Essay on History and Physical Examination Case 4

628 WordsMay 13, 20133 Pages
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…show more content…
Skin- she has some mild equimosis on her skin and some anathema. She has patches but no obvious skin breakdown. She has no fissuring in the buttocks crease. Pulmonary- clear to procession and occultation bilaterally. Cardiovascular- no murmurs or gallops noted. Abdomen- soft, none tender, protuberate, no organomegaly, and positive bells sounds. (Continued) HISTORY AND PHYSICAL EXAMINATION Patient Name: Adela Torres Patient ID: 132463 RM #: 541 Date of Admission: 06/22/---- Page: 3 Neurologic examine- cranial nerves 2-12 are grossly intact, diffuse hyporeflexia. Musculoskeletal- erosive destructive changes in the elbows, wrist, and hands consistent with rheumatoid arthritis, has bilateral total knee replacements with stovepipe legs and perimalleolar pitting edema 1+. I feel no pluses 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 dysphasia with questionable early Stevens Johnson syndrome. 2. Rheumatoid
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