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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Describe when antiretroviral therapy should be initiated in patients with HIV infection, and determine the desired outcome of such therapy.

  • Recommend appropriate first-line antiretroviral therapies for the antiretroviral-naive person.

  • Provide patient education on the proper dose, administration, and adverse effects of antiretroviral agents.

PATIENT PRESENTATION

Chief Complaint

“I am here for regular care. It hurts to swallow.”

HPI

Jenny Baird is a 34-year-old woman diagnosed with HIV infection 2 years ago during a routine exam. At the time of diagnosis, the patient was asymptomatic. She is currently antiretroviral therapy (ART) naïve, and since her diagnosis, she has been following up regularly every 4 months. However, up to this point, she has not been ready to commit to ART. Today she returns for a follow-up visit and reports painful and difficult swallowing over the past 2–3 weeks.

PMH

  • HIV infection, diagnosed 2 years ago; risk factor heterosexual contact

  • Bronchitis

  • Asthma

  • GERD

FH

Noncontributory

SH

  • History of crack cocaine use, last use 1 month ago

  • Smokes marijuana once per month, mainly as an appetite enhancer

  • Tobacco 0.5 ppd

  • EtOH, one to two drinks on weekends

  • Unemployed, lives with partner

  • Sexually active with stable partner, 100% condom use as sole method of contraception; partner is HIV (–) and is aware of her HIV status

Medications

  • Multivitamin with minerals PO once daily

  • Tums PRN heartburn

  • Albuterol HFA MDI, two puffs Q 6 H PRN SOB

All

TMP/SMX (rash)

ROS

Difficulty and pain on swallowing

Physical Examination

Gen

Thin, well-developed black female in NAD, alert and oriented × 3

VS

BP 110/64 mm Hg, P 80 bpm, RR 18, T 35.9°C; Wt 58 kg, Ht 5′5″

Skin

Anicteric, has large tattoo on back, no other skin lesions noted

HEENT

(+) Oral lesions and white plaques, sinuses nontender, PERRLA, ears and nose clear

Neck

Supple, no thyromegaly, R neck lymph node 0.7 cm in diameter

Chest

Lungs clear

CV

S1, S2 without S3, S4, or murmur

Abd

  • (+) BS, soft, nontender, without HSM

  • (+) Bilateral ...

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