Chapter 38 Miscellaneous cases in the elderly

Case 38.1

1. Using only this information, list the possible causes of Martha’s symptoms, and justify your answer:

a dyspnoea

• left heart failure

• congestive cardiac failure

• aortic or mitral valve lesion.

Her dyspnoea suggests a cardiac origin, as the description she gives is that of orthopnoea and paroxysmal nocturnal dyspnoea. There is no indication from the history provided that her dyspnoea is respiratory, neurological or haematological in origin. The presence of oedema supports this rationale.

b ‘puffiness’ of face, hands and ankles

Her description indicates oedema which is dependent on gravity. The distribution of the oedema indicates that the cause is not a ‘local’ one, limited only to her lower limbs. Generalised oedema may be due to congestive cardiac failure, right-sided heart failure, or a disorder in which there is a decrease in plasma proteins available (eg: renal disease, malnutrition etc.).

c increasing fatigue

Many causes are possible. It is consistent with the disorders named in ‘a’ and ‘b’, but there is a possibility that it is an unrelated symptom.

2. What information from her history is given to indicate the presence of orthopnoea?

• The need to sleep with three pillows to be comfortable.

• Waking up at night with a need to get more air into her lungs.

3. What term is used to describe her ‘diminished appetite’?

Anorexia.

4. What type of drug is Ibuprofen? How does it work?

It is a non-steroidal anti-inflammatory drug (NSAID). It works by inhibiting prostaglandin production by inhibiting the action of the enzyme cyclo-oxygenase.

5. What symptoms may Martha have complained of, which would have indicated the need for a hysterectomy?

Dysmenorrhoea, menorrhagia, constipation, varicose veins, urinary retention or frequency.

6. What is your differential diagnosis for her current clinical presentation?

Congestive cardiac failure.

7. What do you need to examine in this patient?

Full examination is required, but specifically: vital signs; a cardiovascular examination; a respiratory examination; and inspection of conjunctiva.

8. What information can you obtain from these findings? Can you narrow your differential diagnosis?

The examination findings indicate the following:

• cardiomegaly

• pulmonary venous congestion

• systemic venous congestion

• hypertension

• carotid artery narrowing.

The signs are consistent with congestive cardiac failure.

9. Explain the significance of the following signs, in context of your differential diagnosis.

a flushed face

May be related to hypertension or systemic venous congestion.

b pitting oedema

Due to the inability of the right ventricle to pump effectively, causing systemic venous congestion, which causes an increase in the hydrostatic pressure in the systemic capillaries, which can result in oedema.

c JVP 4cm

Due to the inability of the right ventricle to pump effectively, causing systemic venous congestion.

d carotid bruit

Indicates narrowing in the carotid artery.

e displaced apex beat

Most commonly indicates an enlargement of the left ventricle, which most likely preceded failure of the left side of the heart.

f triple rhythm

Characteristic of heart failure.

g bilateral basal crackles

Presence of fluid within the alveoli.

h hypo-resonant percussion note at both lung bases

This indicates the presence of fluid or solid within the alveoli, or within the pleural cavities. Based on the other physical examination findings, it is most likely a result of fluid within the alveoli. However, it is important to note that small bilateral pleural effusions can also occur in congestive cardiac failure. Testing for vocal resonance (VR) will help to distinguish between these two possibilities. An increase in VR usually occurs when there is fluid within the alveoli, but a decrease in VR occurs when fluid is within the pleural cavity.

i reduced vesicular breath sounds at both base

The fluid within the alveoli prevents sufficient air from moving into the alveoli, thus causing a reduction in the vesicular breath sounds.

j tachycardia

This is a compensatory response to a diminished cardiac output. The sympathetic nervous system is stimulated, resulting in an increase in heart rate.

10. Will you refer Martha? What type of investigations are required? Why?

The patient needs to be referred to a medical practitioner. Investigations may include:^[1]

• chest X-ray

• electrocardiogram (ECG)

• blood biochemistry assessment (electrolytes, urea, creatinine and liver function tests)

• cardiac magnetic resonance imaging (MRI) is the investigation of choice — this test is very useful in assessing the aetiology of the heart failure, in addition to structural and functional abnormalities. However, availability and suitability of this procedure is limited. Alternatively, echocardiography or a radionuclide multiple gated acquisition scan may be chosen.

• other investigations may include: B-type natriuretic peptide levels, blood gases and pulse oximetry.

11. What information does the X-ray give you?

There is cardiomegaly and accentuation of perivascular and peribronchial vessels, indicative of pulmonary oedema. Some unfolding of the aorta can be observed.

