MORNING REPORT

Thursday, June 3th 2021

• New Inpatient (Emergency Room) Physicians In Charge :
• Regular :1 • I0 : -
• Incovit :1

• IA : dr. Andrew (REGULAR)

• Consultation dr. Silvy (INCOVIT)
• Emergency Room
• Regular :- • IB : dr. Anthony (REGULAR)
• Incovit :2
• Ward dr. Resti (INCOVIT)
• Regular :1
• Incovit :- • II : dr. Caesar

• Death Case :0 • III : dr. Iin Noor Chozin, Sp.P (K)

 MORNING REPORT
Thursday, June 3th 2021
Internal Medicine Resident Cardiology Resident Radiology Resident
• dr. Caesar • dr. Cik Kahadi dr. Fini
• dr. Ferdinando • dr. Ira Microbiology Resident
• dr. Firdha • dr. Indra -
• dr. Hani
• dr. Pandu
• dr. Wahyu
Referral letter from Wajak Husada Hospital
• IDx: Susp Ca Paru + Efusi
Pleura D + Cancer pain

• PTx:
• IVFD NS + Drip Tramadol 1
amp 20 tpm
• IV Ketorolac 3x30 mg
• IV Ceftriaxone 2x1 gr
• IV Diazepam 3x2mg
 History Taking
Patient ID : Mr. Pitono
Chief complaint: Shortness of Breath

- He has been suffering from shortness of breath since 2 months ago and worsening since 7
days ago. SOB does related with activities. DOE (+), PND (-), Orthopneu (-). He usually sleeps
with 2 pillows (better condition). History of leg edema (-).
-He also experience right side chest pain start from back and radiate to the front since 2
months ago, it come and go, and worsening since 1 week ago
-Other symptoms was neck and right hand become swollen since 2 months, there is no history
of trauma.
- Fever (-), cough (-), bloody cough (-) Flu (-), Sore throat (-), Anosmia (-), Augesia (-), Chest pain (-)
- Decrease of appetite (-), Decrease of body weight (-), Nausea (-), Vomitting (-), Bloated (-)
- Urination and bowel habits are normal
• History of previous disease: HT (-), DM(-), COPD (-), TB (-), CVA (-), Cardiac disease (-), Asthma (-).
• History of family’s disease : His mother was died due to cervix cancer in 2015. HT (-), DM(-), TB (-), CVA
(-), Cardiac disease (-), Asthma (-) .
• History of contact with TB patient : Denied
• History of smoking : Ex smoker (stopped since 3 months ago, previous habbit = 5-6 sticks / day and
only social smoker)
• Risk factor of HIV : Tattoo (-), multipartner sex (-), blood transfusion (-) IVDU (-) Alcohol (-)
• Occupation : As a farmer
• History of travelling : Denied
• H/ of contact w/ Covid-19 patient : Denied
• History of Covid 19 vaccination : Denied
• History of steroid and AB use in 3 months : Denied
• History of disease and treatment :
• At 31th May 2021 his symptoms (SOB and pain) become worsening so that he was brought to Wajak
Hospital. After hospitalized for 3 days, he was referred to Saiful Anwar Hospital for further examination
and evaluation. History of treatment: IVFD NS + Drip Tramadol 1 amp 20 tpm, IV Ketorolac 3x30 mg, IV
Ceftriaxone 2x1 gr, IV Diazepam 3x2mg
 Physical Examinations
• General appearance : Moderate
• Level of consciousness : GCS E4V5M6

• Vital sign
BP : 134/82 HR : 102 bpm
RR : 23 x/m SpO2: 92% on RA  99% on 3 lpm NC
Temp : 36.8 W = 60 kg, H= 165 cm --> BMI = 22.0

• Head : Normocephal
• Neck : JVP R+4 cm H2O, distended (+)
• Thorax: Cor
‐ Insp : Ictus cordis invisible
‐ Palp : Palpable at ICS VI
‐ Ausc : S1/S2 regular, Murmur (-), gallop (-), muffled sound (-)
 Thorax Physical Examinations

