You are an APRN working at UCSF

You are an APRN working at UCSF AIDS clinic, your patient, Mr. Hamilton is a 38 yrs old white male diagnosed with AIDS. He was first diagnosed about a year ago and you have been seeing him monthly to monitor his adherence to treatment , viral load, symptom management prophylaxis , and treatment of opportunistic infections. He resides at the Ambassador hotel and lives on social security disability benefits of $900.00 per month. Hey pays $500.00 per month for his single room hotel room. His other diagnosis include agoraphobia and methamphetamine addiction. He is estranged from his family and has not had any contact with them for many years . he is a Gay , but is not sexually active. He is also a smoker using about one pack per day since age 15. He tends to miss appointments because of his extreme anxiety in public places. He has not been on antiretroviral therapy due to his inability to regularly take medications. At clinic today you saw another patient from the Ambassador hotel community who tells you his friend, Mr. Hamilton , has a fever and is not getting out of bed much these days. You make a note that it may be time for a home visit to see home Mr. Hamilton is doing and what is going on. You area aware that there is a special hospice for homeless people with AIDS and perhaps it might be time to consider a referral for more supportive services. Questions: 1 How you will you prepare for this home visit?consider the practical concerns , the equipment you need to bring and your goals for his care . When you arrive at the ambassador hotel , you stop in to say hello to the people you known on the 2 nd floor. The hotel is set up to assist homeless with AIDS and there is a program at the hotel that provides case management and supportive services to the people at the hotel. Questions: 2What might you want to know from the case management and supportive services team? You take the old narrow elevator up to the 3rd floor and knock on MR. Hamiltons door. Questions 3. What specific things will you want to assess at the visit? Use the IN HOMESSS model to organize your assessment plan. A couple of buddies are hanging around , smoking and talking . Cigarette smoke fills the room. It is warm summer day, so the window is open by the little bed . you see that the sheets are clean. There is one sink no bathroom. There are some empty beer cans in the room and open used boxes of simple food. The kitchen is a hot plate on the floor, and there is cold water from the little sink to mix up meals. The room has small working refrigerator .the bathroom is down the hall and shared by everyone on that floor, you check it out and find it clean and stocked with toilet paper. the bathtub which is a separate room is also clean. Questions: 4 What are the essential elements of the history and physical today? History and physical CC: fever ,AIDS HPI: 38 YRS OLD MALE WITH THE HISTORy of AIDS , end stage, addiction and agoraphobia , present with fever x 2 weeks no thermometer available , have diarrhea with 3-4 brown soft to liquid stools daily, no blood , eats 2 small meals a day , friends bring in fast food to prepare something on hot plate , no Shortness of breaths, no pain , continue to smoke 1 Packet per day , usinf IV speed when he can get it, has no come in for care because of increased anxiety in public places , fever work up is declined , he tells you he feels ok but coulld use a pack of cigarettes. He has not been in touch with the case management team on the 2 nd floor because his friends get him what he needs . Medications: Motrin ocassionally for fever Allergies : none PMH- see HPI Vital signs 100/70, 64, 18, 99.8, BMI 17, o2 sat 95% General: thin white male, alert , oriented affect relaxed , unshaven , personal hygiene clean. Skin: dry and flaking multiple nevi ruddy complexion , red flaky rash on naso/labial folds, and scalp with dandruff , no lice. HEENT: EMOS intact, PERRL, TMs grey canal clear, poor dentition , gingivitis, no thyroid enlargement, “shotty” lymph nodes posterior/anterior cervical. Pulmonary: BS clear coarse and distant. CV: RRR S1 S2 systolic ejection murmur grade 2 without radiation no thrill or heaves , PMI 5th ICS. Abdomen : Flat , soft , hyperactive bowel sounds throughout , no masses , no organomegaly GU; deferred MS/Extremities : no pain edema redness or swelling , strength equal Neuro : CN2-12 intact DRTS +3 bilaterally Mood stable , cognition intact. Questions 5 : What is your assessment? Questions 6 : What is your plan? Be sure to include treatments, prescriptions, diagnostics , patient education, follow ups and referral in your plan.

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