Thank you for referring this 42-year-old lady, Zoe Adams, who works as a high school teacher. She is a non-smoker and drinks alcohol socially (2-3 glasses of wine per week). Family history significant for rheumatoid arthritis in her mother and osteoarthritis in her father. Summary: Zoe presents with a 6-month history of progressive joint pain and stiffness, primarily affecting her hands, wrists, and knees. Morning stiffness lasts approximately 2 hours. She reports fatigue and occasional low-grade fever. Previous treatment with over-the-counter NSAIDs provided minimal relief. Symptoms have begun to interfere with her daily activities and work performance. Examination reveals bilateral swelling and tenderness of the MCP and PIP joints of both hands. Wrists show reduced range of motion and synovial thickening. Knees demonstrate mild effusion bilaterally. No rheumatoid nodules observed. Cardiovascular and respiratory examinations unremarkable. Investigations: 15/05/2023: Blood tests show elevated inflammatory markers: CRP 28 mg/L, ESR 40 mm/hr. RF positive at 75 IU/mL, anti-CCP antibodies strongly positive at 120 U/mL. CBC reveals mild anemia with Hb 11.2 g/dL. Liver and kidney function tests within normal limits. 22/05/2023: X-rays of hands and wrists demonstrate early erosive changes in MCP joints bilaterally, consistent with early rheumatoid arthritis. Management: Working diagnosis is rheumatoid arthritis based on clinical presentation, positive serology, and radiographic findings. Differential diagnoses include psoriatic arthritis and systemic lupus erythematosus, but less likely given the absence of skin involvement and negative ANA. Initiating treatment with methotrexate 15 mg weekly, folic acid 5 mg daily (except on methotrexate day), and prednisolone 10 mg daily for 4 weeks, tapering by 2.5 mg every 2 weeks. Advised on potential side effects and importance of regular monitoring. Educated patient on RA course and importance of early aggressive treatment. Follow-up in 6 weeks to assess treatment response, monitor for side effects, and consider addition of hydroxychloroquine if inadequate improvement. Will repeat blood tests including CBC, liver function, and inflammatory markers prior to next visit.

Date and Recipient: 15 May 2023 Dr. Jane Doe 123 Medical Street Cityville, NSW 2000 Patient Details and Diagnosis: Re: Zoe Adams (DOB: 15/09/1985) Diagnosis: 1. Type 2 Diabetes Mellitus 2. Hypertension 3. Obesity (BMI 32) 4. History of appendectomy (2010) I reviewed Zoe Adams today for her ongoing management of type 2 diabetes and hypertension. Her blood glucose readings have been consistently within target range (5.0-7.8 mmol/L) over the past month. Blood pressure today was 132/82 mmHg, which is an improvement from her previous visit. Zoe reports no new symptoms or concerns. She denies any episodes of hypoglycemia. Allergy to penicillin noted. I have suggested increasing her daily walking to 45 minutes and maintaining her current medication regimen. I would appreciate if you could arrange for a lipid profile and HbA1c test to be conducted before our next review in three months. Additionally, I recommend a referral to a dietitian for further weight management support. Once again thank you for involving me in this patient's care. Dr. Smith Footer: CC: Dr. Michael Johnson (GP), Dr. Sarah Lee (Endocrinologist) RECALL: 3 months

Zoe Adams reports persistent joint pain and stiffness, particularly in her hands and knees. Morning stiffness lasts approximately 2 hours. Patient notes some improvement with current medication regimen but still experiences fatigue. Physical examination reveals mild synovitis in the metacarpophalangeal joints of both hands and tenderness in the right knee. 15/05/2023: Blood tests show CRP 12 mg/L (elevated), ESR 28 mm/hr (elevated), RF positive, anti-CCP antibodies positive. X-ray of hands reveals early erosive changes in the MCP joints bilaterally. Ultrasound of right knee shows moderate effusion and synovial thickening. Complete blood count, liver function tests, and renal function within normal limits. Continuing methotrexate 15 mg weekly and prednisone 5 mg daily. Increasing hydroxychloroquine to 400 mg daily. Prescribed naproxen 500 mg twice daily for pain management. Referral to physiotherapy for knee exercises. Follow-up appointment scheduled in 8 weeks. Will reassess disease activity and consider biologics if inadequate response to current treatment.