PTA Medications Drug Dose Indication Levetiracetam (Keppra ) 500 mg PO BID Seizures

Transcription

1 Student APPE General Medicine Rtatin Chief Cmplaint: Visin changes fr the past tw weeks Histry f Present Illness LB is a 53 year ld African American female wh presented t the emergency rm n June 2 nd. She describes nrmal visin prir t tw weeks ag with sudden and rapid deteriratin. The patient states that she currently feels blind. LB explains that she culd nt cme t the hspital sner due t financial reasns. She reprts lsing 60 punds ver several mnths due t pr appetite. Over the last several mnths, LB has nt taken her antiretrviral HIV medicatins and has nt seen a dctr. Past Medical Histry HIV/AIDS (2005) CNS lymphma Cranitmy and bipsy psitive (1/2014) S/P radiatin (3/14-4/14) Cryptcccal meningitis (2012) H/O Fcal seizures Pneumcystis Jirveci Pneumnia (PJP) Immunizatin histry: Pneumvax 23 (9/30/12) Allergy: NKDA Family Histry: nne Scial Histry Single N tbacc, alchl, r illicit drug use Caregiver: daughter PTA Medicatins Drug Dse Indicatin Levetiracetam (Keppra ) 500 mg PO BID Seizures Inpatient Medicatins (Blded Discharge Medicatins) Drug Dse Indicatin Start date Stp date Levetiracetam 500 mg 1 tab PO BID Seizures N/A Cntinue (Keppra ) Azithrmycin 1200 mg PO 1 tab q week MAC Prphylaxis 6/3 Cntinue (Zithrmax ) n Thursday (CD4 < 50) Flucnazle (Diflucan ) 400 mg 1 tab PO daily Cryptcccus 6/3 6/8 200 mg 1 tab PO daily prphylaxis (CD4 < 100) 6/3 Cntinue Sulfamethxazle/ 800 mg/160 mg 1 tab PO PJP prphylaxis 6/3 Cntinue Trimethprim (Bactrim DS ) daily (CD4 < 200) Atrvastatin (Lipitr ) 40 mg PO daily Secndary 6/3 Cntinue Aspirin 81 mg PO daily preventin f strke 6/3 Cntinue Nystatin (Mycstatin ) 5 ml swish and spit QID Oral candidiasis 6/3 6/6 after meals and at bedtime fr 3 days Ganciclvir (Cytvene ) 215 mg IV CMV retinitis 6/3 One dse Valganciclvir (Valcyte ) 450 mg PO BID 6/3 One dse This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site.

2 APPE General Medicine Rtatin 900 mg PO BID 6/3 6/4 Ganciclvir (Cytvene ) 100 mg IV q12h 6/4 6/6 200 mg IV q12h 6/6 Cntinue thrugh 6/19 15 mg intravitreal 6/12 Cntinue injectin Atripla (efavirenz, 600 mg/200 mg/300 mg HIV-AIDS 6/4 6/12 emtricitabine, tenfvir) Stribild (elvitegravir, cbicistat, emtricitabine, tenfvir) DVT Prphylaxis: SCD s 1 tab PO daily 150 mg/150 mg/200 mg/300 mg 1 tab PO daily 6/12 Cntinue Vitals - Admissin Temp: 97.4 F Pulse: 77 bpm Resp: 18 breaths per minute BP: 129/74 mmhg Demgraphics Height: 5 6 Weight 6/2: 43 kg 6/12: 36 kg IBW: 59.3 kg Physical Exam Pupils dilated 7 mm, minimally reactive t light, retina diffusely erythematus L > R eye Visual acuity: OD: 20/400 visin (severe visual impairment) OS: n light perceptin (retinitis invlving ptic nerve) Vitreus: nrmal Optic nerve: pale Macula: extensive areas f hemrrhages and retinal whitening Unable t visualize fingers at 2 inches White plaques n tngue Alert and riented x 3 Labs BMP Glucse (mg/dl) 91 (70-139) BUN (mg/dl) 20 (7-23) Creatinine (mg/dl) 0.72 ( ) Cl- (mml/l) 112 (98-107) H Na+ (meq/l) 142 ( ) K+ (meq/l) 5.4 ( ) H CO2 (mml/l) 23 (21-32) CBC WBC (billin/l) 4 ( ) Hgb (g/dl) 11.7 ( ) L MCV (mg/dl) 88.5 ( ) MCH (pg/cell) 29.1 ( ) This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site.

