Morning &

Duty
Report
15 Juni 2022 MORNING & DUTY REPORT
1

Egi Efrianto, Male, 36 yo, WM

Chief Complaint:
• Fatige and weakness increase since 1 weeks before admission

Present Illness History

• Fatige and weakness increase since 1 weeks before admission, patient can not doing any
daily activity by it self.
• Decrease of appattied since 3 month ago with decrease of body weight about 20 Kg in 3
month. There are white spots in his tongue and quitely discomfort when he was eating
• Cough since 1 month accompanied with shortness of breating since 1 week
• History of prolong fever about 2 weeks ago
• History of free sex since 5 years ago in Jakarta
Past illness history

• Lung tuberculosis : 1 year ago

Family illness history

• History of HIV (-)

• History of tuberculosis (-).
Physical Examination
VII

General appearance: Moderate

Consciousness level: CMC
BP : 90/60 mmHg
HR : 95 bpm, regular
RR : 24 rpm
Sao2 : 98%
T : 36.5 oC
Head, Eye, Mouth & Neck VII
Head : Normocephalic,
Eyes : Conjunctiva anemic (-), icteric (-/-)
Neck : JVP 5-2 cmH2O

Thoraks : normochest
Inspection : symmetric statis and dynamic
Palpation : fremitus left = right
Percussion : Sonor at both of the lung
Auscultation : bronkovesicular, ronkhi +/+, wheezing -/-
Cor: VII
Inspection : Ictus cordis is not seen
Palpation : Ictus is palpated at 1 finger medial
LMCS RIC V
Percusion : Cardiomegaly (-)
Auscultation : Regular, murmur (-)
Abdomen:
Inspection : Concave (-)
Palpation : Soepel
Percussion : tympanic
Auscultation : Bowel sound (+) normoperistaltic
 VII

Extremities:
Edema -/-
Warm, CRT < 2 second
Laboratory
Items Value
VII
Hb 13,3 mg/dl
Ht 37 %
WBC 8.580/mm3
Platelet 140.000/mm3
Diff. Count 0/0/86/9/5
PT/APTT/INR/Ddimer 13,6/30,1/1,27/2.521
RBG 113
Ur/Cr 27/0,7
SOGT/SGPT 62/46
Na/K/Cl/Ca 124/2,2/103
Alb/glo 2,8/2,9
HIV 3 reagen Reaktif/reaktif/reaktif
Anti-HCV Non reaktif
HBsAg Non reaktif
Chest X-Ray VII
Problems

• AIDS
• HIV wasting syndrome
• Hiponatremia
• Hipokalemia
• Oral candidiasis
• Hipercoagulable state
• Abnormal liver function
Working Diagnosis

• HIV clinical stadium clinic IV

• HIV wasting syndrome
• Oral Candidiasis
• Susp Lung Tuberculosis Relapse Case
• Hiponatremia cb low intake
• Hipokalemia cb low intake
• Hypercoagulable state
• Abnormal liver function
Therapy

• Rest/ Soft diet high callories high protein

• IVFD NaCl 3% 500 cc/ 12 hours
• IVFD NaCl 0,9% 6 hours/kolf
• Cotrimoxazole 1 x 960 mg
• UDCA 3 x 250 mg
• Nystatin drop 4 x 10 gtt
• Paracetamol 3 x 500 mg
• N Acetylsistein 3 x 200 mg
Plan

• TCM Tuberculosis Lab Test

• CD4 and Viral Load Lab Test