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CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring
Mr. J/ 38 y.o 1. AFI day 2 + 1.1 UTI Rontgen Non Pharmacology: Plan Monitoring: - Febris since 2 days ago. improved with paracetamol High Calories High Protein Diet • VAS - Left lower back pain, intermitten,worsen when patient leukositosis + complicata Thorax was inhaling, low back pain sometimes spreads to the • Vital sign: TD,HR, RR left front of the stomach, history of abdominal trauma eritrosituria Pharmacology: (-) 1.2 other ECG - Inf. Ciprofloxacin 2x400 mg • Urin output and fluid - Skin rash (-), dyspneu (-), cough (-), nausea et vomitus infection - Inj. Antrain 1 amp if needed balance (-) - Painful urination (-), reddish urine (-), blocked urination - IVFD NS 1.500 cc/24 hour (+) gritty urine (-) Plan Education: • Cause of the diseases • Prognosis of the disease Objective Laboratory results: GCS : E4V5M6 Lab 21/04/24 RSUD Ulin TD : 143/99 mmHg Leukosit 10.700 HR : 85 x/m Neu 54.8% RR : 22 x/m limfosit 36% T : 36,7 C SpO2 : 97% on RA Urinalysis 21/04/2024 VAS 2/10 Protein albumin +1 Glucose (-) Abdomen: flank pain (-) Bilirubin (-) Extermity: Edema (-/-) Blood +3 Bacteria (-)
Urine Sediment 21/03/2024
Leucocute 2-3 Eritrocyte 35-40 Epithel +1 CUE AND CLUE Problem List Initial Planning Planning Planning Diagnosis Diagnosis Therapy monitoring
Mr. J/ 38 y.o 2. Bladder stone Non Pharmacology: Plan Monitoring:
- History of bladder stone since 7 years ago High Calories High Protein Diet • VAS - History of ESWL 2x in 2022 with severe - Previously, an abdominal ultrasound was performed at Hydronephrosis • Vital sign: TD,HR, RR Barabai Hospital and it was said to be severe Pharmacology: hydronephrosis sinistra + - Inj. Antrain 1 amp if needed • Urin output and fluid - Painful urination (-), reddish urine (-), blocked urination Hydroureter sinistra - IVFD NS 1.500 cc/24 hour balance (+) gritty urine (-) Consult to urology division Plan Education: • Cause of the diseases • Prognosis of the disease Objective Laboratory results: GCS : E4V5M6 Lab 21/04/24 RSUD Ulin TD : 143/99 mmHg Ur 34 HR : 85 x/m Cr 0.99 RR : 22 x/m T : 36,7 C Urinalysis 21/04/2024 SpO2 : 97% on RA Protein albumin +1 VAS 2/10 Glucose (-) Bilirubin (-) Abdomen: flank pain (-) Blood +3 Extermity: Edema (-/-) Urine Sediment 21/03/2024 Leucocute 2-3 Eritrocyte 35-40 Epithel +1
Abdominal USG 19/4/24 RS
Barabai Left severe HN and proximal left HU due to ureteral obstruction stone measuring 2.2 x 0.6 cm (current distance +/- 1.6 cm from the tip of the left renal pelvis) CUE AND CLUE Problem List Initial Planning Planning Planning Diagnosis Diagnosis Therapy monitoring
Mr. J/ 38 y.o 3. Elevated liver 3.1 Reactive Check for Non Pharmacology: Plan Monitoring: - Febris since 2 days ago. improved with paracetamol High Calories High Protein Diet • VAS - nausea et vomitus (-) enzym HbsAg and - Jaundice (-) 3.2 Hepatitis Anti HCV • Vital sign: TD,HR, RR Pharmacology: Po. Curcuma 3x1 tab • Check for SGOT/SGPT/ 72 hours
Plan Education: • Cause of the diseases • Prognosis of the disease Objective Laboratory results: Planning diagnosis GCS : E4V5M6 Lab 21/04/24 RSUD Ulin • TD : 143/99 mmHg SGOT 74 HR : 85 x/m SGPT 195 RR : 22 x/m PT 11.1 T : 36,7 C APTT 25 SpO2 : 97% on RA INR 1.03 VAS 2/10
Skin: Jaundice (-)
Eyes: Sclera icteric (-) Abdomen: hepar and lien cannot be palpated Extermity: Edema (-/-)
