MORNING REPORT Monday, Dec, 25th 2023

Duty Junior on ER : dr. Chika

 Duty Junior on Ward : dr. Igha, dr.Anjar, dr.Moris
 Duty senior on ER : dr. Mega

 Duty senior on Ward : dr. Cesar

 Duty Chief : dr. Uci

Supervisor : 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
 accompanied by

ANAMNESIS Tuesday | August 14, 2012

Muhammad Jiding / 712699 / 2-6-192 (61 years old)

Chief complain : Coughing up blood

Allo-anamnesis/Auto-anamnesis:
Referral patient from Tobadak with pulmonary mycosis + massive
hemoptysis. Complaints of coughing up blood since 1 month ago,
worsening 1 week ago, fresh red color and volume of about 1
glass, history of coughing up blood since 2014. No shortness of
breath, no history of shortness of breath. Chest pain, radiated to
the back. History of chest pain. No fever, no history of fever is
absent. No nausea and vomiting. Good appetite. History of weight
loss is 6 kg for 1 month. No history of night sweats without
activity. Defecation and urination within normal limits.
ANAMNESIS Tuesday | August 14, 2012

• History of ATD treatment since 2010 & 2013 (incomplete treatment), Nov 2021 -
2022 (complete treatment for 1 year + 3 months injections)
• No contact history with TB patients
• History of DM since 2004, regular treatment, glimepirid 2mg
• No history of HT, heart and kidney disease
• No family history of malignancy
• History of smoking 3 packs per day for 30 years
• History of cooking with firewood exists for 15 years
• No family history of malignancy
• Occupational history of retired civil servant
• Central mamuju domicile
• History of being treated at the central mamuju hospital on 28/12/2023 for 1 week
with a diagnosis of pulmonary mycosis + massive hemoptysis, can be treated with
tranexamic acid 3x1, cefixime 2x200mg
PHYSICAL EXAMINATION

Moderate Pain / Compos Mentis Thorax: (erect, anterior)

BW: kg BH: cm BMI: Inspection: Symmetrical on static and
dynamic
SpO2 98% without modality Palpation: tactile fremitus is the same on
BP: 128/71 mmHg both hemithorax
N: 100 X/min Percussion: Sonor on both hemithorax
P: 18 X/min Auscultation: Bronchovesicular, no
S: 36.6 C ronchi, no wheezing.

Eyes: no pale of conjunctiva, no icteric Abdomen: convex, increased peristalsis,

sclera. hepar and Lien not palpable.

Neck: midline trachea, no lymph node Extremities: warm acral, pretibial edema.
enlargement.
Radiology ECG
LABORATORY
LAB 23-12-2023 Normal Range
WS Hospital RMT Sputum 3 times 13/1/22
RSWS
WBC 9,5 4.00-10.00
BTA 1 Negative
HB 12,9 12.00-16.00
BTA 2 Negative
Platelet 200 150-400
BTA 3 Negative
Neutrophil 76 52.0-75.0
Lympochyte 13,3 20.0-40.0 Bronchoscopy Chronic inflammation
22/7/21 (RSWS)
GDS 252 140
SGOT/SGPT 16/22 <38/<41
Ur/Cr 21/1,01 Ur 10-50/ Cr <1.3 Anatomic Pathology Inflammatory lesion
Result 22/7/21 (RSWS)
Albumin - 3.5-5.00
Na/K/Cl 134/4.1/100 135-145/3.5-
5.1/97-111
Radiology Chest X- Ray

Chest X- Ray …-…-2023 Chest X- Ray …-…-2023 Chest X- Ray …-…-2023

…..Hospital …..Hospital …..Hospital
 ANALYSIS
No Assessment Planning Therapy Monitoring
Diagnosis
1. Massive hemoptysis ec former pulmonary TB DD / • Check Rapid • Adona • Monitorin
aspergilloma of the lung dextra Molecular 1amp/8jam/drips- g vital and
S: Test • Vit K clinical
coughing up blood since 1 month ago, worsening 1 1amp/8jam/drips- sign
week ago, fresh red color and volume of about 1 glass, • Asam tranexamate
history of coughing up blood since 2014. Chest pain, 500mg/8jam/div-
radiated to the back. History of chest pain. History of • codeine
weight loss is 6 kg for 1 month 10mg/8jam/oral
O:
Thoracic photo 7-12-2023 Central Mamuju Hospital
Old active pulmonary TB with moderate lesions
MSCT thorax with contrast 13/1/2022 RSWS
Old active lung Tb with extensive lesions and
aspergilloma

2. Aspergilloma • Bronchoscopy Monitoring

S: vital and
History of being treated at the central mamuju hospital Clinical signs
on 28/12/2023 for 1 week with a diagnosis of
pulmonary mycosis + massive hemoptysis, can be
treated with tranexamic acid 3x1, cefixime 2x200mg
O:
Thoracic photo 17-4-2022 Central Mamuju Hospital
Suspected lung mass dextra dd/round specific
pneumonia
MSCT thorax with contrast 13/1/2022 RSWS
Old active lung Tb with extensive lesions and
aspergilloma
THANK YOU