Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
New or worsening symptoms suggestive of malignancy (depending on the specific cancer)
Concerns about their risk for HIV-associated malignancies
History of Present Illness:
Onset and duration of any new symptoms
Location and character of any new symptoms (pain, lumps, bleeding)
Changes in bowel or urinary habits
Weight loss, fatigue, night sweats (B symptoms of cancer)
Prior history of any malignancies
Past Medical History:
CD4 count and HIV viral load (most recent and trends over time)
Current HIV treatment regimen and adherence
History of opportunistic infections (OIs)
Risk factors for specific HIV-associated malignancies (e.g., smoking for lung cancer, HPV for anal cancer)
Family History:
History of cancer in first-degree relatives
Social History:
Smoking history
Sexual history (number of partners, history of STIs)
Physical Examination:
General appearance (signs of weight loss, malnutrition)
Focused exam based on presenting symptoms (e.g., lymph node exam, skin exam, rectal exam)
Laboratory Tests:
Complete blood count (CBC) – may show anemia
Blood chemistry panel – may show abnormalities depending on the malignancy
Tumor markers (if indicated based on suspected cancer type)
Viral load (to assess HIV control)
CD4 count (to assess immune status)
Imaging Studies:
Imaging studies as indicated based on suspected malignancy (e.g., chest X-ray, CT scan, ultrasound)
Biopsy (definitive diagnosis for cancer)
Diagnosis:
Suspected HIV-associated malignancy (specify type if suspected)
Confirmed HIV-associated malignancy (specify type and stage)
HIV infection with no evidence of malignancy
Treatment Plan:
If malignancy is confirmed, discuss the specific treatment plan based on cancer type, stage, and patient’s overall health (surgery, radiation therapy, chemotherapy, targeted therapy)
Optimization of HIV treatment to improve immune function and potentially improve cancer outcomes
Management of any OIs
Prognosis:
Discuss the prognosis based on the specific malignancy type, stage, and response to treatment
Importance of adherence to both HIV treatment and cancer treatment
Patient Education:
Explain HIV-associated malignancies and the increased risk for people with HIV
Importance of regular cancer screening based on risk factors and guidelines
Importance of maintaining a healthy lifestyle (smoking cessation, healthy diet, exercise)
Support groups and resources available for people with HIV and cancer
Next Follow-up:
Schedule for the next appointment to monitor response to treatment, address any side effects, and continue monitoring for HIV and potential complications.