Anda di halaman 1dari 23

CASE REPORT

HIV

ARRANGED BY:

Metta Astiana

2011730065

PRESEPTOR :

dr. Ihsanil Husna, Sp.PD

STASE ILMU PENYAKIT DALAM RSIJ CEMPAKA PUTIH

PROGRAM STUDI KEDOKTERAN

FAKULTAS KEDOKTERAN DAN KESEHATAN

UNIVERSITAS MUHAMMADIYAH JAKARTA

2016

1
KATA PENGANTAR

AssalamualaikumWr. Wb.

Alhamdulillah, Puji syukur penyusun panjatkan kehadiran ALLAH SWT atas


terselesaikannya tugas LaporanKasus HIV.

Makalah ini disusun dalam rangka untuk dapat lebih mendalami dan memahami
mengenai HIV . Tujuan khususnya adalah sebagai pemenuhan tugas kepaniteraan Stase Ilmu
Penyakit Dalam.

Semogadengan adanya laporan kasus ini dapat menambah khasanah ilmu pengetahuan
dan bergunabagi penyusun maupun peserta didik lainnya.

Penyusun menyadari bahwa laporan kasus ini masih jauh dari kesempurnaan, oleh karena
itu penyusun sangat membutuhkan saran dan kritik untuk membangun laporan kasus yang lebih
baik di masa yang akan datang.

Terimakasih.

Wassalamualaikum Wr. Wb

Jakarta, Februari 2017

Penulis

2
BAB I
PATIENT STATUS

A. Patients identity
Name : Mrs. N
Age : 34th years old
Marital status : Married
Occupation : Housewife
Religion : Protestan
Date of admission :20 Februari 2017
MR number : 00772249

B. Anamnesis
1. Chief complaint :
Patients complained of cough since 2 days ago
Another complaint :
-
2. History of present illness
Patients complained of cough since two days ago, and also feels uncomfortable in
his throat. Itch in the throat, painful swallowing denied, fever (-). Coughing up
phlegm but sputum is difficult to remove. Breathing difficuty denied. Patients also
often feel dizzy and if the complaint comes on the back of the neck feels really heavy.
Patients have experienced losing her weight dramatically about 5 kg a month, but
now the weight better than before. The initial weight of about 65kg to 60 kg for 1
month but now the patient's weight 72 kg. No decrease in appetite. Heartburn denied,
nausea and vomiting denied, normal frequent unrination, pain when urinating denied.
defection normal and no diarrhea.

3. History of past illness


a. Patients known to have a history of HIV (+) since her second pregnancy in 2012,
when screening for doing a caesarean section at the Islamic Hospital in Jakarta.
Afterwards Consult patients to specialists in internal medicine to do further

3
treatment. Patients admitted to having sex really often before marriage. drug
abuse denied. Patients say that the husband does not have a history of HIV. When
identifying patients affected by HIV patients experienced a drastic weight loss
that in carrying 5 kg a month, and often complain of severe headaches. Patients
also feel decrease her appetite. However, after the treatment, patients admitted to
a growing body weight and appetite is back to normal. Patients routinely control
until now and always taking her medication regulary.
b. History of Hypertension :
The patient had a history of hypertension since 2013, a year before that, she had
always a normal blood pressure. At the first time, patients only complain about
having a headache and felt uncomfortable in the back of the neck. When
examined the patient's blood pressure is 150/100 mmHg, and the doctor gave
antihypertensive drugs. Patients regularly taking high blood pressure medication
and if the drug is depleted patients sometimes buy at pharmacies.
c. No history of DM
d. No history of asthma
e. No history of allergic

4. History of family
a. No history of HIV
b. No history of hypertension
c. No history of DM
d. No history of allergic

5. History of allergy
Patient has no allergy to food, drugs and weather.

6. History of treatment
Patient had drunk the hypertension drug and hiv medication regularly and never
missed the medication. Patients also routine to control at the Jakarta Islamic Hospital.

7. History of social economi


Patients admitted to having sex really often before marriage. Patients work as a
housewife. Patients have been married for 8 years with her husband. Husband of
patients known to be experiencing the same disease with patients. Patients infected
with HIV since her second pregnancy. Patients living with her husband and two
children. History of smoking (-), alcohol consumption (+), a history of the use of
narcotic drugs (-), a history of syringe (-).

