This document presents 3 case studies involving the management of HIV-positive patients. The first case involves Juan, a 25-year-old man newly diagnosed with HIV. His lab results show a CD4 count of 644 and viral load of 56,346. The second case is Janice, a 34-year-old woman who was diagnosed 4 years ago but has not been in care since giving birth. Her labs show a low CD4 count of 75 and high viral load of 132,675. The third case is Donna, a 53-year-old woman recently released from prison where she was diagnosed with HIV 2 years ago. Her previous records show stable CD4 counts between 600-800 and viral loads around 3
This is a log of cases seen during my externship with the Emergency Services department of the University of Pennsylvania, School of Veterinary Medicine, at the Matthew J. Ryan Small Animal Hospital. I learned a great deal and hope you find the cases I saw interesting.
PRN Medications; its justified use: by Dr Prithvi PuwarPrithvi Puwar
The presentation is mentioning the details of PRN medications, its common use, the common problems occured by erroneous medications side effects ...A must to know by duty doctor, registrars and nurses. Most of the presentation slides are in interactive way.
This is a log of cases seen during my externship with the Emergency Services department of the University of Pennsylvania, School of Veterinary Medicine, at the Matthew J. Ryan Small Animal Hospital. I learned a great deal and hope you find the cases I saw interesting.
PRN Medications; its justified use: by Dr Prithvi PuwarPrithvi Puwar
The presentation is mentioning the details of PRN medications, its common use, the common problems occured by erroneous medications side effects ...A must to know by duty doctor, registrars and nurses. Most of the presentation slides are in interactive way.
This workshop will cover best practices for HIV prevention in adolescents with a focus on the implementation of Pre-Exposure Prophylaxis (PrEP) and Post Exposure Prophylaxis (PEP) in SBHCs. Join this workshop to hear an overview of the HIV epidemic among adolescents in California, best practices for determining eligibility for PrEP and PEP, instructions for labs and prescriptions, and suggestions for case management and training of all SBHC staff.
HIV screening and treatment in as changes occur in our healthcare system. Targeted towards specific healthcare centers in Baltimore. Features some data from the Department of health and mental hygiene and new data on HIV transmission across continuum of HIV care.
Miami Regional UniversityDate of Encounter06182020SDioneWang844
Miami Regional University
Date of Encounter:06/18/2020
Student Name: LWC
Preceptor: Silvio Planas APRN
Clinical Site:Gynecology and More INC.
Clinical Instructor:Kirenia Santiuste
Soap Note # 6
Main Diagnosis:Allergic Rhinitis
PATIENT INFORMATION
· Name: TJ
· Age: 28
· Gender at Birth: Female
· Gender Identity: Female
· Source: Patient
· Allergies: allergies to dust, cats and Penicillin
· Current Medications: Albuterol 90mcg, 1-2 puff qid inhaler PRN when symptoms occur.
· PMH: Asthma
· Immunizations: Up to Date, Refused Influenza vaccination this year due to COVID-19 National Pandemic
· Preventive Care: Avoid allergens, Good house hygiene, Regular exercising, annual checkups.
· Surgical History: Appendicitis.
· Family History: 1st relatives Asthma, Mother and grandparents High blood pressure, Father died on car accident DM.
· Social History: Alcohol drinker 2 cups or rum weekly. Preferred hobby Netflix and sport tv programs.
· Sexual Orientation: Female Preference
· Nutrition History: Low Sodium Diet
Subjective Data:
· Chief Complaint: “I have sore throat and itchy, itchy eyes and runny nose”
· Symptom analysis/HPI: Patient has been with those symptoms for a week, the runny nose and eye itchy are the same but the sore throat got worse lately, the discharge is clear. There is tenderness around the nose. The Symptoms improve drinking water and some drops throat lozenges. Denies fever, no nasal blockage, no chills.
Review of Systems (ROS)
· General: Fatigued, Generalized Weakness.
· HEENT: Runny nose, eyes itchy, sore throat, difficult swallowing, blurred vision when reading, no double vision., denies block nose and no bleeding.
