SYNTHETIC RECORD - Example Lakeshore Rheumatology - Consultation Note - 2026-03-05
Patient reference SYN-7724. This 29-year-old woman was seen for evaluation of symmetric hand and foot pain present for over a year.
Her rheumatoid factor and anti-CCP were both strongly positive, and her exam showed synovitis at the wrists, MCPs and MTPs consistent with seropositive rheumatoid arthritis, a diagnosis established at this visit. She reports having completed a course of oral methotrexate, 15 mg weekly, from 2025-10-06 to 2026-03-02, discontinued because her joint swelling did not improve, an inadequate response.
She is being sent back to her primary care physician for ongoing management while awaiting further specialty follow-up. She has no other chronic medical conditions.
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SYNTHETIC RECORD - Example Willowbrook Family Medicine - Office Visit - 2026-04-10
Patient reference SYN-7724. This 29-year-old woman returns to discuss her rheumatoid arthritis and ongoing hand and foot swelling.
She has not previously taken methotrexate; oral methotrexate 15 mg weekly is being started today given the extent of her joint involvement. She will follow up with rheumatology to monitor for a response and to discuss Immunara if the trial does not control her disease. She works as a hair stylist and describes difficulty holding scissors for long periods.