MORNING REPORT 14 November 2021

 Duty 1st on Ward : dr. Bakhrul, dr. haidir, dr. Fahrul

 Duty 1st on ER : dr. julinda

Duty 2nd on Ward : dr. Alfiah


 Duty 2st on ER : dr. Imam

Duty chief : dr. ayu

DPJP : Dr. dr. Erwin Arief, Sp. PD-KP, 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
ANAMNESA Tuesday | August 14, 2012

• Name/Age/RM: Yunus/10-8-1988/951903

• Chief Complain: Shortness of breath

• History of Present Illness:

The patient admitted to IC with chief complain shortness of breath

since 1 year ago, worsening 8 days ago. Affected by activity not by

weather. Coughing occasionally since 8 day ago, with white mucus.

No coughing up blood. No chest pain. Fever since 8 days ago.

There is no night sweating without activity, no weight loss, no

history of decreased appetite. Defecating and urination within

normal limit.
ANAMNESA Tuesday | August 14, 2012

• History of past illness

– No history of ATT drugs and contact with Pulmonary TB patient.
– History of confirm diagnosed HIV at Hermina hospital (15-11-2021)
– History of high risk sexual activity with unsafe partner sex
– History of drugs
– No history of hypertension, DM, Heart desease and Kidney desease
– No history of smoking
– Work as employee in
– Domicili in Makassar

– Test HIV Reactive in Hermina hospital (15-11-2021)

PHYSICAL EXAMINATION
 Status Present: moderate illness / compos mentis
Body weight : 85 Kg, Height: 170 cm, BMI : 29,41 Kg/m2(overweight)

 Vital sign : BP :109/78 mmHg HR 98 x/m RR : 20 x/m, T : 38,oC,

SpO2 98 % with NRM 10 LPM
 Head/Eye : pale conjungtiva (-), icterus or sclera (-)
 Neck : Enlargement of Lymphonode (-), traceha midline.
 Thorax : Supine Position From Anterior
 Cor : S1-2 regulary, murmur (-), gallop (-)
 Pulmo :
Inspection : symmetrical when static and dynamic
Palpation : vocal fremitus same in both hemithorax
Percution : Sonor in both hemithorax
Auscultation : Bronchovesicular, ronchi in both hemithorax, no wheezing
 Abdomen : Soepel, peristaltic is normal, liver and spleen are not palpable,
epigastric pain (+)
 Extremitas : Warm acral, no pretibial edema.
LABORATORY
Blood Result test 19-11-2021 BGA 19-11-2021
WBC 7,0 PH 7,623

Hb 13,3 SO2 96,7

PLT 235 PO2 70,8

Neutrofil 72,10 PCO2 19,3

Lymph 16,6 HCO3 20,2

Ur/Cr 12/1,05 BE -1,2

SGOT/SGPT 75/49 Alcalosis Respiratorik partially

compentated
Old FiO2 1
New FiO2 1,34
Total Lymph count =
(Lymph/100) x Leucocyte)  (30.9/100)x13.400 =
4140,6

Th Cell = 60% x TLC = 60%x4140,6 = 2484,36

CD4 = 40%x Th cell = 40%x2484,36 = 993,74

Radiology foto Thorax 28/11/21

13-11-21 19-11-21
 Problem List Tuesday | August 14, 2012

- shortness of breath
- Fever
- Coughing
- confirm diagnosed HIV
- BMI : 1,64 Kg/m2(mild thinnes)
- Auscultation thorax : ronchi in basal both hemithorax
- Electrolite imbalance (hyponatremia, hypocalemia)
 ANALYSIS
No Assesment P Diagnosis P Therapy P Monitor Education
1 CAP Curb Score Gram smear, MO Ceftazidime 1gr/8 jam/oral Sputum BTA in the - Medication
1, Culture, AB sensitivity end Intensive Phase adherence
- Side Effect of
ATT

2 HIV grade III ARV after 14 days get ATT - CD4 Check Medication
According to tropic adherence
infection division
kotrimoxazole 960 mg/24
jam/oral
3 Moderate • Kalium Correction : Check kalium after Improve oral
Hypokalemia (2,9 (4-2,9)x51x0,3=16,83MEq) corection intake
mEq/L) KSR 600 mg/12 ho/oral
dyspnea

Pathophysiology Tuesday | August 14, 2012

People with HIV
infection

immunocompromised

MTB infection

Inflamation process
Multiplication bacteria

↑ TNF α
Destruction of parenchym

Lost of Appetite

SOB
Intake ↓

Body weight loss

THANK YOU