· Neck: Denies neck pain, able to rotate his neck laterally and in and upward position
· Lungs: No cough, shortness of breath, PND, or orthopnea
· Cardiovascular: No pressure, squeezing, tightness, heaviness or aching about the chest, neck, axilla or epigastrium
· Breast: Denies any pain or lumps
· GI: Denies Abdominal Pain
· Female genital: Denies dysuria, frequency and urgency when urinating
· GU: Denies dysuria, no frequency and urgency when urinating
· Neuro: No burning or tingling, sensation present in all quadrants
· Musculoskeletal: No joint pain no restriction motions.
· Activity & Exercise: no habits of exercise.
· Psychosocial: anxious about the disease.
· Derm: denies any rash, bums or recent lesions.
· Sleep/Rest: more than 6 hours a day but with difficult to breath.
Objective Data/Physical Exam
· BP 141/82 TPR 99.1 HT 170 cm WT. BMI 30.1 O2: 99%
· General: Well-groomed, appropriate posture and gait, normal affect, obesity
· HEENT: Tenderness frontal and right maxillary sinus, Weber and Rinne test intact, cranial nerves intact, no hearing loss, vision left eye 20/20 right eye 20/40. whitish discharge noted from the nose. Edema and erythema of nasal mucosa, uvula and Tonsils, redness noted. Halitosis presents.
· Neck: thyroid gland intact no nodules no lym ...
Yan 2Yichao YanKara WilliamsESL 10696 April 2019 Rough.docxadampcarr67227
Yan 2
Yichao Yan
Kara Williams
ESL 1069
6 April 2019
Rough Draft Analysis of Argument Essay
In the article “What Else Can I Do to Get the School Supplies My Student Need?” the author discusses that, textbook still plays an important role in today’s class. There are so many debates about weather using online text book or physical textbook in school nowadays. The author as a college teacher claims that physical textbook helps her students have better understanding of knowledges. Also, she thinks physical textbook reduced the financial burden on students. However, online source or online textbook should have more benefit then the physical textbook.
First of all, the author claims that physical textbook could helps student read and understand better of new knowledges. The resources that teachers need for their teaching are so differently. It depended on student’s grade and their teaching style. Even people nowadays assume textbooks are outdated, inefficient and biased, author still think using textbook is very important for students to know about some academic basic information, which could help students master the course better.
APPENDIX I r Reports
DIAGNOSES include:
1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma
of unknown PrimarY location.
2. Yeta cava sy.rdromi post placement of Hickman catheter'
3. Anemia due to chronic disease.
4. Hypertension.
HOSPITAL COURSE: The patient is a 78-year-old female whom we have
been following in our clinic ior hypertension and also chronic pudendal
nerve pain. Shie had been recently biagnosed with pelvic me,tastatic clear
cell caicinoma, which her primaiy location is unknown at this time' She
will be discussing this further after the pathology reports are, read. During
her hospital stalia Hickman catheter was placed in order to have IV access
for pain medication or future cancer therapy. She was also admitted for
chronic pain. she did develop swelling of her arms and neck. She was
broughtio interventional radiology and she did have venography and the
Hickman catheter was removed. Her swelling to her arms and neck have
decreased greatly. She denies any shortness of breath. No choking sensation
as previouily noted. Her pain has been managed well with fentanyl patch at
175 mcg. She has also been on IV heparin therapy for anticoagulation
followitig the vena cava syndrome. Today, the patient hasbeen having
complaiits of nausea. She did get some dexamethasone IV for her nausea,
which did improve later this morning. Her blood plessure has been under
good control. Her labs today include a wBC of 5.18, hemoglobin 7.8,
f,ematocrit 23.7, protime 74.4,INR 1'5, PTT 39'6, BUN 6, sodium 139'
potassium 4.2, CO2 27.2.
DISCHARGE, PLANS:
1. IV heparin is discontinued. She will be switched ovel to Lovenox
r mg/kg subcutaneously daily. The patient will have Home Health to
help her set uP these iniections.
2. She will continue with the fentanyl patch 175 mcg for the pain..
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docxrosemariebrayshaw
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
Kharfen: DC HIV Public-Private Partnershipshealthhiv
Michael Kharfen
Bureau Chief, Partnerships, Capacity Building, Community Outreach
DC Department of Health
HIV/AIDS, Hepatitis, STD and TB Administration
The Health Center Program and the NHAS and VHAPhealthhiv
Seiji Hayashi, MD, MPH, FAAFP
Chief Medical Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Bureau of Primary Health Care
SYNCing Government Agencies with NHAS and VHAP healthhiv
Warren W. Hewitt, Jr. DrPH, M.S.
