MedAdmin 250 Imod 3 Job

 MedAdmin two hundred fifty Mod three or more Project Essay

п»їRachel Alejandre

March 3, 2015

MedAdmin two hundred fifty

Module 3 Project

Case Study four History and Physical Examination

Affected person name: Adela Torres

Patient ID: 132463

Area #: 541

Date of Admission: 06/22/----

Acknowledging Physician: Liam Medina MD of Inside Medicine

Admitting Diagnosis: Stomatitis possibly methotrexate related Chief Complaint: Inflammation of lips causing problems swallowing Good Present Health issues: This individual is a 57-year-old Cuban girl with a long history of rheumatoid arthritis. This lady has received methotrexate on a every week basis since an outpatient for many years. Approximately two weeks in the past she designed a breathing infection which is why she received antibiotics and completed that course of antibiotics. She developed some ulceration of her mouth and was directed to cease the methotrexate approximately 10 days ago. She showed a lot of initial improvement but over the last 3-5 days and nights has had malaise, a low-grade fever and severe common alterations with difficulty in swallowing although she can beverage liquids trouble. Patient refuses any other problems at this point apart from flare of arthritis since discontinuing the methotrexate. She has rather diffused pain including both significant and tiny joints this has caused her some stress. Medications: Prednisone 7. a few mg PO daily. Estradiol 0. a few mg PO QAM. Mobic 7. five mg PO daily. Lately discontinued because of questionable allergic reaction HCTZ 25 mg PO every other day and oral calcium supplements. In the past this wounderful woman has been upon pencillamine, azathioprine and hydroxychloroquine but she has not had Azulfidine, cyclophosphamide or chlorambucil. Allergies: none by history

Family and Sociable History: noncontributory

Physical Evaluation: This is a chronically sick appearing feminine alert focused and supportive. She movements with great difficulty due to fatigue and malaise. Vital Signs: Blood pressure 107/80. Heart rate 100 and regular respirations 22. HEENT normal cephalic. No scalp lesions. Dried up eyes with conjuctival injections. Mild exophthalmos. Dry sinus mucosa. Mark cracking blood loss in her lips with erosions in the mucosa. She gets a large ulceration of the mucosa at the bite margin that you write in the cue section. She has a few scattered ulcerations on her center and smooth pallets. This lady has difficulty opening her oral cavity because of discomfort. Tonsils not enlarged. Not any visible exudate. Skin: She gets some slight ecchymosis on her skin and some erythema. She has patches although no clear skin break up. She has several fissuring inside the buttix -wrinkle. Pulmonary: Very clear to safety measure and alcostation bilaterally. Aerobic: No murmurs or galaps noted.

Abdomen: Gentle. non-e soft. Protuberant simply no organomegaly and positive bowel sounds. Neurologic Exam: Cranial nerves 2-12 are grossly intact. Dissipate hyporeflexia. Muscular Skeletal: Rust destructive modifications in our elbows, wrists, and hands consistent with arthritis rheumatoid. Has zwei staaten betreffend total knee replacements with stovepipe legs and perimalleolar pitting edema 1 &. I feel zero pulses distally in possibly leg. Psychiatric: Patient is a little anxious regarding these new symptoms and their value. We discussed her condition and I presented her psychological services. The lady refused for now. Problems:

1 . Puffiness of lip area and dysphasia with questionable early Stevens- Johnsons affliction. 2 . Arthritis rheumatoid class 3 stage four.

3. Sparkle of osteoarthritis after discontinuing methotrexate.

some. Osteoporosis with compression fracture.

5. Slight dehydration.

6. Nephrolithiasis.

several. Anxiety.


1 ) Admit affected person for IV hydration and treatment of mouth ulcerations. 2 . Obtain a dermatology consult.

three or more. IV leucovorin will be started out and the individual will be place on high dose corticosteroids. 5. Considering individuals anxiety most likely obtain services of Stella artois lager Rose Dickinson PHD Mindset at a later date.


Liam Medina, MD

Date: 06/22/----

Case Study your five Discharge Synopsis

Patient Term:...

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