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APPOINTMENT BRIEF

Patient: Sarah M.  |  Specialty: Rheumatology  |  Date: March 15 2026

Generated by Notem from 94 patient-logged entries between December 12 2025 and March 15 2026

Chief Complaint

Patient presents with a 14-month history of bilateral joint pain, persistent fatigue and cognitive difficulties that have progressively worsened despite rest and anti-inflammatory medication. Symptoms are affecting occupational function and daily activities. Average logged severity over the last 90 days is 6.4 out of 10.

Symptom History

Joint pain

Logged 47 times across 14 months. Bilateral involvement of wrists, knees and ankles. Severity highest in the morning (average 7.8/10 before noon vs 5.2/10 in the afternoon). Worsens following cold weather and high physical activity. Has not responded to ibuprofen 400mg in 31% of episodes.

Fatigue

Logged 52 times. Described as unrefreshing and disproportionate to activity level. Present on 73% of tracked days. Significantly elevated on days following less than 6 hours of sleep (7.4/10 vs 4.8/10 with adequate sleep).

Brain fog

Logged 31 times. Co-occurs with fatigue in 84% of entries. Average severity 5.4/10.

Morning stiffness

Logged 28 times. Average duration 45-90 minutes. Increasing in frequency (4 instances in December vs 11 in March).

Current Medications

  • Ibuprofen 400mg as needed - started October 2025 - patient rates relief 4/10
  • Vitamin D 2000 IU daily - patient rates 6/10
  • Magnesium glycinate 400mg nightly

Key Questions for Doctor

  1. Does the bilateral symmetric joint involvement with morning stiffness suggest an inflammatory arthropathy?
  2. Should dysautonomia or hypermobile EDS be considered alongside inflammatory causes?
  3. Is the decline in daily steps (7,800 to 4,200 over 4 months) clinically significant?
  4. The new palpitations and low HRV - should these be evaluated independently?

Symptoms Previously Not Addressed

  • Fatigue: attributed to work stress at GP visit January 2026, no testing ordered
  • Brain fog: not raised at any prior appointment

NOTE: This document was generated by Notem from 94 patient-logged entries. All observations are based solely on patient-reported data. This is not a medical assessment.

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