Rheumatology Clinic Follow-Up

I saw [Patient Initial or Name] in follow-up for [primary rheumatologic condition]. Past Medical History: 1. [List all relevant past medical conditions, including the primary rheumatologic diagnosis and any other chronic conditions. Include conditions common in South African clinical settings such as HIV, TB, diabetes, hypertension, or gout where relevant.] (If information for this section is provided in text in the contextual notes, copy in verbatim and only update if stated in the transcript and notes.) Disease History: [Summarize the history of the patient’s rheumatologic condition(s). Include diagnosis date, any relevant serology, flare history, impact of previous infections (e.g. post-TB arthritis), and any overlap with HIV-related immune reconstitution or comorbid autoimmune disease.] (If information for this section is provided in text in the contextual notes, copy in verbatim and only update if stated in the transcript and notes.) Serology: [State relevant serology results including ANA, RF, anti-CCP, ENA, HLA-B27, or other autoimmune markers used locally. Include results from state or private labs as provided.] (If information for this section is provided in text in the contextual notes, copy in verbatim and only update if stated in the transcript and notes.) DMARDs & Biologics History: [List current and previously trialed disease-modifying anti-rheumatic drugs (DMARDs) and biologics. Include drugs accessible via state hospital formularies or private sector (e.g. methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, or adalimumab). Document response and side effects if applicable.] (If information for this section is provided in text in the contextual notes, copy in verbatim and only update if stated in the transcript and notes.) Medications: [List all current medications including DMARDs, corticosteroids, pain medications (e.g. paracetamol, tramadol), supplements (e.g. folic acid), and any traditional or over-the-counter therapies mentioned by the patient.] (If information for this section is provided in text in the contextual notes, copy in verbatim and only update if stated in the transcript and notes.) Allergies: [List any known drug allergies such as sulphonamides, penicillin, or NSAIDs. Include "NKDA" if explicitly stated.] (If information for this section is provided in text in the contextual notes, copy in verbatim and only update if stated in the transcript and notes.) Clinical Update: [Describe the patient’s reported symptoms and overall condition since the last visit, including improvement or worsening of joint pain, stiffness, fatigue, and ability to perform ADLs or work.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) Review of Systems: [Summarize relevant systemic symptoms across rheumatologic, cardiac, respiratory, dermatologic, and neurological systems—e.g. rash, chest pain, shortness of breath, numbness.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) Physical Examination: [Summarize findings such as joint swelling, tenderness, restricted movement, deformities, skin changes, rashes, or nailfold changes. Include relevant musculoskeletal observations.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) Investigations: [List completed laboratory and imaging results. Include recent ESR, CRP, creatinine, liver function, X-rays of affected joints, or ultrasound findings. Include the year or month/year if provided.] (If information for this section is provided in text in the contextual notes, copy in verbatim and only update if stated in the transcript and notes.) Impression: [Summarize the current status of the patient’s condition. State whether stable, in flare, worsening, or showing signs of remission. Include any impact from comorbid conditions like HIV or diabetes if relevant.] (If information for this section is provided in text in the contextual notes, copy in verbatim and only update if stated in the transcript and notes.) Plan: 1. [Outline medication continuation, changes, or discontinuation. Include details like "Continue methotrexate 20mg PO weekly" or "Reduce prednisone to 5mg/day."] 2. [Describe any lab monitoring required, e.g. "Repeat FBC, LFTs, and ESR in 4 weeks."] 3. [Provide any additional screening or monitoring instructions, e.g. "Refer for DXA if fracture risk identified" or "Eye screening for hydroxychloroquine use."] 4. [Address any symptom management strategies, such as referral to physiotherapy or advice on joint protection.] 5. [State follow-up instructions, e.g. "Review in rheumatology clinic in 3 months or sooner if flare."] (If information for this section is provided in text in the contextual notes, copy in verbatim and only update if stated in the transcript and notes.) Thank you for involving me in this patient's care. If you have any questions or concerns, please do not hesitate to contact me. (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 to include 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 the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)