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 Initial Diagnosis Planning Ward

Identity: P2 / Mrs. N/ 85 y.o Emergency Planning Diagnosis: ER

- - Swab RT-PCR Nasooropahring
Primary survey : SARCOV-2
Circulation: warm, Airway: spontan, Breathing: spontan
Urgency
- Planning Therapy :
Secondary survey : - High calorie high protein Diet
Chief complaint : Epigastric pain 1800 kkal/day
- The patient complained about Epigastric pain since 7 days ago, worsened Non Urgency - Rehydration 500 cc NaCl 0,9%,
since 1 day before admission. Nausea vomiting (-), diarrhea (-) 1. Probable case
- She also complained decrease of appetite, she eats 3 times a day, only 3-4 continued, IVFD NaCl 0,9% 1500
pneumonia covid-19 cc/24hours
spoons per meal since 1 week ago. moderate degree (J12.9)
- Shortness of breath (-), cough (-), fever (-) - IV Omeprazole 1x40 mg  PO
- History of taking herbs or NSAID (-) 2. Epigastric pain (R10.13) Omeprazole 2x 20mg
- HT (-) since more than 20 years ago, routinely consume amlodipine      2.1 GI manifestation of - PO Favipiravir 2x1600mg continue
5mg/day. DM (-) covid-19 2x600mg
- History of contact with a COVID-19 patient (-)      2.2 Acute gastritis - PO Amlodipin 1x5mg
- History of Covid19 Vaccine (-) 3. HT on treatment (I10) - PO NAC 3x200mg
4. Azotemia (R79.89) dt - PO Vit D 1x5000 IU
Objective : looked moderate ill, GCS 456; BP: 137/71 mmHg; HR: 75 bpm; - PO Zinc 3x20mg
RR: 20 bpm; T: 36,2°C; SpO2: 96% RA, VAS 3/10 with provocation volume depletion
5. Geriatric problem(R54) - PO Sucralfat 3x15ml
BB: 45kg, TB : 155 cm, BMI: 18,73 kg/m2 - The patient and family refuse to
H/N : conj anemic (-), icteric sclera (-), Pulmo : Ves/Ves, Rh (-), Cor: ictus (infection, innanition,
palpable at ICS IV, MCL S; Abdomen : flat, LS 10 cm, BS(+)N, epigastric immobility) be hospitalized  Discharge, plan
tenderness (+), Extremities : edema (-), warm acral (+) to self isolation and control to
Incovit Clinic
Barthel Index 40 point (partially dependent), MNA 8 (at risk of malnutrition)
Planning Monitoring:
Laboratory Finding 17/8/2021 - S, VS
DL: 12,8/7330/38,2/283.000; DC: 0,8/0,1/77,6/15/6,5%; NLR: 5,16;
ALC: 1100; PPT: 10(11,7)/22,6(25,8)/0,96; RBS: 108 mg/dl; Ur/Cr: 131,9/1,6
mg/dl; eGFR: 29,2, BUN/Cr: 38,5 (pre renal), Na/K/Cl: 130/4,66/111 mmol/L,
Swab antigen SARSCOV-2: Negative
CXR: Pneumonia typical Viral
 PROBLEM ORIENTED MEDICAL RECORD
Problem List and
Cue and Clue Planning
Initial Diagnosis
P1/ Mrs. P/ 61 yo Emergency: Planning Diagnose
Primary survey :
1. DOC dt hypoxic - UL,
encephalopathy - Swab RT PCR H1
Circulation: warm, Airway: patent Breathing: spontan, tachypneu 2. Respiratory failure type 1
Secondary survey : with moderate ARDS (J96.0) Planning therapy
Urgency:
Chief complaint: gradual decrease of consciousness 3. Confirmed case pneumonia - Bed Rest, prone position
- Patient are brough to the incovit ER by her family because eof gradual decrease of covid-19 critical ill (U07.1) - O2 via NIV maintained SpO2 >95%
consciousness since afternoon, before her complaint arise, she said to have a 4. Hyperglycemia state - insert Cathteter and NGT tube
headache 4.1 type 2 DM with - Fluid diet 6x200 cc
- Shortness of breath worsened since this morning, she didn’t have any prior hyperglycemia (E11.65) - Rehydrate 1000 cc --> IVFD
history of recurrent shortness of breath 4.2 hyperglycenmia in critically WIDAKN2 1500 cc/24 jam
- Cough, fever, and flu-like synptoms are denied ill (R73.9) - Plan for drip rapid acting insulin 0,1
- She had a decrease of apetite since 2 days ago, only ate about ½ portion each IU/kgBW/hour
meal Non Urgency: - IV Dexamethasone 1x 6 mg
- DM are denied, first degree relative with diabetes are denied, classic diabetes -
- IV Vitamin C 3x 400 mg
symptoms are denied,
- History of contact with positive covid-19 patient (-), history of vaccination for sars - Remdesivir 1x200 mg (H1) —>
cov-19 (-) 1x100 mg (H2-H5)
Objective: Looked severely ill, GCS: 2-1-2; BP: 120/70 PR:100 bpm RR;32 tpm, Tax: - PerNGT Vitamin D 1 x 5000 iu
36.5 C; *SaO2; 20% RA 100% NIV* ; qSOFA: 2 - perNGT Colcihcine loading 1.5 mg,
Physical examination (positive findings): within normal limit continue with 0.5 mg 1 hour after
Laboratory findings (17/08/21) CBC: 14.80/12.170/44.50%/164.000 —> 2x0.5 mg  (H2-H15)
PPT/APTT/INR: 10.30/25.40/0.99 seconds; Fibrinogen: 534.8 mg/dL, D-dimer: 0.76 - SC Lovenox 2x 0.6 cc
mg/L FEU; Bil T/D/I: 0.52/0.43/0.09 mg/DL, OT/PT: 78/37 U/L; Albumin: 3.33 - Anesthesiology consultation for ICU
mg/dL,RBS: 340; HbA1C: 13.00%; Ur/Cr: 51.2/1.06 mg/dL, CRP: 9.46 mg/dL, admission
procalcitonin: 0.38 ng/mL; Ferritin: 1915 ng/mL, IL6: 184.50 pg/mL (nomal value: <7
pg/mL); Na/K/Cl: 131/4.32/105 mmol/L Planning monitoring
BGA 17/08/21: - S, VS,SPO2, 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) ,anion gap: 17.0, albumin corrected delta gap:
5.0 meQ, albumin corrected delta ratio: 0.4
conclusion: uncompensated metabolic acidosis, with normal anion GAP
Swab rapid antigen 17/08/21 positive
CXR 17/08/2021: pneumonia typical viral