17. The Ortho

A few patients into that day, I met Josh Harvey. He was a 35-year-old man, and he looked 35, but he had a posture of a 52-year-old. Really, no joke, that was the first thing I noticed about him.

‘Hello, Mr. Harvey! My name is Lisa Diaz and I’ll be the doctor responsible for you today, how are you?’

He opened a wide smile and stretched his hands towards me.

‘I’m good, doctor, thanks for asking.’

‘What can I do for you today?’

He then told me about this really bad arthralgia that had been going on in the last week, which was bothering him. He was also having pain with urination, which was bothering him even more.

‘And did you feel anything else? Any other symptoms?’

‘Not really.’

‘What about a previous diagnosis or recent diseases?’

‘No other diagnosis doc, although I did have gastroenteritis a few weeks ago.’

I asked a few more questions and went to the physical. There was nothing major, but his conjunctiva seemed inflamed. Aka, a triad I quickly recognized: arthritis, urethritis, and conjunctivitis - the well known reactive arthritis. While I was still on the exam, I remembered to ask him what he did for a living.

‘Actually, I’m unemployed right now.’ He turned a little sad. ‘I am a dockworker, but I’ve lost my job recently because I can’t keep up anymore. I know I’m young, but my back aches, my joints hurt. I love my job, but I can’t seem to do it right.’

I felt bad for him. I didn’t know what to say but I tried anyway.

‘I’m sorry to hear that. But I’m sure you can find something else, you’re young!’

His face got serious.

‘I love what I do. I know there are many people that don’t care about their work and wouldn’t mind changing. But I do.’

I nodded. I wasn’t expecting that answer, but I do know what he meant. If someone told me I couldn’t do my job anymore, I would be devastated. And that’s when I realized he was telling me his real problem.

Yes, his arthritis and urethritis were bothering him, but he still smiled and didn’t care so much when he talked about it. His real problem was the pain that limited his work. And there was no way this pain was normal.

I was no ortho expert, but he definitely had a problem worth looking at. I made him a few more questions and he described his pain as polyarthralgia with morning stiffness, including his back and shoulders.

The morning stiffness got me thinking rheumatoid arthritis, and I thought about ordering him a rheumatoid factor. Still, I thought it was better to discuss this one with Dr. Collins first. As I said, I was no ortho expert.

I excused myself and went looking for her. It didn’t take long to find Peter in the hallway first.

‘Why are you always in the hallway? Don’t you have patients to see or something?’

He laughed.

‘I’m fast Lisa, and for some reason, my patients didn’t come today. Don’t hate the player, hate the game.’ He could be so annoying sometimes.

‘Anyway, where’s Dr. Collins?’

‘I haven’t seen her today yet. What do you got?’

‘Nothing major actually, a case of reactive arthritis. A 35-year-old man with arthritis, urethritis, and conjunctivitis after an episode of gastroenteritis.’

‘So what do you need her for?’

‘I think he has something else. He says he has joint pain and morning stiffness. I am thinking about ordering a rheumatoid factor, but honestly, I’m not great with orthopedic complaints.’

‘Am I hearing this right? Is the great Lisa Diaz saying she is not good at something?’

‘Geez, you are hanging too much with Jax.’

I started walking away.

‘C’mon Lisa, I’m kidding. Besides, I think I can help you.’

I stopped and turned back. I could use some help anyway.

‘What do you got, Allen?’

He smiled.

‘Do you have time for coffee?’

‘Not really, my patient is waiting.’

‘C’mon, while we walk there.’ He fixed his hair.

‘Since when do you want to drink coffee with me?’

‘Maybe I like your company.’

I blushed.

‘Sorry Peter, I really don’t have the time.’

He smirked.

‘That’s okay Diaz, I knew you would say no the first time.’

What did he mean by the first time? We had been to the cafeteria a thousand times. Was he asking me out? I don’t know, I was just uncomfortable. I wanted to figure out Josh Harvey’s case and go back to non-uncomfortable topics.

‘You are right about ordering him a rheumatoid factor, but it will probably come back negative. From what you’re saying, it looks like he must have seronegative spondyloarthritis. Reactive arthritis and ankylosing spondylitis are really connected, so you should order a…’

‘HLA-B27! And radiography, of course. Thanks, Peter.’ He looked at me like he was impressed. ‘I said I was not very good at it, but I know a little bit. I just needed some light.’

‘You’re welcome, Lisa.’ He said while I walked away. 'Oh, and order him a CRP and ESR also. If it is AS, they will be elevated.'

I came back to my patient and explained what I thought about his case. I ordered the tests and told him he would need to follow up with a rheumatologist to evaluate what was the best course of treatment. He was so happy and thankful, even after I clarified that the prognosis depended a lot on each case.

I got home satisfied that day. It was a good day. Jax was already there watching sports as always. I sat beside him and we small talked. After a while, I decided to tell him.

‘I think Peter asked me out today.’

‘What?’ He didn’t hide his excitement. ‘What do you mean?‘

‘I don’t know, he was being weird. I don’t want to talk about it.’

He looked at me in disbelief and just shrugged.

‘No surprises there. I think you’re the one that is weird, Lisa.’ 

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     RF: risk factors; Sx: symptoms; Lab: laboratory; RhF: rheumatoid factor;   
IBD: inflammatory bowel disease; Tt: treatment.

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