Documenting a rheumatology clinic
Clinic notes with joint counts and disease activity scores, DMARD changes, and letters to the GP with the monitoring schedule.
A rheumatoid review where treatment steps up
Seropositive RA, diagnosed eighteen months ago. Methotrexate 20 mg weekly with folic acid for twelve months.
Six swollen, eight tender, both wrists and MCPs. Morning stiffness ninety minutes. CRP 18, ESR 32, DAS28-CRP 4.6.
Methotrexate bloods fine, ALT 28.
Add hydroxychloroquine 400 daily, she's 82 kilos, and sulfasalazine 500 daily building to 1 g BD over four weeks.
Baseline eye check for the hydroxychloroquine. Review in three months. If she's still active after three months of combination therapy, I'll do the joint count and ESR and CRP at that visit for a PBS biologic application.
Diagnosis
Seropositive rheumatoid arthritis, 18 months. Methotrexate 20 mg weekly + folic acid, 12 months.
Disease activity
SJC 6, TJC 8 (wrists, MCPs). EMS 90 min. CRP 18, ESR 32. DAS28-CRP 4.6.
Monitoring
FBC, EUC, LFT satisfactory. ALT 28.
Changes
- Hydroxychloroquine 400 mg daily (82 kg)
- Sulfasalazine 500 mg daily, titrate to 1 g BD over 4 weeks
- Methotrexate 20 mg weekly continues
Plan
- Baseline ophthalmology review
- Review in 3 months
- If active after 3 months of combination therapy: joint count, ESR and CRP for PBS bDMARD application
The letter to the GP
Dr Peter LindqvistHarbour Street Medical
RE: Chen, Grace (DOB 09/11/1976) · Synthetic patient
Dear Dr Lindqvist,
I reviewed Mrs Chen today. Her rheumatoid arthritis remains active on methotrexate 20 mg weekly, with 6 swollen and 8 tender joints and a DAS28-CRP of 4.6.
I have added hydroxychloroquine 400 mg daily and sulfasalazine, starting at 500 mg daily and increasing by 500 mg each week to 1 g twice daily. She will have a baseline eye examination for the hydroxychloroquine.
Please arrange FBC, EUC and LFTs every 2 weeks for the first 3 months of sulfasalazine, then every 3 months with her methotrexate bloods. Please let me know if neutrophils fall below 2.0 or ALT rises above twice the upper limit.
I will see her in 3 months. If her disease is still active after 3 months of combination therapy, I will record the joint count, ESR and CRP at that visit for a PBS biologic application.
Kind regards,Consultant rheumatologist
