Hospital Discharge Summary
DISCHARGE SUMMARY
Patient Name: Adela Torres
Patient ID: 132463
Date Admitted: 06/22/2013 Date Discharged: 06/25/2013
Admitting Physician: Leon Medina, MD, Internal Medicine
Consultations: Sachi Kato, MD, Dermatology
Procedures: 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 an 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 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/h. 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. Discharge medications include 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
(Continued)
BuSpar 5 mg daily. No dietary or physical activity restrictions. Return to my office in approximately a week, Dr. Kato p.r.n., and consult with Dr. Dickinson if anxiety persists.
DISCHARGE DIAGNOSES
1.
Patient Name: Adela Torres
Patient ID: 132463
Date Admitted: 06/22/2013 Date Discharged: 06/25/2013
Admitting Physician: Leon Medina, MD, Internal Medicine
Consultations: Sachi Kato, MD, Dermatology
Procedures: 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 an 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 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/h. 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. Discharge medications include 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
(Continued)
BuSpar 5 mg daily. No dietary or physical activity restrictions. Return to my office in approximately a week, Dr. Kato p.r.n., and consult with Dr. Dickinson if anxiety persists.
DISCHARGE DIAGNOSES
1.