NUR 611 HIV Diagnosis and Management Plan: Case Study Overview
SUBJECTIVE
CC – “I was just diagnosed with HIV this past Monday.”
History of Present Illness – H.G is a 29-year-old Hispanic male patient who presents to the clinic
for a recent diagnosis of HIV. Patient stated that he contracted the disease possibly while
crossing the U.S./Mexican border last month. He mentions that he had sex with another man but
is in no contact with him. He reports feeling anxious and slightly overwhelmed about his
diagnosis but expresses his desire to learn about his condition and treatment options. Patient
denies any symptoms related to HIV but expresses concern for his future health regarding the
disease.
PMH:
- Asthma
Medications:
- Albuterol PRN
Allergies: No known allergies
Family History – Patient reports a family history of diabetes and hypertension with his mother
and diabetes with his father. Both parents are alive and well and still lives in Mexico. There is no
known history of HIV or other chronic conditions in the family.
Social History – Patient is currently looking for work. He currently lives with other migrants in
an apartment. He states he has access to food and water. He denies tobacco or recreational drug
use aside from occasionally smoking marijuana and seldom consumes alcohol. He states he is
not currently sexually active.
Review of systems –
Constitutional: denies fever, chills, or cough
Skin: denies rashes or lesions
Respiratory: denies shortness of breath or chest pain
Cardiac: Denies chest pain or palpitations
Gastrointestinal: denies abdominal pain, nausea, vomiting, or diarrhea
Psychiatric: Reports feeling anxious and overwhelmed about diagnosis but denies
symptoms of depression or suicide ideation.
OBJECTIVE
BP: 110/60 HR:66 Temp: 97.0 RR: 18
Physical Exam:
General appearance: patient appears anxious but cooperative during visit.
HEENT: No palpable lymphadenopathy. No evidence of oral thrush or other lesions
Respiratory: Clear lung sounds bilaterally. No wheezing, crackles, or rhonchi present
NUR 611 HIV Diagnosis and Management Plan: Case Study Overview
SUBJECTIVE
CC – “I was just diagnosed with HIV this past Monday.”
History of Present Illness – H.G is a 29-year-old Hispanic male patient who presents to the clinic
for a recent diagnosis of HIV. Patient stated that he contracted the disease possibly while
crossing the U.S./Mexican border last month. He mentions that he had sex with another man but
is in no contact with him. He reports feeling anxious and slightly overwhelmed about his
diagnosis but expresses his desire to learn about his condition and treatment options. Patient
denies any symptoms related to HIV but expresses concern for his future health regarding the
disease.
PMH:
- Asthma
Medications:
- Albuterol PRN
Allergies: No known allergies
Family History – Patient reports a family history of diabetes and hypertension with his mother
and diabetes with his father. Both parents are alive and well and still lives in Mexico. There is no
known history of HIV or other chronic conditions in the family.
Social History – Patient is currently looking for work. He currently lives with other migrants in
an apartment. He states he has access to food and water. He denies tobacco or recreational drug
use aside from occasionally smoking marijuana and seldom consumes alcohol. He states he is
not currently sexually active.
Review of systems –
Constitutional: denies fever, chills, or cough
Skin: denies rashes or lesions
Respiratory: denies shortness of breath or chest pain
Cardiac: Denies chest pain or palpitations
Gastrointestinal: denies abdominal pain, nausea, vomiting, or diarrhea
Psychiatric: Reports feeling anxious and overwhelmed about diagnosis but denies
symptoms of depression or suicide ideation.
OBJECTIVE
BP: 110/60 HR:66 Temp: 97.0 RR: 18
Physical Exam:
General appearance: patient appears anxious but cooperative during visit.
HEENT: No palpable lymphadenopathy. No evidence of oral thrush or other lesions
Respiratory: Clear lung sounds bilaterally. No wheezing, crackles, or rhonchi present
NUR 611 HIV Diagnosis and Management Plan: Case Study Overview
