MORNING REPORT November 10th 2022

Duty 1st on Ward : dr. Anni, dr. Cesar , dr. Gunawan


 Duty 1st on ER : dr. Amirah

 Duty 2nd
on Ward : dr. Esti , dr. Dedi

Duty 2nd on ER : dr. Joko

Duty chief : dr. Devi

DPJP : Dr. dr. Irawati Djaharuddin, 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

•Ny. Rahmatia/15-5-1974/984528
•Chief Complaint : shortness of breath
The patient came in with complaints of shortness of breath since last night.
Shortness of breath affected by activity. History of shortness of breath since
the last 1 month that intermitten worsening are active. Cough with white
phlegm since 2 days ago. No coughing up blood and no history of coughing
up blood. Chest pain intermitten since 6 months ago. Sleeps with 2-3
pillows. And tired easily even with light activity. Fever , No history of fever.
No anosmia and ageusia. No swallowing pain, hoarseness. No nausea and
vomiting. Heartburn. Weight loss has been 6 in the last 2 months.
Defecation and urination within normal limits.
ANAMNESIS Tuesday | August 14, 2012

- No history of consumption of ATD.

- No contact history of TB patients.
- History of DM there 4 months ago but not routine control.
- No history of HT, CHD, kidney disorders- No smoking history
- History of malignancy, sister with a thyroid tumor.
- No history of the covid 19 vaccine.
- Confirmed history of covid 19 exists, 1 month ago.
- IRT
- Domicile in Sinjai
- History of giving birth and breastfeeding 1 child for 6 months, and using 3-month injectable birth control
for 2 years.
- History of being diagnosed with a mammary tumor 7 months ago and 4 cycles of chemotherapy for 4
months.
- History of discharge from the lungs and excreted as much as 800cc month 5, 900cc, 1100cc, 1010 cc and
1010 cc month 11.
 Physical Examination
Moderate Pain/Compos mentis/ Normoweight Thorax (Erect position, from anterior)
• Inspection: asymmetris, left hemitorax lag when static and
Weight: kg Height: cm BMI:kg/m2 dinamic,
SpO2 : 98% with 2 lpm via nasal canul • Palpation : Tactile fremitus decreased in the ICS 2-basal left
hemitoraks
SpO2 : 94% without modality • Percussion : dullness in the ICS 2-basal of left hemithorax
BP : 140/90 mmhg • Auscultation : bronchovesicular, no ronchi, no wheezing,
decreased of breath sound in ICS 2- basal left hemitorax
Pulse : 90 times/minute
Breathing : 24 times/minute Cor : Heart sound I and II are regular, no murmur
Temperature : 36,5 Celcius
Abdomen : Flat, bowel sound is normal, hepar and lien are
Head: normocephalic, no pale of conjunctiva, no not palpable.
icteric sclera
Neck: palpable 2 enlarged supraclavicular glands on Extremity : Acral is warm, there is edema on the left hand
the left with a diameter of 2 cm, the trachea is in the since 5 months ago, there is tenderness.
midline
 LABORATORY FINDING
LAB 15-12-2022 16-12-2022 Normal Range BCG 16-12-2022
pH 7,580
WBC 8,8 8,4 4.00-10.00
HB 12,2 11,8 12.00-16.00 So2 99,5
Platelet 320 333 150-400 PO2 191,7
Neutrophil 76,1 78,8 52.0-75.0
PCO2 35,9
Lympochyte 8,2 9,9 20.0-40.0
HCO3 34
GDS 119 136 140
SGOT/SGPT 24/13 30/19 <38/<41 BE 11,9
Ur/Cr 27/0,68 25/0,58 Ur 10-50/ Cr <1.3 Lactat Blood 1,4
Albumin 3,8 3.5-5.00
Old FiO2
Na/K/Cl 141/4.0/104 132/23,8/97 135-145/3.5-5.1/97-
111 New FiO2
PT/INR/APTT 9.9/0.91/27.3 10,5/0,97/26,7 10-14
-- Conclusion
22.0-33.0

HbsAg/anti HCV NR NR
Total protein 6,2 210-425
LDH 6.6-8.7
 LABORATORY FINDING
BCG 10-12-2022
Pleural Fluid Analysis 10-12-2022
pH
Volume
Color
BJ
Rivaltas Test
Leucocyte
Leucocyte amount
LDH Lights criteria:
Glocose
Result :
Protein Total
 LABORATORY FINDING
CYTOLOGY PLEURAL FLUID 17-11-22
Inflammatory lesion, no malignant cells

CYTOLOGY PLEURAL FLUID 28-10-22

Smears Contain Malignant Cells
(Carcinoma)
Radiology Chest X ray

18-11-2022 07-12-2022
Radiology Chest X ray

16-12-2022
 ANALYSIS
No Assesment Planning Diagnose Therapy Monitoring
1. Left pleural effusion ecausa - Smear gram and culture of pleural fluid - Chest tube WSD evaluation (production,
susp malignancy - AFB, Gene Xpert, and culture MTB of color, bubble, fistel)
pleural fluid
Macroscopis : - Pleuroscopy
- Pleural fluid citology

Microscopis :
- pH
- MN PMN %
- Glocose

Ro thoraks 07-12-22
Left pleural effusion

2. Left Mammae cancer - MSCT Scan thorax with Contrast Monitoring general condition
- Tumour marker (CEA, B-HCG) and vital sign
 ANALYSIS
No Assesment Planning Diagnose Therapy Monitoring

3. Cancer Pain 3/10 • MST 10 mg/12 hours orally Monitoring chest pain
• Paracetamol 500 mg/8 hours/ Orally
s/ Chest pain is on the left
intermitten
TERIMA KASIH