Running head: DUNBAR CASE ANALYSIS
Dunbar: Case Analysis Presentation
Whitney L. Dunbar
Wright State University
Nursing 7103
Dr. Kristine A. Scordo
1
DUNBAR CASE ANALYSIS
2
Dunbar: Case Analysis Presentation
History and Physical
Source
Patient, a reliable source
Chief Complaint
“I have a lump in my neck with flu-like symptoms.”
History of Present Illness
This patient is a 25-year old pleasant African American female who presents to the
infectious disease office with complaints of “a lump in my neck with flu-like symptoms” and
was referred by her primary care physician (PCP). The patient stated she began to have a sore
throat, fever, headache 6/10, and joint pain 3/10 with fatigue and a lack of appetite nine days
ago. She made an appointment to see her PCP that day. Her nasal swab result was negative for
influenza and her throat culture for streptococcal was negative. She was told by her PCP to rest
in addition to taking over the counter medication for her sore throat and headache. The patient
stated she had been taking Tylenol to help relieve her headache, sore throat, and fever. Her
symptoms continued and she found a couple of lumps on the right side of her neck two days ago
while changing her clothes. She saw her PCP again and they implemented further laboratory
tests. Her PCP called her yesterday and told her to make an appointment at the infectious disease
office due to a possible viral infection. She denies any neck pain, chest pain, cough, nausea,
vomiting, or diarrhea.
Medical History
Genital chlamydia ten months ago
Genital gonorrhea 2011
DUNBAR CASE ANALYSIS
3
Appendicitis 2009
Three-pack year smoking
Surgical History
Appendectomy 2009
Family History
Family medical history is significant for hypertension, hypercholesterolemia,
hypertriglyceridemia, chronic obstructive pulmonary disorder, and coronary artery disease.
Social History
The patient is single with no children and lives in a one-bedroom apartment in a safe and
quiet neighborhood. She works full-time at Wal-Mart as a supervisor in customer service and
has health insurance through Anthem. Currently, she is enrolled in two classes at her local
community college to obtain a business management degree. She denies smoking or any
recreational drugs. She drinks three to six alcohol beverages almost every weekend socially and
her last drink was ten days ago. The patient expresses that she has a great support system with
her family and friends.
Obstetric History
Gravida 0/Para 0/ Abortion 0.
Immunizations
Childhood immunizations up to date. No tuberculosis skin test and tetanus booster shot
nine years ago.
Last Examination Date:
Last physical exam two days ago. Last pelvic examination ten months ago with results of
chlamydia. Last dental examination two years ago and last vision examination four years ago.
DUNBAR CASE ANALYSIS
4
Allergies
No known allergies
Medications
The current medication prescribed for the patient is Junel FE 1mg-20mcg tablet by mouth
(PO) daily and states she takes this medication every morning. Over the counter medication the
patient is currently taking is Tylenol 650mg PO two to three times a day for management of her
current symptoms. Reports Tylenol was last taken eight hours ago. She denies any herbal
medication or use of any complementary alternative medicines.
Review of Systems
General:
Patient denies weight loss but reports a decrease in appetite, fatigue, and
weakness for the last nine days. She reports fevers as high as 102 degrees
Fahrenheit for the last nine days, but temperatures have decreased to 99 degrees
Fahrenheit since taking Tylenol. Patient denies chills, but reports having night
sweats twice in the last week.
Skin:
Patient reports areas of a pink, dry, round, small, and flat rash on her anterior
upper chest that appeared five days ago. Denies rash and skin color changes,
pruritus, bruising, or lesions. She reports no history of skin disease, no recent
work-related skin hazards, and on no medication for the rash.
HEENT:
Complains of a headache that started nine days ago. She reports an aching pain
that gradually gets worse over a couple of hours to a moderate pain of 6/10 and
the pain is behind both of her eyes. The pain gets worse with eye movement or
increased activity. Her headaches last for an hour with rest and after taking
Tylenol to relieve the headache to a 0/10. No history of head injury, dizziness, or
DUNBAR CASE ANALYSIS
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syncope. Denies any visual changes, eye pain, or discharge. She denies wearing
correction lenses. Denies any hearing loss or earaches. Denies nasal discharge,
sinus pain, or epistaxis. Complains of a sore throat that started nine days ago.
The pain 5/10 is intermittent and lasts for five minutes after any kind of
swallowing and worse in the morning. She reports gargling salt water twice a day
and drinking hot tea and broth to help relieve the pain.
Neck:
Reports a lump on the right side of her neck that appeared two days ago. Denies
any tenderness, change in size since this morning, or any recent infections.
Denies neck stiffness and any limitation of motion. Denies any thyroid problem
or history of prior irradiation of head, neck, or upper chest. Denies neck pain or
swollen glands.
Breast:
Denies any pain, lumps, nipple discharge, or swelling. Denies breast-self
examination.
Respiratory:
Denies any history of lung disease, chest pain with breathing, shortness of breath,
wheezing, cough, or productive sputum.
CV:
Denies any palpitations, chest pain, irregular heartbeat, cyanosis, dyspnea on
exertion, dyspnea with exertion, orthopnea, or edema in extremities.
GI:
Reports decrease in appetite for the last week but no weight loss. Denies any food
intolerance, indigestion, nausea, vomiting, dysphagia, diarrhea, constipation, or
abdominal pain. Reports history of appendicitis with appendectomy in 2009.
Last bowel movement two days ago.
GU:
Denies pain on urination, frequency, urgency, hesitancy, nocturia, or straining.
Urine is yellow.
DUNBAR CASE ANALYSIS
Genitalia:
6
Last menstrual period 17 days ago. Cycle is 28 days with duration three to five
days, flow moderate, no dysmenorrhea. Denies any vaginal discharge, sores,
lesions, or itching.
Sexual health: Reports being heterosexual with multiple sexual partners. She takes birth control
pills to prevent pregnancy, but reports that only some of her partners use
a form of contraception. She reports her last sexual encounter was a month ago
and denies using any protection. She denies planning to have children at this
time. She has a history of treated chlamydia and gonorrhea, but has never been
tested for human immunodeficiency virus (HIV).
M/S:
Reports generalized weakness and some generalized joint pain 3/10 that started
nine days ago. It is an aching pain that is worse with activity and relieved by rest
and Tylenol. The joint pain is tolerable and the duration is as long as the activity.
