What a bonus!

Happy Halloween!

My daughter had a horse show this past weekend.

It was in a fairly rural area of Florida (you know, it still had a General Store and Deputy Barnie Fife positioned at the speed trap).

Best of all, it still had some of the old fashioned, one story motels that advertised having "clean rooms, phones and TVs."

I couldn't help but reflect how fortunate we are now.

Just think of all the wasted time, in the past, trying to figure out if you wanted to stay at a motel with clean or dirty rooms.

One less thing to worry about now, at least from a macroscopic viewpoint (still no telling from a microscopic viewpoint thanks to all the investigative news reports).

Rudy, part 2

Back to my town house and Rudy (see yesterday's post).

Our complex had a designated trash pick up day (every Tuesday you needed to put your trash can on the curb).

One week, I missed it (had been on call in the hospital and forgot).

We had an office complex adjoining our property with a large dumpster.

I walked a bag of trash over and placed it in the dumpster.

When I got home from work, the next day, the same bag was in front of my door with a note:

"The office complex dumpster is for use by the office complex ONLY. Rudy-homeowners president."

 He must have gone into the dumpster to retrieve it...how did he even know...did he have surveillance camera's?

The next meeting, I decided to join in the vote to remove Rudy from his position.

I felt sort of bad about the coup d' etat (the over throw), but only for a brief moment.

Life lesson from Rudy: never retire without having a WORTHWHILE new hobby or passion to fill your time.

Don't retire unless you have a new passion (that's actually worthwhile)

I lived in a town house for awhile, years ago (I was still a bachelor).

We had a home owners association.

Rudy, a retired elderly man, was the president.

I had an approximate 6 X 6 foot front lawn (as did everyone else) and was responsible for maintaining it.

It was a "homeowners rule" to keep the grass less than 4 inches tall.

The association fees took care of all the common areas.

I didn't own a lawn mower.

I used a weed waker but could have just used a pair of scissors (if I had the time).

At one of the homeowners meetings Rudy handed out photographs.

He had gone around to everyones front lawns (the 6 X 6 lawns), placed a ruler in the ground, and gotten down on the ground to take Polaroids to report (embarrass) on folks whose grass was taller than 4 inches.

I was guilty.

Mine checked in at 4 and 1/4 inches.

Thanks Rudy (part 1).

Flee market weekends

I have a lot of patients who have a spot at a flee market every weekend (often including Friday as well).

Most pay $8-$12/day, depending on the day and the location.

Most, it seems, don't care if they actually make any money (although they do prefer to at least break even).

One nice old man who sells knifes explained the reason. "It gets me out of the house, I've got some good buds there and it gives me and my wife some time away from each other."

Well stated!

Family family where art thou?

I recently made a home visit on Mr. D., a 92 year-old retired car dealer, who is also a WWII Veteran.

I was meeting him for the first time.

In the war he participated in the 1st wave of C-47's that brought the wounded from Omaha beach to the inland hospitals.

He lives alone since his wife of 71 years (his high-school sweetheart) has severe Alzheimer's dementia and has been residing in a Nursing Home for the last year.

He visits her as frequently as possible.

His home was somewhat cluttered but was full of framed and unframed family pictures.

Mr. D.'s health, physically and cognitively, is failing.

He wishes to remain home for as long as possible (he would prefer to stay at his home until his death).

He has all the help that he agrees to accept (and pay for).

I don't know him well and like most families, I'm sure there are many unique family issues/dynamics below the surface.

It was great to spend time with him.

On the drive home, however, I couldn't stop thinking about the song "You don't bring me flowers, anymore."

It would be awesome if, somehow, one of his family members (4 children and 9 grandchildren) could live with him, at his home, during whatever time he has left.

A whole lot of suing going on...

A local malpractice attorney runs an ad on a local radio show everyday.

Unfortunately, I always hear it on my way to work, while trying to listen to sports radio to get an update on all the scores from the day before.

The attorney, in the ad, notes that he believes most doctors are good and states that over 90% of malpractice is committed by less than 10% of physicians.

Recently I read one of my medical newspapers.

The headline stated, "Study: Most Doctors Face A Malpractice Claim by age 65."

In low risk specialties (family medicine, pediatrics, psychiatry), 36% of physicians were projected to face their first claim by age 45 and 75% by age 65.

In high risk specialties (neurosurgery, general surgery, OB/GYN), an estimated 88% were projected to face their first claim by age 45 and 99% by age 65.

