MORNING REPORT

December 4th 2023

Duty on Sunday, December 3rd 2023 Shift 1
Residen on duty :
Duty 2B : dr. Ivan
Duty 2A : dr. Dimas
Duty 1 : dr. Hendi
Supervisor:
dr. Soraya Riefani, Sp.P

DEPARTEMENT OF PULMONOLOGY AND RESPIRATION

MEDICINE
FACULTY OF MEDICINE ULM / ULIN HOSPITAL BANJARMASIN
 VISI
PROGRAM STUDI PENDIDIKAN DOKTER SPESIALIS PULMONOLOGI DAN KEDOKTERAN RESPIRASI
FAKULTAS KEDOKTERAN UNIVERSITAS LAMBUNG MANGKURAT

“Menghasilkan Dokter Spesialis Paru dan Pernapasan yang Beretika dan Berbudi Luhur yang Kompeten
‘

dalam Bidang Kesehatan Paru dan Pernapasan, terutama di Lingkungan Lahan Basah sesuai dengan
Standar Nasional dan Internasional ’’

• Lahan Basah adalah Daerah-daerah seperti Rawa, Payau, Lahan Gambut dan Perairan, baik Alami atau Buatan, Permanen atau
Sementara, dengan Air yang Mengalir atau Tetap, baik Air Tawar, Payau atau Asin, meliputi pula Daerah Perairan Lautan dengan
Kedalaman pada saat Air Surut Terendah tidak Melebihi 6 Meter.

• Etika adalah Kewajiban dan Tanggung Jawab Moral kepada Setiap Orang yang Dihadapi.

• Berbudi Luhur adalah Mempunyai Kecerdasan Akal, Mampu Mengendalikan Emosi atau Perasaannya, Berbahasa dengan Baik,
Memiliki Kecerdasan Spiritual, dan Bekerja secara Cerdas saat Berhadapan Dengan Orang Lain.
 MISI
PROGRAM STUDI PENDIDIKAN DOKTER SPESIALIS PULMONOLOGI DAN KEDOKTERAN RESPIRASI
FAKULTAS KEDOKTERAN UNIVERSITAS LAMBUNG MANGKURAT

1. Menyelenggarakan Program Pendidikan Dokter Spesialis Pulmonologi dan Kedokteran Respirasi yang Beretika dan
‘

Berbudi Luhur serta Berorientasi pada Sistem Kesehatan Nasional.

2. Menyelenggarakan Program Pendidikan yang Menghasilkan Lulusan Dokter Spesialis Pulmonologi dan Kedokteran

Respirasi yang Kompeten dalam Bidang Pelayanan, Pendidikan, Penelitian dan Pengabdian Masyarakat sesuai

dengan Kemajuan dan Perkembangan di Bidang Kesehatan Paru terutama dalam Bidang Lahan Basah untuk

Mencapai Kesetaraan Nasional dan Internasional.

 PATIENT RECAPITULATION
December 3rd 2023 Shift 1
ROOM TOTAL PATIENTS
DAHLIA
DAHLIA 1st floor 10 PATIENTS
DAHLIA 2nd floor 5 PATIENTS
TOTAL 15 PATIENTS
ISOLASI COVID-19
Mawar 2B 0 PATIENTS
ICU COVID-19 0 PATIENTS
TOTAL 0 PATIENTS
BOUGENVILLE 4 PATIENTS
 Passed Away

NO Name/Age DIAGNOSIS Admitted Passed Away Room

TOTAL -
 LIST OF PATIENTS
December 3rd 2023 Shift 1
NO Name/Age/MR DIAGNOSIS Description
1. Lung TB New Case on ATD Intensive
Phase 1st Month
2. Left Lung Absces
Came to ER: 17.15
3. DM Type 2 on Threat
1. Mr. Junaidi/ 46 y.o/ 01549047 Respond: 17.20
4. Hyperbilirubin
Admitted to Dahlia 2nd floor
5. Mild Hyponatremia (133)
6. Hepatitis B
7. General Weakness
1. Pleural Effusion (D) dt CKD Stg V on HD
2. CKD stg 5 on HD 2x/Week Consult from Internal Department
3. ADHF wet warm forrester II pada Considering to Pleural Effusion
Mrs. Syarifah Fadlun binti Habib HFmrEF 41% Management
2. Zainal Abidin / 45 y.o / 01510850 4. HT Stg 2
5. Moderate anemia NN dt renal disease Consult : 18.45 WITA
6. OMI inferior Respond: 18.50
7. Ascites Gr II
THANK YOU
 Morning Report

