Discharge Summary Essay Sample

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Discharge Diagnosis:
1. Methotrexate related dermatitis.
2. Rheumatoid arthritis class 3 stage 4
3. Osteoporosis
4. Kyphosis
5. statis edema
6. Anexity

ADMITTING DIANOSIS: Stomatitis possibly methotrexate related.

HOSPITAL COURSE: This 57-year-old cuban female was admitted from my office for treatment for sevre stomatitis and for mild volume depletion, secondary to poor fuild and food intake. Initially the possibility of erythema multiforme like picture was raised because she did have some skin lesions. However dermatollogy consultation with Dr. Kto suggested this was methotrexate related. She was given intravenus leucovorin and high dose prednisone treatment. This along with her intravenus fluids stableized her condition. At the time of discharge her oral ulcers had marketly decreased. She could swollow without difficulty and her P.O. intake was addiquite. During hospitalizion and after consultation treatment options were disscused 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, platlet count 422,000, westergren sedimentation rate was mildly elevated at 36mm per hour, serum choesterol 120 mg per desaletre, albumin 3, total protein 6.6, liver enzymes were within normal limits.

DISPOSITION: Patient was discharged with improved condition taking P.O well.

1. Folic acid 1mg P.O daily
2. Prednisone 10mg P.O. daily
3. Arava 20mg P.O daily
4. Estradiol 0.5mg QAM
5. Bruspar 5mg daily

No dietary or physical activity restrictions, return to my office in approxmatly in a week. Dr. Kto PRN and cosult with Dr. Dickson if aniexity presists.

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