A staggering 19% of neurosurgeons face a claim EVERY year!

While most claims do not result in a payment to the patient, they still involve significant monetary costs to both the physician and the insurer and results in loss of productivity because a physician is often unable to see patients as they defend cases.

I haven't mentioned the emotional effect of being named in a suit (all who have been named will know what I'm talking about).

So while I believe the ad that the attorney runs, there's still a whole lot of suing going on.

Gee, maybe we have too many starving attorneys?

Just a thought.

Verbal vs visual

A 39 year old male reported 10/10, chronic pain and to being miserable and unable to work or hold down a job.

He was impeccably dressed and well groomed with perfect hair, eyebrows, no body hair (shaved), polished fingernails and wore an assortment of gold bling (earrings, necklaces, rings and one of those huge watches).

For some reason, I found that to be a little odd.

More youth coaching tips

My kids are grown so I want to make sure I get more youth coaching tips down on paper, in case I have some dementia by the time my grandchildren are playing sports.

In no particular order:

1. Everyone should play at least 1/2 of the game. It's awesome to see some of your least athletically gifted players arriving with enthusiasm because they know they will be an active participant.

2. Rotate positions. For example, every kid, deep down, wants to play quarterback. Let him/her try.

3. Always remain positive, win or lose.

4. Never take a kid out of a game right after he/she has made a mistake (should be part of every coaching 101 course).

5. Let them have fun. Most of the boys loved having a 70's night on our basketball teams every year. They would wear short shorts, high tube socks, chuck taylor sneakers and a few even had Afro wigs.

6. Don't over coach (see blog entry dated 10/16/11).

7. Have a family member videotape you coaching if needed. You will, hopefully, realize how pathetic you look if you are standing up screaming at the refs and your players when the score is 6-4 in the fourth quarter of a youth basketball game.

Semantics

I recently became the supervising physician of four ARNP's (Nurse Practitioners).

They are all quite busy and do a great job.

I've noticed that, at times, the word "deferred" is used when a rectal exam was not done as part of a History and Physical, usually on a very elderly patient.

Most of the time, it's not clinically indicated (a palliative or hospice patient, for example).

The problem with the word deferred, however, is that it implies it will be done at a later date.

This is usually not the case.

I have recommended to use one of the following options for "rectal exam" if excluded from the exam:

Not done.

Not clinically indicated.

Patient declined (after being offered).

Reports was done by another health care provider within the last year (especially for folks being followed by, for example, a urologist).

Similar thoughts and words

An 89 year old male lives in an ACLF (assisted care living facility).

Me: How's the food?

Patient: Great; you know I would never complain about any food made for me, prepared by someones efforts. I'm just real thankful.

Me: You and I think a lot alike (and we even talk alike...see below).


My wife is a great cook and I love to eat. She used to make tuna casserole every so often. I hate tuna casserole, but I never told my wife. I love tuna sandwiches but have always despised tuna casserole (my mother used to make it as well growing up). Finally, one day my wife said, "you don't like tuna casserole, do you?" "Why do you ask?" "Because you never have seconds and you have seconds on everything else I make." "You're right, I hate tuna casserole." "Why didn't you tell me?" "Because I would never complain about any food made for me, prepared by you. I'm just real thankful for everything you do for us (my family)."

I think my wife loves to see me eat. We haven't had tuna casserole since.

A thanks flashback

I recently forgot about a patient in my waiting room.

A staff member let me know, at about 1 PM, that he had come in to pick up his parking disability form I had filled out for him.

I said, "tell him to wait a minute in the waiting room and I'll bring it out shortly."

I was in the middle of doing something else.

I forgot.

At about 5 PM a different staff member let me know the same patient had finally gone up to the desk to inquire about his form.

He had been sitting patiently.

I walked the form to him and apologized for the wait.

Surprisingly, he just said, "thanks."

I had a flashback.

During residency, while doing an ER rotation, a fellow resident, who was going off duty, signed a patient out to me in bed #12 at approximately 11 PM (it was a 25 bed emergency room). A blood test was pending and if his blood count was OK he could be discharged home. The curtain was pulled. It ended up being a typically busy night. I totally forgot about the poor fellow in bed #12. During check out rounds at 7 AM, the attending wanted to know what was going on in bed #12.

Oops.

I let him know I was on top of it.

I reviewed the labs that had returned at 11:20 PM and woke the nice man up and let him know his labs were fine and that he could go home.

