Rheumatology — New Patient Consultation Template

Consultation Information

Referring physician: [Name, specialty]
Reason for referral: [Chief complaint]
Date of consultation: [Date]
Urgency: Routine / Urgent

Chief Complaint

[Primary rheumatologic concern]
Duration: [X] days/weeks/months/years
Current status: Improving / Stable / Worsening / Fluctuating

History of Present Illness

Joint Symptoms

Pattern: Monoarticular / Oligoarticular (2-4) / Polyarticular (≥5)
Distribution: Symmetric / Asymmetric
Joints involved: [List specific joints]
Onset: Acute / Gradual / Insidious
Progression: Additive / Migratory / Intermittent
Joint characteristics:

• Pain: [X]/10 average, [X]/10 worst
• Swelling: Yes / No — [Locations]
• Warmth/erythema: Yes / No — [Locations]
• Stiffness:
• Morning stiffness: Yes / No — Duration: [X] minutes/hours
• Gel phenomenon: Yes / No
• Functional limitation: [Specific activities affected]

Pattern timing:

• Better: Morning / Evening / With rest / With activity
• Worse: Morning / Evening / With rest / With activity

Spine involvement:

• Neck pain: Yes / No
• Back pain: Yes / No — [Inflammatory vs mechanical features]
• Inflammatory back pain criteria:

[ ] Age onset <40
[ ] Insidious onset
[ ] Improves with exercise
[ ] No improvement with rest
[ ] Night pain (improves with rising)

Extra-Articular Manifestations

Constitutional:

• Fever: Yes / No — Pattern: [X]
• Fatigue: None / Mild / Moderate / Severe
• Weight loss: No / Yes — [X] lbs over [X] time
• Night sweats: Yes / No

Skin:

• Rash: No / Yes — [Description, distribution, photosensitivity]
• Malar rash: Yes / No
• Discoid lesions: Yes / No
• Psoriasis: Yes / No — [Distribution, severity]
• Raynaud's phenomenon: Yes / No — [Primary vs secondary features]
• Skin thickening: Yes / No — [Distribution]
• Nodules: Yes / No — [Location]
• Nail changes: Yes / No — [Pitting, onycholysis]
• Livedo reticularis: Yes / No
• Purpura: Yes / No

Eyes:

• Dry eyes: Yes / No — [Severity]
• Red eye/uveitis: Yes / No — [Prior episodes]
• Scleritis/episcleritis: Yes / No
• Vision changes: Yes / No

Mouth:

• Dry mouth: Yes / No — [Severity]
• Oral ulcers: Yes / No — [Painful vs painless]

Pulmonary:

• Dyspnea: Yes / No — [Severity]
• Cough: Yes / No — [Character]
• Pleurisy: Yes / No

Cardiac:

• Pericarditis: Yes / No
• Chest pain: Yes / No

Renal:

• Edema: Yes / No
• Foamy urine: Yes / No
• Hematuria: Yes / No
• Known proteinuria: Yes / No

Neurological:

• Numbness/tingling: Yes / No — [Distribution]
• Weakness: Yes / No
• Headaches: Yes / No
• Cognitive changes: Yes / No
• Seizures: Yes / No

GI:

• Dysphagia: Yes / No
• GERD symptoms: Yes / No
• Abdominal pain: Yes / No
• Diarrhea: Yes / No

Infection/Trigger History

Recent infection: No / Yes — [Type, timing]
Tick bite: No / Yes — [When, where]
STI risk factors: [If relevant]
Travel: [Recent, endemic areas]
Trauma: No / Yes — [Timing, relation to symptoms]
New medications: No / Yes — [List]

Rheumatologic History

Prior diagnoses:

• RA: No / Yes — [RF/CCP status, erosions]
• Lupus: No / Yes — [Manifestations]
• Psoriatic arthritis: No / Yes
• Ankylosing spondylitis: No / Yes — [HLA-B27]
• Gout: No / Yes — [Uric acid levels, tophi]
• Pseudogout: No / Yes
• Sjogren's: No / Yes
• Vasculitis: No / Yes — [Type]
• Myositis: No / Yes — [Type]
• Scleroderma: No / Yes — [Limited vs diffuse]
• Fibromyalgia: No / Yes
• OA: No / Yes — [Joints affected]

Prior treatments:

• NSAIDs: [Drugs tried, response]
• Steroids: [Doses, duration, response]
• DMARDs: [Drugs, duration, response, reason stopped]
• Biologics: [Drugs, duration, response, reason stopped]
• Joint injections: [Dates, joints, response]

Past Medical History

[Relevant conditions, especially:]

• Hepatitis B/C: No / Yes — [Status, treatment]
• TB: No / Yes — [Active vs latent, treatment]
• Cancer: No / Yes — [Type, treatment, date]
• Heart disease: No / Yes
• Kidney disease: No / Yes — [Stage]
• Diabetes: No / Yes
• Hypertension: No / Yes
• Osteoporosis: No / Yes
• Infections (recurrent): No / Yes — [Type]

Surgical History

[Relevant surgeries, especially joint surgeries]

Medications

Current medications: [List with doses]
Recent changes: [Additions, discontinuations]
OTC supplements: [Glucosamine, turmeric, etc.]

