7-8 thru 7-10-09 Wed-Fri

Last week at work:

Was crazy busy. I was still trying to get over my sickness when Grace scheduled six KITSO students (2 docs, 2 nurses, and 2 MedEd people from the Bots government) to pilot the case in the scholar’s room, all at the same time. I was told that three would be coming in, so I had only set up three computers. Also, because they all had government e-mails, for some reason, I had to make them all yahoo.com mail accounts and set up their accounts from my computer. All-in-all it was a very stressful beginning to the morning, but it all turned out well in the end.

I had informed all of the students that the case should take about an hour, but because of the slow internet connection and their lack of computer skills, it took the slowest person about 2 hours to complete.

To say the least, I was nervous. This case was my baby and the first pilot with African students had not gone to plan. Stressed, and feeling the sickness, I reviewed the surveys they completed online and was pleasantly surprised. They all loved the case and had very good ideas about improving it.

I met with Grace (training coordinator) and had her set up a focus group with the six students for the following day (Friday). I spent the rest of the day dreaming up case #2.

I was determined to make this case more organized and full of MedEd stuff. So I made case objective and sub-goals along with a SOAP-like presentation and a case outline. The case SOAP-like presentation can be found below if you are interested:

The focus group on Friday blew my mind and my greatest expectations. It was scheduled for 10 mins but lasted about an hour. I started the meeting telling them to rip apart the case and that I needed to get criticism to make the case better. They started off by telling me what problems they had, but quickly they all started talking about how this was the new wave of teaching and how much more they enjoyed learning like this. They went on and on about how this program needs to expand and how simple the interface was and how everyone in HIV should complete this program.

By the end, the entire KITSO class had come in to listen (about 65 people). None of them said anything, but they just sat and listened. Finally, as the session concluded, they all gave me a round of applause. I have never been so proud of my work and it gave me the energy to tackle this difficult second case.

Case Synopsis:


K.M. is a 15yo boy started on AZT/3TC/NVP 2 years ago, now presenting alone to IDCC for scheduled visit. Complains of and itchy scalp and purple bumps on his skin. Denies missed doses. Lives with mother, father and two brothers but claims he is solely responsible for taking medications.

Pill count:
CBV 80% NVP 80%

PMH: PMTCT none. Had PCP, oral thrush, which is why he was tested for HIV. Had longstanding history of good adherence, until 3 months ago. Refuses to take medication because he feels fine and doesn’t think he needs it.

Meds: CBV 1 tab po bd
NVP 200 mg tab po bd

All: NKDA Immun: UTD

SHx: lives with mother father and two brothers, who have both have received adherence counseling when he was initiated on HAART. Child is in standard 5?, getting Bs. Rest of family tested negative 2 year prior (When he was initiated on HAART; probably horizontal transmission). He is currently sexually active but claims he uses condoms.

PE: Stunted and Wasted (will figure out details later)
Head and Neck: carries, generalized lymphadenopathy, white crusted sores on head with alopecia.
Thorax + Extrem: raised sores (Ddx includes: KS, etc)

Labs:
VL 21,000 (2 mos ago) → 55,000 (1 mo ago)
CD4 478/24% (9 mos ago) → 305/?% (3 mos ago)
FBC/LFTs nl (forever)

A: 15yo boy with WHO clinical 4, immune 3, on 1st line HAART, virologic failure
-Adherence: poor
-Disclosure: fully disclosed
-Risk factors: recent failure

P: Switch to 2nd line HAART once adherence improves:
ABC 300mg po bd
D4T 30mg
Aluvia 2 tabs

For now: to test adherence
Cotrimoxazole
Multi vite
Emphasize importance of adherence on 2nd line
Reinforce disclosure process (reminder that even though he felt fine, he has to take meds)
Refer to Social worker for discussion on adherence (where do these guys put their notes?)
In-reach to meet with family and discuss adherence
Refer to dietitian
Psych referral for problems at home and sexuality.
Treat tinea with systemic antifungals
Treat KS
Labs: Urgent VL, CD4
Review in 1 week (have another care giver come with him