TY - JOUR T1 - A Day in the Clinic JF - British Journal of General Practice JO - Br J Gen Pract SP - 983 LP - 987 VL - 56 IS - 533 AU - Danielle Ofri Y1 - 2006/12/01 UR - http://bjgp.org/content/56/533/983.abstract N2 - 8:30 AM: Doing intakes — interviews with new patients at the Bellevue Hospital Medical Clinic. First one is Carola Castaña, a petite 35-year-old Brazilian who immigrated to the US 3 months ago. She folds her hands in her lap as I begin to take her history. She understands my questions better if I ask in Spanish rather than English, but her Portuguese replies are Greek to me, so she struggles to answer in English.Her main complaint is that her joints hurt. Which ones? All of them.How long? Since age 12.Ever see a doctor? Once, as a child. They just told me that I had arthritis and gave me ibuprofen.No X-rays or blood tests? No.I start down the long line of questions, but we are stymied by language. I give up and reach for her hands. A principle of internal medicine holds that ‘It's all in the history.’ An astute clinician should be able to unearth any diagnosis just by asking the right questions. The physical exam is almost an afterthought, a mere confirmation of the already-ascertained diagnosis. But Ms Castaña silently and unwittingly puts this axiom to shame.Her history has led me nowhere, but her hands subsume the work of logical reasoning. Her hands are severely ulnar-deviated: the fingers sail off course, angling out to the sides instead of straight forward. They point away from her body as though she is gesturing for the waters to part. The tips crane upward, forming a line of swan necks. The joints that connect her fingers to her hands are swollen like robin's eggs — bulbous, bony protrusions. This young emissary from Brazil has handed me the hands of rheumatoid arthritis, untreated for 23 years. These are hands that I have seen only in textbooks.I explain … ER -