Surprisingly he just said, "thanks."

Sure...I'll try to help

A male and his wife came in for an unscheduled visit.

They had a request.

The patient wanted me to write him a letter that stated he moved to Florida for health reasons after a heart bypass and that his wife resigned her job in order to accompany him to Florida. She was trying to claim unemployment benefits from the state they moved from.

When I inquired about having his physician up north write the letter, I was informed that the physician left his previous practice and no one knew how to get in touch with him (maybe he moved to Florida also).

When I inquired what "health reasons" were given for the reason for moving he let me know that he could exercise more due to the warmer weather and avoid the harsh winter climates (I guess I'll buy that).

The wife reported she wasn't going to claim unemployment benefits but she had no idea it would be so tough to find a job down here (I guess they didn't read the newspaper before moving about the record unemployment rates in Florida. Also another good reminder-don't quit/resign a job until you have another already lined up).

They were courteous and not demanding in their demeanor (that was a nice change).

I therefore wrote a very quick note along the lines of:

He was advised to move to Florida, by his former physician, to assist with his rehabilitation after his heart bypass and his wife therefore resigned her job to accompany him. Her presence here is helpful to assist in his emotional well being and with some IADL's (Instrumental activities of daily living).

I'm really not sure the unemployment bureau will accept the note but it was about the best I could do with the information gathered.

They seemingly left happy.

Another success story!

His only assignment

A 26 year old male recently came in for his first visit.

He was 6 foot and weighed exactly 300 pounds.

He was married, had 4 daughters and a fifth (the ultrasound had confirmed another girl) on the way.

He worked and they were living with his in-laws in order to save up some money to try and buy their first home.

He reported that he and his wife had a great relationship and that they got along great with his in-laws.

He medically retired from the military one and 1/2 years ago, when he weighed 223 pounds, due to knee problems.

He had gained 77 pounds in approximately 18 months!

I let him know I would do everything possible to help him.

We talked about many approaches to weight loss, including the obvious; diet and exercise (I never include gastric reduction options initially).

I let him know he had a stressful life and it's great he works hard and is a family man.

I decided to keep things simple to start.

His only assignment until the next appointment was as follows:

#1. Buy a scale

#2. Do NOT gain any more weight.

He agreed.

An impressive specimen

Mr. S. is an amazingly spry 87 year old male.

He's not on medications, is cognitively intact, walks unaided and is still the lead vocalist for an oldies band.

My nurse recently placed a sticky note on his chart for me to see before I went into the exam room.

It stated, "87 y/o, WOW!"

I decided to have some fun with it.

Me (after entering the exam room): My nurse is pretty impressed by you. Look at this note she put on your chart. Before we start, I need to know, did she try and put some moves on you?

Mr. S.: Oh no...I'm still the one who chases the girls...I just can't catch them anymore (he laughed).

Me: Do you have a lady friend currently?

Mr. S.: You bet. I stopped looking for the young women 'cause they're looking for the same thing I'm looking for...money (he laughed again). I have a nice companion for the last few years and she's still a young thing...only 73 years old.

After we had finished I told my nurse about showing him the note.

My Nurse: I did tell him that he was an impressive specimen.

Me: Just how much of a nursing exam did you do?

Youth b-ball coaching tip

Quick tip for coaching youth basketball:

Don't over coach.

Watch teenagers when they play a pick up game.

They set picks for each other, pass the ball to an open man, fast break, and even more importantly, look to shoot and take the ball to "the hole (the basket)."

Watch teenagers when they are over coached, told to run only set plays and pulled out of a game when they make a mistake.

They become robotic, paralyzed by over thinking and even worse, are afraid to shoot and to take the ball to the hole, even when they have an unimpeded path to the basket.

Teach skills, good spacing on the court and some basic plays, for when needed, and then let them scrimmage, scrimmage, scrimmage.

While they are scrimmaging sit back, shut up and watch.

Letting it go

I've been holding on to my YMCA coaching polo shirt.

I couldn't get myself to throw it away.

Years ago, it was white.

Over the years it became sort of a whitish-yellow with many visible stains.

It lasted through coaching multiple baseball, soccer, volleyball, flag football and basketball teams.

My daughter stopped doing "Y" teams a few years ago when she became an equestrian, but my son continued, even while playing for his school and club sport teams.

We had some terrible, mediocre and excellent seasons record wise.

ALL were successful, however,  in terms of skill development, as well as trying to instill a love of sports for the kids on my teams.

