HIV Clinic Follow Up

Interval Events

[comment memo="#Co-infection testing"]
[checkbox name="" value="-Viral Hep B panel"]
[checkbox name="" value="-TB testing"]
[checkbox name="" value="-STI testing"]
[checkbox name="" value="-CMV testing"]
[checkbox name="" value="-VZV testing"]
[checkbox name="" value="-Toxoplasma testing"]
[comment memo="Syphillis Done Less than 1 year ago?"]
[checkbox name="" value="-VDL with RPR testing"]

HPI


[checkbox name="" value="-Hypothesis-Based Patient Data Gathering"] [comment memo="ACGME"] 
[comment memo="When did you first notice any symptoms associated with HIV?"]
[checkbox name="" value="First noticed symptoms associated with HIV approximately @@@"] 

[comment memo="Can you describe the main symptoms you have been experiencing since the onset of your HIV infection."]


[comment memo="When did you first notice any symptoms of signs related to your HIV infection?"]
[comment memo="Have you received any treatment for HIV in the past?"]
[checkbox name="" value="Not received any treatment for HIV in the past"]
[checkbox name="" value="Received treatment for HIV in the past:"][comment memo="why did you stop?"] [text name="" default=""]

[comment memo= "Follow Up"]

[checkbox name="" value="Overall he has been feeling well and w/o acute changes in his health status. "] 
[checkbox name="" value="He denies any missed doses of his ARV medications."] 
 
[checkbox name="" value="Vet report that he is already aware of his new colon cancer diagnosis and has plans to schedule his CT scan today after his appt."] 
[checkbox name="" value="He has been coping with this new diagnosis, and has good support from his wife."] 



[comment memo="Missed dose?"] 
[checkbox name="" value="missed dose: @@@"] 
[text name="" default="why"]

[comment memo="something we can do?"] [text name="" default=""]

[comment memo="Can you describe the main symptoms you have been experiencing since the onset of your HIV infection."]


[text name="" default="why"]

[comment memo="Sexually Active?"]
[checkbox name="" value="||Not Sexually Active|Sexually Active"]
[checkbox name="" value="Married, currently sexually active"]
[checkbox name="" value="Married, however not sexually active for a month"]
[checkbox name="" value="Married, however not sexually active for a year"]
[checkbox name="" value="Married, however not sexually active for a decade."]
[checkbox name="" value="Married, currently sexually active"]

[comment memo="Symptoms?"]
[checkbox name="" value="Denies any new symptommatology"]
[checkbox name="" value="-Non-contributory"]




[comment memo="Have you been diagnosed with HIV previously?"]
[checkbox name="" value="Never diagnosed with HIV previously||First dx w/ HIV in @@@|"]
[date name="" default=""]

[comment memo="Have you received any treatment for HIV in the past?"]
[checkbox name="" value="Not received any treatment for HIV in the past"]
[checkbox name="" value="Received any treatment for HIV in the past:"]


[comment memo="Are you currently taking any medications for HIV or any other related conditions?"]
[checkbox name="" value="Not currently taking any HIV meds for HIV or any other related conditions"]
[checkbox name="" value="@@@"]

[comment memo="Have you been diagnosed with any other chronic medical conditions?"]
[checkbox name="" value="Not been diagnosed with other chronic medical conditions"]
[checkbox name="" value="@@@"]

[comment memo="Have you received any treatment for HIV in the past?"]
[checkbox name="" value="Not received any treatment for HIV in the past"]
[checkbox name="" value="Received any treatment for HIV in the past:"]

[comment memo="Have you experienced any significant complications related to your HIV status?"]
[checkbox name="" value="Have not experienced any significant complications related to your HIV status"]
[checkbox name="" value="@@@"]

[checkbox name="" value="FH"]
[checkbox name="" value="-Non-contributory"]

[checkbox name="" value="Allergies:"]
[checkbox name="" value="-NKA"]

[checkbox name="" value="IVDU"]
[checkbox name="" value="-Non-contributory"]
[textarea name="" default=""]

[checkbox name="" value="No Tobacco Use"]