Mr. Junaidi/ 46 y.o/ 01549047

Admitted to Dahlia 2nd floor
December 3rd 2023

DEPARTMENT OF PULMONOLOGY AND RESPIRATION MEDICINE

FACULTY OF MEDICINE ULM / ULIN HOSPITAL BANJARMASIN
ANAMNESIS Mr. Junaidi/ 46 y.o/ 01549047
Chief Complain : General Weakness
History of present Illness :
• General weakness (+) since 2 weeks before admitted. General weakness felt continuously. There was no
change in complaints even though the patient had been treated at Tanjung Hospital for 14 days. Patient
was only on the bed because he complained of weakness.
• Shortness of breath (-)
• Chest pain (-)
• Cough (-). History of cough (+) 1 month ago, patient coughing for 2 weeks, According to patient coughing
up yellowish and smelly phlegm . Now the cough is gone. History of coughing up blood (-)
• fever (-). History of fever (+) 1 month ago. His Fever was high, Patient fever 2 weeks and now theres no
fever
• Weight loss (+) since 1 month ago. Weight loss by 2 kg (60–>58 kg) over 1 month.
• Decreased appetite (+) since 1 month ago. The patient admitted to eating only about 5 tablespoons.
• Night sweats (-)
• Nausea (+), vomiting (+) 1x today.
• Epigastric pain (+)
• Enlarged glands in the neck (-), armpits (-), groin (-)
• Swollen foot (-)
• Dizziness (-), headache (-), history of seizures (-)
• There are no complaints about defecation and urination
ANAMNESIS Mr. Junaidi/ 46 y.o/ 01549047

History of past Illness:

- DM (+) 1 year ago, regularly taking Glimepiride 1x1 mg and Metformin 2x500 mg.
- HT (-), Asthma (-) COPD (-), TB (-)

History of family Illness:

DM (-), HT (-), Asthma (-), COPD (-), TB (-), Heart Disease (-), Malignancy (-)

History of Psychosocial:
Occupation: Driver at the mine
Drugs and Alcohol : (-)
Free Sex : (-)
Smoking: (-), passive smoke from work friends
Covid-19 Vaccine: (+) 3x
Covid-19: (-)
ANAMNESIS Mr. Junaidi/ 46 y.o/ 01549047

History of Hospitalitation :
On November 19th 2023, patient was admitted to Tanjung Hospital due to complaints of
weakness and nausea. The patient was treated for 14 days by internal medicine. During
treatment, the patient check a sputum (Genexpert), and the results were said to be positive
(but the patient did not bring the results). The patient started taking OAT on November 26th
2023 with 4FDC 1x4 tablets. The patient was referred to the DOTS polyclinic at Ulin Regional
Hospital at the request of the family.

Previous RS Therapy:
Inj. Ceftriaxon 2x1 gr
Inj. Lansoprazole 2x30 mg
Inj. Ondancentron 3x4 mg

PO:
OAT 4FDC 1x4 tab
Sucralfate syr 3x2 C
 PHYSICAL EXAMINATION

General Condition : Moderate illness GCS: E4V5M6

VITAL SIGN

BP : 116/82 mmHg BW : 58 kg

HR : 110 Bpm BH : 160 cm

RR : 20 x/min BMI : 22.7 normoweight

Temp : 36.6 o
C SpO2 : 98% RA

Head to Toe
anemic conjunctiva (-/-), icteric sclera (-/-), pupil isochor (+/+) 3mm/3mm, light reflex
Head
(+/+), cyanotic lips (- ), ptosis (-/-), anhidrosis (-/-)
Neck JVP 5 + 2 CmH2O (-), Enlargement or mass a/r colli (-/+)

Cor Insp : Ictus not seen

Palp : Ictus not palpable

Ausc : S1 S2 single, Gallop (-), Systolic murmur (-) Diastolic murmur (-)
Thorax Pulmo :
Static D=S Ant Post
Insp: V/V V/V
Dynamic D=S
Breath Sound
V/V V/V
V/V V/V
Ant Post
N/N N/N Ant Post
Palp (VF):
N/N N/ N Ausc: -/ - -/-
Rh
N/N N/ N -/ - -/-
-/ - -/-
Ant Post Ant Post
S/S S/S -/- -/-
Perc: Wh
S/S S/S -/- -/-
S/S S/S -/- -/-

Abdomen Flat, Bowel Sound (+), H/L not palpable, Abdominal aortic pulsation is not visible, epigastric pain(-)

Extremitas Warm, edema (Sup:-/- Inf: -/-), Motorik (5/5)

Neurological
Meningeal reflex (-), pathological reflex (-), Sensoric (5 5 /5 5)
Status
 3/12/23
Blood Date Ulin Hospital Normal Value
Examinatio Hb 16.4 14.0 – 18.0 g/dl
n WBC 9.3 4.0 – 10.5 ribu/ul
Erytrocyte 6.33 4.10 – 6.00 juta/ul
Hematocrite 48.2 42 – 52 %
Trombosit 531 150 – 450 ribu/ul
MCV 76.1 75.0 – 96.0 fl
MCH 25.9 28.0 – 32.0 pg
MCHC 34.0 33.0 – 37.0 %

Basophil % / # 0.3 / 0.03 0.0 – 1.0%/ < 1.00 rb /ul

Eosinophil %/ # 1.3 / 0.12 1.0 – 3.0%/ < 3.00 rb/ul

Neutrophil % / # 72.8 / 6.79 50 – 81% /2.5 – 7.00 rb/ul

Lymphocyte % / # 14.7 / 1.37 20 – 40%/1.25 – 4.00 rb/ul

Monocyt %/ # 10.9 / 1.02 2.0 – 8.0%/0.30 – 1.00 rb/ul

NLR < 3.0
PT - 9.9 – 13.5 detik
APTT - 22.2 – 37.0 detik
Kontrol APTT -
 3/12/23
Date Ulin Hospital Normal Value
GDS 151 < 200 mg/dl
GDP - < 120 mg/dl
HbA1C - 4.0 – 5.6
3

Albumin 3.9 3,5 – 5,2 g/dl

Bilirubin Total 1.38 0.20 – 1.20 mg/dl
Bilirubin Direk 0.75 0.00 – 0.20 mg/dl
Bilirubin Indirek 0.63 0.20 – 0.80 mg/dl
SGOT 28 5 – 34 U/L
SGPT 36 0 – 55 U/L

Ureum 19 0 – 50 mg/dl
Kreatinin 0.79 0.72 – 1.25 mg/dl

Natrium 133 136 – 145 Meq/L

Kalium 4.2 3.5 – 5.1 Meq/L
Chlorida 105 98 – 107 Meq/L
CHEMIC Date
3/11/23
Normal Value
Ulin Hospital
AL
Cholesterol - 0-200
BLOOD Trigliserid - 0-150
LDL - 0-100
HDL - >40.00

HbsAg Reactive Non Reaktif

HIV Rapid Non Reactive Non Reaktif

Anti HIV (ELISA) -

Anti HCV - <1.00 S/CO

LDH - 0-25
CEA - 8.00-29.00
SITB
 CXR Examination

24/11/2023 3/12/2023
Ulin Hospital Ulin Hospital
 ECG

Sinus Rhythm, 99 bpm

Clinical Photo
SOE
POMR
 Initial Planning Planning Planning
CUE AND CLUE Problem List
Diagnose Diagnose Therapy monitoring

