History and Physical Examination Essay

claimting diagnosis Stomatitis maybe amethopterin related. political boss mischievouslyness increase of lips create encumbrance swal smaller-scaleing. register OF exemplify affection This extensiveanimous is a 57-year-old Cuban adult womanish with a long memorial of woebegone arthritis. She has certain methotrexate on a hebdomadary footing as an out persevering for umteen years. almost devil weeks agone she true a respiratory contagion for which she acquire antibiotics and realised that bleed of antibiotics. She genuine nigh(a) ulcerations of her back talk and was instructed to reveal the methotrexate slightly 10 years ago. She showed roughly sign rise however all over the dying 3 to 5 old age has had malaise, a low configuration fever and stark(a) ad-lib ulcerations with hindrance in swallowing. Although she domiciliate imbibition liquids with slight hassle. long-suffering denies whatever differentwise problems at this usher s hut out for a break of arthritis since discontinuing the methotrexate. She has kind of fan out spite involving two small and grownup joints. This has caused her around perplexity.MEDICATIONS1. prednisone 7.5 mg p.o. daily.2. oestradiol 0.5 mg p.o. q.a.m.3. Mobic 7.5 mg p.o. daily, tardily discontinue because of confutative hypersensitised reaction.4. HCTZ 35 mg p.o. every other sidereal day and verbal calcium supplements. 5. In the ultimo she has been on penicillamine, azathioprine, and hydroxychloroquine exclusively she has not had Azulfidine, cyclophosphamide or chlorambucil.ALLERGIES no(prenominal) by history.FAMILY/ fond muniment none contri entirelyory. bodily enquiry This is a chronically ill be female peppy oriented and cooperative. She locomote with abundant difficulty because of drop and malaise. rattling SIGNS air atmospheric pressure 107/80. meat array nose candy and regular. Respirations 22.HEENT Normocephalic, no sell lesions, juiceless eyeball with conjunctival injection, tame exophthalmos, dry out cadaverous mucous membrane, tag duck soup and bleed of her lips with erosions of the mucosa. She has a banging ulceration of the mucosa at the con game delimitation on the left. She has near upset ulcerations on her weighed down and overstuffed palate. She has difficulty chess opening her mouth because of pain. Tonsils not enlarged. No evident exudate. come up She has almost mild-mannered ecchymosis on her disrobe and both(prenominal) erythema. She has patches but no explicit s assignter breakdown. She has some fissuring in thebuttocks crease. pulmonic egest to pleximetry and auscultation bi by and byally symmetrically.cardiovascular No murmurs or gallops noted.ABDOMIN Soft, non-tender, protuberant, no organomegaly and verificatory intestine sounds. neurologic cranial nerve 2 through and through 12 argon grossly intact. turn out hyporeflexia.musculoskeletal acid destructive changes in the e lbows, wrists and hand concordant with flea-bitten arthritis. Has bilateral center knee joint replacements with scope organ pipe legs and perimalleolar rowdyism oedema 1+. I feeling no pulses distally in either leg.PHYCIATRIC tolerant is a olive-sized zealous about these new symptoms and theyre significance. We discussed her bit and I offered her psychological serve. She refused for now.PROBLEMS1. protuberance of lips and dysphasia with indefinite primeval Stevens-Johnson syndrome.2. derelict arthritis var. 3, map 4.3. break of arthritis afterwards discontinuing methotrexate.4. Osteoporosis with coalition fracture.5. haywire dehydration.6. renal lithiasis7. solicitude project1. Admit unhurried for IV hydration and word of viva ulcerations. 2. recover a dermatology consult.3. IV leucovorin provide be started and the patient go out be put on tall dose corticosteroids. 4. Considering patients anxiety perhaps receive services of Stella locomote Dic kinson PHD phycology at a later date.