[checkbox name="" value="Tobacco Use"]
[checkbox name="" value="Approximately 1 pack per month"]
[checkbox name="" value="Approximately 2 pack per week"]
[checkbox name="" value="Approximately 0.5 pack per day"]
[checkbox name="" value="Approximately 1 pack per day"]
[checkbox name="" value="Approximately 2 pack per day"]
[checkbox name="" value="More than 2 drinks per week"]

[comment memo="Do you drink alcohol"]
[checkbox name="" value="Alcohol"]
[checkbox name="" value="No Ethanol Use"]
[checkbox name="" value="EtOH Use"]
[checkbox name="" value="Approximately 1-2 drinks per month"]
[checkbox name="" value="Approximately 1-2 drinks per week"]
[checkbox name="" value="Approximately 1-2 drinks per day"]
[checkbox name="" value="More than 1-2 drinks per week"]

[text name="" default=""]

[textarea name="" default=""]

[checkbox name="" value="#HIV related testing"]
[date name="" default=""][comment memo="date"]
[checkbox name="" value="-CD4 count"][text box="" default=" wnl@@@"]
[checkbox name="" value="-CD4 percentage"][text box="" default=" wnl@@@"]
[checkbox name="" value="-Viral Load"][text box="" default=" wnl @@@"]
[checkbox name="" value="-Resistance Testing"][text box="" default=" wnl @@@"]
[checkbox name="" value="-HLA B55701 testing"][text box="" default=" wnl @@@"]
[checkbox name="" value="-Tropism testing"][text box="" default=" wnl @@@"]

OBJECTIVE

[checkbox name="" value="Physical Exam"]
[checkbox name="" value="Hypothesis-Based Physical Exam"][comment memo="ACGME"]

[checkbox name="" value="GEN     : Alert and oriented x 4. NAD. Calm and cooperative"]
[checkbox name="" value="HEENT   : Normocephalic. EOMI."]
[checkbox name="" value="NECK    : No LAD. Supple"]
[checkbox name="" value="COR     : RRR, S1,S2."]
[checkbox name="" value="LUNGS   : CTA Bilaterally"]
[checkbox name="" value="ABDOMEN : BS x4"]
[checkbox name="" value="EXTR    : No BLE edema."]
[checkbox name="" value="BODY    : No rashes"]
  
[checkbox name="" value="Labs"]

[checkbox name="" value="#Lab Testing Performed:"]
[checkbox name="" value="-CBC w/diff"]
[checkbox name="" value="-CMP"]
[checkbox name="" value="-G6PD"]
[checkbox name="" value="-Fasting lipid panel"]
[checkbox name="" value="-UA"]
[checkbox name="" value="-Calculated CrCl"]
[checkbox name="" value="-A1C"]
 
[checkbox name="" value="#Co-infection testing:"]
[checkbox name="" value="-Viral Hep B panel"]
[checkbox name="" value="-TB testing"]
[checkbox name="" value="-STI testing"]
[checkbox name="" value="-CMV testing"]
[checkbox name="" value="-VZV testing"]
[checkbox name="" value="-Toxoplasma testing"]
[comment memo="Syphillis Done Less than 1 year ago?"]
[checkbox name="" value="-VDL with RPR testing"]
 




ASSESSMENT

[checkbox name="" value="@@@ year old @@@male pt with hx of long standing HIV on @@@Juluca here for follow up"]
[checkbox name="" value="@@@ year old @@@male pt with hx of long standing HIV on @@@Juluca presents for routine follow up and lab review."]
[checkbox name="" value="@@@ year old @@@male pt with hx of long standing HIV on @@@Juluca here for follow up"]

PLAN
[checkbox name="" value="Prioritized Problem List"][comment memo="ACGME"]


[checkbox name="" value="#HIV"]
[checkbox name="" value="Not sexually active for a decade."]
[checkbox name="" value="Married, however not sexually active for a decade."]
[checkbox name="" value="No hx of HPV/genital warts."]
[checkbox name="" value="No hx of MSM"]
[checkbox name="" value="Denies any hx of anal receptive sex."]
[checkbox name="" value="Remote hx of MSM, however denies any hx of anal receptive sex."]
[checkbox name="" value="Remote hx of MSM, however endorsed hx of anal receptive sex."]
[checkbox name="" value="Recent Hx of MSM, however denies hx of anal receptive sex."]
[checkbox name="" value="Recent Hx of MSM and endorses hx of anal receptive sex."]

