59 year old female

This is a case of a 59 year old professor who is a resident of West Bengal.

CHIEF COMPLAINT:
Case of  Rheumatoid arthritis under medication.

 HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic an year and half ago. 
Then she felt pain in her left wrist joint which was insidious in onset and gradually progressive in nature.
It slowly progressed to the hands and shoulder on both the sides with an increased intensity causing difficulty in daily activities and sleep.
She used painkillers which provided relief for sometime. 
She underwent a physiotherapy for a month.
She also took steroid injections twice in a local hospital in West Bengal but the pain reappeared later.
There is no history of swellings, morning stiffness, malaise, musculoskeletal pain, weight loss,fever or rash.
On February 2022, she went to a specialist in Hyderabad, who suggested her some medications but there was no improvement.
Later she went to an OPD in Nalgonda and she got relieved from pain within 10 days following the prescribed medications.
Presently there is no complaints of pain and she has been taking her medication regularly.

PAST HISTORY:
 History of fall on an outstretched left hand for which she underwent surgery in West Bengal 5 years ago.
Not a known case of diabetes mellitus, hypertension, tuberculosis, epilepsy or any other chronic illness.

PERSONAL HISTORY:
 Married, 1 son
Diet :mixed (consumes fish and meat)
Appetite: normal 
Sleep: adequate 
Bowel and bladder: normal
Addiction : no
Allergy: Allergic to egg in the past. Now since a year consumes 2 eggs per day
Hobbies: listening to songs and touring 

Daily routine

Gets up at early at 6:30am. 
Then takes light breakfast at 7:30 am after freshing up. 
Before heading to the university consumes roti and vegetables around 9:30 am.
Reaches the university by 10 am and returns by evening 5:30-6 pm.
 Her diet mostly includes roti and vegetables. 
After December 2021, she continued to follow her daily routine inspite of having intense pain in the hands which slowly progressed to her shoulders. 
She faced difficulties in daily activities like bathing and doing household work. She even faced difficulty in sleeping due to pain.

FAMILY HISTORY:

Not significant 

Clinical images





Investigation. 

16/2/2022

15/10/22


3/5/2023

22/8/23


Treatment. 


Methotrexate tablets 7.5mg
Folic acid tablets
Prednisolone tablets 5mg

Conversational decision support system.(CDSS)

8/20/23, 8:25 PM - Rakesh Sir : @Vagisha Rani Can you add the patient advocate to the group and ask her to not reveal the patient's identity to preserve her confidentiality and ask her to keep logging the patient's daily hourly activities (energy expenditure) along with sharing her food plate images (energy inputs)?
8/20/23, 8:27 PM - Vagisha Rani: Yes sir

8/20/23, 10:25 PM  @Vagisha Rani ! Did we follow eular criteria for the diagnosis?

8/21/23, 8:11 AM - Rakesh Sir : Please share the Euler or any other criteria (static ontology  ) and let's see how her symptomatology and signs were tied to the existing ontology of rheumatoid arthritis (dynamic ontology creation  )
8/21/23, 10:29 AM - Vagisha Rani: Good morning sir
The euler score was 5/10. 
▪️ 1-3 small joints
▪️ abnormal ECR
▪️ duration > 6 weeks
The serology reports were negative.
Hence not fulfilling Eular criteria.
However, investigations dated 16/2/22 suggested:-
▪️ symmetrical pattern of joint involvement 
▪️power doppler study of wrist joints suggested chronic tenosynovitis of bilateral extensor and flexor tendons.
▪️UGS of shoulder: bilateral biceps tendinitis.
8/21/23, 10:29 AM - Vagisha Rani: IMG-20230820-WA0029.jpg (file attached)
8/24/23, 7:26 PM - Vagisha Rani: IMG-20230823-WA0002.jpg (file attached)
8/24/23, 7:26 PM - Vagisha Rani: IMG-20230823-WA0003.jpg (file attached)
8/24/23, 7:27 PM - Vagisha Rani: X ray done on 22/08/23
8/18/23, 7:01 PM - Vagisha Rani: http://vagisharani.blogspot.com/2023/08/59-year-old-female.html
8/18/23, 7:01 PM - Vagisha Rani: Good evening sir
Presently the patient does not have any complaints. 
She has conveyed her warm regards to you for her treatment 
She was asking whether she can withdraw the medications or not.
8/18/23, 7:28 PM - Rakesh Sir : Thanks 

Please ask her to share her clinical images of the abdomen and biceps from lateral view and the image of her hands bilateral together and her X-ray hands bilateral ap view images asap
8/18/23, 7:29 PM - Rakesh Sir : That opd in Nalgonda was our college! 

Where else did she show in Hyderabad?
8/18/23, 8:02 PM - Vagisha Rani: Yes sir
8/20/23, 6:06 PM - Vagisha Rani: http://vagisharani.blogspot.com/2023/08/59-year-old-female.html
8/20/23, 6:06 PM - Vagisha Rani: Good evening sir
I have uploaded the clinical images.
She'll be sending the X-ray report by Tuesday.
8/20/23, 6:12 PM - Rakesh Sir : Thanks. Well done. Do we have the PaJR group made already for her? 

Can you ask ( name removed )from 2019 who has taken another telemedical patient with knee joint pain to prepare his case report and PaJR group in a similar manner?
8/20/23, 6:25 PM - Vagisha Rani: Yes sir I'll text him.
8/23/23, 8:11 AM - Rakesh Sir : Thanks
8/23/23, 12:04 PM - Vagisha Rani: Good afternoon sir
The x ray reports has come. (reports are attached in the above conversation)
8/23/23, 1:39 PM - Rakesh Sir : There is a lot of significant bony erosions in the carpal bones. Compare this with a normal image of carpal area in any normal X-ray hands from google images and you will understand
8/23/23, 1:40 PM - Rakesh Sir : Share this in her group along with the normal X-ray image from google
8/24/23, 7:28 PM - Vagisha Rani: This is a normal xray from Google.

8/24/23, 7:30 PM - Vagisha Rani: Sir, Can we say that the ulna is deviated ?
8/24/23, 8:22 PM - Rakesh Sir : Hope you can appreciate the differences now in her eroded carpal bones from that of normal?
8/24/23, 8:23 PM - Rakesh Sir : Ulnar subluxation is largely a clinical finding in rheumatoid arthritis
8/24/23, 8:26 PM - Rakesh Sir : Please share all the above as well as PaJR conversations in the patient's case report with a separate heading called CDSS  (conversational decision support system)
8/24/23, 8:32 PM - Rakesh Sir : 👆You can deidentify yourself like the patient if you wish
8/24/23, 8:33 PM - Vagisha Rani: Yes sir. I'll add the case discussions in the case report.

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