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
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

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Sandbox Metrics: Structured Data Index 0, 183 boilerplate words
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