According to the resident, the patient, who we can call Mr. Jones, was 50 years of age and had had rheumatoid arthritis (RA) for about three years. Mr. Jones was on a stable regimen of methotrexate 15 mg per week and 5 mg of prednisone each day. The history suggested that the disease was not very active. The patient worked full time as a manager of an auto parts store and regularly golfed. When I asked the resident about the joint count, he said that the Mr. Jones had “some” tender and swollen joints.
I pressed the resident to be more specific about the actual number, indicating that, in medicine, we do not say that a patient has “some” hypertension or “some” anemia. Good care requires precise numbers, and rheumatology therefore must have its numbers. I then Googled the DAS calculator website to show the resident the picture of the “joint man,” with the essential 28 joints depicted by circles to make it clear where attention is needed.
“Let’s do a real joint count,” I said to the house officer, who, alas, needed a shave, “and then we can calculate a DAS.” Down the hall we went, sidestepping an old man with thick glasses and thin gray hair, shuffling along bent over a walker.
We greeted Mr. Jones, who was sitting comfortably, speaking to someone on his phone, saying quickly, “Gotta go, the doctors are here,” snapping the phone cover closed. Mr. Jones looked up and smiled, extending his hand to shake mine, clearly a sign that his disease was not too active because no one with tender joints wants to risk the pain associated with even with the gentlest clasp. Unless you knew that Mr. Jones had RA, you would probably not have expected this diagnosis. Mr. Jones looked quite healthy, and there was not even a bend or a twist of a finger joint that would be a tell-tale sign of RA.
When I questioned Mr. Jones about his symptoms, he admitted to few complaints, saying that he felt dramatically better compared to the time before he was on methotrexate and prednisone. I then examined him, gently palpating and compressing his joints, starting with the hands, then the wrists, elbows, shoulders, and knees, left and right, all 28 accounted for, keeping a close tally of those that were tender and swollen. I also checked the ankles and feet but left out the counting part.
