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| Description: |
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| Human immunodeficiency virus disease with stable control on Atripla. |
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| Resolving left gluteal abscess, completing Flagyl. |
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| Diabetes mellitus, currently on oral therapy. |
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| Hypertension, depression, and chronic musculoskeletal pain of unclear etiology. |
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| HISTORY OF PRESENT ILLNESS: |
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| The patient is a 41-year-old white male with a history of HIV disease. |
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| His last CD4 count was 425, viral load was less than 50 in 08/07. |
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| He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus. |
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| He also has a history of hypertension and hypertriglyceridemia. |
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| He had been having increased urination and thirst. |
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| He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess. |
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| The endocrine team apparently felt that insulin might be best for this patient, but because of financial issues, elected to place him on Glucophage and glyburide. |
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| The patient reports that he has been taking the medication. |
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| He is in general feeling better. |
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| He says that his gluteal abscess is improving and he will be following up with Surgery today. |
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| CURRENT MEDICATIONS: |
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| 1. Gabapentin 600 mg at night. |
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| 2. Metformin 1000 mg twice a day. |
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| 3. Glipizide 5 mg a day. |
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| 4. Flagyl 500 mg four times a day. |
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| 5. Flexeril 10 mg twice a day. |
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| 6. Paroxetine 20 mg a day. |
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| 7. Atripla one at night. |
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| 8. Clonazepam 1 mg twice a day. |
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| 9. Blood pressure medicine, name unknown. |
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| REVIEW OF SYSTEMS: |
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| He otherwise has a negative review of systems. |
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| PHYSICAL EXAMINATION: |
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| VITAL SIGNS: Temperature 36.6, blood pressure 145/90, pulse 123, respirations 20, and weight is 89.9 kg (198 pounds.) |
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| HEENT: Unremarkable except for some submandibular lymph nodes. |
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| His fundi are benign. |
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| NECK: Supple. |
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| LUNGS: Clear to auscultation and percussion. |
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| CARDIAC: Reveals regular rate and rhythm without murmur, rub or gallop. |
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| ABDOMEN: Soft and nontender without organomegaly or mass. |
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| EXTREMITIES: Show no cyanosis, clubbing or edema. |
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| GU: Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions. |
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| IMPRESSION: |
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| 1. Human immunodeficiency virus disease with stable control on Atripla. |
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| 2. Resolving left gluteal abscess, completing Flagyl. |
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| 3. Diabetes mellitus, currently on oral therapy. |
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| 4. Hypertension. |
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| 5. Depression. |
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| 6. Chronic musculoskeletal pain of unclear etiology. |
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| PLAN: |
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| The patient will continue his current medications. |
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| He will have laboratory studies done in 3 to 4 weeks, and we will see him a few weeks thereafter. |
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| He has been encouraged to keep his appointment with his psychologist. |