CCS- Pneumocystis Carinii Pneumonia with Candida Viginitis.

History of present illness:40 year old homosexual female, cough and fever, vaginal itching . Note where the patient is on presentation, if she is in your office after initial work up, patient should be transferred to Ward or ICU (depending on presentation but most likely to ward). Unless the symptom are mild in that case treat patient in the office.

VITAL SIGNS- will help you to determine if patient is stable or unstable. BP (N= 90-140/60-90), Pulse (N= 60-90, Mean- 72), RR (N= 12-20, Mean- 16), Temp.( N= 37C, 98.6F)Allergy: NKADDX-

Pneumocystis pneumonia- Top of your list because of risk factor and OI at presentation.CytomegalovirusKaposi Sarcoma Legionellosis Lymphocytic Interstitial Pneumonia Mycoplasma Infections Nocardiosis Bacterial Pneumonia Fungal Pneumonia Viral Pneumonia Pulmonary Embolism Tuberculosis

Step I : Emergent management: A, B, C, D- depending on presentation and assessment of O2 sat. if O2 sat is low. Start with one litter O2 and get IV access

.Step II : Physical Examination Any suspect HIV/AIDS patient should have a complete physical exam. General appearance, Skin, Lymph Nodes, HEET/Neck, Chest/Lung, Heart/CV, Abdomen, Genitalia, Extremities, Neuro

.Step III : Diagnostic Investigations: 1. O2 sat.- Pulse oximetry is obtained as part of the initial workup2. ABG- with signs of respiratory distress.(hypoxemia)3. LDH- Levels are noted to reflect disease progression. High levels during treatment indicate therapy failure and worse prognosis.4. CBC/D- 5. Chem-126. CXR- The classic finding is diffuse central (perihilar) alveolar or interstitial infiltrates. Normal CXR is found in 5-10% of cases.7. Sputum- by-sputum induction for Wright-Giemsa stain or direct fluorescent antibody (DFA) for Pneumocystis if PCP is strongly suspected. If negative and PCP suspicion is high next step is bronchoalveolar levage.

8. HIV test- when you order a test like HIV that requires patient consent, it will tell you that patient consented to the test and result will be available in 7 days.9. CD4 count10. PCR assay11. Saline or KOH Vaginal secretion (wet mount).12. LFTs13. VDRL, Toxoplasma IGG, and hepatitis B and C serologies.14. Cervical papanicolaou Smear15. TB skin test.Treatment: 1. IV fluid ľNS (In moderate- severe cases).

2. If suspicions is high for PCP start treatment with Bactrim-DS po bid for 14-21 days. If patient is hypoxic, start with Bactrim IV.3. Report positive result to Department of Health and Human services

.Step IV: Decision about changing patients location 1. Mild-to-moderate disease refers to patients with milder symptoms and a nontoxic clinical appearance. They generally are not hypoxic and may even have a normal CXR. Outpatient oral therapy can be considered for these patients.2. Moderate-to-severe disease describes patients with severe respiratory distress, hypoxemia, and, often, a markedly abnormal CXR. Inpatient management with rapid diagnosis and treatment is essential.3. Admit patient to ward for moderate to severe disease. (ICU if patient unstable). Mild cases should be managed outpatient.

4. Discontinue IV fluid if patient is taking po and is not dehydrated.5. Continue Bactrim - 6. Treat Vaginal candidiasis with antifungal such as nystatin, clotrimazole, miconazole vaginally.

7. When diagnosis of AIDS is established start Antiviral therapy with: A. 2 NRTIs + 1 or 2 PIs. B. 2 NRTIs + an NNRTI8. Vaccines: Influenza, Hepatitis A and B, Pneumococcal vaccine.9. when patient is stabilized cancel IV fluid, move patient to home with follow-up in your office in 5-7 days.10. Continue Bactrim and antifungal- discontinue antifungal when patient returns for follow ľup unless symptoms still persist in that case consider changing antifungal

.Step V: Educate patient and family:1. Educate patient on safe sex. 2. Educate patient on Medication compliance.3. Console patient on HIV support group. When you request this option it tells you arrangements for follow-up has been make

.Step VI: Final Diagnosis:Pneumocystis Carinii Pneumonia (PCP) with Candida Viginitis