MORNING REPORT June 24th 2022

 Duty 1st on Ward : dr. Atika, dr. Fahrul, dr. Auliah

 Duty 1st on ER : dr. Jusman

Duty 2nd on Ward : dr. Joko, dr. Esti


 Duty 2nd on ER : dr. Mey

Duty chief : dr. Musannif Ziad

DPJP : dr. Arif Santoso, 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

• Prasojo/29-11-1966/985516

• Chief Complaint : shortness of breath

• Referred from Palu. Shortness of breath experienced since 2 weeks

ago, not continuously. Patient feel more comfortable in the sit
position. Shortness of breath is not affected by weather and acitivity.
Chronic cough with white mucus is present since 4 months ago. No
history coughing up blood. No chest pain and no history of chest pain.
No fever, no history of fever. No ageusia and anosmia. There is
nausea, but no vomiting. There is no night sweats without activity.
Appetite decreased, with weightloss about 12 kgs for 3 months
recently. Defecation and urination are within normal limits.
ANAMNESIS HISTORY
Tuesday | August 14, 2012

• No history of ATT consumption, and no history of contact with TB patients

• History of DM since November 2021, takes metformin 500 mg daily
• History of HT, routine take amlodipine 10 mg
• History of routine control with cardiologist, takes furosemide, clopidogrel 75 mg,
miniaspi (ISDN), bisoprolol, atorvastatin daily
• No history of malignancies in the familiy
• No history of smoking and exposed by tobacco smoke
• History usage of fireplace when a child
• Work as Palu TVRI head office
• Domiciled in Palu
• History of admitted at RS Palu for 8 days and get therapy Moxifloxacin 400 mg/24 h
(H-10), Omeprazole 40 mg, Ketorolac 30 mg, and Codein 10 mg
PHYSICAL EXAMINATION
 Moderate pain/compost mentis
 Bb : 78 KG, tb 162 CM
 SpO2 93-94% with5 lpm via nasal canule
 BP :140/90 mmhg HR : 90 x/minute
 RR : 22 x/minute Temperature : 36.7 C
 Head: normosefal, no pale conjunctiva, no yellow sclera
 neck: not palpable enlarged lymph nodes
 Thorax
 I : Asymmetrical, hemithorax dextra lags when static and dynamic
 P: Tactile fremitus decreased on hemithorax dextra region ICS V-basal
 P : Dulness on hemithorax dextra from ICS V to basal
 A: decrease breath sound on hemithorax dextra on ICS V region to basal
 Cor : 1-2 pure regular heart sound, no murmur
 Abdomen: normal peristaltic, not palpable liver and spleen
 Extremities: no pretibial edema, warm acral.
 LABORATORY FINDING at Wahidin
LAB 15-6-2022 20-6-2022 29-6-2022 Normal Swab PCR 29-6-2022
(Bhayangkara (Antapura Range
Palu) Palu) Undetectable DNA-
WBC 14.0 16.9 15.3 4.00-10.00
Sars-CoV-2
HB 13.0 14.2 12.5 12.00-16.00
Platelet 375 350 373 150-400
Normal Range
Neutrophil - 89.4 71.4 52.0-75.0
Lympochyte - 7.7 11.0 20.0-40.0 PH 7,542 7,35-7,45
GDS 128 120 140 SO2 99,4 95-98
Ur/Cr 41/1.61 Ur 10-50/ Cr PO2 188,1 80-100
<1.3
PCO2 36,6 35-45
SGOT/PT 35/37 SGOT
<38/SGPT<4 HCO3 31,7 22-26
1
BE 9,0 -2 to+2
Albumin 3.9 3.5-5.00 interpretatio Alkalosis metabolic
Na/K/Cl 143/4.2/106 135-145/3.5- n partially comensated
5.1/97-111

PT/INR/APTT 10.5/0.97/23 10-

.3 13/1.10/25-
35

HBsAG Non reactive Non reactive

LABORATORY FINDING at Bhayangkara Palu

LAB 15-6-2022 Normal Range

WBC 14.0 4.00-10.00

HB 13.0 12.00-16.00
Platelet 375 150-400
Neutrophil - 52.0-75.0
Lympochyte - 20.0-40.0
GDS 128 140
LABORATORY FINDING at Anutapura Palu
LAB 20-6-2022 Normal Range

WBC 16.9 4.00-10.00

HB 14.2 12.00-16.00
Platelet 350 150-400
Neutrophil 89.4 52.0-75.0
Lympochyte 7.7 20.0-40.0

LAB 22-6-2022 Normal Range

Ur/Cr 63/1.49 Ur 10-50/ Cr <1.3

SGOT/PT 66/25 SGOT <38/SGPT<41

 LABORATORY FINDING

Sputum culture on 14-6-22:

ciprofloxacin resistant
levofloxacin resistant

sensitive : neomycin, tetracycline, erythrommycin,

Cotrimoxazole, Ampicillin
 Pleural fluid analysis

LAB 20-6-2022 Normal Range

Pleural fluid was evacuated from right hemithorax

around 1200 cc Seroxanthochrome
Radiology Chest X-Ray at Palu

(1-2-2022)
Radiology Chest X-Ray

• Right pleural
effusion
• Aortic dilatation
• Mass density is
difficult to
evaluate

(29-6-2022)
Radiology Chest CT Scan

- Suggestive pulmonary dextra tumor accompanied by multiple

bilateral pulmonary nodules and right pleural effusion
- Multiple osteoblastic vertebrae susp bone metastases tumor
- Cardiomegaly with dilatatio et atherosclerosis aortae
Radiology Cranial CT Scan

- Lacunar infarction cerebri sinistra

- Cerebri atrophy
- Maxillary sinusitis dextra

(7-3-2022)
 ANALYSIS

No` Assesment Planning Diagnose Therapy Monitoring

1. Right Lung Tumor MSCT chest scan with contrast - IVFD NaCl 0.9% 20 drops per  Evaluation of
Type (?) T4N3M1b Bronchoscopy minute cancer pain
(meta bone) Stage TTNA/core biopsy - Nacetylcysteine
IVA PS 2 ​200mg/8hour/oral
- Ketorolac 30mg/8h/iv

2. Right pleural • Thoracosintesis with USG • Monitoring

effusion et causa guiding, pleural fluid general condition
malignancy analysis and pleural flyuid and vital sign
cytology
• Nasopharyngeal PCR Swabs

3. Paraneoplastic
syndrome
THANK YOU