3 APPE General Medicine Rtatin Platelets (billin/l) 319 ( ) Micrbilgy CD4 (cells/mm 3 ) (6/2): 1 2/27/14: 3 1/15/14: 2 9/29/12: 1 HIV Viral lad (cpies/ml) (6/2): 17,503 2/27/14: 119,486 1/15/14: 118,649 9/29/12: 579,665 Bld PCR (6/3) Cytmegalvirus (CMV) detected CSF PCR (6/4) Varicella zster virus (VZV) detected All PCRs negative fr txplasma, herpes simplex virus (HSV), syphilis, epstein-barr virus (EBV), and cryptcccus Prcedure Results MRI (6/3): questinable enhancement f ptic nerves, new subdural hygrma Likely nrmal enhancement: rule ut neurlgical cause r lymphma Lumbar puncture (6/4): psitive fr VZV TTE (6/4): left ventricular hypertrphy, nrmal EF Gentype testing 10/2/12: n resistance 6/3/15: Resistance t delavirdine, efavirenz, nevirapine (NNRTIs) Drug resistance mutatin: reverse transcriptase gene K103N CMV Retinitis Epidemilgy 1,2 Befre antiretrviral therapy, CMV retinitis ccurred in 30% f AIDS patients. Patients with AIDS and CMV retinitis have a 60% greater mrtality. The intrductin f HAART decreased the incidence f CMV retinitis by 80-90%. Pathphysilgy 1,3 CMV is a DNA virus in the herpes virus family. In immunsuppressed individuals, CMV causes a disseminated infectin r lcalized end-rgan damage. End-rgan disease typically ccurs in patients with CD4 cunts < 50 cells/mm 3 wh are nt receiving HAART r did nt respnd t treatment. Retinitis is the mst cmmn CMV end-rgan disease. Necrsis f the retina results in scar tissue frmatin, which can then tear and cause retinal detachment. The retina affected by CMV cannt regenerate. Retinitis ccurs in ne eye in tw-thirds f patients, but ultimately prgresses t bilateral in mst patients wh are untreated r whse immune systems cannt recver. Withut treatment, retinitis prgresses within days f presentatin. Risk factrs 1 : CD4 < 50 cells/mm 3, previus pprtunistic infectins, HIV RNA levels > 100,000 cpies/ml, high level f CMV viremia Signs and Symptms 1 Peripheral retinitis: asymptmatic, flaters, decreased peripheral visin Central retinitis invlving macula and/r ptic nerve: decreased visual acuity Prphylaxis 1 Latex cndms, hand-washing This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site.

4 APPE General Medicine Rtatin Maintain CD4 > 100 cells/mm 3, adherence t HAART Recgnizing signs and symptms early Valganciclvir primary prphylaxis is nt recmmended because it failed t shw a benefit in high risk patients (CD4 < 100 cells/mm 3, CMV viremia). Diagnsis 1 Retinal Exam: fluffy yellw-white retinal lesins CMV PCR: CMV is detected in the vitreus fluid 80% f the time while als detected in the bld 70% f the time. Therefre, negative bld test des nt rule ut end-rgan CMV infectin. Treatment 1,5,7 Gal: stabilize visin CMV replicatin is cntrlled 1-2 weeks after initiatin f antiviral therapy. Chse agent based n lcatin and severity f the lesins, level f immunsuppressin, and ability t adhere t treatment. Systemic therapy +/- intravitreal injectins Systemic therapy imprves survival and reduces cntralateral invlvement. Intravitreal injectins are recmmended in patients with immediate sightthreatening lesins within 1500 micrns f the fvea. Duratin: 3-6 mnths May cnsider discntinuatin f IV r PO anti-cmv agent when CD4 > 100 cells/mm 3 fr 3-6 mnths. Secndary prphylaxis: re-initiate anti-cmv treatment if CD4 < 100 cells/mm 3 Treatment Dsing ADRs Mnitring Clinical Pearls Valganciclvir (Valcyte ) **preferred** 900 mg PO BID x 14-21d, then nce daily CBC + differential Ganciclvir (Cytvene ) Ganciclvir + Valganciclvir Fscarnet (Fscavir ) Cidfvir (Vistide ) Ganciclvir Intravitreal Injectin 5 mg/kg IV q12h x 14-21d then 5 mg/kg IV daily ganciclvir 5 mg/kg IV q12h x 14-21d then valganciclvir 900 mg PO daily 60 mg/kg IV q8h r 90 mg/kg IV q12h fr 14-21d then mg/kg IV q 24h 5 mg/kg/week fr 2 weeks, then 5 mg/kg every ther week 2 mg/injectin 1-4 dses ver 7-10 days Anemia, neutrpenia, thrmbcytpenia, nausea, diarrhea, renal dysfunctin Nephrtxicity, electrlyte abnrmalities, seizures, renal dysfunctin, anemia dse-related nephrtxicity, neutrpenia, uveitis, hyptny bacterial r fungal infectins, Requires renal dse adjustments if CrCl < 70 CBC, Chem-7: K, Mg, Ca, Phs, SCr, BUN BUN, SCr, urinalysis befre each infusin, eye exams Visin changes, pain, irritatin - Preferred in pregnancy. - May be used as mntherapy in patients with small, peripheral lesins. - Mnitr renal functin twice weekly during inductin and nce weekly during maintenance - Requires hydratin and PO prbenecid befre and after administratin - Avid in sulfa allergy because reactin can ccur with prbenecid - C/I in renal dysfunctin r prteinuria This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site.