My son's last basketball season (that concluded this past August), ended with him scoring a basket with one second left in the championship game to complete an undefeated season.

The oldest "Y" league goes up to age 16.

He just turned 17.

Time to move on.

It was time to let my shirt go.

Don't wait

I'm old enough to have learned a lot of life lessons.

One I keep forgetting, however, because it doesn't happen very often, is to correct folks who call me by an incorrect first name.

I'm called "Will" by the receptionist at the YMCA who greets me every morning.

I'm called "Mike" by another physician who works in my same building.

Both are my fault.

I just keep saying "hi" back every time they address me.

I waited too long to correct them...my bad.

My two favorite stop smoking stories

#1. The pastor of our church let us know he tried to quit smoking while in Seminary school in Ohio. He spent many weekends, while in school, filling in for pastors, in various parts of the state, who were away on vacation. He reports driving down the highway on his way to preach while asking GOD to take away his urge to smoke. He would crumple up the pack in his possession and throw it out the window of the car. A short time later he would stop at a convenience store to buy a new pack. He reports there were partially full cigarette packs all over the highways of Ohio for a couple of years. He finally quit.

#2. My father in law reports that the last time he quit for three weeks he was just looking for an excuse to start again. He was hoping for some sort of tragedy to use as an excuse. Eventually, he started to even hope that an appliance would break, the roof would leak, anything. For three weeks nothing happened. Finally, he and my mother in law were going to go out to dinner together. He wanted to wear his favorite shirt and it was dirty. He got mad and had his excuse to re-start. He still smokes.

No approval granted

A 44 year old women wanted an approval on an herbal supplement that she was interested in taking to improve her "cardiovascular health and energy."

I'm usually open to folks trying supplements as long as I can recognize some of the ingredients.

I didn't recognize any this time.

She repeatedly pointed out the heading at the top that said, "PROVIDED BY NATURE, PROVEN BY SCIENCE."

I repeatedly pointed out the disclaimer at the bottom of the page:

THIS PRODUCT IS NOT INTENDED TO DIAGNOSIS, TREAT, CURE OR PREVENT ANY DISEASE PROCESS.

I didn't give my approval.

I don't think she actually cared.

She let me know she had already purchased it through the mail and was already taking it.

Words of wisdom

A 74 year old male reported some family stress.

A grandson, who was in college, had recently been charged with a DUI and his father (my patients son) was reportedly beside himself and threatening to take his son out of college.

Me: How are you doing with everything?

Patient: Fine. He's a good kid. He's always been a good kid. He's never gotten into trouble before. I told my son that we should be thankful no one got hurt and I reminded him that both of us have driven after drinking in the past and gotten away with it. He did nothing that we didn't do at his age. He just got caught. I'm sure my grandson has learned his lesson. It's a real expensive lesson.

The unabomber

Mr. D. is a very nice 81 year old man.

He's had a nickname, in our office, for the last year however.

He still carries a briefcase with him everywhere he goes.

Instead of wearing a watch he carries an old fashioned alarm clock.

He always arrives very early for his appointments.

Last year he came in for an appointment that was scheduled a few hours after fasting blood work was done.

Because his briefcase is heavy and because he's very trusting, he placed his briefcase, with the alarm clock duct taped to it, in the corner of our waiting room while he went over to the next building to get something to eat.

He didn't tell any staff members that he left it there.

Another patient, in the waiting room, noticed it while reading a magazine.

I wasn't aware of the commotion taking place.

By the time Mr. D. returned to our office, the local police were just about to call in the bomb squad.

Mr. D. felt bad.

Since then he's had his new nickname.

Shucks

My Mom is 79 years old.

I've been meaning, for sometime now, to remind her to get the shingles vaccine.

It's the newest adult vaccine and it's use had not yet been part of my standard recommendations for folks over age 60.

I forgot to tell her.

She is in the midst of a shingles outbreak now.

She's been miserable, and she's a tough cookie (she's also a long term breast cancer survivor).

I feel terrible for her.

Even though it's not nearly as effective as many vaccines, in clinical trials involving thousands of adults 60 years and older, the vaccine reduced the risk of shingles by about half (51%) and the risk of (the dreaded) post-herpetic neuralgia by 67%.

The value of the vaccine now "hits home."

It will now become part of my health maintenance recommendations for older folks.

That's the only good thing that has come from my Mom's misery.

