MORNING REPORT Sunday, January 24th, 2024

Duty Junior on ER : dr. Yusuf

 Duty Junior on Ward : dr. Nurhikmah, dr. Yusma, dr. Igha
 Duty senior on ER : dr. Ema

 Duty senior on Ward : dr. Farma, dr. Mute

 Duty Chief : dr. Anti

Supervisor : Dr. dr. Harun Iskandar, 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
 accompanied by

ANAMNESIS Tuesday | August 14, 2012

Megawati/1-7-1977/46/82824

Chief complain : Left upper back pain

Auto-anamnesis : Patient referred from Bulukumba Hospital with
diagnosis of left lung tumor. Patients with complaints of left upper
back pain since 3 years ago, worsening since last a week. No Cough,
No history of Chronic cough. No Coughing up blood. No History of
coughing up blood. No Shortness of breath, No history of shortness
of breath. No Fever, No history of fever. No Hoarseness. Throat pain
after cov19 antigen swab, No swallowing pain. No Nausea and
vomiting. No Decrease appetite. No Weight loss. No Night sweats
without activity. Defecation is constipation but can flatus, urination
within normal limits.
ANAMNESIS Tuesday | August 14, 2012

•No History of ATD consumption

•history of contact with TB patients (Husband)
•No History of Hypertension, DM and kidney disease
•No history of malignancy
•History of cooking using firewood
•Occupation as a housewife
•Domicile in Bulukumba
•The patient was referred from Bulukumba Hospital with diagnosis of left lung
tumor, received Ceftriaxone 1 gr/12 hours (H5), dexketoprofen iv, hydrocortisone iv,
oral acetyl and oral amlodipine.
PHYSICAL EXAMINATION

Moderate Ilness /composmentis / - / GCS Thorax (Supine Anterior) :

E4M6V5 Inspection: simetrycal when static and dynamic
Weight : Palpation: tactil fremitus same in both hemithorax
Height : Percussion: sonor in both hemithorax
BMI : Auscultation: bronchovesiculer, no ronchi, no
wheezing
SpO2 97% on room air
Cor : heart sound I/II irregular, no murmur.
BP : 168/111 mmHg
HR : 87 times/min Abdomen : flat, normal peristalsis, tenderness (-),
RR : 20 times/min liver and spleen are not palpable
T : 36.8 Celcius
Extremities : Warm extremities, crt < 2 sec, no
Head : Normocephal, no pale of conjunctiva, no edema
sclera icteric
Neck : No lymph node enlargement, trachea
midline
LABORATORY

LAB 15-01-2024 Normal Range

WBC 12,04 4.00-10.00

HB 9,3 12.00-16.00

HCT 29,7 37-48%

Platelet 309 150-400

Neutrophil 67,2 52.0-75.0

Lympochyte 22,3 20.0-40.0

GDS 156 140

Ur/Cr 41/0,9 10-50L <1,3 P<1,1

RMT (23-01-2024) Negative

Radiology CXR Thorax

20-01-2024
(H Andi Sulthan Dg. Radja Hospital)
Radiology CXR Abdomen

19-01-2024
(H Andi Sulthan Dg. Radja Hospital)
 ANALYSIS
No Assessment Planning Diagnosis Therapy Monitoring
1. Multiple Nodules In Lung, Suspected Tumor Metastasis To • MSCT Thorax with Monitoring vital and
Lung Dd/ Primary Left Lung Tumor contrast clinical sign
• Bronchoscopy
S/ left upper back pain since 3 years ago, worsening since last diagnostic
a week. Throat pain after cov19 antigen swab, No swallowing
pain
O/
X-Ray Thorax PA - 20/1/24 - Bulukumba Hospital
- Suspected metastatic tumor to lung dd lung tumor sinistra
- Left pleural effusion

Msct scan thorax without Contras (22-1-24)

- sugestif bronchogenic mass pulmo sinistra dd lesi metastasis

2. Left Pleural Effusion • Thorachosintesis Monitoring vital and

S/ • Analysis and clinical sign
O/ Cytology Pleural
X-Ray Thorax PA 20/1/24 Bulukumba Hospital Effusion
-pleural effusion sinistra

Msct scan thorax without Contras (22-1-24)

- Left Pleural Effusion
 ANALYSIS
No Assessment Planning Diagnosis Therapy Monitoring
3. Chest Pain VAS 3/10 • Observation chest Paracetamol 500 Monitoring vital and
S Left upper back pain pain mg/8h/oral clinical sign
O • Consult
Msct scan thorax without Contras (22-1-24) cardiologist
- Cardiomegaly with aortic atherosclerosis departement

4. Normocytic Normochrome Anemia (9.3) Monitoring vital and

S clinical sign
O
Laboratoium (15-1-2024)
HB : 9.3

5. Cardiac Arrhythmia • ECG According to Monitoring vital and

• Consult cardiologist clinical sign
S: cardiologist department
O: departement
BP : 168/111 mmHg

6. Essential Hypertensions • Consult Amlodipine 10mg/24 Monitoring vital and

cardiologist h/oral clinical sign
S: departement
O:
BP : 168/111 mmHg
THANK YOU