Rheumatoid Arthritis in a Woman of 61

Abstract: Rheumatoid arthritis (RA) is an inflammatory rheumatic disease with a progressive course affecting articular and extra-articular structures resulting in pain, disability and mortality. Persistent inflammation leads to erosive joint damage and functional impairment in the vast majority of patients.

The onset of disease is not similar in all patients but varies in regard to type, number, and the pattern of joint involvement. The course of disease may also be different according to the presence or absence of several variables including genetic background, frequency of swollen joints, autoantibodies in the serum and severity of the inflammatory process.

The Case

introduction: A 61 years female presented with various complaints out of which issues related to rheumatoid arthritis were her main concern. She also had other accompanying complaints like diabetes mellitus, dyslipidaemia, hypertension and occasional raised uric acid.

She also had constipation which occurred only when she didn’t have fruits or a proper balanced meal. Patient was diagnosed with rheumatoid arthritis 3 years back. She started experiencing a lot of pain and stiffness which markedly started from right side (shoulder, hand, fingers and ankle).

Pains shifted from right shoulder to left. She was unable to clench or grip anything and lot of effort had to be used to straighten the fingers. The inflammation in the joints were noticeable by her. Pain was there the whole day, especially in the morning. Curd and lemons aggravated the pain whereas icy cold water and movement ameliorated it.

Case As Narrated By The Patient:

D: How does the pain bother you?
P: It is irritating me. Doesn’t make me feel good. My hold is not good. I don’t feel good when I am not able to take care of myself and house. I have the tendency of working fast and multi-tasking, which I am not able to do now.

D: What does Multi -Tasking means?
P: Like if I am working in the kitchen, I’ll cook several things at a time by using all gas burners (and then she started thinking). There too many things going on in my head at the same time. I think it is wasting my time, if I can do those things one at a time then why not…??

Now I am learning to be slow with this constant pain. For me it is important that the house stays clean. One thing or the other is happening in my body that is forcing me do things otherwise.

D: How will you describe her Nature?
Patient’s Husband jumps in and answers on behalf of the patient: We have been married for 40 years. She wants to just finish everything and then stop. If she can’t do that, she doesn’t like that. She has accepted it because of her age.

She always wants to do something. She has a very hyperactive personality. She has been brilliant in studies. Physically she doesn’t take much care of herself.

D: If there is any stressful situation, how will she react?
Patient’s Husband: She will not ponder about it for a long time. If it is her fault, she doesn’t like that. If she wants to go somewhere, she must know the route. She doesn’t like to make mistakes. She likes to give her 100% in everything. She doesn’t like it if anyone points out her mistake.

P: I don’t like to make mistake because I feel dejected. If it is something transient, then its ok. I just keep quiet, and then it just settles down. It takes time to settle in my mind. I talk to myself and think that I make this mistake and next time I should be alert. I just clam up. I just withdraw.

 I feel it is better than arguing and making things bad. I just keep to myself, interact less with the person. In family you don’t get along with everybody. in public life I will withdraw quietly. 90% I will give away and move out quietly. Earlier I was more of the attacking kind.  would give it back on the face.  used to say openly on face and not mince it. What you have done is wrong.

Patient’s Husband: Her natural tendency was to react. you leap before you look. earlier it was spontaneous reaction and now it is a controlled reaction.

{Notes: This phenomenon is very critical to realize and notice. Some of the words the patient and her husband are using describe a strategy, a process. This is usually missing in a plant or mineral case.

D: Can you talk more about this feeling?
p: I just point out because the person is wrong. I have 2 daughters, and if they do something that I don’t like I will just react and will not take time to analyse and think about it. I am very quick to make a judgement. I won’t give them benefit of doubt.

But now it is not like voicing my opinion loudly like before I’m just keeping quiet now. I just don’t use sugar coated words. If they say we will increase the money we put in the kitty party, then I just voice my opinion out without looking left or right.

I would just say it. If they don’t accept it is fine but I make sure that I have made my point. I have a habit of talking it out with my husband and he shows me the other side of the conversation. There is no such thing like open fighting. I don’t think open fighting is helpful it just gets murky.

(Notes: Within animal kingdom, which source wouldn’t prefer an open fight and why?)

