Shellie Ray CRNP



S: 23 yo white homosexual male here for new patient visit. He tested positive for HIV with a rapid screening test and Western Blot Analysis at the Davis Clinic in Huntsville in November 2010. He is transferring care here after moving to Gadsden to live with his HIV positive partner at his partner’s mother’s house. He was testing every 6 months due to being in a high risk group. He has protected sex with his partner but states they have broken condoms on occasion. He has been sexually active since age 18 with an unknown amount of partners not always practicing safe sex. He denies any use of IV drugs. He denies any symptoms other than night sweats that have occurred approximately 1 year that sometimes require him to change his bed linens. PMH: chickenpox as a child, MVA at age 16 with minor lacerations to his arms, Right jaw cellulitis due to an abscessed tooth 6 months ago that was treated with antibiotics that he does not remember the name of.Immunizations: childhood immunizations up-to-date, unknown hepatitis immunization, unaware of last TB skin test and tetanus shot. Has never received pneumonia or flu vaccinations.Allergies: Penicillin causing a rash. Mold, mildew, fungus, trees, soy, wheat, corn and peanutsFamily History: Mother, age 41, has type II diabetes due to obesity. Father’s history unknown, he does not know who his father is. No siblings.Personal/Social history: Born and raised in Alabama, he has lived in several different cities in Alabama. He has a high school diploma but no further education. He is currently unemployed but has previous experience in fast food. He has been aware of his homosexuality since he was 8 years old, stating he has never tried to hide his sexuality. He was picked on in high school, never feeling like he fit in. He found a group of friends after high school who were also homosexuals and found acceptance. His mother and partner’s family are aware of his HIV status and are very supportive. He lives with his partner at his mother’s house. He receives some financial assistance from his mother. His partner receives food stamps. He is currently looking for employment at a fast food restaurant. He is anxious to get started on HIV medications, but is worried about the side effects especially the drowsiness. He seems well educated on the different regimens stating his partner and friends have taught him about them. He states he has a history of a DUI at age 21, a 3rd degree theft charge and a few speeding tickets. No exercise and diet consists of prepacked, processed and fast foods Alcohol, Smoking and Drug Use: Social drinker only on weekends drinking vodka and beer but rarely gets drunk, has a past DUI. Smokes cigarettes, 3 PPD max, currently trying to quit. Denies present or past IV drug use, uses marijuana on occasion.Review of SystemsGeneral: weight stable, max weight 155, no recent weight changes. No weakness, fatigue or fever.HEENT: Head: No history of head injury, headaches, dizziness or lightheadedness. Eyes: No vision problems, no pain, redness, excessive tearing, double or blurred vision, no glasses or contacts, has never had a vision test that he can recall. Ears: no hearing loss, tinnitus, vertigo, earaches, infection or discharge. No use of hearing aids. Nose and sinuses: occasional rhinitis due to allergies. Allergy testing at age 18; allergic to: fungus, mold, mildew, trees, wheat, corn, soy peanuts. No nosebleeds. Throat and mouth: missing teeth on upper and lower jaws, inflamed gingiva, has not had dental exam in more than 10 years. History of cellulitis right upper jaw 6 months ago due to an abscessed tooth that he went to the ER for and was given antibiotics but does not remember name of antibiotic. No history of thrush or oral lesions.Neck: no lumps, goiter, pain or swollen glandsRespiratory: No cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray was 6 months ago when he was in ER for cellulitis, reports no significant findings. No history of asthma, bronchitis, emphysema, pneumonia or tuberculosis.Cardiovascular: No known heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema. No history of electrocardiogram or other cardiovascular tests.Gastrointestinal: appetite good, no nausea, vomiting, diarrhea, constipation or indigestion. Bowel movements daily with soft, brown stool, no rectal bleeding or blood in stool. No hemorrhoids. No abdominal pain, food intolerance includes above listed food allergies. No jaundice, no liver or gallbladder problems. No history of hepatitis.Peripheral Vascular: no leg cramps, varicose veins, swelling in calves, legs or feet. No history of DVT.Urinary: No frequency, dysuria, hematuria, nocturia or flank pain. No incontinence or dribbling, No history of UTI.Genital: no hernia, penile discharge, testicular pain or masses, scrotal pain or masses. No history of STD. Homosexual in a relationship