Center for Substance Abuse Treatment
Substance Abuse Mental Health Services Administration
U.S. Department of Health & Human Services
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...
Treatment outcome case studies perez
1. Case Studies in the Management
of HIV-Positive Patients
Stephen Perez, RN, NP, AAHIV-S
2. Overview and Objectives
• Review case studies involving the
management of HIV-infected patient
• Apply knowledge to determine
appropriate ARV initiation and
management for case patients
• Engage in group discussion around the
complexities of initiating ARV’s
2
3. Case One: Juan
• 25 y.o. Salvadorian, bisexual male.
• Tested HIV-positive 4 weeks ago after
visiting a county clinic and being
treated for GC/CT
• He is presenting for his first visit with you
today
• Prior to his visit to the county clinic, he
has not had care since 1 year ago, he
has not had primary care since
childhood
4. Case One: Juan
• Juan brings a copy of
his records from the
county clinic
– RX with Rocephin and
Azithromycin
– Twinrix #1
– Positive HIV WB
– Positive GC NAAT
(urine), RPR non-
reactive, neg CT NAAT
(urine).
– Information flyer for
your clinic
4
5. Case One: Juan
• On initial history:
– UTI symptoms 6 weeks ago, now
resolved
– No other recent illnesses
– No history of chronic illness
– Family history relatively unknown
• Married with one child in El Salvador
– No Surgical Hx
– ED visit 1 year ago for
CAP, resolved with abx, prior ED
visit 3 years ago, for laceration
at work
– NKDA, no current meds 5
7. Case One: Juan
• What other information do we want to know about Juan?
• Previous testing
– No previous HIV tests or STD history, no hx of ARV’s
• ETOH, Illicit Drugs
– Drinks alcohol 3-4 times a week, intoxicated 2 times a
week (approx. 8 beers)
• Sexual Activity
– Sexually active with 2 male partners last sexual activity last
week. Oral sex (no condoms), receptive anal sex (with
condoms)
• Work History
– Works as a cook at a local 24 hour restaurant. He works
alternate day and night shifts
• Immunizations
– Unknown, received a “shot” at the ED 3 years ago after
sutures
• Mental Health History
7
– None reported
8. Case One: Juan
• Physical Exam
– WNWD, NAD, BMI 26, VS wnl
– Mild palpable LN in anterior cervical chain
– 4cm well healed scar on left palm
– Otherwise unremarkable
8
9. Case One: Juan
• What Lab Tests Do We Want to Order?
– CD4 count
– Viral Load
– CMP/CBC
– Hepatitis Serologies (HAV, HBV, HCV)
– Urinalysis
– Genotype
– Fasting Plasma Glucose, Fasting Lipids
– Repeat Urine GC/CT, Throat GC/CT
– PPD
– Anti-Toxoplasma IgG
9
10. Case One: Juan
• Results
– CBC/CMP within normal
– CD4 644, VL is 56,346
– HBsAg neg, anti HBc Ab positive, anti HBs Ab
positive, Total anti-HAV Ab postive, anti HCV
Ab neg.
– UA wnl
– Genotype is pan-sensitive
– Lipids: TC-1, LDL-130, HDL-50, TG-200.
– FPG: 98
– Repeat GC/CT negative
– PPD 0mm, anti-toxo is <6.5
10
11. Case One: Juan
Should Juan Start Antiretroviral Therapy
(Audience Response)?
1. Yes
2. No
3. Maybe So
11
12. Case One: Juan
• What ARV’s Would You
Recommend for Juan?
– ARV Naïve
– Genotype is pan-sensitive
– Works odd hours
12
13. Case One: Juan
What ARV’s Would You
Recommend for Juan?
(Audience Response)
1. Atripla (EFV/TDF/FTC)
2. Prezista, Norvir and
Truvada (DAR/r +
TDF/FTC)
3. Reyataz, Norvir and
Truvada (ATV/r
+TDF/FTC)
4. Isentress and Truvada
(RAL + TDF/FTC)
5. Complera
13
(RPV/FTC/TDF)
14. Case One: Juan
• What are benefits
and risks of your
selected ARV
regimen?
• If starting Juan at his
next visit, when do
you want him to
return for follow-up?
• How would you
monitor his response
to therapy?