5 APPE General Medicine Rtatin Fscarnet Intravitreal Injectin 2.4 mg/injectin 1-4 dses ver 7-10 days hemrrhage, retinal detachment * In the last 15 years, n cmparative trials were perfrmed t shw superirity f treatments. Mnitring 1 Regular eye exams are required because patients have been shwn t relapse, even with CD4 cunts up t 1,250 cells/mm 3. Indirect phthalmscpy thrugh a dilated pupil at the time f diagnsis, 2 weeks after initiating therapy, and then mnthly while the patient is being treated with anti-cmv therapy. Ophthalmlgic fllw-up every 3 mnths and then every year after immune recnstitutin. Patients are still at risk fr relapses and retinal cmplicatins, but the risk is decreased. Clinical Trial 4 Objective T cmpare the effects f ral valganciclvir with intravenus ganciclvir fr inductin therapy t treat CMV retinitis in AIDS patients. Study Design 42 sites in the United States, Eurpe, Mexic, Canada, Australia, and Brazil Randmized, nn-inferirity study Inclusin criteria Initially, patients had t have retinitis lcated mre than 1500 μm frm the fvea; hwever, this criteria was expanded t include patients with mre psterir retinitis. May have received up t three mnths f prphylaxis with ral ganciclvir Exclusin criteria Histry f treated CMV retinitis Severe uncntrlled diarrhea (> 3 watery stls/day) Abslute neutrphil cunt < 750 cells/mm 3 Platelets < 75,000 per mm 3 CrCl < 70 ml/min Primary Outcme: prgressin f CMV retinitis at 4 weeks determined by retinal phtgraphs Brder f lesin mvement by at least 750 μm r new area f CMV retinitis at least 750 μm in diameter Secndary Outcmes Achievement f satisfactry respnse t inductin treatment in 4 weeks N mvement f lesin brder by > 750 μm, n develpment f a new lesin 750 μm r mre in diameter, decrease in retinitis activity Time t prgressin f retinitis, effect f treatment n CMV cultures and PCR results, safety and tlerability f regimens, develpment f cntralateral and extra cular CMV, and survival Study Duratin Ocular exams and ther wrk-up perfrmed every tw weeks until week 16, then mnthly until prgressin f retinitis ccurred Statistical Analysis: range f efficacy defined by cnfidence interval (CI) > Study Ppulatin N = 160 with 80 patients assigned t each treatment grup 5 mg/kg IV ganciclvir q12h x 3 weeks + 5 mg/kg q24 h x 1 week 900 mg PO valganciclvir BID x 3 weeks mg nce daily x 1 week This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site.

