History and Physical Examination Case 4 Essay
HISTORY AND PHYSICAL EXAMINATION Patient Name: Adela Torres Patient ID: 132463 RM #: 541 Date of Admission: 06/22/—- Admitting Physician: Leon Medina MD, Internal Medicine Admitting Diagnosis: Stomatitis, possibly methotrexate related CHIEF COMPLAINT: Swelling of lip causing difficulty swallowing HISTORY OF PRESENT ILLNESS: This patient is a 57 yr. old, Cuban woman with a long history of rheumatoid arthritis.
She has received methotrexate on a weekly basis as an outpatient for many years, approximately 2 weeks ago she developed a respiratory infection for which she received antibiotics and completed that course of antibiotics. She developed some ulcerations of her mouth and was instructed to discontinue the methotrexate approximately 10 days ago. She showed some initial improvement, but over 3-5 day has had malaise, a low-grade fever and severe oral ulcerations with difficulty in swallowing, although she can drink liquids with less difficulty.
Patient denies any other problems at this point, except for a flair of arthritis sense discontinuing the methotrexate. She has rather diffused pain involving both large and small joints; this has caused her some anxiety. FAMILY/SOCIAL HISTORY: Noncontributory ALLERGIES: None by history. MEDICATIONS: Prednisone 7. 5mg PO Daily; Estradiol 0. 5mg PO qd; Mobic 7. 5mg PO Daily, recently discontinued because of questionable allergic reaction; HCTZ 25mg PO qod; and Oral Calcium supplements. (Continued)?
HISTORY AND PHYSICAL EXAMINATION Patient Name: Adela Torres Patient ID: 132463 RM #: 541 Date of Admission: 06/22/—- Page: 2 In the past she has been on penicillamine, azathioprine, and hydroxychloroquine but she has not had azulfidine, cyklofosfamid, or chlorambucil. PHYSICAL EXAMINATION: This is a chronically ill appearing female; alert, oriented, and cooperative. She moves with great difficultly because of fatigue and malaise. Vital Signs: BP-107/80 HR- 100 and regular Resp- 22
HEENT-normal cephalic; no scalp lesions; dry eyes with conjunctival injections; mild exophthalmos; dry nasal mucosa; marked cracking and bleeding of her lips with erosions of the mucosa; she has a large ulceration of the mucosa at the bite margin on the left; she as some scattered ulcerations on her hard and soft pallet; she has difficulty opening her mouth because of pain; tonsils not enlarged; no visible exudate. Skin- she has some mild equimosis on her skin and some anathema. She has patches but no obvious skin breakdown. She has no fissuring in the buttocks crease.
Pulmonary- clear to procession and occultation bilaterally. Cardiovascular- no murmurs or gallops noted. Abdomen- soft, none tender, protuberate, no organomegaly, and positive bells sounds. (Continued)? HISTORY AND PHYSICAL EXAMINATION Patient Name: Adela Torres Patient ID: 132463 RM #: 541 Date of Admission: 06/22/—- Page: 3 Neurologic examine- cranial nerves 2-12 are grossly intact, diffuse hyporeflexia. Musculoskeletal- erosive destructive changes in the elbows, wrist, and hands consistent with rheumatoid arthritis, has bilateral total knee replacements with stovepipe legs and perimalleolar pitting edema 1+.
I feel no pluses distally in either leg. Psychiatric- patient is a little anxious about these new symptoms and their significance. We discussed her situation and I offered her psychologic services, she refused for now. PROBLEMS 1. Swelling of lips and dysphasia with questionable early Stevens Johnson syndrome. 2. Rheumatoid arthritis class 3 stage 4. 3. Flair of arthritis after discontinuing methotrexate. 4. Osteoporosis with compression fracture 5. Mild dehydration 6. Nephrolithiasis 7. Anxiety (Continued)?
HISTORY AND PHYSICAL EXAMINATION Patient Name: Adela Torres Patient ID: 132463 RM #: 541 Date of Admission: 06/22/—- Page: 4 PLAN 1. Admit patient for IV hydration and treatment of oral ulcerations. 2. Obtain a dermatology consult. 3. IV leucovorin will be started and the patient will be put on high dose cortaca steroids 4. Considering the patients anxiety, perhaps obtain services of Stella Rose Dickenson Ph. D. Phycology at a later date. _________________________ Leon Medina MD, Internal Medicine LM: xx D: T: