Consult

Consult Patient boot Adela Torres Hospital ID 13246 Consultant Sachi Kato, M. D. , Dermatology Requesting mendelevium Leon Medina, M. D. , Internal Medicine Date of Consult 06/23/2011 Reason for character reference Please evaluate stomatitis, possibly methotrexate sodium related. HISTORY OF PRESENT ailment The patient role is a very pleasant 57-year old female, a ingrained of Cuba, being 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 severe and debilitating rheumatoid arthritis for which she has had numerous treatments, entirely over the past ten geezerhood she has been treated with methotrexate quite successfully. Her dosage has varied aboutwhere between 20 and 25 mg per week. About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of a flare of the rheumatoid arthritis, it was increased to 22. 5 mg per week. She has had no problems with methotrexate as f ar as she knows.She as rise took an NSAID about a month ago that was recently stop because of the ulcerations in her mouth. About two weeks ago, just about the time the stomatitis began, she was situated on an antibiotic for suspected upper respiratory infection. She does not esteem the name of the antibiotic, although she claims she remembers taking this type of medication in the past without every problems. She was on that medication, three pills a day, for three to four days. She notes no new(prenominal) problems with her skin. She remembers no allergic reactions to medication.She has no foregoing history of fever blisters. (Continued) denote Patient Name Hospital ID13246 Page 2 PHYSICAL mental testing Reveals superficial corrosions along the lips, particularly the lower lips, the back tooth 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 e rosions on the areas today. There did however appear 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, plus the deformities from her rheumatoid arthritis on her hands and feet, as well as scars on her knees from total joint replacement surgeries. IMPRESSION Erosive stomatitis, likely secondary to methotrexate. Even though the medication has been used for ten years without any problems, methotrexate may produce an erosive stomatitis and enteritis after much(prenominal) a use. The patient also may have an enteritis that at this orchestrate may have become more quiescent, as she notes that she did have some diarrhoea 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 familiar with the NSAID do an erosive stomatitis. I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the near likely etiology for the stomatitis. RECOMMENDED THERAPY I agree with your therapeutic regimen regarding this terminus with the use of prednisone and folic acid. I also agree that the methotrexate must be discontinued in order to produce a colonization 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 extended outcome of time, because the medication is stored within the liver and in fatty tissue. Topically I have prescribed Lidex gel, which I find works extremely well in stomatitis conditions. It can be applied t. i. d. (Continued) CONSULTATION Patient Name Hospital ID13246 Page 3 Thank you very much for allowing me to pct in the care of this pleasant patient. I will follow her with you as needed. _____ ____________________ Sachi Kato, M. D. SKYM D06/23/2011 T06/23/2011