Allergies

[Drug allergies with reactions, especially to DMARDs, biologics, contrast]

Family History

Rheumatoid arthritis: No / Yes — [Relationship]
Lupus: No / Yes — [Relationship]
Psoriasis/PsA: No / Yes — [Relationship]
Ankylosing spondylitis: No / Yes — [Relationship]
Gout: No / Yes — [Relationship]
Autoimmune disease other: No / Yes — [Type, relationship]
IBD: No / Yes — [Relationship]

Social History

Tobacco: Current / Former / Never — Pack-years: [X]
Alcohol: [Quantity, frequency]
Occupation: [Type, physical demands]
Exercise: [Current ability, limitations]
Living situation: [Home setup, assistance needs]

Review of Systems

[Comprehensive ROS organized by system]
Additional positives: [List]
Additional negatives: [List]

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
RR: [X]
Temp: [X]°F
Weight: [X] — BMI: [X]

General

Appearance: Well / Ill / [Cushingoid features]
Distress: None / [Discomfort level]
Mobility: Independent / Assisted / [Device]

Skin

Rash: None / [Description, distribution]
Psoriatic plaques: None / [Location, severity]
Nodules: None / [Location, size]
Sclerodactyly: Absent / Present
Skin thickening: None / [Distribution, modified Rodnan score]
Telangiectasias: None / [Location]
Calcinosis: Absent / Present
Nail changes: None / [Pitting, onycholysis, etc.]
Raynaud's: Not assessed / [Findings]
Tophi: None / [Location]
Livedo: Absent / Present
Digital ulcers: None / [Location]

HEENT

Eyes: Normal / [Dry, red, injection]

• Schirmer test: [If performed]

Mouth: Moist / Dry

• Dental: [Status]
• Ulcers: None / [Location]
• Salivary glands: Normal / Enlarged

Nose: Normal / [Saddle deformity, septal perforation]

Neck

Lymphadenopathy: None / [Location]
Thyroid: Normal / [Enlarged, nodules]
Cervical ROM: Full / Limited [X]

Cardiovascular

Rhythm: Regular / [Irregular]
Murmurs: None / [Description]
Peripheral pulses: [Assessment]
Edema: None / [Grade, distribution]
Vascular: [Capillary abnormalities if scleroderma]

Pulmonary

Breath sounds: Clear / [Crackles, decreased]
Expansion: Symmetric / Decreased

Abdominal

Soft, non-tender / [Hepatosplenomegaly, tenderness]

Musculoskeletal - Joint Examination

#### Hands

MCPs:

	R1	R2	R3	R4	R5	L1	L2	L3	L4	L5
Swelling
Tender

PIPs:

	R2	R3	R4	R5	L2	L3	L4	L5
Swelling
Tender

DIPs:

	R2	R3	R4	R5	L2	L3	L4	L5
Swelling
Tender

Wrists: R: [Swelling/tenderness/ROM] L: [Swelling/tenderness/ROM] Thumb CMC: R: [Findings] L: [Findings]

Grip strength: R: [Normal/weak] L: [Normal/weak]
Dactylitis: None / [Digits affected]
Deformities: None / [Swan neck, boutonniere, ulnar drift, Z-thumb]
#### Upper Extremities

Elbows: R: [Swelling/tenderness/nodules/ROM] L: [Findings] Shoulders: R: [Swelling/tenderness/ROM] L: [Findings]

#### Lower Extremities

Hips: R: [ROM, pain with motion] L: [Findings] Knees: R: [Swelling/effusion/tenderness/ROM/stability] L: [Findings] Ankles: R: [Swelling/tenderness/ROM] L: [Findings] MTPs: R: [Squeeze test, individual tenderness] L: [Findings]

#### Feet
Heel tenderness: R: [Achilles/plantar fascia] L: [Findings]
Arch: Normal / [Pes planus]
Dactylitis: None / [Toes affected]
#### Spine
Cervical: ROM [Full/limited], Tenderness [None/present]
Thoracic: Kyphosis [Normal/increased]
Lumbar:

• Schober's test: [X] cm expansion (normal >5 cm)
• Lateral flexion: R [X] cm / L [X] cm
• FABER test: R [Neg/Pos] / L [Neg/Pos]

Sacroiliac: Tenderness: R [None/present] / L [None/present]
Chest expansion: [X] cm (normal >2.5 cm)
Occiput-to-wall: [X] cm