Lets see...ah, no

A 56 year old male requested "a brief minute of time" in the middle of a hectic day.

He didn't have an appointment.

Patient: I just need a quick favor. I need you to write a note that says I was sick last week and that my son stayed home from college for the day to take care of me.

Me: Is everything all right?

Patient: He didn't go in for an exam because he didn't feel he was ready and now the professor is giving him a hard time because it was an unexcused absence. A bad grade would ruin his over all grade for the semester.

Me: Were you sick?

Patient: No, but could you just do this favor for me?

Me: Ah, no. Sorry I can't help your son. I would just tell him to tell the professor the truth and see if there are any extra projects or work he can do to make up for it. Anything else?

Patient: Nope.

As he left I couldn't help but wonder if he had a hidden tape recorder and was trying to catch me in an ethics violation.

My only other thoughts were:

1. My wife (a nurse practitioner) would be so proud of me because she does school based health and deals with school/test avoidance issues all year long.

2.  Are you kidding me!

Frequent flyer

Mr. T., an 81 year old, comes to our office, unannounced, approximately 1-3 times a week.

He navigates the public bus system to get here.

He ambulates with the assist of a cane only.

He has all our contact numbers to call for triage advice but always chooses to just come in.

He does have very mild cognitive impairment and is followed by a memory disorder specialist and a psychologist as well.

He's completely compliant with his medications and lives with his two sons.

He'll come in for colds, transient-fleeting headaches, skin tears, a splinter in his finger, an isolated, slightly elevated home blood pressure reading, etc., etc..

Most recently he came in due to a disturbing dream.

I was able to obtain his records from his previous health care facility and this has been his modus operandi for many years.

He usually just needs a brief physical exam and reassurance and heads home satisfied and thankful.

When my nurse noticed he was in again she said, "Mr. T. hadn't been in for awhile. Where has he been?"

My only reply was, "you missed his last three visits because you were on vacation last week for your son's wedding."

She smiled and so did I.

Mine for 6 months

Mr R., a 74 year old,  comes to Florida, from up north, every October (and stays for about 6 months).

He is a wonderful man (I'm not kidding...once you get to know him).

He's a wonderful man that's also cantankerous (I'm sure he would agree).

I'm his primary care physician while he's here.

He recently called (he'd been back in Florida for three days).

I was out of practice, in terms of how to deal with him, since I hadn't seen him for the previous 6 months.

My Nurse: Mr. R. is on the phone and demands to be seen. He says it's an emergency. He also wants you to know he had a bad summer due to the earthquake and hurricane Irene. He says he should have never left Florida this year.

Me: OK, tell him to come right in. I'll be happy to see him.

A little while later...

My Nurse: He doesn't want to come in now, he wants to come tomorrow.

It obviously wasn't an emergency (now I'm starting to remember).

Me: OK, tell him to get here as early as possible so I can see him before other scheduled patients arrive.

A little later...

My Nurse: He doesn't want to come early in the morning. He says he's not an early morning person and he told you that last year.

He's right, I do remember him telling me that last year.

Me: OK, tell him to come sometime during the day and I'll see him between patients with scheduled appointments.

A little later...

My Nurse: He says he won't come and just wait. He's afraid he'll catch something and get sick from all the other folks in the waiting room.

I'm now at full recall...he wants to be seen only when he wants to be seen...how could I have forgotten?

Me: OK, tell him to come at "lunch" when no other patients are scheduled.

That's what I did last year and it seemed to work.

A little later...

My Nurse: He says OK but feels bad you never get to eat lunch.

Me: Yeah, I'm sure he does.

Let's see, only about 5 and 1/2 more months to go (I'm sure you all know what I'm talking about).

Accidental flatulence (at that time of the day)

I get to the YMCA on most weekdays and exercise from about 5:30 until 6:15 AM.

It's usually an older crowd (at that time of the day).

I wake up to my alarm at 5:15 AM.

I already have a bag packed (from the night before) and the "Y" is only about a mile from our home.

Most of the really elderly folks, who exercise (at that time of the day), report having been up since about 3 to 4 AM.

The cushioned floor mats are used by most for stretching and sit-ups.

Occasionally, someone has some accidental flatulence (farts).

Sometimes, there's only one other person on the mat so I know who it was.

Other times I don't know because there's a small group.

Without fail, no one laughs and no one takes ownership (of course many possibly have hearing loss in the  flatulence frequency range).

I had never been a member of the floor mat flatulence club.