Insp : - Statis D>S

- Dynamic D<S
Use of assesoris muscle - Breathing type : thoraco abdominal Ausc : Breath sound
(ant / post) Ant Post

Palp : SF Ant Post ⬇️ v v ⬇️

Decrease Normal Normal Decrease ⬇️ v v ⬇️

Decrease Normal Normal Decrease ⬇️ v v ⬇️

Decrease Normal Normal Decrease Rhonki Ant Post

Perc : Ant Post - - - -

Dull Sonor Sonor Dull - - - -

Dull Sonor Sonor Dull - - - -

Dull Sonor Sonor Dull Wheezing Ant Post

- - - -

- - - -

- - - -
Abdomen : Soefl, epigastric pain (-), bowel sound (+)
Extremity : Edema +-/--
 Laboratory Finding - 1

Laboratories Wajak 31/05/2021 RSSA 3/6/21 Value

Hb 14.1 10.4 /µL 11,4 – 15,1

WBC 9780 19760 g/dL 4.700 – 11,300

Hematocrite 44.3% 31.8% % 38 – 42

PLT 293000 267000 /µL 142.000 – 424.000

MCV 72.8 fL 80 – 93

MCH 23.2 Pg 27 – 31

MCHC 31.9 g% 32 – 36

Eosinophil 0.1 % 0–4

Basophil 0.1 % 0–1

Neutrophil 82 87.4 % 51 – 67

Lymphocyte 12.8 5.0 % 25 – 33

Monocyte 5.1 7.4 % 2–5

 Laboratory Finding - 2

RSSA 3/6/21
Laboratories Wajak 31/05/2021 Value

RBS 122 115 <200

Ureum 37.1 29.9 mg/dL 16,6-48,5
Creatinine 1.3 0.81 mg/dL < 1,2
SGOT 32.6 19 U/L 0 – 40
SGPT 27.9 31 U/L 0 – 41
Albumin 3.57 2.99 g/dL 3,5 – 5,5
CEA 2.86 Ng/mL <5
Procalcitonin 0.58 Ng/mL <0.5
LDH 236 U/L 135-225
CRP 21.95 Ng/mL <10
Lactic acid 1.5 Mmol/L <2
Bil Total
2.90 mg/dL <1

Bil Direct 2.42 mg/dL < 0,25

Bil Indirect 0.48 mg/dL < 0,75

 Laboratory Finding - 3
Laboratories Wajak 31/05/2021 Value

Swab PCR Sars Cov 2 - Negative

Rapid Test Antigen Negative

Antibody IgG & IgM Non Reactive

 Laboratories RSSA 3/6/21 Value

Total protein 2.15 g/dl <3

Glucose 2 Mg/dl >60

LDH 773 IU/L Transudate <320 U/L, exudate >320 IU/L

Pleural analyze -
Macroscopic

Warna Merah
Bekuan Negatif

Kejernihan Sangat keruh

Microscopic

Eritrosit 534000
WBC 2956
PMN cell 40%
MN cell 60%
 CXR 31/05/2021 in Wajak
AP position, Asymetric

• Soft tissue : Normal

• Bones : - Costae D: Normal

S: Normal

- ICS D: Normal

S: Normal
• Hillus : D : Dte
S : normal

• Trachea : Normal

• Cor : - Site : Pushed to the left

- Size : Dte

- Shape : Dte

• Hemidiaphragma : D: Dte

S: Domeshape

• Costophrenicus angle : D: Dull

S: Sharp

• Pulmo : D: Homogenous Opacity in all area upper to lower (+),

fibrotic (-), cavity (-)

Conclusion: S: Infiltrate (-), fibrotic (-), cavity (-)

Pleural Effusion D Massive
 CXR 03/06/2021 in RSSA
AP position, Asymetric

• Soft tissue : Normal

• Bones : - Costae D: Normal

S: Normal

- ICS D: Normal

S: Normal
• Hillus : D : Dte
S : normal

• Trachea : Deviated to the left

• Cor : - Site : Pushed to the left

- Size : Dte

- Shape : Dte

• Hemidiaphragma : D: Dte

S: Domeshape

• Costophrenicus angle : D: Dull

S: Sharp

• Pulmo : D: Homogenous Opacity in all area upper to lower (+),

fibrotic (-), cavity (-)

