History and Physical Examination Essay

Admitting Diagnosis Stomatitis possibly methotrexate related Chief Complaint Swelling of lips causing worry swallowing History of register Illness This patient is a 57-year-old Cuban woman with a retentive history of rheumatoid arthritis. She has received methotrexate on a both week basis as an outpatient for many years. Approximately two weeks ago she highly- demonstrable a respiratory infection for which she received antibiotics and completed that course of antibiotics. She developed some ulceration of her mouth and was instructed to discontinue the methotrexate approximately 10 days ago. She showed some initial improvement but over the start 3-5 days has had malaise, a low-grade fever and severe ad-lib alterations with obstacle in swallowing although she can drink liquids with less difficulty. Patient denies any separate problems at this point except for flare of arthritis since discontinuing the methotrexate. She has rather diffused chafe involving both large and small joints this has caused her some anxiety. Medications Prednisone 7.5 mg PO daily. Estradiol 0.5 mg PO QAM. Mobic 7.5 mg PO daily. Recently quit because of questionable allergic reaction HCTZ 25 mg PO every other day and oral calcium supplements. In the past she has been on pencillamine, azathioprine and hydroxychloroquine but she has not had Azulfidine, cyclophosphamide or chlorambucil.Allergies none by historyFamily and Social History noncontributoryPhysical Examination This is a chronically ill appearing female alert oriented and cooperative. She moves with great difficulty because of fatigue and malaise. Vital Signs Blood pressure 107/80. Heart rate ascorbic acid and regular respirations 22. HEENT normal cephalic. No scalp lesions. Dried eyes withconjuctival injection. daft exophthalmos. Dry nasal mucosa. Mark cracking bleeding in her lips with erosions of the mucosa. She has a large ulceration of the mucosa at the bite margin on the left. She has some scattered ulcerations on her heart and soft pallets. She has difficulty outset her mouth because of pain. Tonsils not enlarged. No visible exudate. Skin She has some diffused ecchymosis on her pare down and some erythema. She has patches but no obvious skin break down. She has some fissuring in the buttix crease. Pulmonary Clear to precaution and alcostation bi by and byally. cardiovascular No murmurs or galaps noted.Abdomen Soft. None tender. Protuberant no organomegaly and lordly bowel sounds. Neurologic Exam Cranial nerves 2-12 are grossly intact. Diffuse hyporeflexia. Muscular Skeletal Corrosive destructive changes in the elbows, wrists, and men consistent with rheumatoid arthritis. Has bilateral total knee replacements with stovepipe legs and perimalleolar play off edema 1 +. I feel no pulses distally in either leg. Psychiatric Patient is a little anxious just about these new symptoms and their significance. We discussed her situation and I offered her psychological services. She refused for no w.Problems1. Swelling of lips and dysphasia with questionable earlier Stevens- Johnsons syndrome.2. Rheumatoid arthritis class 3 stage 4.3. Flare of arthritis after discontinuing methotrexate.4. Osteoporosis with condensate fracture.5. Mild dehydration.6. Nephrolithiasis.7. Anxiety.Plan1. Admit patient for IV hydration and intervention of oral ulcerations.2. Obtain a dermatology consult.3. IV leucovorin volition be started and the patient will be put on high dose corticosteroids.4. Considering patients anxiety maybe obtain services of Stella Rose Dickinson PHD Psychology at a later date.X______________________________________________Liam Medina, MD meshing 06/22/-Case Study 5 open fire SummaryPatient Name Fanny CopelandPatient ID 115463Date of bear 10/26/Age 58Sex FemaleDate of Admission 04/26/-Date of Discharge 05/01/-Procedure Performed CT scan.Ms. Copeland is seen for her abridgment conference from her work up here at Hillcrest Memory symptomatic Center. I initially saw h er on 04/28/- at which duration there was the suspicion of depression. She has since had CAT scan of the brain with contrast of 04/30/- which was unremarkable. Laboratories studies were completely negative to include normal thyroid function B12 and RPR. She had a formal neurophysiological battery with Dr. Stella Dickinson on 04/26/- she scored 136 on the hallucination rating scale, which is within normal limits for her age.The test result were consistent with indulgent cognitive defaces manifested by problems with concept formation. Attention and concentration and verbal store. but the patient is significantly depressed which can produce some memory problems. Her past MRI suggests someone who is experiencing stress. Impression There was no clinical evidence of dementia but there is evidence of a depressive sickness as the cause of her symptom etiology. No further suicidal or homicidal ideation are present. Recommendations We recommend a psychiatric evaluation and treatment wit h re-testing in our facility in one years time.