HIV PrEP

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a HIV PrEP follow-up

Last visit was ‍ ‍months ago



Updates on risk factors:

‍Unprotected sex

‍Multiple sexual partners

‍Sexual partner with HIV

‍Intravenous drug use

‍Occupational exposure

‍Blood transfusion



Medications:

‍PrEP

Adherence: ‍goodaveragepoor, ‍adverse effects



Screenings:

HIV: ‍positivenegative

STIs: ‍positive fornegative

Hepatitis B: ‍positivenegative

Hepatitis C: ‍positivenegative



Vaccinations:

Hepatitis A: ‍up-to-dateincompleteunvaccinated

Hepatitis B: ‍up-to-dateincompleteunvaccinated

HPV: ‍up-to-dateincompleteunvaccinated





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Genital: penis ‍normal, testes and epididymis ‍normal, ‍inguinal hernia





ASSESSMENT:

‍Pre-exposition prophylaxis, ‍adequately adherent





PLAN:

Investigations:

- Blood work: ‍HIV, ‍Hepatitis B and C, ‍Syphilis, ‍CBC, ‍creatinine, ‍ALT

- STI screening: ‍Chlamydia, ‍Gonorrhea

- Urinalysis

Treatments:

- ‍PrEP medications

- Condom use counseling

- Safe sex practices counseling

Further care:

- Referral to infectious disease specialist

- Referral to social worker

- Follow-up in ‍ ‍months

- Return if symptoms of acute HIV infection develop (fever, fatigue, rash, sore throat, swollen lymph nodes, muscle aches)