Case 4 History and Physical Essay

596 Words Apr 25th, 2012 3 Pages
HISTORY AND PHYSICAL EXAMINATION

Patient Name: Adela Torres

Patient ID: 132463

Room No.: 541

Date of Admission: 06/22/----

Admitting Physician: Leon Medina, MD, Internal Medicine

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 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
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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.
HISTORY AND PHYSICAL EXAMINATION

Patient Name: Adela Torres
Patient ID: 132463
Date of Admission: 06/22/----
Page 2

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. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Soft, nontender, protuberant, no orgonomegaly, and positive bowel sounds. NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia. MUSCULOSKELETAL: Erosive, 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 psychologic services. She refused for now.

PROBLEMS:
1. Swelling of lips and dysphagia with questionable early Stevens-Johnson syndrome.
2. Rheumatoid arthritis, class 3, stage 4.
3. Flare of arthritis after discontinuing…

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