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.