Description: During placement I had the pleasure and privilege to meet MW, a 76 year old lady. She suffers from Osteoarthritis in both knees, and this was diagnosed by her GP. She presented with symptoms of joint pain and stiffness in both knees in her 50’s (she has been suffering for over 20 years) Her GP referred her to a consultant rheumatologist who did X-rays to confirm the same. As she had tenderness, discomfort and restricted movement in her knee joint she had a partial knee replacement in her left knee in August 2016. Since the operation and after undertaking physiotherapy she has full range of motion in the right knee. She has swelling and reports a dull ache in her unoperated right knee which is due for a partial knee replacement in February 2019. She is eagerly waiting for her operation to regain full mobility in her lower limbs.
She resides at her home with her husband, and her background is that of a home-maker. She lives in a two-storey house (and has lived there for over 50 years) which is located at the top of a very steep hill. Her ability to climb up the stairs, drive and walk the dog up the steep hill has been impaired by her condition.
When taking her history and so as to find out if there had been excessive use of her joints, it transpired that four decades ago she used to drop off and pick up her four children from school every week day at the adjacent valley. The one-way journey was a 30 minute walk downhill at a gradient of 18% and she used to wear a basic plimsole/pump shoes which was all she could afford.
MW would also undertake a five mile journey on a daily basis in addition to the school run. Her mother was diagnosed with Alzheimer’s Disease which lead to Dementia and MW would drop off lunch and dinner for her mother. When MW was in her 50’s, she experienced pain in both knees and found activities of daily living progressively more challenging. As a Christian, she attends church every week and finds it difficult to walk in a straight line up the aisle to receive communion- this left her feeling upset with her state.
Feelings: I wasn’t sure what to expect. Having volunteered with elderly people at a residential home during sixth form, I was used to interacting with elderly people. This was the first time I was making a home visit and taking on a more clinical role as a medical student rather than a volunteer. Some pre-conceptions I had were that she may be apprehensive and not willing to open up as I was a stranger to her. I was also scared that I may ask her questions that may offend her or discuss sensitive information with her that she may not wish to discuss further.
The GP that co-ordinates the care of MW calmed my nervousness and anxiousness by reassuring me that MW is such an open and kind lady. She has met several medical students and happily shared her story for the past 5 years. When I met MW, I was struck by her optimism. Her condition has not deterred her from leading an active family and social life. The couple was so friendly and kind when my partner and I first walked in. I noticed that the stairs that led to her bedroom were steep and that the furniture in the living room was scattered in a way that she would be able to lean on them when walking from one end to another. She answered each and every question that we had and I was surprised when I saw how many medications she has to take on a daily basis. I found it challenging to hear her difficulties and found it insightful when she told me had challenges with walking downhill by herself, being unable to reach the landline before it stops ringing and being unable to drive. She has pain walking up and down stairs and her unoperated knee would stiffen if she sat idle for too long.
We had studied the science behind Osteoarthritis in lectures yet meeting MW and interacting with helped me to view her day to day challenges in a practical and meaningful way. I learnt that in her left knee, the degeneration occurred in a lateral to medial fashion which is unusual as it is usually the other direction that it occurs.This was noticed by the consultant who operated on her in 2016. I was shocked when she told me how quickly she had recovered after her partial knee operation, having been operated on Monday morning and being discharged on Wednesday evening. Starting on a zimmer frame, she moved to crutches and then progressed to a walking stick within 4 weeks. She told me how useful she had found the Physiotherapist that attended to her in the hospital and I later learnt about their role in rehabilitation.
I found that as this was a home visit, MW was directing the conversation more towards the social aspect of her life rather than at the clinical, as she was much more open to answering questions and elaborating when asked about her life story. She was happy to tell me that she is the mother of four and grandmother to four grandchildren. When we took a Full Medical History some of her answers, I noticed were more closed off and she did not wish to expand. She retold her story in a mixed chronological order and would go off topic at times. I learnt that she did feel that her management ended up being long winded, especially with the hospital waiting list.
Her husband is highly supportive and drives her to the local park which has a much gentler slope where they are able to walk the dog and get fresh air in the mornings and evenings. She has adapted to her situation by to climbing up the stairs to her bedroom by using a sidestep motion. She also has a walking stick and furniture is carefully positioned in the house so she can use it as a hand support.
I read an article by A. Shane Andersonand Richard F. Loeser(2009) which informed me that ‘osteoarthritis is the most common joint disorder in the world and one of the most common sources of pain and disability in the elderly’ so I learnt that increasing age is a high risk factor in osteoarthritis.
Before meeting MW I had not considered the physical implication of chronic illness, which promoted me to read an article by Di Chen. et al. (2017) which taught me that ‘Currently, apart from pain management and end stage surgical intervention, there are no effective therapeutic treatments for OA’ This prepared me to be more understanding to MW and her mental and social needs. Her condition was one which had altered her way of life in terms of engaging in activities of daily living as aforementioned.
MW did mention briefly that her mother had issue of walking in straight line as she got older yet I did not ask any follow up questions. When I read an article by Ananthila Anandacoomarasamy and Lyn March (2010), I learnt that a common risk factor for osteoarthritisis genetics. I feel that I should have been more confident in my history taking and asked more clinically relevant questions in this regard whilst taking the patient history.
Action Plan: If I were required to do anther home visit, I would be more thorough in my history taking. As I am a medical student and have not qualified, there are many things I am yet to learn, so I will not be as hesitant to ask as many questions.
I would have the basic structure written out and refer to my notepad more. I believe that practice is important in effective history taking, so I would speak to the Clinical Skills tutor in the Self-Directed Learning zone and get their guidance and practice my history taking technique to prepare me better.
I also believe that I need to adjust my approach my consultation towards chronic pain. I will do research into what causes OA, which would allow me to direct the conversation towards a more clinical direction. I would ask the advice of my personal mentor who is a GP and has 10 minute consultation slots. The articles mentioned pain management, I wish to read articles relating to the painkillers and NSAIDS that are commonly used to settle pain as a direct cause of OA.
I would also research mechanisms patients use to cope with their situation when surgery is not an option or is to be delayed for several years.
Word count 1471
Auther: Robbie Anand
Shane Anderson, A and Richard F Loeser. “Why is osteoarthritis an age-related disease?” Best practice & research. Clinical rheumatology vol. 24,1 (2010): 15-26.
Chen, Di et al. “Osteoarthritis: toward a comprehensive understanding of pathological mechanism” Bone research vol. 5 16044. 17 Jan. 2017, doi:10.1038/boneres.2016.44
Anandacoomarasamy, Ananthila and Lyn March. “Current evidence for osteoarthritis treatments” Therapeutic advances in musculoskeletal diseasevol. 2,1 (2010): 17-28.