Denies any joint swelling, deformity, or decreased range of motion. Denies
muscle pain.
Neurological: Denies any sensory changes, mood changes, fainting, confusion or memory
problems, poor coordination or history of seizures.
Psychosocial: Reports of stress from working full time and taking two college classes. She
reports having the inability to sleep well this last week due to nighttime
awakenings from a headache or night sweats. Denies any depression, anxiety, or
any suicidal ideations.
Physical Exam
General:
Patient is awake, alert, pleasant, articulates clearly, and appropriately responds to
stimuli. Her hygiene is clean and she is dressed appropriate for her age, setting,
DUNBAR CASE ANALYSIS
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and gender. She is in no distress. Her weight is 72 kilograms with a height of
five feet and five inches.
Vital Signs:
Temperature of 101.6 degrees Fahrenheit, heart rate of 92 beats per minute, blood
pressure of 108/64 mmHg, respiratory rate of 12 breaths per minute, and oxygen
saturation of 97% on room air.
Skin:
Warm, dry, intact, and skin turgor good. Small well-circumscribed fivemillimeter pink macule generalized rash on anterior upper thorax and collar
region. Normal hair distribution and texture. No clubbing or discoloration of
nails and nail beds pink.
HEENT:
Head is normocephalic with no lesions, lumps, parasites, or tenderness on
palpitation. Face is symmetric without weakness, swelling, or involuntary
movements. Eye acuity by Snellen chart with 20/20 vision in both eyes. No
abnormalities in fields with confrontation and corneal light reflex symmetric
bilaterally. Extra-ocular movements are intact. Conjunctiva clear and sclera
white. No lesions, discharge, swelling, or ptosis. Pupils are equal, round, reactive
to light, and accommodate. The pinna of the ear has no lesions, mass, discharge,
or tenderness bilaterally. The ear canals are clear and tympanic membranes are
pearly gray with no perforations and landmarks intact. Bilaterally heard
whispered words. Nose has no deformities or tenderness on palpitation. Nares
patent with septum midline and mucosa pink with no lesions. No tenderness of
sinuses. Mouth mucosa and gingivae is pink with no lesions or bleeding. Tongue
is midline with midline protrusion. Tonsils are 2+. Pharyngeal wall bright red
with edema and no exudate on pharyngeal or tonsils.
DUNBAR CASE ANALYSIS
Neck:
8
Smooth movement with full range of motion. Symmetric. Two palpable cervical
lymph nodes, two centimeters, soft, mobile, no tenderness, and no erythema or
warmth. Trachea midline. No jugular vein distention at 45 degrees. Carotids two
plus bilaterally with no bruits.
Breast:
Symmetric with no lesions, discharge, masses, tenderness, or lymphadenopathy.
Respiratory:
Anteroposterior to transverse diameter one to two and no lesions. Respirations
are even and relaxed with no use of accessary muscles. Symmetric chest
expansion. Vesicular breath sounds clear in all lung fields. No adventitious
sounds. Capillary refill less than one second and no cyanosis.
CV:
Regular rate, rhythm, and S1 and S2 present. No murmurs, clicks, or rubs. No
visible pulsations, no heave or lift, and no thrill. Pulses are two plus in upper and
lower extremities bilaterally.
Abdomen:
Skin is smooth with no lesions or striae. One-centimeter scar at midline
umbilicus, one-centimeter scar midline suprapubic, and one-centimeter scar right
upper quadrant at mid-clavicle. Contour is flat and symmetric. Bowel sounds
present with no bruits. Tympany in all four quadrants. Soft, no masses, no
organomegaly, no tenderness, and no inguinal lymphadenopathy.
M/S:
Symmetric with no swelling, deformity, or masses. Smooth full range of motion
of joints with no crepitus, but generalized joint pain with movement. No
deformity or curvature of vertebral column. Strength four out of five bilaterally in
upper and lower extremities. No muscle tenderness.
Neurological: Behavior and speech appropriate. Alert and oriented to person, place, and time.
Recent and remote memory intact. Cranial nerves two through twelve intact. No
DUNBAR CASE ANALYSIS
9
atrophy or tremors, but generalized weakness. Gait is smooth and coordinated.
Negative Romberg. Light touch, pinprick, and vibration intact. Deep tendon
reflexes two plus. Negative Kernig and Brudzinski.
Genitalia:
No lesions or discharge from external genitalia. A specimen for a Papanicolaou
smear, gonorrhea, chlamydia, trichomoniasis, moniliasis collected.
Laboratory Findings
According to AIDSinfo (2012) and Infectious Disease Society of America (IDSA)
(2009), the succeeding laboratory tests help determine the diagnosis, stage of the disease, and
assist in selection of the drug regimen for the patient.
Table 1
Basic Metabolic Panel (BMP) and Complete Blood Count (CBC)
BMP
Results
Normal
CBC
Results
Normal
Sodium
2.8 mm3
4.5-10.5 mm3
3%
3-6%
44%
1%
0%
48%
4%
50-62%
0-3%
0-1%
25-40%
3-7%
144 mEq/L
136-145
mEq/L
White blood cell
count (WBC)
Neutrophil
Bands/Stab (%)
Neutrophil
Segs/Polys (%)
Eosinphils (%)
Basophils (%)
Lymphocytes (%)
Monocytes (%)
Red blood cell
count (RBC)
Hemoglobin
4.3 mm3
24 mEq/L
3.5-5.2
mEq/L
96-106
mEq/L12
22-30 mEq/L
Hematocrit
43.8%
97 mg/dL
70-110
Mean corpuscular
volume (MCV)
88 fL
3.6-5.0 mm3
(female)
12.0-16.0
g/dL (female)
36%-48%
(female)
82-98 fL
Mean corpuscular
hemoglobin
29 pg/cell
26-34 pg/cell
Potassium
3.6 mEq/L
Chloride
99 mEq/L
Carbon
Dioxide
Glucose
14.6 g/dL
mg/dL
Blood urea
nitrogen
10 mg/dL
6-20 mg/dL
DUNBAR CASE ANALYSIS
10
(BUN)
Creatinine
1.1 mg/dL
0.6-1.2
mg/dL
Calcium
9.1 mg/dL
8.8-10.4`
mg/dL
(MCH)
Mean corpuscular
hemoglobin
concentration
(MCHC)
RBC distribution
width (RDW)
Platelet
Mean platelet
volume (MPV)
Note. Normal laboratory values (Fischback & Dunning, 2009).
