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    Santoso Tumpar

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    Juli2022 Semnol-Semsa
    Dr. Farma, Dr. Muti, and Dr. Diana are on duty for the ward on August 28th while Dr. Cesar and Dr. Yusuf are on duty for the ER. Dr. Nur Ahmad Tabri is the DPJP. The morning report provides the duty schedule for doctors on the ward and ER.

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    Santoso Tumpar

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    Juli2022 Semnol-Semsa
    30 views13 pages
    Dr. Farma, Dr. Muti, and Dr. Diana are on duty for the ward on August 28th while Dr. Cesar and Dr. Yusuf are on duty for the ER. Dr. Nur Ahmad Tabri is the DPJP. The morning report provides the duty schedule for doctors on the ward and ER.

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    Dr. Farma, Dr. Muti, and Dr. Diana are on duty for the ward on August 28th while Dr. Cesar and Dr. Yusuf are on duty for the ER. Dr. Nur Ahmad Tabri is the DPJP. The morning report provides the duty schedule for doctors on the ward and ER.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    30 views13 pages

    Santoso Tumpar

    Uploaded by

    Juli2022 Semnol-Semsa
    Dr. Farma, Dr. Muti, and Dr. Diana are on duty for the ward on August 28th while Dr. Cesar and Dr. Yusuf are on duty for the ER. Dr. Nur Ahmad Tabri is the DPJP. The morning report provides the duty schedule for doctors on the ward and ER.

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    Download as pptx, pdf, or txt
    of 13

    MORNING REPORT August 28th 2022

     Duty 1st on Ward: dr. Farma, dr. Muti, dr. Diana


     Duty 1st on ER : dr. Cesar, dr Yusuf
    Duty 2nd on Ward : dr. , dr.

    Duty 2 nd
    on ER : dr.

    Duty chief : dr.

    DPJP : Dr.dr. Nur Ahmad Tabri,Sp.PD, K-P, 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
    ANAMNESIS Tuesday | August 14, 2012

    Santoso/9-4-1972/961573

    Chief Complaint : Chest pain

    The patient complaint of chest pain since 4 months ago, pain was felt at
    the former WSD site (late February WSD, March miniWSD, and April
    aff WSD). Shortness of breath since 2 years ago, influenced by activity
    but not affected by the weather. Cough with white phlegm, history of old
    cough since 6 months ago. Coughing up blood today there are spots,
    history of coughing up blood 6 months ago. No fever, no history of fever.
    No night sweats with activity. No headaches, no smell and taste
    disturbances, no sore throat. Nausea and vomiting every time eat since
    this morning. decrease in appetite,weight loss but it is not known how
    many kilograms. defecation and urination within normal limits
    ANAMNESIS Tuesday | August 14, 2012

    • History of TB, consumption of ATD from 13-11-2021 to 03-01-2022, the patient


    stopped taking OAT because he felt that his complaints were getting worse while
    taking ATD
    • No history of contact with TB patient
    • History of being treated at RSWS January 2022, diagnosed as Left Lung
    Adenocarcinoma, Type Wild Type T4N3M1C stage IV B PS 2, already in the 4th
    cycle of chemotherapy
    • No history of DM, hypertension, heart disease and kidney disease.
    • No family history of malignancy
    • History of smoking there for 30 years, 2 packs per day
    • History of cooking using firewood 20 years
    • No history of contact with Covid-19 patients
    • No history of the Covid-19 vaccine
    • History of Confirmed covid 19 month 1 2022 isman
    • Domicile wesabbe, Makassar
    PHYSICAL EXAMINATION

    O : Moderate illness/Compos mentis/Normoweight Thorax (Supine, Anterior):


    I : asymmetry, left hemithorax left lagging
    Weight Kg statically and dynamically. WSD installation
    scar visible on left hemithorax lumpy, size
    Height Cm
    2x1 cm, not tender, color like surrounding
    IMT kg/m2 skin, immobile, hard surface palpable, border
    not firm,
    SpO2 : 95% room air P : Tactile fremitus decreased at apex-basal
    BP 180/90 mmHg of left hemithorax
    HR 140 times/min P : Dullness at left hemithorax, ICS II-basal
    RR 22 times/min (thoraco-abdominal) A :Bronchovesicular, decreased of breath
    T 36.7 C sound at apex-basal of left hemithorax, no
    rhonki and wheezing.
    Head : Normocephal
    Eyes : No pale conjunctiva, No icteric sclera Heart : Regular, pure heart sound I/II
    Abdomen: increased of peristaltic sound, hepar
    and lien not palpable
    Neck : enlarged lymph node in a single left colli, the
    color is like the surrounding skin, not tender,
    singular, immobile, firm boundaries, the trachea Extremities: warm, no edema
    seems to deviate to the right
    LABORATORY FINDING
    LAB 14-12-22 16-12-22 Normal Range BGA

    WBC 9,3 10,9 4.00-10.00


    pH
    HB 11 11,7 12.00-16.00
    SO2
    Platelet 299 317 150-400
    Neutrophil 59,2 53,4 52.0-75.0
    PO2

    Lympochyte 28,2 34,5 20.0-40.0 PCO2


    GDS 88 148 HCO3

    Ur/Cr 34/0,85 26/0,92 Ur 10-50/ Cr <1.3


    BE
    Old FiO2
    SGOT/PT 11/10 11/9 SGOT <38/SGPT<41
    New FiO2
    Albumin 3,7 3,7 3.5-5.00
    Na/K/Cl 140/4,3 142/4,2 135-145/3.5-5.1/97-111

    Tcm sputum Tcm sputum


    HbsAg non reaktif non reaktif 18.8.2022 4.7.2022
    Not detected Not detected
    Radiology
    klinis
    ECG
    cytology
    ANALYSIS
    No Assesment Planning Diagnose Therapy Monitoring

    1. Adenocarsinoma Paru Sinistra  Khemoterapi adjuvant  Clinical and vital sign


    Jenis Wild Type T4N3M1C stage
    IVB PS 1 post kemoterapi siklus
    ke-6
    s/ chest pain, shortness of breath
    o/ cytology : Non-small Cell Lung Carcinoma due
    to adenocarcinoma
    Hystopathology : Non-small Cell Lung
    Carcinoma due to adenocarcinoma
    2. - Cancer pain VAS 5/10
     MST 10mg/12 ho /oral  Clinical and vital sign
     Blood routine
    s/chest pain since 4 months ago, pain was felt at  paracetamol 500 mg / 8 ho/ oral
    the former WSD site (late February WSD, March
    miniWSD, and April aff WSD).

    3. Hemoptisis non masif ecausa malignancy


     Adona drips  Monitoring of hemoptisis

    S/Coughing up blood today there are spots,  N acetyl cysteine 200 mg / 8 ho/
    history of coughing up blood 6 months ago. oral
    ANALYSIS
    No Assesment Planning Diagnose Therapy Monitoring

    6. - Syndrome dyspepsia  Injeksi ranitidin 50 mg / 12 ho/ iv


     Injeksi metoklopramid 10 mg
    extra iv

    6. - multiple kista hepar  Check albumin post


    correction

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