Soap Notes

4 April 2017

This patient with history of Aids status post newmosotisis kerantina ammonia. Hairpes esogasutisis perrectual herpes and cmv hepatisis. Is seen today for the first time in four an half months. The patient indicates that mid November he stopped all his medications because, โ€œI just got confused about the dosingโ€, when I asked why he had not called he said he just never thought about it.

He relates that his most acute problem right now is that development of non productive cough associated with congestion. There been no fevers, chills, pluratic chest pain, anorexia, nausea, voimting, increased diaherra or, GU symptoms. are basically unrealiving with no posterior drainage. Neck supple good range of motion. No significant adanapate. Back exam benign. Chest is relatively clear although he does have diminshed breath sounds in the basis. Cardo vascular S1, S2, without rubs or murmurs. Abdomen bowels sounds present, abdomen is soft non tender with no guarding or rebound.

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Extremities are unrealvealing. Skin clear. No rashs, ulcerations, or lesions at this time. Broncitis at this point I think the prudent thing is to address this problem acutely with Zithormax and Vicodin tusk cough supresent. 2. )History of acquired immunodefiency syndrome. Once again I reviewed how critical it is for him to maintain complaince and follow-up. I have expressed that if Iโ€™m going to make 100% commitment to him. He likewise has to commitment to his own health care. As such, if he fails to return and follow-up will have to seek an alternative physician to provide his care.

He indicates that he understands my concern and anxiety. I have stated that were going to deal with his acute illness and then I will place him back on his medications. Repeat labs today to assess his status. 3. )Cytomeglovirus hepatisis. We will recheck his liver functions. 4. )Status postherpes esogahus and perifirectual area, no current symptoms. PLAN: 1. )Z pack. 2. )Vicodin tuss one teaspoon poq 6h prn. 3. )CBC come 18 CD 4 count and viral load. 4. )Return in 10 to 14 days to review data and make some decisions about his future therapy. Thanks Beth Bryant, Infectious Disease

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