AM didn’t feel too well 24 hours previously after having feelings of nausea and lethargy. Next day she felt faint, went to lie down and blacked out. She then woke up on the kitchen floor. The fall was witnessed by the granddaughter who called 999. During the blackout AM was incontinent of urine and faeces. Granddaughter recounts that she fell onto the left side but AM did not recall the incident. She was not confused when she came round.
PMHx:
CABG – 12 years previously
Hypertension
Right total knee replacement – 6 years ago
Asthma
Previous syncopal episodes
DHx: NKDA
Drug Name
Dose
Indication
Ramipril
2 mg
ACE inhibitors, hypertension
Aspirin
75mg
Salicylate drug used for analgesia
Cocodamol
30/500
Compound analgesic
Omeprazole
20mg
Proton Pump Inhibitor
Quinune Sulphate
200mg
Antipyretic, Analgesic, Anti-inflammatory, Anti-arrhythmic
Seretide
1 puff
Beta receptor agonist for asthma
Salbutamol
2 puffs
Beta receptor agonist for asthma
FHx:
Mother and Father died of MI aged 76 and 94 respectively
Daughter – Advanced metastatic breast cancer
SHx:
Lifestyle
Alcohol: Social
Ex smoker: from 18-76, stopped after right knee replacement. 10/day
Exercise: Gentle walking
Diet: Reasonable is good, wife makes sure of this.
Occupation: Retired Rolls Royce Inspector
Lives at home with granddaughter and family
15 stairs to front door
Uses zimmer but wants to move to a walking stick
Systemic enquiry:
GU:
nil
GI:
Nausea: yes
Nil else
RS:
Cough with sputum
Nil else
CVS:
Chest pain: no
Breathlessness: yes
Oedema: no
Palpitation: no
No PND or orthopnoea
MSS:
nil
CNS:
Syncope
Examination:
1. General appearance:
Alert and well
2. Vital Signs:
Pulse: 59 regular
BP: 170/70,
T°: 36.6°,
SpO2: 98% on air
RR: 14
BMI:
3. Hands, nails, eyes:
o clubbing, o koilonychias, , o splinter haemorrhages
o cyanosis, central or peripheral o Jaundice oLeukonychia o Palmar erythema.
4. Mouth, tongue:
nil
5. Neck:
o cervical lymphadenopathy
GI:
Denied weight loss
Abdomen: abdomen soft, non tender
hepatomegaly: nil
splenomegaly: nil
Ascites: nil
Bowel sounds: present and normal
No palpable bladder.
RS
Rate: 14
Inspection: o
Trachea: central
Chest expansion: normal
Tactile vocal fremitus: normal
Percussion: normal
Breath sounds: Scattered crackles bilaterally
Vocal resonance: normal
PR exam:
n/a
CVS
JVP normal,
carotid pulse: 59 regular
apex beat: apex in 5th intercostal space MC line
Heart sounds: I + II + o
Oedema: o
Peripheral Pulses: normal radial, brachial, carotid, dorsalis pedis
Breasts:
nil
CNS:
GCS 15/15
GU
nil
Vaginal exam:
n/a
Urinalysis:
n/a
MSS
Pain on moving L lower limb
Power 5/5 all others
Investigations
Blood Test
Result
Normal Range
FBC:
Hb
RCC
Haematocrit
MCV
WBCC
Platelets
Neutrophils
11.2
6.7
343
13-18g/dl
3.9-5.6×1012
0.35-.5
79-100fl
4-11x109fL
150-400x109L
1.5-7.5 x109L
LFT
bilirubin
alk phos
G GT
AST
ALT
total protein
albumin
globulin
26
3-17umol/L
33-221iu/L
8-60
3-35iu/L
62-82g/L
37-50g/L
21-35g/L
U&Es:
urea
creatinine
sodium
potassium
chloride
bicarbonate
5.9
66
136
4
2.5-7.5 mmol/L
44-80umol/L
135-145 mmol/L
3.5-5.0 mmol/L
97-107 mmol/L
23-30
Glucose
(3.5-5.5 mmol/L)
CRP
199
2-10mg/L
Bone
APhos
Calcium
Phosphate
ECG:
Inverted T-waves, Sinus bradycardia
CXR:
R upper zone opacification, suspected tumour + infection
CT Scan:
Appearance consistent with primary carcinoma, density 3.1×2.5
Plan:
L hip replacement
Investigation of R upper lung opacity
Bronchoscopy + biopsy for confirmation
Consider a rail for the steps outside her home
Diagnosis
Left neck of femur fracture
Potential primary lung tumour
Reflective Commentary
I feel like AM was an interesting case for GMC themes 3 and 4 because she presented with an obvious fracture but had an underlying potential carcinoma too.
Clinical and practical skills
She was a useful patient in that I was able to see a variety skills implemented to help diagnose her. When she presented in emergency she first underwent a hip examination and then had standard clinical examinations afterwards.
The object of a hip examination is to look for pathology of the joint. The examination is purely physical. The exam itself is divided into 5 parts looking at position, inspection, palpation, motion and special manoeuvres. In layman’s terms it is split into look, feel and move.
Position is important as the patient must be lying flat and hands must remain by their sides with the head resting on the pillow. The knees and the hips should be resting naturally in the anatomical position. If possible the patient should be standing when being inspected. Obviously AM was unable to test gait but we look for antalgic gait in those out with the acute setting. The hip is then examined for masses, scars, lesions, trauma, surgery, bone alignment, muscle bulk and symmetry at the hip and knee. AMs leg was shortened and in external rotation. An example is shown below:
http://www.utahmountainbiking.com/firstaid/images/pics-firstaid/fxhip.jpg
Palpation merely involves testing pain over the ischial spines and the pubic rami. Movement is tested by examining the normal leg first and then the affected leg. The examiner will put the leg through various movements testing for pain or resistance. The movements tested are internal rotation, external rotation, flexion extension, abduction, adduction, assessment for flexion contracture. Finally the examiner will do a Trendelenburgs test. The patient is asked to raise one leg and if the test is positive the hip on the raised side drops. This is suggestive of weakness of the abductors of the other hip. A knee examination is often performed out with the acute setting looking for ipsilateral knee pathology.

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Because AM also had syncope it was important to do full examinations of the other systems too. I feel that this was an excellent opportunity to revise prior knowledge of basic examination techniques. The most important finding in her examination (hip exam aside) was the discovery of basal crackles and the productive cough. Since she was a long term smoker bronchial carcinoma should be high up on the list of diagnosis to rule out. After examining her blood results it was clear that something wasn’t right. Coupled with the fact she had weight loss she also had a low Hb as well as a very high CRP. Given that on her X-Ray and CT there was clear right upper lung opacity it is important to consider bronchial carcinoma as high up on the list of differential diagnosis.
Communication skills
AM was an interesting case from the perspective of communication skills as she was clearly in denial about the possibility of having lung cancer. When asked about how she felt about it she said she really did not think it was anything worth worrying about. I was not in a position to break bad news but I feel for the Dr who is, it would be a difficult challenge. The communication issues we have to address here are that before the fracture she felt she was completely fine. After injuring herself she now has a fracture and is being told she might have cancer. It is possible to assume that she may be going through the five stages of grief:
Denial
Anger
Bargaining
Depression
Acceptance
Through denial she is avoiding the implication that she is facing a life threatening condition. It is possible to avoid the 3 stages between denial and acceptance but this is only possible with good support from both family, councillors and the health care team around her.
Treatment of the fractured neck of femur
Treatment of the neck of fracture need input from several medical disciplines including the emergency services, departments of radiology, anaesthetics, orthopaedics, medicine and rehabilitation services. It also may require the use of social services as well such as in the case of AM. It might be wise to consider a rail for the 15 steps outside her house as well as arrange gritting to prevent ice in the winter.
Hip fractures are treated operatively either by open reduction and internal fixation (dynamic hip screw), or by a hip replacement (hemiarthroplasty). Some hip fractures are still treated by traction.
Dynamic Hip Screw
http://www.wheelessonline.com/images/i1/subtt3.jpg
Hemiarthroplasty
http://www.gentili.net/thr/images/t350/021-2Garden-IV-fx-tx’ed-w-b.jpg
Total Hip Replacement
http://www.bodyinmotion.co.uk/home/wp-content/uploads/2010/04/total-hip-replacement.jpg
Summary of care components
After admission:
Pain relief
Fluid replacement if necessary
Monitoring of fluid balance
Assessment of associated injuries and other conditions
Ward:
Help with eating post operatively
Nutritional support
Thromboembolic prophylaxis
Surgery
Surgery within 48 hours
Pre op antibiotic prophylaxis
Post op supplementary oxygen
After surgery
Mobilisation as soon as possible
Early rehabilitation and plans for discharge
Summary
AM was all round a very interesting case as she had many interesting issues to think about. She was an elderly lady who had fractured her femur during a syncopal episode who then turns out to have possible lung cancer. She was also clearly in denial about the possibility of having lung cancer. In the end the path was clear for the clinicians and surgeons to follow. She had to have surgery for her fracture and then the causes of her other problems must be identified. In due course the challenge of this ladies diagnosis will be unravelled and all her issues treated accordingly.