Table 2
Other Laboratory Tests and Results
Lipid Profile
Result
Normal
Total
Cholesterol
178 mg/dL
140-199
mg/dL
High Density
Lipoprotein
(HDL)
Low Density
Lipoprotein
(LDL)
Triglyceride
55 mg/dL
35-80 mg/dL
98 mg/dL
<130mg/dL
125 mg/dL
<150 mg/dL
Lab Test
Alanine
Transaminase
(ALT)
Aspartate
Transaminase
(AST)
Fasting Blood
Glucose
34%
32%-36%
12.2%
11.5%-14.5%
135 mm3
140-400 mm3
8.0 fL
7.4-10.4 fL
Result
Normal
38 unit/L
7-35 unit/L
40 unit/L
10-36 unit/L
97 mg/dL
70-110 mg/dL
Note. Normal laboratory values (Fischback & Dunning, 2009).
Table 3
Serologies for Hepatitis A, B, and C Viruses
Lab Test
Result
Hepatitis A Virus:
Hepatitis A Antibody
(HAV IgG)
Hepatitis B:
Core Antibody (AntiHBc,IgG)
Antibody (Anti-HBs)
Surface Antigen (HBsAg)
Hepatitis C:
Normal
Negative
Negative-Offer hepatitis
vaccine
Positive- Immune
Anti-HBc,IgG Negative
Negative
Negative: No chronic
infection, offer vaccine
Anti-HBs: If positive, patient
is immune by previous
infection or immunization
Anti-HBs Negative
HBsAg Negative
DUNBAR CASE ANALYSIS
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Antibody (HCV IgG)
HCV IgG negative
Note. Normal laboratory values (Fischback & Dunning, 2009).
Table 4
Labs for HIV
Lab Test
HCV Negative
Result
Normal
Enzyme-linked
immunoabsorbent assay
(ELISA)
Western Blot
Negative
Negative
Negative
Negative
CD4 T-cell count and
Percentage
Plasma HIV RNA (Viral
Load)
P24 antigen capture assay
740 cells/mm3 and 34%
500-1000 cells/mm3
562,000 copies/mL
Not detectable
Reactive
Negative
HIV Genotypic Resistance
Testing
Coreceptor Tropism Test
Low-level resistance
Low-level resistance
Negative
Negative
HLA-B*5701
Negative
Negative
Aptima HIV-1 Qualitative
Positive
Negative
Assay; GenProbe
Glucose-6-phosphate
Negative
Negative
dehydrogenase
Note. Normal laboratory values (Fischback & Dunning, 2009; IDSA, 2009).
Table 5
Papanicolaou Test and other Sexually Transmitted Infection (STI) Tests
Test
Result
Normal
Papanicolaou
Nucleic Acid Amplification
Test for Cervix swab:
/Gonorrhea and Chlamydia
No abnormal or atypical cells;
No inflammation, no
infection, no partially
obscuring blood;
Major cell types within normal
limits
Negative and Negative
Vaginal Swab: Trichomoniasis Negative
No abnormal or atypical cells;
No inflammation, no
infection, no partially
obscuring blood;
Major cell types within normal
limits
Negative
Negative
DUNBAR CASE ANALYSIS
Vaginal Swab: Moniliasis
12
Negative
Negative
Note. Normal laboratory values (Fischback & Dunning, 2009).
Table 6
Urinalysis
General Characteristics and
Measurements
Test/Normal
Result
Chemical Determinants
Test/Normal
Result
Color: pale
yellow to
amber
Amber
Glucose:
negative
Negative
Specific
gravity:
1.005-1.025
with a normal
fluid intake
pH: 4.5-8.0
1.022
Blood:
negative
Negative
5.5
Protein:
negative
Negative
Volume 6002,500
mL/24/h
Appearance:
clear to
slightly hazy
700 mL/24h
Ketones:
negative
Negative
Clear
Bilirubin:
Negative
negative
Urobilinogen:
0.5-4.0 mg/d
0.7 mg/dL
Nitrite for
bacteria:
Negative
negative
Leukocyte
esterase:
Negative
negative
Note. Normal laboratory values (Fischback & Dunning, 2009).
Table 7
Other Tests
Test
Lymph Node Biopsy
Epstein-Barr Virus (EBV)
Microscopic Examination of
Sediment
Test/Normal
Result
Casts
Casts
negative:
negative
occasional
hyaline casts
Red blood
Negative
cells: negative
or rare
White blood
Negative
cells: negative
or rare
Crystals:
Negative
negative
Epithelial
cells: few;
hyaline casts
0-1/lpf
Few
Result
Normal
Hyperplasia and
multinucleated syncytia of T
cells with damaged follicular
dendritic network
No abnormalities
DUNBAR CASE ANALYSIS
13
Antibodies to viral load (antiVCA)
Antibodies to EBV nuclear
antigen using ELISA
Blood Cultures
Negative
Negative
Negative
Negative
Pending
Negative
Urine Cultures
Pending
Negative
Purified protein derivative
Negative, induration 3mm
skin testing for tuberculosis
(TB)
Cytomegalovirus (CMV)
Negative for CMV-specific
antibody test
IgG and IgM by ELISA
Syphilis
Nonreactive, negative for
Venereal Disease Research
syphilis
Laboratory Test
Anti-Toxoplasma antibody by Titer <1:16: no previous
indirect fluorescent antibody
infection by IFA
(IFA)
Pregnancy Test
Negative
Note. Normal laboratory values (Fischback & Dunning, 2009).
