MORNING REPORT

August 13th 2015

Summary of Database
Identity

:Mr G/23yo/W 29

Chief Complain: General Weakness

Present Medical History
Patient suffer from general weakness since 1 month before admission,
gradually onset and get worse since 3 day ago.He felt powerless, didnt have
enough strength to do his daily basic
The patient complain about decrease of appetite since 1 week ago, he
only ate 5 spoon of food each meal. His bodyweight decreased in 1 month
from 53 kg to 38 kg.
The patient also complain about having oral trush since 1 week ago
went to RSSA and given fluconazole 1x150 mg. In the last 3 days, he felt
pain in swallowing.
The patient had already diagnosed HIV since 2 years ago and routinely
took ARV (Duviral and Neviral)
Familial History : He work medicine salesman
Social History : he is single, and a gay (homosexual)
Physical Examination
General
Appearance:
moderatelly ill

Looked:
underweight

VAS Score:-

PR: 127 bpm

RR:
24x/menit

GCS: 456

BP:90/60
mmHg

Head

Pupil isokor, diameter: 3 mm, anemic conjunctiva ,

icteric sclerae - oral trush +

Neck

JVP R+0 cm H2O (300), lymphnode enlargement -/-

Chest

Wall

Symmetric,

Tax:
36,50C

Ictus visible, palpable at ICS IV 1 cm lateral

MCL S
Trill: Heaves: Heart

RHM ~ SL D

LHM ~ ictus

S1 and S2 single
Stem Fremitus N N
Rh - Wh - Lung

- -

Extremities

NN

Sonor Sonor

NN

Sonor Sonor

--

- Abdomen

Sonor Sonor

--

flat,bowel sound N, liver span 8 cm, Traubes space

tympani, shifting dullness -, flank pain Warm, edema -/- , sensoris N/N, lateralisasi (-)
-/-

N/N

Urine
Production

Laboratory Result
Parameter

Result

Normal Value

Hb

8,10

g/dL

13.4 17.7 g/dL

Leucocyte

8240

/L

4.300-10.300/L

Hematocrit

25,20

40 47 %

Thrombocyte

314000

/L

142.000424.000/L

MCV

87,80

fL

80 93 fL

MCH

28,20

pg

27 31 pg

Differential count

0,0/

0-4/0-1/51-

0,0/84,1/5,3/10,6%

67/25-33/2-5 %

Random Blood Sugar

g/dL

<200 mg /dl

SGOT

308

U/L

0-40 U/L

SGPT

265

U/L

0-41 U/L

Ureum

37,30

mg/dL

16.6 48.5

Creatinine

0,87

mg/dL

<1.2

Determinan HIV

Natrium (Na)

131

mmol/L

136 45 mmol/L

Kalium (K)

3,25

mmol/L

3.5 5.0 mmol/L

Chloride (Cl)

99

mmol/L

98 106 mmol/L

TLC

437

ECG

Rhythm

:Sinus tachycardia

Rate

:114 bpm

Frontal Axis

: normal

Horizontal Axis

: normal

PR interval

: 2,0.

QRS complex

: 0,8.

QT interval

: 2,8

Conclusion

: sinus tachycardia HR114 bpm

CUE AND
CLUE

Problem
List

Initial
Diagnosis

Planning
Diagnosi
s

Planning
Therapy

Pmo &
Pedu

1.
Male/23YO/W
29

1.
General
Weaknes
s

1.Anemia
Normocrom
Normositer

-Blood
smear

-O2 4-6
lpm nasal
canula

S, VS

History
Weakness
Decrease of
Appetite

1.1. drug
induced
ARV
1.2. related
HIV

Reticulocy
te count
-Ferritrin
test

- IVFD NS
0,9% 20
dpm
-HCHP diet

Hb level
Pedu :
managem
ent
disease,
treatment,
complicati

Nausea and
vomite

infection

-Treat
underlying
disease

HIV on
treatment ARV
(Duviral and
Neviral)

on

- Switch
ARV
induced
anemia

Physical
Examination
BP 90/60 PR
127 RR 24 Tax
36.5
Conjuctiva
anemis
Lab:
HB ; 8,10 g/dL
MCV : 87,80 fL
MCH : 87,80 pg
Na : 131
mmol/L
TLC 437

2. Male/23YO/W 29
History
General Weakness
Chronic Cough
Oral Trush
Decrease of body
weight
Roitenely controle to
RSSA and consume

2. HIV stage
IV on
treatment

2. HIV stage IV
on
treatment

- HCHP diet

CD4

- ARV as above

S, VS
Pedu :
management
disease,
treatment,
complication

FDC ARV
Physical Examination
Tax: 36,4
Oral trush (+)
Lab:
Hb: 8.1 g/dL
TLC : 437

3Male/23 YO/W 29

3.Oral Trushl

History

3.Candidias
ofaringea
l

KOH swab

Decrease of appetite
Dysfagia

-Infusion
Fluconazole
loading 1 x
400 mg Iv
continue with
1x200 mg IVpo
-Nystatin oral
drop 4x3cc

Oral trush

Subjective
Oral trush
Pedu :
management
disease,
treatment,
complication

Physical
Examination
Oral trush (+)

4. Male/23 YO/W 29
History
Routenely control to
RSSA and take FCD
ARV
Physical

4. Increase
of serum
transaminas
e

4.1. Hepatitis
infection

HBsAg

Confirm
diagnosed

Anti HCV
4.2 dt. ARV
induced

Albumine

S,VS
SGOT, SGPT

Changed ARV
induced
transaminitis

Pedu :
management
disease,
treatment,

Examination
Icteric sclerae
Lab
SGOT 308
SGPT 265

complication