Rheumatology Consultation

Rheumatologist Subjective: The patient, Ms. Zola Mkhize, a 45-year-old female, presents for consultation due to chronic, worsening pain and swelling in her hands and knees, active for the past six months. She reports significant morning stiffness lasting over an hour, which improves slightly with movement but never fully resolves. She is concerned about her ability to continue her work as a domestic worker. Ms. Mkhize's current rheumatologic concerns include bilateral hand and knee joint swelling, chronic widespread pain, and fatigue. She initially noticed a dull ache in her right index finger, which progressively worsened and spread to both hands and knees. The pain is described as a throbbing sensation, rated 7/10 at its worst, interfering with daily activities such as gripping and walking. She also reports difficulty climbing stairs and standing for prolonged periods. The swelling is visible and palpable, particularly in the MCP and PIP joints of both hands, and the suprapatellar regions of both knees. Over the past six months, the pain and swelling have followed a fluctuating pattern, with periods of increased severity followed by mild improvement, but never full remission. The onset was insidious. She has tried over-the-counter paracetamol and ibuprofen with minimal, transient relief. She denies any specific triggers for flare-ups but notes that cold weather seems to exacerbate her symptoms. She reports generalised fatigue, but denies fever, night sweats, or significant weight loss. There are no associated skin rashes, oral ulcers, photosensitivity, or hair loss. She reports some difficulty sleeping due to pain. Past Medical History: Diagnosed with well-controlled hypertension 5 years ago. No prior surgeries. No history of TB arthritis, HIV, or gout. Current Medications: Amlodipine 5mg daily for hypertension. She also mentions using "Moringa leaf powder" daily for general well-being, which she believes helps with joint pain, though she has not noticed significant improvement in her current symptoms. Social History: Ms. Mkhize is a domestic worker, which involves prolonged standing, kneeling, and manual tasks. She denies tobacco use and consumes alcohol occasionally (socially, 1-2 units per week). She lives with her husband and two children in a peri-urban area and has good access to public transport to reach the clinic. Her mother had severe arthritis in her later years, although the specific diagnosis is unknown. Known Allergies: Penicillin (rash). ROS: "A complete 12-point review of systems, including a comprehensive rheumatologic ROS, was performed and is negative except as noted in the HPI." Objective: - Vital signs: BP 130/80 mmHg, HR 78 bpm, Temp 36.8°C, SpO₂ 98% on room air. - Musculoskeletal findings: Bilateral symmetrical swelling and tenderness noted in MCP (2nd and 3rd) and PIP (2nd and 3rd) joints of both hands. Moderate effusions present in both knees, with mild warmth but no overt erythema. Range of motion is limited in both hands (grip strength reduced) and knees (flexion to 90 degrees only) due to pain and swelling. No significant crepitus in hands, but crepitus noted in both knees with movement. No significant deformities currently, but early ulnar deviation noted in left hand. - Inflammatory findings: Synovitis noted on the MCPs, PIPs and Ankles. No synovitis noted on the MTPs or Wrists. - Oral or facial findings: No Oral Ulcers, Malar Rash, Discoid Rash. - Lymph node examination: No Cervical or Supraclavicular lymphadenopathy. - Dermatologic findings: No rashes, nodules, tophi or purpura. - Cardiovascular findings: Regular heart sounds, no murmurs or bruits. - Pulmonary findings: CTA BL No Wheezing, Rales, Rhonchi. Investigations: Completed Investigations: None yet. Patient is a new referral. Assessment & Plan: - Rheumatoid Arthritis (suspected) - Assessment and likely diagnosis: Chronic polyarthritis with morning stiffness and symmetrical joint involvement, highly suspicious for Rheumatoid Arthritis. Patient's age, gender, and presentation are consistent with RA. The chronicity and inflammatory nature of symptoms (morning stiffness, symmetrical swelling) strongly support this diagnosis. - Differential diagnosis: Seronegative spondyloarthropathy (less likely given symmetrical peripheral joint involvement without axial symptoms), osteoarthritis (less likely given inflammatory markers and morning stiffness duration), crystal arthropathy (less likely given polyarticular presentation and absence of specific acute flares). - Investigations planned for diagnosis or monitoring: ESR, CRP, Rheumatoid Factor (RF), Anti-CCP antibodies, ANA, full blood count (FBC), renal and liver function tests. Plain radiographs of hands and knees to assess for erosions and joint space narrowing. These will be requested from the public hospital laboratory. - Planned medical treatment: Initiate Methotrexate (MTX) 10mg weekly, increasing to 15mg weekly after 4 weeks, pending laboratory results and tolerability. Prescribe Folic Acid 5mg weekly (day after MTX). Prescribe Prednisone 10mg daily for 2 weeks, then taper to 5mg daily for 2 weeks for symptom control while MTX takes effect. Provide paracetamol 1g PRN for pain. - Recommended lifestyle modifications: Encourage gentle range-of-motion exercises within pain limits. Advise regular, low-impact exercise such as swimming or walking. Education on joint protection techniques. Discuss diet for overall health, no specific restrictions currently indicated for RA. - Referrals: Referral to occupational therapy for assessment of hand function and adaptive equipment. Referral to physiotherapy for a guided exercise program for knee pain and stiffness. - Follow-up plan: Review in 4 weeks with all investigation results. Blood monitoring (FBC, LFT, RFT) every 2 weeks for the first 3 months of MTX treatment, then monthly for 3 months, then quarterly. Goals include reduction in pain, morning stiffness, and joint swelling, with improved functional ability. - Referrals to other specialties: None currently indicated. Additional Notes: - Patient education: Explained suspected diagnosis of Rheumatoid Arthritis, its chronic nature, and the importance of early and consistent treatment to prevent joint damage and preserve function. Discussed the mechanism of action, potential side effects (nausea, fatigue, mouth ulcers) of Methotrexate, and the necessity of Folic Acid. Emphasized the slow onset of action for MTX and the role of Prednisone for initial symptom relief. Provided written information on RA and medication instructions. - Instructions given for symptom monitoring: Advised patient to monitor for increased joint swelling, persistent pain flares, or new symptoms. Instructed to report any severe abdominal pain, persistent nausea/vomiting, fever, or signs of infection immediately (as these could be side effects of MTX). Advised to avoid alcohol while on MTX and to use contraception. - Any concerns raised by the patient or family: Ms. Mkhize expressed concerns about the cost of medication if not available at the state hospital pharmacy and the frequency of clinic appointments conflicting with her work schedule. Reassured her that efforts would be made to ensure medication access through the public sector and that follow-up appointments would be scheduled strategically to minimise disruption to her employment. Discussed the possibility of providing a letter for her employer regarding necessary medical appointments.