Eden Suryoiman WInoto

MORNING REPORT
Monday, 8 May 2017

PHYSICIAN IN CHARGE :
IA : dr. Eden, dr. Fatony, dr. Tio
II CVCU : dr. Indri
II HCU : dr. Norma
II UGD : dr. Rahmad, dr. Irma
Chief : dr. Bayu
Consultant : dr. Syifa Mustika, SpPD
Facilitator : dr. Djoko Heri H., SpPD-KHOM
 SUMMARY OF DATABASE
Mr. R/32 yo/ w.27
Autoanamnesa and Heteroanamnesa (patient’s mother)
Chief Complaint : Fatigue and body weakness
HISTORY OF PRESENT ILLNESS :
• Patient suffered from body weakness and fatigue since 2 weeks before admission. The
patient also complained about light-headedness and blackout when he stood still for
quite a long time. Because of the complaint he suffered from, his daily activities
became limited, and he got out from his working place.
• He also complained about shortness of breath that occured when he walked about 10
metres, and subsided when he took a rest. Because of these complaints, his family took
him to ER military hospital in Malang. He was diagnosed with low level of Hemoglobine
and then got transfused with 2 packs of blood. He was then refered to RSSA for further
management. In RSSA ER, he got another pack of lood transfusion, and when he was
transfered to ward, his complaint about weakness and dyspneu was subsided.
• Patient complained about white plaque that covered his tongue since 3 months ago.
Initially the plaque only covered his tongue and then gradually spread to all over his
oral cavity. Now, he complained about pain when he swallow solid food or fluid. This
complaint was occured since the last 2 weeks before admission. Because of the bitter
sensation in his mouth, he also suffered from decrease of appetite. He only ate ¼
portion of his regular meal.
 SUMMARY OF DATABASE Cont.
HISTORY OF PRESENT ILLNESS (cont) :
• He also complained about bloating sensation, sometimes accompanied with nausea
and vomiting. The vomit contain food, water and sometimes felt heart burn and
epigastric pain when he got vomiting.
• Patient was diagnosed with HIV infection in the beginning of March 2017 in Malang
military hospital. At the time he was diagnosed, he was suffered from white plaque
that didn’t resolved after 1 month of treatment using Nystatin drop. An internist in the
previous hospital suggested him to perform HIV check, and the result was positive.
After the diagnosis was confirmed, ARV treatment (Duviral and Neviral) was started
since 12 March 2017, 2x1 tab daily.
 SUMMARY OF DATABASE Cont.

PAST MEDICAL HISTORY & MEDICATION:

