Thank you for your referral of Zoe Adams to our clinic. Zoe Adams has completed all of their provided physiotherapy appointments through the EPC Scheme. • Manual therapy for lower back and neck • Home strength program focusing on core and upper body exercises If you have any questions regarding Zoe Adams's physiotherapy, please do not hesitate to contact me on 0412 345 678. Thank you again for your referral.

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.

I saw Zoe Adams again today on 15th May 2023 accompanied by her mother. As you are aware, Zoe has a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), predominantly inattentive type. Recent assessments indicate a potential comorbid anxiety disorder, which we are monitoring closely. On the whole, I am extremely pleased with Zoe's progress. Her concentration has improved significantly, particularly in school settings. However, some challenges persist in social interactions, possibly related to emerging anxiety symptoms. We discussed implementing cognitive behavioral strategies to address Zoe's anxiety. I've provided her family with resources on relaxation techniques and mindfulness exercises suitable for adolescents. Zoe remains on Methylphenidate 30mg once daily, which has been effective in managing her ADHD symptoms. We're considering adding a low dose of Sertraline to address the anxiety, pending further evaluation. I plan to see Zoe again in 6 weeks to reassess her progress and decide on potential anxiety medication. In the meantime, please monitor for any adverse effects from her current medication regimen. If you have any concerns, please don't hesitate to contact me on 0412 345 678.