CUE AND CLUE Problem List Initial Planning Planning Planning

Diagnosis Diagnosis Therapy monitoring

Mrs. R/ 32 y.o 1. Shortness of 1.1 CAP non Sputum Non-Pharmacology: Plan Monitoring:
- Shortness of breath since 5 hours before admitted
- Cough (+) breath severe culture Oxygenation with Simple Mask • Symptom : SOB, cough
- Patients often woken up because of the SOB (+) 1.2 Acute Lung 5-10 lpm • SpO2, RR
- SOB decreases when patient sitting (+)
Oedema Check for
sputum Pharmacology: Plan Education:
Sp. Furosemid 10 mg/hour
gram titrate up • Educate that the condition
SP. Fasorbid 2 mg/hour titrate still needed to be
BTA up diagnosed first before
Objective Laboratory results: Inj. Ceftriaxone 1g/ 12 hour treated
GCS 15 Lab 12/03/24 RSUD Ulin • Educate the prognosis
TD: 140/100 mmHg , N: 125x/m Leukosit 8.000 Po : about the disease
RR: 28x/m Neut% 79.0 Azythormicine 1x 500 mg
T: 37.2 C Limf% 10.5%
SpO2 : 90% RA--> 93% NK 5 lpm Join care with GEH division
--> 97% on SM 7 lmp Blood gas analuysis
Lab 12/03/24 RSUD Ulin
Pulmo: pH 7.454
Breath sound (VVV/VBVBV) PCO2 32.1
Rough wet rales (-++/--+) PO2 86.0
Wheezing (---/---) HCO3 22.5
BE -1.0
Laboratory results: O2 saturasi 97%
Lab 11/02/24 Prodia FiO2 57
Leu 5.100 P/F ratio 150
N% 68.1 Alcalosis respyratoric half
L% 23.3 compensated

Thorax Ronthen 12/03/24 in

RSUD Ulin
- Cardiomegaly
- Infiltrate pulmo bilateral
- Cranialisasi
 INITIAL PLAN

CUE AND CLUE Problem List Initial Planning Planning Planning

Diagnosis Diagnosis Therapy monitoring

Mrs. R/ 32 y.o 2. SLE with Check UL Pharmacology: Plan Monitoring:

