History and Physical Examination Case 4

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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...
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