MORNING REPORT Juni 23th 2022

Duty Junior on ER : dr.


Duty Junior on Ward : dr.

Duty senior on ER : dr.

 Duty senior on Ward : dr.

Duty Chief : dr.

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
 ANAMNESA Tuesday | August 14, 2012

•Sigit Isvaldi/13-01-2003/986191

• Chief Complaint : shortness of breath

• The patient was referred from Lagaligo Hospital with complaints of shortness of
breath since the last 1 week, shortness of breath is not affected by activity and
weather, the patient cannot lie down and can only sit. There was no previous history
of shortness of breath. there is a cough that has been experienced since 1 month ago,
cough is not accompanied by mucus, no history of long cough, no coughing up blood,
no history of coughing up blood, no chest pain, no history of chest pain, no fever,
history of fever there 1 day ago. No headaches. No nausea, no vomiting. No Ageusia
and anosmia. Night sweats without activity are non-existent. Good appetite, no
weight loss. Urinate and defecate within normal limits.
ANAMNESIS Tuesday | August 14, 2012

-There is no History of OAT

-There is no contact history of TB patients
-There is no history of HT, DM, kidney disease and heart disease
-There is no history of smoking
-History of covid-19 vaccine 3 times
-There is no confirmed history of covid-19
-There is no history of malignancy in the family
- History of being treated at Gorontalo Hospital since 5 days ago then referred
to Wahidin Hospital
- Work as a Student
- Domicile Gorontalo
• There was no history of taking anti-tuberculosis drugs.
• No history of contact with tuberculosis patients.
• No confirmed history of Covid-19
• Vaccine history there are 2 doses.
• No family history of malignancy
• No history of hypertension.
• No history of diabetes mellitus.
• No history of heart or kidney disease
• History of smoking for 10 years 10 cigarettes per day (IB: 100 light smokers)
• Domiciled in East Luwu
• Contractor Work
• History of being treated at Lagaligo Hospital for 3 days.
PHYSICAL EXAMINATION
 Moderate pain/compost mentis
 Weight : 52 kg Height :160 cm
 Spo2 93% without modality
 Spo2 97% with modality 02 4 lmp via nasal cannula
 BP :100/70 mmhg HR : 100 x/minute
 RR : 27 x/minute Temperature : 36,7 C
 Head: normocephal
 Eyes : no pale conjunctiva, no yellow sclera
 Neck: palpable enlarged lymph nodes in bilateral supraclavicular, and bilateral axilla, JVS + 4 cm
 Thorax: (Supine, anterior)
 Inspection: Asymmetry when static and dynamic, left hemithorax left impression, there is a
lump measuring 6x6 cm on the left hemithorax
 Palpation: tactile fremitus decreases in the left hemithorax at the level of the apex-basal
 Percussion: dullness in left hemithorax at Apex-Basal level
 Auscultation: vesicular, decreased breath sounds in the left hemithorax, no Rhonki and
Wheezing
 Cor : BJ I/II Pure Regular, no murmur.
 Abdomen: normal, peristalsis normal impression, no palpable enlargement of the liver and spleen.
 Extremities: warm acral, no pretibial edema.
• Neck: palpable enlarged lymph nodes in bilateral supraclavicular, and bilateral
axilla, JVS + 4 cm

• Thorax: (Supine, anterior)

• Inspection: Asymmetry when static and dynamic, left hemithorax left
impression, there is a lump measuring 6x6 cm on the left hemithorax
• Palpation: tactile fremitus decreases in the left hemithorax at the level of the
apex-basal
• Percussion: dullness in left hemithorax at Apex-Basal level
• Auscultation: vesicular, decreased breath sounds in the left hemithorax, Rhonki
and Wheezing absent