solved

Chief Complaint
“This rash started 3-4 days ago on my back and stomach. My whole left side has been hurting, and I’ve also been feeling weaker than usual lately.”
HPI
John Rutherford, a 27-year-old man with a past medical history of HIV on HAART, presents with left upper quadrant/left back/left side pain and a diffuse rash. He states the rash started 3-4 days ago, and is mostly on his chest, abdomen, and arms. He also has seven macules on his scalp. The rash is nonpainful and nonpruritic, except on his scalp where he has developed a few scabs from itching; no drainage from any lesions is noted. He also has been having some chest pain that is worse with breathing. He notes nausea, though no vomiting, and reports ongoing non bloody diarrhea for months. He presents to the ED primarily because of pain in his upper left back that radiates around his left side. His urine is very dark, and brownish-red; however, he has no dysuria. The patient also states he has felt weaker than usual for the past few days
PMH
Hepatitis B, now immune
HIV diagnosed 6 months ago, on HAART
FH
Both parents with hypertension, still living
SH
Unemployed
Tobacco 1.5 ppd since early teens
Social alcohol usage (average four drinks per week)
Occasional methamphetamine use—both smoked and injected (with clean needles)
Previous MSM Hx (four partners in last 6 months) with inconsistent use of condoms
Meds
Tenofovir/emtricitabine 300/200 mg PO once daily
Raltegravir 400 mg PO BID
Acetaminophen-hydrocodone 325/5 mg PO Q 6 H PRN
All
Codeine
ROS
Constitutional: reports weakness and malaise; denies fever
Eyes: denies vision changes
Ears, nose, and throat: denies sore throat, rhinorrhea, or sinus pressure
Lymphatic: denies lymph node swelling
Respiratory: denies shortness of breath, dyspnea on exertion, or cough
Cardiovascular: reports some chest pain on inspiration
Gastrointestinal: reports intermittent nausea, no vomiting, and consistent diarrhea
Neurologic: denies neuropathy symptoms
Musculoskeletal: reports arthralgias and myalgias
Skin: rash on scalp, abdomen, arms, and legs present
Pain: reports persistent abdominal and left side pain
Physical Examination
Gen
Awake and alert, NAD. Appropriate. Oriented to person, place, and year.
VS
T 98.4°F, BP 114/70, HR 92, RR 16, O2 sat 98; Ht 61 in, Wt 59 kg
Skin
Numerous palpable, blanchable macules mostly ~5 mm with one area of confluence on the left lower abdomen. Macules present on both arms, chest, and back. Four to five scabs with surrounding erythema on scalp.
HEENT
Moist mucous membranes, neck supple. No cervical, postauricular, or supraclavicular lymphadenopathy. No obvious oral lesions. Mild icterus.
Neck
Supple; no lymphadenopathy, bruits, JVD, or thyromegaly
Lungs
CTA bilaterally. No crackles or wheezes.
Heart
RRR; S1, S2; no m/r/g
Abd
Soft, nondistended. Diffuse tenderness with minimal localization to the RUQ and more prominent on the epigastrium, LUQ, and back. (+) BS. No rebound or guarding.
Genit
Rash extending to penis; no other lesions present. Moderate inguinal lymphadenopathy.
Rectal
Scar from recently healed ulcer noted
Ext
Warm, well perfused, no edema. 2+ DP and PT pulses
MS
No joint swelling, or effusions
Neuro
CN II-XII grossly intact. No dysmetria. Strength 5/5 on all four extremities.
Labs
Na 138 mEq/L
WBC 9.3 × 103/mm3
K 3.9 mEq/L
Plt 391 × 103/mm3
Cl 96 mEq/L
ALT 66 IU/L
CO2 28 mEq/L
AST 95 IU/L
BUN 7 mg/dL
Alk phos 1271 IU/L
SCr 0.7 mg/dL
T. bili 5.0 mg/dL
Glu 100 mg/dL
CD4 460 cells/mm3
Hgb 12.3 g/dL
HIV viral load < 48 copies/mL Hct 36.9% Other RPR: Titers positive at 1:256. FTA-ABS: Positive. Hepatitis B: HBsAb positive, HBsAg negative. Hepatitis C: RNA negative CT abdomen and pelvis: Mild hepatosplenomegaly with minimal intrahepatic biliary ductal dilatation and prominence of the common duct. There are multiple tortuous perirectal vessels that may represent varices secondary to portal hypertension. Proctitis is present with innumerable reactive perirectal and pelvic lymph nodes. Team Case Study Questions Based on the presenting case of the patient's H&P what is the focus diagnosis? Support your answer. Based on your answer to question 1, what pharmacological management would be appropriate for this patient in regards to the focus diagnosis? Be sure to address dosing and titration in your answer. Be sure to address the need to continue AND/OR discontinue any medications that may be contributory. Describe the mechanism of action for any drug you provided in question 2. Additionally, what are the contraindications (if any) to using the drug(s)? For each drug, be sure to the rationale behind your choice of drug regimen. What are the monitoring parameters for any drug listed in question 2. Be sure to address appropriate follow-up times and any necessary testing or labs. What patient education should be provided in order achieve a therapeutic effect and minimize any potential harm? Be sure to address any lifestyle modifications/non-pharm therapy, drug-drug interactions, drug-diet interactions, and adverse drug effects.

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."