Case 4- Discharge Summary

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Patient Name: Adela Torres

Patient ID: 132463

Date of Admission: 6/22/----

Date of Discharge: 6/25/----

Admitting Physician: Leon Medina, MD, Internal Medicine

Consultations: Sachi Kato, MD, Dermatology

Procedures Performed: Intravenous Hydration.

Complications: None.

Admitting Diagnosis: Stomatitis possibly methotrexate related.

HOSPITAL COURSE: This 57-year-old Cuban female was admitted from my office for treatment of severe stomatitis and mild volume depletion secondary to poor fluid and food intake. Initially, the possibility of erythema multiforme-like picture was raised because she did have some skin lesions. However, dermatology consultation with Dr. Kato suggested this was most likely methotrexate related. She was given intravenous leucovorin and high dose prednisone treatment. This along with her intravenous fluids stabilized her condition. At the time of discharge her oral ulcers had markedly decreased; she could sallow without difficulty and her p.o. intake was adequate.

During hospitalization and after consultation with Dr. Kato, treatment options were discussed with the patient. At this point, she has elected to return to treatment with methotrexate albeit at a lower dose with concurrent use of folic acid.

DIAGNOSTIC DATA: White blood cell count 5200, hemoglobin 12, platelet count 422,000. Westergren sedimentation rate was mildly elevated at 36 mm per hour. Serum cholesterol 120 mg/dL. Albumin 3. Total protein 6.6. Liver enzymes were within normal limits.

DISPOSITION: Patient was discharged in improved condition, taking p.o. well.


Patient Name: Adela Torres
Patient ID: 132463
Date of Discharge: 06/25/----

DISCHARGE MEDICATIONS: Includes folic acid 1 mg p.o. daily, prednisone 10 mg p.o. daily, Arava 20 mg p.o daily, estradiol 0.5 mg q.a.m., and buspar 5 mg daily.

No dietary or physical activity restrictions. Return...
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