MORNING REPORT Sunday (February 3rd 2024)

Duty Junior on ER : dr. Juned


Duty Junior on Ward : dr. Moris, dr. Sadil, dr. Puji

Duty senior on ER : dr. Diana

 Duty senior on Ward : dr. Jusman, dr.Mila

Duty Chief : dr. Rasi

Supervisor : dr. Arif Santoso, Sp.P(K), Ph.D, FAPSR

 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
 accompanied by

ANAMNESIS Tuesday | August 14, 2012

Mrs. Hasnawati/1131837 / 25-5-1973 (50 yo)

• Chief complain : shortness of breath

• Auto-anamnesis:
Patient referred from Lamaddukkelleng Sengkang Hospital with
suspected right lung mass + right pleural effusion. Chief
complaint occasional shortness of breath since 17 days ago,
decrease if lying on right side. Not affected by activity and
weather. No previous history of shortness of breath. Cough with
yellowish white sputum since 17 days ago. No history of cough.
No coughing up blood. No history of coughing up blood. Chest
pain around the chest tube insertion site. No history of chest
pain. Occasional fever since 1 day ago, no history of fever. No
nausea and vomiting. History of heartburn. Good appetite, no
weight loss. No night sweats without activity. Defecation and
urination within normal limits.
ANAMNESIS Tuesday | August 14, 2012

• No history of ATD consumption.

• No history of contact with TB patients.
• No history of HT, DM, heart disease, kidney disease.
• No history of malignancy in family
• No history of confirmed covid-19.
• History of passive smoking from her husband, for 20 years, 16 cigarettes per day
(IB Score = 320, moderate smoker)
• Occupation housewife
• Domicile in Sengkang
• History of treated at Lamaddukkelleng Hospital for 10 days get therapy
Cefoperazone 1 gr/12 hour/IV (H3), ketorolac 30 mg/8 hours/IV, Solvinex/8
hours/IV, Omeprazole 40 mg/24 hours/IV, Paracetamol 500 mg/8 hours/Oral.
• Chest tube inserted by surgeon on 25-01-2024 and the production was 300 cc
and flowed every 4 hours (200 cc) xerohemorrhagic
PHYSICAL EXAMINATION

Moderate Ilness /composmentis / GCS Thorax :

Inspection: Asymmetrical, right hemithorax lagging
E4M6V5
when static and dynamic, Chest Tube inserted at
Weight : ICS VI right hemithorax
Height : Palpation: Decreased tactil fremitus at basal right
BMI : hemithorax
Percussion: Dullness at ICS VI – basal right
hemithorax
SpO2 97% via room air Auscultation: Bronchovesiculer, decreased breath
sounds at ICS VI – basal posterior right hemithorax.
BP : 101/78 mmHg No ronchi and no wheezing
HR : 88 times/min Cor : heart sound I/II regular, no murmur.
RR : 21 times/min
T : 36.7 Celcius Abdomen : Flat, peristaltic normal, tenderness at
VAS – right hypochondria
hepatic and splenic enlargement not palpable.

Head : Normocephal, conjunctiva pale, Extremities : Warm extremities, crt < 2 sec, no
sclera icteric edema
Neck : No lymph node enlargement,
trachea midline
LABORATORY
24-01-2024
LAB 27-01-2024 Normal Range
(Lamaddukelleng)

WBC 10,3 4.00-10.00

HB 15 12.00-16.00
Platelet 310 150-400
Neutrophil/Lympochyte 52.0-75.0 / 20.0-40.0
Got/Gpt 26/23 <38/<41
Na/K/Cl 135/3.8/97 135-145/3.5-5.1/97-111
Ur/Cr 17 / 0,8 10-50L <1,3 P<1,1
GDS 164 140
LED 32
HbsAg NR Negative
HIV NR Negative
CT/BT 6/3
TCM MTB not MTB not detected
detected
Radiology Thorax X-Ray

24-1-2023 30-1-2023
(Wahidin Hospital) (Wahidin Hospital)
ANALYSIS
No Assessment Planning Therapy Monitoring
Diagnosis
1. Massive Right Pleural Effusion on WSD H.10 ecausa - Chest X-ray - According to Monitor clinical and
suspected malignancy - Check pleural histopathologi vital sign
fluid analysis cal result
S: and cytology - Pleurodesis
Occasional shortness of breath since 17 days ago,
decrease if lying on right side. Cough with yellowish
white sputum since 17 days ago. Chest pain around
the chest tube insertion site.
O:
Thorax:
Inspection: Asymmetrical, right hemithorax lagging
when static and dynamic, Chest Tube inserted at ICS
VI right hemithorax
Palpation: Decreased tactil fremitus at basal right
hemithorax
Percussion: Dullness at ICS VI – basal right
hemithorax
Auscultation: Bronchovesiculer, decreased breath
sounds at ICS VI – basal posterior right hemithorax.
No ronchi and no wheezing

WSD production:
4/2/24 : 200 cc, seroxantcrom, undulation -, bubble -

CXR 24/01/2024 Wahidin Sudirohusodo Hospital

Massive pleural effusion dextra
ANALYSIS
No Assessment Planning Diagnosis Therapy Monitoring

2. Suspected right lung mass - MSCT Thorax scan According to Monitor clinical and
with contrast histopathological vital sign
S: - Bronchoscopy result
History of passive smoking from her husband, for 20
years, 16 cigarettes per day (IB Score = 320,
moderate smoker)

O:
Head : Pale of conjunctiva, Sclera icteric

Inspection: Asymmetrical, right hemithorax lagging

when static and dynamic, Chest Tube inserted at ICS
VI right hemithorax
Palpation: Decreased tactil fremitus at basal right
hemithorax
Percussion: Dullness at ICS VI – basal right
hemithorax
Auscultation: Bronchovesiculer, decreased breath
sounds at ICS VI – basal posterior right hemithorax.
No ronchi and no wheezing
THANK YOU