[date name="" default=""] [comment memo="date"][checkbox name="" value="Urine PCR GC/Chlamydia Negative"] [checkbox name="" value="Syphilis Ab negative"]
[date name="" default=""] [comment memo="date"]
[checkbox name="" value="-CD4 count"][text box="" default=" wnl@@@"]
[checkbox name="" value="-CD4 percentage"][text box="" default=" wnl@@@"]
[checkbox name="" value="-Viral Load"][text box="" default=" <20 @@@"]
[checkbox name="" value="-Viral Load"][text box="" default=" undetectable @@@"]

[checkbox name="" value="-Resistance Testing"][text box="" default=" unremarkable@@@"]
[checkbox name="" value="-HLA B55701 testing"][text box="" default=" unremarkable@@@"]
[checkbox name="" value="-Tropism testing"][text box="" default=" unremarkable@@@"]

[date name="" default=""][comment memo="date"]
[checkbox name="" value="#Lab Testing Performed:"]

[checkbox name="" value="-order CBC w/diff"]
[checkbox name="" value="-repeat CBC w/diff"]
[checkbox name="" value=" order CMP"]
[checkbox name="" value="-repeat CMP"]
[checkbox name="" value="-order G6PD"]
[checkbox name="" value="-repeat G6PD"]
[checkbox name="" value="-order fasting lipid panel"]
[checkbox name="" value="-repeat fasting lipid panel"]

[checkbox name="" value="-order UA"]
[checkbox name="" value="-repeat UA"]

[checkbox name="" value="-order Calculated CrCl"]
[checkbox name="" value="-repeat Calculated CrCl"]

[checkbox name="" value="-order A1C"]
[checkbox name="" value="-repeat A1C"]

[comment memo="" value="#Co-infection testing:"] 
[checkbox name="" value="-order Viral Hep B panel"]
[checkbox name="" value="-order TB testing"]
[checkbox name="" value="-order STI testing"]
[checkbox name="" value="-order CMV testing"]
[checkbox name="" value="-order VZV testing"]
[checkbox name="" value="-order Toxoplasma testing"]
[comment memo="Syphillis Done MORE THAN than 1 year ago?"]
[checkbox name="" value="-VDL with RPR testing"]
[checkbox name="" value="Labs"]
[checkbox name="" value="-Repeat CD4 now"]
[checkbox name="" value="-viral load now"]
[checkbox name="" value="-Repeat CD4 count and viral load now"]
[checkbox name="" value="-Repeat VL, CBC, CMP in 6 months"]

[checkbox name="" default="Anal Pap|Anal Smear"]


[comment memo="MEDS"]
[checkbox name="" value="-Continue Juluca"]
[checkbox name="" value="-Opportunistic infection prophylaxis"]
[comment memo="VACCINATIONS"]
[checkbox name="" value="-Up to date on most vaccines"]
[checkbox name="" value="-Needs COVID bivalent booster, will work on getting it here "]
[checkbox name="" value="-meningococcal booster today"]
[checkbox name="" value="Immunizations Are Req:"]
[checkbox name="" value="-HPV"]
[checkbox name="" value="-Pneumococcal"]
[checkbox name="" value="-Influenza"]
[checkbox name="" value="-Varicella"]
[checkbox name="" value="-Hep A"]
[checkbox name="" value="-Hep B"]
[checkbox name="" value="# Follow Up Labs"]
[checkbox name="" value="-order HPV"]
[checkbox name="" value="-order Pneumococcal"]
[checkbox name="" value="-order Influenza"]
[checkbox name="" value="-order Varicella"]
[checkbox name="" value="-order Hep A"]
[checkbox name="" value="-order Hep B"]

[checkbox name="" value="Other conditions not addressed at this visit but to be managed per PCP"]


[comment memo="A"]

