Robin Goodfellow (42-5)

Three years since Robin began his column, his enthusiasm and iconoclasm know no bounds. He only wishes he had paid more attention to anatomy as a boy (‘Mr Robin’, said the Dean of his medical school as Robin asked if that was all after an astonishing short 2nd MB viva, ‘You know, and I know, that there is little to be gained except pain from prolonging this interview’). But rheumatology lends itself to anatomical studies and along come Fairbank and Corlett to show how interesting tennis elbows can be, anatomically speaking (J Hand Surg 2003;27B:405–9). It is the extensor digitorum communis that is exciting. Do you do Maudsley's test? Does it confirm radial tunnel syndrome if positive? Probably not. Some very nice drawings accompany the text. This confirms that the art of medical illustration is alive and well.

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) [Free Full Text] is an admirable summary for generalists of how to deal with chronic back pain, with advice on rapid return to work and no rest unless there are red flag signs. Let's hope it gets read and so reduces unnecessary referrals into secondary care. Robin is currently in the process of agreeing policies with his physiotherapists on what they should turn away, and how — re-referral for chronic back pain is on the list for consideration.

Is visual loss due to giant cell arteritis reversible? This is the question posed by Calguneri et al. (Yonsei Med J 2003;44:155–8) [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;2003:10–13) 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;348:1027–32).[Free Full Text]

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;32:28–34).[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) [Abstract/Free Full Text] report that RA is an independent risk factor for myocardial infarction in women. Robin was going to pair this report with one from yet another sample journal issue (J Rheumatol) until he realised that, unlike N Engl J Med, the publishers were not offering current stock but remaindered stuff, and he had actually already read the article nearly a year ago. He was not, therefore, encouraged to take up a subscription. Wooing is needed (particularly given today's prices). Robin would no more send dead roses to Mrs Robin than have journals send old hat to him.

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.





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