6 APPE General Medicine Rtatin Results Bth grups received valganciclvir 900 mg PO nce daily at the end f week 4 fr maintenance therapy 7 patients in each grup were excluded due t deviatin frm prtcl Valganciclvir 7 f 71 patients (9.9%) Ganciclvir 7 f 70 patients (10%) Prgressin CI Satisfactry Respnse f patients (71.9%) 47 f 61 patients (77%) This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site. CI Median Time CI T Prgressin 160 days > days < 99 Relative risk f prgressin: 0.9 in the valganciclvir grup (CI ) N significant changes in HIV lad r CD4 cunt Adverse Effects Diarrhea: valganciclvir 19% vs. 10% in the ganciclvir grup (p = 0.11) Catheter-related events: valganciclvir 4% vs. 9% in the ganciclvir grup Neutrpenia ~14% in bth grups Pharmackinetics Systemic expsure t ganciclvir was similar with bth treatments AUC at week 4 Ganciclvir: (μg hr/ml) Valganciclvir: (μg hr/ml) Authr s Cnclusins Valganciclvir is as effective as ganciclvir fr inductin treatment f CMV retinitis and has a similar safety prfile. CMV retinitis prgressin, satisfactry respnse, and PK parameters were similar amng the tw regimens. The valganciclvir grup had mre diarrhea and the ganciclvir grup had mre catheter-related cmplicatins. Critique Strengths Althugh patients were nt blinded, the individuals interpreting the retinal phtgraphs were. This prtects against bias in interpretatin f the data. Pharmackinetic data shwing similar systemic expsure t ganciclvir helps supprt the authr s cnclusin, despite shrt-cmings with prving statistical significance. Weaknesses The cnfidence intervals were large and included zer, which des nt imply statistical significance. Patients may have received prphylaxis with ganciclvir befre enrllment, which may have affected their respnse t therapy. CMV primary prphylaxis utilizing antiviral medicatins is n lnger the standard f care. Applicatin T Patient Due t the nn-inferirity f valganciclvir, it was apprpriate t switch the patient frm IV t PO therapy after admissin. Valganciclvir 450 mg BID was initiated based n the patient s lw weight. Hwever, this dse was increased t the guideline recmmended 900 mg BID fr inductin therapy. There is n mentin f weight in this clinical trial r in the guidelines t help supprt a lwer dse. The risk f catheter-related cmplicatins utweighed the benefits f IV therapy. Other than a higher Cmax with ganciclvir, there is n pharmackinetic advantage t using the IV rute.

7 APPE General Medicine Rtatin Hwever, when VZV meningitis was detected the team apprpriately decided t treat aggressively with IV ganciclvir. Clinical Trial 2 Objective T cmpare systemic therapy versus intracular therapy in the treatment f CMV retinitis Study Design Prspective chrt study Inclusin criteria Diagnsis f CMV retinitis CD4 < 100 cells/mm 3 at enrllment Primary Outcme Retinitis prgressin Mvement f CMB lesin > ½ disc diameter r new lesins > ¼ disc area in size Secndary Outcmes Visual acuity Visual field Study Duratin Mean fllw-up: 5 years Patients were seen every 3 mnths Statistical Analysis The results were adjusted fr CD4 cunts, HIV lad, and HAART use. Hwever, the adjusted results did nt substantially differ frm the riginal analyses. Study ppulatin N = 250 patients Systemic therapy grup Oral therapy: 30% ganciclvir, 70% valganciclvir IV therapy: 90% ganciclvir Intravitreal injectin grup: ganciclvir r fscarnet Mre active lesins (81%, p < 0.01) and mre fvea/ptic nerve invlvement (69%, p = 0.002) than the ther grups Sme eyes had the implant as well, indicating resistant CMV retinitis Ganciclvir implant grup 35.2% had bilateral disease at enrllment 12.4% f patients had a visual acuity f 20/200 r wrse 44.8% f patients switched at least nce amng the three grups Results Systemic therapy vs. intracular therapy alne 50% reductin in mrtality (CI , p = 0.006) 90% reductin in new visceral CMV disease (CI , p = 0.004) 80% reductin in cntralateral disease (CI , p = ) Intravitreal injectins vs. systemic therapy alne Mre retinitis prgressin, HR = 3.4 (p = 0.004) Greater visual field lss, HR = 5.5 (p < 0.01) Intravitreal implants vs. systemic therapy alne 50% reductin in prgressin (p = 0.26) 50% reductin in lss f visual field (p = 0.45) Nt statistically significant due t small sample size This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site.