D: If somebody has a strong opinion of what they are saying…??
P: If it concerns me, I’ll react but now I have the wisdom about it so I won’t interfere now. Earlier I would take sides, now I don’t. Best is to leave them alone, to settle their differences. It is with age you realize that. Maybe I feel this way but the other person might not think the same, so I don’t react now. But it alerts me of the person’s behaviour for future.

(Notes: The word alert has come up twice, so must be part of the phenomenon of the source)

D: What do you feel on your body (physically)?
P: I don’t feel any changes in my body as such except for the anger. I have the tendency that I can’t be spontaneous outside in public but I do it at home.

D: How will you describe your anger?
P: I don’t have anger that will go out of control. Why the other person cannot see it or why they can’t understand it. Whatever level it goes, I try to control it. Talking at home or airing out my opinion. I don’t like being dominated.. If they are elder to me, they should not dominate me. I will rebel or answer back.

D: What do you feel that time?
P: Why does the person want to do it in that way…?  To a degree I feel insulted. Strike back in the sense of answering back. I just tell to that person, don’t try to control me.

I will just cut the relation out with that person. I will not discuss, or bad mouth the person. I will just cut off and withdraw. I will try to avoid meeting as well. I don’t want to do it. I just pretend that the person is not there at all, but that doesn’t happen. Ii don’t forgive easily.

{Notes: You see the phenomenon of hierarchy, one upsmanship and also a theme of control, being controlled. In the strategy of attack/defence – we have themes of strike, no open fight, cut off, withdraw, open – no sugar coating, no mincing words}

D: Tell us about your fears…
P: I don’t like to fail. I want to be good at whatever I am doing. I am apprehensive that it’s done well. I don’t like to venture into something new not knowing how it will go.

I don’t like going to unknown streets. It is just conditioning. When I was unmarried, we travelled, we knew what we did or where we went. But after marriage we don’t know the person, we don’t know the house. Fear of not being understood, not being welcomed. Maybe not being liked because of my outspoken behaviour. If you give a surprise, then I become shaky.

{Notes: This unknown fear of dark, unknown streets, surprises is another clinical tip to identify this group of remedies. Anything unknown/hidden shakes them up}

D: What will happen if they don’t like you…?
P: We make an effort to make it congenial. I don’t have to be so brash; it can hurt someone. Between the balancing at you try to do what is required.

D: Can you tell us more about your fear?
P: I’m not comfortable going on high places. I like my house to be open. I don’t like to seat in a confined space. I need fresh air. There is uneasiness. I like to be outdoors. I have fear of water because I had lot of dreams of drowning in water long time back.

D: What was your experience in that dream?
P: It’s scary. I don’t know where it is going to take me. I am there fallen and going down. A lot of waves are there.

D: Okay… Tell us more about your dreams?
P: When I sleep, I sometimes feel that one part of me is conscious, either it is planning about my day or talking to myself. My mind is ticking or working.

{Notes: In sleep also, there is element of alertness}

D: What are your hobbies?
P: I like teaching. I like to do a lot of research before going for a class. I love reading. It gives me a lot of satisfaction. My ability to contribute something. I always wanted to work and didn’t have the drive to work earlier. When I am teaching nothing will come in my mind.

When something is unpleasant and then I don’t want to think of it then at that time I play video games, so that I don’t have to focus on it. And then I become quiet and less angry after some time. I like meeting people and hosting dinners. It is like if I am aware of it then I can be prepared for it and plan it well.

I also like board games with my grandchild.

D: Tell us more about you.
P: For me duty is important. If I have to go for something or sacrificing something it is okay. It is not something big I am doing; I feel I owe it to them. I am a family-oriented person. I care for them. They give me self – confidence and they will be there for me. I don’t have the habit of calling my daughters and interfering in their lives. I don’t feel neglected if my daughters don’t call me.

{Notes: This is a developed personality, more adult stage of development.}

D: WHAT DO YOU LIKE IN NATURE…?
P: Flowers. Silence in Nature.  Sitting in open. My cup of tea out in open. It is just being out in open that makes me happy. It makes my mood light. I like fresh air. After dinner walks. I don’t know what is happening in the house, if the door is closed, there is no control. I like to sit in the centre of the house at the dining table. It’s like you are in control of the situation.