4
C. Physical Examination
- Generalis status : Looks healthy
- Conciusness: composmentis
- Vital sign
o Blood pressure : 130/90 mmHg
o Heart rate : 82x/minute
o Respiratory rate : 18x/minute
o Temperature : 36.5 C

D. General physical examination


1. Head : normocephal, deformity (-)
2. Eyes : anemic conjungtiva (-/-), icteric sclera (-/-),pupil isokor diameter
3mm/3mm, light reflex (+/+)
3. Mouth : the oral mucosa moist
4. Neck : not palpable mass, suprasternal retracion (-)
5. Thorax
a. Inspection : The movement of the chest symmetrical, intercosta
retraction (-)
b. Palpation : Same vocal fremitus in dextra and sinistra
c. Percussion : Sonor
d. Auscultacion : Vesicular breath sounds + / +, ronkhi - / -, wheezing - / -
6. Heart
a. Inspection : Ictus cordis does not seen
b. Palpation : Heave, palpable 2 finger, ictus cordis palpable in 5 ICS linea
midclavikula
c. Percussion
i. Right Heart : ICS 4 lineaparasternalis dextra
ii. Upper Heart : ICS 2 linea parasternal sinistra
iii. Waist heart : ICS 3 linea parasternalis sinistra
iv. Left Heart : ICS 5, 2 cm medial linea midclavicula sinistra
d. Auscultation : BJ I-II regularly pure, noisy (-),
7. Abdomen
a. Inspection : Looked flat
b. Auscultation : Bowel sounds (+)
c. Palpation : Touching pain epigastrik (-) epigastrik retraction (-)
d. Percussion : Timphani (+)
8. Extremities
a. Superior: Edema (- / -), warm akral(+ / +), RCT <2 seconds (+ / +)
b. Inferior: Edema (- / -), warm akral (+ / +), RCT <2 seconds (+ / +)

5
E. Laboratorium

6
7
8
9
10
11
12
F. Resume :

13
Ny. N, aged 34 years came with complaints of cough since 2 days ago., Feels
uncomfortable in his throat. Coughing up phlegm but sputum is difficult to remove.
Patients also often feel dizzy and if the complaint comes on the back of the neck feel
really heavy. Patients have experienced losing her weight drastic about 5 kg a month,
but now the weight better than before. The initial weight of about 65kg to 60 kg for 1
month but now the patient's weight 72 kg. History of past illness: a history of HIV (+)
since her second pregnancy in 2012. Hypertension (+) since 2013. History of
treatment: Patient had taking hypertension drug and hiv medication regularly.
Socioeconomic Status: sex-free (+), alcohol (+). Physical examination: BP 130/90
mmHg.

G. Problem List:
HIV
Hypertension
faringitis

H. Assesment
1. HIV
S: Patients experienced a drop in weight About a 5 kg within 1 month. The initial
weight of about 65kg to 60 kg for 1 month but now the patient's weight 72 kg.
Patients infected with HIV during pregnancy to 2 in 2012, sex-free (+), drinking
alcohol (+). And until now the patients are still routinely control and take
medicine regularly.
O: -
A : HIV
P:
Medikamentosa
Pemeriksaan limfosit CD4
Antiretroviral therapy (ART)
Curcuma 3x1
Nonmedikamentosa
Clinical monitoring: BB, drug effect
Monitoring quality of life patient

2. Hypertension
S: Patients also often feel dizzy and if the complaint comes on the back of the
neck heavy. The patient had a history of hypertension since 2013. When

14
questioned by the patient's blood pressure 150/100 mmHg. She has History of
hypertension treatment drugs.
O: TD: 130/90 mmHg
A: hypertension
P: Controlled blood pressure
Amlodipin 1x 5mg

3. Faringitis
S: Patients present with cough since two days ago, and also feels uncomfortable
in his throat. She feels Itchy in the throat, painful swallowing denied, fever (-).
Coughing up phlegm but sputum is difficult to remove. Breathing difficulty
denied.
O: -
A: Faringitis
P: Ambroxol 3x1 cth

BAB II

LITERATURE REVIEW

I. Human immunodeficiency virus (HIV)


A. Human immunodeficiency virus (HIV)
The human immunodeficiency virus (HIV) infects cells of the immune system,
destroying or impairing their function. Infection with the virus results in progressive
deterioration of the immune system, leading to "immune deficiency." The immune system
is considered deficient when it can no longer fulfil its role of fighting infection and
disease. Infections associated with severe immunodeficiency are known as "opportunistic
infections", because they take advantage of a weakened immune system.

15
HIV is a virus spread through certain body fluids that attacks the bodys immune
system, specifically the CD4 cells, often called T cells. Over time, HIV can destroy so
many of these cells that the body cant fight off infections and disease. These special cells
help the immune system fight off infections. Untreated, HIV reduces the number of CD4
cells (T cells) in the body. This damage to the immune system makes it harder and harder
for the body to fight off infections and some other diseases. Opportunistic infections or
cancers take advantage of a very weak immune system and signal that the person has
AIDS. Learn more about the stages of HIV and how to know whether youre infected.

