50. The Rings

 

        It was finally time. The last day of intern year and I would spend it at the clinic. Who would’ve thought, if you had asked PGY-0 Lisa, she would tell you she hated outpatients and would never work with them after residency. Who knew. It was the end of only the first year and I was already sure that I would definitely work in clinics as well.

I once thought patients couldn’t give me the answers I was looking for. MS4 Lisa Diaz thought the answers of modern medicine were in a patient’s labs, and sometimes on their physical. Boy was I wrong. Intern year was incredibly tough, but I had learned valuable lessons, the most important of them being that the patient is the one that tells you what they have. You just put a name on it.

So my last patient before becoming a PGY-2 illustrates just that. Gerard Penn, 66 years old. His notes said that he was sent to the clinic from Brooklyn Hospital. He had been admitted 2 weeks before for an episode of community-acquired pneumonia, but during his hospital stay they noted some cognitive dysfunction, so they scheduled an appointment at the clinic saying in the request note: ‘Dementia?’

‘Mr. Penn.’ I said in a loud voice at my office’s door.

A man slowly got up from a chair in the waiting room. He had white hair and his movements were slow but still he reached out his hand to lift an old lady that was sitting by his side. She was an elegant woman in her sixties, Mrs. Penn from what I could guess. I welcomed them both into the office and sat across from them. 

‘Good afternoon, Mr. Penn. I am Dr. Lisa Diaz, I am a resident here. How can I help you today?’

‘My mind has been letting me down lately. Adele thinks I should get this checked out… I am not sure if there’s help for this though.’ The woman nodded agreeing with him.

‘I see. How is your mind letting you down?’

‘Well, we have a hardware store downtown, me and Adele have taken care of everything there for the past 25 years. And I was always so great at math, you know, but now I am making a lot of mistakes with clients.’

‘When did this start, Mr. Penn?’ I said looking at both of them.

‘About a month ago, Dr. Diaz.’ Mrs. Penn answered and I waited for her to continue. ‘Since then, Gerard has been having problems even with simple math. And it’s not just that, he can’t write anymore either.’

I continued asking several more questions to characterize his difficulties. During the interview I could see it didn’t seem like a global deficit, or a dementia as interrogated in his chart. His wife’s complaints were quite specific, not to mention his sudden symptoms. His ability to maintain a conversation, cook a meal or recognize a loved one were pretty much intact. I quickly reviewed his systems and general health concerns, and it all seemed ok. In previous history, he had smoked and drinked for 30 years, but had quit when he was 60, after a transient ischemic attack.

I then excused myself from the room to find a piece of paper on which I could ask Gerard to write on. I ran into an excited Peter in the hallway, who gave me a scrap paper that was in his white coat pocket. 

‘See you tomorrow, PGY-2.’ He winked and left.

I opened the door on the way back and saw Mr. and Mrs. Penn waiting for me at the office. They were holding hands, which I remember thinking was pretty cute. But there was something off. It took me a couple of seconds but then I knew. His wedding ring was on his middle finger, not on his ring finger. I didn’t know what to make of that, but I decided to ask either way.

‘How long have you two been together?’

‘40 years.’ Mrs. Penn said proudly.

‘And what about your wedding ring? Do you usually put it on the middle finger, Mr. Penn?’

‘No, doctor! It’s called the ring finger for a reason.’

I shouldn’t, but I frowned.

‘Well, then you should switch it today.’ I pointed at his finger and he looked surprised as he suddenly realized he had been wearing it wrong.

‘That’s weird.’ He said with a hesitant laugh and switched the ring to his fourth finger. 

His wife caressed his hands and confided to me. ‘Lately, he gets them mixed up.’

I kept that in the back of my mind and asked him to write some sentences on the paper I took from Peter. He struggled badly, took a long time to actually write something and when he did, it looked terrible. The math was a failure also, I asked him simple questions and he got them wrong. I was almost getting up to discuss the case with the attending when something occurred to me. 

‘Mr. Penn, can you name this finger?’ I asked as I held his index finger.

He took his time thinking and asked unsure ‘Middle?’

‘Actually, that would be the index. What about this one?’ I said taking his fifth finger.

‘Humm… I am not sure. I think it’s the ring one.’

  A memory from the time I was studying for the boards came to mind. Acalculia, agraphia, finger agnosia. There was only one thing missing: left-right disorientation.

‘Now please point to your right eye with your left hand for me.’ After a little thinking he lifted the wrong hand and pointed to his left eye, then switched for the right eye. ‘Now use your right hand and point it at my left shoulder.’ This time he got it totally wrong.

I thanked him and excused myself one more time. I opened my phone and googled what I was looking for: Gerstmann Syndrome. He had all 4 signs. The cause in adults is usually ischemic, in the parietal lobe of the dominant hemisphere, classically on the angular gyrus. It’s not always so pure though, Gerard had the classic presentation, but most patients with parietal lesions have overlapping symptoms. He most likely had a stroke a month ago, which explained the sudden appearance of these deficits.

I got home excited to tell Jax all about this crazy textbook-like diagnosis I had cracked. We had a pineapple pizza night planned as a celebration for becoming second-years. I found him with 2 glasses of wine and the pizza box on the table. We ate more than we should and talked about all the things we would not miss from intern year, and I also told him about Gerard. By the end of the story, his expression got more serious.

‘Liz, speaking of rings, there’s something I need to tell you.’

He took a little black box from his pocket and opened the lid. A beautiful diamond ring shone inside of it.

‘I am proposing to Meg.’ I couldn’t hide the shock on my face.

‘Oh God, congratulations, Jax!’ I smiled and hugged him to hide my conflicting feelings.

All I could think of in that moment was that Jax would be gone soon. 

It would be just me from then on.

And everything would change.

…

Want to read more about Gerstmann Syndrome?

https://rarediseases.org/rare-diseases/gerstmann-syndrome/

Want to see what Gerstmann Syndrome looks like?

https://www.youtube.com/watch?v=GLJdcmSIoNQ

Clinical Board