Monday, 30 June 2008

Examination

I'm glad to say that things have been going well chez Brown. We've had some happy family events and a bit of holiday, and I've not been feeling too stressed. That tends to mean that there isn't so much to blog about - the happier I am, the less I write. But I intend to post from time to time, when something interesting crops up.

Today I was asked to visit an elderly lady in a nursing home. She mostly sits in a wheelchair, but staff had noticed recently that she complained of pain in her left leg when she stood up. Paracetamol didn't help. She was brought into the treatment room in her wheelchair, and I liked her straight away. She has considerable memory problems but she is chatty and cheerful, and of a generation who consider seeing a GP to be a privilege and not a right. It seemed fairly clear that she had bad osteoarthritis in her left hip. Her right hip had been replaced some years ago but the left hip had not, because of deteriorating general health. From the limited examination I could do with her sitting in the wheelchair the left hip was stiff and painful to move. I was already running through my plan of action. It looked as though she would benefit from an NSAID, although these drugs can do a lot of harm in the elderly and her renal function is already a bit impaired. Nevertheless, it seemed unkind to leave her without adequate pain relief, so I was thinking along the lines of starting an NSAID with PPI cover. (You can ignore these technicalities, they don't really matter.) The diagnosis of arthritis seemed obvious and I had no reason to think she had suffered any trauma. The nursing staff didn't remember her having a fall.

And yet I wasn't really happy to leave things like that. I wouldn't be doing my job properly without examining the hip fully. When you are old and demented you can't help yourself, you rely on other people doing their jobs properly. And in the back of my mind was the sad tale of my mother, whose final deterioration towards an ignominious death began when she fell and languished on the ward of a German orthopaedic hospital for several weeks with fractures of the pubic rami that were not diagnosed until she was brought back to our local hospital and seen by an astute house officer.

So I asked the staff to help her onto her bed, where it was immediately obvious that her left leg was 3cm shorter than the right, and that her hip joint was very tender and immobile. She had fractured her hip, and the plan of action changed to immediate hospital admission.

You can take this tale either way. Perhaps I am to be congratulated for getting the diagnosis right. Or maybe I should be castigated for even considering making a diagnosis without a full examination. But there are learning points for any doctors-in-training who may be reading this. Always carry out an adequate examination, even though it may be inconvenient. And you should do your best for each patient, not because you have a duty to do so (though you do), but because they are human like you. That patient could be your mother, and one day it could be you.

10 comments:

Anonymous said...

thanks and well done

if only the useless butchers looking after my father were half as decent

Gimlet said...

Great to see you posting again. I look forward to more, although that is tempered by the admission that more posts means you are not so happy. Perhaps you could try and post when you are happier (sort of passing on a bit of your happiness?). Anyway, it's good to hear that the elderly lady's problem was diagnosed and also good to hear that she in a home that bothered to call you in the first place; I gather that many wouldn't even have bothered.

Take care!

raconteur said...

Good story. I work in a hospital where 80% of our patients can be classified as elderly. At 3AM at night when you are seeing your 10th confused elderly lady, sometimes I curse. Then I think of my own parents and perspective comes back. We need people like you to add a little more than knowledge to our work.

steph said...

Having just spent the day in the nursing home with my mother who suffers from dementia, is wheelchair bound, and relies on other people for EVERYTHING... I want to say a big THANK-YOU for writing this post.

The elderly lady you describe, might just as easily have been my mother (to the tee) about five years when she was still at home. She'd already had one hip replaced, was semi-mobile, having frequent falls and was found to have a broken hip (other one) three days after a fall.

I'm so sorry to hear the sad tale of your mother's experience and subsequent demise.

Dragonfly said...

Right on. Keep up the good work!!

Lulu said...

Thankyou for your wonderful post. As a medical student in Australia on my GP rotation, it is great to hear of someone bothering to do a proper examination on a nursing home resident. My GP supervisor always asks me "what would you want done if this patient was your mum/grandma/spouse/sibling."

Xavier Emmanuelle said...

Right on Dr. Brown, well done.

Dr Andrew Brown said...

Thank you very much everyone for your comments, which are kind and supportive as usual. I'm glad that you enjoy reading these postings, and I will try to continue writing them.

Ms Medic said...

Thank you Dr Brown for providing the insight into the thought process that we don't otherwise get to see. For us beginners it can seem that plans of action pop fully formed into our seniors heads, making it hard to imagine ever getting it right. You make it seem more human and admirable somehow.

Dr Andrew Brown said...

Ms Medic: I certainly agree it would help if seniors involved in teaching sometimes explained their thought processes. I've just written another post on this subject which you may find helpful.

And congratulations on becoming Dr Medic. :-)