMNESIS Tuesday | August 14, 2012

Santoso/9-4-1972/961573

Chief Complaint : Chest pain

The patient complaint of chest pain since 4 months ago, pain was felt at
the former WSD site (late February WSD, March miniWSD, and April
aff WSD). Shortness of breath since 2 years ago, influenced by activity
but not affected by the weather. Cough with white phlegm, history of old
cough since 6 months ago. Coughing up blood today there are spots,
history of coughing up blood 6 months ago. No fever, no history of fever.
No night sweats with activity. No headaches, no smell and taste
disturbances, no sore throat. Nausea and vomiting every time eat since
this morning. decrease in appetite,weight loss but it is not known how
many kilograms. defecation and urination within normal limits
ANAMNESIS Tuesday | August 14, 2012

• History of TB, consumption of ATD from 13-11-2021 to 03-01-2022, the patient

stopped taking OAT because he felt that his complaints were getting worse while
taking ATD
• No history of contact with TB patient
• History of being treated at RSWS January 2022, diagnosed as Left Lung
Adenocarcinoma, Type Wild Type T4N3M1C stage IV B PS 2, already in the 4th
cycle of chemotherapy
• No history of DM, hypertension, heart disease and kidney disease.
• No family history of malignancy
• History of smoking there for 30 years, 2 packs per day
• History of cooking using firewood 20 years
• No history of contact with Covid-19 patients
• No history of the Covid-19 vaccine
• History of Confirmed covid 19 month 1 2022 isman
• Domicile wesabbe, Makassar
PHYSICAL EXAMINATION

O : Moderate illness/Compos mentis/Normoweight Thorax (Supine, Anterior):

I : asymmetry, left hemithorax left lagging
Weight Kg statically and dynamically. WSD installation
scar visible on left hemithorax lumpy, size
Height Cm
2x1 cm, not tender, color like surrounding
IMT kg/m2 skin, immobile, hard surface palpable, border
not firm,
SpO2 : 95% room air P : Tactile fremitus decreased at apex-basal
BP 180/90 mmHg of left hemithorax
HR 140 times/min P : Dullness at left hemithorax, ICS II-basal
RR 22 times/min (thoraco-abdominal) A :Bronchovesicular, decreased of breath
T 36.7 C sound at apex-basal of left hemithorax, no
rhonki and wheezing.
Head : Normocephal
Eyes : No pale conjunctiva, No icteric sclera Heart : Regular, pure heart sound I/II
Abdomen: increased of peristaltic sound, hepar
and lien not palpable
Neck : enlarged lymph node in a single left colli, the
color is like the surrounding skin, not tender,
singular, immobile, firm boundaries, the trachea Extremities: warm, no edema
seems to deviate to the right
 LABORATORY FINDING
LAB 14-12-22 16-12-22 Normal Range BGA

WBC 9,3 10,9 4.00-10.00

pH
HB 11 11,7 12.00-16.00
SO2
Platelet 299 317 150-400
Neutrophil 59,2 53,4 52.0-75.0
PO2

Lympochyte 28,2 34,5 20.0-40.0 PCO2

GDS 88 148 HCO3

Ur/Cr 34/0,85 26/0,92 Ur 10-50/ Cr <1.3

BE
Old FiO2
SGOT/PT 11/10 11/9 SGOT <38/SGPT<41
New FiO2
Albumin 3,7 3,7 3.5-5.00
Na/K/Cl 140/4,3 142/4,2 135-145/3.5-5.1/97-111

Tcm sputum Tcm sputum

HbsAg non reaktif non reaktif 18.8.2022 4.7.2022
Not detected Not detected
Radiology
klinis
ECG
cytology
 ANALYSIS
No Assesment Planning Diagnose Therapy Monitoring

1. Adenocarsinoma Paru Sinistra  Khemoterapi adjuvant  Clinical and vital sign

Jenis Wild Type T4N3M1C stage
IVB PS 1 post kemoterapi siklus
ke-6
s/ chest pain, shortness of breath
o/ cytology : Non-small Cell Lung Carcinoma due
to adenocarcinoma
Hystopathology : Non-small Cell Lung
Carcinoma due to adenocarcinoma
2. - Cancer pain VAS 5/10
 MST 10mg/12 ho /oral  Clinical and vital sign
 Blood routine
s/chest pain since 4 months ago, pain was felt at  paracetamol 500 mg / 8 ho/ oral
the former WSD site (late February WSD, March
miniWSD, and April aff WSD).

3. Hemoptisis non masif ecausa malignancy

 Adona drips  Monitoring of hemoptisis

S/Coughing up blood today there are spots,  N acetyl cysteine 200 mg / 8 ho/
history of coughing up blood 6 months ago. oral
 ANALYSIS
No Assesment Planning Diagnose Therapy Monitoring

6. - Syndrome dyspepsia  Injeksi ranitidin 50 mg / 12 ho/ iv

 Injeksi metoklopramid 10 mg
extra iv

6. - multiple kista hepar  Check albumin post

correction