Admiting Diagnosis: Stomatitis perchance methotrexate related Chief Ailment: Swelling of lips doing trouble get downing History of Present Illness: This patient is a 57-year-old Cuban adult female with a long history of arthritic arthritis. She has received amethopterin on a hebdomadal footing as an outpatient for many old ages. Approximately two hebdomads ago she developed a respiratory infection for which she received antibiotics and completed that class of antibiotics. She developed some ulceration of her oral cavity and was instructed to stop the amethopterin about 10 yearss ago. She showed some initial betterment but over the last 3-5 yearss has had unease. a low-grade febrility and terrible unwritten changes with trouble in get downing although she can imbibe liquids with less trouble. Patient denies any other jobs at this point except for flair of arthritis since stoping the amethopterin. She has instead diffused hurting affecting both big and little articulations this has caused her some anxiousness. Medicines: Prednisone 7. 5 mg PO daily. Estradiol 0. 5 mg PO QAM. Mobic 7. 5 mg PO daily. Recently discontinued because of questionable allergic reaction HCTZ 25 milligram PO every other twenty-four hours and unwritten Ca addendums. In the past she has been on pencillamine. Imuran and Plaquenil but she has non had Azulfidine. cyclophosphamide or Leukeran.

Allergies: none by history

Family and Social History: noncontributory

Physical Examination: This is a inveterate sick looking female qui vive oriented and concerted. She moves with great trouble because of weariness and unease. Critical Signs: Blood force per unit area 107/80. Heart rate 100 and regular respirations 22. HEENT normal cephalic. No scalp lesions. Dried eyes with conjuctival injection. Mild exophthalmos. Dry rhinal mucous membrane. Mark checking hemorrhage in her lips with erodings of the mucous membrane. She has a big ulceration of the mucous membrane at the bite border on the left. She has some scattered ulcerations on her bosom and soft palettes. She has trouble opening her oral cavity because of hurting. Tonsils non enlarged. No seeable exudation. Skin: She has some mild ecchymosis on her tegument and some erythema. She has spots but no obvious tegument interrupt down. She has some fissuring in the buttix fold. Pneumonic: Clear to safeguard and alcostation bilaterally. Cardiovascular: No mutter or galaps noted.

Abdomens: Soft. None stamp. Bellied no organomegaly and positive intestine sounds. Neurologic Exam: Cranial nervousnesss 2-12 are grossly integral. Diffuse hyporeflexia. Muscular Skeletal: Caustic destructive alterations in the cubituss. carpuss. and hands consistent with arthritic arthritis. Has bilateral sum articulatio genus replacings with stovepipe legs and perimalleolar roughness hydrops 1 + . I feel no pulsations distally in either leg. Psychiatric: Patient is a small dying about these new symptoms and their significance. We discussed her state of affairs and I offered her psychological services. She refused for now.

Problems:

1. Swelling of lips and dysphasia with questionable early Stevens- Johnsons syndrome.
2. Rheumatoid arthritis category 3 phase 4.
3. Flare of arthritis after stoping amethopterin.
4. Osteoporosis with compaction break.
5. Mild desiccation.
6. Nephrolithiasis.
7. Anxiety.

Plan:
1. Admit patient for IV hydration and intervention of unwritten ulcerations.
2. Obtain a dermatology consult.
3. IV leucovorin will be started and the patient will be put on high dose corticoids.
4. Sing patients anxiousness possibly obtain services of Stella Rose Dickinson PHD Psychology at a ulterior day of the month.

X______________________________________________
Liam Medina. MD
Date: 06/22/—-

Case Study 5 Discharge Summary
Patient Name: Fanny Copeland
Patient ID: 115463
Date of Birth: 10/26/—
Age: 58
Sexual activity: Female
Date of Admission: 04/26/—-
Date of Discharge: 05/01/—-
Procedure Performed: CT scan.

Ms. Copeland is seen for her drumhead conference from her work up here at Hillcrest Memory Diagnostic Center. I ab initio saw her on 04/28/—- at which clip there was the intuition of depression. She has since had CAT scan of the encephalon with contrast of 04/30/—- which was everyday. Labs surveies were wholly negative to include normal thyroid map B12 and RPR. She had a formal neurophysiological battery with Dr. Stella Dickinson on 04/26/—- she scored 136 on the dementedness evaluation graduated table. which is within normal bounds for her age.

The trial consequence were consistent with mild cognitive defaces manifested by jobs with concept formation. Attention and concentration and verbal memory. However the patient is significantly down which can bring forth some memory jobs. Her past MRI suggests person who is sing emphasis. Impression: There was no clinical grounds of dementedness but there is grounds of a depressive upset as the cause of her symptom etiology. No farther suicidal or murderous ideation are present. Recommendations: We recommend a psychiatric rating and intervention with re-testing in our installation in one years’ clip.