Pratista Adi Krisna

MORNING REPORT
Morning, 6 April 2017

PHYSICIAN IN CHARGE :
IA : dr. Tata, dr. Bunga, dr. Nadin
II CVCU : dr. Akta
II HCU : dr. Nudi
II UGD : dr. Reza, dr. Jaja
Chief : dr. Somarnam
Consultant : dr. Rulli Rosandi, Sp.PD
Facilitator : dr. Bogi Pratomo, Sp.PD-KGEH
 SUMMARY OF DATABASE
Mr. AY/43 yo/ w.24B
Autoanamnesa and Heteroanamnesa (patient’s wife)
Chief Complaint : weakness
HISTORY OF PRESENT ILLNESS :
• Patients complain of weakness since 7 days before admission. Weak perceived as having no power
and since these 3 days, the patient had difficulty to walk and felt shortness of breath when trying to
walk for 5 meters. Because of it, Patients simply lie down for 3 days at home. There is no Fainting
• Patient also suffered from headache. He felt “cekot-cekot” in the left side of his head. The pain
didn’t radiate. He took Panadol 3 times in a day mg but the complaint didn’t improved. Patient also
told that he had problem of white plaque on his mouth since 2 months ago, but didn’t followed by
painful swallowing.
• Patient also complained nausea without vomiting and decreasing of appetite since 2 days before
admission that caused her to reduce his portion of meal. He used to eat 3 times a day with full
portion, but since 2 days ago he only took 3 times of meal a day with 4-5 spoons of meal for each
serving. He also complained about weight loss approximately 5 kg in 2 months.
• At RSSA he was examined and diagnosed as HIV at 2006 and he got ARV, but didn’t routinely took it.
Since 2015, He began took the ARV (Duviral and Aluvia) and cotrimoxazole routinely.
• Currently, he suffered from low grade fever sometimes, cough and common cold. Urination and
passing stool was normal as usual
 SUMMARY OF DATABASE Cont.
PAST MEDICAL HISTORY & MEDICATION:
• Patient was hospitalized 2 months ago for 22 days in RSSA, due to seizure 1 times occured
in 5 minutes, his body was jerking. Then, he undergone several examination and
diagnosed as Brain Toxoplasmosis. Since then He got Pirimethamine, Clyndamycin, Vit B6,
Folic Acid, Phenytoin.
FAMILY HISTORY :
• His father had Diabetes Mellitus
• No family that have same complain with him. Patient’s wife didn’t have the same
symptoms
SOCIAL HISTORY :
• Married for 17 years, has 2 children.
• He is a soldier in Air Force
• Multipartner sex (+) before married
REVIEW OF SYSTEM :
• Diarrhea (-), Melena (-), Bleeding (-)
 PHYSICAL EXAMINATION
General appearance looked moderately ill underweight Sat O2 96% on Room Air
GCS 456
BP 120/80 mmHg PR 100 bpm regular strong RR 20 tpm Tax 36.7 oC
Head Conjuctiva Anemic (+), Sclera Icteric (-), Oral Thrush (+)
Neck Lymphadenopathy (+) mass at regio Colli S (2x2x2cm), rounded, mobile, elastic
JVP R+2 cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : - | -
Sonor | Sonor Vesicular | Vesicular -|- -|-
Sonor | Sonor Vesicular | Vesicular -|- - |-
Cardio Ictus invisible, palpable at MCL (S) ICS IV
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (+) 3/6 gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) N, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (+)
Lien/ Traube space tymphany
Extremities Edema (-), pale (+), MMT 5 | 5
5|5
 LABORATORY FINDINGS
(6 April 2017)

LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 1500 4.700 – 11.300 /µL Ureum 30.1 20-40 mg/dL

Haemoglobine 2.6 11,4 - 15,1 g/dl Creatinine 1.27 <1,2 mg/dL

Hematocrite 7.4 38 - 42% Albumin 3.34 3.5-5.5 g/dL

Thrombocyte 9.000 142.000 – 424.000 /µL Natrium 136 136-145 mmol/L

ANC 501 1500-8000/µL Kalium 3.38 3,5-5,0 mmol/L

TLC 650 1000-4800/µL Chlorida 107 98-106 mmol/L

MCV 84.1 80-93 fl CD4 129 637-1485

MCH 29.5 27-31 pg

Eo/Bas/Neu/ 6/0,0/33.4/4 0-4/0-1/51-67/

Limf/Mon 3.3/17.3 25-33/2-5

SGOT 10 0-40 U/L

SGPT 16 0-41 U/L

LABORATORY FINDINGS
(5 February 2017)

