CUE AND CLUE Problem List Initial Planning Planning Planning

Diagnosis Diagnosis Therapy monitoring

Mr. S/ 28 y.o 1.1 Drug Non Pharmacology: Plan Monitoring:

- Shortness of breath since 2 days ago, suddenly felt like 1. Shortness of O2 NC k/p
being crushed. Shortness of breath appears at night breath Hypersensitivi • Subjective
when the air is cold, Complaints decreased after the ty Reaction High Calories High Protein diet
patient took Neo Napacin (Theophylline tab 150 mg) 1500 kkal/day • Vital sign: TD,HR, RR, SpO2
- 6 hours before admitted the patient went to
Bhayangkara Hospital with similar complaints, then was 1.2 Asthma Pharmacology:
given an injection (do not know the name of the drug) acute Plan Education:
at around 08.30, then the patient was outpatient and - Inj. Difenhidramin 3x1 amp
was given tablets (cetirizin, omeprazole, b complex, and exaserbation - Nebul combivent /8 hour • Cause of the diseases
dexamethasone). (improved) • Prognosis of the disease
- The patient was discharged at 10.00. On the way home, Consult to pulmonology
the patient's eyes started to swell.
- chest tightness reappeared at 12.00, accompanied by division to consider spirometry
reddish bumps on the body without pruritus
Objective Laboratory results: Consult to dermatovernology
GCS: E4V5M6 Lab 27/06/24 RSUD Ulin to consider skin prick test
TD: 149/108 mmHg Leukosit 10.800
HR: 120 x/menit Neu% 72.4
RR: 20x/menit Eosi% 0.6
T: 36 C limfosit% 19.1
SpO2: 91% RA --> 99% Nk 2 lpm
CxR 27/6/24
Skin Abnormalities: Multiple Exp(-), normal cast, increased
external dominant macular bronchovesicular cleft, ICS
erythema, pruritus (-) dilation
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Mr. S/ 28 y.o 2. Multiple 2.1 Rt drug Non Pharmacology: Plan Monitoring:

- 6 hours before admitted the patient went to O2 NC k/p
Bhayangkara Hospital with similar complaints, then was erythemed macules eruption • Subjective
given an injection (do not know the name of the drug) High Calories High Protein diet
at around 08.30, the ulcer pain decreased, then the with predominantly 1500 kkal/day • Vital sign: TD,HR, RR, SpO2
patient was outpatient and was given tablets (cetirizin, peripheral areas 2.2 Eritema
omeprazole, b complex, and dexamethasone). multiform Pharmacology:
- The patient was discharged at 10.00. On the way home, Plan Education:
the patient's eyes started to swell. - Inj. Difenhidramin 3x1 amp
- chest tightness reappeared at 12.00, accompanied by - Inj. Methylprednisolone • Cause of the diseases
reddish bumps on the body without pruritus 2x62.5mg • Prognosis of the disease
Objective Laboratory results: Consult to dermatovernology
GCS: E4V5M6 Lab 27/06/24 RSUD Ulin to consider skin prick test
TD: 149/108 mmHg Leukosit 10.800
HR: 120 x/m Neu% 72.4
RR: 20x/m Eosi% 0.6
T: 36 C limfosit% 19.1
SpO2: 91% RA --> 99% Nk 2 lpm

Skin Abnormalities: Multiple

external dominant macular
erythema, pruritus (-)
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Mr. S/ 28 y.o 3. PVC Occasional Non Pharmacology: Plan Monitoring:

- History of hypertension O2 NC k/p
- Dyspneu (+) • Subjective
Epigastric pain since 2 days ago, appears slowly, feels High Calories High Protein diet
-
hot and stabbing in the centre of the chest. 1500 kkal/day • Vital sign: TD,HR, RR, SpO2
• Evaluates ECG if there is a
Pharmacology: palpitation
- IVFD NS 1500/24 jam
Plan Education:
• Cause of the diseases
• Prognosis of the disease
Objective Laboratory results:
GCS: E4V5M6 Lab 27/06/24 RSUD Ulin
TD: 149/108 mmHg Leukosit 10.800
HR: 120 x/m Neu% 72.4
RR: 20x/m Eosi% 0.6
T: 36 C limfosit% 19.1
SpO2: 91% RA --> 99% Nk 2 lpm
ECG 27/6/24
Cor: S1- S2 single, irregular, Sinus tachycardia 120 bpm, RAE
murmur (-)
ECG on monitor
PVC (+)