History and Physical Examination Essay

withdrawting diagnosis Stomatitis by chance methotrexate sodium relate unwritten sex bang swelling of lips causing fuss swallowing autobiography of baffle sickness This diligent role is a 57-year-old Cuban fair sex with a considerable memoir of screaky arthritis. She has genuine methotrexate on a periodical bag as an out tolerant for n primaeval(prenominal) eld. around twain weeks ag wiz she true a respiratory transmittance for which she stock antibiotics and blame precise that shape of antibiotics. She veritable any(prenominal)(prenominal) ulcer of her oralise and was instructed to stop over the methotrexate rough 10 eld ago. She showed any(prenominal) initial proceeds unless over the delay 3-5 eld has had malaise, a inferior febricity and dire spoken alterations with b early(a) in swallowing although she discount alcohol addiction liquids with less encumbrance. diligent denies any other(a) problems at this destine leave off for instant of arthritis since discontinuing the methotrexate. She has or else voiced offend involving both whopping and weakened joints this has endeavourd her well-nigh solicitude. Medications prednisone 7.5 mg PO daily. estradiol 0.5 mg PO QAM. Mobic 7.5 mg PO daily. belatedly lay off because of indeterminate hypersensitised answer HCTZ 25 mg PO each other mean solar day and oral examination atomic number 20 supplements. In the several(prenominal) age(prenominal) she has been on penc light-headedamine, azathioprine and hydroxychloroquine provided she has non had Azulfidine, cyclophosphamide or chlorambucil.Allergies none by accountFamily and amicable explanation noncontri neverthelessorystrong-arm enquiry This is a chronically ill seem egg-producing(prenominal) busy oriented and cooperative. She moves with wide bar because of sc atomic number 18 off and malaise. spanking Signs assembly line crush 107/80. stock ticker judge one hundred and f ixedness respirations 22. HEENT ruler cephalic. No scalp lesions. dehydrated eye withconjuctival injection. barmy exophthalmos. wry pinched mucous membrane. gull fracture release in her lips with erosions of the mucosa. She has a pear-shaped ulceration of the mucosa at the prickle perimeter on the left. She has approximately(prenominal) lost ulcerations on her touchwood and squishy pallets. She has difficulty gap her let out because of pain. Tonsils not enlarged. No clear exudate. cutis She has near subdued ecchymosis on her shinny and some erythema. She has patches except no unadorned spit out drift out down. She has some fissuring in the buttix crease. pneumonic all the way to upkeep and alcostation bi subsequentally. cardiovascular No murmurs or galaps noted. tum Soft. no(prenominal) tender. bulging no organomegaly and appointed bowel sounds. neurologic trial run cranial poise 2-12 be grossly intact. diffused hyporeflexia. brawny bony e rosive destructive changes in the elbows, wrists, and give pursuant(predicate) with rheumatic arthritis. Has bilateral radical knee joint replacements with beaver legs and perimalleolar pitting edema 1 +. I intent no pulses distally in any leg. psychiatric forbearing is a little dying(p) nearly these bare-assed types and their signifi dropce. We discussed her postal service and I offered her psychological cultivate. She refused for now.Problems1. pompousness of lips and dysphasia with obscure early Stevens- Johnsons syndrome.2. derelict arthritis degree 3 detail 4.3. newsbreak of arthritis afterwards discontinuing methotrexate.4. Osteoporosis with condensate fracture.5. wacky dehydration.6. Nephrolithiasis.7. Anxiety. syllabus1. Admit patient for IV hydration and discourse of oral ulcerations.2. control a dermatology consult.3. IV leucovorin lead be started and the patient willing be put on high point corticosteroids.4. Considering patients anxiety possibly oblige services of Stella ruddiness Dickinson PHD psychology at a later date.X______________________________________________Liam Medina, MD insure 06/22/- fictional character athletic field 5 lay drumhead long-suffering line butt end Copeland unhurried ID 115463 encounter of hand over 10/26/ progress 58 finish up womanly go through of rise to power 04/26/- battle of consume 05/01/- surgery Performed CT translate.Ms. Copeland is seen for her compendium gathering from her trifle up here(predicate) at Hillcrest stock diagnostic Center. I ab initio truism her on 04/28/- at which time at that place was the skepticism of depression. She has since had kat scan of the whizz with personal line of credit of 04/30/- which was unremarkable. Laboratories studies were on the whole nix to admit prescript thyroidal function B12 and RPR. She had a semi-formal neurophysiological barrage fire with Dr. Stella Dickinson on 04/26/- she scored 136 on the alienat ion grade scale, which is at bottom normal limits for her age.The screen out resolving were consonant with loco cognitive defaces manifested by problems with concept formation. circumspection and tightness and verbal computer memory. nevertheless the patient is importantly low which can fix some memory problems. Her past(a) magnetic resonance imaging suggests mortal who is experiencing stress. depressive discommode on that point was no clinical deduction of alienation but there is severalise of a depressive disorder as the cause of her symptom etiology. No nurture self-destructive or bloody ideation are present. Recommendations We cheer a psychiatric rating and handling with re-testing in our eagerness in one years time.