B. Epidemiology
According to estimates by WHO and UNAIDS, 36.9 million people were living
with HIV globally at the end of 2014. That same year, some 2 million people became
newly infected, and 1.2 million died of HIV-related causes.

The length of time can vary widely between individuals. Left without treatment,
the majority of people infected with HIV will develop signs of HIV-related illness within
510 years, although this can be shorter. The time between acquiring HIV and an AIDS
diagnosis is usually between 1015 years, but sometimes longer. Antiretroviral therapy
(ART) can slow the disease progression by preventing the virus replicating and therefore
decreasing the amount of virus in an infected persons blood (known as the viral load).
.
C. Etiology
a. Unprotected sexual intercourse (vaginal or anal)
b. Oral sex with an infected person
c. Transfusion of contaminated blood
d. Sharing of contaminated needles, syringes or other sharp instruments
e. It may also be transmitted between a mother and her infant during pregnancy,
childbirth and breastfeeding.

D. Patophysiology
HIV affects specific cells of the immune system, called CD4 cells, or T cells.
Over time, HIV can destroy so many of these cells that the body cant fight off infections
and disease. When this happens, HIV infection leads to AIDS.
HIV stands for human immunodeficiency virus. It is the virus that can lead to
acquired immunodeficiency syndrome or AIDS if not treated. Unlike some other viruses,

16
the human body cant get rid of HIV completely, even with treatment. So once you get
HIV, you have it for life.
HIV attacks the bodys immune system, specifically the CD4 cells (T cells),
which help the immune system fight off infections. Untreated, HIV reduces the number
of CD4 cells (T cells) in the body, making the person more likely to get other infections
or infection-related cancers. Over time, HIV can destroy so many of these cells that the
body cant fight off infections and disease. These opportunistic infections or cancers take
advantage of a very weak immune system and signal that the person has AIDS, the last
stage of HIV infection.

E. Clinical Manifestations

17
a. The Stages of HIV
When people get HIV and dont receive treatment, they will typically progress
through three stages of disease. Medicine to treat HIV, known as antiretroviral therapy
(ART), helps people at all stages of the disease if taken the right way, every day.
Treatment can slow or prevent progression from one stage to the next. It can also
dramatically reduce the chance of transmitting HIV to someone else.

Stage 1: Acute HIV infection


Within 2 to 4 weeks after infection with HIV, people may experience a flu-
like illness, which may last for a few weeks. This is the bodys natural response to
infection. When people have acute HIV infection, they have a large amount of
virus in their blood and are very contagious. But people with acute infection are
often unaware that theyre infected because they may not feel sick right away or
at all. To know whether someone has acute infection, either a fourth-generation
antibody/antigen test or a nucleic acid (NAT) test is necessary. If you think you
have been exposed to HIV through sex or drug use and you have flu-like
symptoms, seek medical care and ask for a test to diagnose acute infection.

Stage 2: Clinical latency (HIV inactivity or dormancy)


This period is sometimes called asymptomatic HIV infection or chronic
HIV infection. During this phase, HIV is still active but reproduces at very low
levels. People may not have any symptoms or get sick during this time. For
people who arent taking medicine to treat HIV, this period can last a decade or
longer, but some may progress through this phase faster. People who are taking
medicine to treat HIV (ART) the right way, every day may be in this stage for
several decades. Its important to remember that people can still transmit HIV to
others during this phase, although people who are on ART and stay virally
suppressed (having a very low level of virus in their blood) are much less likely to
transmit HIV than those who are not virally suppressed. At the end of this phase, a
persons viral load starts to go up and the CD4 cell count begins to go down. As

18
this happens, the person may begin to have symptoms as the virus levels increase
in the body, and the person moves into Stage 3.

Stage 3: Acquired immunodeficiency syndrome (AIDS)


AIDS is the most severe phase of HIV infection. People with AIDS have
such badly damaged immune systems that they get an increasing number of
severe illnesses, called opportunistic illnesses.
Without treatment, people with AIDS typically survive about 3 years.
Common symptoms of AIDS include chills, fever, sweats, swollen lymph glands,
weakness, and weight loss. People are diagnosed with AIDS when their CD4 cell
count drops below 200 cells/mm or if they develop certain opportunistic illnesses.
People with AIDS can have a high viral load and be very infectious.

F. Treatment
a. Antiretroviral drugs

Antiretroviral drugs are used in the treatment and prevention of HIV infection.
They fight HIV by stopping or interfering with the reproduction of the virus in the body,
reducing the amount of virus in the body.