14
16. Case Two: Janice
• 34 year-old A.A. female with HIV
infection
• She was diagnosed 4 years ago when
she presented to an OB clinic at 26
weeks, but has not been engaged in
care since her delivery.
• She recently moved to the area, and is
concerned because she has been
feeling tired. Also has some intermittent
throat pain
16
17. Case Two: Janice
• She does not have
her previous records
with her but tells you
the following
– She took HIV meds
during pregnancy but
can’t remember the
names
– Remembers “a lot of
pills” (yellow and white
)
– Her daughter is HIV
negative
– She stopped her meds
after delivering
17
18. Case Two: Janice
• On initial history:
– Has been feeling tired for about 3
months
– Intermittent night
sweats, intermittent pain with
swallowing ROS otherwise negative
– Family history
• Mother A&W with HTN, DM2, Father
Deceased from MI
• One daughter, 3 yrs old
– Surgical Hx includes C-Section 3 yrs
ago
– ED visit 6 months ago for GI
symptoms
– Allergic to Sulfa
– GYN: G2 P1, SAB X1, irregular
menses, LMP 2 months ago
18
19. Case Two: Janice
• What other information do we want to know about Janice?
• HIV History
– Viral Load was undetectable while on meds, thinks her
CD4 count was around 200, had a lot of GI side effects
with the meds, but never missed any doses.
• ETOH, Illicit Drugs
– Denies any alcohol or drug use. Does not smoke
• Sexual Activity
– Has a monogamous male partner, who is HIV negative.
They use condoms 100% of the time.
• Work History
– Full time work at small PR firm, does not have insurance
because she doesn’t want anyone at work to know about
her HIV.
• Immunizations
– Unknown, had a PPD from OB which was negative
• Mental Health History
– Was treated for depression 5 years ago after her father passed
away (x 1 year) 19
20. Case Two: Janice
• Physical Exam
– WNWD, NAD, BMI 24, VS: BP 144/90
otherwise wnl
– Well healed surgical scar from C-section
– White coating noted on posterior
oropharynx, scrapable with tongue
depressor
– Otherwise unremarkable
20
21. Case Two: Janice
• What Lab Tests Do We Want to Order?
– CD4 count
– Viral Load
– CMP/CBC
– Hepatitis Serologies (HAV, HBV, HCV)
– Urinalysis
– Genotype
– Fasting Plasma Glucose, Fasting Lipids
– RPR, GC/CT
– PPD
– Pregnancy Test
– Anti-Toxoplasma IgG
21
22. Case Two: Janice
• Results
– CBC Hgb: 8.7, Hct: 30, Plt 75,000, CMP: WNL
– CD4 75, VL is 132,675
– HBV sAg neg, anti HBc Ab negative, anti HBVs
Ab positive, HAV total Ab postive, anti HCV Ab
neg.
– Genotype is pan-sensitive
– Lipids: TC-175, LDL-98, HDL-40, TG-130. FPG: 98
– Urine Pregnancy test, negative, UA wnl
– PPD 0mm
– G6PD <3 U/g Hb
– Anti-toxoplasma IgG <6.5 IU/ml
22
23. Case Two: Janice
Does Janice needs PCP prophylaxis
(Audience Response)?
1. Yes
2. No
3. Maybe So
23
24. Case Two: Janice
What is the best option for PCP Prophylaxis for Janice
(Audience Response)?
1. Dapsone 100mg 1 tablet daily
1. Bactrim DS 1 tablet daily
1. Bactrim DS 1 tablet Q MWF
1. Mepron 1500 mg PO daily
1. Crossing your fingers
24
25. Case Two: Janice
Should Janice Start Antiretroviral Therapy
(Audience Response)?
1. Yes
2. No
3. Maybe So
25
26. Case Two: Janice
• What ARV’s Would You
Recommend for Janice?
– Her genotype is pan-
sensitive
– You show her a medication
chart in your office and she
identifies Combivir and
Kaletra as her previous
regimen
26
27. Case Two: Janice
What ARV’s Would You
Recommend for Janice?
(Audience Response)
1. Atripla (EFV/TDF/FTC)
2. Prezista, Norvir and
Truvada (DAR/r +
TDF/FTC)
3. Reyataz, Norvir and
Truvada (ATV/r
+TDF/FTC)
4. Isentress and Truvada
(RAL + TDF/FTC)
27
28. Case Two: Janice
• What are benefits and
risks of your selected ARV
regimen?