Conclusion: S: Infiltrate (-), fibrotic (-), cavity (-)

Pleural Effusion D Massive
CXR Lateral D
• Summary:
• Pleural Effusion D
 CXR Comparison
CXR 31/05/2021 in Wajak CXR 03/06/2021 in RSSA

Worsening
USG Abdomen in Wajak Hospital 31/5/21
USG Abdomen on site

Loculated Pleural effusion Proof Punctie + 10 cc serohemorrhagic

 RSSA BGA 3-6-2021

BGA with O2 3 lpm NC 00.36 3 lpm NC

pH 7,46 7.35-7.45 Fi02 0,32
pCO2 29,8 mmHg 35-45 PaO2 target 100
pO2 68 mmHg 80-100 PAO2 actual ((760-47)*0,32)-(29,8x1,25)
Original PO2
HCO3 21,5 mmol/L 21-28 190,91
BE -2,6 44,625 mmol/L -3 - +3 A-a DO2 122,91
Moderate
Sat O2 93,8 % > 95
Hypoxemia PAO2 target 280,75
FiO2 needed 0,446002805

Before Oxygen Therapy After Oxygen Theraphy FIO2 needed

• Severe Hypoxemia Alcalosis Respiratoric Uncompensated • 44%  4-5 lpm NC
Hypocarbia
 Internal Validity of BGA

[H+] = 24(PaCO2)
           [HCO3-]
= 24(29,8)
[21,5]
= 33.26

pH 7.46
BGA is consistent

7.50 30
 ECG 3/6/2021

• Sinus ritem HR 115bpm, FA nomal, HA CWR, P

wave nomarl, QRS 80ms, ST-T Changes (-)
• Kes. Sinus tachicardia, Clockwise rotation
SOFA SCORE

Total SOFA
SCORE : 4
 LDH Pleura : Serum = 773:236 = 3.27

LDH Pleura fluid >2/3 upper limit normal (N=320)

