MORNING REPORT Saturday, Dec, 23rd 2023

Duty Junior on ER : dr. Isra

 Duty Junior on Ward : dr. Anjar, dr. Fadli, dr. Yusma
 Duty senior on ER : dr. Anni

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

 Duty Chief : dr. Esti

Supervisor : dr. Arif Santoso, Sp.P(K) Ph.D FAPSR

 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

Andi maulida nur saffanah/1083799/14-4-2005 (18 yo)

Chief complain : Shortness of breath

Allo-anamnesis/Auto-anamnesis:
Patient reffered from hermina hospital with complaints of shortness of
breath since 1 day ago, shortness of breath not affected by activity and
weather. Patient feels comfortable when sitting. History of shortness of
breath 1 month ago for 2 days. Cough since 2 months ago, especially at
night and lying. No Coughing up blood, no history of coughing up
blood. Occasionally chest pain since 1 month ago, not radiate. No
fever, no history of fever, no hoarseness. No nausea and vomiting. No
night sweats without activity. Decreased appetite, weight loss of 1 kg
in 2 months. Defecation and urination within normal limits.
ANAMNESIS Tuesday | August 14, 2012

• No history of ATD consumption

• No history of contact with TB patients
• No history of smoking, no history of passive smoking
• No history of HT, Diabetes mellitus, heart disease and kidney disease
• No history of malignancy in family
• Occupation as medical student
• Domicile in Makassar
• History of hospitalized at RSWS on 29/11/2023 until 8/12/2023 with
diagnosed tumor mediastinum anterior + left pleural effussion. Installed
pigtail on 1/12/2023. Evaluated 4400 cc, serous hemoragik.
• History of hospitalized at Hermina hospital 23/12/2023 with oxygenation
therapy and referral to Wahidin hospital.
PHYSICAL EXAMINATION

Moderate illness / Compos mentis / Thorax: (erect, anterior)

E4M6V5/ Underweight Inspection: Asymmetric lagging of left
BW: 42kg BH 155 BMI: 17,48 hemithorax when static and dynamic. No
venectation. Pigtail insertion at ICS V left
SpO2 95% without modality hemithorax
SpO2 99% with NC 3 lpm Palpation: Decreased tactile fremitus on
Blood Pressure: 113/66 mmHg left hemithorax
Pulse Rate: 92 times/min Percussion: Dullness on ICS III-basal left
Breathing: 22 times/min hemithorax
Temperature: 36,7 C Auscultation: Broncovesicular, decreased
breath sound on left hemithorax, no
Eyes: no pale of conjunctiva, no icteric ronchi and no wheezing.
sclera.
Abdomen: Flat, with breath. There is no
Neck: midline trachea, no lymph node tenderness.
enlargement.
Extremities: no edema, warm palpable
acral.
LABORATORY
LAB 24-12-2023 Normal Range BGA BGA Normal Range
WS Hospital (24-12-2023)
WS Hospital
WBC 7.8 4.00-10.00

HB 10.9 12.00-16.00 PH 7,35 7.35-7.45

SO2 99,7 95-98

Platelet 526 150-400
PO2 204,6 80-100
Neutrophil 76.0 52.0-75.0
PCO2 29,7 35-45
Lympochyte 4.6 20.0-40.0
HCO3 16,5 22-26
GDS 120 140
BE -9,4 -2 s/d +2
SGOT/SGPT 32/15 <38/<41
Acid lactat 10,8 0.6-1.5
Ur/Cr 28/0,87 Ur 10-50/ Cr <1.3 Former Fio2 0,28
(NC 2lpm)
Na/K/Cl 136/3.6/100 135-145/3.5-5.1/97-
111
New Fio2 0,16

Procalcitonin 0,05 <0,05 Conclusion Fully

compensated
Anti-HIV NR NR metabolic
acydosis
LABORATORY Pleural fluid analysis
Pleural Fluid (WS Hospital)
Cytology 08/12/2023

Macroscopic 4 slides and 21 cc of reddish yellow rinse liquid were received, 4 slides were made.

