MORNING REPORT Wednesday, Dec, 27th 2023

Duty Junior on ER : dr. Kiki

 Duty Junior on Ward : dr. Igha, dr.Moris, dr.Cipto
 Duty senior on ER : dr. Cesar

 Duty senior on Ward : dr. Mega, dr. Andika

 Duty Chief : dr. Joko

Supervisor : 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
 accompanied by

CONSULT Tuesday | August 14, 2012

 accompanied by

ANAMNESIS Tuesday | August 14, 2012

Sangkala Ruddin/1106048/07-01-1947/77 years old

Chief complain : Shortness of breath
Allo-anamnesis/Auto-anamnesis:
Patients consulted from Interna division with complaints
shortness of breath since 2 weeks worsened 1 week ago. No
history shortness of breath. Occasionally cough with white
phlegm since 2 weeks ago, history of chronic coughing 1 year ago.
No coughing up blood, no history coughing up blood. No chest
pain, no history of chest pain. No fever, no history of fever. No
nausea and vomiting. No abdominal pain. Decreased appetite,
Weight loss of 5kg over the past 2 months. Night sweats without
activity. Defecation and urination within normal limit,
ANAMNESIS Tuesday | August 14, 2012

• No history of ATD consumption

• No history of contact with TB patients
• History of Hypertension since last 1 year, no treatment
• No history of diabetes, heart d, kidney disease, liver disease.
• History of smoking, 16 cigarettes/day for 20 years (IB 320, moderate smoker)
• History of Alcohol consumption
• History of covid 19 vaccine, two times
• History of covid does not exist
• Occupation as retiree
• Domicile in Pangkep
• History of being treated at Batara siang Hospital in Pangkep for 7 days with
therapy:
PHYSICAL EXAMINATION
Moderate illness / Compos mentis /
E4M6V5/ BW: 47kg BH: cm BMI:
SpO2: 94% without modality
Sp02: 98% via Nasal cannula 3 lpm
Blood Pressure: 160/84 mmHg
Pulse: 80 beats/minute
Breathing: 22 beats/minute
Temperature: 36.5 degrees Celsius
APE 100
Eyes: No pale of conjunctiva, no icteric
sclera.
Neck: midline trachea, no lymph node
enlargement.
Thorax: (erect, anterior)
Inspection: Symmetrical on static and
dynamic
Palpation: Tactile fremitus Same both
hemithorax
PercussionSonor both hemithorax
Auscultation: Bronchovesicular, Rhonki
and Wheezing absent.
Abdomen: Flat, with breath. There is no
tenderness, lien and hepar not palpable
Extremities: no edema, warm acral.
LABORATORY
LAB Batara Siang Hospital Nor-mal Range
(27-12-23)

WBC 5,2 4.00-10.00

HB 11,3 12.00-16.00
MCV/MCH 93/27 80-97/ 26,5-33,5/31,5-35,0

Platelet 243 150-400

Neutrophil 66,1 52.0-75.0
Lympochyte 24,4 20.0-40.0
GDS 100 140
SGOT/SGPT 30/14 <38/<41
Ur/Cr 56/1,9 Ur 10-50/ Cr <1.3

Albumin - 3.5-5.00
Na/K/Cl - 135-145/3.5-5.1/97-111

TCM sputum 27/12/2023

MTb detected, Rifamfisin sensitive
Radiology ECG
Radiology ECG
Radiology Chest X- Ray

Chest X- Ray …-12-2023

…. Hospital
 ANALYSIS
No Assessment Planning Diagnosis Therapy Monitoring

1. Acute COPD exacerbation mild-moderate degree, • Check AGD and • O2 via Nasal Cannula • Clinical
in group A COPD blood lactate 3 lpm observation and
S: • Spirometry • Combivent vital signs
Cough with white mucus since 2 days ago. History 1respul/8hrs/Inhalatio
of chronic cough 2 months ago. history of fever 10 n
days ago
O:
SpO2: 94% without modality
Sp02: 98% via Nasal cannula 3 lpm
Blood Pressure: 160/84 mmHg
Breathing: 22 beats/minute

Thorax: (erect, anterior)

Inspection: Symmetrical on static and dynamic
Palpation: Tactile fremitus Same both hemithorax
PercussionSonor both hemithorax
Auscultation: Bronchovesicular, Rhonki and
Wheezing absent.
 ANALYSIS
No Assessment Planning Diagnosis Therapy Monitoring
2. New Case Pulmonary Tuberculosis bacteriologically • MTb culture check, • 4KDT OAT • Monitoring
confirmed, HIV status unknown. OAT sensitivity, 1st 3tabs/24hrs/Oral vital and
S: line LPA • N-Acetylcysteine Clinical signs
Cough with white mucus since 2 days ago. History of 200mg/8hrs/Oral
chronic cough 2 months ago. history of fever 10 days
ago.Decreased appetite, Weight loss of 5kg over the
past 2 months. Night sweats without activity.

O:
TCM sputum 27/12/2023
MTb detected, Rifamfisin sensitive
3. Acute Kidney Injury dd CKD • Ureum and creatinine • Rehydration fluid • Monitoring
S: control NaCl 0.9% 1000cc vital and
O: Clinical signs
Laboratiry 27/12/23
Ur/Cr 56/1,9

4. Grade II Hypertension • Amlodipine • Monitoring

S: 10mg/24hours/Oral vital and
History of Hypertension since last 1 year, no treatment Clinical signs

O:
Blood Pressure: 160/84 mmHg
THANK YOU