Miscellaneous cases in the elderly

Chapter 38 Miscellaneous cases in the elderly

Case 38.1

History

Martha is a 75-year-old woman who presents with shortness of breath. She notices this most when walking up a flight of stairs. She can walk slowly for about 10 minutes on a flat surface before becoming breathless.

Occasionally she wakes up during the night with a feeling that she cannot get enough air into her lungs. When this happens, she gets out of bed and stands by her open window, which eventually eases that feeling. She states that she needs to be propped up on three pillows in order to sleep comfortably.

Martha has also noticed that her ankles get puffy by the end of the day, but that they seem to be better by the next morning. However, sometimes she awakes with puffiness in her face or hands.

These symptoms have been developing gradually over the last 12 months, slowly increasing in severity. She has also noticed increasing fatigue, and will often have an afternoon nap because she ‘cannot keep her eyes open’.

Martha states that she often wakes at night with the need to urinate, and this has been a problem for a number of years. Her urinary frequency and output do not appear to have changed over this period.

Martha had a hysterectomy at age 50 due to the presence of multiple uterine fibroids, and a hip replacement at age 60 due to severe osteoarthritis. She also has osteoarthritis in both hands and knees, for which she takes Ibuprofen.

System review is unremarkable.

She is a non-smoker, a social drinker and is married with three adult children. Martha says her diet is reasonably balanced, but her appetite has lately been diminished.

Physical examination

Vitals	•Pulse rate/min	94, regular
	•Respiratory rate/min	20
	•Blood pressure mm Hg	145/95 sitting 140/90 standing
	•Temperature (degrees C)	36.4
HEENT	Face appears flushed
Neck	Jugular venous pressure (JVP) — 4 cm Carotids — bruit heard on right side
Chest	Heart • Apex beat — displaced 3 cm lateral to the mid-clavicular line • No parasternal heave • Auscultation: heart sounds — triple rhythm • No murmurs Lung fields • Percussion: dullness at both bases • Auscultation: vesicular breath sounds reduced but no bronchial breath sounds; crackles at both bases
Abdomen	Mildly obese, soft and non–tender, no organomegaly
Limbs	• Pitting oedema at both ankles • Peripheral pulses: present
Neurological	Grossly normal

Case 38.2

History

Anthony is a 76-year-old retired accountant who presents with a worsening cough. He has complained of a daily cough for many years, which he admits is ‘self-inflicted’ due to his refusal to quit smoking. Normally he wouldn’t seek help, but he has noticed a definite change in the intensity and frequency of the cough. For many years, it occurred predominantly in the mornings, and was productive of white sputum. Over the past 6–9 months, however, it has gradually become more prolonged, and now occurs at any time of the day or night. Anthony has not noticed any blood in the sputum, but says he doesn’t really look at what he coughs up. His energy levels are diminished, and he notices that he gets short of breath after only minor levels of activity. This does not seem to get any worse when lying in a horizontal position.

He has smoked since the age of 16, and averages 20 cigarettes per day. He drinks 3–4 midis of beer daily, although admits that his alcohol intake pre-retirement was actually much higher.

He occasionally had attacks of acute bronchitis, especially during the winter months.

Anthony lives with his wife, and has four adult children. His father was also a heavy smoker, and died from a myocardial infarction at the age of 57.

He has no chest pain, abdominal pain, back pain, headaches, dizziness or digestive complaints. He admits to a few problems with urination, characterised by some hesitancy in initiating the flow, and that it takes a long time to complete it. Anthony states that this is not a new problem, but is progressively worsening.

He has also noticed some weight loss (3 kg in the last 2 months), but says that it is because he is ‘just not that hungry’.

Physical examination

Vitals	•Pulse rate/min	76
	•Respiratory rate/min	20
	•Blood pressure mm Hg	140/86
	•Temperature (degrees C)	36.9
HEENT	No swelling of head or neck, colour normal
Neck	No lymphadenopathy
Chest	Heart sounds normal, no murmurs
	Scattered wheezes over both lung fields, no crackles
	At the left base there is dullness to percussion and decreased vesicular breath sounds
Abdomen	Soft, non-tender, no masses
Limbs	Unremarkable
	No clubbing of digits
Neurological	Unremarkable

Tags: Cases in Differential Diagnosis for the Physical and Manipulativ

Dec 26, 2016 | Posted by admin in MANUAL THERAPIST | Comments Off

Full access? Get Clinical Tree

Get Clinical Tree app for offline access

Get Clinical Tree app for offline access