Mr. Junaidi/ 46 y.o/ 01549047 1. General Lung TB New - LED Pharmacology : Planing
- General weakness (+) since 2 weeks Weakness Case on ATD - 4FDC 1 x 4 tablets Monitoring
- Weight loss (+) since 1 month 2. Weight Loss Intensive
Phase 1st
• Vital Sign
- Decreased appetite (+) since 1 month 3. Decrease
- History of cough (+) 1 month ago Appetite Month Nonpharmacologist : • Clinical Sign
- History of fever (+) 1 month ago 4. Chronic • Good nutrition and • Side effect of
Cough hydration ATD
5. Chronic • LFT and RFT
Fever evaluation
Physical Lab findings:
examination
Physical ex: Planning
General Exam : Radiological Finding Education
Weak Cavity in left hemithorax • Educate about
GCS : E4V5M6 with infiltrate surrounding patient condition
BP : 116/82 mmHg with patient and
HR : 110 x/menit family
RR : 20 x/menit
T : 36,5°C
• Educate to take
SpO2 : 98% RA medicine
routinely
Thorax • Educate about
BS (VVV/VVV) side effect of TB
Ronkhi
(---/---)
 Initial Planning Planning Planning
CUE AND CLUE Problem List
Diagnose Diagnose Therapy monitoring

Mr. Junaidi/ 46 y.o/ 01549047 1. Genereal Left Lung - HRCT Pharmacology : Planing
- General weakness (+) since 2 weeks Weakness Absces - C/S Sputum - Metronidazole 3 x Monitoring
- Weight loss (+) since 1 month 2. Weight Loss 500mg • Vital Sign
- Decreased appetite (+) since 1 month 3. Decrease
- History of cough (+) 1 month ago, Yellowish Apetite
- Ondancetron 3 x mg • Clinical Sign
and smelly pleghm 4. Chronic
- History of high fever (+) 1 month ago Cough Nonpharmacologist : Planning
5. History of • Good nutrition and Education
yellowish and hydration • Educate about
smelly patient condition
Physical Lab findings: pleghm
examination with patient and
6. History of
Physical ex: High Fever family
General Exam : Radiological Finding • Educate to take
Weak Cavity in left hemithorax medicine
GCS : E4V5M6 with infiltrate surrounding routinely
BP : 116/82 mmHg
HR : 110 x/menit
RR : 20 x/menit
T : 36,5°C
SpO2 : 98% RA

Thorax
BS (VVV/VVV)
Ronkhi
(---/---)
 Initial Planning Planning Planning
CUE AND CLUE Problem List
Diagnose Diagnose Therapy monitoring

Mr. Junaidi/ 46 y.o/ 01549047 1. History Of DM Type II - Fasting Pharmacologist: Planning

- DM (+) 1 year ago DM Normoglicemi Blood - Glimepiride 1x2mg Monitoring
c State Sugar - Metformin 1 x 500 mg • Cs/Vs
- GD2PP
Blood
• FBS/ Clinic
Sugar Non pharmacologist:
- HbA1C - Diet diabetasol 6 x 50 Planning
cc Education
Physical Lab findings: - Good hydration with • Educate patient
examination GDS: 151 fluid balance & family about
Physical ex: patient’s
General Exam : condition
Weak • Educate family
GCS : E4V5M6
BP : 116/82 mmHg
about continue
HR : 110 x/menit insulin therapy
RR : 20 x/menit
T : 36,5°C
SpO2 : 98% RA
 Initial Planning Planning Planning
CUE AND CLUE Problem List
Diagnose Diagnose Therapy monitoring

Mr. Junaidi/ 46 y.o/ 01549047 1. Decrease of Mild - Urine Pharmacologist: Planning

- Decease of Apetite Apetite Hyponatremia Elektrolite - IVFD Nacl 0.9% Monitoring
2. Low Natrium 1500/24hours • Cs/Vs
serum level
• Lab
Non pharmacologist: Evaluation/3day
- Good Nutrition and s
Good Hidration Planning
Physical Lab findings: Education
examination Natrium : 133 • Educate patient
Physical ex: Kalium : 4.2 & family about
General Exam : Chlorida : 105 patient’s
Weak condition
GCS : E4V5M6
BP : 116/82 mmHg
HR : 110 x/menit
RR : 20 x/menit
T : 36,5°C
SpO2 : 98% RA
 Initial Planning Planning Planning
CUE AND CLUE Problem List
Diagnose Diagnose Therapy monitoring

