Monday, April 30, 2012

A cold alarm

I sort of remember intermittently hearing a loud chirping sound the other day during the early morning hours. It eventually stopped. When I opened the refrigerator later the same morning to get milk for my cereal, I was surprised to see one of our smoke alarms on a shelf.

My wife had awoken to the chirping (the sound a smoke alarm makes when the battery is on its last leg) and when she couldn't figure out how to open it to remove the battery, decided to put it in the refrigerator so she wouldn't hear the chirp (she was thinking outside the box at 3 AM).

Here are some smoke alarm facts:

* The largest percentage of fire deaths in the home occurs at night while people are asleep. 
* Almost two-thirds of fire deaths from 2005-2009 resulted from fires in the home with no smoke alarms or non-functioning smoke alarms. 
* Homes with working smoke detectors have a 40-50% lower death rate from fires.
* And finally, battery powered smoke alarms only work if the battery isn't dead (now that’s an interesting fact!). 

Manufacturers recommend checking smoke alarms every month. Many recommend changing the batteries twice a year when you change your clocks for daylight savings time.

Sunday, April 29, 2012

A drive-by inspiration

On the road to a soccer game yesterday, for my son, we passed a small rural church that had a catchy little quote on their sign out front:

"Aspire to Inspire before you Expire."

It was short enough to read, and remember, while driving past at 35 miles an hour so I figured I would pass it on.

Have a GREAT day!

Saturday, April 28, 2012

Try to say "centenarian" ten times fast

A colleague recently gave me a copy of a research study.

It's a study on depression in the elderly, published in the 2012 Journal of the American Geriatrics Society.

I really haven't spent a lot of time absorbing the results because I was distracted by the thought of one of the subgroups in the study.

The study included 139 centenarians!

One-hundred and thirty-nine folks over the age of 100!

How/where did they find these folks?

The other groups included 91 sexagenarians (between the age of 60-70) and 93 octogenarians (between the age of 80-90).

I've had quite a few patients over the years in their 90's, but I've never had the honor of taking care of someone in their 100's.

As an aside, I did need to review a few other definitions. A septuagenarian is a person between the age of 70-80 and a nonagenarian is someone between the age of 90-100.

A supercentenarian is a person who has lived to the age of 110 or more, something achieved by only 1/1000 centenarians.

You see, aren't you distracted as well?

Lets get back to the study. Basically, the results of the study were as follows: Although the current rating scales for depression indicated most of the centenarians were depressed (on paper, that is), ALL the centenarians reported being in good spirits. In summary, therefore, the validity of the currently used depression rating scales for use in centenarians (I just like saying the word) is questionable.

Friday, April 27, 2012

The glue

Mrs R. is an incredibly steady and calm woman.

Her husband, Mr. R., is only 57 years old but his health took a turn for the worse 8 years ago when he was found to have lymphoma, chronic hepatitis C and had four strokes over the next 3-4 years. He was obviously no longer able to work as a welder. He had also been a volunteer baseball and football coach. She assumed the caregiver role for him, in addition to continuing to hold down a full time job.

Their oldest son was 17 when Mr. R. became ill. He dropped out of school with 2 weeks remaining in his senior year.

The next oldest, a daughter was 15 when Mr. R. became ill. She became pregnant and had her child at age 16. The boyfriends family wanted nothing to do with their son, his girlfriend or their baby. They lived with Mr. and Mrs. R.. Shortly after the baby was born, her boyfriend, now her fiancee, was the passenger in a bad car accident and is an incomplete paraplegic.

The next oldest, a daughter was 13 when Mr. R. became ill. She dropped out of high school at age 15 and dabbled in the drug scene.

The youngest, a daughter was 9 when Mr. R. became ill. She's now 17.

Mrs R. has been resilient throughout. She understands her husbands health issues had a great impact on their kids. They all made some bad choices along the way, but she made sure "they all knew they were loved and that they always had a home."

Her husband health is now stable. He walks with assistance, his lymphoma is in remission and has had no further strokes on his current medication regimen.

The oldest son has completed his GED and is employed doing golf course maintenance. He's also a scratch handicap golfer and has some folks trying to sponsor him to become a teaching pro.

The next oldest is a devoted caregiver for her fiancee and 7 year old child and they recently bought a home. They live only 2 blocks from Mr. and Mrs. R..

The next oldest completed her GED, is working full time as well as going to night school for an Associate degree from a local college. She no longer dabbles in drugs.