 ASSESSMENT
IDx/
1. Lung tumor D T4NxM1A st IVa KS 70-80, Kx Cancer
Pain, Efusi Pleura D, VCSS Gr I
2. Cancer pain vas 4/10
PTx/
3. Pleural Effusion D Loculated
• Oxygenation on 2-4 lpm NC
4. VCSS Gr I
• IVFD NS 12 dpm
5. Hyperbilirubinemia
• Inj Ranitidine 2x50 mg
6. Moderate Hypoalbuminemia
• Inj Furosemide 2x20 mg
7. Leucocytosis dt Paraneoplastic syndrome
• Inj Dexamethasone 2x5 mg
• PO PCT 3x500 mg
PDx/ -
• PO Codein 3x10 mg
CT Scan Thorax + Contrast
• PO Vip Albumin 3x2 caps
USG Thorax Pro Marker
• Proof Punctie + 10 cc serohemorrhagic
Citology of Pleural Fluid if sample +
• Pleural fluid evacuation if marker (+)
Citology sputum
FOB/TTNA if possible
 POMR
TPL PPL IDX PDX PTX PMO
1. Mr. P/50/11510352 1. Lung Tumor 1.1 Susp Ca CT Scan Thorax + Confirm diagnose • Clinical features
Bronchogenic D Contrast • Vital sign
History taking T4NxM1A st IVa KS 70- Citology of Pleural Fluid
SOB since 2 months ago, worsening 7 80, Kx Cancer Pain, Efusi if sample +
days Pleura D, VCSS Gr I Citology sputum
Chest pain that radiate from back since 2 FOB/TTNA if possible
months and worsening in 7 days
History of smoking
History of his Mother died et causa 
Cancer cervix
Physical Examination
GA Moderate GCS 456
BP 134/82 mmHg. HR 102 x/minute
RR 24 x/minute. Temp 36.8
SpO2 92% RA  99 % on 3 lpm NC
•Insp : St D > S, Dy D < S, Neck: JVP R+ 4 cm
H20 + distended +
•Palp : SF /N
•Perc : D/S
•Ausc : /V
Laboratory Finding
WBC 19760
Albumine 2.99
CEA 2.86
Analyze Pleural fluid  Exudate
Proof Punction + serohemorrhagic
USG
Pleural effusion complex D
Radiology
Efusi Pleura D massive
 POMR
TPL PPL IDX PDX PTX PMO
2. Mr. P/50/11510352 2. Loculated Pleural 2.1 Susp Lung Tumor D USG Thorax Pro Marker Oxygenation on 2-4 lpm NC • Clinical features
Effusion D T4NxM1A st IVa KS 70- Thoracocentesis • Vital sign
History taking 80, Kx Cancer Pain, Efusi Proof punctie was Done Treat underlying disease
SOB since 2 months ago, worsening 7 Pleura D, VCSS Gr I Pleural effusion fluid
days analysis (done) Confirm diagnose
Chest pain that radiate from back since 2
months and worsening in 7 days
History of smoking
History of his Mother died et causa 
Cancer cervix
Physical Examination
GA Moderate GCS 456
BP 134/82 mmHg. HR 102 x/minute
RR 24 x/minute. Temp 36.8
SpO2 92% RA  99 % on 3 lpm NC
•Insp : St D > S, Dy D < S, Neck: JVP R+ 4 cm
H20 + distended +
•Palp : SF /N
•Perc : D/S
•Ausc : /V
Laboratory Finding
WBC 19760
Albumine 2.99
CEA 2.86
Analyze Pleural fluid  Exudate
Proof Punction + serohemorrhagic
BGA: Alcalosis Respiratoric
Uncompensated
USG
Pleural effusion complex D
Radiology
Efusi Pleura D massive
 POMR
TPL PPL IDX PDX PTX PMO
3. Mr. P/50/11510352 3. VCSS 3.1 dt Malignancy CT scan thorax + Oxygenation 2-4 lpm NC • Clinical features
contrast Inj Furosemide 2x20 mg • Vital sign
History taking Inj Dexamethasone 2x5 mg
SOB since 2 months ago, worsening 7
days Radiotherapy if condition
Chest pain that radiate from back since 2 stable
months and worsening in 7 days
neck and right hand become swollen since 2 Confirm diagnose
months, there is no history of trauma.
History of smoking
History of his Mother died et causa 
Cancer cervix

Physical Examination
GA Moderate GCS 456
BP 134/82 mmHg. HR 102 x/minute
RR 24 x/minute. Temp 36.8
SpO2 92% RA  99 % on 3 lpm NC
•Insp : St D > S, Dy D < S, Neck: JVP R+ 4 cm
H20 + distended +
•Palp : SF /N
•Perc : D/S
•Ausc : /V
Laboratory Finding
WBC 19760
Albumine 2.99
CEA 2.86
USG
Pleural effusion complex D
Radiology
Efusi Pleura D massive
 POMR
TPL PPL IDX PDX PTX PMO
4. Mr. P/50/11510352 4. Cancer pain vas 4.1 dt Malignancy CT scan thorax + Oxygenation 2-4 lpm NC • Clinical features
4/10 on tx contrast PO PCT 3x500 mg • Vital sign
History taking PO Codein 3x10 mg
SOB since 2 months ago, worsening 7
days Confirm diagnose
Chest pain that radiate from back since 2
months and worsening in 7 days
neck and right hand become swollen since 2
months, there is no history of trauma.
History of smoking
History of his Mother died et causa 
Cancer cervix

