MORNING REPORT Juni 23th 2022

Duty Junior on ER : dr.


Duty Junior on Ward : dr.

Duty senior on ER : dr.

 Duty senior on Ward : dr.

Duty Chief : dr.

Supervisor : Dr. dr. Arif Santoso, Sp. P(K), PhD, 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
 ANAMNESA Tuesday | August 14, 2012

• Suciaty Praha / 26-11-2005 / 984094

• Chief Complaint : swallowing pins

A new patient was referred from Gorontalo with complaints of swallowing pins since 5 days ago. Currently the patient is
not coughing, a history of coughing yesterday afternoon and getting worse at 15.30 today, a heavy cough accompanied
by nausea, after coughing nausea, the patient does not complain of coughing anymore . Coughing up blood and riw
coughing up blood didn't exist. No shortness of breath. There was a history of shortness of breath 2 days ago.
Shortness of breath is not affected by activity and weather. No headache, no nausea and vomiting. Defecating and
urinating smoothly without complaints.
ANAMNESIS Tuesday | August 14, 2012

-There is no History of OAT

-There is no contact history of TB patients
-There is no history of HT, DM, kidney disease and heart disease
-There is no history of smoking
-History of covid-19 vaccine 3 times
-There is no confirmed history of covid-19
-There is no history of malignancy in the family
- History of being treated at Gorontalo Hospital since 5 days ago then referred
to Wahidin Hospital
- Work as a Student
- Domicile Gorontalo
PHYSICAL EXAMINATION
 Moderate pain/compost mentis
 Spo2 99% without modality
 BP :120/80 mmhg HR : 70 x/minute
 RR : 18 x/minute Temperature : 36,7 C
 Head: normocephal
 Eyes : no pale conjunctiva, no yellow sclera
 neck: not palpable enlarged lymph nodes, trachea midline
 Thorax (supine, anterior)
 I : Symmetrical both hemothorax, when static and dynamic.
 P: Tactile fremitus the same effect on both hemothorax
 P : sonor in both hemithorax
 A: Vesicular, ronkhi and wheezing are absent.
 Cor : BJ I/II Pure Regular, no murmur.
 Abdomen: normal, peristalsis normal impression, no palpable enlargement of the liver
and spleen.
 Extremities: warm acral, no pretibial edema.
LABORATORY
LAB June 22st 2022 Normal Range
Tanggal 22 juni 2022

WBC 8.6 4.00-10.00 Hbsag Non reaktif

HB 12 12.00-16.00

Platelet 314 150-400 Swab PCR Negatif

Neutrophil 57.8 52.0-75.0

Lympochyte 34.0 20.0-40.0

SGOT/PT 14/8 SGOT <38/SGPT<41

Ur/Cr 20/0.50 14/0.58

Albumin 4.1 3.5-5.00

Radiology Chest X ray PA

18-6-2022 19-6-2022
Radiology Chest X ray lateral

18-6-2022 19-6-2022
Radiology

18-6-2022
Radiology Chest X ray Abdomen

18-6-2022 19-6-2022
Radiology Broncoscopy

Tanggal 24-6-2022
Radiology Broncoscopy

Tanggal 24-6-2022
LABORATORY
LAB June 22st 2022 Normal Range
Tanggal 22 juni 2022

WBC 8.6 4.00-10.00 Hbsag Non reaktif

HB 12 12.00-16.00

Platelet 314 150-400 Swab PCR Negatif

Neutrophil 57.8 52.0-75.0

Lympochyte 34.0 20.0-40.0

SGOT/PT 14/8 SGOT <38/SGPT<41

Ur/Cr 20/0.50 14/0.58

Albumin 4.1 3.5-5.00

Radiology Chest X ray PA

18-6-2022 19-6-2022
Radiology Chest X ray lateral

18-6-2022 19-6-2022
Radiology

18-6-2022
Radiology Chest X ray Abdomen

18-6-2022 19-6-2022
Radiology
23/06/2022 pukul 22.25

Foto thorax PA+ Lateral

Kesan : Tidak tampak kelainan radiologik pada
foto thorax

23/06/2022 pukul 20.19

Foto polos abdomen
Kesan : Metal density berbentuk linier dengan
panjang +/- 3.47 cm pada regio hipokondrium
kiri setinggi CV L1-L2

23/06/2022 pukul 10.12

MSCT scan thorax tanpa kontras
Kesan : Corpus alienum (metal density) main
bronkus kiri setinggi CV T3-T5 Cor dan pulmo
dalam batas normal
Radiology Broncoscopy

Tanggal 24-6-2022
 ANALYSIS
No` Assesment Planning Diagnose Therapy Monitoring

1. Airway - Consult to Gastro - Paracetamol  Monitoring

Laceration Intervention 500mg/8ho/oral general
(Trachea and - Methylprednisolon condition and
Bronchus) 125mg/24ho/iv vital sign
- Ceftriaxone 1 gr/12ho/iv
THANK YOU