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| Description: |
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| Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. |
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| The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. |
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| CHIEF COMPLAINT: |
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| 1. Chronic lymphocytic leukemia (CLL). |
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| 2. Autoimmune hemolytic anemia. |
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| 3. Oral ulcer. |
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| HISTORY OF PRESENT ILLNESS: |
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| The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. |
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| He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. |
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| He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day. |
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| He comes in to clinic today for follow-up and complete blood count. |
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| At his last office visit we discontinued this prophylactic antivirals and antibacterial. |
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| CURRENT MEDICATIONS: |
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| Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d. |
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| ALLERGIES: |
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| Vicodin. |
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| REVIEW OF SYSTEMS: |
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| The patient reports ulcer on his tongue and his lip. |
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| He has been off of Valtrex for five days. |
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| He is having some difficulty with his night vision with his left eye. |
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| He has a known cataract. |
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| He denies any fevers, chills, or night sweats. |
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| He continues to have headaches. |
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| The rest of his review of systems is negative. |
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| PHYSICAL EXAM: |
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| VITALS: BP: 120/74. |
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| HEART RATE: 72. |
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| TEMP: 97.8. |
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| Weight: 112.7 kg. |
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| GEN: |
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| He has a obvious cold sore on his bottom lip on the left. |
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| HEENT: |
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| Pupils are equal, round, and reactive to light. |
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| Sclerae are anicteric. |
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| His oropharynx is notable for ulcer on his tongue. |
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| No ulcers on his buccal mucosa. |
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| NECK: Supple. |
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| He has no cervical or supraclavicular adenopathy. |
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| LUNGS: |
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| Clear to auscultation bilaterally. |
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| CV: Regular rate; normal S1, S2, no murmurs. |
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| ABDOMEN: Soft. |
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| He has positive bowel sounds. |
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| No hepatosplenomegaly. |
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| EXT: No lower extremity edema. |
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| LABORATORY DATA: |
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| His white blood cell count is 4.6, hemoglobin 14.2, hematocrit 42, and platelets 207,000. |
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| ASSESSMENT/PLAN: |
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| This is a 72-year-old gentleman with chronic lymphocytic leukemia on chronic steroids for autoimmune hemolytic anemia. |
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| His blood counts are relatively stable at 5 mg of prednisone every other day. |
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| We will plan on putting him back on the Valtrex and decreasing his steroids to 1 mg daily. |
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| I will see him back in clinic in a week. |