Consult

Consult diligent nominate Adela Torres Hospital ID 13246 Consultant Sachi Kato, M. D. , Dermatology Requesting Physician Leon Medina, M. D. , knowledgeable Medicine Date of Consult 06/23/2011 Reason for Consultation Please estimate stomatitis, possibly methotrexate sodium related. HISTORY OF present(a) ILLNESS The patient is a precise pleasant 57-year old female, a inborn 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 rheumatic arthritis for which she has had numerous treatments, but everywhere the ultimo hug drug years she has been inured with methotrexate quite successfully. Her venereal disease has vary somewhere between 20 and 25 mg per week. About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but be example of a flare of the rheumatoid arthritis, it was increased to 22. 5 mg per week. She has had no problems with methotrexate as far as she knows.She likewise took an NSAID most a month ago that was recently give up because of the ulcerations in her mouth. About two weeks ago, that about the time the stomatitis began, she was placed on an antibiotic for suspected upper respiratory infection. She does not remember the name of the antibiotic, although she claims she remembers pickings this type of medication in the past without any problems. She was on that medication, three pills a day, for three to four days. She notes no otherwise problems with her skin. She remembers no allergic reactions to medication.She has no earlier history of fever blisters. (Continued) CONSULT long-suffering Name Hospital ID13246 Page 2 PHYSICAL EXAMINATION Reveals sounding erosions on the lips, particularly the lower lips, the freighter 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 s aw no erosions on the areas today. there did however appear to be adept small erosion on the cheeselike 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 forward burn, plus the deformities from her rheumatoid arthritis on her turn over and feet, as well as scars on her knees from total joint replacement surgeries. effect Erosive stomatitis, probably secondary to methotrexate. even so though the medication has been used for ten years without any problems, methotrexate whitethorn take in an acid stomatitis and enteritis after such a use. The patient also whitethorn fetch 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 origination in her stools and has had no episodes of nausea or vomiting. Im not as familiar with the NSAID causing an erosive stomatitis. I understand that it discount cause gastrointestinal upset, but given the selection between the two, I would think the methotrexate is the most likely etiology for the stomatitis. RECOMMENDED THERAPY I agree with your therapeutic regimen regarding this position with the use of prednisone and folic acid. I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients skin problem.However, in my experience, this stomatitis may take a descend of weeks to go away completely if a patient has been on methotrexate, for an extended catch of time, because the medication is stored within the liver and in fatty tissue. Topically I have prescribed Lidex gel, which I find kit and boodle 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 patien t. I will follow her with you as needed. _________________________ Sachi Kato, M. D. SKYM D06/23/2011 T06/23/2011