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Morning Report

th

Friday, September, 7 2012

Moderator :
Physician In Charge:
IA : dr. Herman, dr. Anshory, dr. Greg (cardio)
IB : dr. Yuni, dr. Rifai
II : dr. Hidayat
III : dr. Bogi, Sp.PD-KGEH

Summary Of Database:
Tn Fanani/30 Y.O/W 29

Chief Complaint: Unable to eat


Patient presented with the chief complaint unable to eat since 1 month prior to admission, nausea (+), vomiting
(+) 5x/day, volume was glass, contained of water and residual food. It was accompanied with decrease of
body weight 5 kg in the past 2 months. He also felt epigastric pain since 1 month ago, getting worse if he ate.
Pain when swallowing also felt since 1 month ago.
He also complained of fever since 1 month prior to admission, on and off. Night sweating (-). It was accompanied
with lump on neck and left inguinal that is painful since 1 month ago. Also with pain when passing urine.
He also complained of dizziness if he stands or walks since 2 months ago. Already controlled to PHC, and told as
anemia.
The is no history of diarrhea, or cough in this patient.
History of past illness: Diagnosed as HIV since 5 years ago. Not getting medication because he is not ready.
Patient was referred at Puskesmas Kendalsari because of weakness. Family History: He has not married yet. IDU
since 15 years ago, sexual intercourse was denied, blood transfusion was denied.
Social history: History of free sex, IDU, tattoo, and transfusion were denied. She was a housewife.
Medication: No history of drug allergy. He took methadone 1x130 mg as replacement of his narcotics since 1
year ago.

Physical Examination
BP= 90/60 mmHg
PR= 88 bpm regular
General App.: looked moderately ill

RR =24 tpm
GCS : 456

Ax. Temp.= 37.5 0C

2( Dr. Herman)

Looked underweight
Icteric sclerae (-), oral
PERRL 3 mm/3 mm
trush (+)
JVP : R + 2 cm H2O; 300, Lnn enlargement (+) multiple on coli D/S,
submandibular D, and occiput S, neck stiffness (-)
Cor
Ictus invisible, palpable at fifth ICS MCL S
RHM SL D
LHM ictus
S1, S2 single, murmur Pulmo
Symmetric; S| S V |V Rh -| - Wh - | S| S V |V
-| -| S| S V |V
-| -|-

Head

Anemic conjunctiva (+)

Neck
Thorax
Macula fine squama
brownish central
healing (+)

Abdomen

Flat, BS (N), Liver span 10 cm, traubes space dullness, liver/spleen unpalpable,
soft, tenderness (-)
Edema (-), Papular Pruritic Eruption (-), Lymphnodenitis inguinal S (+)

Extremities
LABORATORY FINDINGS
LAB

RESULT

NORMAL VALUE

LAB

RESULT

Leukocyte

12.010

3,500-10,000/L

Sodium

132

NORMAL
VALUE
136-145 mmol/l

Hemoglobine

4.0

11.0-16.5 g/dl

Potassium

4.21

3.5-5.0 mmol/L

MCV
MCH

60.10
19.20

80-97 m3
26.5-33.5 m3

Chloride

105

98-106 mmol/L

PCV

12.5

35-50%

RBS

57

>200 mg/dL

Thrombocyte

328,000

150,000-

Ureum

106.60

10-50 mg/dL

500,000/l
SGOT

133

11-41U/L

Creatinine

1.72

0.7-1.5 mg/dL

SGPT

39

10-41U/L

Albumin

2.68

3.5-5.5 g/dL

Diff count

0/0.2/73.8/7.4/2.3

CD4

316

410-1590

Eos/Ba/Neu/Ly/Mo

URINALYSIS ->
SG
PH
Leucocyte
Nitrite
Protein
Glucose
Erythrocyte
Keton urine
Urobilinogen
Bilirubin

1.030
5.5
1+
1+
1+
-

10 x
Epithelia +
Cylinder +
Hyaline +
Granular +
Leukocyte
Erythrocyte
40 x
Erythrocyte 1.6
Leukocyte 9.2

3( Dr. Herman)

Crystal
Bacteria 222.4x103

BGA -> not yet performed

ECG:
Sinus rhytim HR90x/m, PR int 0.12, QRS complex 0.04, QT interval 0.36, Frontal Axis Normal, Horizontal Axis
Normal, Conclusion: Sinus rhytim HR 90x/m

CXR :
AP position, less inspiration, KV enough, asymmetric, trachea in the middle, bone and soft tissue normal,
Phrenicocostalis angle D/S sharp, Hemidiaphragm D/S domeshape, Pulmo: increased of broncho vascular
shadowing, fibroinfiltrate in right lung, medial and basal with air bronchogram (+), Cor: site normal, size CTR
50%, and shape normal.
Conclusion : Pneumoniae

CUE&CLUE
Male/30 y.o
Unable to eat
Nausea vomiting
Epigastric pain
Fever
Lump on coli and
inguinal
Dx as HIV before
IDU
On tx methadon
-GCS 456
-BP 90/60 mmHg
-PR 88 bpm
-RR 24 tpm
T ax 37.5 C
-anemic +
-oral trush +
-lymphadenitis
multiple
-Leu 12.010,
netrofilia
-Hb 4.0, MCV 60,
MCH 19.20
-alb: 2.68

1.

