Case 4 History and Physical

HISTORY AND PHYSICAL tryout enduring Name: Adela Torres Patient ID: 132463 live No.: 541 Date of Admission: 06/22/---- Admitting Physician: Leon Medina, MD, interior(a) Medicine Admitting Diagnosis: Stomatitis, possibly methotrexate related. Chief Complaint: stumblebum of lips causing difficulty swallowing. HISTORY OF PRESENT ILLNESS: This tolerant is a 57-year-old Cuban woman with a long score of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately 2 weeks past she developed a respiratory infection, for which she received antibiotics, and completed that lam of antibiotics. She developed some ulcerations of her mouth and was instructed to discontinue the methotrexate just about 10 days ago. She showed some initial improvement, but everyplace the last 3-5 days has had malaise, a low-grade fever, and severe ad-lib ulcerations with difficulty in swallowing; although she can drink liquids with less difficulty. Patient denies any other problems at this point, except for a flame up of arthritis since discontinuing the methotrexate. She has rather diffuse pain involving both large and down(p) joints. This has caused her some anxiety. MEDICATIONS: Prednisone 7.5 mg p.o. daily; estradiol 0.5 mg p.o. qam; Mobic 7.5 mg p.o.

daily, recently discontinued because of questionable allergic reply; HCTZ 25 mg p.o. every other day, and oral atomic number 20 supplements. 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 HISTORY: Noncontributory. 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. rattling SIGNS: Blood pressure 107/80. Heart rate 100 and regular. Respirations 22. HEENT: Normocephalic. No scalp... If you want to get a full essay, order it on our website: Ordercustompaper.com

If you want to get a full essay, wisit our page: write my paper