Gloria Ramos
Hospital Course: This 57-year old white 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 a 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 swallow without difficultly 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 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.
(Continued)
Discharge Summary
Patient Name: Gloria Ramos
Hospital No.: 13246
Discharged: 06/25/2010
Page 2
Diagnosis Data:
1. Methotrexate stomatitis.
2. Rheumatoid arthritis Class 3 Stage 4.
3. Steroid aggravated osteoporosis.
4. Nephrocalcinosis.
5. Stasis edema.
__________________________
Leon Medina, MD
LM:CG
D: 06/25/2010
T:
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.
(Continued)
Discharge Summary
Patient Name: Gloria Ramos
Hospital No.: 13246
Discharged: 06/25/2010
Page 2
Diagnosis Data:
1. Methotrexate stomatitis.
2. Rheumatoid arthritis Class 3 Stage 4.
3. Steroid aggravated osteoporosis.
4. Nephrocalcinosis.
5. Stasis edema.
__________________________
Leon Medina, MD
LM:CG
D: 06/25/2010
T: