Mr. Johnson is a 20 year old male who tested positive for HIV2 years ago. He has regular follow-ups with the HIV clinic every 3months. He has been stable on antiretroviral therapy for the past12 months. He is in the clinic today with concerns of moderatedyspnea, a persistent and non-productive cough, andfatigue.
Review ofSystems:
No nausea, vomiting, diarrhea, chills, night sweats, headache,urinary frequency, nocturia, or pain with urination.
He has had loss of appetite and lost 5lbs in the lastweek.
He continues to have dyspnea, a non-productive cough, andfatigue.
Allergies:Trimethoprim-Sulfamethoxazole(fever/rash)
SocialHistory:
Sexual preference: Male, new stable partner, engages inunprotected oral and anal intercourse
Smoked 3 ppd for 10 years, quit 2 years ago, no relapsesreported
Prior history of IV drug use and alcohol abuse, completedinpatient treatment for this and has been drug and alcohol free forthe past 5 years.
PhysicalExam:
VS: BP 130/87, HR 98, RR 30, T 101.9
General: thin, acutely ill-appearing, young male withtachycardia
Skin: soft, intact, warm, dry. No visible lesions, rash,ecchymosis, petechiae, or cyanosis
HEENT(Head, Ears, Eyes, Nose, Throat): PERRLA, ear and noseclear, non nasal passage swelling, sinuses non-tender, oral cavitynegative for erythema, exudates or lesions.
Neck/Lymph Nodes: Neck supple with no masses or bruits. Slightcervical lymphadenopathy, thyroid normal.
Chest and Lungs: Minimal axillary lymphadenopathy, bilaterallower lung lobe crackles with auscultation.
Heart: Normal sinus rhythm, Normal S1 and S2, no rubs,murmurs, or gallops present.
Abdomen: Soft and non-tender, no hepatosplenomegaly, bowelsounds active in all 4 quadrants, no costovertebral angeltenderness
Neurologic: Alert and oriented x3. Normal deep tendonreflexes. No focal neurologic deficits.
- Johnsonhas signs of opportunistic infections and weakened immune function.What would you do to determine if his HIV has progressed toAIDS?
