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John Green, 33 year-old Caucasian male

CASE STUDY 1

John Green, 33 year-old Caucasian male, presents to the office to establish as a new patient. John’s natal sex is female but he identifies as a male. He transitioned from female to male 2 years ago. He has made a full transition with family and socially last year. He just moved back home and is unemployed at this time. He has been obtaining testosterone from the internet to give to himself. He has not had any health care since he decided to change other than getting his suppression medications through Telehealth 3 months ago. His past medical history includes smoking 2 packages of cigarettes per day for the last 10 years, smokes 3-6 marijuana joints every weekend (has an active green card), and does suffer from depression episodes. He is HIV positive for the last 3 years but remains virally suppressed at his last blood draw 6 months ago. He has been feeling very weak over the last few weeks which prompted him to move back home with his parents. He takes Biktarvy once daily that comes in the mail for free, tolerates it well, and 100 mg Testosterone IM every 7 days. His PMH is non-contributory. No past medical history. He has never been married. No significant family history. He is worried since moving back home and unemployed he will be a burden on his family, and he thinks his health may be declining.

BY DAY 3 OF WEEK 2

Post an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks

Introduction

            I was assigned to case study 1. The patient in the case study is a 33-year-old Caucasian male who presents to the office to establish new patient care. The patient is a transgender male who transitioned two years ago and fully transitioned with family and socially last year. He had just moved back home to live with his parents after he felt his health was declining, as he had become very weak over the last few weeks. He is unemployed and worries about being a burden to his parents. He has been obtaining testosterone from the internet for the past three months. He has smoked two packs of cigarettes daily for the last ten years and smokes 3-6 marijuana joints every weekend (active green card). He has depressive episodes. He has been HIV+ for the last three years and is virally suppressed demonstrated by his last blood draw six months ago. He takes Biktarvy once daily, which he receives for free via mail. There are several culturally sensitive factors to consider for this patient.

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Patient-Specific Cultural and Sensitive Factors

To begin, the patient is a transgender male. Transgender individuals have no history of having good experiences with healthcare professionals. A qualitative report conducted in 2017 demonstrated that 45.7% of transgender and gender non-conforming patients within the emergency department witnessed medical personnel gossiping, mocking, or telling jokes (Mehta & Warner II, 2021). A zero-tolerance policy for these behaviors must be enacted and practiced in all healthcare facilities if effective and safe patient-centered care is to be delivered.

The healthcare provider must begin the health assessment interview by addressing the patient with their preferred pronoun; it should never be assumed, and the healthcare provider should directly ask the patient how they wish to be addressed (Ball et al., 2019). Beginning the interview this way demonstrates to the patient that their needs are at the forefront of the clinician’s treatment plan. It is essential that the patient feels comfortable and confident with their healthcare provider and plan of care for effective patient outcomes. The prudent healthcare provider should know that transgender individuals have higher unemployment rates, poverty, homelessness, discrimination, psychological distress, HIV infection, substance abuse, suicide, and violence (Mehta & Warner II, 2021). These topics should be discussed during the initial meeting and regularly followed up on.

There are high rates of uninsured transgender individuals or a lack of coverage for transgender-related services (Mehta & Warner II, 2021). The healthcare provider should discuss insurance coverage with the patient, especially since he is unemployed and recently moved back in with his parents. It may be necessary to guide the patient to the local Department of Health Services office to inquire about public assistance. The healthcare provider should also inquire about whether the patient expects to continue receiving his testosterone and Biktarvy through the mail and whether these will continue to be offered for free to the patient. It may be necessary to provide the patient with drug discount coupons. The patient has been feeling weaker over the past couple of weeks, and a more thorough assessment of medication habits is warranted. The patient should be asked if he has been taking the Biktarvy as prescribed. It is possible that the patient is not taking Biktarvy as prescribed, which could lead to the patient being weaker. It is necessary to determine who is prescribing and dispensing the testosterone and Biktarvy for the patient to assess for authenticity and accreditation. Obtaining new labs to assess whether values have changed is also essential.

The patient is prescribed Biktarvy, an antiretroviral medication for the treatment of HIV. Antiretroviral medications can cause adverse effects on the liver, including idiosyncratic reactions, direct cholestatic injury, mitochondrial dysfunction, nonalcoholic steatohepatitis, or isolated hyperbilirubinemia (Parmar et al., 2023). Therefore, ordering liver functioning labs would be necessary when diagnosing the patient’s cause of weakness.

The patient is HIV+, another sensitive issue that the provider must discuss with the patient. Though the patient in the case study is a transgender male, transgender women have a 34.2 times higher risk of HIV infection than the US population (Stevens & Fajardo, 2021). This data is vital to this case as it represents the transgender community and demonstrates how this population is particularly vulnerable. Due to previous poor experiences, the patient may be hesitant to share intimate details about his sexual history; however, the provider must inquire about these details to assess the patient’s current risk status. Building a solid rapport before this conversation would likely aid in a more productive conversation. The provider and patient must come to an agreed-upon treatment plan to manage HIV+ sensitively.

Targeted Questions

How would you like me to address you? What is your preferred pronoun? Is there any information that you feel uncomfortable discussing?
Tell me about your lifestyle prior to moving back with your parents.
Where did you live? Did you live with anyone? Was the location in a safe place?
What did you do for work previously? Do you plan on searching for employment while staying here?
Where do you obtain your prescriptions from? Do you know the prescriber of the medications? What pharmacy do the medications come from? Will you continue receiving the medications for free, or do you need assistance?
What is your relationship status? How many partners have you been with? Is your current partner aware of your HIV+, and do they regularly get tested?

