He handed me a vial of hydrocodone. “How often are you taking these?” I asked.
“A couple at night. I rest better, but feel wacky if I take them during the day. Can you refill it? I’m running low. Anyway, I’m in Portland [Maine] now, living with an older brother, and the medical clinic at Maine Medical Center says the X-rays show my back is messed up big time.” He smiled out of the corner of his mouth. “Big surprise there.”
I reached over and picked up the folder off the exam table and slid out the films. A surge of frustration and anger flowed over me: How had this poor guy slipped through the cracks? I put on my stethoscope and listened to Joshua’s lungs to settle my mind. It’s not often I’m shaken to the point that emotions take me out of my usual routine. I consciously made an effort to begin over. Where else has this disease settled in?
The Exam
“Besides the back, are you hurting anywhere else?”
“My knees are killing me. That’s been maybe a year or two. Can you help me roll my pants legs up?”
I pulled up the right jean cuff. A barbed-wire tattoo encircled one calf. Over the mid-shin was a crusty, oozing scab. It was a challenge to roll the jeans up and over the knees, so I had Joshua N. undo his belt and slip the jeans down. The sight was gut-wrenching. Each knee held enough fluid to fill a grapefruit. The fluid seemed to extend into the back of the calves—giving them a pseudo-Popeye appearance—and tracked upward into the lower thighs. Above and below the swelling, the muscles in the legs were atrophied. I placed one hand on the kneecap and the other on the back of the calf to assess range of motion.
“I’d appreciate it if you more or less, just look. They don’t move so well.” He draped the cloth gown I’d given him to cover himself. “It’s OK if you call me Josh. That’s my name.”
“Okay, Josh. Mind if I take off your sneakers?” With the enormous knee effusions, I was looking for clues of inflammation elsewhere.
Although nearly all rheumatologic conditions are more common in women than men, ankylosing spondylitis, at least in its most severe forms, occurs more frequently in men.
“That’s fine. I can’t reach down there anyway, so my brother scrubs them if he has time.” As I undid the Velcro fasteners and slid his shoes and socks off, I could see that two of the toes on the right foot were obviously red and swollen. The left ankle moved poorly and was tender to touch. When Josh tried to flex and extend each knee, the muscles in his thigh quivered.