[checkbox name="" value="#Afib"]

[date name="" default=""] [comment memo="date"]
[checkbox name="" value="One episode at HOAG in the setting of sepsis. Never been on AC and did not f/u with cardiology. "]
[checkbox name="" value="Never been on AC "]
[checkbox name="" value="One episode at HOAG in the setting of sepsis. Never been on AC and did not f/u with cardiology. "]
[checkbox name="" value="follows with cardiology. "]

[checkbox name="" value="-Apixaban 5 mg BID "]
[checkbox name="" value="-Propranolol 10 mg BID "]


[comment memo="B"]

[checkbox name="" value="#Benign Essential Tremor"]
[checkbox name="" value="-Propranolol 10 mg BID"]

[comment memo="C"]

[checkbox name="" value="# CHEST PAIN"]
[checkbox name="" value="# CHEST PAIN/HYPERTENSION"]
[checkbox name="" value="# CHEST PAIN/HYPERTENSION/HYPERLIPIDEMIA"]
[checkbox name="" value="-Currently asymptomatic. No CP for several months"]
[checkbox name="" value="-Nitroglycerin SL tab PRN "]
[checkbox name="" value="-Nitroglycerin SL tab PRN for CP but has not had to use. "]


[checkbox name="" value="#Colon Cancer"]

[checkbox name="" value="-Currently asymptomatic. No CP for several months"]
[checkbox name="" value="-Nitroglycerin SL tab PRN "]
[checkbox name="" value="-Nitroglycerin SL tab PRN for CP but has not had to use. "]

[comment memo="D"]

[checkbox name="" value="# DM2"]
[checkbox name="" value="Asymptomatic."]
[date name="" default=""][comment memo="date"][checkbox name="" value=" FBG ~180"]
[date name="" default=""][comment memo="date"][checkbox name="" value=" FBG:"] [text name="" default="<126@@@"]
[date name="" default=""][comment memo="date"][checkbox name="" value=" A1C: 7.3%"]
[date name="" default=""][comment memo="date"][checkbox name="" value=" A1C:"] [text name="" default="<7%@@@"]

[checkbox name="" value="-continue Lantus to @@@ units daily"]
[checkbox name="" value="-increase Lantus to @@@ units daily"]

[checkbox name="" value="-continue Alogliptan 25 mg daily"]

[checkbox name="" value="-continue Metformin 1,000 mg daily"]
[checkbox name="" value="-continue Metformin 1,000 mg BID"]
[checkbox name="" value="-increase Metformin 1,000 mg BID"]

[comment memo="E"]

[checkbox name="" value="# Esoniphilia"]
[checkbox name="" value="-followed by heme/onc since 2019"]

[comment memo="F"]

[comment memo="G"]


[comment memo="H"]

[checkbox name="" value="# HLD"]

[date name="" default=""][comment memo="date"] [checkbox name="" value="Lipids stable"]

[date name="" default=""][comment memo="date"] [checkbox name="" value="Lipids stable @"][text name="" default=""]
[checkbox name="" value="-continue to closely monitor"]
[checkbox name="" value="-continue Rosuvastatin 10 mg QHS"]
[checkbox name="" value="-continue Gemfibrozil 600 mg BID"]

[checkbox name="" value="# HTN"]

[date name="" default=""] [comment memo="date"] [checkbox name="" value="BP controlled"]

[date name="" default=""] [comment memo="date"] [checkbox name="" value="BP @"][text name="" default=""]
[checkbox name="" value="-continue to closely monitor"]

[checkbox name="" value="#Hyperkalemia"]

[date name="" default=""] [comment memo="date"][checkbox name="" value="K+"][text name="" default=""]

[date name="" default=""] [comment memo="date"][checkbox name="" value="K+ wnl"]

[date name="" default=""] [comment memo="date"] [checkbox name="" value="Repeat K+ now WNL "]

[date name="" default=""] [comment memo="date"] [checkbox name="" value="K+"][text name="" default=""]
[checkbox name="" value="Asymptomatic. Denies cramping, N/V, palpitations"]
[checkbox name="" value="-Increase water intake. Avoid foods high in potassium."]
[checkbox name="" value="-Repeat K+ levels"]
[checkbox name="" value="-Repeat K+ levels in 1 week@@@"]