with a HIV positive partner, uses condoms but states sometimes condoms break.Musculoskeletal: No muscle or joint pain or stiffness. No history of arthritis or gout. No back pain. History of MVA at age 16 with only minor lacerations to bilateral arms. No history of broken bones.Psychiatric: no treatment for any psychiatric disorders, no depression or anxiety or suicide attempts.Neurologic: no fainting, seizures, motor or sensory loss. No headaches, dizziness, vertigo. No numbness or loss of sensation.Hematologic: no anemia, no transfusions. Does not bleed or bruise easily.Endocrine: No thyroid problems, no heat or cold intolerance, no excessive thirst or hunger. Reports night sweating for 1 year.O: General: R.S. is a young adult, tall and lean, with poor dentition. His color is good. He appears slightly nervous. He is appropriately dressed in jeans, sweatshirt and flip-flops. His hair is oily and is wearing a cap. He is alert and oriented to person, place and time and answers all questions appropriately. Height: 6’ Weight: 154 BMI: 20.9 Vital Signs: T 97 P 80 R 20 O2 sat 99%Skin: palms cool and dry, color is good. Nails without clubbing or cyanosis.HEENT: Head: hair oily, evenly distributed, no presence of nits or lice, no folliculitis or lesions. Normocephalic. Eyes: vision 20/20 in each eye. Visual fields full by confrontation. Conjunctiva pink, sclera white. Pupils 4 mm constriction to 2 mm, round, regular, equally reactive to light accommodation. Extraocular movements intact. Disc margins sharp, no hemorrhage or exudates. Ears: TM with good cone of light, ears without pain, redness, drainage, wax present. Acuity good to whispered voice. Nose: mucosa pink, septum midline. No sinus tenderness. Mouth: poor dentition with multiple missing teeth, dental caries noted, inflamed gingiva. No presence of thrush or lesions. Tongue midline, tonsils present, pharynx without exudate.Neck: trachea midline, no thyroid enlargement, no goiters. Lymph Nodes: Small palpable, nontender, mobile tonsillar, post cervical, and axillary nodes. No epitrochlear or inguinal nodes.Thorax and Lungs: thorax symmetric with good excursion. Resonant on percussion. Clear to auscultation bilaterally, no rales, wheezes or rhonchi. Diaphragm descends 4 cm bilaterally.Cardiovascular: S1, S2 no S3 or S4. No gallops or murmurs. No presence of JVD. No carotid bruits.Abdomen: Flat, nontender, positive bowel sound all quadrants, no masses. Liver palpable but not enlarged. Spleen and kidneys not felt. No costovertebral angle tenderness.Genitalia: Circumcised , no penile discharge or lesions. No scrotal swelling or discoloration. Testes descended bilaterally, smooth, without masses. Epididymis nontender. No inguinal or femoral hernia. No presence of nits or lice in pubic hair.Extremities: pink, warm and dry without edema. No varicosities or stasis changes. Calves are nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis and posterior tibial pulses are 2+ and symmetricMusculoskeletal: Full range of motion in all joints. No evidence of swelling or deformity.Neurologic: Alert, slightly nervous, oriented to person, place and time. Thought process coherent. Cranial nerves tested and intact. Strength 5/5 throughout, good muscle tone. Normal gait. Pinprick, light touch intact. Reflexes 2+ and symmetric with plantar reflexes down going.Laboratory DataWBC3.4Hemoglobin14.5Hematocrit43.8Platelets190BUN11Creatinine0.8Glucose81SGOT33SGPT24Bilirubin0.4Cholesterol150HDL38Triglycerides219*LDL83CD4332*Viral load149,000*Toxoplasmosis negativeRPRnegativeGC/chlamydianegativeA: HIVTobacco AbuseElevated triglyceridesDental caries, gingivitisHealth maintenanceP:Discuss starting antiretroviral treatment as soon as possible, provide treatment regimine options including side effects and administration options. Genotype testing today for antiretroviral drug resistance to variants of HIV. Return to clinic in 1 month to begin treatment.Discuss health hazards of smoking, offer referral to smoking cessation program, offer nicotine patch to enhance abstinence.Diet modifications for elevated triglycerides. Limit carbs, processed food and high fat, high sugar foods. Bake or broil food versus fried. Choose lean cuts of red meat, fish, chicken and turkey. Choose more fruits and vegetables. Encourage exercise.Make dental referral.Administer flu and pneumonia vaccinations, tetanus shot and TB skin test. Draw serologic tests for Hepatitis A, B, C and provide vaccinations for A, B if negative provide vaccinations and counsel to prevent acquisition. Perform anal pap for HPV. Perform testicular exam and teach how to do monthly self exams. Baseline EKG and chest x-ray. Social worker referral for housing assistance, transportation assistance to medical appointments. Fill out ADAPT form for medication assistance ................
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