- Patient were diagnosed with SLE since 2013, never moderate Venflon: • Monitor complaints;
been relapsed until 2023 October
- SOB (+) activity Inj Methyprednisolon fatigue, SOB
- Stomatitis (-) 125mg/12 hour • Evaluates Ur/Cr 48 hours
- Fatigue (+) since 2 days ago again
- Butterfly rash (-) PO:
- Alopecia (-)
- Joint involvement (-) MMF 2x 1000 mg Plan Education:
- Urine looks like tea since 4 days ago Sandimun 2x 25 mg • Explain patient and family
- Treatment history: MMF 2x 1000mg, HCQ 2x 200mg, HCQ 2x200 mg about the treatment of
MP 2x 16mg, Calos 3x500mg CaCO3 3x500mg SLE and what its
Objective Anna Profile 21/12/23 Prodia manifestasions
GCS : E4V5M6 dsDNA +2, NUC +1, Histones +1, Control
(Ko) +3 Join care with
TD : 140/100 mmHg Rheumatology division
Pulse : 125 x/m Laboratory results:
T: 37.2 Lab 12/03/24 RSUD Ulin
UO: 500 cc/3 jam Hb 8.7
Diur: 2.77 cc/kgbb/3 jam Leucocyte 8.000
Neut% 79.0
Face: Butterfly rash (-) Limf% 10.5%
Eye: Anemis (+) Trombocyte 147.000
Mouth: oral ulcers (-) Calcium 9.0
Scoring Ur 115/ Cr (Reagen out of stock)
MEX Sledai (Hemolisis(2),
fatigue with no proper Echocardiography 12/02/24 RSUD Ulin
Pericard efusion mild
explanation(1), pericard
effusion(2), renal
involvement(6)
Total: 11 --> Moderate disease
Activity
 INITIAL PLAN
Initial Planning Planning
CUE AND CLUE Problem List Diagnosis Diagnosis Therapy Planning
monitoring
Mrs. R/ 32 y.o 3. Moderate 3.1 rt no 2 Check Blood Non-Pharmacology: Monitoring:
• Weakness (+) Anemia NN 3.2 blood loss routine post Oxygenation with Simple Mask • Monitor side effect
• Patient look pale (+) tranfusion 5-10 lpm after tranfusion
• Menstruation (-)
• Gum bleeding (-) Education:
• Epikstasis (-) Pharmacology: • Explain to patient
(10-8.7) ×4×60= 312 ~ Prepare and family about the
2 kolf PRC leukodepleted 1 disease and
kolf/ day with premed
Pem. FIsik: Lab 12/03/24 RSUD Furosemid 1 amp tranfusion planning
RR: 28 x/menit Ulin • Explain the side
Pulse: 125x/m Hb 8.7 effect after tranfusin
SpO2: 90% RA--> 93% MCV 87.6
NK 5 lpm --> 97% on MCH 30.9
SM 7 lmp PT 12.3
INR 1.15
Eyes: Anemis (+) APTT 23.1
 INITIAL PLAN
Initial Planning Planning
CUE AND CLUE Problem List Diagnosis Diagnosis Therapy Planning
monitoring
Mrs. R/ 32 y.o 4. HFpEF Non-Farmakologi: Monitoring:
• Shortness of breath (+) (52%) stage C Oxygenation with Simple Mask • Monitor HR, RR,
• Dyspneu on effort (+) FC III 5-10 lpm SpO2
• Orthopneu (+) High Calories, high protein Diet
Education:
Farmakologis • Explain to patient
- Sp. Furosemid 10 mg/hour and family about the
titrate up
- SP. Fasorbid 2 mg/hour titrate disease and the
Physical examination: ECG 12/03/24 RSUD Ulin up planning therapy
RR: 28 x/menit Sinus tacychardia, 135x/m - Inj. Omeprazole 40 mg/hour
Pulse: 125x/m - Inj. Metoclopramide 10
SpO2: 90% RA--> 93% NK 5 Echocardiography 12/02/24 mg/hour
lpm --> 97% on SM 7 lpm RSUD Ulin
- LV dilates PO
Neck : JVP 5+2cmH2O - No thrombus Candesartan 1x 16mg
Pulmo: - Normokinetik
Breath sound (VVV/VBVBV) - IVS dan IAS intact
Atorvastatin 1x 20mg
Rough wet rales (-++/--+) - systolic function LV was
Wheezing (---/---) good (EF: 52%)
Cor: - Distrubance on FS LV
murmur (-) diastolic mild (E/A: 2,16)
Extermity: edema (+/+), - Good RV systolic function,
pitting edema (+/+) TAPSE 26 mm
- Valves: MR mild, TR
Scorning: - Pericardial effusion mild
Framingham: DOE,
Cardiomegaly, Rales Thorax Ronthen 12/03/24 in
RSUD Ulin
- Cardiomegaly
 Initial Planning Planning
CUE AND CLUE Problem List Diagnosis Diagnosis Therapy Planning
monitoring
Mrs. R/ 32 y.o 5. Hypertension Farmakologis Monitoring:
• History of hypertension (+) on therapy - Candesartan 1x 16mg • Monitor patient’s
• Treatment history : Candesartan 1x16mg blood pressure

Education:
• Explain to patient
and family about the
disease and therapy
Physical examination: - • Explain to the patient
BP: 140/100 and family about
Pulse: 125x/m dietary choice on
people with
hypertension
 INITIAL PLAN
Initial Planning Planning
CUE AND CLUE Problem List Diagnosis Diagnosis Therapy Planning
monitoring
Mrs. R/ 32 y.o 6. Moderate Farmakologis Monitoring:
• Weakness (+) hypokalemia - Hypokalemia correction: • Monitor Electrolyte
• Loss of apetite since 3 days ago (3.5-2.8)x 0.4x 60= 16.8+60= serum after
76.8 correction
Drip KCL 2 flsh in NS 500
completed by d12 hour Education:
- KSR 2x 600mg
• Educate patient to eat
food that high in
Physical examination: Lab 12/03/24 RSUD kalium, such as
RR: 28 x/menit Ulin banana, avocado, and
Pulse: 125x/m Kalium : 2.8 fish

ECG 12/03/24 RSUD

Ulin
Sinus tacychardia,
135x/m
 INITIAL PLAN
Initial Planning Planning
CUE AND CLUE Problem List Diagnosis Diagnosis Therapy Planning
monitoring
Mrs. R/ 32 y.o 7. Moderate Non Pharmacology Monitoring:
• Weakness (+) hipoalbuminem High Calories, high protein Diet • Monitor albumin
• Loss of apetite since 3 days ago ia
• Edema since 2 days ago. Edema was reduced if Pharmacology Education:
patient’s leg was prop - Onoiwa 2x1 sachet • Educate patient to eat
food that high in
protein, such as fish
and white egg
Physical examination: Lab 11/02/24 Prodia
RR: 28 x/menit Albumin 2.8
Pulse: 125x/m
SpO2: 90% RA--> 93%
NK 5 lpm --> 97% on
SM 7 lmp

Abdomen: Shifting
dullness (+)
Extermity: Edema (+/+),
pitting oedema (+/+)