Supplemental Case Studies without Leading Questions

Reynaldo is a 48-year-old gentleman who was on vacation in the Philippines in August 2013 when he developed headaches, visual changes and fever. He was admitted to hospital in the Philippines and diagnosed as HIV positive (HIV+) with cryptococcal meningoencephalitis. Reynaldo remained in hospital in the Philippines for 28 days and returned to Toronto and was admitted for treatment. Between October 2013 and September 2014, he required 8 admissions to hospital – spending more time in hospital versus out of hospital for a number of sequelae from HIV or treatment complications including fever, renal failure, C. difficile colitis.

Past Medical History: Type 2 Diabetes mellitus; gout

Social History: Prior to August 2013, Reynaldo worked two jobs as a machine operator. He was economically independent and owned his own condominium. His ethnicity is Filipino; he came to Canada in 1993. He is one of 5 children; he has 2 older sisters, 1 younger sister and brother. His sexual orientation is MSM.

After August 2013, Reynaldo sold his condominium, as he was unable to live on his own due to his ongoing health issues. He is now on long-term disability and is unable to return to work at this time. Reynaldo currently lives with his 2 sisters. His family members prepare his meals, provide transportation and accompany him to all his appointments.

Current Medical History:

• HIV+
• Disseminated Mycobacterium kansasii
• Polyarthritis
• Gout
• Hypertension
• Type 2 diabetes mellitus
• Stage 3 Chronic Kidney diseases
• Perinephric hematoma secondary to lithotripsy
• Depression

Medications:

Issues:

• Re-creating independence from family.
• Cannot go back to previous work – query return to school or retraining.
• Transitioning from the sick role.

Christopher is a 55-year-old gentleman who was diagnosed as HIV positive in 1997. He has been on antiretroviral therapy since time of diagnosis. CD4 counts >400/mm³ and viral load results have been below the level of detection. Earlier this year he was admitted to hospital with fever and abdominal pain. He was diagnosed with sepsis secondary to sigmoid perforation requiring total colectomy and several weeks in the ICU. He was discharged to a rehabilitation facility but was readmitted after 3 days with bleeding from his stoma. Investigations revealed cirrhosis of the liver and emphysema.

Past Medical History:

• HIV+ – 1997
• Pulmonary tuberculosis – 1997
• Kaposi sarcoma – 1997
• Recurrent anal abscess

Social History: Single. Currently lives alone and his housing is connected to his job as a building manager. Estranged from his brother (until this hospitalization). Parents are deceased. Friends described as his family but they do not live in Ontario. Ethnicity – Caucasian/English. Sexual Orientation – MSM. Christopher reports 4-5 drinks/night and 30 years of smoking one pack to a pack and a half of cigarettes/day.

Current Medical History:

• HIV+
• Cirrhosis of the liver
• Emphysema
• Total colectomy

Medications:

Atripla 1 tablet OD
spironolactone 25 mg OD
furosemide 40 mg OD
ipratropium bromide 20 mcg/puff ii puffs q6h
Gaviscon oral suspension OD – bid
pantoprazole 40 mg OD
Proferrin 1 tablet OD

Issues:

• Decreased mobility and strength.
• Previous to hospitalization he was independent with ADL but is now dependent.
• Unable to return to work at this time as building superintendent and therefore housing issues.
• New diagnosis of cirrhosis – recommended changes in lifestyle especially alcohol intake.
• New diagnosis of emphysema – dealing with smoking cessation.
• Mood changes secondary to body image – total colectomy.

Bill is a 59-year-old gentleman diagnosed as HIV positive in 2000. He experienced a myocardial infarction (MI) earlier this year but received no intervention other than Plavix and beta-blocker as the clot was over 48 hours. Bradyarrhythmia was asymptomatic and in normal sinus rhythm. Bill will require routine follow-up and if he becomes symptomatic then surgical intervention will be required. Bill’s driver’s licence was suspended because of the MI and he is to be reassessed.

Past Medical History:

• HIV+ – 2000
• Burkitt’s Lymphoma – 2004
• Stage 3 Chronic Kidney Disease – secondary to chemotherapy
• Superior mesenteric vein thrombosis – 2002
• Anal fistula
• Obstructive sleep apnea
• Peripheral neuropathy secondary to chemotherapy
• Major depression in 2010 secondary to employment, financial and social stressors

Social History: Bill lives alone and has frequent job changes. His family lives in Montreal. He has no identifiable friendships/social network. Ethnicity – Caucasian/English. Sexual Orientation – MSM. Bill experiences ongoing financial stresses.

Current Medical History:

• HIV+
• Obstructive sleep apnea
• Peripheral neuropathy
• Restless leg syndrome
• Stage 3 Chronic Kidney Disease
• MI
• Obesity – BMI 37

Medications:

Kivexa 1 tablet OD
Kaletra 2 tablets bid
Pantoprazole 40 mg OD
Plavix 75 mg OD
Crestor 10 mg OD
metoprolol 12. 5 mg bid
NTG spray PRN

Issues:

• Obesity – weight loss as treatment for coronary artery disease (CAD).
• Sedentary lifestyle – worsening of CAD.
• Current employment in jeopardy because of CAD.
• Increased risk for mood alterations because of MI and lifestyle changes required.
• Minimal social support.

Gail is a 54-year-old woman diagnosed HIV positive in 2013 after her husband tested HIV positive. She was diagnosed with non-Hodgkin’s lymphoma in December 2012. Initial absolute CD4 count 10/mm³ and viral load viral load 295,000 copies/mL. One year later, her absolute CD4 count is 294/mm³ and viral load below the level of detection. Her non-Hodgkin’s lymphoma is in remission. She does not feel physically able to return to work and has ongoing financial stress.

Past Medical History:

• HIV+
• Hypothyroidism
• Osteoarthritis
• Anxiety

Social History: Gail has been married for 30 years. Her husband was diagnosed as HIV positive 2012. Her parents are deceased and she has 2 sisters. Gail worked as a collection officer until she went on long-term disability with the diagnosis of non-Hodgkin’s lymphoma. Ethnicity – Caucasian/English. Sexual Orientation – WSM

Current Medical History:

• HIV+ 2013
• Hypothyroidism
• Osteoarthritis
• Anxiety
• Stage 2 Chronic kidney disease secondary to long-term use of meloxicam
• Abnormal Pap tests
• Shingles

Medications:

Truvada 1 tablet OD
raltegravir 400 mg bid
Meloxicam 15 mg OD
lorazepam 1.5 qhs
Elavil 150 mg qhs
Synthroid .125 mg OD
Cycloprine 10 mg OD
Oxycocet PRN

Issues:

• Impaired ability to carry out ADL secondary to pain associated with osteoarthritis.
• Decreased energy levels.
• Persistent anxiety regarding finances and long-term disability.

Social isolation – only she and her husband.