Rheumatologist's Note

**Diagnosis**: Rheumatoid Arthritis 1 November 2024 **Clinical Phenotype**: The diagnosis was made based on clinical presentation and serological markers, including elevated rheumatoid factor and anti-CCP antibodies. **Relevant medications**: Current medications include Methotrexate 15mg weekly, Adalimumab 40mg bi-weekly, and Naproxen 500mg as needed for pain. Prior medications included Hydroxychloroquine, which was discontinued due to inefficacy. The patient has a known allergy to Ibuprofen. **Notable comorbidities**: The patient has a history of hypertension and underwent knee arthroscopy in 2022. Since the last appointment, the patient reports increased morning stiffness and joint swelling, particularly in the hands and wrists. The consultation was sought due to worsening joint pain and fatigue. The presenting complaint began six months ago with symmetrical joint pain and morning stiffness lasting over an hour. Previous treatments with NSAIDs provided minimal relief. No interval changes in medical or surgical history were discussed. The patient has not had any recent infections. Vaccination status is up to date. Review of systems: The patient reports fatigue and joint pain. Otherwise negative. Vitals: Blood pressure 130/85 mmHg, heart rate 78 bpm. On examination, the patient appears well. Conjunctiva are clear. Normal salivary pooling. No visible nasal or oral ulcerations. HR 78 bpm, RRR. S1+S2 without murmurs, rubs or gallops. Lung fields are clear without rales or wheeze. There is no alopecia, rash, or Raynaud’s. On musculoskeletal examination, there is tenderness and swelling in the metacarpophalangeal joints bilaterally. **Investigations** Recent blood tests show elevated ESR and CRP levels. X-rays of the hands reveal joint space narrowing and erosions. **Assessment**: The patient has rheumatoid arthritis, and the condition is currently active with increased joint inflammation. The likely diagnosis is confirmed by serological and imaging findings. Investigations planned include a repeat ESR and CRP in four weeks to monitor inflammation levels. Medical treatment planned involves continuing Methotrexate and Adalimumab, with a possible increase in Methotrexate dosage if symptoms persist. The patient is advised to continue Naproxen for pain management. Lifestyle modifications include a recommendation for a balanced diet and regular low-impact exercise. A referral to physical therapy is made for joint protection strategies and mobility enhancement. Follow-up appointments are scheduled in six weeks to assess treatment response and adjust the management plan. Patient education on rheumatoid arthritis was provided, emphasizing the importance of medication adherence and monitoring for joint swelling and pain levels. **Plan** - Continue current medications - Monitor ESR and CRP levels - Referral to physical therapy - Follow-up in six weeks **Procedure** No joint injection performed at this visit. **Follow up**: Follow-up scheduled in six weeks. Thank you for this referral. If you have any questions or concerns, please do not hesitate to contact me.