Patients can produce new problem words just as secretaries do. A letter lands on Robin's desk from a patient whom he had referred for carpal tunnel decompression. It refers to a problem with the meridian nerve. There can't be many places where this nerve exists... but then in comes another missive from the ENT department (about a lady with a pleasing hoarseness from a vocal cord irregularity). Robin sees her for her Raynaud's phenomenon which, according to the letter, is part of an over lapse syndrome. Seductive voice or no, she has never looked like a fallen woman. Cold hands, warm heart?
And even labs can cause confusion, but this one is a salutary warning to all those who speak in abbreviations. Robin was puzzled to find a report indicating that the subject had angular stomatitis; now why do a full blood count for that? Think rheumatology, O lab!
It's actually amazing what people will do to make sure they are not late for appointments. At Robin's hospital it is impossible to park after 9.30a.m., so patients regularly turn up early and sit around. The first patient on one of his clinics had come, with her husband, early enough to have a leisurely breakfast chez nous. They had brought their own cutlery: them plastic knives won't cut the bacon, doc. Robin had to be astonished by this (not least because His cutlery set was a natty, clip together, swastika stamped WW2 trophy) but because he is more used to patients who bring in their own food. As it happened, a couple of days later his hospital was outed as being one of the worst 10 in the UK, food-wise. These two would clearly beg to differ; Robin would not know, as he never eats in the hospital canteen.
Too much chatter, you say, and I agree. How many of you would agree that the British Medical Journal has become a model of political correctness, with overtones of sanctimony? Nevertheless a 10-minute consultation from Leicester
(Samanta et al., Br Med J 2003;326:535)
Is visual loss due to giant cell arteritis reversible? This is the question posed by Calguneri et al. (Yonsei Med J 2003;44:1558) [ISI][Medline] they suggest from their experience that it may not be if caught early enough. Perhaps we should be making a list of rheumatology emergencies that require instant management (infected joints and cauda equina syndrome come to mind). Indeed the current edition of UK Casebook, the horror mag of the Medical Protection Society, devotes a whole article and its cover to cauda equina syndrome (Casebook 20;2003:1013) and because they had this column in mind there is also a case report of missed temporal arteritis (p. 23); and for good measure there is also a piece on tendon rupture following steroid injection. Funny, then, that none of these pieces mention rheumatologists... That said, Robin's last emergency referral with supposed cord compression turned out to have multiple sclerosis, a diagnosis Robin suspected when the patient said they had had an episode of saddle anaesthesia and incontinence eight years previously, and was anyway ataxic. Perhaps we should also be reminding some of our colleagues that taking a history is important.
What other diagnoses are invariably wrong? Hip pain, as readers of this column well know, is one of Robin's bêtes noires as it is usually gluteal enthesopathy. It would be so much easier if tailors and dressmakers measured buttocks, not hips. Gout is usually not gout but Robin was reminded, by virtue of yet another sample issue of the New England Journal of Medicine he was sent, that vertebrobasilar ischaemia is usually vertigo due to vestibular problems. He commends the review of vestibular neuritis to you all
(Balsh, N Engl J Med 2003;348:102732).
When Robin X-rays an osteoarthritic knee (not a lot) he wants a lateral to assess the patellofemoral joint, so is unhappy with his radiology department's radiation-limiting policy of only allowing general practitioners a standard AP view. Why do any X-rays if just the one is useless? Anyway he was interested to read a nice mechanics study from Japan (Yamanaka et al., Skeletal Radiol 2003;32:2834).[ISI][Medline] It seems a weight-bearing PA film in 15° of flexion both accurately detects joint space narrowing and is good for assessing the medial tibial plateau and tibiofemoral angle. Whether the extra writing on the request form so as to obtain this view is worth it is, however, questionable. Robin doubts it would alter his management much.
The evidence continues to build that rheumatoid arthritis is associated with increased cardiac disease and Solomon et al.
(Circulation 2003;107:1303)
So, with a toss of the head Robin is flouncing out into the garden to move a shrub from the bed by the air-raid shelter to a sunnier spot. It's a Hibiscus syriacus, if you must know. It did not flower wonderfully well last year.