Kristen Mazurkiewicz
HIV
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Heterosexual
Does not use IV drugs
Recent “all consuming” fatigue, general malaise, recent fever
Swollen neck glands for “about three weeks”
Doesn’t know how he is going to handle this or be able to tell his family/friends
Allergy to sulfa drugs and peanuts
Lives with girlfriend of 6 years, has cheated on her with women from the bar
Uses condoms most of the time
Drinks (socially) “a six pack or so” on nights he is not working, and 2-3 drinks if he is drinking
Started smoking when 21
Works as a bar-back and bouncer (wed-sat 9-4)
Works at a local garage (mon-thurs 9-4)
Gets Adderall, Provigil, and flexeril to regulate waking up, staying awake, and going to sleep.
o Obtains medications in the club
Works out 6 nights a week
Doesn’t want to look sick
No determined religion
Doesn’t use army health benefits (doesn’t want anyone from the armed forces to know)
o Has some insurance from the garage
Afraid of dying, doesn’t want to add more stress to his body
Aware of PNAP program
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Diagnosed with HIV in October 2011
Temp: 102.4, Pulse: 120, Resp: 21, BP: 128/89, ht: 6’2, wt: 210
Mucosal plaque like lesions on tounge and back of throat
Crackles and rhonchi in lungs, some SOB on slight exertion
Some difficulty swallowing
Puritis
Numbness in thumbs and forefingers of both hands
Depression and PTSD: In counseling seeing a psychiatrist to help with admitted psychiatric
condition
Lymphadenopathy in cervical, axillary, and inguinal nodes
Allergy to sulfa drugs
Neut%: 89.5 Lymph%: 7.5 Mono%: 2.5 Eos%: 0 Baso%: 0.5
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Urine Tox positive for benzodiazepines and amphetamines
CD4 count: 41cells/mm3 (baseline), 39cells/mm3 (one month ago)
HIV Viral Load: 1,590,000 (baseline), 1,389,000 (one month ago)
Positive C. trachomatis and N. gonorrhea NAAT
Decreased G6PD, negative HLA-B*5701
Positive toxoplasma IgG
Omeprazole 20mg po qab
A: JB has been diagnosed with HIV, and it has progressed to AIDS. This diagnosis is confirmed by a
CD4 count of 39cells/mm3, a viral load of 1,389,000 copies/ml. He also has tuberculosis and
toxoplasma gondii, two opportunistic infections. Other symptoms that can be attributed to his AIDS
diagnosis include the peripheral neuropathy in his thumbs and forefingers of both hands, his fatigue,
and malaise. Based on lab values, JB does not have any hematologic disorders due to AIDS.
To treat JB for AIDS, I recommend he be started on Truvada (TDF/FTC), a once daily regimen that can
be taken without regards to food. To complete the recommended triple therapy, I would also start
Raltegravir. This medication would be taken twice daily. I would not use a protease inhibitor
because he does not want to look sick, and these medications can cause an increase in bilirubin
which leads to jaundice. Also, protease inhibitors interact with PPI’s, and JB is on omeprazole. Due
to JB’s history with depression and PTSD, I would like to avoid using Efaverenz as it can have
neuropsychiatric effects. JB should be monitored for renal insufficiency and bone demineralization,
two side effects of Truvada.
JB should be counseled on possible changes in color pigmentation, the importance to adherence and
its implication in treatment failure. JB should also be counseled on the importance of safe sex
practices, and be given resources for HIV support groups. It is important to establish trust with JB,
and so he feels comfortable coming back if he has any questions. JB should be directed to a
pharmacist or other easily contacted health professional to go to if he has any questions.
JB should be encouraged to use the medical insurance he has from serving in the military, as these
medications are expensive and he will not be able to afford them without insurance. JB should also
be counseled on how to approach his girlfriend.
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Start Truvada (TDF+FTC), po qd
Start Raltegravir po bid
Counsel on possible changes in color pigmentation and adherence
Monitor patient for renal insufficiency and bone demineralization
Inform JB of local HIV support groups
Counsel on safe sex practices
7. Follow up in one month with patient to assess adherence and lab values
TB
S:
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

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Recent “all consuming” fatigue, general malaise, recent fever
Swollen neck glands for “about three weeks”
Allergy to sulfa drugs and peanuts
Drinks (socially) “a six pack or so” on nights he is not working, and 2-3 drinks if he is drinking
Started smoking when 21
Works as a bar-back and bouncer (wed-sat 9-4)
Works at a local garage (mon-thurs 9-4)
Doesn’t want to look sick
Doesn’t use army health benefits (doesn’t want anyone from the armed forces to know)
o Has some insurance from the garage
Afraid of dying, doesn’t want to add more stress to his body
Served in the army for the past 18 months in Afghanistan
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Temp: 102.4, Pulse: 120, Resp: 21, BP: 128/89, ht: 6’2, wt: 210
Crackles and rhonchi in lungs, some SOB on slight exertion
puritis
Some difficulty swallowing
Numbness in thumbs and forefingers of both hands
Depression and PTSD: In counseling seeing a psychiatrist to help with admitted psychiatric
condition
Lymphadenopathy in cervical, axillary, and inguinal nodes
Allergy to sulfa drugs
Neut%: 89.5 Lymph%: 7.5 Mono%: 2.5 Eos%: 0 Baso%: 0.5
Urine Tox positive for benzodiazepines and amphetamines
Decreased G6PD, negative HLA-B*5701
Positive tuberculosis IGRA
Sputum and blood are negative for acid fast bacilli
A: JB should be diagnosed with tuberculosis, as he has a positive IGRA and an abnormal chest x-ray. TB
can also help explain the all-consuming fatigue, malaise, and recent fever. JB should be assessed for
military TB, as he has involvement in lymph nodes, he has a fever, and puritis, but the blood and sputum
were negative for acid fast bacilli.
Rifabutin (not rifampin due to drug interactions)
Isoniazid
PZA
Ethambutol
X2 months
Then 4 months of Rifabutin and isoniazid
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1. Report TB to CDC
Toxoplasmosis:
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Candidiasis:
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STD’s:
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