case 4

Topics: Rheumatoid arthritis, Dysphagia, Rheumatology Pages: 3 (513 words) Published: March 26, 2014
HISTORY AND PHYSICAL EXAMINATION

Patient Name: Adela Torres

Patient ID: 132463

Room No.: 541

Date of Admission: 06/22/2014

Admitting Physician: Leon Medina, MD of Internal Medicine

Admitting Diagnosis: Stomatitis, possible methotrexate related .
Chief Complaint: Swelling of the lips, causing difficulty swallowing.

HISTORY OF PRESENT ILLNESS: This patient is a 57 year 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 repertory infection for which she received antibiotics and completed that cores of antibiotics she developed some ulcerations in her mouth and was instructed to discontinue the methotrexate approximately 10 days ago, she showed some initial improvement but over the last 3 to 5 days she has had delays, 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 a flare of arthritis sence discontinuing the methotrexate. She had reather difusing pain in 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 discontinued because of questionable allergic reaction, HCTZ 25 mg Po 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, or chlorambucil.

ALLERGIES: None by history

FAMILY/SOCIAL HISTORY: None contributory

PHYSICAL EXAMINATION: This is a conically ill appearing female alert, oriented, and cooperative. She moves with great difficulty because of fatigue imalays. VITAL SIGNS: Blood pressure 107/80, heart rate 100 and regular, respirations 22. HEENT: nurosentalic, no scalp lesions, dry eyes with conjunctival injection,...
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