The youngest is a junior in high school and on course to graduate next year with her high school degree. She does virtual school at home on her computer.

Things are looking up again for the R. family, thanks to Mrs. R..

Thursday, April 26, 2012


“Potentially inappropriate medications (PIMs) continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults.”

Below is the link to the 2012 updated Beers criteria for Potentially Inappropriate Medication Use in Older Adults (come on, don’t be scared to look at it…it’s only a 14 page table!):

Wednesday, April 25, 2012

Another oldie but goodie

Came across another short article I wrote for Medical Economics in 2001.

You know, I still get a laugh when I read it because a similar patient interview takes place almost everyday.

"Take this patient’s history–please"

There’s plenty of humor in medicine–if you keep a lighthearted perspective. The author’s encounter with "Harry" is a case in point.

Like many doctors, I’m often stressed out from trying to get through my workday. But some patients inadvertently thwart my attempts to be efficient.
Take Harry. I’d already addressed his medical problem, so when he returned for a checkup I took the opportunity to fill in some gaps in his medical history.
But Harry, 55, was incapable of giving me a straight answer. Our colloquy was more reminiscent of a Marx Brothers routine than a doctor-patient dialogue. At first, I was frustrated by our inability to communicate. Then I began to see the humor in it. When I recount the experience to my colleagues, it cracks them up. See what you think.
Me: You’re married, aren’t you?
Harry: Yes.
Me: Is that your wife in the waiting room?
Harry: No, it’s my lady friend.
Me: I thought you were married?
Harry: I am, but my wife and I haven’t been together for years. We just never divorced.
Me: Well, we should probably test you for exposure to hepatitis C.
Harry: Why?
Me: Because you’ve had sex with more than one partner in your lifetime.
Harry: No, I haven’t.
Me: Didn’t you have sexual relations with your wife and your lady friend?
Harry: You bet I did. But only one at a time. I’ve often fantasized about being in bed with more than one woman, but I haven’t been that lucky.
Me: I’ll just send your blood sample to the lab. Do you have children?
Harry: Not anymore.
Me: Oh, gosh, I’m sorry for your loss. What happened?
Harry: They grew up and moved out.
Me: Oh, I see. How many children do you have?
Harry: By which wife?
Me: Er, how many wives have you had?
Harry: Four.
Me: Four! How many children do you have in all?
Harry: Six. I think. Who can remember? I haven’t seen some of their mothers in quite some time.
Me: Have you ever smoked?
Harry: Yes.
Me: Still smoking?
Harry: Yes.
Me: How much do you smoke?
Harry: A lot less than I used to.
Me: So, how much?
Harry: Hard to say.
Me: Well, on a typical day.
Harry: It depends.
Me: On what?
Harry: On whether it’s a weekday or a weekend.
Me: I see. How much do you smoke on a Saturday or Sunday?
Harry: It depends.
Me: On what?
Harry: On whether there’s a football game on TV.
Me: So if there’s a game on TV, how much do you smoke?
Harry: A lot more than I smoke when there’s no game.
Me: Let’s try a different approach. Do you buy cigarettes by the pack or the carton?
Harry: Carton.
Me: How many cartons do you buy a week?
Harry: I don’t buy a carton every week.
Me: So you smoke less than 10 packs a week?
Harry: I don’t think so.
Me: If you don’t buy a carton every week, you must be smoking less than 10 packs a week, because there are 10 packs in a carton.
Harry: I see what you’re getting at. I meant that I don’t have to go to the store every week. When I do go, I usually buy more than one carton at a time.
Me: How many cartons do you typically buy?
Harry: It depends.
Me: On what?
Harry: On whether or not there’s a sale.
Me: Okay, on a typical weekday, how many cigarettes do you smoke?
Harry: I’m not sure. You see, I don’t always smoke the whole cigarette. And now I smoke a light brand. So that doesn’t count as much as smoking a regular cigarette.
Me: Well, take a wild guess. A pack a day? Two?
Harry: Sure, I suppose, if you must write something down. But I really have no idea.
Me: Let’s move on. Do you ever drink alcoholic beverages?
Harry: Sure, but I haven’t had a drink in quite some time.
Me: Good for you. When did you quit?
Harry: I didn’t say I quit.
Me: How long since your last drink?
Harry: It’s been at least a couple of days.
Me: How much do you typically drink a day?
Harry: I don’t drink the hard stuff–only beer.
Me: How much beer a day?
Harry: It depends.
Me: On what?
Harry: On whether there’s a football game on TV and my buddies are there to watch it with me.
Me: Well, if there’s a game on, and your buddies are over, how many beers do you drink?
Harry: More than if I’m watching alone.
Me: Let’s try this: How many cases of beer do you buy a week?
Harry: I don’t buy cases every week.
Me: Oh, right. You probably buy more than one case at a time if there’s a sale.
Harry: Actually, I never buy cases–only six-packs and 12-packs.
Me: Do you normally drink a six-pack a day?
Harry: If you must write something down, I suppose that will do. The truth is, sometimes I drink more, sometimes less.
Me: Well, that’s enough history-taking for one session. How about I give you a flu shot?
Harry: No thanks. Every time I get a flu shot I come down with the flu.
Me: When was the last time you had a flu shot?
Harry: Oh, 1976 or thereabouts.
Me: It’s up to you. Have you been taking those blood pressure pills I prescribed the last time you were here?
Harry: Most of the time. Sometimes I forget.
Me: According to your chart, your last refill was for 30 pills. That was two months ago.
Harry: Really? No wonder I have no more left. I took the last one just before coming here. You know, going to the doctor can be a nerve-racking experience.

Tuesday, April 24, 2012

Warning, warning Will Robinson (for lost-in-space fans)

I saw a 79 year old male recently. When I asked his wife to bring out all his medication, she produced an industrial sized trash bag full of medications from the closet (a scenario familiar to all in health care).

The brief article below (“Too Many Pills for Aging Patients”) is an excellent example of over-medication concerns in the elderly, as well as “the cascade of deterioration” that often occurs in our elderly hospitalized patients.

It’s an easy read but makes some excellent points.

I've also included the site to an article I wrote about 11 years ago in Medical Economics for a few laughs:

Monday, April 23, 2012


I know there has been a lot of discussions over the last few years concerning the term “Allow Natural Death (AND)” along with, or in place of, the term “Do Not Resuscitate (DNR).”

Many have criticized the term DNR because it sounds as if something important is being withheld. The term AND focuses on what is being done, not on what is being withheld/avoided.

I think the use of both terms has value as long as the health care provider is able to effectively communicate with the patient and/or family.

“Researchers have reliable data concerning the success rates of Cardiopulmonary Resuscitation (CPR), without the use of automatic defibrillators, in a variety of settings:

·       2% to 30% effectiveness when administered outside of the hospital
·       6% to 15% for hospitalized patients
·       Less than 5% for elderly victims with multiple medical problems”

Unfortunately, it’s still estimated that only about 20% of the population has advance directives.

Please look at this site when possible:

Sunday, April 22, 2012

A 2012 version

"To cure sometimes, to relieve often, to comfort always," which, as best I can figure, was first said by Dr. Edward Trudeau (founder of a tuberculosis sanatorium) in the 1800's.

I came across sort of a 2012 version, recently, by Dr. George Ferenczi (Physicians Practice, April 2012, 19-20).

"People bring me their health problems, some of which are curable, many of which are treatable, all of which need to be made endurable. It is with the chronic and the incurable that we physicians face our greatest challenge. It is then that we must help our patients develop a new narrative about life and its meaning. We can teach how to refocus on the things that are still possible rather than on what has been irretrievably lost-if not curing, then relieving pain, easy suffering, offering compassion."

Saturday, April 21, 2012

Easily amused

I often get to travel through some rural areas of Florida when going to visit patients in their homes.

I drove by a motel, in Leesburg, yesterday that still advertised "clean, quiet rooms."

I'm easily amused.

I get a kick out of just thinking there might be some folks who would decline to stay because of a preference for dirty, noisy rooms.

Friday, April 20, 2012

Stepping up to the plate

Mary L. is a 57 year old accomplished ball room dancer and instructor.

She never married and doesn't have any children.

She has kept an incredibly busy schedule over the years and has traveled extensively.

4 months ago she helped to rescue her parents.

Her 90 year old Dads dementia progressed to the point that her Mom was considering Nursing Home placement.

He has incontinence and like many folks with advanced dementia (due to being dis-inhibited), he has become LOUD and bossy and uses inappropriate language.

She had her parents move in with her.

Her life and daily chores/responsibilities have dramatically changed.

She's committed, however, for the long haul.

"I know you can't really tell it now but my father was always such a gentleman. It's hard for my Mom to understand but no so much for me. Having them here, surrounded by all our family pictures, also helps to remind me what great parents they have been and how lucky I was to have their support in leading such a privileged life. It's the least I can do to pay them back."

