History and Physical Examination Essay

Admitting Diagnosis: Stomatitis possibly methotrexate related 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. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately two weeks ago she developed 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 last 3-5 days has had malaise, a low-grade fever and severe oral alterations with difficulty in swallowing although she can drink liquids with less difficulty. Patient denies any other problems at this point except for flare of arthritis since discontinuing the methotrexate. She has rather diffused pain 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 discontinued 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 history Family and Social History: noncontributory 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: Blood pressure 107/80. Heart rate 100 and regular respirations 22. HEENT normal cephalic. No scalp lesions. Dried eyes with  conjuctival injection. Mild 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 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 break down. She has some fissuring in the buttix crease. Pulmonary: Clear to precaution and alcostation bilaterally. Cardiovascular: No murmurs or galaps noted. Abdomen: Soft. None tender. Protuberant no organomegaly and positive bowel sounds. Neurologic Exam: Cranial nerves 2-12 are grossly intact. Diffuse hyporeflexia. Muscular Skeletal: Corrosive destructive changes in the elbows, wrists, and hands consistent with rheumatoid arthritis. Has bilateral total knee replacements with stovepipe legs and perimalleolar pitting edema 1 +. I feel no pulses 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 psychological services. She refused for now. Problems: 1. Swelling of lips and dysphasia with questionable early Stevens- Johnsons syndrome. 2. Rheumatoid arthritis class 3 stage 4. 3. Flare of arthritis after discontinuing methotrexate. 4. Osteoporosis with compression fracture. 5. Mild dehydration. 6. Nephrolithiasis. 7. Anxiety. 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 corticosteroids. 4. Considering patients anxiety perhaps obtain services of Stella Rose Dickinson PHD Psychology at a later date. X______________________________________________ Liam Medina, MD Date: 06/22/—- Case Study 5 Discharge Summary Patient Name: Fanny Copeland Patient ID: 115463 Date of Birth: 10/26/— Age: 58 Sex: Female Date of Admission: 04/26/—- Date of Discharge: 05/01/—- Procedure Performed: CT scan. Ms. Copeland is seen for her summary conference from her work up here at Hillcrest Memory Diagnostic Center. I initially saw her on 04/28/—- at which time 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 dementia rating scale, which is within normal limits for her age. The test result were consistent with mild cognitive defaces manifested by problems with concept formation. Attention and concentration and verbal memory. However 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 disorder as the cause of her symptom etiology. No further suicidal or homicidal ideation are present. Recommendations: We recommend a psychiatric evaluation and treatment with re-testing in our facility in one years’ time.