п»їHISTORY AND PHYSICAL EXAMINATION

Patient Name: Adela Torres

Patient IDENTITY: 132463

Space No .: 541

Date of Admission: 06/22/2014

Admitting Medical professional: Leon Medina, MD of Internal Treatments

Acknowledging Diagnosis: Stomatitis, possible methotrexate related.

Primary Complaint: Puffiness of the lip area, causing difficulty swallowing.

GREAT PRESENT HEALTH ISSUES: This sufferer is a 57 year old Cuban woman has a long history of arthritis rheumatoid, she has received methotrexate over a weekly basis as an outpatient for many years, approximately 14 days ago the girl developed a repertory disease for which your woman received antibiotics and finished that cores of remedies she designed some ulcerations in her mouth and was directed to stop the methotrexate approximately week ago, the lady showed some initial improvement but during the last 3 to 5 days she has had delays, low grade fever, and severe oral ulcerations with trouble swallowing, although she may drink fluids with less difficulty. Sufferer denies any other problems at this moment except a flare of arthritis sence discontinuing the methotrexate. Your woman had reather difusing pain in the two large and small bones. This has triggered her some anxiety.

PRESCRIPTION DRUGS: Prednisone several. 5 magnesium Po daily, estradiol 0. 5 mg Po QAM, Mobic several. 5 magnesium Po daily recently stopped because of doubtful allergic reaction, HCTZ 25 magnesium Po alternate day, and dental calcium supplements, before she has recently been on penicillamine, azathioprine, and hydroxychloroquine yet she has certainly not had azulfidine, cyclophosphamide, or perhaps chlorambucil.

ALLERGIES: non-e by history

FAMILY/SOCIAL HISTORY: None contributory

PHYSICAL EXAMINATION: This can be a conically ill appearing female alert, oriented, and cooperative. The girl moves with great difficulty because of tiredness imalays. ESSENTIAL SIGNS: Stress 107/80, heart rate 100 and regular, respirations 22. HEENT: nurosentalic, no scalp lesions, dry eyes with conjunctival injection,...

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