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:Mr G/23yo/W 29
Looked:
underweight
VAS Score:-
RR:
24x/menit
GCS: 456
BP:90/60
mmHg
Head
Neck
Chest
Wall
Symmetric,
Tax:
36,50C
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
--
N/N
Urine
Production
Laboratory Result
Parameter
Result
Normal Value
Hb
8,10
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 %
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
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
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