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A case that reinforced my practice: neurology in the community
  1. Leone Ridsdale
  1. Correspondence to Professor Leone Ridsdale, Clinical Neuroscience, King's College, IOP, King's College London, IOP, PO 41, Denmark Hill Campus, London SE5 8AF, UK; leone.ridsdale{at}

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After I had been in general practice for several years, I joined a local sports club. This brought me into sometimes problematic contact with past, present and future patients. There were lots of older men at the club, who continued to play sport, despite gradual physical decline. They usually liked to play tennis with other men, and mostly they accepted their declining performance gracefully. Many of them made up for lack of mobility by employing long-practised skills, charm and humour.

One man was an exception. He evidently had been a good athlete in the distant past. He was thin, spidery and bent at the ankles, knees and back, making it difficult to walk. He had completely lost his sense of humour about his declining abilities. Everyone tried to avoid playing with him.

Local general practitioners (GPs) occasionally would ask my advice on their patients, knowing of my training in neurology and with such long neurology outpatient waiting times. On one occasion, I was asked to do a domiciliary visit for a neighbouring practice on an older man who was behaving increasingly irascibly, particularly towards his wife. Apparently her husband had been locking her out of the house and had written letters accusing her of having lovers. The deterioration in behaviour had occurred over such a long time, that it was difficult to know quite when it had started. The man was becoming impossible to live with. Her husband did not agree that there was anything wrong with him.

I could see that getting the patient to agree to see me at his home was going to be challenging. It was then that I recognised his name, and realised that this was the bad tempered man from the club. I saw him, and managed to gain a limited interview. It was difficult to do more, as he was keen to assert that he was fine. I did persuade him to have some blood tests, and requested a B12, T4 and VDRL. Although these investigations are intended to identify treatable causes of memory decline and abnormal behaviour in adults, in my experience they were almost invariably negative. I performed them almost as a ritual, in the faint hope of finding something.

Sometime later I attended a grand round at the neurological centre. The Registrar presented the history of an older patient who had become paranoid, and had been admitted to a psychiatric hospital under a Sectioning Order. The patient's GP had telephoned shortly after the admission with results of blood tests taken on a domiciliary visit. The VDRL was positive, and his wife's was weakly positive too. I heard my patient's story spun as ‘classical’ tertiary syphilis, with Charcot joints. There was general wonderment…a textbook case…almost never seen nowadays. At the end, the group quickly concurred, penicillin was indicated for the patient, and for his wife.

I continue to test for syphilis but moved to a sports club a greater distance from my home.

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  • Competing interests None.

  • Provenance and peer review Not commissioned. Internally peer reviewed.

  • Funding None.

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