The two Mr Ms were admitted to a local nursing home at the same time from a nearby town. They had similar names and were friends. Apart from loss of hearing they were remarkably fit 90-year-olds. Mr M1 was said to suffer from angina and Mr M2 needed a small daily dose of insulin for his diabetes.
Mr M1’s chest pain was reported by the nursing staff, and local chest wall tenderness confirmed an apparent Tietze’s syndrome. However, he was seen lying on his bed, obviously quite distressed, after a small amount of exercise and this led to investigation of his angina. A haemoglobin (Hb) level of 70 g/L and further studies confirmed iron deficiency. A question arose about the cause of probable blood loss. The author, having just read Medical Choices, Medical Chances (Bursztajn et al., 1983), was determined not to ‘over investigate’ the situation.
Discussions with several doctors, including Family Medicine Programme trainees, indicated there was an inverse relationship between the intensity with which the symptomless iron deficiency anaemia should be investigated and the time since graduation. The obvious answer came from one group: ‘Ask the patient what he wants’. Mr M1’s reply was disconcerting: ‘Do whatever helps you, Doc’.
Ultimately, the decision was made to do a barium enema and leave it at that. This investigation revealed diverticular disease and the patient was started on oral iron. Three months later he had no bowel symptoms and his abdomen was normal on palpation, but he was still suffering from angina and the Hb level had increased only slightly.
Mr M1 later had a haematemesis. A hard mass palpable in the epigastrium was diagnosed clinically as a carcinoma of the stomach. Subsequent epigastric pain was relieved by oxycodone hydrochloride suppositories and oral morphine. He requested no medical intervention and died in his sleep two weeks later.
Then Mr M2 reported a mild intermittent pain in his right iliac fossa. An almost casual examination of his abdomen revealed a large sausage-shaped mass over the caecum.
Immediate referral to a surgeon confirmed the clinical diagnosis of a carcinoma. (Hb level was 97 g/L.) While the patient awaited a barium enema, the nursing staff thought he had ‘dropped his bundle’ because he started to vomit. The diabetes might have been out of control. Sixth sense suggested a visit to the nursing home while off duty during the weekend.
Mr M2 was found in constant pain, with slight abdominal distension and not looking quite as well as he had two days earlier.
An emergency laparotomy performed that day revealed a carcinoma of the caecum, which had perforated retrocaecally. A hemicolectomy was performed and Mr M2’s postoperative course was uneventful. His only complaint was that he could not remember much about the operation.
DISCUSSION AND LESSONS LEARNED
Apparently insignificant symptoms in otherwise well geriatric patients should be taken seriously.
Be prepared to discuss the need for investigation with patients no matter how old they are.
Presentation of serious pathology in elderly patients might not be as straight-forward as in younger people. With our ageing population in Australia, geriatric medicine is a discipline with which all general practitioners will have to come to terms.