Rheumatology Clinic Letter to GP

Rheumatology Clinic Letter to GP Diagnosis Rheumatoid Arthritis (seropositive, erosive type) Past Medical History Mrs. Eleanor Vance, 58 years old, has a history of well-controlled hypertension diagnosed 10 years ago, managed with Amlodipine 5mg OD. She also had an appendectomy at age 25 with no complications. No other significant past medical history. Family history Her mother had rheumatoid arthritis diagnosed in her late 60s. Her father had type 2 diabetes. No other relevant family history of autoimmune conditions. Medications Amlodipine 5mg OD Methotrexate 15mg weekly (started 3 months ago) Folic Acid 5mg weekly (24 hours after Methotrexate) Plaquenil (hydroxychloroquine) 200mg OD (started 6 months ago) Prednisolone 5mg OD (tapering dose) Assessment Mrs. Vance presented today with ongoing concerns regarding stiffness and pain in her hands and feet, despite the current medication regimen. She reports morning stiffness lasting approximately 2-3 hours, which is a slight improvement from prior to starting methotrexate but still significantly impacts her daily activities. She finds it difficult to grip small objects and experiences pain when walking for extended periods. She denies any new rashes, fevers, or other systemic symptoms. She has been compliant with her medications and reports no significant side effects from methotrexate, aside from mild nausea on the day of administration which is controlled with antiemetics. Social History Mrs. Vance lives with her husband in a detached house. She is retired from a career as a primary school teacher. She enjoys gardening and knitting, but these hobbies are now significantly limited by her symptoms. She is a non-smoker and consumes alcohol socially (approximately 2-3 units per week). She has good social support from her family. On examination General: Alert and cooperative, no acute distress. Hands: Swelling and tenderness noted in the MCP joints of the 2nd and 3rd fingers bilaterally, and PIP joints of the 2nd, 3rd, and 4th fingers bilaterally. Bilateral ulnar deviation of the MCP joints. Limited range of motion due to pain and swelling. Mild synovitis palpated at the wrist joints. Feet: Swelling and tenderness over the MTP joints of the 2nd and 3rd toes bilaterally. Pes planus noted. Mild hallux valgus. Joints: No significant effusions in large joints (knees, shoulders, elbows). Skin: No rashes or nodules. Investigations Recent blood tests (taken 1 week prior): ESR: 45 mm/hr (previous: 68 mm/hr) CRP: 18 mg/L (previous: 32 mg/L) Rheumatoid Factor: 250 IU/mL (positive) Anti-CCP antibodies: >200 U/mL (positive) Liver Function Tests: Within normal limits. Renal Function Tests: Within normal limits. X-rays of hands and feet (taken 3 months ago): Showed early erosions in the 2nd and 3rd MCP joints bilaterally and some joint space narrowing. Impression Mrs. Vance has seropositive, erosive rheumatoid arthritis that is partially controlled with her current DMARDs (Methotrexate and Hydroxychloroquine). Despite some improvement in inflammatory markers, she continues to experience significant functional impairment and active synovitis, indicating a need for escalation of treatment. Plan 1. Increase Methotrexate to 20mg weekly, closely monitor for side effects and provide appropriate antiemetic advice. 2. Discuss initiation of a biological DMARD (e.g., Adalimumab) at the next appointment if current escalation of methotrexate is insufficient or poorly tolerated. Provide patient with information leaflets regarding biological therapies. 3. Refer to occupational therapy for assessment of adaptive aids and joint protection strategies. 4. Refer to physiotherapy for a tailored exercise program focusing on hand and foot strengthening and mobility. 5. Continue Prednisolone 5mg OD for another 2 weeks, then attempt a gradual taper by 1mg every 2 weeks, guided by symptoms. 6. Schedule follow-up appointment in 6-8 weeks to assess response to increased Methotrexate and discuss biological options. Outcome Follow-up appointment booked for 1 November 2024 at 10:30 AM in the Rheumatology Clinic.