PATIENT REPORT

February, 2nd 2025

DUTY SUPERVISOR
Dr. dr. Muh. Ilyas, Sp.PD, K-P, Sp.P(K)
DUTY RESIDENT
Duty Senior on ER : dr. Azhar, dr. Rahman
Duty Junior on Ward : dr. dr. Anet, dr. Arwan, dr. Yanto
Duty Senior on Ward : dr. Anni
Duty Chief : dr. Afifah
 VISI DAN MISI
PROGRAM STUDI PULMONOLOGI DAN KEDOKTERAN
RESPIRASI

VISI

Menjadi Program Studi Pulmonologi dan Kedokteran Respirasi terkemuka

di Indonesia dan kawasan Asia Tenggara, yang unggul dalam pendidikan,
penelitian, serta pelayanan masyarakat di bidang penyakit paru dan
kedokteran respirasi, berbasis maritim dan kearifan lokal untuk
menciptakan tenaga medis profesional, inovatif, dan berdaya saing global
pada tahun 2028
 VISI DAN MISI
PROGRAM STUDI PULMONOLOGI DAN KEDOKTERAN
RESPIRASI

MISI

1. Penyelenggaraan pendidikan unggul dan inovatif melalui pendekatan budaya maritim

secara paripurna dan bermutu
2. Penguatan Riset di bidang penyakit paru dan kedokteran respirasi berbasis kearifan
lokal dan berkualitas Internasional
3. Pengabdian Masyarakat Berkelanjutan di bidang penyakit paru dan kedokteran
respirasi
4. Kerja Sama Strategis dan Peningkatan Kompetensi di bidang penyakit paru dan
kedokteran respirasi Berbasis Etika dan Kearifan Lokal
 Patient Resume
EMERGENCY ROOM PATIENT TOTAL
Emergency Room 0

PATIENT HOSPITALIZED TOTAL

From Emergency Room 0
From Policlinic 0

TOTAL
Patient Consult 0
Patient Died 0
DUTY REPORT
1 PATIENT
ANALYSIS

No. Identity Problem Planning Dx Planning Tx Monitoring

1. The patient came with complaints shortness of breath since 1 day Community Acquired Pneumonia • Check Gram Smear, MO • Ceftriaxone 2gr/24h/iv • Monitoring vital and
ago, not affected by activity and weather. no history of shortness of PSI Skor Minimal 58 Low Risk Culture and Ab • Azithromicin clinical sign
breath. Class I Sensitivity (SPUTUM) 500mg/24h/oral • Check Blood Routine
2. Cough with white sputum since 3 days ago, worsening since 1 day PSI Score after 72 hours AB
ago, no history of chronic cough. • Age +68 Symptomatic therapy administration
3. Fever since 2 days ago, no history of fever. • Woman -10 - O2 3 LPM
4. Heartburn and nausea - N-Acetylsistein
5. Right thigh pain since 3 weeks ago after falling in the kitchen. 200mg/8h/oral
6. Work as retired civil servant
7. History of treatment at Orthopedic poly dr. Petrus Johan, M.Kes,
Ph.D, Sp.OT (K) at Primaya Hospital on 30/01/2023 with Fracture 1/3
Right Proximal Femur and planned for surgery at Wahidin Hospital
8. Moderately illness/Composmentis (GCS 15, E4M6V5)
• SpO2: 93% without modality, 97% with Oxygen via Nasal Cannula 3
lpm Fraktur 1/3 Proksimal Femur • Consult Orthopedic • According to Orthopedic • Monitoring vital and
• Blood pressure: 115/64 mmHg Dextra Division Division clinical sign
• Heart Rate: 82 beats/minute
• Respiratory Rate: 24 times/minute
• Temperature: 39.5 Celsius Sindrom Dispepsia • Ranitidin 50mg/12/iv • Monitoring vital and
10. Thorax (Supine, Anterior): clinical sign
• Inspection: Symmetrical at both hemithorax when static and dynamic.
• Palpation: Tactile fremitus same at both hemithorax.
• Percussion: Sonor at both hemithorax
• Auscultation: Bronchovesicular, ronchi at media-basal left hemithorax,
ronchi at basal hemithorax, no wheezing
13. Laboratory 02/02/2025 RSWS (WBC 16.2, NEU 76 %)
14. Blood Gas Analysis Wahidin Hospital in 12/01/2025 (Nasal Cannula 5
lpm) waiting result
15. Chest X-Ray in 02/02/2025 at Wahidin Hospital (penumoia
bilateral)
LABORATO
RY

LAB 02-02-2025 Normal Range

Wahidin hospital
(Waiting Result)

WBC 16.2 4.00-10.00

HB 11.6 12.00-16.00
HCT 36 36-48
MCV 82 80-94
MCH 28 27-31
Platelet 328 150-400
Neutrophil 76.6 52.0-75.0
Lympochyte 16.4 20.0-40.0
GDS 101 140
SGOT/SGPT 31/18 <38/<41
Ur/Cr 18/0,59 Ur 10-50/ Cr <1.3
Albumin 3,6 3.5-5.00
Na/K/Cl 136/3,8/103 135-145/3.5-5.1/97-111
 BGA 02-02-2024 Normal Range
Wahidin Hospital (via NC 5 Lpm)
(Waiting Result)
PH 7.345 7.35-7.45
SO2 99 95-98
PO2 106 80-100

PCO2 36,5 35-45

HCO3 20 22-26
BE -1,6 -2 s/d +2
Blood Lactat 1,6 0.6-1.5
Old FiO2 0,36

New FiO2 0,28

AaDO2 -1,9
Conclusion Acidosis metabolic
RADIOLOGY FINDING

CXR 02-02-2025 XRAy Pelvic 30-01-2025

Wahidin Hospital Primaya Hospital
USG

Hemithorax sinistra et dextra

Pleural line (-)
A Line (+)
B Line (+)
C Line (-)
Hipoechoic (-)
Conclusion:
No pleural effusion

USG Thorax
02-01-2025
Wahidin Hospital
ECG

ECG
02-02-2025
Wahidin Hospital
THANK YOU