Rheumatology Review Letter

Dear Dr Sarah Jenkins

Re: Chloe Mitchell

Rheumatology Diagnosis

Oligoarticular Juvenile Idiopathic Arthritis (JIA), ANA positive, diagnosed 14/11/2023 (affecting right knee and left ankle).

Rheumatology Medications

• methotrexate 10 mg SC once weekly (administered Fridays)
• folic acid 5 mg PO once weekly (administered Mondays)
• naproxen (Naprosyn®) 150 mg PO BID PRN for joint pain

Impression And Management

1. Oligoarticular JIA currently in clinical remission on subcutaneous methotrexate.
2. Continue methotrexate 10 mg SC weekly and folic acid 5 mg PO weekly.
3. Repeat FBC, UEC, LFT, ESR, and CRP in 3 months prior to the next clinic review.
4. Routine 6-monthly ophthalmology screening due next month to monitor for JIA-associated uveitis.

Additional Notes

• Reinforced education regarding the autoimmune nature of oligoarticular JIA, the risk of asymptomatic anterior uveitis, and the necessity of strict adherence to DMARD therapy to prevent joint damage.
• Advised parents to monitor for recurrent morning stiffness, joint effusion, limping, or intercurrent febrile illnesses requiring temporary withholding of methotrexate.
• Addressed maternal concerns regarding mild post-injection nausea; advised administering methotrexate on Friday evenings and trialling ondansetron 4 mg PO PRN if nausea persists.

Follow-up Arrangements

Review in the Paediatric Rheumatology clinic in 3 months with repeat blood tests completed 1 week prior.

Progress

It was a pleasure to review Chloe Mitchell today. Since her last review three months ago, Chloe has remained clinically well with no recurrence of joint pain, swelling, or morning stiffness. She participates fully in school physical education and dance classes without limitation. Her mother reports good adherence to weekly subcutaneous methotrexate, noting only mild, transient nausea on Saturday mornings without vomiting. She has not required any breakthrough naproxen over the past eight weeks, and there have been no intercurrent infections or ocular symptoms.

Examination

Wt 24.5 kg, Ht 122 cm, BP 98/62 mmHg, HR 84 bpm, Temp 36.6 °C. Musculoskeletal examination (pGALS) was unremarkable. Specifically, the right knee and left ankle were quiet with no warmth, effusion, or synovial thickening, and both joints demonstrated a full, painless range of motion. No leg length discrepancy, muscle wasting, or enthesitis noted. Cardiorespiratory and abdominal examinations were NAD.

Investigations

• Pathology (10/05/2024): Hb 126 g/L, WCC 6.8 x 10^9/L, Plt 290 x 10^9/L, Neut 3.5 x 10^9/L, Cr 42 µmol/L, ALT 18 U/L, AST 22 U/L, ESR 6 mm/hr, CRP < 1 mg/L.
• Ophthalmology review (12/12/2023): Slit-lamp examination normal bilaterally; no evidence of anterior chamber cells or flare.

The plan remains as outlined above, and I will review Chloe Mitchell in 3 months. Please contact me if any concerns arise before then.

Kind regards Dr David Vance