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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Sunnie Kim, MD PGY3 Tuesday, May 29, 2012. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Sunnie Kim, MD PGY3 Tuesday, May 29, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint • The patient is a 25 year-old man who presents for follow-up for chronic leukopenia and requesting HIV testing and counseling, as well as information about pre-exposure prophylaxis. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  3. History of Present Illness • History of multiple male sexual partners. • Six months prior to presentation was evaluated after a high-risk sexual contact with condom malfunction and penile laceration. • Treated with 28-day course of zidovudine, tenofovir and lamivudinefor post-exposure prophylaxis. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  4. History of Present Illness • Also evaluated and treated for chronic facial acne vulgaris in dermatology clinic. • Having failed topical antibiotics and antimicrobials, was initiated on isotretinoin. • During this time, he was noted to have persistent leukopenia and was referred to medicine clinic. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  5. History of Present Illness • The patient also requests HIV testing, and counseling on means of prevention, including medications or vaccines. • He reports several HIV-negative friends on chronic anti-retroviral therapy for HIV prevention. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  6. Additional History • Past Medical and Surgical History • None • Social History: • Multiple concurrent male sexual partners • Inconsistent condom use • No known history of sexually transmitted infections • Occasional MDMA/ecstasy use • Occasional alcohol use with intermittent binge drinking • Family History: • none • Allergies: • NKDA • Medications: • Isotretinoin 20mg bid UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  7. Physical Examination • Well appearing. • Vitals: T97.8F, BP 106/62, HR 61, RR 16 • Numerous hyperpigmentedmacules and atrophic scars over the face and upper back. • Otherwise normal examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  8. Prior Laboratory Findings • CBC: • WBC 3.1 (N 59%, L 34%, Eos 6%, Baso 1%) • Hg 14.1g/dl • Platelets 182,000 • Cr 0.9mg/dl • AST 41mg/dl (11-39) • ALT 45mg/dl (11-35) • The remainder of the hepatic panel and basic metabolic panel was normal UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  9. Working Diagnosis Mildly elevated transaminases with leukopenia - chronic viral infection - iatrogenic from chronic acne treatment (antimicrobials or isotretinoin) UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  10. Clinical Course • The patient received counseling on safe sex practices including consistent condom use. • No HIV vaccine is currently available for clinical use. • Pre-exposure prophylaxis was not initially offered to the patient due to limited evidence and interim CDC guidelines. • Scheduled for follow-up visit for further counseling. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  11. Clinical Course • The patient screened negative for HIV, hepatitis B and C, gonorrhea, and chlamydia infections. • Repeat CBC showed stable WBC (3.1-5.0) • Transaminases normalized after completion of isotretinoin treatment. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  12. Final Diagnosis Otherwise healthy man engaging in high-risk sexual activities despite counseling. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

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