Age: 43.0
Sex: M
Vaccine: COVID19
Symptoms: Anti-cyclic citrullinated peptide antibody positive, Antinuclear antibody negative, Aphasia, Arthralgia, Aspartate aminotransferase normal
Clinical narrative: After 1st dose (April 8, 2021)-immediate numbness and tingling of face, aloofness, trouble with finding words, exhausted for 3 days.   After 2nd dose (April 29, 2021)-immediate face numbness, cramps in neck, severe exhaustion for 3 days, on-going brain fog.   May 29, 2021: 30 days after 2nd MRNA vaccine, started having pain, redness, stiffness, and swelling of right wrist. May 31, 2021:  Called out of work due to severe pain and swelling of right wrist.  Urgent Care visit #1 at Health Care, seen by, PA-C.  In addition to right wrist pain and swelling, also noted to have nystagmus, vertigo, high blood pressure, and severe brain fog.  Stroke ruled out.  X-ray of right wrist showed no fracture or dislocation.  Received prescription for Cephalexin 500 mg four times a day for 7 days for ?cellulitis of wrist? and instructed to take meclizine for vertigo. June 1, 2021: Called out of work due to right wrist pain, fatigue, and vertigo. Mid June 2021:  Left hand swelling, redness, pain.  Took Advil and Tylenol round the clock for pain.  Symptoms resolved after 3-4 days. July 1-4, 2021:  Left shoulder painful with worsening range of motion - no immediate trauma or injury. July 13, 2021:  Seen by Dr. (surgeon at Orthopedics) for left shoulder pain.  Multiple X-rays of left shoulder were unremarkable; Depo-Medrol/ketorolac/dexamethasone injection was done and sent home with home therapy regimen. August 2021:  Experiencing worsening brain fog, short term memory issues, fatigue and exhaustion. November 24, 2021:  Severe swelling and pain of left hand/knuckles and fatigue/exhaustion, lasted approximately 5 days. December 7, 2021:  Called out of work due to severe pain and swelling of right wrist, severe exhaustion, and brain fog worsening.  Urgent Care visit #2 at Health Care, seen by, PA-C.   X-ray of right hand/wrist and the following labs drawn: Sedimentation rate - 15 mm/hr; C-Reactive Protein - 0.49 mg/dL; Rheumatoid Factor ? Positive (30 IU/mL); comprehensive metabolic panel-within normal limits; CBC w/Auto Differential -WBC 11.5 k/mcL, platelets 465 kmcL, Absolute monocytes 1.2 kmcL; Antinuclear Antibody HEp-2 Substrate - negative.  Right hand/wrist Xrays significant for mild dorsal soft tissue swelling, no fracture of dislocation noted.  Started on Prednisone and Norco for pain.  Referral submitted for Rheumatologist. December 26, 2021 through March 2022 (current date): Intermittent pain and swelling in both knees, pain and swelling to various fingers, cold intolerance, severe exhaustion, and poor stamina.  January 13, 2022:  Initial visit with Dr., Internal Medicine Physician.  Experiencing increased right knee swelling and pain, vertigo 10 minutes after getting out of bed, brain fog, losing words mid-sentence, fatigue.  Dr. ordered labs (see January 14, 2022 for results), x-rays, and brain MRI without contrast. January 14, 2022:  Labs and results:  Lyme antibody - negative; CCP3 Antibody IgG - >250 (strong positive); LDL- within normal limits; hemoglobin A1C and estimated average glucose - both within normal limits;  megaloblastic anemia panel - within normal limits; TSH w/Free T4 ?within normal limits; CBC - within normal limits; comprehensive metabolic panel - within normal limits except AST(SGOT) low  (12 U/L); lipid panel- within normal limits except cholesterol high (203 mg/dL), Non-HDL cholesterol high (159 mg/dL), and LDL high (136 mg/dL). Bilateral hand and bilateral knee xrays ? mild bilateral quadriceps with enthesopathic change. January 17, 2022:  MRI brain without contrast - within normal limits, except mild bilateral lobe cerebral volume loss. January 28, 2022:  Initial visit with Dr., Rheumatologist ? diagnosed with new onset Rheumatoid Arthritis.  Ordered labs (see results on February 19, 2022). Received prescription for Methotrexate 10 mg once a week and Folic Acid 1 mg daily. February 17, 2022:  Follow-up visit with Dr., Internal Medicine Physician.  Received Pneumococcal Polysaccharide (PPSV23) Vaccine. Received referral to neurologist (appoint scheduled for April 21, 2022 with Dr.).   February 19, 2022:  Labs and results (ordered by Rheumatologist) -- hepatitis C antibody w/reflex - non-reactive; hepatitis B surface antibody ? positive/immune; hepatitis B surface antigen ? non-reactive; hepatitis B core antibody ? non-reactive; C-reactive protein - within normal limits; serum creatinine - within normal limits; hepatic function panel - within normal limits; CBC w/Auto differential ? within normal limits except platelets high (405 K/uL); Quantiferon TB ? negative. February 20, 2022:  Worsening right hand pain and swelling, notified Dr. and received prescription for prednisone 20 mg for 1 week then 10 mg for 1 week, also to increase Methotrexate to 6 tablets (15 mg) once a week. February 27, 2022:  Called out of work due to generalized pain flare and severe fatigue. March 4, 2022:  Follow-up with Dr., Rheumatologist.  Increased Methotrexate dose to 8 tablets (20 mg) once a week, stop prednisone and keep in case of future flares.  Ordered labs (CBC w/Auto diff, C-Reactive Protein, hepatic function panel, serum creatinine, sedimentation rate, and chest xray.) March 18, 2022:  CXR completed -within normal limits; all ordered labs (see list under March 4, 2022) within normal limits except platelets high (405 K/uL).   Missed full days of work due to pain flares and severe fatigue: 5/31/2021, 6/1/2021, 12/7/2021, 1/13/2022, 2/27/2022. Missed half day of work or greater due to worsening pain and fatigue: 8/21/2021, 1/5/2022, 1/12/2022, 2/21/2022.