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 lower dose with concurrent use of folic acid.
Diagnostic Data: White blood count 5200. Hemoglobin 12. Platelet count 422,000. Westergren sedimentation rate was mildly elevated at 36mm per hour. Serum cholesterol 120mg per deciliter. Albumin 3. Total protein 6.6. Liver enzymes were in normal limits.
Disposition: Patient was discharged in improved condition taking p.o. well. Discharge medications included folic acid 1mg p.o.q.d.. Prednisone 10mg p.o.q.d. and Disalcid 100mg p.o.b.i.d.. No dietary or physical activity restrictions. I will follow patient in my office in approximately one week and with Dr. Kato as needed.
Patient Name: Gloria Ramos
Hospital No.: 13246
1. Methotrexate stomatitis.
2. Rheumatoid arthritis Class 3 Stage 4.
3. Steroid aggravated osteoporosis.
5. Stasis edema.
Leon Medina, MD