Now that's awesome.

Thursday, April 19, 2012

The right thing

I leave home most weekday mornings at about 5:30 AM; prior to anyone else in my family getting up.

This morning, our dog had escaped from the kitchen (where she was spending the first night home from the vet after a bout of pancreatitis) after peeing everywhere and then gnawing away at the gate until it gave free and dropped to the ground. She was lying in her usual spot, in the living room (where her dog bed usually resides), much to my surprise.

On seeing the sight before me, in the kitchen, I had two choices.

1. Continue to sneak out of the house and leave all as is-after all, no one would know it happened before I had left for the morning or
2. Clean up

Appropriately, I choose #2 but I do have to admit, choice #1 was very tempting!

"Good" Bill won out again!

Wednesday, April 18, 2012

Senior codes

My brother sent this my way. They're "senior codes" to be used when sending a text to another senior. I'm friends with a lot of seniors so I better start to memorize them before ICRS (I can't remember Sh_t)!

* ATD - At the Doctor's

* BFF - Best Friends Funeral

* BTW - Bring the Wheelchair

* BYOT - Bring Your Own Teeth

* CBM - Covered by Medicare

* DWI - Driving While Incontinent

* GGPBL - Gotta Go, Pacemaker Battery Low

* GHA - Got Heartburn Again

* HGBM - Had Good Bowel Movement

* IMHO? - Is My Hearing-Aid On?

* LMDO - Laughing My Dentures Out

* LOL - Living on Laxatives

* OMMR - On My Massage Recliner

* OMSG - Oh My, Sorry, Gas

* ROFL...CGU - Rolling on the Floor Laughing...Can't get Up

* TOT - Texting on Toilet

* TTYL - Talk to You Louder

* WAITT? - Who Am I Talking To?

* WTFA - Wet the Furniture Again

* WTP? - Where're the Prunes?

Tuesday, April 17, 2012

The root snakes

My Mom is 80 and does have some mild memory deficits.

Recently, I was concerned.

On our last few phone calls she seemed overly preoccupied about the palm trees outside her condominium.

The kept talking about something snaking up the trees and her desire to have someone do something about it as soon as possible.

I was worried she was hallucinating or getting delusional.

Finally, my brother sent me a picture.

I think it's fair to say it was a good description!

Monday, April 16, 2012

No surprise here

I delivered almost 40 children (and was amazed by each one), years ago, during residency, so a new report issued today is certainly no surprise:

"A report from Sweden has shown that women who deliver naturally (vaginally instead of by cesarean section) are more inclined to suffer from urinary incontinence later in life."

To witness first hand the miracle of birth, as well as the changes in the female anatomy that allowed passage of the newborn, was an honor and privilege I'll never forget.

It's really hard to make an analogy for men but I'll try.

I don't think it would be a surprise if any man, who had a tennis ball sized kidney stone come through their penis, had a greater incidence of urinary incontinence in their later years.

I know...ouch, but you get the picture, don't you?

Sunday, April 15, 2012

Right on the money

My son is doing AP Psychology this year in high school.

He had our family all take the Jung Typology Test at the following web site:

Read each of the 72 questions and pick an answer quickly without thinking/pondering each answer in depth.

After taking the test you get a description of your personality type, find out what "famous" folks share your type and also get to look at the Jung Career Indicator to see if your type matches your chosen career.

I'm an ESFJ (Extraverted Sensing Feeling Judging); a Provider.

My chosen career seems to fit:

The Guardian type known as the Provider (ESFJ) is sometimes known as the "Santa Claus" personality since they are generally well-liked and notice whenever situations become "naughty or nice." They provide for the welfare of many and usually show well-developed social skills. They are happiest in positions where they need to deal with people. It is not uncommon to find them in health care, as a physician, nurse, or respiratory therapist. They also can be attracted to the field of education, social service, or religion. In business they may be a retail owner, receptionist, real estate agent, or sales representative. The common theme is their service to others.

For some reason, my wife and kids got a kick out of part of the description for an ESFJ that follows (actually, I've got to admit that I do like to be appreciated):

Providers are extremely sensitive to the feelings of others, which makes them perhaps the most sympathetic of all the types, but which also leaves them somewhat self-conscious, that is, highly sensitive to what others think of them. Loving and affectionate themselves, they need to be loved in return. In fact, Providers can be crushed by personal criticism, and are happiest when given ample appreciation both for themselves personally and for the tireless service they give to others.

