APPRECIATION

Firstly, I would like to thank Almighty God because with his bountiful grace it is possible
for me to finish this case presentation report. Besides that, I would like to thank my lecturer
Puan Rosnita Binti Mohd Hashim for the help, support and guidance in all stages to
completing my research project paper.

Additionally, I would like to express my sincere gratitude to the Ward 4C management for
their superb assistance in enabling me to finish my case research project paper on time. I
received a lot of direction and room to grow. Their guidance increases my knowledge in this
area and enables me to grow.

Furthermore, I would like to thank my family members for being pillar of strength for me
to finishing my research report. I also would like to thank all my friends and my team mates
for sharing helpful information and going through all the projects together.

Finally, I like to express my gratitude to everyone who help me to finish this assignment,
whether they were directly or indirectly. Thank you so much.
INTRODUCTION
LITERARURE REVIEW
 CURRENT MEDICAL CONDITION

Patient is 60 years old, Chinese, male, and single. Patient was admitting to wad 4C at
1/6/2023. Patient have newly diagnosed has retroviral infection (RVD) during 30/4/2023.
Besides that, patient has Pneumocystis carinii Pneumonia (PCP) and oral candidiasis. Patient
also did not have Hepatitis B and Hepatitis C.

Patient was referred from red zone Emergency Department Hospital Sultanah Bahiyah due
to complain of shortness of breath (SOB), dry cough, feverish and night sweat. On
examination founded whitish patch over his tongue.

Patient has no hemoptysis, vomiting and other upper respiratory tract infection (URTI)
symptoms. In general observation patient was alert, conscious, lethargy, and mild
dehydration. His vital sign quite good, only his oxygen not to good. His blood pressure (BP)
was 118/77, pulse 91 and SPO2 is 97% under high flow mask.

His lungs clear, equal air entry. His CVS was Dual Rhythm No Murmur, abdomen was
soft not tender. His skin normal no nodule, no rash, no herpers zoster and no scabies. Then,
his lymph node not palpable. His HIV stage was stage 3.
 DEMOGRAPHIC DESCRIPTION

This patient is 60 years old, Chinese, Male and third child in his family. His lived at Jalan
Tokai, Hujung Kepala Parit, Stargate Alor Setar, Kedah. His only school at primary school.
His school at Sekolah Rendah Batu 6. His staying alone.

BACKGROUND/HISTORY

Personal, Social and Family History: Patient is Chinese, male, age 60 years old and
single. Patient was born in Alor Setar and schooled there. Patient is the third child in his
family. Patient claimed alleged no risks behavior during the schooling time. Patient had
multiple sexual partners including at Danok, Thailand. His father dead because of Colon
Cancer and his mother dead because of Diabetics Mellitus and Hipertension.

Mental Health Story: Patient is calm, alert, denied any mental issues. Patient understands
and have basic knowledge on HIV and ART therapy. Cooperates well during the counselling
session. Patient stated that going through counselling session lessens his mental burden and
Wad 4C Hospital Sultanah Bahiyah provides psychological support.

Employment History: Before diagnosed, patient had multiple works such as farmer.
Financially supported by his brother.

Legal History: Patients have clean record and free from police detention.

Medical History: Patient had previous record of warded at Hospital Sultanah Bahiyah
due to oral candidiasis and Pneumocystis carinii Pneumonia (PCP). Patient has newly
diagnose as RVD positive.
 RISK BEHAVIOR

Patient had mode of transmission with sexually transmitted and denied involved in
injecting drug. Type of sexuality is Heterosexual and denied involved in homosexual and
bisexual. Number of partners is multiple partners and age of intercourse started around 19
years old. Recent status is single and never usage of condom (unprotected sex). Partner of
status was undefined because loss of contact. Lastly, denied usage of drug of any kind.