Negative for cutaneous
hypersensitivity- area of
induration <10mm
Negative for CMV-specific
IgG and IgM by ELISA
Nonreactive, negative for
syphilis
Titer <1:16: no previous
infection by IFA
Positive or Negative
Diagnostic Findings
Usually, the diagnosis of HIV is by serologic tests that validate the presence of antibodies
to HIV. The recommended initial tests for HIV-type 1 infection diagnosis are a rapid HIV test
or an ELISA. If the initial test is reactive, it should be confirmed by a western blot or indirect
immunofluorescence assay. Also, if a person seems to be involved in high-risk activity in the
past three months and HIV-seronegative, the person should have repeated serologic testing at
weeks six, 12, and 24 because there may be delayed appearance of HIV antibodies in recent
infected persons. In addition, if a person who is reporting involvement in high-risk behavior and
presents with signs and symptoms of acute retroviral syndrome, implement testing for plasma
viral load in addition to HIV antibody testing. However, the Federal Drug Administration (FDA)
does not approve quantitative plasma viral load for HIV diagnosis and necessitates validation by
following serologic testing in order to document seroconversion. The qualitative HIV-1 RNA
DUNBAR CASE ANALYSIS
14
test aptima HIV-1 qualitative assay has been approved for diagnosing HIV infection and helps
diagnosing the acute or primary HIV-1 infected person. A positive result in this test can be
considered confirmatory, but a western blot serology should be implemented two to four months
after the initial indeterminate or negative test for confirmation (IDSA, 2009).
Differential Diagnosis
The differential diagnoses for a patient presenting with flu-like symptoms and
lymphadenopathy incorporate mononucleosis from Epstein-Barr virus (EBV) or
cytomegalovirus, toxoplasmosis, syphilis, viral hepatitis, other viral infections, meningitis, and
lymphoma (AIDSinfo, 2012; IDSA, 2012; Lexi-Comp, 2013).
The diagnosis of HIV infection can be attained from the patients’ clinical presentation,
diagnostic findings, sexual history, and medical history. First, the patient presents with a fever,
pharyngitis, arthralgia, rash, and lymphadenopathy after having unprotected sex a month ago.
Around 50% of individuals experience the acute HIV syndrome with similar presenting
symptoms that occur three to six weeks after exposure to HIV. Abnormal diagnostic results that
help diagnose HIV infection include leukopenia with lymphocytosis, thrombocytopenia, elevated
liver enzymes, viral load of 562,000 copies/mL, and a reactive P24 antigen capture assay. The
positive aptima HIV-1 qualitative assay confirms the diagnosis of HIV infection. The patients’
sexual and medical history entail risk factors associated with the diagnosis of HIV infection. The
risk factors include a history of chlamydia and gonorrhea, multiple sexual partners, and not using
any form of protection during the sexual encounters (AIDSinfo, 2012; IDSA, 2012; Lexi-Comp,
2013).
DUNBAR CASE ANALYSIS
15
Plan
According to AIDinfo (2012) guidelines, the primary treatment goals for starting
antiretroviral therapy (ART) are to decrease HIV-associated illnesses and lengthen the duration
and quality of survival, reestablish and preserve immunologic function, maximally and strongly
overpower plasma HIV viral load, and inhibit HIV transmission since HIV infection cannot be
eradicated. Antiretroviral (ARV) regimens should have at least, desirable three, active drugs
from two or more drug classes in order to attain viral suppression. Around the initial 12 to 24
weeks of therapy, the viral load is usually decreased to below limits of assay detection in the
ART-naive patient. The provider and patient must work together to define individualized
strategies in order to improve adherence, develop long-term treatment achievement, and attain
treatment goals. The initial ARV regimen should be customized and based on virologic efficacy,
pill burden, dosing frequency, potential of drug-to-drug interactions, anticipated side effects,
convenience, genotypic resistance testing, and comorbidities.
Drug Therapy
Within six mechanistic classes there are over 20 permitted ARV drugs accessible for
design combination regimens. The six classes include nucleoside/nucleotide reverse
transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs),
protease inhibitors (PIs), fusion inhibitors (FIs), CCR5 antagonists, and integrase strand transfer
inhibitors (INSTIs). The initial ARV regimen usually entails two NRTIs in combination with a
NNRTI, a PI, an INSTI, or a CCR5. The following two tables provide information about the
recommended and alternative initial ARV combination regimens for the ARV naïve patient
(AIDsinfo, 2012).
DUNBAR CASE ANALYSIS
16
Table 8
Recommended and Alternative Initial Combination Regimens for the ARV Naïve Patient
Preferred
Alternative
NNRTI-Based Regimen
 Efavirenz/Tenofovir/Emtricitabine
PI-Based Regimens
 Ritonavir-Boosted Atazanavir +
Tenofovir/Emtricitabine

Ritonavir-Boosted Darunavir +
Tenofovir/Emtricitabine
INSTI-Based Regimen
 Raltegravir + Tenofovir/Emtricitabine
Note. Recommendations (AIDSinfo, 2012).
