Joints

"Bend your knee," I told the man sitting on the exam table.

"Wha?" he grunted in reply, his gravelly voice emerging past worn and green teeth out of a mouth surrounded by a lined and stubbled face.

I raised my voice. "Bend! Your! Knee!"

"Oh-kaay," he responded, and slowly his lower left leg rose until the joint was straight. His body odor was enough to take my breath away, but I had to touch his dirty epidermis. I put my right hand on the top of his thigh between his aged knee and his tattered boxer shorts, my left on his shin and then flexed the leg downward.

He yelped. "Owww!"

"Yes…" I could feel the resistance in the joint.

"I told you it's only arthritis!"

Moving the joint back and forth I could feel a stuttering catch as I bent his leg. I released him, and wincing, he twisted his leg about. "Damn," he muttered.

"Other leg."

Sighing, he raised his right leg, and I repeated the process. The left leg was the worst.

"How long have the knees been troubling you, Mr. … Jenkins?"

"Johnson, I told you afore!" he protested. "And the knees been a mess for long, long time." He stared at me with red-rimmed eyes. "Longer than you been at this."

"Mm." I glanced at his notes; he was sixty-eight but looked much older.

"Been rode hard and put away wet my whole life, you see," the man cackled.

He had a heart murmur - which I had confirmed - crepitatious breathing listening to his lungs, documented low-stage diabetes, and something else. "Says here," I flipped his notes over, "you were in the Navy."

"Aye," he replied. "Boy and man both." He winced when he moved his torso.

"Is your abdomen sore?"

"Yeah. Been a right pain in the arse," he laughed, "but higher."

"Lay back."

"Wha?"

"On your back. Pull up your shirts."

He did as I asked, grimacing at the change in position, pulling up his dirty flannel shirt and the undershirt underneath.

I palpated his abdomen, and found his stomach to be bloated, and he yelped loudly when I touched his tense belly. "Toileting?"

"Been a bloody mess, at the back I mean."

"Long time?"

"Aye."

I stared into his red eyes. "Do your eyes hurt?"

He looked at me with worry. "Yep. They ache a lot, Doc."

"And you are tired," I prompted him.

He nodded. "Yeah, a bunch. Seems like I just can't keep any energy." He coughed, something he did every minute of so.

"And you have been coughing this whole time."

"Yes," the patient cleared his throat. "Can't shake it. Hay fever."

Dr. Barrows was suddenly at my elbow. "Ellingham, Mr. Johnson has been complaining of joint pain, especially knees," he said, directing me. Barrows was observing my practice patient exam. The clinic pulls in a bunch of people, gives them a few quid and now this dirty person was under my care.

I turned to Barrows who was proctoring this practice exam. "Who vetted this person?"

He glared at me. "I did."

"Well, you missed the fact that he is quite ill." I turned to the man on the exam couch. "You have lost weight." His arms and legs were scrawny, not unexpected given his general debilitation, however joining all the symptoms into one cause, it was obvious to me.

The patient nodded his head slowly. "Suppose I have. A bit maybe."

I scooped up the notes and held them in front of Barrows' eyes, pointed to the weight measurements. "Lost a stone in the last six months."

"Almost seven kilos." Barrows grumbled but then snatched the notes out of my hands, flipping back through the pages. "Yes, I see…"

I made the man sit back up, then turned to Barrows. "Chest – listen."

"Hm. Right." Barrows took his own instrument, held it to the man's chest. He held the cup there for many seconds, moving it at last from over the heart itself to under the left arm. He finished the exam. "Murmur is quite loud."

"And squishy," I prompted him. "Check the lymph glands. I didn't palpate them, but I can tell they are swollen."

"Did hear those heart sounds," Barrows said. He turned back to the patient, palpated under his arms and his neck.

"Wha's goin' on?" the patient asked, his voice shaking.

"Swollen lymph glands," Barrows nodded to me. "What's causing that?"

It all added up. Joints, lymphatics, heart, the cough, and the weight loss. "Whipple's disease. Endoscopy and biopsy should confirm it. I suspect there is pericarditis as well."

Barrows shook his head. "You put it all together and I…" he gulped, "missed it." He stared at me for long seconds. "This was a practice exam."

I cleared my throat. "Ahem, nonetheless, this case has a heart murmur, joint pain, bloody stools, weight loss, a cough, and swollen lymph glands. It all adds up. Eye pain as well. Whipple's disease."

The man on the couch stared at me horror stricken. "What in bloody hell you two talkin' about?"

I turned to the patient. "Whipple's disease is a bacterial infection of the intestine. A bacterium named T. whipplei has infected your digestive system. The disease prevents proper absorption of food and vitamins and the other symptoms you are experiencing are a result of those deficiencies. Your past 'hard life' as you stated can also make the disease worse."

"Am I gonna die?" the patient asked his voice trembling.

"Not today, but a long-term course of antibiotics will put you right."

Barrows coughed. "Mr. Johnson, we'll get you started straight away on a course of treatment."

"How long's that gonna take? I got things to do!" the man protested.

I added, "It will require intravenous antibiotics for at least two weeks and then oral medication for a year."

Jenkins - or Johnson - blinked at me. "I suppose I orter thank you."

"Doing my job," I replied. "And while you are in hospital dieticians can inform you on eating better foods which will help your recovery plus social services can advise you on better personal hygiene."

"I take a bath once a week!" he protested.

"And wash your clothing. They stink of body odor and urine, not to mention the rest of you."

Barrows grimaced as I said the last. "Mr. Johnson you can get dressed now and then we'll get you over the main hospital." Barrows pointed to the door, so I went out. When he came out and the door swung shut, he took my elbow. "Ellingham, that was unexpected."

"Oh?"

Barrows shook his head. "Good thing we… you… picked that up."

"Yes. Straight forward, actually."

"But – you're a surgeon!" protested Barrows.

"Vascular. Yes."

Barrows stared at me over his half-glasses. "Hm. How did you…?"

"I read a lot."

"Must have an excellent memory."

I nodded assent.

He glared at me. "But about patient names. You kept flubbing his name, Ellingham. You need to work on that."

"Right."

Barrows sighed. "Next time I observe you I expect you to get that correct."

"Yes," I answered.

He walked away from me, shaking his head.