Rheumatology New Patient Consultation Note

Date: [Date of encounter]

Location: [Clinic location / facility]

Clinician: [Clinician name, credentials]

Visit Type: Rheumatology – New Patient Consultation

Referral Source: [Referring clinician, organization]

Referral Question: [Specific question or condition to evaluate]

Primary Historian: [Historian(s) and reliability statement]

Allergies: [Drug allergies and reaction types, or "NKDA"]

Chief Complaint

[Primary reason for consultation] (One line; include brief clarifying patient quote if helpful.)

Outside Records Reviewed

(List sources with date ranges. If none available, state: "No outside records available at time of visit.")

• [Source, record type, date range]
• [Source, record type, date range]

Synthesis:

• [Key trends or patterns relevant to today's decisions]
• [Discordance between reported and documented findings, if present]
• [Prior treatments, response, and tolerability]
• [Pertinent prior diagnoses with supporting data]
• [Other high-yield findings]

Gaps: [Missing records and plan to obtain] (Omit line if not applicable.)

History of Present Illness

[Narrative HPI] (Include: onset and evolution with first symptom date or best estimate; anatomic pattern with joints/regions and symmetry; inflammatory features including morning stiffness duration, nocturnal pain, swelling, response to NSAIDs/steroids; associated systemic symptoms if relevant; functional impact on ADLs, work, sleep; prior evaluation and treatments with response and adverse effects; contextual triggers or exposures. Add targeted rheumatology features per referral question: prior autoimmune diagnoses and serologies; thrombosis/pregnancy history if APS suspected; sicca symptoms for Sjögren's; Raynaud's pattern for scleroderma spectrum; proximal weakness for myositis; psoriasis/IBD for spondyloarthritis.)

Autoimmune Review of Systems

(Include positives and discriminating negatives only. Omit domains not assessed or not relevant.)

• Constitutional: [Fever, weight change, fatigue]
• Eyes: [Redness, dryness, vision changes]
• Oral/ENT: [Dry mouth, ulcers, salivary swelling]
• Skin/Hair/Nails: [Photosensitivity, rash, psoriasis, nail changes, alopecia, digital ulcers]
• Vascular: [Raynaud's characteristics and triggers]
• Cardiopulmonary: [Pleuritic pain, dyspnea, cough]
• GI: [Dysphagia, abdominal pain, IBD features]
• Renal: [Foamy urine, hematuria, edema]
• Neurologic: [Headaches, neuropathy symptoms]
• MSK: [Joint swelling, enthesitis, dactylitis, inflammatory back pain]
• Hematologic/OB: [Cytopenias, miscarriages, thrombosis]

Past Medical & Surgical History

• [Prior rheumatologic or autoimmune diagnoses]
• [Malignancy history and treatment status]
• [Chronic infections: HBV, HCV, HIV, TB]
• [Hepatic or renal disease]
• [History of recurrent or serious infections]
• [Relevant surgeries]

Medications

Current medications:

• [Medication – dose, route, frequency; adherence notes if relevant]

Prior anti-inflammatory and immunomodulatory therapy:

• [Agent – dates – response – adverse effects – reason stopped]

Family History

• [Inflammatory arthritis or connective tissue disease]
• [Psoriasis or IBD]
• [Gout]
• [Thrombosis or pregnancy losses]
• [Other autoimmune conditions]

Social History

• [Occupation; functional/disability status]
• [Tobacco and alcohol use with treatment implications]
• [Relevant exposures: travel, ticks, TB risk factors]
• [Reproductive considerations if relevant to treatment planning]

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO2, weight]

General: [Appearance, level of distress]

Skin: [Lesion morphology and distribution; psoriasis locations; nail findings; scleroderma-spectrum signs if relevant]

Musculoskeletal: [Focused / Comprehensive] joint exam performed. [Tender and swollen joints by region; warmth, effusion; ROM limitations; deformities; synovitis vs bony enlargement; grip strength; gait. Include axial exam, enthesitis sites, and dactylitis assessment if spondyloarthritis suspected.]

Neurologic: [Strength, sensation, reflexes; proximal muscle strength if myositis suspected]

Other systems: [Eyes/ENT, cardiopulmonary, extremities/vascular findings as indicated]

(State explicitly if any portion was limited or not performed.)

Results Reviewed Today

• [Key laboratory data with dates – highlight abnormal and discriminating normal results]
• [Imaging findings]
• [Pathology if applicable]
• [Disease activity measures if obtained]

Assessment

[Summary statement: patient demographics, key comorbidities, core symptom pattern and duration, salient exam findings, most discriminating labs/imaging, and the referral question]

[Problem 1: Diagnosis or symptom-based label]

• Evidence for: [Supporting features]
• Evidence against: [Contradictory findings or alternative explanations]
• Differential: [Ranked realistic options; note "can't miss" entities]
• Uncertainty: [What is missing to confirm/exclude diagnosis]

(If autoantibodies present without supportive clinical features, explicitly state insufficient evidence for diagnosis.)

[Problem 2: Diagnosis or symptom-based label]

• Evidence for: [Supporting features]
• Evidence against: [Contradictory findings]
• Differential: [Ranked options]
• Uncertainty: [Missing information]

Plan

(Organize by problem: severity/urgency first, then patient priorities, then preventive/safety items.)

[Problem 1]: Plan

• Diagnostic: [Tests to order; how results will change management; plan for missing data]
• Therapeutic: [Nonpharmacologic measures; medication changes with doses and taper strategies]
• Monitoring: [Lab schedule tied to therapies; infection risk counseling if immunosuppression]
• Coordination: [Communication with referring clinician; co-management needs]
• Return precautions: [Red-flag symptoms warranting earlier contact]

[Problem 2]: Plan

• Diagnostic: [Tests and rationale]
• Therapeutic: [Treatment plan]
• Monitoring: [Monitoring plan]
• Coordination: [Care coordination]
• Return precautions: [Warning signs]

Immunosuppression pre-treatment checklist (Include if initiating or considering immunosuppressive therapy):

• Vaccinations: [Status; plan for indicated vaccines and timing relative to therapy]
• Infection screening: [TB, hepatitis B/C, HIV as indicated; results or tests ordered]
• Baseline labs: [Required for chosen therapy]
• Reproductive health: [Pregnancy intention; contraception; teratogenic risk counseling]
• Bone health: [Calcium/vitamin D; bisphosphonate consideration; DEXA status] (If glucocorticoids planned.)

Follow-up

Follow-up interval: [Timeframe and modality]

Pending results: [What is pending; communication plan for results]

Referrals placed: [Specialty, reason, urgency]

Consult report: [Sent to / will be sent to] referring clinician.

(Omit sections not relevant or not performed. For high-impact missing information affecting safety—pregnancy status before teratogenic therapy, infection screening before biologics, uncertain medication history—insert explicit placeholder indicating unknown/pending status and plan to obtain. Maintain source attribution for information from outside records or non-patient historians.)