Some confirmatory questions below:

D: What do you think you have analogy with in nature …?
P: Flowers, I have an affinity for them. I get fresh flowers in my home. I have green pots in and out of my house. Maybe birds. Lizards, cockroaches, snakes creep me. There is an eerie feeling.

D: Are you comfortable wearing tight clothing?
P: No, I can’t tolerate. I want comfortable clothes to wear.

D: What if someone hurts you purposefully?
P: I don’t like it one bit. It will bother me for a long time. It will make me want to settle scores. Speak about openly. Voicing my opinion. I would retort if given a chance.

D: Do you feel revengeful?
P: You want to hurt the person because he has hurt you. Maybe by speaking something unpleasant. Earlier I used to open up and speak my mind and regret latter. Now it’s a little difficult. I now try to be in control.

PHYSICAL GENERALS:

CRAVINGS: Sweets+++ Pickles+++ Chillies+++
I like eating ice.

Rx:
Elaps 1M once in 15 days

REPERTORIAL SHEET:
Since the case was solved by Sensation and PEM understanding, repertorial chart was not required

FOLLOW UPS:
21/09/2020: 
I am much better now. Pain and stiffness are much less. Pain comes and goes but the stiffness has reduced a lot. Initial 5 – 6 days I was not able to work at all. Now I am much better. I am 60 – 70% better in Stiffness. Pain is 40 – 50% better. There is some patience in me. I don’t try to rush up.

SLEEP: Better (Sound Sleep). Talking to myself or I feel I am awake, that is not there now (40 – 50% better).

MOTIONS: I am not able to clear my stomach. Lot of flatulence

Rx:  Elaps 1M once in 15 days — Divided Doses (Water Dose)
SL twice in a day

13/05/2021: 
Mood is okay, it’s not very depressive or joyful with we being locked inside. It’s a self-quarantine since the time we have come back. I miss going out walking, miss meeting my friends. Overall, I am feeling better.

OVERALL:
RA → 95%
MOTIONS → 50% better
SLEEP → 50% better

REPORT ANALYSIS
RA FACTOR (Serum): 
27/10/2020 →   71.8
14/12/2020 →   48.9
24/03/2021 →   <10

HBA1C:
27/10/2020 → 5.9
14/12/2020 → 5.9
24/03/2021 → 6.0
01/09/2021 → 6.2

URIC ACID:
27/10/2020 → 4.0
14/12/2020 → 4.0
24/03/2021 → 7.3 [Had stopped Feburic for 3 months. The value is slightly outside the normal range but the patient is asymptomatic.]

Analysis & Understanding:

The patient clearly has themes of venomous snakes, so we can rule out the constrictors. Within the venomous snakes we see the themes of adult stage of development.

Venomous Snakes	Constrictor Snakes
Inject, Poisoned	Engulf, Choke
Toxic	Encompass
Venomous, Lethal	Suffocate, Strangulate
Spiteful	Oppress
Wicked	Constrict
Noxious	Tight, Tighter
Witty, Cynical	Squeeze
	Without breath
	Grip, fasten the grip

So, we need to differentiate between Crotalidae and Elapidae. In this case we see that the patient is attacking only when she feels insulted or intruded. She has the power to confront and strike back. She is not as hidden as the Crotalidae. This directs to Elapidae.

CROTALIDAE	ELAPIDAE
Level of development: Late Adulthood/Old Age	Level of development: Adulthood
Constantly anticipating unexpected, covert attack	I will attack you, if you attack me.
Hence, need for constant vigilance e.g., Airports	Alert when someone intrudes
Warns several times before striking	May/May not and on least intrusion
Launching sudden hidden attacks.	Confront in a face-to-face encounter
Feels small & powerless against opponents who are powerful. Hence, stealth, sudden, covert, big attack. Never F2F.	Small fangs, can’t bite properly. Hence, F2F right in front and repeated injuries/repeated attacks
E.g., Lachesis: Attract by active seduction. They impose their presence on other people	E.g.  Elaps: Indirectly seek attention. Seduce people by indirect ways like in this patient she says she gives 100% to everything, she wants to make sure everything is good.