Patient Information
Mr.Johnson is a 20 year old male who tested positive for HIV 2 yearsago. He has regular follow-ups with the HIV clinic every 3 months.He has been stable on antiretroviral therapy for the past 12months. He is in the clinic today with concerns of moderatedyspnea, a persistent and non-productive cough, and fatigue.
Review ofSystems:
Nonausea, vomiting, diarrhea, chills, night sweats, headache, urinaryfrequency, nocturia, or pain with urination.
Hehas had loss of appetite and lost 5lbs in the last week.
Hecontinues to have dyspnea, a non-productive cough, and fatigue.
Allergies:Trimethoprim-Sulfamethoxazole (fever/rash)
SocialHistory:
Sexual preference: Male, new stable partner, engages in unprotectedoral and anal intercourse
Smoked 3 ppd for 10 years, quit 2 years ago, no relapsesreported
Priorhistory of IV drug use and alcohol abuse, completed inpatienttreatment for this and has been drug and alcohol free for the past5 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 nose clear,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.
Chestand Lungs: Minimal axillary lymphadenopathy, bilateral lower lunglobe crackles with auscultation.
Heart: Normal sinus rhythm, Normal S1 and S2, no rubs, murmurs, orgallops present.
Abdomen: Soft and non-tender, no hepatosplenomegaly, bowel soundsactive in all 4 quadrants, no costovertebral angel tenderness
Neurologic: Alert and oriented x3. Normal deep tendon reflexes. Nofocal neurologic deficits.
Case Study Discussion Questions:
- In the case study, identify the two most significant riskfactors our patient had for developing HIV. Share thereasons why you selected these two. Did thispatient have any other risk factoes?
