HIV Intake
New HIV diagnosis FH: Allergies: Social: IV/Injection drug use Tobacco Sexual EtOH Plan: HIV related testing: HIV serology, CD4 count and percentage, Viral load, Resistance testing, HLA B55701 testing, Tropism testing Lab testing: CBC w/diff, CMP, G6PD, Fasting lipid panel, UA, Calculated CrCl, A1C Co-infection testing: Viral Hep B panel, TB, STI, CMV, VZV, Toxoplasma Select testing- Anal pap? Immunizations- HPV, Pneumococcal, Influenza, Varicella, Hep A, Hep B Opportunistic infection prophylaxis Counseling: Discussed HIV infection and its natural course. Described the various pharmacologic treatment currently available for HIV. We discussed the importance of taking this medication daily w/strict adherence to prevent the virus from developing resistance to medications. Patient also counseled on importance of safe sex w/100 % condom use and informing all partners of his HIV positive status. Also advised patient regarding potential opportunistic infections and signs/symptoms to monitor. Recommend that patient avoid exposure to cats, especially cat feces/litter boxes. Patient verbalized understanding of this education Dispo: F/u in 1 month for lab results. Will f/u sooner if CD4 count dictates. Answered all patient's questions
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 183 boilerplate words
More SOAPnotes by this Author:
Send Feedback for this SOAPnote