All Things Come in Threes

One saying we have in medicine is that all things come in threes.  That means if you admit someone with pneumonia, you can expect two more are on their way.  To me this “coincidence”, which has happen numerous times throughout my training, is actually the providence of God.  Because after you’ve seen a medical condition present three similar but different ways, and you care for all three patients at the same time, you’ll never forget ever again.  One of these “providences” actually occurred this week for me. A condition that occurs commonly in Peru for whatever reason is rheumatoid arthritis.  I’d yet to have diagnosed this condition—though I found lots of osteoarthritis due to patients age, long history of manual labor, and being overweight. 

                My first lady was in her 40’s, had be diagnosed with “maybe arthritis” two years earlier at a different hospital and started on Prednisone (an oral steroid) 5mg twice a day, and was suppose to follow up with that doctor.  The Prednisone worked well for her so she continued to take it for two years.  (Two issues here.  Number one, patients don’t need a prescription to buy medications here, or at least not new ones.  Number two, prednisone is a very dangerous medication to take chronically, even when you have a doctor monitoring side effects and weighing risks and benefits of the meds in light of your particular situation/medical condition.)  Her rheumatoid factor came back 250ish (normal is less than 14).

                Later the same day I saw a 42 years old lady who looked cachectic and chronically ill.  When she took of her three pants and skirts to show me her knees that were hurting her I saw thin “chicken legs”, especially the left leg, with huge swollen, warm, painful to touch, knees.  She walked with great difficulty, much pain, and a limp. Her fingers were also painful but not as noticeably swollen.  I ordered some labs to evaluate for chronic illness and xrays of the knees.  Her left Knee joint was literally bone on bone.  Not even a millimeter of joint space.  The right knee joint had 1-2 mm in a couple areas of the joint.  The labs all came back normal except for her rheumatoid factor was 4500ish.

                As I was about to go home after seeing my patients for the day, I got a call from the hospital floor.  I was on call and a 26 year old male had just arrived to be evaluated for knee pain.  I took one look at him in a wheel chair with thin legs, huge swollen tender knees that hurt him even as I lifted his feet to pull his pant legs up.  Third time’s a charm.  I gave him a Toradol injection and a lab slip for the next morning since it wasn’t enough of an emergency to call the lab people in.  The next day his rheumatoid factor came back 300ish.

                I talked to both Kirsten and Dr. Martina and confirmed their recommendations with UpToDate when I got home and had a slightly faster internet connection.  Methotrexate is the mainstay here.  A Prednisone taper and Meloxicam are what you given to work immediately and make them love you and trust you. UpToDate says to consult a rheumatologist before starting Meloxicam….I guess we’re rheumatogists now. 

                P.S.  I saw a Juvenile Polyarthritis the next day.  Eleven years old female with warm painful ankles and elbows.  And with pain in her fingers as well. Treatment is similar.  Start Methotrexate early.