Joint Count Summary

Tender joint count (28 or 68): [X]
Swollen joint count (28 or 66): [X]
DAS28 (if RA): [Score]

Neurological

Strength: [Proximal/distal assessment]
Sensation: Intact / [Deficits]
Reflexes: [Symmetric/asymmetric]

Diagnostic Studies Review

Laboratory

CBC: WBC [X], Hgb [X], Plt [X]
CMP: [Key values]
ESR: [X] mm/hr
CRP: [X] mg/L
Uric acid: [X] mg/dL

Serologies

RF: [Negative / Positive — titer]
Anti-CCP: [Negative / Positive — titer]
ANA: [Negative / Positive — titer, pattern]

• If positive:
• Anti-dsDNA: [Result]
• Anti-Smith: [Result]
• Anti-RNP: [Result]
• Anti-SSA/Ro: [Result]
• Anti-SSB/La: [Result]
• Anti-Scl-70: [Result]
• Anti-centromere: [Result]
• Anti-Jo1: [Result]

HLA-B27: [Negative / Positive]
ANCA: [Negative / Positive — PR3/MPO]
Complement: C3 [X], C4 [X]
Antiphospholipid: [If tested]

Urinalysis

Protein: [Result]
Blood: [Result]
Casts: [Result]

Imaging

X-rays:

• Hands/feet: [Erosions, joint space narrowing, periarticular osteopenia]
• [Other relevant]: [Findings]

MRI: [If performed, findings]
Ultrasound: [If performed, synovitis, erosions, power Doppler]
CT: [If performed]

Other Studies

Joint aspiration: [If performed — cell count, crystals, culture]
EMG/NCS: [If performed]
Echocardiogram: [If performed]
PFTs: [If performed]

Assessment

1) [Primary rheumatologic diagnosis]
Activity: [Active/inactive, DAS28 if applicable]
Severity: [Mild/moderate/severe]
Complications: [Erosions, extra-articular manifestations]
2) [Secondary diagnoses]
Differential diagnosis:

• [Most likely]
• [Alternative 1]
• [Alternative 2]

Plan

Diagnostic Workup

Laboratory:

• [ ] CBC, CMP, LFTs
• [ ] ESR, CRP
• [ ] RF, Anti-CCP
• [ ] ANA with reflex
• [ ] Complement levels
• [ ] Uric acid
• [ ] Urinalysis with microscopy
• [ ] HLA-B27
• [ ] Myositis panel
• [ ] ANCA
• [ ] Other: [Specific]

Pre-treatment screening:

• [ ] Hepatitis B (HBsAg, HBcAb, HBsAb)
• [ ] Hepatitis C antibody
• [ ] TB testing (TST or IGRA)
• [ ] Baseline chest X-ray
• [ ] G6PD (if considering HCQ)
• [ ] TPMT (if considering azathioprine)

Imaging:

• [ ] X-rays [Joints]
• [ ] MRI [Area]
• [ ] Ultrasound [Joints]

Other:

• [ ] Joint aspiration [Joint]
• [ ] Ophthalmology evaluation
• [ ] [Other studies]

Treatment

Acute/Bridge Therapy:

• [ ] NSAIDs: [Drug, dose, duration]
• [ ] Prednisone: [Dose, taper schedule]
• [ ] Joint injection: [Joint, medication]

Disease-Modifying Therapy:

• [ ] Methotrexate: [Dose, route, folic acid]
• [ ] Hydroxychloroquine: [Dose]
• [ ] Sulfasalazine: [Dose]
• [ ] Leflunomide: [Dose]
• [ ] Biologic: [Drug, dose, frequency]
• [ ] JAK inhibitor: [Drug, dose]
• [ ] Other: [Specify]

Adjunctive:

• [ ] Folic acid: 1 mg daily (with MTX)
• [ ] Calcium/Vitamin D: [If on steroids]
• [ ] Osteoporosis prophylaxis: [If prolonged steroids]
• [ ] PCP prophylaxis: [If indicated]

Monitoring Plan

Labs: [Specific tests, frequency]
Imaging: [If needed for disease activity]
Ophthalmology: [If on HCQ — baseline, then per guidelines]

Patient Education

• Diagnosis explanation
• Disease course and prognosis
• Medication instructions, side effects, monitoring
• Joint protection strategies
• When to call (infection signs, severe flare)
• Pregnancy considerations if applicable

Referrals

• [ ] Physical therapy / Occupational therapy
• [ ] Ophthalmology
• [ ] Nephrology
• [ ] Pulmonology
• [ ] Dermatology
• [ ] Orthopedics
• [ ] Pain management

Follow-up

Return: [X] weeks for [Lab review, treatment response]
Sooner if: [Significant worsening, infection signs, medication side effects]

Communication

Discussed with patient: [Topics, questions answered]
Report sent to: [Referring physician, PCP]