Saturday, April 14, 2012

The T-shirt sign

We recently came back from touring some colleges/universities with our kids.

My son is a junior in high school and our daughter is a sophomore.

I read an article some time ago that reported kids can usually tell within eleven minutes of the start of a college tour if the school "feels right."

The positive T-shirt sign is another way of knowing their interest.

If there's no desire to go to the college bookstore after the tour to purchase a T-shirt, we've found that the school is no longer seriously being considered.

It's a nice non-verbal clue.

No explanation is needed. If the school, for whatever reason, is a bust, why would one possibly want to wear a T-shirt?

Thursday, April 12, 2012

The circle dancer

An 86 year old man and an 87 year old woman have been married for 40 years (Mr. and Mrs. M.).

It's the second marriage for both.

Me: How did you all get together?

Mrs M.: He was somewhere he shouldn't have been and I was somewhere I should have.

Me: What do you mean?

Mrs. M.: It was a dance for singles. I had lost my husband, Bill, the year before but he was still married. He was separated from his wife, but still married. I would have never danced with him if I knew he was still married.

Me: He must have been a great dancer.

Mrs. M.: No he wasn't. He pretty much only danced with one leg so he tended to go in circles.

Mr. M. heard every word and just smiled and nodded his head in agreement. I'm sure he's heard the same story told a lot of times over the years.

Wednesday, April 11, 2012

So sad

Mr. T. is a 68 year old who worked as a cook for the railroad for 36 years, after he finished 7 years of active duty in the Army.

He was "on the rail" and away from his wife and 6 kids every Sunday through Thursday.

He retired at age 61.

He and Mrs. T. spent many a day planning all the fun things they would do during "their" retirement, including, finally, traveling together.

A few months after his retirement, while driving to church services on a Wednesday night, he was shot in the head.

The assailant, who was caught and has been in jail since, reported it was a mistake.

Mr. T. was mistaken for someone else.

He survived but he's wheelchair bound, has no use of his right side, only partial use of his left side and talks very infrequently.

The few words he speaks are usually always curse words.

They have not been able to travel together.

Mrs T. reports, "he was such a good man, a great provider, a wonderful husband and father. He never used a foul word in his life. He was a church deacon, a leader of men. It hurts so much to see him like this. I know the way he talks now is not him, but it is you know what I mean?"

She was teary eyed.

So was I.

Tuesday, April 10, 2012

A much needed dose reduction

Our dog started thyroid replacement therapy about ten days ago.

It seems to have "kicked in."

She had a couple of days and nights with almost no sleep.

Before starting on treatment, we think she was averaging close to 20 hours of sleep a day.

The two nights she didn't sleep, my wife and I didn't sleep much either.

She spent the nights "wired", drooling, hyperventilating, panting, looking out all the windows and drinking a lot of water.

The vet agreed that we needed to cut the dose.

She slept through the night last night...and so did we!

Monday, April 9, 2012

A couple of weeks for thyroids

Our dog, Bailey, was diagnosed with hypothyroidism last week.

Her treatment should be relatively easy.

She gladly takes her medication everyday, especially since we always enhance the pills taste with a small amount of peanut butter.

She will eat ANYTHING dipped in peanut butter

My wife was diagnosed with thyroid cancer this past week.

She's scheduled for surgery early next month.

The surgery should be curative but she will have a crummy couple of weeks of post operative recovery, we are told.

She will also then need to take thyroid replacement therapy for the rest of her life.

I don't think we will have to use the peanut butter for her, however, but it will be on stand-by if needed.

Sunday, April 8, 2012

Happy Easter!

I hope everyone has a great Easter holiday today!

Celebrate the reason for the day and enjoy any time together with family and friends, for those so fortunate.

Saturday, April 7, 2012

Some interesting Florida history

I spent some time yesterday with Mr. and Mrs. B..

Mr. B. suffers from end-stage Parkinson's disease and Mrs. B. has been his sole caregiver for many years.

She does an amazing job in this role.

Mr. B. isn't able to effectively communicate due to his disease.

They have 10 children but none live locally.

They get a lot of support through their church on the weekends.

Mrs. B. is a native Floridian.

She's the great-granddaughter of Barron and Juliet Collier.

Barron and Juliet Collier, with their three sons, moved to Southwest Florida in 1911.

Collier County was named after Barron.

This morning, I decided to get more information. A simple Google search of his name revealed many "hits."

