History and Physical Examination Essay

Admitting Diagnosis Stomatitis possibly methotrexate related. Chief bearing Swelling of lips causing fuss swallowing.HISTORY OF PRESENT ILLNESS This patient role is a 57-year-old Cuban woman with a long history of decrepit 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 most ulcerations of her backtalk and was instructed to discontinue the methotrexate approximately 10 long time ago. She showed some sign improvement but over the last 3 to 5 days has had malaise, a low grade fever and severe oral ulcerations with worry in swallowing. Although she can drink liquids with less difficulty. Patient denies any other(a) problems at this point except for a flare of arthritis since discontinuing the methotrexate. She has rather lot pain involving both small and large joints. This has cau sed her some anxiety.MEDICATIONS1. Prednisone 7.5 mg p.o. daily.2. Estradiol 0.5 mg p.o. q.a.m.3. Mobic 7.5 mg p.o. daily, recently discontinued because of questionable hypersensitised reaction.4. HCTZ 35 mg p.o. every other day and oral atomic number 20 supplements. 5. 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 enquiry This is a chronically ill appearing female alert point and cooperative. She moved with great difficulty because of fatigue and malaise.VITAL SIGNS Blood contract 107/80. Heart rate 100 and regular. Respirations 22.HEENT Normocephalic, no scalp lesions, dry look with conjunctival injection, mild exophthalmos, dry nasal mucosa, markedcracking and discharge of her lips with erosions of the mucosa. She has a large ulceration of the mucosa at the bite allowance account 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.SKIN She has some mild ecchymosis on her skin and some erythema. She has patches but no perspicuous skin breakdown. She has some fissuring in thebuttocks crease.PULMONARY Clear to percussion and auscultation bilaterally.cardiovascular No murmurs or gallops noted.ABDOMIN Soft, non-tender, protuberant, no organomegaly and positive bowel sounds.NEUROLOGIC cranial nerves 2 through 12 are grossly intact. dot hyporeflexia.MUSCULOSKELETAL Corrosive destructive changes in the elbows, wrists and hands consistent with woebegone arthritis. Has bilateral total knee replacements with stove pipe legs and perimalleolar pitting oedema 1+. I feel no pulses distally in either leg.PHYCIATRIC Patient is a little anxious about these new symptoms and theyre significance. We discussed her bit and I offered her psychological services. She refused for n ow.PROBLEMS1. Swelling of lips and dysphasia with questionable early Stevens-Johnson syndrome.2. Rheumatoid arthritis human body 3, stage 4.3. Flare of arthritis after discontinuing methotrexate.4. Osteoporosis with compression fracture.5. Mild dehydration.6. Nephrolithiasis7. disturbancePLAN1. Admit patient for IV hydration and treatment of oral ulcerations. 2. control a dermatology consult.3. IV leucovorin will be started and the patient will be put on high dose corticosteroids. 4. Considering patients anxiety perhaps support services of Stella Rose Dickinson PHD phycology at a later date.