Rheumatology Clinic Follow-Up

I saw Ms. A. Khumalo in follow-up for Rheumatoid Arthritis. Past Medical History: 1. Rheumatoid Arthritis (diagnosed 2018) 2. Hypertension (diagnosed 2015, well-controlled) 3. Type 2 Diabetes Mellitus (diagnosed 2019, on metformin) 4. Latent Tuberculosis (treated 2017 with INH) Disease History: Ms. Khumalo was diagnosed with seropositive Rheumatoid Arthritis in June 2018. Initial presentation involved symmetrical polyarthritis affecting small joints of hands and feet. Serology at diagnosis showed elevated RF and anti-CCP. She experienced a significant flare in early 2023 following a viral infection, but has otherwise shown a generally good response to treatment. No overlap with HIV-related immune reconstitution. No other comorbid autoimmune diseases identified. Serology: ANA: Negative RF: 120 IU/mL (elevated) Anti-CCP: 350 U/mL (elevated) ESR: 45 mm/hr (previous: 20 mm/hr, 3 months prior) CRP: 15 mg/L (previous: 5 mg/L, 3 months prior) HLA-B27: Not performed DMARDs & Biologics History: * Methotrexate: 20mg PO weekly (started 2018, good response, current) * Sulfasalazine: 1000mg BID (trialed 2019, discontinued due to GI upset) * Hydroxychloroquine: 200mg PO daily (started 2020, ongoing, no significant side effects) * Adalimumab: Not yet trialed. Medications: * Methotrexate 20mg PO weekly (with Folic Acid 5mg PO weekly) * Hydroxychloroquine 200mg PO daily * Prednisone 5mg PO daily * Metformin 500mg PO BID * Amlodipine 5mg PO daily * Paracetamol PRN for pain * Multivitamin daily Allergies: NKDA (No Known Drug Allergies) Clinical Update: Patient reports an increase in joint pain and stiffness over the past month, primarily affecting her wrists and knees. Morning stiffness now lasts approximately 2 hours, compared to 30 minutes previously. She also notes increased fatigue and difficulty with fine motor tasks, impacting her ability to perform daily household chores. Her overall ability to perform ADLs has moderately declined. Review of Systems: Rheumatologic: Increased joint pain and stiffness, fatigue. No new nodules. Cardiac: No chest pain or palpitations. Respiratory: No shortness of breath or cough. Dermatologic: No new rashes or skin changes. Neurological: No numbness, tingling, or weakness. Physical Examination: General: Alert and oriented, appears comfortable at rest. Musculoskeletal: * Hands: Swelling and tenderness noted in MCPs 2-3 bilaterally. Reduced grip strength. * Wrists: Mild swelling and tenderness, restricted flexion/extension bilaterally. * Knees: Mild effusions bilaterally, tender to palpation. * Shoulders: Full range of motion, no tenderness. * Skin: No rashes or nodules. Investigations: * ESR: 45 mm/hr (1 November 2024) * CRP: 15 mg/L (1 November 2024) * LFTs: Within normal limits (1 October 2024) * Creatinine: 70 µmol/L (1 October 2024) * X-rays of hands and wrists: Stable erosive changes (June 2024) Impression: Patient is currently in a moderate flare of her Rheumatoid Arthritis. This is evidenced by increased joint pain, stiffness, fatigue, and elevated inflammatory markers (ESR, CRP). Her comorbidities (hypertension, diabetes) remain stable and are not contributing to the current rheumatologic flare. Plan: 1. Increase Prednisone to 10mg PO daily for 2 weeks, then reduce to 7.5mg daily for 2 weeks, then revert to 5mg daily. 2. Consider escalation of DMARD therapy if flare not controlled with prednisone taper. Discuss adding a biologic (e.g. adalimumab) at next visit if current regimen proves insufficient. 3. Repeat FBC, LFTs, ESR, and CRP in 4 weeks. 4. Reinforce importance of adherence to current medication regimen and regular exercise within pain limits. 5. Referral to occupational therapy for assessment and provision of adaptive aids to assist with ADLs. 6. Review in rheumatology clinic in 6 weeks or sooner if symptoms worsen significantly. Thank you for involving me in this patient's care. If you have any questions or concerns, please do not hesitate to contact me.