"Barron Gift Collier (23 March 1873—13 March 1939) was an American advertising mogul, who became the largest landowner and developer in the U.S. state of Florida, as well as, the owner of a chain of hotels, bus lines, several banks, and newspapers. He also owned a telephone company and a steamship line.

The Colliers went on to acquire more than a million acres of land in Southwest Florida, making them the largest private land owners in the state. He invested millions of dollars to transform and develop the wilderness, including drainage of the Everglades and construction of the Tamiami Trail. For his influence and investment in the state's future, the Florida legislature named the newly-created Collier County in his honor on May 8, 1923."

A local public high school in Naples is named after him and his heirs have continued his company:

"The Barron Collier Companies - dedicated to the responsible development, management and stewardship of its extensive land holdings and other assets in the businesses of agriculture, real estate, and mineral management."

I've done extensive research into my family tree (prior to a family trip to Ireland a couple of years ago) and, unFORTUNately, I can claim no family connection to them.

Friday, April 6, 2012

How to stretch a prescription

Patient: The pills you gave me for my blood plessure aren't working.

Me: Really? Oh (while scanning through the medication section of the computerized record), it looks like you only got one month of pills filled 6 months ago, for your blood PRESSURE.

Patient: Yeah, I took the last one last night.

Me: You only got thirty pills of each, 6 months ago. You had refills available but never called in for a refill.

Patient: I know, it's like I said, I took the last pill last night.

Me: You were suppossed to take one a day. The thirty pills should have only lasted thirty days, not 180 days.

Patient: I don't remember you telling me to take one every day. That's going to be a lot more expensive!

Thursday, April 5, 2012

A new phrase for me

It always great when intuitively obvious things have an official name.

I've seen many examples over the years in which there has been a deterioration in the social relationships between a patient, staff and other members of the medical team due to negative perceptions of the patients behavior.

The patient is often perceived as being provocative, unreasonable, aggressive-volatile and/or overly dependent, chronic and felt not likely to improve.

A colleague informed me a few days ago that the official term is "Malignant alienation."

It's so much more appropriate than many of the other terms used in the past!

Wednesday, April 4, 2012

A book work-out

     We just got back from looking at some colleges and universities for my son. One of our stops was the College of William and Mary.
     The Wren Building is one of the original central classrooms at the College and now serves as a historical landmark. It's still used for special occasions. My Mom has her picture in the Wren museum to depict the era (late 1940's) when freshman men and women wore "beanies" and the freshman men always carried the books for the freshman women (and their own books as well). It's was pretty cool to see it again.

Tuesday, April 3, 2012

A little over 80 years ago

I went to an excellent talk today on suicide in the elderly.

It brought back a memory from a few years ago when we flew into Rochester N.Y. to start a trip touring upstate NY and Canada.

We started with a tour of the George Eastman ("Mr. Kodak") estate in Rochester.

He was a successful and wealthy man, a world traveler and a philanthropist.

Unfortunately, he developed a condition called spinal stenosis and spent the last few years of his life miserable and in pain.

He committed suicide on March 14, 1932 at age 77.

His suicide note was on display in a case and was incredibly short (especially considering the amazing life that he led): To my friends-My work is done-Why wait?

The official report states that he placed a folded towel over his chest and shot himself with an automatic Luger.

Monday, April 2, 2012

It's good to meet you

Mr. K is a 63 year old with severe emphysema.

He has had multiple hospital admissions over the last ten years for this diagnosis and has been followed in an outpatient clinic as well for the same length of time.

I recently met him for the first time.

When I shook his hand I noticed his 3rd through 5th fingers were in a sustained flexed position; he was unable to extend them.

We reviewed his history in detail.

Finally, I said, "I noticed the trouble you're having with your hand. When did it start?"

Mr. K.: The fingers started curling about 9 years ago and for the last seven I haven't been able to straighten them out.

Me: Have you had any one evaluate them?

Mr. K.: 5 years ago a Doctor said he thought I had arthritis.

Me. Any X-rays?

Mr. K.: No.

When I got back to the office I looked through all his old records. Over the last ten years, there was no mention of his right hand.

He came in for an x-ray that showed ulnar deviations, joint erosion's and subluxation at the MCP joints of the involved fingers.

Labs returned consistent with rheumatoid arthritis.

I'm glad I shook his hand.

It's another example of how we sometimes lose site of the trees (other medical diagnoses) in the midst of the forest (his most significant medical problem-his emphysema).