CASE REPORT

Identity of patient
Name : Mr. A.S
Age : 33 Year
Sex : Male
DoB : December 22nd 1983
Marital status : Single
Occupation : Employee
Religion : Moslem
Date of admission : August, 16th 2017
MR number : 009732xx
ANAMNESIS
CHIEF COMPLIMENTS
Dyspneu since 3 days

ANOTHER COMPLIMENTS

Fever since 2 weeks.

 History of Present Illness
Patient come to the hospital with complaints of breathlessness since 3 days

ago. He stated that increasing shortness of breath and fever since 2 weeks ago. He has

felt febrile at times, but has no measured his temperature. He admitted loss of appetite

during this time because there is so much oral ulceration and notes that his clothes are

loose on him. In the fact, he had lost 13 kg in weight from 52 kg to 39 kg. He said has

not been defecating for 3 days and had experienced of nausea, malaise and abdominal

pain felt like being stabbed. Coughing, haemoptysis, night sweats, vomitus and diarrhea

are denied.
 History of past illness
Had history of TBC since 10 years ago but he only took the drugs
(anti-tuberculous therapy) for 1 week
Has history of candidiasis oral since 2 weeks ago
No history of DM and Hypertension
No history of operation or trauma

HISTORY OF FAMILY
None of his family has same problem
No history of DM
No history of Hypertension
 HISTORY OF ALLERGY

Patient has allergy to antibiotics but he

didnt know that name of the antibiotics

HISTORY OF TREATMENT

TBC on OAT.
 HABITS
When he was in college in Malang, he confessed to having free sex with
same-sex and did oral sex twice a time.
In 2016 he stated that he used putau twice a time. Alcoholic and smoking
are denied.
 PHYSICAL EXAMINATION

Generalized Status Vital Sign

General condition : Mild ill Blood pressure : 100/60 mmHg
Conciousness : CM Heart rate : 70x/minute
Body weight : 52 kg (before HIV/AIDS) Respiratory rate: 19x/minute
Body weight : 39 kg (after HIV/AIDS) Temperature : 36,7 C
Body height : 165 cm
BMI : 14,44kg/m2 (underweight)
GENERAL PHYSICAL EXAMINATION

Normocephal, deformity (-)

Anemic conjungtiva (-/-), icteric sclera (-/-), pupil isokhor.

Deviasi septum (-), Sekret (-), epistaksis (-)

Normotia, Sekret (-/-)

kandidiasis

Mass (-), lymphadenopathy (-)

GENERAL PHYSICAL EXAMINATION
Pulmo Inspection
the movement of the chest symmetrical

Palpation
: vocal fremitus is same in dextra and sinistra

Percussion
Sonor

Auscultacion
vesicular breath sounds + / +, ronkhi +/ -,
wheezing - / -
GENERAL PHYSICAL EXAMINATION
Inspection

Heart
ictus cordis not seen

Palpation
ictus cordis not palpable

Percussion
Right heart margin: sternalis line sinistra ICS-V
left heart margin: midclavicula line sinistra ICS-V.

Auscultacion
Regular 1st & 2nd heart sounds, murmur (-), gallop
(-)
GENERAL PHYSICAL EXAMINATION
ABDOMEN Inspection
looked flat

Palpation
bowel (+) sounds, 7x/minutes

Percussion
pain (-), ascites (-)

Percussion
Timpani, shifting dullness (-)
GENERAL PHYSICAL EXAMINATION

warm akral warm akral

Edema (-) Edema (-)
RCT <2 RCT <2
seconds seconds

warm akral warm akral

Edema (-)
Edema (-) RCT <2 seconds
RCT <2
seconds
 LABORATORY EXAMINATION
August, 3rd Result Unit Reference Methods
August,
August, 4th
2nd2017
2017 Result Result Unit Reference
Unit Methods
Reference
2017

Non Serologi
Hematologi
HIV (3 methods)
Routine
SD HIV 3.0 Reaktif Non Reaktif Rapid Test I
Hematologi
Hemoglobin 10.4 g/dL 13.2-17.3
Special count
Leukosit 7.18 10/
ONCOPROBE Reaktif Non Reaktif Rapid Test I3.80-10.60
CD 4Hematokrit
HIV 32 % 40-52
CD 4 Abs 13 410-1.590 Sel/ Flowcytometry
HIVTrombosit
Ag/Ab Reaktif 293 Non
<1.00 : 10/ CMIA 150-440
(Chemiluminescent
Eritrosit
Combo 699.17 3.95 Reaktif 106 / 4.40-5.90
Microparticle Immunoassay)
CD 4 % 1,00 31-60 % Flowcytometry
MCV/VER 80 fL 80-100
MCH/HER
Conclusion Reaktif 26
S/CO pg 26-34
MCHC/KHER 33 g/dL 32-36
Explanation Lymphocyte T Helper

