SCENARIO MO, a 27-year old, heterosexual female was brought by relatives to the EMS department. According to the relatives of the patient, the patient was experiencing fatigue, weight loss, fevers, chills, night sweats, and a productive cough for several weeks. MO was diagnosed with HIV infection on September 2008 with P. carinii pneumonia as AIDS-defining illness. Her last HIV clinic visit was 2 months ago. She was also clinically diagnosed with depression since September 2008. She currently lives with her sexual partner who was also diagnosed with HIV infection. She works as an accountant. She is nonsmoker and drinks alcohol occasionally. Medications: Nelfinavir, 1250 mg PO BID Zidovudine 300 mg/lamivudine 150 mg (combination), 1 tablet PO BID Trimethoprim/sulfamethoxazole, 1 DS tablet PO 3X/week Sertraline, 50 mg PO QD Oral contraceptive (30 pg ethinyl estradiol and 0.3 mg norgestrel), 1 tablet PO qD Multivitamin with iron, 1 tablet PO qD Allergies: NKDA Physical Examination : GEN: Thin female with productive cough VS: BP 110/72, HR 90, RR 22, T 37.5C, Wt 50 kg (Wt 2 months ago was 55 kg), Ht 160 cm HEENT: PERRIA, lymphadenopathy COR: RRR CHEST: Radiograph: apical fibrocavitary infiltrates ABD: Nontender, no masses GU: WNL RECT: WNL, guaiac negative EXT: WNL NEURO: A and O X 4, no headache Laboratory Examination Results in SI units (Conventional unit) Na 137 (137) Hgb 100 (10) Plts 160 x 109 K 3.6 (3.6) RBC 3.6 x 1012 Glu 6.1 (110) Cl 98 (98) MCV 115 (115) Ca 2.2 (8.8) HCO3 26 (26) AST 0.37 (22) PO4 0.92 (3.0) BUN 3.6 (10) ALT 0.38 (23) Uric acid 190 (3.2) Cr 70.7 (0.8) Alk Phos 1.5 (90) T Bili 3.4 (0.2) Tot Chol 4.65 (180) Alb 36 (3.6) Mg 1.2 (2.5) HDL 1.22 (47) LDH 1.7 (100) Hct 0.30 (30) Lkcs 3.2 x 109 Pregnancy test: Negative G6PD deficiency screening test: Negative (test result 9/08) PPD tuberculin skin test: 8 mm Three serial sputa for AFB stains and cultures were obtained AFB smear: Positive for mycobacteria Culture and sensitivity: Pending Blood, urine, and stool cultures and sensitivity: Pending Induced sputum: Negative for Pneumocystis carinii pneumonia Arterial oxygen: 90 mm Hg (on room air) Assessment and therapy justification for each problem Health Care Problems Therapeutic Goal Therapeutic Recommendation Rationale
SCENARIO
MO, a 27-year old, heterosexual female was brought by relatives to the EMS department. According to the relatives of the patient, the patient was experiencing fatigue, weight loss, fevers, chills, night sweats, and a productive cough for several weeks.
MO was diagnosed with HIV infection on September 2008 with P. carinii pneumonia as AIDS-defining illness. Her last HIV clinic visit was 2 months ago. She was also clinically diagnosed with depression since September 2008.
She currently lives with her sexual partner who was also diagnosed with HIV infection. She works as an accountant. She is nonsmoker and drinks alcohol occasionally.
Medications:
Nelfinavir, 1250 mg PO BID
Zidovudine 300 mg/lamivudine 150 mg (combination), 1 tablet PO BID
Trimethoprim/sulfamethoxazole, 1 DS tablet PO 3X/week
Sertraline, 50 mg PO QD
Oral contraceptive (30 pg ethinyl estradiol and 0.3 mg norgestrel), 1 tablet PO qD
Multivitamin with iron, 1 tablet PO qD
Allergies: NKDA
Physical Examination :
GEN: Thin female with productive cough
VS: BP 110/72, HR 90, RR 22, T 37.5C, Wt 50 kg (Wt 2 months ago was 55 kg),
Ht 160 cm
HEENT: PERRIA, lymphadenopathy
COR: RRR
CHEST: Radiograph: apical fibrocavitary infiltrates
ABD: Nontender, no masses
GU: WNL
RECT: WNL, guaiac negative
EXT: WNL
NEURO: A and O X 4, no headache
Laboratory Examination Results in SI units (Conventional unit)
|
Na |
137 (137) |
Hgb |
100 (10) |
Plts |
160 x 109 |
|
K |
3.6 (3.6) |
RBC |
3.6 x 1012 |
Glu |
6.1 (110) |
|
Cl |
98 (98) |
MCV |
115 (115) |
Ca |
2.2 (8.8) |
|
HCO3 |
26 (26) |
AST |
0.37 (22) |
PO4 |
0.92 (3.0) |
|
BUN |
3.6 (10) |
ALT |
0.38 (23) |
Uric acid |
190 (3.2) |
|
Cr |
70.7 (0.8) |
Alk Phos |
1.5 (90) |
T Bili |
3.4 (0.2) |
|
Tot Chol |
4.65 (180) |
Alb |
36 (3.6) |
Mg |
1.2 (2.5) |
|
HDL |
1.22 (47) |
LDH |
1.7 (100) |
||
|
Hct |
0.30 (30) |
Lkcs |
3.2 x 109 |
||
Pregnancy test: Negative
G6PD deficiency screening test: Negative (test result 9/08)
PPD tuberculin skin test: 8 mm
Three serial sputa for AFB stains and cultures were obtained
AFB smear: Positive for mycobacteria
Culture and sensitivity: Pending
Blood, urine, and stool cultures and sensitivity: Pending
Induced sputum: Negative for Pneumocystis carinii pneumonia
Arterial oxygen: 90 mm Hg (on room air)
Assessment and therapy justification for each problem
|
Health Care Problems |
Therapeutic Goal |
Therapeutic Recommendation |
Rationale |
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