Chapter 6 - Chart Note Transcription

Tonsillectomy

AIDS Clinic Report - Subjective: The patient reports having undergone surgery at age four to remove his tonsils. What procedure is documented?

Lymphocytes

AIDS Clinic Report - Objective: Bloodwork reveals a mild deficiency in the patient's white blood cells responsible for immune responses. Which type of white blood cell is decreased?

HIV antigen/antibody immunoassay

AIDS Clinic Report - Objective: The physician orders a blood test that detects both HIV antigens and antibodies to screen for infection. What test was performed?

Human immunodeficiency virus (HIV)

AIDS Clinic Report - Objective: Blood testing confirms infection with the virus that attacks the immune system and can eventually lead to AIDS. What virus was identified?

Kaposi sarcoma (KS)

AIDS Clinic Report - Objective: A biopsy of the patient's dark skin lesions confirms a cancer associated with HIV/AIDS. What condition was diagnosed?

AIDS-related complex (ARC)

AIDS Clinic Report - Assessment: The physician notes that the patient has progressed beyond an earlier symptomatic stage of HIV infection historically classified before AIDS. What is this stage called?

Acquired immunodeficiency syndrome (AIDS)

AIDS Clinic Report - Assessment: The patient's HIV infection has progressed to the advanced syndrome characterized by severe damage to the immune system. What syndrome is documented?

Immunocompromised

AIDS Clinic Report - Assessment: The physician describes the patient as having weakened immune defenses and a reduced ability to fight infections. What term describes this condition?

Protease inhibitor

AIDS Clinic Report - Plan: The physician prescribes an antiviral medication that blocks an enzyme HIV needs to produce mature infectious virus particles. What medication class is prescribed?

Chemotherapy

AIDS Clinic Report - Plan: The patient is referred to an oncology specialist for treatment of Kaposi sarcoma using medications that destroy or inhibit cancer cells. What treatment is being considered?