• Patient had no history of drugs nor food allergies
• Patient had never been hospitalized before
• HT and DM were denied
FAMILY HISTORY :
• He is a single, not yet married
• His parents already knew about the patient’s disease, and they support him to
undergone treatment
SOCIAL HISTORY :
• He used to work in the insurance agency for 3 years in Surabaya. He lived by himself,
far from family
• Risk factor for HIV : multi-partner heterosexual
REVIEW OF SYSTEM :
• Decrease of body weight 20kgs in 2 months, diarrhea (-), cough (-), headache (-),
decrease of consciousness (-), history of seizure (-), blurred vision (-), signs and history of
bleeding (-), defecating and urinating were normal
 PHYSICAL EXAMINATION
General appearance looked moderately ill Looked underweight
GCS 456 Sat. O2 98% on O2 10Lpm via NRBM
BP 100/70 mmHg PR 100 bpm RR 28 tpm Tax 38 oC
Head Conjuctiva Anemic (+), Sclera Icteric (-), oral thrush (+)
Neck Lymphadenopathy (-), JVP R+2 cmH20
Chest Lung Sonor | Sonor V|V Rhonkhi : - | - Wheezing : - | -
Sonor | Sonor V|V -|- -|-
Sonor | Sonor V| V -|- - |-
Cardio ictus invisible, palpable at MCL (S) ICS IV
LHM ~ ictus, RHM ~ SL (D)
S1 S2 single, regular, murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) Normal, epigastric and RUQ pain on
palpation (VAS Score 4/10)
Liver/ unpalpable, liver span 10 cm
Lien/ unpalpable, Traube‘s space tympani
Extremities Edema (-)
 LABORATORY FINDINGS
(7 May 2017)
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 3.200 4.700 – 11.300 /µL Natrium 141 136-145 mmol/L
Haemoglobine 4,1 11,4 - 15,1 g/dl Kalium 4,86 3,5-5,0 mmol/L
Hematocrite 12,0% 38 - 42% Chlorida 113 98-106 mmol/L
Thrombocyte 218,000 142.000 – 424.000 /µL RBS 126 < 200 mg/dl
MCV 85.1 80-93 fl Ureum 67,8 20-40 mg/dL
MCH 29.1 27-31 pg Creatinine 1,7 <1,2 mg/dL
Eo/Bas/Neu/ 0.0/0.0/85.6/ 0-4/0-1/51-67/ eGFR (MDRD) 49,89 > 90 ml/min/1,73 m2
Limf/Mon 9.7/4.7 25-33/2-5
Albumin 3,10 3,5 - 5 g/dL
CD 4 52 637-1485 cell/uL SGOT 1595 0-40 U/L
SGPT 1072 0-41 U/L
HBsAg Non-reactive Anti Toxoplasma IgM 0,168 (-) Negative (<0,8 COI)
Anti HCV Negative Anti Toxoplasma IgG 145,8 (+) Negative <1 IU/mL
Anti CMV IgM 1,86 (+) Negative (<0,7 COI) VDRL Non- Non-reactive
reactive
Anti CMV IgG 146,3 (+) Negative (<0,5 U/mL) TPHA Non- Non-reactive
reactive
 LABORATORY FINDINGS
BGA on O2 10 Lpm via NRBM
TEMP O2 L/M
pH 7.41 7.35-7.45
PCO2 18,1 35 – 45 mmHg
PO2 86,7 80 – 100 mmHg
HCO3 11,7 21 – 28 m mol/L
O2 sat Art 99 > 95 %
BE -13,1 (-3) - (+3) m mol/L
Conclusion : Metabolic acidosis fully compensated with respiratory alkalosis
CHEST X-RAY
__________
7 May 2017
 CXR interpretation
• AP position, asymmetric, enough KV, less inspiration
• Soft tissue thin and Bone normal
• Trachea in the middle
• Right/Left Hemidiaphragm were dome-shaped
• Right/Left Phrenicocostalis angle were sharp
• Pulmo D/S: normal broncovascular pattern D/S, infiltrate in
perihilar D/S and medio basal area S
• Cor: site Normal, size CTR 50%, cardiac waist (+)
__________________________________________________________________________________________

Conclusion : Pneumonia
 PLANING
PROBLEM INITIAL PLANNING PLANNING
CUE AND CLUE MONITORING
LIST DIAGNOSE DIAGNOSE THERAPY
& EDUCATION
Mr. R/ 32 y.o/ W. 27 1. HIV St IV on - - • Bed rest Subjective
ARV (Duviral + • IVFD NaCl 0,9% 20 dpm complaint, VS
SUBJECTIVE Neviral) • Plan for switch to FDC ARV
- Body weakness (Tenofovir 300mg, Efavirenz P. Edu
- Decrease of BW + 20kgs in 600mg, Lamivudine 150mg) Educate the
2 months • Peroral : Paracetamol 3x500mg patient about the
- White plaque all over the disease, planning
mouth with pain when for management
swallowing food/ fluid and prevention of
- Diagnosed with HIV and infecting others
undergone ARV therapy for
the last 2 months

OBJECTIVE
Physical Examination
Looked underweight
GCS 456
BP 100/70 mmHg
PR 100 bpm
RR 28 tpm
Tax 38 oC
SaO2 98% with O2 10 Lpm via
NRBM
Conjunctiva anemis (+)
Oral thrush (+)