PL
HIV St III
IV

IDx

PDx
HIV Viral Load,
VDRL/TPHA,
Blood culture,
Sputum culture
and sensitivity,
Toxoplasma
IgG/IgM, Blood
culture and
sensitivity, Urine
culture and
sensitivity

PTx
O2 2-4 lpm via NC
IVFD NaCl 0/9% 16 dpm
HCHP Diet 2100 Kcal/day +
extract snakehead fish
Plan ARV into Stavudine +
Lamivudine 2x 1tab and
Nevirapine 2x 1 tab
Cotrimoxazole 1x960 mg

PMo
S
VS
Hb
Opportunistic
Infection

4( Dr. Herman)

-CD4: 316
-CXR: Lung
infection
Male/30 y.o
Unable to eat
Nausea vomiting
Epigastric pain
Fever
Lump on coli and
inguinal
Dx as HIV before
IDU
On tx methadon
-GCS 456
-BP 90/60 mmHg
-PR 88 bpm
-RR 24 tpm
T ax 37.5 C
-anemic +
-oral trush +
-lymphadenitis
multiple
-Leu 12.010,
netrofilia
-Hb 4.0, MCV 60,
MCH 19.20
-alb: 2.68
-CD4: 316
-CXR: Lung
infection
Male/30 y.o
COugh
Unable to eat
Nausea vomiting
Epigastric pain
Fever
Lump on coli and
inguinal
Dx as HIV before
IDU
On tx methadon
-GCS 456
-BP 90/60 mmHg
-PR 88 bpm
-RR 24 tpm
T ax 37.5 C
-anemic +
-oral trush +
-lymphadenitis
multiple
-Leu 12.010,
netrofilia
-Hb 4.0, MCV 60,
MCH 19.20
-alb: 2.68

2. Candidiasis Oral

2.1 due to no 1

3. Cough + Fever

3.1 PCP
3.2 Pneumonia
CAP
3.3 Lung TB

Sputum culture
and sensitivity

Nystatin oral drop 4x 1

S
VS

Levofloxacin 1x750 mg
Adjust antibiotic regarding
sputum culture result
Paracetamol 3x500 mg

S
VS

5( Dr. Herman)

-CD4: 316
-CXR: Lung
infection
Male/30 y.o
Unable to eat
Nausea vomiting
Epigastric pain
Fever
Lump on coli and
inguinal
Dx as HIV before
IDU
On tx methadon
-GCS 456
-BP 90/60 mmHg
-PR 88 bpm
-RR 24 tpm
T ax 37.5 C
-anemic +
-oral trush +
-lymphadenitis
multiple
-Leu 12.010,
netrofilia
-Hb 4.0, MCV 60,
MCH 19.20
-alb: 2.68
-CD4: 316
-CXR: Lung
infection
Male/30 y.o
Unable to eat
Nausea vomiting
Epigastric pain
Fever
Lump on coli and
inguinal
Dx as HIV before
IDU
On tx methadon
-GCS 456
-BP 90/60 mmHg
-PR 88 bpm
-RR 24 tpm
T ax 37.5 C
-anemic +
-oral trush +
-lymphadenitis
multiple
-Leu 12.010,
netrofilia
-Hb 4.0, MCV 60,
MCH 19.20
-alb: 2.68
-CD4: 316

4. Anemia
Normochrom
Normocytair

4.Def FE
4.2 Chronic
Disease

5. HF St C Fc 1

5.1 Anemic Heart


Disease

Blood smear,
SI/TIBC

Folic Acid 1x3 tab


B6/B12 3x1 tab
Transfusion PRC 2 pack/day
until Hb more than 10 gr/dL

Hb

Treat underlying disease


Captopril -> postponed
Furosemide -> postponed

S, VS

6( Dr. Herman)

-CXR: Lung
infection
Female/32 y.o
Leg swelling
Cough
Decrease of
appetite
Decrease of Body
weight
Diagnosed HIV,
took Duviral and
Nevirapine 2x1
tab
Husband died
because of
lymphnode tumor
-GCS 456
-BP 100/60 mmHg
-PR 128 bpm
-RR 30 tpm
T ax 38.6 C
-anemic +
-oral trush +
-ictus at ICS VI 2
cm lat MCL S
-murmur systolic
gr 2/6 all valves
-edema +
-PPE +
-Leu 760
-Hb 2.80
-alb: 2.68
-CD4: 93
-CXR: Lung
infection and
cardiomegaly
Male/30 y.o
Unable to eat
Nausea vomiting
Epigastric pain
Fever
Lump on coli and
inguinal
Dx as HIV before
IDU
On tx methadon
-GCS 456
-BP 90/60 mmHg
-PR 88 bpm
-RR 24 tpm
T ax 37.5 C
-anemic +
-oral trush +
-lymphadenitis

6. Multiple
lymphadenopathy

7. Drug Abuse in
Methadone
treatment

6.1 TB infection
6.2 Lymphoma
Maligna

Blood smear,
LDH

Confirm diagnosis

S, VS

Methadone 1x130 mg

S, VS

7( Dr. Herman)

multiple
-Leu 12.010,
netrofilia
-Hb 4.0, MCV 60,
MCH 19.20
-alb: 2.68
-CD4: 316
-CXR: Lung
infection
Male/30 y.o
Unable to eat
Nausea vomiting
Epigastric pain
Fever
Lump on coli and
inguinal
Dx as HIV before
IDU
On tx methadon
-GCS 456
-BP 90/60 mmHg
-PR 88 bpm
-RR 24 tpm
T ax 37.5 C
-anemic +
-oral trush +
-lymphadenitis
multiple
-Leu 12.010,
netrofilia
-Hb 4.0, MCV 60,
MCH 19.20
-alb: 2.68
-CD4: 316
-CXR: Lung
infection

8. Dyspepsia
syndrome

8.1 Gastritis
erosiva
8.2 PUD

Ranitidine 2x50 mg iv
Metoclopramide 3x10 mg iv

S
VS