NNRTI-Based Regimens
 Efavirenz + Abacavir/Lamivudine
 Rilpivirine/Tenofovir/Emtricitabine
 Rilpivirine + Abacavir/Lamivudine
PI-Based Regimens
 -Atazanavir/ritonavir +
Abacavir/Lamivudine
 -Darunavir/ritonavir +
Abacavir/Lamivudine
 Fosamprenavir/ritonavir (once or twice
daily) + Abacavir/Lamivudine or
Tenofovir/Emtricitabine
 Lopinavir/ritonavir (once or twice daily)
+ Abacavir/Lamivudine or
Tenofovir/Emtricitabine
INSTI-Based Regimen
 Raltegravir + Abacavir/Lamivudine
Running head: DUNBAR CASE ANALYSIS
17
Table 9
Information on Preferred and Alternative ARV Medication for the ARV Naïve Patient
Drug and Cost
Drug-to-Drug Interactions
Adverse
Effects/Precautions
Follow Up Monitoring
Nucleoside Reverse
Transcriptase
Inhibitors (NRTIs)
Drugs that increase effects of
NRTIs: Ribavirin, GanciclovirValganciclovir, Atazanavir,
Ethanol, Lopinavir, Telaprevir, and
Protease Inhibitors may increase
Tenofovir,
Common Side
Effects: headache,
nausea, diarrhea,
pancreatitis,
neutropenia,
transaminase
increased, myalgia,
neuropathy,
musculoskeletal pain,
nasal signs and
symptoms, cough,
sore throat, infections,
weakness, and
hyperpigmentation
Monitor CBC with
differential, reticulocyte
count, renal and hepatic
function tests, serum
phosphorus, CD4 count,
HIV RNA plasma
levels, serum
transaminases, amylase,
bilirubin, triglycerides;
HLA-B*5701 genotype
status prior to initiation
of therapy, signs and
symptoms of
hypersensitivity
Abacavir and
Lamivudine
(Epzicom®) Abacavir
600mg and Lamivudine
300mg; (30): $977.61)
once daily
Tenofovir and
Emtricitabine
(Truvada®) Tablets
Emtricitabine 200mg
and Tenofovir 300mg;
200-300 mg (30):
$1149.01 once daily
Drugs that decrease effects of
NRTIs: Acyclovir-Valacyclovir,
Food, Adefovir, Protease Inhibitors
decrease Abacavir, and
Trimethoprim
NRTIs increase effects of other
drugs: Emtricitabine
NRTIs decrease effects of other
drugs: Atazanavir, Didanosine,
Dabigatran Etexilate, Linagliptin,
P-glycoprotein/ABCB1 Substrates,
Vincristine, and Tenofovir may
decrease Protease Inhibitors
Severe Side Effects:
Evaluate for risk factors
lactic acidosis,
for heart disease prior to
hepatomegaly,
treatment
myocardial infarction,
anaphylaxis,
paresthesia,
neuropathy, red cell
aplasia, splenomegaly,
steatosis,
rhabdomyolysis,
hyperbilirubinemia,
Advanced
Practice Nurse
(APN) May
Prescribe
No, physician
initiated or
physician
consult
DUNBAR CASE ANALYSIS
18
anemia,
Precautions:
chronic hepatitis B,
coronary heart
disease, renal
impairment,
preexposure
prophylaxis,
decreased bone
mineral density,
hypersensitivity, and
immune reconstitution
syndrome, fat
redistribution
Abacavir: Positive for
the presence of the
HLA-B*5701 allele
are at an increased
risk for
hypersensitivity
reactions and use with
caution in patients
with plasma HIV
RNA levels ≥100,000
copies/mL
Non-nucleoside
Reverse Transcriptase
Inhibitors (NNRTIs)
Drugs that increase effects of
NNRTIs:
Boceprevir, Darunavir,
Mifepristone, Saquinavir,
Common Side
Effects:
hypercholesterolemia,
dizziness, depression,
Testing for hepatitis B
virus prior to the
initiation of
antiretroviral therapy
No physician
initiated or
physician
consult
DUNBAR CASE ANALYSIS
Efavirenz (Sustiva®)
Capsules 200mg (90):
$633.96; Tablets 600mg
(30): $643.97 once
daily
Rilpivirine (Edurant®)
Tablet 25mg (30):
$804.38 once daily
Efavirenz,
Emtricitabine, and
Tenofovir (Atripla®)
Tablets Efavirenz
600mg, Emtricitabine
200mg, and Tenofovir
300mg (30): $1878.96
once daily
Rilpivirine, Tenofovir,
and Emitricitabine
(CompleraTM) Tablets
Rilpivirine 25mg,
Tenofovir 300mg, and
Emtricitabine 200mg
(30): $2,195.83
Voriconazole, Food, Ethanol,
Ketoconazole, and Lopinavir
Drugs that decrease effects of
NNRTIs: Rifampin, St Johns Wort,
Antacids, Carbamazepine,
Dexamethasone, Didanosine,
Fosphenytoin (Rilpivirine), H2Antagonists, OXcarbazepine,
Phenobarbital, Phenytoin
(Ripivirine), Primidone, Proton
Pump Inhibitors, and Rifamycin
Derivatives,
NNRTIs increase effects of other
drugs: Bepridil, Cisapride,
CYP3A4 inhibitors, substrates,
inducers, CYP2C9 inhibitors,
CYP2C19 inhibitors, CYP2B6
inducers, Dihydroergotamine,
Ergoloid Mesylates, Ergonovine,
Ergotamine, Fosphenytoin,
Methadone, Methylergonovine,
Midazolam, Nevirapine, Phenytoin,
Pimozide, Rilpivirine, Ritonavir,
and Triazolam
NNRTIs decrease effects of other
drugs: Atazanavir, Atorvastatin,
Atovaquone, Apixaban,
Aripiprazole, Apixaban,
Buprenorphine, Bupropion,
Cyclosporine, CYP3A4 inducers
19
insomnia, anxiety,
headache, rash,
diarrhea, and ALT
increased
Monitor CBC with
differential, reticulocyte
count, CD4 count, HIV
RNA plasma levels,
Severe Side Effects:
renal and hepatic
allergic reaction,
function tests,
ataxia, pancreatitis,
cholesterol,
seizures, suicidal
triglycerides, bone
ideation, neuropathy,
density (long-term),
dyspnea, lactic
serum phosphorus,
acidosis, body fat
serum transaminases,
accumulation,
signs of skin rash, signs
abdominal discomfort, and symptoms of
anxiety, cholecystitis, infection
glomerulonephritis,
nephrotic syndrome,
Monitor for CNS
vomiting, and
effects, redistribution of
somnolence
body fat,
hyperglycemia,
Precautions:
hyperlipidemia, and
chronic hepatitis B,
cushings appearance,
hepatomegaly, hepatic and review patient’s
and renal impairment, medications
seizure disorder,
hypercholesterolemia,
central nervous
system (CNS) effects,
decreased bone
mineral density,
depressive disorders,
hypersensitivity, and
immune reconstitution
DUNBAR CASE ANALYSIS
Protease Inhibitors
(PIs)
Atazanavir (Reyataz®)
Tablets 150mg (30):
$557.97; 200mg (60):
$1064.94; 300mg (30):
$1067.99 once daily
Darunavir (Prezista®)
Tablets 400mg (60):
$1,086.03; 600mg (60):
$1,129.04 once daily
Fosamprenavir
(Lexiva®) Tablets
700mg (30): $439.98
once or twice daily
Lopinavir/ritonavir
(Kaletra®) Solution
and inhibitors, CYP2C19 substrates
inhibitors, CYP2B6 inhibitors,
CYP2C9 substrates, Etonogestrel,
Etravirine, Everolimus, Active
metabolite of Fosamprenavir,
