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Note

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NOTE: This case demonstration was developed using the diagnostic process described in Chapter 4 and demonstrated in Chapter 5. The reader is encouraged to use this diagnostic process in order to ensure thorough clinical reasoning. If additional elaboration is required on the information presented in this chapter, please consult Chapters 4 and 5.

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THE DIAGNOSTIC PROCESS

  • Step 1 Identify the patient's chief concern.

  • Step 2 Identify barriers to communication.

  • Step 3 Identify special concerns.

  • Step 4 Create a symptom timeline and sketch the anatomy (if needed).

  • Step 5 Create a diagnostic hypothesis list considering all possible forms of remote and local pathology that could cause the patient's chief concern.

  • Step 6 Sort the diagnostic hypothesis list by epidemiology and specific case characteristics.

  • Step 7 Ask specific questions to rule specific conditions or pathological categories less likely.

  • Step 8 Re-sort the diagnostic hypothesis list based on the patient's responses to specific questioning.

  • Step 9 Perform tests to differentiate among the remaining diagnostic hypotheses.

  • Step 10 Re-sort the diagnostic hypothesis list based on the patient's responses to specific tests.

  • Step 11 Decide on a diagnostic impression.

  • Step 12 Determine the appropriate patient disposition.

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Case Description

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Alex is a frail 42-year-old male presenting with concerns of fatigue and generalized weakness. He attributes his symptoms to being inactive and losing 20 lbs recently during his illness. He has noted excessive sweating especially at night. Past medical history includes human immunodeficiency virus (HIV; 8 years) and hospitalization for Pneumocystis carinii pneumonia 1 month ago. Prior to this recent bout of pneumonia, Alex was active as a self-employed business owner and participated in triathlons. He has been off work for the past month following a hospitalization for pneumonia. Since that episode of care, he has been too tired and short of breath to ride his bike or run. His goals are to return to work and eventually return to triathlon training. The employees at his business and his family have not been informed of his diagnosis of HIV. His most recent blood testing indicates CD4+ T lymphocytes 450 cells/mm3. Alex's medication includes the highly active antiviral reactive therapy (HAART) regimen (for the past 8 months), which includes tenofovir, emtricitabine, ritonavir, and a daily multivitamin.

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Teaching comments:

The U.S. Department of Health and Human Services Panel on Clinical Practices for Treatment of HIV Infection sets guidelines for the treatment of HIV including initialization of HAART regimen. In the question of "when to start" this therapy, the panel has been unable to reach a two-thirds consensus for their recommendations. The 2009 guidelines stated: "Based on cumulative observational cohort data demonstrating benefits of antiretroviral therapy in reducing [acquired immune deficiency syndrome] AIDS- and non-AIDS-associated morbidity and mortality, the Panel now recommends antiretroviral therapy for patients with CD4 count between 350 and 500 cells/mm3. This recommendation is made with 50% of the Panel ...

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