That's no longer the case.

The only other person, in the vicinity, on my memorable morning, had ear phones in place.

Maybe. just maybe, my membership is still a secret because I didn't laugh and I didn't take ownership.

False advertising

My wife asked if I would take my daughter to get a flu shot on the way to her daily horseback ride.

We had received a flu shot ad for the "minute clinic (a Nurse Practitioner run clinic that advertises quick, inexpensive visits for common ailments and concerns)," in a local CVS, that opened at 10 AM on Sunday morning.

We got there at 10:01 AM.

We were the 4th in line.

We left at 11:15 AM (when we were third in line), without having received the flu shot (we got tired of waiting).

I doubt we'll return unless they change their name to the "hour and 15 minute" clinic.

Tr, not Thr

A 68 year old male was annoyed that his blood pressure and cholesterol were above goal.

Mr. M.: I don't understand, I've been exercising 5 to 6 days a week on the threadmill.

Me: It's great you're exercising on the TREADMILL. You should continue.

Mr. M.: I thought exercising on the threadmill would keep me off  blood pressure and cholesterol lowering medications.

Me: Exercising on the TREADMILL is a great thing to do but many folks, like you, that do everything correctly, still need to be on medications to help control both.

Mr. M.: But I've really been pushing it on the threadmill.

Me: And you should continue to exercise on the TREADMILL.

Mr. M.: I was hoping to get better results from the threadmill.

I think you get the picture. We were able to finally move on to a new subject after a few more back and forth threads vs TREAD.

Come to think of it, maybe I should have told him that walking or jogging on a treadmill would give better results than exercising at the mill making thread.

Now I understood

Mr. P., a 77 year old, had always been insistent on having an annual PSA, despite his age and despite previous discussions on PSA testing in the elderly.

The most recent result was slightly high and the biopsy performed (at his insistence) by the urologist showed a "minute focus of adenocarcinoma (not surprising)." The amount was so small that a Gleason score couldn't be determined.

He wanted to undergo radiation therapy.

He was going to see the radiation oncologist the next week for a consultation.

He came to see me prior.

Me: Have you just thought about watchful waiting (I did not think he needed to aggressively treat his microscopic prostate cancer)?

Mr. P.: No, I just want to get rid of it once and for all.

Me: Are you aware that it might be such a small amount of cancer that it won't shorten your life...are you aware it still might come back after radiation...are you aware of the potential complications and adverse side effects of radiation therapy...are you aware that some folks develop colitis from the radiation, have incontinence and erectile dysfunction?

Mr. P.: Yeah, I just want to get rid of it once and for all.

Me: Do you know anyone who has had prostate cancer?

Mr. P.: My best friend, my buddy for over 50 years, died from it. He and I were retired Army and Civil service workers. We were also hunting and fishing partners. He got diagnosed with prostate cancer and decided not to do anything. He went and bought a casket and paid for his funeral. He died 6 weeks later.

Now I understood. I briefly discussed the fact that his friend most certainly had metastatic cancer at the time of diagnosis, not microscopic as was his prostate cancer, but I let him know I hoped everything would go well with the consultation for possible radiation therapy.

Mr. P.: And thanks for talking to me about this. You gave me some things to think about. At least I know some additional questions to ask before I make my final decision.

Cool, he really was listening.

No more fungus among us

I hadn't seen Mr. H., a 63 year old, for about 6 months.

He looked great.

He had lost over 50 pounds and mentioned he had a girlfriend for the first time in over 10 years ago.

Mr. H.: Thanks for helping to get my confidence back.

Me: (I actually had no idea what he was talking about) I'm real happy things are going well with you.

Mr. H.: I'm glad you asked me if I would like to treat the fungus in my fingernails when I saw you last year.

Now I remembered. About a year ago, he had come in for a follow-up on his blood pressure. For the first time, I noticed he was sitting with his fingers, of both hands, curled up in a fist. At first I thought he was just tense, but when I went to check his pulse I noticed most of his fingernails had significant onychomycosis. I asked him if he would like treatment for the fungus. He agreed. On follow-up, 6 weeks later, you could see the demarcation beginning between the normal and the abnormal nails growing out. I hadn't seen him since.

Mr. H.: I didn't want to socialize because of my fingernails. I didn't go the church. I felt embarrassed to shake hands. I didn't want to go on a date. I didn't think anything could be done. I've been exercising, eating better and met a great gal.

Now that sure made my day!