 

 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Mehta, A. H., & Warner II, D. M. (2021). Identifying and addressing barriers to transgender healthcare: Where we are and what we need to do about it. JGIM: Journal of General Internal Medicine36(11), 3559–3561. https://doi.org/10.1007/s11606-021-07001-2Links to an external site.

Parmar, K., Mekraksakit, P., Nugent, K., & Nichols, J. (2023). A possible case of bictegravir-associated severe unconjugated hyperbilirubinemia. AIDS Research & Therapy20(1), 1–5. https://doi.org/10.1186/s12981-023-00501-7Links to an external site.

Stevens, G. A., & Fajardo, F. J. (2021). LGBTQ+ health research guides at North American health sciences libraries: A survey and content analysis. Journal of the Medical Library Association109(3), 406–413. https://doi.org/10.5195/jmla.2021.1189Links to an external site.

BY DAY 6 OF WEEK 2

Respond on or before Day 6 on 2 different days to at least two of your colleagues who were assigned a different patient than you. Critique your colleague’s targeted questions, and explain how the patient might interpret these questions. Explain whether any of the questions would apply to your patient, and why.

Thank you XX

Your post has a lot of great considerations for addressing this population of patients. It is so important for providers to be aware and non judgemental. One thing you didn’t mention that I feel is essential to discuss and evaluate with this patient is his depression level and risk for suicide. Suicide rate and suicidal tendencies among transgender persons are considerably high compared to general population. This patient admits to feeling like a burden, is unemployed, ill and weak, and admits to depression symptoms currently. These could be precursors to a suicide attempt if the patient isn’t given the support he needs. The high prevalence of depression and suicidal tendencies among transgender persons seems to be highly influenced by societal stigma, lack of social support, HIV status, all of which possibly applies for this patient.

 

Virupaksha, H. G., Muralidhar, D., & Ramakrishna, J. (2016). Suicide and suicidal behavior among transgender persons. Indian journal of psychological medicine. Retrieved March 9, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5178031/

 

RESPONSE 2

Great job on your post! I liked how you questioned how this patient obtains his prescriptions and then inquire on where he gets this from. Obtaining this information can help us comply an accurate health history and identify pertains health risks this patients has the potential for developing. A journal article by (Warner & Mehta, 2021) identified that, “Structural barriers to transgender healthcare include high uninsured rates or lack of coverage for transgender-related services, inadequate training of physicians on transgender-sensitive care, and limited access to providers who offer transgender-related care” (para. 2). In addition, (Gorton, 2007) concluded that “the United States is the only developed nation without universal health insurance and among uninsured Americans, the majority are uninsured for transgender care because of policy exclusion” (para.1). Because of this, uninsured transgender patients have a more difficult time obtaining the necessary prescriptions needed to optimize their health.

Gorton, R. N. (2007). Transgender health benefits: Collateral damage in the resolution of the National Health Care Financing Dilemma – Sexuality Research and Social Policy. SpringerLink. Retrieved March 8, 2023, from https://link.springer.com/article/10.1525/srsp.2007.4.4.81#citeas

Warner, D. M., & Mehta, A. H. (2021). Identifying and addressing barriers to transgender healthcare: Where we are and what we need to do about it – journal of general internal medicine. SpringerLink. Retrieved March 8, 2023, from https://link.springer.com/article/10.1007/s11606-021-07001-2#citeasLinks to an external site.

Response 3

This was a thorough analysis of the case study on the 33-year-old Caucasian transgender person who presents to the office to establish new patient care, and who has a history of HIV, spanning back to three years back. Your position holds that the healthcare provider must address the patient with their preferred pronoun, should be aware of the needs of transgender individuals, and must discuss insurance coverage and treatment plans with the patient. In light of this, It is agreeable the healthcare provider should be aware of the needs of transgender individuals and should be cognizant of the potential for discrimination and poor experiences with healthcare personnel (Klein et al., 2018). Additionally, it is important that the healthcare provider is aware of the patient’s financial and insurance situation, to ensure that the patient is able to receive the necessary care in a timely and affordable manner. Also, it is necessary to add that the healthcare provider should also be aware of the patient’s mental health needs, as transgender individuals are at a higher risk for depression and suicidal ideation (Klein et al., 2018). This is particularly important in light of the patient’s history of depressive episodes. It is also important for the provider to address these mental health issues with the patient, recognize the patient’s feelings of being a burden to their parents, and ensure that the patient is connected with appropriate mental health services.

Furthermore, it is also important to recognize the patient’s lifestyle prior to moving in with their parents, as this can provide context for the patient’s current health status. As the patient is HIV+ and has been receiving medications from the mail, it is important to inquire about the prescriber and the pharmacy of the medications to ensure that the patient is receiving medications from a legitimate source and that the medications are authentic. According to the CDC, it is important to be aware of the potential for counterfeit medications, as “counterfeit medications can include products with the wrong ingredients, without active ingredients, with incorrect amounts of active ingredients, or with fake packaging.” (“Counterfeit Medication,” 2021). In addition, it is also important to ask questions about the patient’s sexual history, as this can provide insight into their HIV status and risk factors. Overall, this was a comprehensive analysis of the patient’s case study, and the questions provided are appropriate and necessary in order to provide effective patient care.

References

Counterfeit Medication. (2021). Centers for Disease Control and Prevention. Retrieved from https://wwwnc.cdc.gov/travel/page/counterfeit-medicine

Klein, D. A., Paradise, S. L., & Goodwin, E. T. (2018). Caring for transgender and gender-diverse persons: what clinicians should know. American family physician, 98(11), 645-653.

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