Laboratory Result
TLC 301 cell/uL
CD4 52 cell/uL
 PLANING
PROBLEM INITIAL PLANNING PLANNING
CUE AND CLUE MONITORING
LIST DIAGNOSE DIAGNOSE THERAPY
& EDUCATION
Mr. R/ 32 y.o/ W. 27 2. Anemia 2.1 Drug induced Blood smear • Stop Duviral (Zidovudine) Subjective
normochromic dt. Zidovudine • O2 10 Lpm via NRBM complaint, VS
SUBJECTIVE normocytair 2.2 Chronic • PRC transfussion 2 packs/day until
- Body weakness disease Hb >/= 10 g/dL P. Edu
- Light headed-ness, syncope Educate the
- Pale appearance patient about the
- Diagnosed with HIV and disease, planning
undergone ARV (Duviral for management
and Neviral) therapy for
the last 2 months
- History of bleeding was
denied

OBJECTIVE
Physical Examination
Looked underweight
GCS 456
BP 100/70 mmHg
PR 100 bpm
RR 28 tpm
Tax 38 oC
SaO2 98% with O2 10 Lpm via
NRBM
Conjunctiva anemis (+)
Oral thrush (+)

Laboratory Result
Hb 4,1 g/dL
MCV 85,1 fl
MCH 29,1 pg
 PLANING
PROBLEM INITIAL PLANNING PLANNING
CUE AND CLUE MONITORING
LIST DIAGNOSE DIAGNOSE THERAPY
& EDUCATION
Mr. R/ 32 y.o/ W. 27 3. Oroesopha- - KOH swab • Fluconazole 1x400mg (D1) continue Subjective
geal candidiasis with 1x200mg (D2- so on) complaint, VS
SUBJECTIVE
- Body weakness P. Edu
- White plaque in all over Educate the
oral cavity patient about the
- Pain when swallowing solid disease, planning
fluid and fluid for management
- Diagnosed with HIV and and prevention of
undergone ARV (Duviral infecting others
and Neviral) therapy for
the last 2 months

OBJECTIVE
Physical Examination
Looked underweight
GCS 456
BP 100/70 mmHg
PR 100 bpm
RR 28 tpm
Tax 38 oC
SaO2 98% with O2 10 Lpm via
NRBM
Conjunctiva anemis (+)
Oral thrush (+)

Laboratory Result
TLC 301 cell/uL
CD4 52 cell/uL
 PLANING
PROBLEM INITIAL PLANNING PLANNING
CUE AND CLUE MONITORING
LIST DIAGNOSE DIAGNOSE THERAPY
& EDUCATION
Mr. R/ 32 y.o/ W. 27 4. Increase of 4.1 Drug induced IgM Anti HAV • Avoid hepatotoxic drug (Stop Subjective
transaminase dt. Nevirapine Neviral) complaint, VS,
SUBJECTIVE 4.2 Acute viral SGOT/SGPT serial
- Body weakness hepatitis A per 3 days
- Low intake
- Diagnosed with HIV and P. Edu
undergone ARV (Duviral Educate the
and Neviral) therapy for patient about the
the last 2 months disease, planning
for management
OBJECTIVE
Physical Examination
Looked underweight
GCS 456
BP 100/70 mmHg
PR 100 bpm
RR 28 tpm
Tax 38 oC
SaO2 98% with O2 10 Lpm via
NRBM
Epigastric and RUQ pain on
palpation, VAS Score 4/10

Laboratory Result
SGOT/SGPT : 1595/1072 U/L
Albumin 3,10 g/dL
 PLANING
PROBLEM INITIAL PLANNING PLANNING
CUE AND CLUE MONITORING
LIST DIAGNOSE DIAGNOSE THERAPY
& EDUCATION
Mr. R/ 32 y.o/ W. 27 5. Azotemia 5.1 Prerenal dt. Urinalysis, Renal • Equal balance fluid Subjective
Volume biopsy • Avoid using of nephrotoxic drugs complaint, VS
SUBJECTIVE depletion
- Body weakness 5.2 Renal dt. HIV P. Edu
- Decrease of appetite, low associated Educate the
intake nephropathy patient about the
- Nausea and vomiting disease, planning
- Diagnosed with HIV and for management
undergone ARV therapy for
the last 2 months

OBJECTIVE
Physical Examination
Looked underweight
GCS 456
BP 100/70 mmHg
PR 100 bpm
RR 28 tpm
Tax 38 oC
SaO2 98% with O2 10 Lpm via
NRBM
Conjunctiva anemis (+)
Oral thrush (+)

