Rheumatology - Follow up

Sarah Davies, 45, Female. Reason for visit: Follow-up for rheumatoid arthritis. ---OVERVIEW--- Date of initial visit with me: 15 July 2023 Details about medical history adapted from Contextual data, highlighting any previous rheumatologic diagnoses, treatments, infections, hospitalizations, outcomes, etc.: - Diagnosed with Rheumatoid Arthritis (RA) in 2022, seropositive (RF and anti-CCP positive). - Initially treated with Methotrexate, tolerated well for 6 months but with incomplete disease control. - History of mild viral gastroenteritis in March 2024, resolved spontaneously. - No hospitalisations related to RA. Relevant clinical phenotype including how diagnosis was made, relevant labs that informed diagnosis: - Diagnosis based on symmetric polyarthritis, morning stiffness >30 minutes, elevated inflammatory markers (ESR, CRP), and positive RF and anti-CCP antibodies. - Imaging (MRI wrists/hands) showed early erosions consistent with RA. ---NOTABLE COMORBIDITIES--- - Hypertension, well-controlled with medication. - Osteoarthritis of the knees, managed with NSAIDs and physical therapy. ---PRIOR PERTINENT MEDICATIONS--- - Methotrexate 15 mg weekly (ceased due to incomplete disease control). ---CURRENT PERTINENT MEDICATIONS--- - Adalimumab 40 mg subcutaneously every other week. - Hydroxychloroquine 200 mg daily. - Prednisone 5 mg daily (tapering dose). - Lisinopril 10 mg daily. - Ibuprofen 400 mg PRN for knee OA. ---INTERVAL HISTORY (INCLUDE TODAY'S DATE)--- 1 November 2024 Last visit: 15 October 2024 - Patient reports overall improvement in RA symptoms since initiating Adalimumab and Hydroxychloroquine. - Morning stiffness reduced from 60 minutes to approximately 20 minutes. - Joint pain significantly decreased, particularly in hands and wrists. - Fatigue has improved but is still present intermittently. - Reports occasional mild knee pain, managed with Ibuprofen. - No new infections, adverse drug reactions, or other rheumatologic flares. ---RELEVANT FAMILY HISTORY--- Mother with rheumatoid arthritis. ---RELEVANT SOCIAL HISTORY--- Non-smoker, occasional alcohol consumption. Works as an accountant. Lives with partner. ==================================================================== ---PHYSICAL EXAMINATION--- - General: NAD, well-appearing. - Vitals: BP 128/78, HR 72, Temp 36.8°C. - Joints: Symmetric, mild swelling and tenderness in bilateral MCPs (2nd and 3rd), however, overall synovitis improved from last visit. No warmth or erythema. Full range of motion in most joints, mild limitation in wrist extension bilaterally. No new deformities. Knees with mild crepitus, no effusions. - Skin: No rashes, nodules, or other skin changes. - Lungs: Clear to auscultation bilaterally. - Heart: Regular rate and rhythm, no murmurs. - Abdomen: Soft, non-tender, no hepatosplenomegaly. ---PERTINENT LABS--- - CBC Older date (01 Aug 2024): WNL Newer date (01 Oct 2024): WNL Newest date (25 Oct 2024): WNL - CMP Older date (01 Aug 2024): Creatinine WNL, LFTs WNL, Albumin WNL, Alk phos WNL Newer date (01 Oct 2024): Creatinine WNL, LFTs WNL, Albumin WNL, Alk phos WNL ---PERTINENT DIAGNOSTICS--- - X-ray hands/wrists (01 May 2024): Stable mild erosions, no significant progression from prior imaging. ---PERTINENT PATHOLOGY--- - Synovial Fluid Analysis (10 Apr 2022): Inflammatory fluid, negative for crystals or infection. Consistent with RA. ============================================================ ---ASSESSMENT AND PLAN--- # RHEUMATOID ARTHRITIS (RA): IMPROVED Relevant clinical phenotype including how diagnosis was made, relevant labs that informed diagnosis: Diagnosis based on symmetric polyarthritis, morning stiffness >30 minutes, elevated inflammatory markers (ESR, CRP), and positive RF and anti-CCP antibodies. Imaging (MRI wrists/hands) showed early erosions consistent with RA. CDAI improved from 18 (moderate disease activity) to \7\ (low disease activity). Assessment, including the likely diagnosis and rationale based on subjective and objective findings: 45-year-old female with seropositive rheumatoid arthritis demonstrating improved disease activity on Adalimumab and Hydroxychloroquine. Patient reports reduced morning stiffness and joint pain. Physical examination confirms decreased synovitis in MCPs. Labs indicate controlled inflammation. Current treatment regimen appears effective in achieving low disease activity. ---PLAN--- - Continue Adalimumab 40 mg subcutaneously every other week. - Continue Hydroxychloroquine 200 mg daily. - Prednisone 5 mg daily: continue tapering as planned, aim for discontinuation over the next 2-4 weeks. - Monitor CRP and ESR in 3 months to assess ongoing disease activity. - Discuss potential long-term risks of biologic therapy at next visit. - Encourage regular low-impact exercise and adherence to Mediterranean diet principles. # HYPERTENSION: CONTROLLED Assessment, including the likely diagnosis and rationale based on subjective and objective findings: Patient's blood pressure remains well-controlled on current Lisinopril therapy, with no associated symptoms. Vitals confirm normotension. ---PLAN--- - Continue Lisinopril 10 mg daily. - Routine BP monitoring at home. # OSTEOARTHRITIS, KNEES: STABLE Assessment, including the likely diagnosis and rationale based on subjective and objective findings: Chronic mild knee pain managed effectively with PRN Ibuprofen, consistent with prior diagnosis of osteoarthritis. No signs of inflammatory arthritis in knees on exam. ---PLAN--- - Continue Ibuprofen 400 mg PRN for knee pain. - Consider referral to physical therapy if symptoms worsen or become more frequent. - Encourage maintenance of healthy weight. IMMUNOSUPPRESSION DUE TO DRUG THERAPY: Adalimumab Monitoring needed: Routine CBC, LFTs, and renal function every 3-6 months. Tuberculosis screening as per guidelines. ---FOLLOW UP--- Follow up scheduled: In 3 months, or sooner if symptoms worsen or new issues arise. ---PATIENT INSTRUCTIONS--- - Your rheumatoid arthritis is showing good improvement with the current medications (Adalimumab and Hydroxychloroquine). - We will continue to slowly reduce your Prednisone dose. - Please continue to take all your medications as prescribed. - Keep an eye out for any new symptoms, particularly fevers, chills, or new infections, and contact the clinic if these occur. - We will recheck your blood tests in three months to monitor your condition and medication safety. - Maintain a healthy lifestyle with regular exercise and a balanced diet. - Your next appointment is scheduled for three months from now.