MORNING REPORT August 7th 2022

 Duty 1st on Ward : dr. dr , dr

 Duty 1st on ER : dr.

Duty 2nd on Ward : dr. . dr.

Duty 2 nd
on ER : dr.

Duty chief : dr.

DPJP : dr. Nurjannah Lihawa, 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
ANAMNESIS Tuesday | August 14, 2012

Tn. Muh. Saleh/8-5-1976/987648

Chief Complaint : Cough
The patient was transferred from Interna with a lung tumor, the
complaint coughing since 2 weeks ago,white mucus, tno coughing
up blood, no history of coughing up blood. Chest pain when
coughing. No shortness of breath, no history of shortness of breath.
No fever, history of fever this morning. Weakness since 1 day ago.
No nausea and vomiting, no anosmia, no ageusia. Hoarse voice. No
pain swallowing. No nausea or vomiting. Weight loss there is not
known how many kilograms. No night sweats without activity.
Weakness in both legs since 4 months ago, beginning with pain in
the spine. defecation can not be felt, Defecation within normal
limits.
ANAMNESIS Tuesday | August 14, 2012

- History of ADT has existed since 10 months (negative sputum results) stopped since
11 months because the patient's wife felt the patient was nauseous and short of
breath after taking ADT.
- No history of contact with TB patients
- No History of DM, heart and kidney disease
- History of high blood pressure, no regular treatment
- Smoking history for 30 years, 1 pack per day (IB 480 , moderate smoker)
- No family history of malignancy
- No history of contact with positive cov19 patients
- No history of COVID-19 vaccination
- Labor job
- Makassar domicile
 PHYSICAL EXAMINATION
O/ Thorax : (supine, anterior)
Moderate Illness/composmentis /normoweight Inspection: symmetrical when static and dynamic
Weight : BMI : Palpation: tactile fremitus the same on both hemithorax
Height : cm Percussion: sonor in both hemithorax
SpO2 88 % without modality Auscultation: bronchovesicular, rhonki on the left
SpO2 96 % with modality 2lpm via NK (medial) hemithorax and no wheezing
BP : 140/90 mmHg
HR : 98 times/minute Abdomen: flat,hepar and lien not palpable, normal
RR : 24 times/minute, (Abdominalthoracal) peristaltic
T : 36.8 ° C
Extremities: Warm acral, CRT <2 sec, no pretibial
Head: normocephal, no pale conjunctiva, no edema
yellowish sclera
Neck: no lymphnodes enlargement, midline
trachea
 LABORATORY FINDING
LAB 21-12-2022 Normal Range
Swab Antigen 20- Negative
WBC 7,1 4.000-10.000 12/2022
HB 11,4 12.00-16.00
Platelet 412 150.000-400.000
Neutrophil 85,2 52.0-75.0
Lympochyte 6,5 20.0-40.0
GDS 150 140

SGOT/SGPT 13/7 <38/<41

Ur/Cr 32/0,43 Ur 10-50/ Cr <1.3
Albumin 3.5-5.00
Na/K/Cl 141/4,3/105 135-145/3.5-5.1/97-111

PT/INR/APTT 10,3/0,95/24,6 10-13/25-35/<1.10

HBsAg Non Reactive

Anti HCV Non Reactive

Chest X-Ray
 ANALYSIS
No Assesment Planning Diagnose Therapy Monitoring
1 Righ lung tumor unknown type, • Sputum Citology • According to histopathology result and lung  Clinical symptom
T2bN0M0 stage Min.IIIb PS 3 • Bronchoscopy cancer staging  Vital sign
• TTNA
• MSCT Scan Brain and Bone Survey

Upper motor neuron paraparesis • Consult to neurologi devision  according to neurologi devision  Clinical symptom
 Vital sign

TB spondylitis
 ANALYSIS
No Assesment Planning Diagnose Therapy Monitoring

4. DM Type 2 non Obese  HbA1c  According to Endocrine Division  FBG control

 FBG, Consult to Endocrine division
History of uncontrolled DM
RBG 222mg/dL

5. Normocytic normochromic  Peripheral blood analysis  Transfusion of 1 bag PRC  Check Hb post Transfusion.
anemia ((10-8,8)x55x4 : 264 )

Pale of Conjungtiva
Hb 8,8
MCV 90
MCH 29