Date:
Patient:
Reason for Visit:
Follow-up for rheumatoid arthritis (RA)
Assessment of disease activity and joint pain
Evaluation for response to treatment
Management plan discussion
History:
Presenting Illness:
Date of initial RA diagnosis
Current symptoms (joint pain, stiffness, swelling, fatigue)
Functional limitations due to RA
Past Medical History (PMH):
Underlying medical conditions (e.g., osteoporosis, Sjögren’s syndrome)
Prior medications used for RA treatment
Social History:
Smoking history (risk factor)
Physical Exam:
General: Assess for signs of fatigue, weight loss, and joint tenderness.
Musculoskeletal:
Evaluate for joint tenderness, swelling, redness, warmth, and symmetry of joint involvement.
Assess range of motion in affected joints.
Document specific joint involvement (e.g., small joints of hands and feet, knees, wrists).
Functional assessment: Evaluate ability to perform daily activities (dressing, bathing)
Diagnostic Tests (may be ordered depending on clinical presentation):
Laboratory Tests:
Acute phase reactants: Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) suggestive of inflammation.
Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA): While not diagnostic, these antibodies can be positive in RA and support the diagnosis.
Complete blood count (CBC): May reveal anemia if chronic inflammation is present.
Imaging Studies (may be used depending on clinical presentation):
X-rays of affected joints: May show joint erosions (damage) in later stages of RA.
Ultrasound: Can detect early synovitis (inflammation of the joint lining) and monitor disease activity.
MRI (less commonly used): May provide detailed information about joint inflammation and damage.
Assessment:
Disease activity: Based on joint symptoms, physical exam findings, and inflammatory markers (ESR, CRP).
Consider using disease activity scores (DAS) to quantify disease activity.
Functional status: Evaluate the impact of RA on daily activities.
Response to treatment: Assess if current medications are effectively controlling symptoms and disease activity.
Radiographic progression: Review X-rays for evidence of joint damage.
Plan:
Medication management:
Consider adjusting medications or adding new ones based on disease activity and response to treatment.
Disease-modifying antirheumatic drugs (DMARDs) are the mainstay of treatment, often combined with other medications like corticosteroids or biologics.
Physical and occupational therapy: To improve joint function, strength, and pain management.
Patient education: Provide information about RA, disease course, treatment options, and self-management strategies.
Discuss the importance of medication adherence, healthy lifestyle practices (exercise, weight management), and proper joint protection techniques.
Pain management: Medications (analgesics) and non-pharmacological approaches (heat, cold therapy) to manage pain and improve function.
Referral to a rheumatologist: May be recommended for patients with complex disease, significant functional limitations, or requiring advanced treatment options.
Follow-up:
Schedule for follow-up appointments based on disease activity:
More frequent visits for patients with high disease activity or requiring medication adjustments.
Less frequent visits for patients with well-controlled disease.
Monitor inflammatory markers and disease activity scores to track response to treatment.
Repeat imaging studies (X-rays or ultrasound) at defined intervals to monitor for joint damage progression.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of rheumatoid arthritis