After thirty years, a case of Reiter’s syndrome, and my last Keosauqua patient shatters my complacence.


When I stopped to check out the heart,

The rhythm gave me a start.

     It was going too fast,

     And that patient, the last,

Went out on the ambulance cart.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks off, I’m having adventures, working, and visiting friends and relatives.  I’ve been on assignment in Keosauqua, in southeast Iowa.

Today I finished my last clinical day in Keosauqua.  The first patient of the day and the last patient of the day each gave their permission to write the information below.

Reiter’s Syndrome includes the triad of conjunctivitis (inflammation of the eye membranes), urethritis (inflammation of the lower urinary tract), and synovitis (joint inflammation).  Such a constellation signals the body’s abrupt inappropriate reaction to an infection; while attacking germs, the defense mechanisms start to attack the person’s own tissues. 

Separately, each of these three items comes as common as rain, and for the last thirty years I’ve asked each patient with one of them about the other two.  I also ask about fever and rash.  The interview sequence qualified long ago as low-yield, but I persisted for sake of thoroughness, and, later, from habit. 

Over the years, my interview technique has evolved.  In the beginning I listen, later on I ask focused questions.  Today, when I said to the patient, “Tell me more,” three sentences in quick succession revealed knee pain, discharge from the eye, and discharge from the penis.

For the first time, ever, today I made the diagnosis of Reiter’s Syndrome.  I started the proper lab investigation and turned the case over to a colleague.

For those interested in medical history, Christopher Columbus suffered from Reiter’s Syndrome on his last voyage.

The last patient of the day came in with a routine complaint of cough, also a frequent problem in temperate climates in the winter.  Such symptoms have been going around Van Buren County during my short stay here, and I anticipated ending my tenure routinely.

The human condition tends towards complacence.  We tend to “know” we’ll find a normal cardiac exam singing “lub-dub, lub-dub.”  If those sounds don’t come through the stethoscope, the brain tends to want to make the perceived sound fit into the expected sound.

Today it didn’t.  “Breathe normally,” I told the patient, and tried to hear the heart sounds over the abnormal breath sounds.  Unsuccessful, I said, “Hold your breath.”  The first and second heart sounds refused to distinguish themselves; the first kept shifting in timing and character.  And the rate came way too fast.

I took my stethoscope off and checked the pulse, which came through nice and regular.  I listened to the heart again.  The chaotic rhythm pounded irregularly irregular. 

The reassurance I sought from the electrocardiogram fled before my eyes.  Yet the patient had no heart symptoms at all; no chest pain or sensation of his heart racing.

I grabbed one of my colleagues and showed him the strip.  In short order we had sent the patient off in an ambulance.

We agreed that the weird stuff is out there.

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