Laboratory Result
Ureum/Creatinine
67,8/1,7 mg/dL
BUN/Cr ratio 18
eGFR (MDRD) 49,89
ml/min/1,73 m2
 PLANING
PROBLEM INITIAL PLANNING PLANNING
CUE AND CLUE MONITORING
LIST DIAGNOSE DIAGNOSE THERAPY
& EDUCATION
Mr. R/ 32 y.o/ W. 27 6. Nausea and - - • Treat underlying disease Subjective
vomiting • IV : Omeprazole 1x40mg complaint, VS
SUBJECTIVE Metoclopramide 3x10mg
- Body weakness P. Edu
- Decrease of appetite, low Educate the
intake patient about the
- Nausea and vomiting disease, planning
- Diagnosed with HIV and for management
undergone ARV therapy for
the last 2 months

OBJECTIVE
Physical Examination
Looked underweight
GCS 456
BP 100/70 mmHg
PR 100 bpm
RR 28 tpm
Tax 38 oC
SaO2 98% with O2 10 Lpm via
NRBM
Epigastric and RUQ pain on
palpation, VAS Score 4/10
 PLANING
PROBLEM INITIAL PLANNING PLANNING
CUE AND CLUE MONITORING
LIST DIAGNOSE DIAGNOSE THERAPY
& EDUCATION
Mr. R/ 32 y.o/ W. 27 7. Shortness of 7.1 PCP LDH • Cotrimoxazole 4x1440mg Subjective
Breath 7.2 CAP • Prednisone 1x40mg (D1-D5) complaint, RR,
SUBJECTIVE Continue with 1x20mg (D6-D10) SaO2, BGA
- Body weakness
- Fever P. Edu
- Diagnosed with HIV and Educate the
undergone ARV therapy for patient about the
the last 2 months disease, planning
for management
OBJECTIVE
Physical Examination
Looked underweight
GCS 456
BP 100/70 mmHg
PR 100 bpm
RR 28 tpm
Tax 38 oC
SaO2 98% with O2 10 Lpm via
NRBM

Laboratory Result
BGA : pH 7,41/ pCO2 18,1/
pO2 86,2/ HCO3 11,7/BE -13,1
CXR : pneumonia
 DUVIRAL & NEVIRAL THERAPY
HIV St. IV
IMMUNOCOMPROMISED

OROESOPHAGEAL
PCP CANDIDIASIS ANEMIA NN

NAUSEA & VOMITING,

DECREASE OF APETITE,
INCREASE OF LOW INTAKE
TRANSAMINASE

DYSPEPSIA
ANEMIA HM SYNDROME

HYPOALBUMINEMIA
PROBLEM
ANALYSIS
 Risk Factor Analysis
Problem Theory Analysis
HIV  Unprotected sex Unprotected sex
 Intravenous drug user Multiple partners
 Have a Sexually
transmitted infection
 Blood transfusion
 Multiple partners
 Anal, vaginal or oral
sex in homosexual
person
 Exposed to the virus as
a fetus or infant before
or during birth or
through breastfeeding
from a mother
infected with HIV
 Management Analysis
Problem Theory Analysis
ARV on HIV 1. Start antiretroviral ARV given at least 2
therapy in all patients weeks after patients
with a CD4 count <350 receive treatment of
cells / mm3 regardless of opportunistic infections
the clinical stage.
2. ARV therapy is
recommended in all
patients with active
tuberculosis, pregnant
women and Hepatitis B
coinfection regardless of
the of CD4 count.

Source:
Pedoman Nasional Tatalaksana
Klinis Infeksi HIV dan Terapi
Antiretroviral pada orang Dewasa
 Key Message Pathogenesis

Heiser et al. Nat Rev Immunol 2010; 20: 9-12

 Key Messages
Management

Pedoman Nasional Tatalaksana Klinis Infeksi HIV dan Terapi

Antiretroviral pada orang Dewasa
 Key Messages Social
• Patient with HIV who received ARV should be
educated for the compliance of the drugs
• Good emotional support from the family,
health care provider, and spiritual support
must be given to the patient
 Condition this morning
• GCS: 456
• BP: 110/70 mmHg
• HR: 90 x/m
• RR: 28 x/m
• Tax: 37.5 oC
• SaO2 95% room air
Thank You