• If starting Janice at her
next visit, when do you
want her to return for
follow-up?
• How would you monitor
her response to therapy?
28
30. Case Three: Donna
• 53 year-old Caucasian female with HIV
infection
• She was diagnosed 2 years ago while
incarcerated.
• She was recently released from prison
and has not been treated for HIV in the
past. She is presenting today for
primary care/HIV Care
30
31. Case Three: Donna
• She has brought in her previous records from
prison
– CD4 count has been between 600 and 800 with a
nadir of 575 cells/mm3
– Viral Loads ~ 3,000 copies
– HBV sAg neg, anti HBc Ab negative, anti HBVs Ab
positive, HAV total Ab postive, anti HCV Ab neg.
– Genotype is pan-sensitive
– She also has hypertension and hypothyroid disease
for which she is taking:
• HCTZ 25 mg
• Lisinopril 20 mg
• Levothyroxine 100 mcg
– She has been taking prescriptions as above
31
32. Case Three: Donna
• On initial history:
– Has been feeling well in the past few months
– Is concerned about finding work and getting in touch
with family
– Family history
• Mother deceased from trauma, Father Deceased from
MI, Sister alive 49 with hypothyroid disease and high
cholesterol
• Two adult children whom she has little contact with, Alive and
Well as far as she knows
– Surgical Hx unremarkable
– NKDA
– GYN: G2 P2, LMP 5 years ago
32
33. Case Three: Donna
• What other information do we want to know about Donna?
• HIV History
– Previous HIV test 10 years ago which was negative. Risk factor is
heterosexual contact
• ETOH, Illicit Drugs
– Drinking 3-4 beers a day, no illicit drugs. Smokes ½ pack a
day
• Sexual Activity
– Has a monogamous female partner, who is HIV negative.
They use barrier protection 50% of the time
• Work History
– Previous work in retail. Is currently applying for jobs in the
area
• Immunizations
– UTD, had a PPD 9 mos ago which was negative
• Mental Health History
– Was treated for depression but has been off meds since she was
released
33
34. Case Three: Donna
• Physical Exam
– WNWD, NAD, BMI 28, VS: BP 128/84
otherwise wnl
– Unremarkable PE
34
35. Case Three: Donna
• What Lab Tests Do We Want to Order?
– CD4 count
– Viral Load
– CMP/CBC
– Urinalysis
– Fasting Plasma Glucose, Fasting Lipids
– RPR, GC/CT, PAP
– Anti-Toxoplasma IgG
35
37. Case Three: Donna
Should Donna Start Antiretroviral
Therapy? (Audience Response)
1. Yes
2. No
3. Maybe So
37
38. Case Three: Donna
• What ARV’s Would You Recommend for
Donna?
– Her genotype is pan-sensitive
– She is ARV Naïve
38
39. Case Three: Donna
What ARV’s Would You Recommend for
Donna? (Audience Response)
1. Atripla (EFV/TDF/FTC)
2. Prezista, Norvir and Truvada (DAR/r
+ TDF/FTC)
3. Reyataz, Norvir and Truvada (ATV/r
+TDF/FTC)
4. Isentress and Truvada (RAL +
TDF/FTC)
5. Complera (RPV/FTC/TDF)
39
40. Case Three: Donna
• What are benefits and risks of your selected
ARV regimen?
• If starting Donna at her next visit, when do
you want her to return for follow-up?
• How would you monitor her response to
therapy?
40
42. AETC NCHCMC Contacts
Clinical Team Contacts
Stephen Perez, RN, NP, AAHIVS, HIV Clinical Specialist
stephen@healthhiv.org
Mona Moore, PA-C, MA, AAHIVS, HIV Clinical Program Specialist
Kmona@healthhiv.org
42
43. HealthHIV
AETC NCHCMC
2000 S Street NW
Washington, DC 20009
www.NCHCMC.org
202-232-6749
Editor's Notes
What about an HLA-B5701 what about a co-recptor tropism assay?
What is Janice’s STAGE ACCORDING TO CDC STAGING. B3, she techincally does not have any AIDS indicator conditions, oropharyngeal thrush is not an aids indicator, but esophageal is. Does she need any opportunistic prophylaxis? Yes, for what? Should we take into account the G6PD finding? Can she be on Mepron?