8 APPE General Medicine Rtatin Adverse Effects Neutrpenia, anemia, thrmbcytpenia, and elevated creatinine did nt differ significantly amng treatment grups. There was ne case f endphthalmitis after intravitreal injectin and tw cases after surgical placement f ganciclvir implant. Authr s Cnclusins In the HAART era, systemic treatment f CMV retinitis results in lnger survival and decreased disseminatin f the disease t ther rgans in immune cmprmised patients. The grup f patients wh received intravitreal injectins appeared t d wrse than thse receiving systemic therapy r ganciclvir implants. This may be the result f cnfunding factrs including resistant CMV, active retinitis, and mre severe CMV retinitis. Systemic therapy with and withut the ganciclvir implant shwed equivalent incidence f prgressin and severe visual field lss after adjusting fr cnfunding factrs, but nt befre adjustment. Therefre, the effect f cnfunding variables n the study s results may be substantial. Critique Strengths Weaknesses Applicatin T Patient The study attempted t cntrl fr pssible cnfunding variables including CD4 cunts, HIV lad, and HAART use. This allwed fr a better cmparisn f utcmes acrss all treatment grups. Being a chrt study and nt a clinical trial, cnfunding variables culd have resulted in the pr utcmes assciated with intravitreal injectins. Mrever, the patients in this grup appeared t have mre severe CMV retinitis based n baseline characteristics. A small sample size in the patients receiving intracular therapy resulted in large cnfidence intervals and lss f statistical significance. Patients received a variety f treatments, which mimics the real wrld setting but als limits ability t attribute crrelatin f utcmes t a specific treatment. Previus studies demnstrated lnger times t prgressin in patients receiving the ganciclvir implant in additin t systemic therapy. The current guidelines extraplate the clinical trial data using the currently discntinued ganciclvir implant t intravitreal injectins. In this study, nly 12.4% f patients had a visual acuity f 20/200 r wrse. LB has a visual acuity f 20/400. Therefre, she has mre severe CMV retinitis than the study ppulatin. Based n clinical trial data utilized in the guidelines, intravitreal ganciclvir injectins are an apprpriate treatment ptin fr LB. Hwever, intravitreal injectins will nt imprve LB s visin and LB is already legally blind. Als, intravitreal injectins put LB at a higher risk f experiencing endphthalmitis. Assessment and Plan CMV Retinitis Gals: Stabilize visin, minimize adverse drug reactins A: LB s CMV retinitis is severe and currently uncntrlled. Differential diagnses included CMV retinitis, txplasma, recurrence f CNS lymphma, cryptcccus, and HIV encephalitis. CMV retinitis was suspected based n lw CD4 cunt, therefre ganciclvir was initiated in the emergency department. MRI and ther test results ruled ut ther pssible causes and ruled in CMV as well as VZV. The initial dse f ganciclvir 215 mg was dsed per guideline recmmendatins f 5 mg/kg utilizing the patient s weight f 43 kg. Then, This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site.

9 APPE General Medicine Rtatin valganciclvir was initiated at a dse f 450 mg PO BID. The dse was decreased frm guideline recmmendatins f 900 mg BID due t the patient s weight. The infectius disease team increased this dse back t 900 mg BID based n severity f infectin. Ganciclvir IV was re-started t treat VZV meningitis as well as CMV retinitis at 100 mg q12h. This dse was then increased t 200 mg q12h and will be cntinued fr tw weeks. Ophthalmlgy recmmended an intravitreal injectin due t the prximity f the infectin t the fvea. LB received a 15 mg injectin befre discharge. The guidelines recmmend 2 mg per injectin with a maximum f 8 mg per dse. Therefre, the dse LB received is nt apprpriate per the guidelines. P: After cmpletin f IV therapy, initiate valganciclvir 900 mg PO BID until CD4 > 100 cells/mm 3 fr 6 mnths. Discntinue ganciclvir intravitreal injectins as the risk f infectin utweighs the benefit. The injectin will nt be able t restre LB s deterirated visin. Educate: Avid skin cntact with valganciclvir, take with fd, hydrate fr renal prtectin, and d nt crush tablets. Side effects include nausea, diarrhea, and vmiting. Mnitr: CBC and BMP twice weekly during inductin, then nce weekly. If bne marrw suppressin ccurs, decrease the dse f valganciclvir t 450 mg PO BID r cnsider using a different agent. Repeat CMV PCR 1 week frm discharge. Fllw-up with phthalmlgist in 3 days. VZV Meningitis 8 Gals: Eradicate the infectin, prevent neurlgical signs and symptms A: LB s VZV meningitis is currently asymptmatic, but is uncntrlled. VZV was detected in the CSF indicating VZV meningitis. LB is nt experiencing signs f altered mental status. Acyclvir, famciclvir, and valacyclvir are preferred agents t treat VZV. Hwever, ganciclvir has activity against bth VZV and CMV because it penetrates the bld-brain barrier. The team is mre cncerned abut ptimizing therapy fr end-stage CMV retinitis. P: Cntinue IV ganciclvir fr treatment f CMV retinitis and VZV meningitis as described abve. Educate: As described abve. Mnitr: As described abve and mnitr fr mental status changes. HIV/AIDS Gals: Reduce mrtality, imprve quality f life, decrease viral lad, and increase CD4 cunts A: HIV/AIDS uncntrlled at time f admissin due t lack f cmpliance with HAART. CD4 cunts decreased frm 3 cells/mm 3 n 2/27/14 t 1 cells/mm 3 n 6/2/15. Patient is experiencing weight lss and pprtunistic infectins. LB was nt n recmmended prphylactic antibitics and antifungals t prevent pprtunistic infectins. Therefre, azithrmycin, flucnazle, and Bactrim were initiated t prevent mycbacterium avium cmplex (MAC), cryptcccus, and pneumcystis jirveci pneumnia (PJP), respectively. Due t lack f cmpliance, gentype testing fr resistance is indicated. LB was started n Atripla until the results f gentype testing return. LB was fund t be resistant t efavirenz, therefre Atripla was discntinued and Stribild was initiated. P: Cntinue prphylactic antibitics and antifungals as well as Stribild fr HIV/AIDS. Educate: Emphasize adherence t medicatins, especially Stribild. Nausea and diarrhea may ccur with Stribild, s it is best t be taken with fd. This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site.