Indinavir, Itraconazole, Lopinavir,
Lovastatin, Norgestimate,
PACLitaxel, Posaconazole,
Pravastatin, Proguanil, Raltegravir,
Rifabutin, Sertraline, Simvastatin,
Tacrolimus, Telaprevir, and
Vitamin K Antagonists
Drugs that increase effects of PIs:
Carbamazepine, Cyclosporine,
Delavirdine, Enfuvirtide,
Posaconazole, Other PIs, and Food
Drugs that decrease effects of PIs:
Antacids, Boceprevir, Efavirenz,
Garlic, Fusidic Acid, H2Antagonists, Minocycline, Proton
Pump Inhibitors, Rifampin,
Tenofovir, and St Johns Wort
PIs increase effects of other drugs:
Alfuzosin, Alprazolam,
Atorvastatin, Bosentan,
Buprenorphine, Cisapride, CYP3A4
inhibitors, CYP2D6 inhibitors,
Digoxin, Ergot derivatives,
Etravirine, Indinavir, Irinotecan,
Meperidine, Midazolam,
Nefazodone, Nefazodone,
20
syndrome
Efavirenz should not
be used during first
trimester of
pregnancy, women
trying to conceive, or
not using efficient and
regularly taking
contraception
Common Side
Effects: rash,
cholesterol increased,
nausea, amylase
increased, bilirubin
increase, cough, liver
enzymes increased,
vomiting,
hypertriglyceridemia,
weakness, creatine
phosphokinase (CPK)
increased, and
diarrhea
Severe Side Effects:
alopecia, angioedema,
AV block,
cholecystitis, edema,
stroke, nephrolithiasis,
pancreatitis, left
bundle branch block,
Monitor viral load, CD4,
serum glucose, liver
function tests,
cholesterol, electrolytes,
triglycerides, bilirubin,
drug levels (with certain
concomitant
medications), CPK
level, uric acid, serum
amylase and lipase,
electrocardiogram
monitoring in patients
with prolonged PR
interval or with
concurrent AV nodal
blocking drugs
Monitor for
hypersensitivity
reaction, gastrointestinal
disturbance,
No, physician
initiated or
physician
consult
DUNBAR CASE ANALYSIS
400mg-100mg/5mL
(160): $419.98
Tablets 100mg-25mg
(30): $103.99; 200mg50mg (30): $199.99
once or twice daily
Ritonavir (Norvir®)
Capsules 100mg (30):
$290.98; Solution
80mg/mL (240):
$1508.58; 100mg (30):
$289.99 once or twice
daily
Integrase Strand
Transfer Inhibitor
(INSTI)
Raltegravir (Isentress®)
Tablets 400mg (60):
Nevirapine, Pitavastatin, Rifabutin,
Rosuvastatin, Sildenafil,
Simvastatin, Sirolimus,
Temsirolimus, Tenofovir,
Trazodone, Triazolam, Tricyclic
Antidepressants, Vardenafil, and
Warfarin
PIs Decrease effects of other drugs:
Abacavir, Amiodarone, Calcium
channel blockers, Clarithromycin,
Contraceptives, CYP3A4 inducers,
Didanosine, Divalproex, Eplereone,
Pimozide, Quinidine, Tacrolimus,
Telaprevir, Theophylline
derivatives, Valproic Acid, and
Zidovudine,
Drugs that increase effects of
NNRTIs: Proton Pump Inhibitors
Drugs that decrease effects of
NNRTIs: Rifampin, Tipranavir,
Rifabutin, Fosamprenavir,
21
QT prolongation,
Stevens-Johnson
syndrome, torsades de
pointes, lymphoma,
metabolic acidosis,
seizures, acute
respiratory distress
syndrome, myocardial
infarction, lactic
acidosis
hyperlipidemia, rash,
CNS effects, and
electrolyte imbalance
Precautions: renal and
hepatic impairment,
hemophilia A or B,
conduction
abnormalities,
diabetes, fat
redistribution,
hypersensitivity,
diabetes, pancreatitis,
sulfonamide allergy,
increased cholesterol,
nephrolithiasis,
hemolytic anemia,
immune reconstitution
syndrome,
cardiovascular disease
Common Side
Monitor viral load, CD4
Effects: headache,
count, and lipid profile
insomnia, glucose
increased,
Severe Side Effects:
No, physician
initiated or
physician
consult
DUNBAR CASE ANALYSIS
$1030.04 twice daily
Efavirenz, and St John’s Wort
Increase effects of other drugs:
None listed
Decrease effects of other drugs:
None listed
22
abdominal pain,
anemia, cerebellar
ataxia, depression,
drug rash with
eosinophilia and
systemic symptoms,
hepatic failure,
hepatitis, herpes
simplex,
hypersensitivity,
myopathy,
nephrolithiasis, renal
failure, StevensJohnson syndrome,
suicidal ideation,
thrombocytopenia,
toxic epidermal
necrolysis, vomiting,
and weakness
Precautions:
immune reconstitution
syndrome, myopathy,
and skin and
hypersensitivity
reactions
Note: Drug information (AIDSinfo, 2012; Lexi-Comp, 2013; Ohio Board of Nursing, 2011).
Running head: DUNBAR CASE ANALYSIS
23
Even though the patients CD4 count is above 500 cells/mm3, the patient should be started
on ART because the viral load is >100,000 copies/mL and the patient is at high risk for
transmitting HIV to any future sexual partner due to her high viral load level. Also, there has
been an increasing attentiveness to untreated HIV infection or uncontrolled viremia could be
related to the development of cardiovascular disease, kidney disease, liver disease, neurologic
complications, and malignancies (AIDSinfo, 2012).
Before initiating ART, the patient should be agreeable and committed to treatment,
comprehend the risks and benefits of therapy, and the importance of adherence. Once there is
informed consent, the patient will be started on Atripla (Efavirenz 600mg, Emtricitabine 200mg,
and Tenofovir 300mg) tablet PO daily for life-long treatment. The medication should be taken
on an empty stomach and usually at nighttime. Atripla is the medication of choice because
Abacavir and Rilpivirine are to be used in caution with patients who have a pretreatment viral
load >100,000 copies/mL. This eliminated all of the alternative recommended regimens and one
of the preferred regimens. Also, the patient is busy working full-time and taking two college
courses. Therefore, it would be beneficial for the patient to have a medication with lower
frequency and lower pill burden. Atripla is only one pill once a day versus the PI-based
regimens of more than one pill. Even though the patient has health insurance with Anthem, cost
is still a factor on deciding what ART to initiate because Anthem will only cover 90% of total
cost per month of ARV medications. The cost of Atripla is $1878.96 ($188 after insurance
coverage) a month (thirty tablets) compared to over $2,000 for the PI-based regimens (AIDSinfo,
2012; Lexi-Comp, 2013).
