Looking up at the clock over the exam room door, I brought myself back to the problem at hand. Start over. When all else fails, the saying goes, examine the patient. If there was an answer to Leon’s illness in the referral notes and labs, he wouldn’t be here. Start over.
Start at the Beginning
The first thing I noticed when I shook Leon’s hand was that, at the corner of his elbow, folded neatly at the crease, was a completed New York Times crossword puzzle, in ink. Put that into the mix, I thought. He cautiously extended his hand. The fingers were cracked and calloused. Subtle swelling was present in the second knuckle. The right forearm was bruised. “Leon Woodle. Everyone calls me Leon. Thanks for not gripping too hard, Doc.” He noticed the internal medicine resident hovering at the door. Some patients are reluctant to have another stranger sit in on their consultation, but Leon was comfortable with the attention. “Come on in. Two heads are better than one.”
If at first the diagnosis eludes me, a careful review of the history & a good physical exam with a dash of focused lab usually makes the obscure apparent.
With a look of relief, the resident entered and leaned against the sink. For the past week, this particular third-year resident, “Dr. Litmus,” had shown that she was a cut above most of her classmates who rotated through my office. She was comfortable with patients, bright, logical and empathetic, and I was hoping to interest her in applying for a fellowship in rheumatology rather than her stated interest in cardiology.
I asked Leon how long he’d lived in Maine. “Five years. Came back to live with my mother. Help out with the farm. My opportunities for making a living in New Jersey were, what I would call, limited.” He hesitated for a moment and added, “Prison will do that.”
“What’s it like working with pigs?” I asked.
“Yeah … You know, pigs are pigs. They eat most anything, and as long as you shovel their sh*t and keep their shed clean, they’re pretty content. Seasonally, I tar driveways. Money’s actually pretty good. Keeps me busy.”
“So what was the first thing you noticed when your health changed?” I asked.
“Fatigue. That was maybe six months ago. The heat and I don’t agree, so when I began to get the sweats at night, and it was summer, I didn’t think much of it at first. But I got so bone tired, it was all I could do to drag myself out of bed.” He stopped for a moment and scratched at his elbow. “I think the swelling in my right hand came next. This one was first,” he pointed to the second knuckle, “then this one.” The fourth finger’s middle joint was reddened and boggy.