Art Case Conference Patient Summary

ART CASE CONFERENCE PATIENT SUMMARY

Patient: / MR#: / Provider:
DOB: / // / HIV Dx Date: / // / Race: / CaucasianAfrican AmericanHispanicAsian/Pacific IslanderBlack AfricanNative AmericanOther / Sex: / FemaleMaleTrans: F to MTrans: M to F

Concurrent Diagnoses:

Active Substance Abuse / Active Hepatitis B / Liver Disease / Other
Active Psychiatric Illness / Active Hepatitis C / Active Tuberculosis / Other
Drug Allergies / Intolerances:
Reason Presented: 1st Initiate ART per Guidelines (Tx-Naive)Initiate ART per Guidelines (Tx-Experienced)Immunologic FailureVirologic Failure with ResistanceVirologic Failure with NO ResistanceToxicity/IntoleranceClinical Progression (OI/ADE)Comorbidities (Non-ADE)Pt. Preference/Pill BurdenFinancial IssuesPregnancy (PMTCT)Other 2nd Initiate ART per Guidelines (Tx-Naive)Initiate ART per Guidelines (Tx-Experienced)Immunologic FailureVirologic Failure with ResistanceVirologic Failure with NO ResistanceToxicity/IntoleranceClinical Progression (OI/ADE)Comorbidities (Non-ADE)Pt. Preference/Pill BurdenFinancial IssuesPregnancy (PMTCT)Other 3rd Initiate ART per Guidelines (Tx-Naive)Initiate ART per Guidelines (Tx-Experienced)Immunologic FailureVirologic Failure with ResistanceVirologic Failure with NO ResistanceToxicity/IntoleranceClinical Progression (OI/ADE)Comorbidities (Non-ADE)Pt. Preference/Pill BurdenFinancial IssuesPregnancy (PMTCT)Other
Comment: / REPOS: / 1 / 2
Consented
Declined
Not a Candidate
I / II
MEDS: / MEDS:
Start: // / Stop: // / Start:// / Stop://
Date / CD4 / CD4% / Viral Load / Date / CD4 / CD4% / Viral Load
Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment: / Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment:
III / IV
MEDS: / MEDS:
Start:// / Stop:// / Start:// / Stop://
Date / CD4 / CD4% / Viral Load / Date / CD4 / CD4% / Viral Load
Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment: / Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment:
Patient: / MR#: / Provider:

Reason Presented: 1st 2nd 3rd

Comment:

V / VI
MEDS: / MEDS:
Start:// / Stop:// / Start:// / Stop://
Date / CD4 / CD4% / Viral Load / Date / CD4 / CD4% / Viral Load
Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment: / Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment:
VII / VIII
MEDS: / MEDS:
Start:// / Stop:// / Start:// / Stop://
Date / CD4 / CD4% / Viral Load / Date / CD4 / CD4% / Viral Load
Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment: / Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment:

ARV Abbreviations:

3TC= lamivudine (Epivir) / d4T = stavudine (Zerit) / FPV = fosamprenavir (Lexiva) / RAL = raltegravir (Isentress) / TPV = tipranavir (Aptivus)
ABC = abacavir (Ziagen) / DAR = darunavir (Prezista) / FTC = emtricitabine (Emtriva) / RPV = rilpilvirine (Edurant) / SCH-D = vicriviroc
ATP = EFV/FTC/TDF (Atripla) / ddl = didanosine (Videx) / IDV = indinavir (Crixivan) / RTV = ritonavir (Norvir)
ATV = atazanavir (Reyataz) / EFV = efavirenz (Sustiva) / LPVr = lopinavir/ritonavir (Kaletra) / SQV = saquinavir (Invirase)
AZT = zidovudine (Retrovir) / ENF = enfuvirtide (T-20, Fuzeon) / MVC = maraviroc (Selzentry) / TDF = tenofovir (Viread)
CBV = 3TC/AZT (Combivir) / EPZ = 3TC/ABC (Epzicom) / NFV = nelfinavir (Viracept) / TVD = FTC/TDF (Truvada)
CPA = FTC/PRV/TDF(Complera) / ETR = etravirine (Intelence) / NVP = nevirapine (Viramune) / TZV = 3TC/AZT/ABC (Trizivir)
Patient: / MR#: / Provider:

Reason Presented: 1st 2nd 3rd

Comment:

V / VI
MEDS: / MEDS:
Start:// / Stop:// / Start:// / Stop://
Date / CD4 / CD4% / Viral Load / Date / CD4 / CD4% / Viral Load
Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment: / Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment:
VII / VIII
MEDS: / MEDS:
Start:// / Stop:// / Start:// / Stop://
Date / CD4 / CD4% / Viral Load / Date / CD4 / CD4% / Viral Load
Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment: / Genotype Date://
RT Mutations:
PI Mutations:
Other Mutations: / HLA-B*5701: NegPos
Comment:

ARV Abbreviations:

Reason Presented: 1st 2nd 3rd

Comment:

ARV Abbreviations: