For Student

You have been called to see a 72-year-old man who lives alone at home. The district nurse has
become increasingly concerned about his health. The patient has been housebound for some time
but is now unable to rise from his chair. He is a large man and his left hip is very painful. There is
no history of a fall. He is unkempt and his clothes smell of urine. He is a heavy smoker, and he is
breathless and wheezy with a chronic cough. His legs are swollen and blistered. Detailed
examination is difficult but reveals signs of airflow obstruction, cyanosis, elevated JVP and
peripheral oedema. Movement at the left hip is restricted and painful. He is very reluctant to leave
his home.

Tasks:

1.What investigations would you perform?

2.What treatment options are available?
3. What are the likely causes of his immobility?
4. What can be done to improve the situation at home?
Student’s name
For examiner

You have been called to see a 72-year-old man who lives alone at home. The district nurse has
become increasingly concerned about his health. The patient has been housebound for some time
but is now unable to rise from his chair. He is a large man and his left hip is very painful. There is
no history of a fall. He is unkempt and his clothes smell of urine. He is a heavy smoker, and he is
breathless and wheezy with a chronic cough. His legs are swollen and blistered. Detailed
examination is difficult but reveals signs of airflow obstruction, cyanosis, elevated JVP and
peripheral oedema. Movement at the left hip is restricted and painful. He is very reluctant to leave
his home.
Task 1 (3.0) Basic investigations should include:
hip radiograph (essential for osteoarthritis or avascular necrosis of femoral head or fractured neck
of femur) FBC (secondary polycythaemia and infection) renal function tests (uraemia and
electrolyte imbalance) measurement of ABGs should be considered because of the signs of
respiratory failure and possible hypercapnia chest radiograph and ECG (to support the diagnosis
of chronic obstructive pulmonary disease [COPD] and cor pulmonale) peak expiratory flow rate
or spirometry before and after inhaled bronchodilator will confirm COPD and determine the degree
of reversibility.
Task 2 (3.0) Management will be difficult at home as a result of the need for radiographs and
specialist tests, and the presence of respiratory failure. Brief hospital assessment (a rapid-access
day hospital clinic or short-stay elderly care ward) is advisable to confirm the diagnoses and assess
the degree of respiratory failure. Time will be needed for rehabilitation and adaptations to the home
environment. Treatment will be along the following lines:
 analgesia for osteoarthritis (avoiding opiates and non-steroidal anti-inflammatory drugs
[NSAIDs] if possible – potential respiratory depression and fluid retention, respectively)
 bronchodilators, controlled oxygen and cautious use of diuretics for COPD and cor
pulmonale
 laxatives and enemas for faecal impaction or constipation
 in due course, consideration of hip replacement if the patient is agreeable and
cardiorespiratory status permits.
Task 3 (2.0)
The likely causes are:
 osteoarthritic hip – a hip fracture is less likely as a result of the chronicity of the symptoms
and absence of trauma
 COPD (chronic bronchitis and emphysema) and cor pulmonale
  urinary incontinence caused by immobility – almost inevitable in this situation, perhaps
exacerbated by coexisting prostatism or faecal impaction.

Task 4 (2.0) Much depends on the patient’s potential to improve and the feasibility of hip
surgery. Adaptations to the home with appropriate seating and bedding, and a review of toilet
and washing arrangements, will be necessary. The patient’s ability to climb stairs safely will
need to be assessed. He will need assistance with shopping and other household tasks. A
multidisciplinary team approach is required to resolve these various issues, including
physiotherapy, occupational therapy and social worker involvement. Early discharge from
hospital can be achieved with forward planning and use of domiciliary rehabilitation services.

Final score: