Pre-Chart: HIV

HIV Clinic Patient Oral Presentation Mad-Libs (Speech Format) with Dropdowns

Patient: [text name="Patient Name"]
DOB: [date name="Date of Birth"]
MRN: [text name="Medical Record Number (MRN)"]
Date of Visit: [date name="Date of Visit" default="today"]
Reason for Visit: [select name="Reason for Visit" value="Routine Follow-up|New Patient Evaluation|Medication Refill|Concerns about Side Effects|Other"][text name="other_reason" memo="If 'Other', please specify"]

HPI:

They first came in on [date name="Initial Presentation Date"] with [textarea name="Initial Symptoms"]. Today, they're telling us about [textarea name="Current Main Symptoms"] that started [text name="Duration"] ago. They're also concerned about [textarea name="Additional Symptoms"].

Currently, they're taking [textarea name="Current HIV Regimen"] [select name="Medication Frequency" value="daily|twice daily|weekly|monthly|other"]. They say their adherence is [select name="Adherence" value="Good|Fair|Poor"], and if it's not perfect, it's because of [textarea name="Adherence Challenges"].

Their latest labs from [date name="Lab Date"] show a CD4 count of [text name="CD4 Count"] and viral load of [text name="Viral Load"].

Looking back, they have a history of [textarea name="Opportunistic Infections, Comorbidities"] and have had [textarea name="Relevant Surgeries/Hospitalizations"].

It's also important to note their social history includes [select name="Smoking Status" value="Never smoked|Currently smokes|Quit smoking (Year:)[text name='Year Quit']"] [text name="Packs Per Day" memo="If currently smoking, indicate packs per day"] ppd x [text name="Smoking Years"] years, drinks [text name="Alcohol Amount"] [select name="Alcohol Unit" value="drinks/day|drinks/week|drinks/month"], and [textarea name="Drug Use"]. Their sexual history includes [textarea name="Sexual History"] and they [select name="PrEP/PEP Use" value="have|have not"] used PrEP/PEP in the past.

Exam:

On exam, they [select name="General Appearance" value="appear well|appear ill|are in no acute distress|are in mild distress|are in moderate distress|are in severe distress"].

Vitals: BP: [text name="BP_systolic"]/[text name="BP_diastolic"] mmHg, HR: [text name="HR"] bpm, Temp: [text name="temp"] °F, Weight: [text name="weight"] lbs, BMI: [calc value="BMI = (weight / (height * height)) * 703" memo="Body Mass Index (BMI)"]
HEENT: [textarea name="HEENT findings"]
Cardiovascular: [textarea name="Cardiovascular findings"]
Respiratory: [textarea name="Respiratory findings"]
Abdomen: [textarea name="Abdomen findings"]
Extremities: [textarea name="Extremities findings"]
Neurological: [textarea name="Neurological findings"]
Skin: [textarea name="Skin findings"]
Assessment:

Based on their CD4 count of [text name="CD4 Count"] and today's exam, their HIV is classified as [select name="HIV Stage" value="Stage 1|Stage 2|Stage 3|Unknown"].

Right now, the main issues are:
1. [textarea name="Problem 1"]
2. [textarea name="Problem 2"]
3. [textarea name="Problem 3"]

We're thinking the most likely cause of [textarea name="Main Symptom/Problem"] is [textarea name="Most Likely Diagnosis"] because of [textarea name="Reasoning"]. Other possibilities to consider are [textarea name="Possible Diagnosis 1"], [textarea name="Possible Diagnosis 2"], and [textarea name="Possible Diagnosis 3"].

Plan:

For their HIV, we plan to [select name="HIV Meds Plan" value="continue|adjust|initiate"] their [textarea name="Current HIV Regimen"] because [textarea name="Reasoning for HIV Meds Plan"].

To figure out more, we'll get [textarea name="Labs/Tests"] and maybe some imaging: [textarea name="Imaging"].

We're also going to refer them to [textarea name="Specialist"] for [textarea name="Reason for Referral"].

And of course, we'll talk with them about [textarea name="Patient Education Topics"] and make sure they understand [textarea name="Patient Education Summary"].

They'll come back in [text name="Follow-up Timeframe"] so we can check on [textarea name="Specific Follow-up Concern"] and see how everything else is going.

Questions/Concerns:
[textarea name="Questions for Team"]