PROGRAM STUDI PENDIDIKAN SPESIALIS

ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA

VISI
Menjadi Institusi Program Pendidikan Dokter Spesialis Ilmu Penyakit Dalam
terkemuka yang mampu memenuhi kebutuhan kesehatan masyarakat bertaraf
internasional tahun 2020

MISI
1. Menciptakan tatakelola Program Pendidikan Dokter Spesialis IImu Penyakit
Dalam yang baik melalui penataan dan perbaikan manajemen yang
berkesinambungan
2. Menyelenggarakan pendidikan, penelitian dan pengabdian masyarakat di
bidang IPD sesuai perkembangan IPTEKDOK yang memenuhi kebutuhan
kesehatan masyarakat luas
3. Menghasilkan Iulusan dengan standard kompetensi internasional pada tahun
2020
RESUME
Admission Discharge MedCon Pass away Remaining Total
2 0 0 0 0 0

Admission
Discharge
Medcon
Pass away
Remaining

100%
 PROBLEM ORIENTED MEDICAL RECORD
Cue and Clue Problem List and Planning War
Initial Diagnosis d
Identity: P1 Incovit/ Mrs. HH/ 67 y.o Emergency Planning Diagnosis: ER
Primary survey : Circulation: warm, Airway: patent; Breathing: Tachypnoea 1. Respiratory Failure -
Secondary survey : Chief complaint : Shortness of breath Type 1 dt No.2
- Patients are referred from Pindad Turen Hospital with complaints of Planning Therapy:
Complain shortness of breath. Shortness of breath are felt since 14 days Urgency - Prone position
before admission which aggravated with light physical activity and felt 2. Septic Condition - O2 JR 15 NRBM lpm
more aggravated day by day. Chief complaints are accompanied with dry 2.1 dt no.3 - Fluid Diet 6x200cc/day, Low Sodium
cough and slight fever 14 days before admission. She also felt ageusia and 3. Confirmed Pneumonia <2 gr/ day, Extra Protein
COVID-19 Critically Ill - IVFD NS 500 cc/24 Hour+Kabivent
eugesia since 13 days before admission. Degree concomitan with 1440cc/24 hour
- HPI: Patients Suffered for hypertension for more than 10 years with the secondary infection - IV Drip NAC 5 gr/24 Hour
highest tension of 140-150mmHg, and regularly take amlodipine 1x10mg - IV Drip Vit C 400 mg + NS 100 cc/8
and furosemide 1x40 mg. Non-Urgency hour
- History of Exposed to Confirmed Patients Covid (-), Vaccine Sarcov-2 3. HT st II - IV Dexamethasone 2x6 mg (H1)
History (-), SWAB RT PCR (+) 4. Moderate - IV Azitromisin 1x500mg (H1-5)
- HIS: She is a widow who lives alone due her sons are already married and Hypoalbuminemia - PO Captropil 3x25mg
lived with their family 4.1 Hypercatabolic State - PO Amlodipin 1x10mg
Objective: GA: Looked Severely Ill, GCS: 224 BP: 174/110 mmHg, N: 120x/m 5. Geriatric problems - PO Vit D 1x5000 IU
RR: 38 x/m, T: 36,3C SpO2: 65% RA --> 89% on JR 15 lpm BW: 70 kg, BH: 156 (Infection) - PO Zinc 3x20 mg
cm, BMI: 29 (Obesity class I), Geneva score: 11 (risk VTE), Padua score: 6 - PO Favipiravir 2x1600mg (D1) ->
(high), Physical Examination wasn’t performed, Barthel Index: 8 Favipiravir 2x600 mg (D2-5)
(independent), Clinical Frailty score: 4 (very mild Frailty), SOFA Score 5 (33% - PO Colchisine 1,5mg loading dose _>
Mortality) 1hour 0,5 mg -> 2x0,5mg (H2-14)
Laboratorium 5/9/2021: CBC: 14,2/24.000/41,1%/237.000uL DC: - SC Enoxaparine 2x0,6 cc
0,8/0,2/82,7/12,3/4% TLC: 2.950 cell/uL NLR: 6,74 Blood Type: A+ FH: - Plasma Convalence Therapy
12,4(10,3)/25,3(23,8)/1,21 Fibrinogen: 489,2mg/dL, D-Dimer: 2,55 mg/L 200cc/D1-2 as accordingly blood
OT/PT: 52/20 U/L, Albumin: 2,88 g/dL GDS: 150 mg/dL, Ur/Cr: 65,4 mg/dL, type
- Consult to Anestesiology
0,86 mg/dL SE: 136/3,72/104 mmol/L IL-6: 231,5 pg/mL CRP: 11,49, Department for Intensive Care:
Procalsitonin: 2,56 ng/mL Patien will be admission in ICU,
BGA on JR: Respiratory Failure Type 1 (Severe ARD) pH 7,31/ pCO2 37,1/ pO2 patient will performed intubation if
51,2/ HCO3 18,8/ BE -7,7/ Sat O2 82,4%/ pf ratio: 53 (Severe ARDS) family were consent
Swab Nasooropharingeal Antigen Sarcov-2 (24/08/2021): Positive,
CXR 5/9/2021: Pneumonia typical e.c virus, Cardiomegaly Planning Monitoring:
S, VS, SpO2, BGA/6 hours, Swab RT-PCR
Covid19 D10

References:
Panduan Tatalaksana
Covid-19
CXR