Rheumatology General Consult

Dear Dr. Carter,

RE: Consultation Letter - Harper

Thank you for referring Harper to our rheumatology clinic. I had the opportunity to evaluate her in my office on January 14, 2026.

Harper presented to the clinic with ongoing joint pain and swelling for follow-up of her rheumatoid arthritis and osteoarthritis. She reports persistent arthralgia predominantly affecting her hips, knees, and hands, with chronic paresthesia in her hands for at least two years. Her leg pain, particularly in the hip and knee regions, has slightly improved, while her hand pain and swelling, especially in the right hand, remain significant. She experiences morning stiffness in her hands lasting approximately thirty minutes, and pain in her hands can awaken her from sleep. She denies any new medical diagnoses, surgeries, or changes to her medication regimen in the past few months.

The review of systems is largely negative with no symptoms suggestive of systemic involvement. No constitutional symptoms such as fever, fatigue or weight loss. No recent infections, skin rashes, eye problems or gastrointestinal complaints were present.

In terms of past medical history, Harper has a known diagnosis of rheumatoid arthritis and osteoarthritis. She is currently taking hydroxychloroquine 300 mg daily and Celecoxib once daily for pain management. Family history reveals her brother has arthritis and is on methotrexate therapy.

On objective evaluation, Harper was well appearing. Her blood pressure was elevated at 160s/80s and heart rate was 84 beats per minute. The physical examination revealed swelling and tenderness in the right second and third MCP and PIP joints, reduced flexion and extension in the right wrist, minimal swelling in the left hand, and tightness in the left hip during internal rotation. Both wrists exhibited reduced range of motion, and cervical range of motion was slightly reduced. No rashes or nail changes were observed. No gross neurological deficits were noted, though chronic paresthesia was reported in the left hand. Recent blood tests were normal.

Based on the clinical evaluation, I have initiated methotrexate 15 mg weekly (six tablets once a week) and prescribed folic acid 5 mg daily in addition to her current regimen. Blood tests are scheduled in one month to monitor for potential side effects of methotrexate, including liver function. Nerve conduction studies for the left hand are recommended to evaluate for carpal tunnel syndrome, with consideration of surgical intervention if symptoms persist or worsen. My working diagnosis is active rheumatoid arthritis of the hands with possible carpal tunnel syndrome, and osteoarthritis affecting other joints.

I am planning a follow-up visit for Harper in my clinic in one month to assess her response to the initiated treatment plan and discuss further management.

Thank you again for referring Harper to our practice. Moving forward, I will keep you updated regarding the progress and management of her.

Sincerely,

Alex Kim Rheumatology