10 APPE General Medicine Rtatin Mnitr: ID clinic fllw-up in 1 week Strke Gals: Prevent recurrence f strke A: A brain MRI perfrmed n 6/3 indicated a small, right frntal infarct that is likely ld. Atrvastatin 40 mg daily and aspirin 81 mg daily were initiated fr secndary preventin f strke. Pravastatin was cnsidered because it is knwn t have less drug interactins with antiretrviral medicatins. Hwever, atrvastatin interacts primarily with prtease inhibitrs, which are nt cmpnents f Atripla r Stribild. Atrvastatin is als assciated with increased efficacy fr secndary preventin f strke cmpared t pravastatin. P: Cntinue atrvastatin 40 mg daily and aspirin 81 mg daily. Educate: Reprt signs f muscle pain r dark urine, avid large amunts f grapefruit juice. Mnitr: Liver functin tests as clinically warranted Oral Candidiasis Gals: Eradicate fungal infectin A: White patches cnsistent with ral candidiasis were fund n LB s tngue during physical exam. LB s candidiasis was uncntrlled at presentatin t the ER. Nystatin 5 ml swish and spit fr 3 days was initiated. Nt all dses were received because the flucnazle initiated fr cryptcccus prphylaxis als cvers candida albicans. P: Cntinue flucnazle fr cryptcccus prphylaxis and the treatment f ral candidiasis Educatin: Flucnazle may cause nausea, vmiting, r headaches Mnitr: Recurrence f ral candidiasis Seizures Gals: Prevent recurrence f seizures A: Seizures are currently cntrlled. Histry f seizures upn admissin likely secndary t CNS lymphma P: Cntinue hme levetiracetam (Keppra ) 500 mg PO BID Educatin: Emphasize adherence because discntinuing Keppra culd result in seizure recurrence Mnitr: Renal functin This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site.

11 APPE General Medicine Rtatin References 1. Guidelines fr preventin and treatment f pprtunistic infectins in HIV-infected adults and adlescents. Natinal Institutes f Health. (accessed 1 Jul 2015). 2. Jabs DA, Ahuja A, Natta MV, et al. Cmparisn f treatment regimens fr cytmegalvirus retinitis in patients with AIDS in the era f highly active antiretrviral therapy. Ophthalmlgy June; 120(6): Pathgenesis, clinical manifestatins, and diagnsis f AIDS-related cytmegalvirus retinitis. UpTDate. (accessed 1 Jul 2015). 4. Martin DF, Sierra-Mader J, Walmsley S, et al. A cntrlled trial f valganciclvir as inductin therapy fr cytmegalvirus retinitis. N Engl J Med. Apr 2002;346(15): Ganciclvir mngraph. Drug Facts & Cmparisns. Facts & Cmparisns (accessed 1 Jul 2015). 6. Valganciclvir mngraph. Drug Facts & Cmparisns. Facts & Cmparisns (accessed 1 Jul 2015). 7. Treatment f AIDS-related cytmegalvirus retinitis. UpTDate. (accessed 1 Jul 2015). 8. The management f encephalitis: clinical practice guidelines by the infectius diseases sciety f America. Infectius Diseases Sciety f America. (accessed 5 Jul 2015). This example is t be used fr instructin n an example frmat, but nt fr clinical cntent. Please cnsult yur preceptr regarding specific expectatins at yur rtatin site.