morning report

1. December 17th 2023
MORNING REPORT
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Duty Junior on ER : dr. Aan
Duty Junior on Ward : dr. Hardian, dr. Fadli, dr. Sadil
Duty senior on ER : dr. Auliah
Duty senior on Ward : dr.Amirah,dr. Bakhrul
Duty Chief : dr. Reza
Supervisor : dr. Arif Santoso, Ph.D Sp.P (K)

2. VISIDANMISI
PROGRAMSTUDIPULMONOLOGIDANKEDOKTERAN
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.

3. VISIDANMISI
PROGRAMSTUDIPULMONOLOGIDANKEDOKTERAN
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

4. • Mr. Ramli/1094110/31 Desember 1967
• Chief complaint : Shortness of breath
Patients with complaints of shortness of breath since 1 month ago and
worsening since last 1 week, shortness of breath is not affected by activity
and weather. Cough with white sputum since 2 months ago and
worsening since last 10 days. Coughing with blood since 4 days ago as a
blood strike. No. history of coughing up blood before. There is
occasionally right chest pain, no history of chest pain before. No Fever,
history of fever is 1 day ago. No anosmia and augesia, No heartburn. No
night sweats without activity. No nausea and vomiting. No decrease
appetite, No weight loss. Defecation and urination within normal limits.
Anamnesis

5. • No History of taking ADT
• No history of contact with patients with tuberculosis
• No family history of malignancy
• No history of hypertension, DM, heart disease and kidney disease
• History of Smoking since 41 years 16 cigarettes/day (IB 656 Severe smoker)
• History of Covid-19 vaccine 2 times
• No history of confirmed Covid-19
• Domicile in Pinrang
• Work as a Occupation
• History of being treated at Pinrang hospital for 1 day.
Anamnesis

6. PHYSICAL EXAMINATION
O/ Moderate Ilness /composmentis /
normoweight / GCS E4M6V5
BW :
BH :
BMI :
SpO2 97% via room air
BP : 123/75 mmHg
HR : 93 times/min
RR : 22 times/min
T : 36.7 Celcius
Head : Normocephal, no Pale of conjunctiva, No
sclera icteric
Neck : No lymph node enlargement, trachea
midline
Thorax (Supine, From Anterior) :
Inspection: Asymmetrical, lagging right hemithorax when
static and dynamic
Palpation : Tactile fremitus decreased on medio- basal right
hemithorax
Percussion : Dullnes at ICS IV – Basal right hemithorax
Auscultation : Vesicular, breath sounds decreased on medio-
basal right hemithorax. Ronchi at hemithorax dextra and no
wheezing
Cor : heart sound I/II regular, no murmur.
Abdomen : flat, normal peristalsis, liver and spleen are not
palpable
Extremities : Warm extremities, crt < 2 detik, no edema
pretibial, muscle atrophy

7. LABORATORY FINDING
LAB
15/12/23
Wahidin Hospital
Normal Range
WBC 24.4 4.00-10.00
HB 13.7 12.00-16.00
Platelet 224 150-400
Neut/Lymp 93.1/3.4 52.0-75.0/20.0-40.0
GDS 144 <200
Na/K/Cl 134/3.0/102 135-145/3.5-5.1/97-111

8. LABORATORY
AGD
RSWS
17-12-2023
Normal
pH 7.35-7.45
SO2 95-98
PO2 80-100
PCO2 35.0 - 45.0
HCO3 22-26
BE -2 s/d 2
Old FiO2
New FiO2
AaDO2
Impression :

9. Chest X-Ray
15-12-2023
Wahidin Hospital

10. No Assesment Planning Diagnose Therapy Monitoring
1. Community Acquired Pneumonia PSI Score 106
Risk Medium Class IV
S:
Patients with complaints of shortness of breath since 1
month ago and worsening since last 1 week, Cough with
white sputum since 2 months ago and worsening since
last 10 days. History of fever 1 day ago.
O:
RR : 22 times/min
Thorax (Supine, From Anterior) :
Auscultation : Ronchi at hemithorax dextra and no
wheezing
CXR 15/12/23 Wahidin hospital
Right Pneumonia
PSI Score
Age 56
Neoplastic Disease +30
Pleural effusion +30
• Check procalcitonin
• Check smear gram,
sputum culture and
antibiotic sensitivity
(if needed)
• Oxygen via nasal
canula 2-3 lpm (if
needed)
• Ceftriaxone 2gr/24h/iv
• Azithromicyn 500
mg/24hrs/orally
• Acetylcysteine
200mg/8h/Oral
• Monitoring vital and
clinical sign
• Check blood routine
after 72 hours of
antibiotic
administration
• Check procalcitonin
after 24 hours of
antibiotic
administration

11. No Assesment Planning Diagnose Therapy Monitoring
2. Unkwon type of right lung mass T4N0M1a stageIVA
PS 2 dd/Mesotelioma DD/ Schwarte
T4: >7 cm
N0 : No lymph node enlargnement
M1a: Pleural Effusion minimal
S:
Patients with complaints of shortness of breath since 1
month ago and worsening since last 1 week, Cough with
white sputum since 2 months ago and worsening since
last 10 days. Coughing with blood since 4 days ago as a
blood strike.
O:
RR : 22 times/min
Thorax (Supine, From Anterior) :
Inspection: Asymemetrical, lagging lright hemithorax static
and dynamic
Palpation : Tactile fremitus decreased on medio- basal
right hemithorax
Percussion :dullnes atICS IV – Basal right hemithorax
Auscultation : Vesicular, breath sounds decreased on
medio- basal right hemithorax.
CXR 15/12/23 Wahidin hospital
Suspected right lung mass
• MSCT scan thorax
with contrast
• Bronchoscopy
diagnostic
• TTNA/core biopsy
• Tumor marker check
According to
histopathological result
Monitoring vital and
clinical sign

12. No Assesment Planning Diagnose Therapy Monitoring
2. Hipokalemia
S: General Weakness
O :
Kalium : 3.0
Kalium Corection :
(3.5-3.0) x BB x 0. 3 :
• KSR 600 mg/ 12 ho/
oral
• Monitoring vital and
clinical sign
• Check Kalium post
Correction