Case Presentations

Thu, Aug 30, 2012

NIMART Cluster Meeting: Case Presentations

  On the 24 August 2012, three Eastern Cape Regional Training Centre (ECRTC) staff members from the East London satellite site attended a Nurse Initiated Management of Anti Retroviral Therapy ( NIMART) cluster meeting. This was a case presentation meeting were different health disciplines converge to review challenging cases presented by NIMART trained nurses. Apart from the three ECRTC staff, sixteen professional nurses and two doctors representing ten health facilities, attended the meeting.

Cases presented

Case 1: On the 25th April 2012 a female client who had been on TB treatment since the 13 April 2012 came to a clinic presenting with confusion and vomiting. She was referred to the hospital were depression was diagnosed and treated with fluxetine. On the 08 May 2012, the patient returned to the clinic complaining of oral sores and dyspnoeic. Oral thrush was diagnosed and fluconazole prescribed for the client. HCT was conducted and results came back positive. Baseline blood results were as follows: CD4 106, Hb 11.5, Cr 53, Gfrwas greater than 60, ALT 82, AFB positive. LFT ‘s were also done and the results were as follows: ALT 53, Bil 53, AST 102, ALP 133, GGT 284, Hepatitis B negative. The presiding sister telephonically consulted a doctor regarding the ARV regimen to initiate the client on. The sister was advised to avoid EFV since the client was a psychiatric and NVP since the client was on TB treatment. On the 22 August 2012, the client was initiated on HAART, on 3TC, TDF and Alluvia. The sister expressed concerned over the client’s abnormal blood test results. Discussions from the case  
  • Questions arose regarding the issuing of flucanozole to treat oral thrush, nistatin was considered to be a better option. Flucanazole is used to treat oesophageal thrush.
  • HAART initiation should have been delayed until after the completion of TB treatment so that she could have in an NVP containing regimen
  • The client should have been referred to a doctor for initiation since she had more than one condition.
  • Blood tests are abnormal and should have been repeated two weeks later
  • Alluvia should be stopped after two weeks of TB treatment, ALT should be conducted and the client should be started on NVP as fluxoextine cannot interact with it.
  Case 2   A 23 year old, pregnant, single female patient presented at a clinic for a first ANC visit on the 25 July 2012. HCT was done and the results came back positive. The client had no history of TB no STI. Blood tests were conducted on the 01 August 2012 and results were as follows: CD4 263, ALT 11, Cr 43, GFR grater than 60, Hb 12. Feeding option was discussed with the client, she opted for formula feeding. She disclosed her status to close family members but not her partner. Client was initiated on HAART on, 3TC, TDF, EFV. The sister’s concern was how to initiate PMTCT clients.     Case 3   A female client prepared for ART disappeared before commencing ART treatment. At the time of the disappearance, she was on treatment for herpes zoster and TB. The client has adherence issues. Client was refereed to the specialist clinic facilitated by ECRTC doctors but due to protest action by university staff she could not be seen. Later it was discovered that the client is bed ridden and her 80 year old mother was the one collecting her TB treatment from the clinic. According to the mother the client is very ill and keen to start ART. The mother was told that the client had to come to the clinic for HAART preparation for ARV’s to be issued. Client was then referred to a community health centre on the 23 August 2012   Discussions from the case
  • A suggestion was made that the referal hospital should be informed about the plight of this particular patient and if necessary she should be booked in.
  • A Dot supporter should be roped in to assist with the transportation of TB treatment.