History and Physical Essay

CHIEF COMPLAINT: Swelling of lips causing difficulty swallowing.

HISTORY OF PRESENT ILLNESS: This patient is a 57-year-old Cuban woman with a long history of rheumatoid arthritis - History and Physical Essay introduction. 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 the past 3 to 5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing, although she can drink liquids with less difficulty.

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Patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate. She has rather diffuse pain involving both large and small joints; this has caused her some anxiety.

MEDICATIONS: Prednisone 75 mg p.o. daily, estrodiol 0.5 mg p.o qam, Mobic 7.5 mg p.o. daily, recently discontinued because of questionable allergic
reaction, HCTZ 25 mg p.o. every other day and oral calcium supplements. In the past she has been on penicillamine, azathioprine and hydroxychloroquine but she has not had azulfidine cyclophosphamide chlorambucil.

ALLERGIES: None by history.


PHYSICAL EXAMINATION: This is a chronically ill appearing female, alert oriented and cooperative. She moves with great difficulty because of fatigue and malaise. VITAL SIGNS: BP 107/80, HR 100 regular, R 22. HEENT: Normocephalic. No scalp lesions. Dry eyes with conjunctival injections, mild exophthalmos.


Patient Name: Adela Torres
Patient No.: 132463
Date of Admission: 06/22/—-
Page 2

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 has some scattered ulcerations on her hard and soft palate. She has difficulty opening her mouth because of pain. Tonsils not enlarged, no visible exudate. SKIN: She has some mild ecchymosis on her skin and some erythema; she has patches but no obvious skin breakdown. She has some fissuring in the buttocks crease. PULMONARY: Clear to percussion and auscultation bilaterally. CARDIOVASULAR: No mummers or gallops note. ABDOMEN: Soft non-tender protuberant, no organomegaly and positive bowel signs. NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffused hyporeflexia. MUSKUOSKELETAL: Erosive destructive changes in the elbows, wrists, and hands consistent with rheumatoid arthritis. As bilateral of total knee replacements with stovepipe legs and perimalleolar
pitting edema 1+. I feel no pulses distally in either leg. PHYSCIATCI: patient is a little anxious about these new symptoms and their significance. We discussed her situation and I offered her physiologic services; she refused for now.

1. Swelling of lips and dysphasia with questionable early Stevens Johnsons syndrome. 2. Rheumatoid arthritis class III state 4.
3. Flare of arthritis after discontinuing methotrexate.
4. Osteoporosis with compression fracture.
5. Mild dehydration.
6. Nephrolithiasis.
7. Anxiety

1. Admit patient for IV hydration and treatment of oral ulcerations. 2. Obtain a dermatology consult.
3. IV leukovorin will be started and patient will be put on high dose corticalsteroids. 4. Considering the patients anxiety perhaps obtain services of Stella Rose Dickenson, PhD Psychology at a later date.

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