LAB VALUE NORMAL

IgM anti Toxo 0.257 <0,8

IgG anti Toxo 650.0 <1 IU/ml

IgM anti CMV 0.245 <0,7

IgG anti CMV >500 <0,5

HbsAg Non reactive Non reactive

AntiHCV Negative Negative

CD4 18 637-1485

VDRL Non Reactive Non Reactive

TPHA Non Reactive Non Reactive

 BLOOD GAS ANALYSIS
BGA Value Normal Value
(room air)
PH 7,49 7,35-7,45
PCO2 26.0 35-45 mmHg
PO2 92.0 80-100 mmHg
HCO3 20.0 21-28 mmol/L
Base Excess -3.5 -3 until +3 mmol/L
O2 saturation 97.9 > 95%
Conclusion Respiratory alkalosis partially compensated
ECG (5 April 2017)
ECG
 Sinus Tachycardia, HR 102 bpm
 Frontal Azis : Normal
 Horizontal Axis : Normal
 PR interval : 0.12”
 QRS complex : 0.08”
 QT interval : 0.36”

Conclusion : Sinus Tachycardia, HR 102 bpm

 POMR (PROBLEM ORIENTED MEDICAL RECORD)
CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr. AY/43 yo/ w.24B 1. General 1.1 low intake • Diet HCHP 2100 Subj
weakness 1.2 Anemia kcal/day VS
Subjective • Lansoprazole 1x30 mg Bleeding
- weakness since 7 days • Tranfusion of PRC 250-
before admission 500cc/days until Hb > P.Ed :
- Difficulty to walk and 10 g/dL
felt shortness of breath
when trying to walk for
5 meters
- Nausea
- Decrease of Appetite

Objective
BP : 120/80 mmHg
HR : 100 x/mnt
Sa O2 96% Room Air
ConjuctivaAnemic (+)
Ext pale (+),

Laboratory
Hb : 2,6 g/dL
 CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr. AY/43 yo/ w.24B 2. Anemia 2.1 bone O2 NC 4 lpm Subj
Gravis marrow Zidovudine  STOP VS
Subjective Normochromic supresion dt Tranfusion of PRC 250-
- weakness since 7 days Normocytic HIV 500cc/days until Hb > 10 P.Ed : Stop
before admission 2.2 Drug g/dL the use of
- Difficulty to walk and Induced Vit B 1x25 mg Zidovudine
felt shortness of breath 2.2.1
when trying to walk for zidovudine
5 meters induced
- Diagnosed as HIV at (megaloblastic
2006 and he got ARV ?)
- Took the ARV (Duviral
and Aluvia) and
cotrimoxazole routinely.

Objective
BP : 120/80 mmHg
HR : 100 x/mnt
Sa O2 96% Room Air
ConjuctivaAnemic (+)
Ext pale (+),

Laboratory
Hb : 2,6 g/dL
MCV : 84.1
MCH : 29.5
 CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr. AY/43 yo/ w.24B 3. HIV stage 4 Duviral  change with the Subj
on ARV other drug VS
Subjective
Aluvia CBC post
- Diagnosed as HIV at
Cotrimoxazole 1x960 mg correction
2006 and he got ARV
- Took the ARV (Duviral
P.Ed :
and Aluvia) and
Change
cotrimoxazole routinely.
Duviral
- White plaque on his
mouth
- Seizure 1 times occur in
5 minutes, diagnosed as
Brain Toxoplasmosis.
Since then He got
Pirimethamine,
Clyndamycin, Vit B6,
Folic Acid, Phenytoin

Objective
BP : 120/80 mmHg
HR : 100 x/mnt
Sa O2 96% Room Air
ConjuctivaAnemic (+)
Ext pale (+),
Oral Thrush (+)
Lymphadenopathy(+) mass ColliS
(2x2x2cm),

Laboratory
Hb : 2,6 g/dL
 CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr. AY/43 yo/ w.24B 4. Candidiasis Nystatin drop 3x4cc Subj
oral VS
Subjective
- Diagnosed as HIV at P.Ed : Take
2006 and he got ARV the drug
- Took the ARV (Duviral Routinely
and Aluvia) and
cotrimoxazole routinely.
- White plaque on his
mouth

Objective
BP : 120/80 mmHg
HR : 100 x/mnt
Sa O2 96% Room Air Oral
Thrush (+)

Laboratory
 CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr. AY/43 yo/ w.24B 5. 5.1. dt HIV FNAB coli S Confirm Diagnose Subj
lymphadenopa 5.2 VS
Subjective thy limfadenitis TB
- Diagnosed as HIV at
2006 and he got ARV
- Took the ARV (Duviral
and Aluvia) and
cotrimoxazole routinely.

Objective
BP : 120/80 mmHg
HR : 100 x/mnt
Sa O2 96% Room Air
Lymphadenopathy (+) mass ColliS
(2x2x2cm),

Laboratory
 CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr. AY/43 yo/ w.24B 6. Nausea 6.1 Duviral Lansoprazole 1x30 mg Subj
Induced VS
Subjective
- Diagnosed as HIV at
2006 and he got ARV
- Took the ARV (Duviral
and Aluvia) and
cotrimoxazole routinely.
- White plaque on his
mouth
- Nausea
- Decrease of Appetite

Objective
BP : 120/80 mmHg
HR : 100 x/mnt
Sa O2 96% Room Air
ConjuctivaAnemic (+)
Ext pale (+),
Oral Thrush (+)
Lymphadenopathy (+) mass ColliS
(2x2x2cm),
Epigastrium tenderness (+)

Laboratory
Hb : 2,6 g/dL
 CUE AND CLUE PL Idx PDx PTx PMo&Ed
Mr. AY/43 yo/ w.24B 7. Toxoplasma Head CT Pirimetamin 1x75 mg Subj
cerebral on scan Clindamycin 4x600 mg VS
Subjective Treatment contrast (7-
- Diagnosed as HIV at 4-2017) Folate Acid 1x1
2006 and he got ARV Phenytoin 3x100 mg
- Took the ARV (Duviral
and Aluvia) and
cotrimoxazole routinely.
- Seizure 1 times occur in
5 minutes 2 months ago
(Tonic Clonic) diagnosed
as Brain Toxoplasmosis.
Since then He got
Pirimethamine,
Clyndamycin, Vit B6,
Folic Acid, Phenytoin
- Post

Objective
BP : 120/80 mmHg
HR : 100 x/mnt
Sa O2 96% Room Air

Laboratory
IgM anti Toxo : negative
IgG anti Toxo : 650.0
 PROBLEM ANALYSIS

LYMPHADENOPATHY
GENERAL
TONIC CLONIC
SEIZURE
HIV
LYMPHADENITIS TB
ZIDOVUDINE
TOXOPLASMA
BONE MARROW CEREBRAL
SUPPRESION
NAUSEA
IMMUNO
COMPROMISED
STATE
ANEMIA
LOW INTAKE

CANDIDIASIS
GENERAL WEAKNESS ORAL
 RISK FACTOR ANALYSIS
Theory Factual
On This Patient
 Unprotected sex Multiple partners
 Intravenous drug user
 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
 PATHOPHISIOLOGY KEY MESSAGE

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

 MANAGEMENT KEY
MESSAGE

Pedoman Nasional Tatalaksana Klinis Infeksi HIV dan Terapi

Antiretroviral pada orang Dewasa
DUVIRAL
• Lamivudine and Zidovudine is an inhibitor of HIV-1 and HIV-
2 selective and potent, lamivudine shows a synergistic effect
with Zidovudine in inhibiting HIV replication in cell culture.
Both drugs are metabolised sequentially by intrasetuler
kinase to 5-triphosphate (TP). Lamivudine and Zidovudine-
TP-TP is a substrate and a competitive inhibitor of HIV
reverse transcriptase. Nevertheless, the main activity both
through incorporation monophosphate form into the viral
DNA chain, resulting in chain termination. Lamivudine and
Zidovudine triphosphate showed a lower affinity
significantly on the host cell DNA polymerases.
• Zidovudine is contraindicated for patients with a low
neutrophil counts (<0.75 x 100 / L) or low hemoglobin levels
<7.5 g / dL or 4.65 mmol / L), so that the drug is
contraindicated for patients with these conditions.
 SOCIAL KEY MESSAGE

• 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
Conditions this Morning
• GCS: 456
• BP: 110/80 mmHg
• HR: 88 x/m
• RR: 20 x/m
• Tax: 36,5 oC
THANK YOU
DUVIRAL
• Lamivudine dan Zidovudine merupakan inhibitor HIV-1 dan HIV-2
yang selektif dan poten, Lamivudine menunjukkan efek yang
sinergis dengan Zidovudine dalam menghambat replikasi HIV
dalam kultur sel. Kedua obat tersebut dimetabolisme secara
berurut oleh intrasetuler kinase menjadi 5-trifosfat (TP).
Lamivudine-TP dan Zidovudine-TP merupakan substrat dan
inhibitor kompetitif HIV reverse transkriptase. Meskipun
demikian, aktivitas utama keduanya melalui inkorporasi bentuk
monofosfat ke dalam rantai DNA virus, yang menghasilkan
terminasi rantai. Lamivudine dan Zidovudine trifosfat
memperlihatkan affinitas yang lebih rendah secara signifikan
terhadap sel inang DNA polimerase.
• Zidovudine dikontraindikasikan untuk pasien dengan jumlah
neutrofil rendah (‹0,75 x 100/L) atau kadar hemoglobin rendah ‹
7,5 g/dL atau 4,65 mmol/L), sehingga obat ini dikontraindikasikan
untuk pasien dengan kondisi tersebut.
Alur Layanan HIV
IRIS
Conditions this Morning
• GCS: 456
• BP: 110/80 mmHg
• HR: 88 x/m
• RR: 20 x/m
• Tax: 36,5 oC
THANK YOU