1. Saturday, June 30th 2023
MORNING REPORT
Duty Junior on ER :
Duty Junior on Ward :
Duty senior on ER :
uty senior on Ward :
Duty Chief :
Supervisor : Dr. dr. Erwin Arief, Sp. PD.K-P., Sp.P. (K).
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. Syaifu Pirono/20-2-1937 (86 yo)/998150
• Chief Complaint : Shortness of breath
Patient came in RSWS with Shortness of breath since this morning. Shortness of
breath worsening when patient complains of lower abdominal pain with
difficulty urinating. Shortness of breath affect with weather, history Shortness of
breath. Cough with white sputum since 2 month ago. No coughing up blood, No
history coughing up blood. No chest pain, No history of Chest pain. No fever, No
Hoarseness, No swallowing pain, No augesia and No anosmia. No Heartburn. no
nausea and vomiting. lower abdominal pain. Decreased appetite, No weight
Loss. no history of night sweats without activity. Redness urine with Catheter and
Defecation within normal limit.
Anamnesis
5. • No History of ATD
• No history of contact with TB patients
• History OF DM, Consumsed metformin
• History of Heart Disease
• History Of BPH, Consumsed Tamsulosin
• No history of family’s malignancy
• History of Smoking, for 30 years, 16 ciggeretes/day (IB : 480 moderate smoker)
• History of covid vaccine, 3 times
• Job as Seller
• Domicile Makassar
• The patient currently taking Symbicort, Berotec, and Tamsulosin drugs that he bought himself
Anamnesis
6. PHYSICAL EXAMINATION
O/ Moderate Ilness / composmentis
/Normoweight
Weight ;63 kg
Hight; 172 cm
IMT 21.35 kg/m2
SpO2 96% in room air
SpO2 99% with 2 liters Oxygen via NC
BP : 167/79 mmHg
HR : 87 times/min
RR : 22 times/min
T : 36.7 Celcius
Head : Normocephal, No Pale of conjunctiva, no
yellowish sclera.
Neck : No enlargement of lymphonodes, trachea
midline,
Thorax :
Inspection: symmetrical static and dynamic.
Palpation : Tactile fremitus in both of hemothorax
Percussion : Sonor in both of hemitorax
Auscultation : Vesicular, No rhonci, Wheezing on both
hemitorax, prolonged expiratoion
Cor : heart sound I/II regular, no murmur
Abdomen : Flat, peristaltic within normal limit, liver and spleen
within in normal limit
Extremities : Warm extremities, CRT <2 second, No edem
pretibial
Bronchodilator test (patient not cooperative, Condition not
Optimal)
7. LABORATORY FINDING
LAB 30-06-2023 Normal Range
WBC 12,2 4.00-10.00
HB 14,4 12.00-16.00
Platelet 133 150-400
Neutrophil 84,6 52.0-75.0
Lympochyte 5,8 20.0-40.0
Ur/Cr Waiting for the result Ur 10-50/ Cr <1.3
Got/gpt <38/<41
Albumine - 3.5-5.00
Na/K/Cl - 135-145/3.5-5.1/97-111
RBG - 140
LDH 210-425
Total protein 6,6-8,7
Procalitonin <0,05
Elektrolit Na+ 132 135-145 mEq/L
K+ 4,8 3,5-5,3 mEq/L
Cl- 98 100-106 mEq/L
11. No Assesmen Planning Diagnose Therapy Monitoring
1. Acute Exacerbation COPD
S :
• Shortness of breath
• Lower abdominal pain with difficulty urinating.
• Shortness of breath affect with weather
• history Shortness of breath
• Cough with white sputum since 2 month ago
• Decreased appetite
O :
SpO2 96% in room air
SpO2 99% with 2 liters Oxygen via NC
BP : 167/79 mmHg
HR : 87 times/min
RR : 22 times/min
Thorax :
Inspection: symmetrical static and dynamic.
Palpation : Tactile fremitus in both of hemothorax
Percussion : Sonor in both of hemitorax
Auscultation : Vesicular, No rhonci, Wheezing on both hemitorax,
prolonged expiratoion
• Chest X-ray (waiting
expertise)
• Examine Blood Gas
Analysis and Blood lactic
• O2 nasal canule 2 Lpm
• IVFD NaCl 0.9% 20 Bpm
• Farbivent 1 rsp/8ho/inhalation
• Pulmicort 1rsp/12ho/inhalation
(TAO)
• Acetylsistein 200mg/8ho/oral
• Ceftriaxone 1gr/12ho/intravena
• Monitoring clinical and
vital sign
12. No Assesmen Planning Diagnose Therapy Monitoring
2. Hematuria ec. Suspect Stricture uretra
S :
• Lower abdominal pain with difficulty urinating.
• Redness urine with Catheter
O :
Urine Output (30-06-2023) 500cc, hemorrhage (+)
• Examine routine urinary
• Abdominal USG
• Consul Urology division
• IVFD NaCl 0.9% 20 Bpm
• Ceftriaxone 1gr/12ho/intravena
• Paracetamol 500mg/8 ho/oral
• Monitoring clinical and
vital sign
• Monitoring urinary output
13. No Assesmen Planning Diagnose Therapy Monitoring
3. Suspect Benign Prostate Hypertrophy
S :
• Lower abdominal pain with difficulty urinating.
• Decreased appetite
O :
• Abdominal USG
• Consul Urology division
• According urology division • Monitoring clinical and
vital sign
14. No Assesment Planning Diagnose Therapy Monitoring
4. Hypertension gr I I
S:
History of Hipertension, and consumed Amlodipine but
not take medicine regulary
O :
BP : 167/79 mmHg
• ECG • Amlodipin 10
mg/24hours/Oral
Monitor clinical and
vital sign
15. No Assesment Planning Diagnose Therapy Monitoring
5. Hyponatremia
S:
History of Hipertension, and consumed Amlodipine but
not take medicine regulary
O :
Na 132
• Correction
• 135-132 x 0,6 x
63=151,2
• IVFD NaCl 0.9% 20 Bpm Evaluated Na+ post
correction
