Consult

Consult Patient Name Adela Torres Hospital ID 13246 Consultant Sachi Kato, M. D. , Dermatology Requesting Physician Leon Medina, M. D. , Internal medicinal drug Date of Consult 06/23/2011 Reason for Consultation Please evaluate stomatitis, possibly amethopterin related. narrative OF PRESENT ILLNESS The patient is a very pleasant 57-year old female, a native of Cuba, be seen for evaluation and treatment for sores in her mouth that she has had for the last 10-12 days.The patient has a long history of grueling and debilitating rheumatoid arthritis for which she has had numerous treatments, but over the past ten age she has been treated with methotrexate quite successfully. Her dosage has varied somewhere between 20 and 25 mg per week. About the stolon of this year, her dosage was decreased from 25 mg to 20 mg, but because of a flare of the rheumatoid arthritis, it was increase to 22. 5 mg per week. She has had no problems with methotrexate as far as she knows.She withal took an NSAID round a month ago that was recently discontinued because of the ulcerations in her mouth. About two weeks ago, just nearly the time the stomatitis began, she was placed on an antibiotic for suspected upper respiratory infection. She does not remember the separate of the antibiotic, although she claims she remembers taking this type of medication in the past without any problems. She was on that medication, triad pills a day, for three to four days. She notes no other problems with her uncase. She remembers no allergic reactions to medication.She has no previous history of fever blisters. (Continued) meditate Patient Name Hospital ID13246 Page 2 PHYSICAL EXAMINATION Reveals superficial erosions along the lips, peculiarly the level lips, the posterior buccal mucosa, along the sides of the tongue, and also some superficial erosions along the upper and lower gingiva. Her posterior pharynx was difficult to visualize, but I saw no erosions on the areas today. There did yet a ppear to be one small erosion on the soft palate. Examination of the rest of her skin revealed no areas of dermatitis or blistering.There were some macular hyperpigmentation on the right arm where she has had a previous burn, positivist the deformities from her rheumatoid arthritis on her hands and feet, as well as scars on her knees from total joint shift surgeries. IMPRESSION Erosive stomatitis, probably secondary to methotrexate. Even though the medication has been used for ten years without any problems, methotrexate whitethorn produce an erosive stomatitis and enteritis after such a use. The patient also may provoke an enteritis that at this point may have become more quiescent, as she notes that she did have some diarrhea about the time her mouth problem developed.She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting. Im not as acquainted(predicate) with the NSAID causing an erosive stomatitis. I understa nd that it can cause gastrointestinal upset, but granted the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis. RECOMMENDED THERAPY I total with your therapeutic regimen regarding this condition with the use of prednisone and folic acid. I also agree that the methotrexate mustiness be discontinued in order to produce a resolution of this patients skin problem.However, in my experience, this stomatitis may take a number of weeks to go away completely if a patient has been on methotrexate, for an widen period of time, because the medication is stored within the liver and in fatty tissue. Topically I have ordained Lidex gel, which I find works extremely well in stomatitis conditions. It can be applied t. i. d. (Continued) cite Patient Name Hospital ID13246 Page 3 Thank you very much for allowing me to share in the care of this pleasant patient. I will follow her with you as needed. _________________________ Sachi Kato, M. D. SKY M D06/23/2011 T06/23/2011