Mr. Junaidi/ 46 y.o/ 01549047 1. High Bilirubin Hyperbilirubin Pharmacology : Planing

level emia - UDCA 3 x 250mg Monitoring
• Vital Sign
Nonpharmacologist : • Clinical Sign
• Good nutrition and • Lab Evaluation/3
hydration days

Physical Lab findings: Planning

examination Bilirubin Total : 1.38 Education
Physical ex: Bilirubin Direct : 0.75 • Educate about
General Exam : Bilirubin Indirect : 0.63 patient condition
Weak with patient and
GCS : E4V5M6
BP : 116/82 mmHg
family
HR : 110 x/menit
RR : 20 x/menit
T : 36,5°C
SpO2 : 98% RA
 Initial Planning Planning Planning
CUE AND CLUE Problem List
Diagnose Diagnose Therapy monitoring

Mr. Junaidi/ 46 y.o/ 01549047 1. General Hepatitis B - HbSAG Pharmacology : Planing

- General weakness Weakness ELISA - Curcuma 3 x 1 Tablet Monitoring
- Nausea and Vomiting 1 days 2. Nausea and - Anti HAV • Vital Sign
Vommit - Anti HCV
3. Reactive - Consult to
Nonpharmacologist : • Clinical Sign
HbSAG Gastrohepato • Good nutrition and • Lab Evaluation/3
logy Division hydration days

Physical Lab findings: Planning

examination HbSAG : Reactive Education
Physical ex: • Educate about
General Exam : patient condition
Weak with patient and
GCS : E4V5M6
BP : 116/82 mmHg
family
HR : 110 x/menit
RR : 20 x/menit
T : 36,5°C
SpO2 : 98% RA
 Initial Planning Planning Planning
CUE AND CLUE Problem List
Diagnose Diagnose Therapy monitoring

Mr. Junaidi/ 46 y.o/ 01549047 1. Genereal Genereal Pharmacology : Planning

- General weakness (+) since 2 weeks Weakness Weakness - Inj. Omeprazole 1 x Monitoring :
- Weight loss (+) since 1 month 2. Weight Loss 40mg - Clinical
- Decreased appetite (+) since 1 month 3. Decrease
- Nausea (+), vomiting (+) 1x today. Apetite
- Inj. Ondancetron 3 x 4 - Vital Sign
4. Nausea and mg (nausea/vomit) - CXR/Clinical
Vommit
Nonpharmacology : Planning
- Good Nutrition Education :
Physical Lab findings:
- Bed rest • Educate about
examination
Physical ex: patient condition
General Exam : with patient and
Weak family
GCS : E4V5M6
BP : 116/82 mmHg
HR : 110 x/menit
RR : 20 x/menit
T : 36,5°C
SpO2 : 98% RA
THANK YOU
 MORNING REPORT
Ny. Syarifah Fadlun binti Habib Zainal Abidin / 45
tahun / 01510850
Konsulan IPD
IGD

DEPARTMENT OF PULMONOLOGY AND RESPIRATION MEDICINE

FACULTY OF MEDICINE ULM / ULIN HOSPITAL BANJARMASIN
ANAMNESIS Ny. Syarifah Fadlun / 45 thn/ 01510850
Keluhan Utama: Sesak Napas
Riwayat Penyakit Sekarang
- Pasien mengeluh sesak nafas sejak 3 hari SMRS dan memberat setelah HD terakhir (kemarin). Sesak
tidak membaik dengan istirahat dan pemberian oksigen di rumah. Sesak bertambah bila posisi berbaring
- Pasien dikatakan keluarga tampak Pucat
- Batuk (-) demam (-)
- Nyeri dada (-)
- Keringat malam (-)
- Penurunan BB (-)
- Penurunan nafsu makan (+) sejak 1 minggu ini. Pasien mengaku makan hanya 5 sendok tiap makannya,
makan 3x/hari
- Bengkak kedua kaki dan perut membesar sejak 3 bulan terakhir. Tidak pernah dilakukan penarikan
cairan perut.
- Pembesaran kelenjar di leher (-), ketiak (-), selangkangan (-)
- Mual, muntah (-)
- Saat cuci darah kemarin, pasien minum lebih banyak dan makan sayur berkuah- BAK 2-3x/hari, keluar
sedikit, sekitar ± 200 cc/hari.
ANAMNESIS Ny. Syarifah Fadlun / 45 thn/ 01510850
Riwayat Penyakit Dahulu
-Terdiagnosis gagal ginjal dan rutin cuci darah sejak 1 th 3 bulan, 2x/minggu (Rabu, Sabtu), terakhir cuci
darah Sabtu, 2/12/23. Akses AV shunt tangan kiri, selama 4-5 jam, biasa ditarik 3.5 Kg. Hemapo (-)
karena TD tinggi- HT (+) sejak 1 tahun ini. TDS rata-rata >200 mmHg, sejak 3 tahun terakhir
- DM (-), Asma (-), PPOK (-), TB (-)

Riwayat Penyakit Keluarga

HT (-), DM (-), Asma (-), PPOK (-), TB (-), Keganasan (-)

Riwayat MRS
Tgl 20-11-23 pasien MRS di RS Ulin karena keluhan sesak napas. Pasien dirawat di Ruang Tulip lantai 3
(IPD) selama 1 minggu. Selama dirawat pasien 3x dilakukan tindakan thoraxocentesis pada paru kanan
(500cc, 400cc, 500cc) dengan warna cairan kuning jernih.
 PHYSICAL EXAMINATION

General Condition : Moderate illness GCS: E4V5M6

VITAL SIGN

BP : 200/130 mmHg BW : 57 kg

HR : 97 Bpm BH : 160 cm

RR : 26 x/min BMI : 22,3 normoweight

Sp O2 : 93% RA —> 98% on nk 4 lpm
Temp : 36,9 o
C
UO 200 cc/ 24 jam (0,16 cc/kgBb/jam)
Head to Toe

Head Konj pucat (+), sklera ikterik (-), distensi JVP 5+2 cmH2O, KGB tidak teraba

Neck JVP 5 + 2 CmH2O (-), Enlargement or mass a/r colli (-/-)

Cor Insp : Ictus not seen

Palp : Ictus not palpable

Ausc : S1 S2 single, Gallop (-), Systolic murmur (-) Diastolic murmur (-)
Thorax Pulmo
Static D=S Ant Post
Insp:
Dynamic D=S V/V V/V
Breath Sound
</V </V
Ant Post
</BV </BV
N/N N/N
Palp (VF): Ant Post
</N </N
</N </N Ausc: Rh -/- -/-
-/- -/-
+/+ +/+
Ant Post Ant Post
Perc: S/S S/S -/- -/-
Wh
S/S S/S -/- -/-
S/S S/S -/- -/-
Abdomen BU (+) timpani, supel, nyeri tekan (-), hepar dan lien SDE , shifting dullness (+)
Ekstremitas Akral hangat, edema (-) parese (-)
 03/12/23
Date Nilai Normal
Darah RSUD Ulin
Rutin Hb 7.8 14.0 – 18.0 g/dl
WBC 5.7 4.0 – 10.5 ribu/ul
Erytrocyte 2.82 4.10 – 6.00 juta/ul
Hematocrite 23.6 42 – 52 %
Trombosit 323 150 – 450 ribu/ul

MCV 83.7 75.0 – 96.0 fl

MCH 27.7 28.0 – 32.0 pg
MCHC 33.1 33.0 – 37.0 %

Basophil % / # 0.0 – 1.0%/ < 1.00 rb /ul

Eosinophil %/ # 1.0 – 3.0%/ < 3.00 rb/ul
Neutrophil % /
66.4/3.80 50 – 81% /2.5 – 7.00 rb/ul
#
Lymphocyte
19.7/1.10 20 – 40%/1.25 – 4.00 rb/ul
%/#
Monocyt %/ # 13.9/0.8 2.0 – 8.0%/0.30 – 1.00 rb/ul
NLR 3
ALC 1123

