Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
New or worsening symptoms suggestive of opportunistic infections (OIs) based on specific organ system (e.g., cough, fever for Pneumocystis pneumonia)
Adherence concerns with HIV medications
Side effects of HIV medications
Anxiety, depression, or other mental health concerns
Review of recent CD4 count and viral load
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset, duration, and severity of any new symptoms
Prior hospitalizations or urgent care visits
Any recent illnesses or infections
Changes in bowel or urinary habits
Unintentional weight loss or fatigue
既往史 (jì wàng shǐ) Past Medical History:
Date of HIV diagnosis
Current HIV treatment regimen and adherence
History of opportunistic infections (OIs)
Prior hospitalizations (unrelated to HIV)
Allergies and medication intolerances
Social history (sexual history, substance use)
家族史 (jiā zú shǐ) Family History:
History of HIV/AIDS in first-degree relatives
社会史 (shè huì shǐ) Social History:
Living situation and social support system
Sexual history (number of partners, condom use)
Substance use (injection drug use)
查体 (chá tǐ) Physical Examination:
Vital signs (temperature, weight)
General appearance (illness, malnutrition)
Lymph node exam (swollen nodes)
Skin exam (rashes, lesions)
Oral mucosa exam (candidiasis)
Funduscopic exam (retinal abnormalities)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC) – to assess for anemia, low white blood cells
CD4+ T-lymphocyte count (most recent and trends over time) – reflects immune function
HIV viral load (most recent and trends over time) – reflects viral replication
Chemistry panel – to assess overall health and potential organ dysfunction
Syphilis and hepatitis B/C testing (routine screening)
Tests for specific OIs as indicated by symptoms
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Chest X-ray (if respiratory symptoms suggestive of OI)
CT scan (if complex presentation or suspicion of specific OI)
诊断 (zhěn duàn) Diagnosis:
HIV infection (state specific stage based on CD4 count)
Current status: controlled vs. uncontrolled viral load
Suspected or confirmed opportunistic infection (OI) – specify type if applicable
治疗方案 (zhì liáo fāng àn) Treatment Plan:
HIV treatment regimen adjustment based on viral load, CD4 count, and resistance testing (if indicated)
Treatment for any diagnosed OI
Prophylaxis for common OIs based on CD4 count
Management of side effects from HIV medications
Mental health referrals if needed
预后 (yù hòu) Prognosis:
Discuss the outlook based on current CD4 count, viral load, and adherence to treatment. With effective treatment, HIV can be a manageable chronic condition.
Importance of maintaining a healthy lifestyle and regular follow-up care.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of adherence to HIV medications for viral suppression
Safer sex practices to prevent HIV transmission
Healthy lifestyle modifications (diet, exercise, smoking cessation)
Importance of mental health and available support resources
Vaccination schedule (routine and recommended for immunocompromised individuals)
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment to monitor response to treatment, address any side effects, and assess for complications.
Discuss the importance of adherence to medication and healthy behaviors.