Beruflich Dokumente
Kultur Dokumente
th
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
Physical Examination
BP= 90/60 mmHg
PR= 88 bpm regular
General App.: looked moderately ill
RR =24 tpm
GCS : 456
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
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
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
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
Blood smear,
SI/TIBC
Hb
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