All of the drug-to-drug interactions, side effects, follow-up monitoring, and precautions
of Atripla are noted in table nine, but there specific issues from these topics that should be
DUNBAR CASE ANALYSIS
24
addressed for this patient. The common side effect of Atripla is hypercholesterolemia and with
the patients’ strong family history of hypercholesterolemia, there should be close monitoring of
the patients lipid panel once Atripla is initiated. Also, there are two drug-to-drug-interactions
that need to be addressed specifically with the patient. Alcohol increases the effects of Atripla
and the patient admits to drinking alcohol. Therefore, the patient should be educated on the
effects alcohol has with their new medication and the importance of alcohol cessation. The
patient is currently taking Junel FE 1mg-20mcg tablet PO daily and Atripla decreases the
effectiveness of the hormonal contraceptive. Therefore, the patient should be educated on using
an alternative or additional contraceptive method to prevent pregnancy. The patient needs to be
educated on notifying the ANP if she is ever pregnant or thinking of having a child due to the
adverse effects of Efavirenz during pregnancy. A pregnancy test should be drawn at the
initiation of Atripla. Follow-up monitoring for this patient includes a viral load, BMP, liver
enzymes and bilirubin, CBC with differential, and fasting lipid panel at two to eight weeks post
Atripla initiation. Every three to six months a CD4 count, viral load, BMP, CBC with
differential, and liver enzymes with bilirubin should be measured. A fasting lipid panel should
be monitored every twelve months and a urinalysis and fasting glucose should be monitored
every six months. Serologic testing should be performed over the next three months for
confirmation (AIDSinfo, 2012; Lexi-Comp, 2013).
In addition to ART, it is vital that the patient be educated on HIV infection, importance of
adherence to medication, prevention of secondary transmission, offered different support groups,
and government programs. The patient should be educated about HIV infection at diagnosis and
understand that there is no cure for HIV infection. Educating on the importance of adherence
includes that ART has been significantly associated with HIV viral suppression, decreased rates
DUNBAR CASE ANALYSIS
25
of resistance, an increase in survival, and a better quality of life. When providing education on
the importance of adherence to ART, the consequences of not adhering to ART should also be
discussed (AIDSinfo, 2012). In addition, the patient should be educated on how HIV is
transmitted and how to prevent transmitting HIV to other people. It would be important to
educate this patient on the different contraceptive methods available in order to have safe sex and
not transmit HIV. Counseling and related behavior interventions, for example, Partnership for
Health, Options, and Positive Choice, have proven to be effective interventions in decreasing
behaviors associated with secondary transmission of HIV for people living with HIV. These
three interventions can be provided in the treatment setting and by the APN. It is important to
educate the patient on different support groups that can be provided. Support groups that would
be applicable for this patient include Sister to Sister and Women Involved in Life Learning from
Other Women (WILLOW). These support groups involve behavioral interventions and
education for adult sexually active women in order to reduce sexual risk behaviors and prevent
transmission of HIV (Center for Disease Control and Prevention, 2012). The patient should be
educated on the different government programs that can offer HIV-related services and financial
assistance. The APN could recommend the patient to apply for the Ryan White HIV/AIDS
Program that provides HIV-related services and could financially assist with medical costs after
insurance coverage (AIDS.gov, 2013).
Advanced Practice Nurse Authority to Prescribe
Ohio APNs who hold a valid Certificate to Prescribe have the authority to prescribe any
of the ARV medications from the recommended regimens only if it is physician initiated or a
physician consult (Ohio Board of Nursing, 2013).
DUNBAR CASE ANALYSIS
26
Clinical Study
Efavirenz (EFV) has been studied and compared to other NNRTIs, PIs, and INSTIs in
combination regimens including two NRTIs and still no other regimen has demonstrated to be
better than EFV-based regimens for virologic responses.
Findings from large randomized,
controlled trials and cohort studies of ART-naïve patients have exhibited effective viral
suppression in EFV-treated patients, where a significant percentage of these patients have plasma
viral loads <50 copies/mL up to seven years of follow-up (AIDSinfo, 2012).
A randomized double blind, double-dummy, active-controlled trials assessed the efficacy
and safety between rilpivirine (RIL) and EFV with tenofovir and emtricitabine in treatment-naïve
adults with HIV-1 infection at 112 sites across 21 countries. The inclusion criteria for the
population were 18 years or older, viral sensitivity to every studied drug, had a plasma viral load
at screening of 5,000 copies/mL or greater, and no previous treatment of ARV medications. The
method consisted of a computer-generated interactive web response system to randomly assign
patients to take either once-daily 25mg RIL PO or once-daily 600mg PO and everyone took a
fixed-dose regimen of once-daily 300mg tenofovir PO and one-daily 200mg emtricitabine PO.
The population was stratified with the screening viral load (<100,000 copies/mL, >100,000 to
≤500,000 copies/mL, and >500,000 copies/mL and randomized. The RIL or matching placebo
was to be taken with a meal, while EFV or matching placebo was to be taken at night on an
empty stomach in order to achieve the double-dummy design. There was a six-week screening
period, a 96-week treatment period, and a four-week follow-up period for the trial. The findings
included 287 of the 346 (83%) patients who received RIL and 285 of the 344 (83%) patients who
received EFV attained an established response (viral load less than 50 copies/mL) at week 48.
Even though RIL demonstrated to be non-inferior to EFV overall, the incidence of virological
DUNBAR CASE ANALYSIS
27
failure (VF) (failure to attain or maintain a serum viral load <50 copies/mL) consisted of 45
(13%) patients who received RIL and only 13 (6%) patients who received EFV. Also, only 62%
(21 of 34) of the patients who received RIL that started with a baseline viral load >500,000
copies/mL attained an established response compared to 81% (38 of 47) of patients who received
EFV. In addition, patients who were taking RIL and experienced VF were more likely to have
genotypic resistance to other NNRTIs and to their prescribed NRTIs compared to patients taking
EFV and experiencing VF. The issues of concern incorporate that the findings cannot be applied
to the general population because it did not include patients who had HIV-2, patients with more
than one NNRTI resistance-associated mutation, or had a clinically significant disease. Also, the
trial only used one NRTI regimen. There were no legal or ethical implications present in the
study when reviewed (Molina et al., 2011).