Physical Examination
GA Moderate GCS 456
BP 134/82 mmHg. HR 102 x/minute
RR 24 x/minute. Temp 36.8
SpO2 92% RA  99 % on 3 lpm NC
•Insp : St D > S, Dy D < S, Neck: JVP R+ 4 cm
H20 + distended +
•Palp : SF /N
•Perc : D/S
•Ausc : /V
•Vas 4/10
 POMR
TPL PPL IDX PDX PTX PMO
5. Mr. P/50/11510352 5. Leucocytosis dt 5.1. Susp Lung Tumor D - Treat underlying disease • Clinical features
Paraneoplastic T4NxM1A st IVa KS 70- • Vital sign
History taking syndrome 80, Kx Cancer Pain, Efusi Confirm diagnose • CBC
SOB since 2 months ago, worsening 7 Pleura D, VCSS Gr I
days
Chest pain that radiate from back since 2
months and worsening in 7 days
History of smoking
History of his Mother died et causa 
Cancer cervix

Physical Examination
GA Moderate GCS 456
BP 134/82 mmHg. HR 102 x/minute
RR 24 x/minute. Temp 36.8
SpO2 92% RA  99 % on 3 lpm NC
•Insp : St D > S, Dy D < S, Neck: JVP R+ 4 cm
H20 + distended +
•Palp : SF /N
•Perc : D/S
•Ausc : /V

Laboratory Finding
WBC 19760

USG
Pleural effusion complex D
Radiology
Efusi Pleura D massive
 POMR
TPL PPL IDX PDX PTX PMO
6. Mr. P/50/11510352 6. Hyperbilirubinemia 6.1 Dt susp malignancy - Treat underlying disease • Clinical features
• Vital sign
History taking • Bilirubin level
-

Physical Examination
GA Moderate GCS 456
BP 134/82 mmHg. HR 102 x/minute
RR 24 x/minute. Temp 36.8
SpO2 92% RA  99 % on 3 lpm NC
•Insp : St D > S, Dy D < S
•Palp : SF /N
•Perc : D/S
•Ausc : /V

Laboratory Finding
Bil T/D/I 2.90/2.42/0.48
 POMR
TPL PPL IDX PDX PTX PMO
7. Mr. P/50/11510352 7. Moderate 7.1 Due to Pleural Treat underlying disease • Clinical features
Hypoalbuminemia Effusion Loculated D Vip Albumine 3x2 caps • Vital sign
History taking 7.2 Dt Low intake • Albumin level
SOB since 2 months ago, worsening 7
days
Chest pain that radiate from back since 2
months and worsening in 7 days
History of smoking
History of his Mother died et causa 
Cancer cervix

Laboratory Finding
Albumine 2.99

USG
Pleural effusion complex D

Radiology
Efusi Pleura D massive
 Patient’s Condition This
Morning
S O A P
‐ SOB (+) ‐ GA : Moderate ill 1. Lung tumor D T4NxM1A st IVa PDx:
decrease KS 70-80, Kx Cancer Pain, CT Scan Thorax + Contrast
‐ GCS : E4V5M6 USG Thorax Pro Marker
‐ Chest pain Efusi Pleura D, VCSS Gr II Citology of Pleural Fluid if sample +
decrease ‐ BP : 135/80 mmHg 2. Cancer pain vas 4/10 Citology sputum
‐ Swollen neck + ‐ HR : 90 Bpm 3. Pleural Effusion D Loculated FOB/TTNA if possible
4. VCSS Gr II
‐ RR : 22 x/min 5. Hyperbilirubinemia PMO:
6. Moderate Hypoalbuminemia Lab evaluation / 3 days
‐ Temp : 36C

7. Leucocytosis dt Paraneoplastic PTx:

‐ SpO2 : 99% on 4 lpm NC syndrome Oxygenation on 2-4 lpm NC
‐ Insp ‐ Aus  V IVFD NS 12 dpm
Inj Ranitidine 2x50 mg
Static D>S  V Inj Furosemide 2x20 mg H2
Dynami D<S  V Inj Dexamethasone 2x5 mg H2
PO PCT 3x500 mg
c PO Codein 3x10 mg
‐ Palp  N Rh - - PO Vip Albumin 3x2 caps
SF Pleural fluid evacuation if marker (+)

 N - -
 N - -
‐ Perc D S Wh - -
D S - -
D - -
-- Thank You --