Microscopic Smear, stain and rinse preparations consist of squamous epithelial cells, ciliated cylindrical epithelial cells against a
background of erythrocytes, lymphocyte cells and netrophils. No malignant cells were found in these preparations
Conclusion No malignant cells

Pleural Fluid (WS Hospital) Normal Range

Analysis 24/12/2023
Volume 57 1-10

Color reddish brown Clear

SG 1.025 < 1.08

pH 7,5 7.60 – 7.64

Clothing Positive Negative

Rivalta test Positive Negative

Leukocytes count 640 < 200

Types of Leukocytes PMN 28%; MN 72% 60 -70%

count Mononucleus

LDH 13711 100-190

Glucose 3130 <200 Light Criteria (Exudate)

LDH Pleural fluid > 2/3 upper level of LDH serum
Protein total 4270 <3000

Conclussion Exudate
Histopathology December 6th , 2023
Sitology December 6th, 2023
Histopathology December 8th , 2023
Sitology December 8th, 2023
Histopathology December 21st, 2023
ECG December 24st, 2023
Bronchoscopy December 6th, 2023

Conclusion:
• The primary carina is obtuse. Right and
left secondary carina are obtuse.
• The left main bronchus orificium is
partially closed, there is compression
narrowing the left main bronchus mouth
from anterior and posterior directions,
the infiltrated mucosa bleeds easily.
• The orifices of the left upper and lower
lobes are narrowed. Impression of
malignancy.
• Corresponding to a mediastinal tumor,
suggestive of infiltration into the left
main bronchus.
Radiology Chest X- Ray

28-11-2023 24-12-2023
(Wahidin Hospital) (Wahidin Hospital)
Radiology MSCT Thorax With Contrast

04-12-2023
(Wahidin Hospital)
 ANALYSIS
No Assessment Planning Therapy Monitoring
Diagnosis
1. Thymoma type A T3N0MO stage IIIa PS1 • Bone survey • According to Clinical
X-ray thymoma staging observation and
S: • Brain CT-scan (Extende thymo- vital signs
• shortness of breath thymecthomy and
• history of shortness of breath since 25 days ago for 2 days Extended resection
• Cough since 2 months ago continiously
• Chest pain since 1 month ago radiotherapy and
• Decreased appetite, weight loss of 1 kg in 2 months. chemotherapy)
O:
SpO2 95% without modality
SpO2 99% with NC 3 lpm
Pulse Rate: 92times/min
Breathing: 22 times/min

Thorax: (erect, anterior)

Inspection: Asymmetric lagging of left hemithorax when static and
dynamic. No venectation. Pigtail insertion at ICS V left hemithorax
Palpation: Decreased tactile fremitus on left hemithorax
Percussion: Dullness on ICS III-basal left hemithorax
Auscultation: Broncovesicular, decreased breath sound on left
hemithorax, no ronchi and no wheezing.

MSCT scan (4-12-2023, Wahidin hospital):

- Anterior mediastinal mass suspected of Lymphoma DD/
Thymoma, resulting in compressive atelectasis of the inferior
lobe of the left lung

Hystopatology 19/12/2023
Thymoma
 ANALYSIS
No Assessment Planning Diagnosis Therapy Monitoring
2 Left Pleural Effussion ecausa malignancy on • Installed pigtail (done) Clinical observation and
pigtail D24 • pleurodesis vital signs

S:
• shortness of breath
• history of shortness of breath since 25 days ago
for 2 days

O:
SpO2 95% without modality
SpO2 99% with NC 3 lpm
Pulse Rate: 92 times/min
Breathing: 22 times/min

Thorax: (erect, anterior)

Inspection: Asymmetric lagging of left hemithorax
when static and dynamic. No venectation. Pigtail
insertion at ICS V left hemithorax
Palpation: Decreased tactile fremitus on left
hemithorax
Percussion: Dullness on ICS III-basal left
hemithorax
Auscultation: Broncovesicular, decreased breath
sound on left hemithorax, no ronchi and no
wheezing.

Chest XRAy 28-11-2023 Hermina Hospital :

Left pelural effussion
 ANALYSIS
No Assessment Planning Diagnosis Therapy Monitoring
3. Pericardial Effusion • Consult to BTKV • According to BTKV Clinical observation and
S: division division vital signs
• shortness of breath
• history of shortness of breath since 25 days ago for 2
days
O:
SpO2 95% without modality
SpO2 99% with NC 3 lpm
Pulse Rate: 92 times/min
Breathing: 22 times/min

Thorax: (erect, anterior)

Inspection: Asymmetric lagging of left hemithorax when
static and dynamic. No venectation. Pigtail insertion at
ICS V left hemithorax
Palpation: Decreased tactile fremitus on left hemithorax
Percussion: Dullness on ICS III-basal left hemithorax
Auscultation: Broncovesicular, decreased breath sound
on left hemithorax, no ronchi and no wheezing.

Chest XRAy 28-11-2023 Hermina Hospital :

Left pelural effussion

MSCT scan (4-12-2023, Wahidin hospital):

Mild pericard effusion
THANK YOU