Issues
There are important considerations when determining what medication to prescribe for
this patient. First, the consideration of effectiveness of the medication because the patients
plasma viral load is 562,000 copies/mL and it is important to choose the best drug that will
effectively bring the patients plasma viral load to not detectable in a short period of time.
Through research atripla is the most effective medication to bring the plasma viral load to not
detectable. Second, drug-to-drug interactions were a consideration in medication choice. The
patient is currently taking Junel FE 1mg-20mcg tablet PO daily and through research, atripla
could decrease the effectiveness of the oral contraceptive, but no other interactions noted. The
patient could either switch to a new contraceptive method, for example, an intrauterine device, or
add another contraceptive method, for example, condoms, to the oral contraceptive (AIDSinfo,
2012). Third, patient compliance is an important factor in considering what medication to
DUNBAR CASE ANALYSIS
28
prescribe because this patient will be on ART for the rest of her life and the patient lives a
stressful life with working full-time and taking college courses. Therefore, it is important to
have a simple ARV regimen and atripla is only one pill a day that can be taken on an empty
stomach. Fourth, there will be necessary follow-up appointments throughout the patients’ life
once the medication is started. There will be laboratory tests implemented in order to make sure
atripla is effective. Fifth, financial cost is another consideration because atripla is $188.00 a
month after insurance coverage and is the least expensive of the recommended or alternative
ARV regimens available (Lexi-Comp, 2013). The patient can apply to government programs
that can assist with the rest of the monthly cost. The patients’ education level, ability to
understand the importance of taking atripla, compliance with current medication, and making the
appointment at the infectious disease office soon after her appointment with her PCP, allows the
APN to gain confidence that the patient will be adherent with taking atripla and making followup appointments.
Legal and Ethical Considerations
The legal and ethical considerations that need to be taken into account when prescribing
atripla include autonomy, beneficence, nonmaleficence, and justice. First, the right to autonomy
consists of the patient being able to decline the medication regimen or be noncompliant while the
APN respects the patients’ decision. The APN has the responsibility of providing all of the
education the patient should have in order to make an informed decision on adhering to the
medication regimen. This includes education on the use, side effects, cost, benefits, and the
treatment goals of atripla. Also, the consequences of not taking atripla should be discussed with
the patient. The APN needs to have the patient agree to taking atripla before prescribing the
medication. Second, the right to beneficence includes the APN believing the prescribed
DUNBAR CASE ANALYSIS
29
medication regimen will benefit the patients’ health, improve quality of life, and lengthen the
duration of life. Applying the right to beneficence for this patient includes the APN believing
atripla will decrease the patients’ plasma viral load to a not detectable level and decrease risks
for opportunistic infections in order to enhance her quality and length of life. Third, the right to
nonmaleficence includes the APN prescribing the medication regimen with the intent of doing no
harm or causing adverse effects. The intent for prescribing atripla should not be to cause the
patients plasma viral load to increase, CD4 count to drop, cause an opportunistic infection, or
decline quality and length of life. Last, the right to justice includes the APN treating all persons
fairly and equally (American Nurses Association, 2013). Right to justice for this patient includes
the APN treating this patient the same whether they were or were not diagnosed with HIV.
Discussion Questions
1. It has been two years since the patient first started taking atripla and she has been adhering to
her ARV regimen and follow-up appointments with you. She is coming into the office today for
a follow-up appointment regarding her laboratory results and treatment plan. You review with
her that her CD4 count is now 842 cells/mm3 and her plasma viral load is not detectable. When
discussing the treatment plan, she tells you that she is getting married in a month and her fiancé
and her would like to start a family soon after their wedding. As her healthcare provider and
using the AIDSinfo ART guidelines for adults, would you change her ARV regimen knowing
that she is planning to have a child soon? Why or why not? If you decide to change her ARV
regimen, what would you change her ARV regimen to and why?
2. Discuss the HIV infection classification system for adults. What clinical category is this
patient and why? How will you know if this patient moves to a different clinical category?
Please explain.
DUNBAR CASE ANALYSIS
30
References
AIDS.gov. (2013). Federal resources. Washington, DC: Author. Retrieved February, 11, 2013,
from http://www.aids.gov/federal-resources/
AIDSinfo. (2012). Guidelines for the use of antiretroviral agents in hiv-1-infected adults and
adolescents. Rockville, MD: Author. Retrieved February 2, 2013, from
http://www.aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf
American Nurses Association. (2013). Code of ethics for nurses. Silver Spring, MD: Author.
Retrieved February, 16, 2013, from
http://nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses
Fischbach, F. & Dunning, M. (2003). A manual of laboratory and diagnostic tests (8th ed.).
Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Williams.
Center for Disease Control and Prevention. (2012). HIV/AIDS. Atlanta, GA: Author. Retrieved
February, 6, 2013, from http://www.cdc.gov/hiv/
Infectious Disease Society of America. (2009). Primary care guidelines for the management of
persons infected with human immunodeficiency virus: 2009 update by the hiv medicine
association of the infectious disease society of america. Clinical Infectious Disease, 49,
651-681. Retrieved February 2, 2013, from
http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/HIV%20Primary%20Care.pdf
Lexi-Comp, Inc. (2013). Lexi-DrugsTM. Lexi-Comp, Inc. Accessed February 8, 2013.
Molina, J., Cahn, P., Grinsztejn, B., Lazzarin, A., Mills, A., Saag, M.,… Boven, K. (2011).
Rilpivirine versus efavirenz with tenofovir and emtricitabine in treatment-naïve adults
infected with hiv-1 (echo): A phase 3 randomised double-blind active-controlled trial.
DUNBAR CASE ANALYSIS
31
Lancet, 378, 238-246. Retrieved February 8, 2013, from
http://journals.ohiolink.edu.ezproxy.libraries.wright.edu:2048/ejc/pdf.cgi/Molina_JeanMichel.pdf?issn=01406736&issue=v378i9787&article=238_rvewtap3rdat
Ohio Board of Nursing (2013). The formularly developed by the Committee on Prescriptive
Governance. Retrieved February 9, 2013, from
http://www.nursing.ohio.gov/PDFS/AdvPractice/1-20-13_Formulary.pdf