PTT 13.6 9.9 – 13.5 detik

APTT 28.0 22.2 – 37.0 detik
Kontrol APTT 24.8
 3/12/123
Tanggal Nilai Normal
RSUD Ulin
KIMIA GDS 107 < 200 mg/dl
DARAH GDP < 120 mg/dl
G2JPP < 200 mg/dl
HbA1C 4.0 – 5.6

Albumin 3,5 – 5,2 g/dl

Bilirubin Total 0.20 – 1.20 mg/dl

Bilirubin Direk 0.00 – 0.20 mg/dl

Bilirubin Indirek 0.20 – 0.80 mg/dl

SGOT 26 5 – 34 U/L
SGPT 13 0 – 55 U/L

Ureum 64 0 – 50 mg/dl
Kreatinin 6.93 0.72 – 1.25 mg/dl
eGFR 7

Natrium 136 136 – 145 Meq/L

Kalium 3.5 3.5 – 5.1 Meq/L
Chlorida 105 98 – 107 Meq/L
AGD
AGD
RSUD Ulin 03/12/23 Nilai Normal
5 lpm

Suhu 36,9 -
pH 7,475 7.350-7.450
PCO2 33.6 35-45 mmHg
PO2 147 80-100 mmHg
HCO3 24.8 22-26 mEq/L

BE 1.0 - 2-2 mEq/L

SpO2 99 %
%FIO2 41 %
PaO2/FiO2 358

Alkalosis respirasi tidak terkompensasi

CXR Examination

RS Ulin
3/12/23
USG Thorax Portable

RS Ulin
3/12/23
 ECG

RS Ulin 3/12/2
Sinus rhytme, HR 100
bpm, q patologis iii, aVF
 Ekokardiografi

17/11/2023 RS Ulin
Dimensi ruang jantung LA dilatasi, LV
eksentris hipertrofiFungsi sistolik global dan
segmental LV menurun dengan EF 41% by
teichFungsi diastolik LV disfungsi grade 3
Fungsi sistolik RV menurunTR moderate,
MR mild, AR mildEfusi pericard mild
 Assessment IPD

1. Shortness of breath
1.1 ADHF wet warm forrester II pada HFmrEF 41%
1.2 Efusi pleura dextra
1.3 efusi pericard ringan
2. CKD stg 5 on HD 2x seminggu (Rabu & Sabtu)
3. HT resistant
4. Moderate anemia NN dt renal disease
5. OMI inferior
6. Ascites Gr II
 Planning IPD

Planning Therapy Planning diagnosis

O2 NK 4 lpm, target SpO2 >95% • Monitoring UOP dan BC target -500
Diet renal 1600 kkal/hariRG <5 gram/hari, cc/hari
protein 1.2 g/kgBB/hari • Konsul paru di IGD
Transfusi PRC 2 kolf durante HD • Raber Div. Nefrologi di Ruangan untuk
Drip Fasorbid 2mg/jam, titrasi up HD lanjutan
Drip Furosemid 5 mg/jam, titrasi up
Inj. Omeprazole 40 mg/24 jam

P.O
Amlodipine 10 mg-0-0
Candesartan 0-0-16 mg
Clonidin 3x0.15 mg
CaCO3 3x500 mg
Asam folat 1x5 mg
Clopidogrel 1x75 mg
 Kesimpulan dari Departemen Paru

Diagnosis saja.
1. Efusi Pleura Dextra dt CKD Stg V on HD 9. Terapi lain sesuai DPJP
2. CKD stg 5 on HD 2x seminggu (Rabu &
Sabtu) Planning diagnosis
3. ADHF wet warm forrester II pada 10. MRS ruangan sesuai DPJP
HFmrEF 41% 11. Cek Analisa Cairan pleura
4. HT Stg 2 12. USG Thorax marker
5. Moderate anemia NN dt renal disease 13. Pasien kami ikuti, lapor ulang bila pasien
6. OMI inferior sudah setuju tindakan
7. Ascites Gr II

Planning Therapy
8. Pasien kami KIE untuk tindakan
Thoracocentesis pada thorax Dextra,
pasien menolak dilakukan tindakan di IGD
dan meminta dilakukan saat di ruangan
Terima Kasih