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
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and
Cue and Clue Planning
Initial Diagnosis
P1 Incovit/ Mr. A/ 80 yo Emergency: Planning Diagnose
Primary survey : Circulation: warm, Airway: patent Breathing: tachypnea 1. DOC - UL
Secondary survey : 1.1 hypoxic encephalopathy - Swab RT PCR sarscov 2
Chief complaint: gradual decrease of consciousness 1.2 septic encephalopathy
2. Respiratory failure type 1 with Planning therapy
- Patient are referred to the incovit ER because of gradual decrease of moderate ARDS
consciousness since afternoon, before her complaint arise, she said to have a - Bed Rest, prone position
headache Urgency: - O2 via NIV maintained SpO2 >95%
- Shortness of breath worsened since this morning, she didn’t have any prior 3. Probable case pneumonia - Insert Cathteter and NGT tube
history of recurrent shortness of breath covid-19 critical ill - Fluid diet 6x200 cc
- Cough, fever, and flu-like symptoms are denied - IVFD NS 1500 cc/24 jam
- She had a decrease of appetite since 2 days ago, only ate about ½ portion each Non Urgency: - IV Remdesivir 1x200 mg (D1) —>
meal 4. AKI st.2 dt Septic MODS 1x100 mg (D2-5)
- DM (-), HT (-) 5. Geriatric problem ( infection, - IV Levofloxacin 1x750 mg
- History of contact with covid-19 patient (-), history of vaccination covid-19 (-) immobility, innanition) - IV Dexamethasone 1x6 mg
- IV Vitamin C 1x200 mg
Objective: GA: Looked severely ill, GCS: 223; BP: 120/70, PR:100 bpm RR: 32 tpm, T: - PerNGT Vitamin D 1 x 5000 iu
36.5 C; SaO2: 20% RA 100% NIV ; UOP: 0,8cc/kg/h; BW: 60 kg, BH: 160 cm, BMI: - perNGT Zinc 3 x20mg
23,4 kg/m2; qSOFA: 2; IMPROVE score: 4, PADUA score: 5, Barthel Index: 75 - SC Lovenox 2x 0.6 cc
(minimally independent), MNA: 12 (normal nutritional status)
The Physical Examination wasn’t performed - Anesthesiology consultation for ICU
admission
Laboratory (13/09/21): CBC: 14.80/12.170/44.50%/164.000 Planning monitoring
PPT/APTT/INR: 10.30/25.40/0.99; Fibrinogen: 534.8 mg/dL, D-dimer: 0.76 mg/L FEU; S, VS, GCS, SPO2, UOP
OT/PT: 78/37 U/L; Albumin: 3.33 mg/dL, RBS: 340; Ur/Cr: 51.2/1.06 mg/dL, CRP: BGA, Ur/Cr evaluation
9.46 mg/dL, procalcitonin: 0.38 ng/mL; Na/K/Cl: 131/4.32/105 mmol/L
BGA : pH/pCO2/pO2/HCO3/BE/SaO2: 7.33/20.2/119.8/110.7/15.5/97.8%
P/F ratio: 120 mmHg (moderate ARDS) 
Swab antigen 13/09/21: Negative
CXR 13/09/2021: Pleuropneumonia S