Diagnoses:
- Rheumatoid Arthritis
- Raynaud's Phenomenon
Current Rheumatology Medication:
1. Methotrexate 15mg weekly
2. Hydroxychloroquine 200mg twice daily
Allergies:
- Penicillin
Previous DMARDs:
- Sulfasalazine (stopped due to side effects)
Investigations:
1. Rheumatoid factor: Elevated
2. Anti-CCP antibodies: Positive
3. ESR: 45 mm/hr
4. CRP: 25 mg/L
Disease activity score:
For Rheumatoid Arthritis, list:
- Tender joint count: 6
- Swollen joint count: 4
- Patient visual analogue score: 60mm
- CRP: 25 mg/L
- Duration of early morning stiffness: 60 minutes
Activity of Daily Living:
- Difficulty with buttoning clothes due to hand swelling.
- Problems with walking long distances due to knee pain.
Discussion:
The patient, [insert age] years old, presented today with a flare-up of their rheumatoid arthritis. They report increased joint pain and stiffness, particularly in the morning. The patient also reports ongoing symptoms of Raynaud's phenomenon, with episodes of finger discolouration in cold weather. The patient reports they have been experiencing increased fatigue. The patient's current medications were reviewed, and the patient reports they are tolerating them well. The patient's disease activity score was calculated, and the results indicate moderate disease activity. The patient was educated on the importance of medication adherence and lifestyle modifications. The patient was also advised on non-pharmacological management of Raynaud's phenomenon.
Key points:
- Increased joint pain and stiffness.
- Moderate disease activity.
- Ongoing Raynaud's symptoms.
Impression:
- Rheumatoid arthritis flare-up with moderate disease activity.
- Stable Raynaud's phenomenon.
GP Actions:
1. GP to please add folic acid 5mg once weekly to repeat prescription.
2. GP to please add hydroxychloroquine to repeat prescription — there are no monitoring requirements and no shared care agreement necessary.
Plan:
- Continue current medications.
- Review in 3 months.
- Discussed non-pharmacological management of Raynaud's phenomenon.
Raynaud’s management:
Non-pharmacological management:
- Avoiding inciting environmental factors, such as direct contact with frozen foods or cold drinks.
- Insulation against cold and local warming, including gloves, heavy socks, and hat particularly in winter.
- Avoiding smoking.
Pharmacological options:
- Calcium channel blockers are the class of drugs most widely used for treatment of Raynaud syndrome (e.g. nifedipine, nicardipine). The usual dosage of Nifedipine is 30–60 mg of the extended-release formulation taken once daily. Start with the lowest dose and titrate up as tolerated. If adverse effects occur, decrease the dosage or use another agent such as amlodipine or diltiazem.
- Other medications that may be of help include:
- Topical nitroglycerin (1% or 2%) may be helpful; however, some patients develop headaches and flushing which limits its use.
- Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine or sertraline.
- Losartan.
Diagnoses:
[List each diagnosis on a new line] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current Rheumatology Medication:
[List medication, numbered and on a separate line. This may be from context, new medication from conversation, or alteration in dose] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Allergies:
[List from context or add if mentioned in conversation; otherwise do not list this section.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous DMARDs:
[List from context or add if mentioned in conversation; otherwise do not list this section.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Investigations:
[List the investigations, numbered on separate lines if mentioned in the context or clinic discussion, and where possible a short summary of the findings.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Disease activity score:
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit this section entirely.)
For Rheumatoid Arthritis, list:
- Tender joint count
- Swollen joint count
- Patient visual analogue score
- CRP
- Duration of early morning stiffness
For Psoriatic Arthritis, list:
- Tender joint count
- Swollen joint count
- Patient visual analogue score
- Dactylitis
- Enthesitis index scored out of 6
- Axial symptoms
- Skin disease
For Axial Spondyloarthropathy or Ankylosing Spondylitis, list:
- BASDAI
- BASFI
- Spinal pain score
- Peripheral arthritis
- Enthesitis
If any dermatology assessment is mentioned, include details such as PASI and specifically DLQI.
Activity of Daily Living:
[List any activities which are difficult to perform as heard in the conversation. If not heard, omit this section entirely.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Discussion:
[Summarise a detailed review of the discussion in full sentences and paragraphs.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Make a bullet point summary of key points discussed at the end of the paragraph of discussion.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Impression:
[Give an overall impression if mentioned in the conversation; otherwise omit this section.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
GP Actions:
[Specify actions or recommendations for the GP regarding the patient's ongoing care, including monitoring requirements, medication adjustments, or referrals.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a numbered list.)
(Do not routinely include blood monitoring unless specifically mentioned in transcript as a GP action.)
(If a biologic medication is started, include: “GP to please offer influenza vaccination (and yearly thereafter), pneumococcal vaccine (and every five years after), and Shingrix (as patient is immunocompromised).”)
(If methotrexate is started, include: “GP to please add folic acid 5mg once weekly to repeat prescription.”)
(If hydroxychloroquine is started, include: “GP to please add hydroxychloroquine to repeat prescription — there are no monitoring requirements and no shared care agreement necessary.”)
Plan:
[List plan with each new item on a separate line.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(If Raynaud’s is confirmed in the consultation, add the following to the plan at the end:)
Raynaud’s management:
Non-pharmacological management:
- Avoiding inciting environmental factors, such as direct contact with frozen foods or cold drinks.
- Insulation against cold and local warming, including gloves, heavy socks, and hat particularly in winter.
- Avoiding smoking.
Pharmacological options:
- Calcium channel blockers are the class of drugs most widely used for treatment of Raynaud syndrome (e.g. nifedipine, nicardipine). The usual dosage of Nifedipine is 30–60 mg of the extended-release formulation taken once daily. Start with the lowest dose and titrate up as tolerated. If adverse effects occur, decrease the dosage or use another agent such as amlodipine or diltiazem.
- Other medications that may be of help include:
- Topical nitroglycerin (1% or 2%) may be helpful; however, some patients develop headaches and flushing which limits its use.
- Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine or sertraline.
- Losartan.
(For any injections or procedures mentioned in the conversation, list them and use the codes from the list below, but do not add this list to the letter — only include the procedure mentioned with its code.)
Biopsy of lesion of joint W92.1
Joint aspiration (diagnostic or therapeutic) W90.1
Bursa aspiration T62.4
Joint injection (e.g. shoulder, elbow, wrist, hand, hip, knee, ankle, foot) W90.3
Subacromial bursal injection T62.5
Tendon injection (e.g. hand, LHB, wrist, ankle, lateral or medial epicondyle) T74.4
Plantar fascia injection T57.5
Injection of soft tissue T96.7
Intra-muscular depomedrone injection T96.7
Lateral hip injection for trochanteric bursitis T62.5
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care — use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state that it was not mentioned — simply leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points as needed to capture all the relevant information from the transcript.)