By mid 2015, 15.8 million people were receiving HIV antiretroviral therapy
(ART) globally. Until 2003, the high cost of the medicines, weak or inadequate health
care infrastructure, and lack of financing prevented wide use of combination ART in low-
and middle-income countries. But in recent years, increased political and financial
commitment has allowed dramatic expansion of access to treatment.

There is no cure for HIV. But with good and continued adherence to ART, the
progression of HIV in the body can be slowed to a near halt. Increasingly, people living
with HIV can remain well and productive for extended periods of time, even in low-
income countries. WHO now recommends treatment for all people living with HIV.

19
In addition to ART, people with HIV often need counselling and psychosocial
support. Access to good nutrition, safe water and basic hygiene can also help an HIV-
infected person maintain a high quality of life.

No effective cure currently exists for HIV. But with proper medical care, HIV can
be controlled. Treatment for HIV is called antiretroviral therapy or ART. If taken the right
way, every day, ART can dramatically prolong the lives of many people infected with
HIV, keep them healthy, and greatly lower their chance of infecting others. Before the
introduction of ART in the mid-1990s, people with HIV could progress to AIDS (the last
stage of HIV infection) in a few years. Today, someone diagnosed with HIV and treated
before the disease is far advanced can live nearly as long as someone who does not have
HIV

II. Hypertension
A. Hypertension
Hypertension is a state of systolic blood pressure greater than 140 mmHg and
diastolic blood pressure over 90 mmHg (LM Wilson, 1995). Blood pressure is measured
with spygmomanometer calibrated correctly (80% of the size of the cover sleeve cuff)
after the patient is resting comfortably, sitting upright or lying back for at least five
minutes to thirty minutes after smoking or drinking coffee. .

B. Classification Of Hypertension

20
Blood pressure measurements are classified based on the average of two times or
more measurements at two or more visits.

C. Etiology
Hypertension is caused by a variety of interrelated factors. Secondary
hypertension is caused by factors such as primer known that kidney damage, certain
medications disorders, acute stress, vascular damage and others. The most common cause
in patients with malignant hypertension is untreated hypertension.

D. Clinical symptoms
1. Dizziness
2. Flushing, headache
3. Bleeding from the nose of a sudden (Rarely)
4. Neck stiff, and others
5. The impact that can be caused by hypertension is kidney damage, bleeding in the
cornea (the eye's retina), rupture of blood vessels in the brain

E. Management
1. The goal of treatment of patients with hypertension are:
a. Target blood pressure is <140/90 mmHg and for high-risk individuals such as
diabetes mellitus, renal failure the target blood pressure is <130/80 mmHg.
b. The decrease cardiovascular morbidity and mortality
2. Non-Pharmacological Therapy
a. Lose weight if excessive nutritional status.
b. Weight gain in adulthood influence on blood pressure. Therefore, weight
management is very important in the prevention and control of hypertension.
c. Increase physical activity.
d. The person whose activity is low risk of hypertension 30-50% rather than active.
Therefore, between 30-45 minutes of physical activity of> 3 times / day is
important as primary prevention of hypertension.
3. Reducing sodium intake.
a. If the diet does not help in 6 months, it is necessary anti-hypertensive medication
by a doctor.
4. Lowering consumption of caffeine and alcohol
a. Caffeine can stimulate the heart to work more quickly, so that more fluid flow in
every second. While alcohol consumption of more than 2-3 cups day can increase
the risk

21
REFERENCES

1. Weber R, Ruppik M, Rickenbach M, et al. Decreasing mortality and changing


patterns of causes of death in the Swiss HIV Cohort Study. HIV Medicine.
2013 Apr;14(4):195207.
2. Low-Beer S, Chan K, Yip B, et al. Depressive symptoms decline among
persons on HIV protease inhibitors. Journal of Acquired Immune Deficiency
Syndromes. 2000 Apr 1;23(4):295301.
3. www.who.int/gho/hiv/en/. Diakses pada tanggal 22 Februari 2017.
4. http://emedicine.medscape.com/article/1937383-overview. Diakses pada
tanggal 23 Febriari 2017.
5. http://emedicine.medscape.com/article/241381-overview. Diakses pada
tanggal 23 Februari.

22
6. http://emedicine.medscape.com/article/211316-overview. Diakses pada
tanggan 22 Februari 2017.
7. Sudoyo, W. Aru. et. al. 2007. Buku Ajar Ilmu Penyakit Dalam Jilid I Edisi IV.
Jakarta : Pusat. Penerbitan Ilmu Penyakit Dalam FKUI

23