Suggestion Confirmation HIV with Westren Bolt Less than normal

 Resume
Patient come to the hospital with complaints of breathlessness since 3 days ago. He
stated that increasing shortness of breath and fever since 2 weeks ago. He has felt febrile at times,
but has no measured his temperature. He admitted loss of appetite during this time because there
is so much oral ulceration and notes that his clothes are loose on him. In the fact, he had lost 13
kg in weight from 52 kg to 39 kg. He said has not been defecating for 3 days and had experienced
of nausea, malaise and abdominal pain felt like being stabbed.

Physical examination : Blood pressure 100/60 mmHg, Heart rate: 70 times/minute,

Respiratory rate : 19 times/minute, Temperature : 36,7 C. Candidiasis in mouth, ronkhi + / -.

Laboratory examination : CD 4 : Lymphocyte T Helper less than normal, test HIV

(3 methods) : Reaktif, Hemoglobin : 10.4 g/dL (L), Hematokit : 32% (L), Eritosit : 3.95106 /
(L).

Radiology examination : Thorax Photo : Bilateral upper and lower lobe infiltrate.
 PROBLEM LIST

HIV
Dyspnea ec TBC
Anemia
Candidiasis in mouth
 ASSESMENT (A)
S: O:
Fever since 2 weeks ago. He admitted Blood pressure : 100/60 mmHg
loss of appetite during this time because Heart rate : 70x/minute
there is so much oral ulceration and notes Respiratory rate : 19x/minute
that his clothes are loose on him. had Temperature : 36,7 C
experienced of nausea, malaise and Body weight : 52 kg (before
HIV/AIDS)
abdominal pain felt like being stabbed. In Body weight : 39 kg (after
the fact, he had lost 13 kg in weight from HIV/AIDS)
52 kg to 39 kg. When he was in college in Body height : 165 cm
Malang, he confessed to having free sex BMI :14,44 kg/m2 (underweight)
with same-sex and did oral sex twice a Mouth : Oral ulceration (Candidiasis)
time. In 2016 he stated that he used putau CD 4 : Lymphocyte T Helper, Less
twice a time. Than Normal
Test HIV (3 metode) : Reaktif
A : HIV
P : Healthy lifestyles
Cifrofloksasin 2x200mg
Parasetamol Tab 3x500mg
Ranitidine Tab 2x50mg
Antiretrovirus (Zidovudin 2 x 250mg, lamivudine 2 x 150mg, efavirenz 1 x
600mg).
Niastin drop 3x1cc iv
 ASSESMENT (A)
S : Dyspnea, fever since 2 weeks ago, malaise, had A : Pulmonary Tubercolosis
history of TBC since 10 years ago but he only took
P:
the drugs (anti-tuberculous therapy) for 1 week. He

had lost 13 kg in weight from 52 kg to 39 kg Oxygen Nasal Canule 2-3L

O: Rifampisin 1x450mg
Blood pressure : 100/60 mmHg
Isoniazid 1x300mg
Heart rate : 70x/minute
Pirazinamid 1x500mg tab
Respiratory rate : 19x/minute

Temperature : 36,7 C
Etambutol 1x500mg

General examiation : thorax auscultation: ronkhi

+/-

Thorax Photo : Bilateral upper and lower

lobe infiltrate.
 PROGNOSIS
Quo ad vitam : bonam
Quo ad functionam : bonam
Quo ad sanationam : malam
LITERATURE REVIEW
 The HIV infects cells of the immune system, destroying or
HIV impairing their function. Infection with the virus results in
progressive deterioration of the immune system, leading to
"immune deficiency."

Etiology AIDS
HIV disease is caused by infection with HIV-
1 or HIV-2, which are retroviruses in the Acquired immunodeficiency
Retroviridae family, Lentivirus genus. syndrome (AIDS) is a term
which applies to the most
advanced stages of HIV
infection.
 Epidemiology
According to estimates by WHO and
UNAIDS, 36.7 million people were
living with HIV globally at the end of
2015.
That same year, some 2.1 million
people became newly infected, and
1.1 million died of HIV-related
causes

:
HIV-TB
 Pemeriksaan Penunjang
Diagnosis Laboratorium :
Serologis / deteksi antibodi : rapid tes, ELISA,
Western Blot
Virus Detection : RT-PCR, antigen p24
 Treatment
Suportive
Symptom
Treatment for Oportunistik
Infection
Antiretroviral