[checkbox name="" value="-continue to closely monitor"]

[comment memo="I"]

[comment memo="J"]

[comment memo="K"]

[comment memo="L"]

[comment memo="M"]

[comment memo="N"]

[comment memo="O"]

[checkbox name="" value="#Onychomycosis"]
[checkbox name="" value="-on miconazole"]

[checkbox name="" value="#Orthopnea"]
[checkbox name="" value="-Chronic. No flare ups."]
[date name="" default=""] [comment memo="date"]
[checkbox name="" value="CXR with findings suggestive of reactive airway disease."]
[date name="" default=""] [comment memo="date"]
[checkbox name="" value="TTE with mild aortic regurg. "]
[date name="" default=""] [comment memo="date"]
[checkbox name="" value="PFT showed a normal FEV1/FVC ratio and a reduction in the FVC, suggesting restrictive ventilatory dysfunction. "]
[date name="" default=""] [comment memo="date"]
[checkbox name="" value="PFT is consistent w/ mild obstructive ventilatory dysfunction. FVC is much greater than the FEV1/FVC ratio. "]

[checkbox name="" value="#Osteopenia"]
[date name="" default=""] [comment memo="date"]
[checkbox name="" value="DEXA positive for osteopenia"]
[date name="" default=""] [comment memo="date"]
[checkbox name="" value="Vitamin D"] [text name="" default=""]
[checkbox name="" value="-Continue Calcium/Vitamin D supplement"]
[checkbox name="" value="-Repeat DEXA q1-2y"]


[comment memo="P"]

[checkbox name="" value="# Peripheral esoniphilia"]
[checkbox name="" value="-followed by heme/onc since 2019"]



[checkbox name="" value="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"]
[comment memo="Oral Receptive Sex? Selective Testing"]
[comment memo="Oral Receptive Sex? Selective Testing"]
[comment memo="Anal Receptive Sex? Selective Testing"]

[comment memo="Selective Testing"]

[checkbox name="" value="Opportunistic infection prophylaxis"]

[checkbox name="" value="#Dispo"]
[checkbox name="" value="-RTC in 6 months with labs"]
[checkbox name="" value="-RTC in 1 month with labs."]
[checkbox name="" value="-Will f/u sooner if CD4 count dictate"]
[checkbox name="" value=""]
Interval Events

#Co-infection testing






Syphillis Done Less than 1 year ago?


HPI


ACGME
When did you first notice any symptoms associated with HIV?


Can you describe the main symptoms you have been experiencing since the onset of your HIV infection.


When did you first notice any symptoms of signs related to your HIV infection?
Have you received any treatment for HIV in the past?

why did you stop?

Follow Up









Missed dose?



something we can do?

Can you describe the main symptoms you have been experiencing since the onset of your HIV infection.




Sexually Active?







Symptoms?






Have you been diagnosed with HIV previously?



Have you received any treatment for HIV in the past?




Are you currently taking any medications for HIV or any other related conditions?



Have you been diagnosed with any other chronic medical conditions?



Have you received any treatment for HIV in the past?



Have you experienced any significant complications related to your HIV status?























Do you drink alcohol













date







OBJECTIVE


ACGME




























Syphillis Done Less than 1 year ago?






ASSESSMENT





PLAN
ACGME













date
date









date



























Syphillis Done MORE THAN than 1 year ago?










MEDS


VACCINATIONS





















A



date









B




C















D



date
date
date
date










E




F

G


H



date

date






date

date




date

date

date

date







I

J

K

L

M

N

O






date

date

date

date



date

date





P







Oral Receptive Sex? Selective Testing
Oral Receptive Sex? Selective Testing
Anal Receptive Sex? Selective Testing

Selective Testing








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Sandbox Metrics: Structured Data Index 0.91, 358 form elements, 6 boilerplate words, 25 text boxes, 2 text areas, 24 dates, 236 checkboxes, 71 comments, 293 total clicks
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