12. Using only the information provided, can you determine possible reasons which would explain the development of her condition?

Possible reasons are:

• hypertension

• left ventricular hypertrophy (left ventricle has to work harder due to the increased pressure in the aorta)

• left heart failure

• pulmonary venous congestion

• pulmonary resistance increases

• right ventricular hypertrophy (right ventricle has to work harder due to the increased pressure in the pulmonary vasculature)

• right heart failure

• systemic venous congestion.

13. What are other possible causes of this disease in the general population?

The following description refers to causes of both left heart failure and right heart failure. Congestive cardiac failure is most commonly a result of two events: the left heart fails first, and the right heart eventually fails as a consequence of this event. However, in cases of ventricular muscle disease, both sides may fail simultaneously.

• Pressure overload — the work of the ventricle is increased when it is required to work against an increased pressure. Examples:

systemic hypertension → excess load on the left ventricle → left ventricular (LV) hypertrophy → eventual LV failure.

chronic lung disease → pulmonary hypertension → excess load on the right ventricle → right ventricular (RV) hypertrophy → eventual RV failure.

• Volume overload — the work of the ventricle is increased when required to cope with an abnormally high volume output. Examples:

aortic incompetence, mitral incompetence, aortic stenosis, patent ductus arteriosus all increase the volume of blood in the LV → LV hypertrophy → eventual LV failure

mitral stenosis → pulmonary vascular congestion → increase volume load in RV → RV hypertrophy → eventual RV failure

atrial septal defect, tricuspid incompetence → increase volume load in RV → RV hypertrophy → eventual RV failure.

• Control mechanism defect; for example, defects in the conducting system (eg: cardiac arrhythmia → inefficient pumping action).

• Ventricular muscle disease. Examples:

secondary to coronary artery disease

primary disease of heart muscle (cardiomyopathy)

inflammation and toxic degeneration of myocardium (eg: myocarditis).

These may cause either left or right ventricular failure.

Case 38.2

1. What is the likely cause of Anthony’s long history of cough and sputum?

Chronic bronchitis.

2. Using only this information, list the possible causes of Anthony’s worsening cough. Justify your answer.

• A worsening of the chronic bronchitis.

• The occurrence of a ‘new’ pathology (eg: lung cancer; he is a smoker).

3. Why was the patient asked about the presence of:

a haemoptysis

The presence of haemoptysis in a smoker with a cough would alert the practitioner to the possibility of a malignancy in the lungs. Tuberculosis is also a possibility in any individual. Many other causes of haemoptysis exist, such as pulmonary infarction, laryngeal carcinoma, pneumonia and severe pulmonary oedema.

b dyspnoea and its relationship to position

Dyspnoea, which is worse when the patient is horizontal, may suggest a cardiac aetiology.

c chest pain

Anthony is a smoker and has a family history of ischaemic heart disease (IHD). The presence of chest pain which is retrosternal and ‘tight’, or of a ‘squeezing’ nature, may indicate the presence of IHD. The presence of chest pain which was sharp and worse with inspiration may indicate a pathology involving the pleura.

d headache and dizziness

Smokers who present with a change in the nature of an existing cough need to be assessed for the possibility of a malignancy. Headaches and dizziness may be symptoms of intracranial metastases.

e back pain

As described in ‘d’, a lung malignancy may metastasise to bone, and present with back pain.

4. What are the possible causes of his difficulties with urination?

At his age, the most likely cause is benign prostatic hyperplasia, although prostatic carcinoma needs to be considered.

5. Anthony states that he has had a number of episodes of acute bronchitis. How would have he presented clinically during those times?

Typical presentation would be an increase in the severity of his cough, and a change in sputum colour to yellow or yellow–green. In an individual with a respiratory disorder, acute bronchitis may also present with dyspnoea. Fever may or may not be present.

6. What do you need to examine in this patient?

A full examination is required, but in particular, a respiratory and cardiovascular examination is essential. Ideally, a rectal examination should be performed to assess his likely prostatic enlargement, although in most countries this will be done only by a medical practitioner. (As prostate cancer primarily affects the posterior lobe of the prostate, a rectal examination may reveal a hard enlargement of the gland, as compared to benign hyperplasia which affects lateral and median lobes.)

7. Explain the significance of the following signs.

a scattered wheezes

Indicates generalised narrowing of airways, typical of chronic bronchitis.

b dullness to percussion at left lung base

Indicates an increase in density of the tissue deep to the percussed area. (liquid or solid).

c reduced vesicular breath sounds at left base

Either there is less air moving in and out of the alveoli (eg: due to fluid in the alveoli or solid infiltrate), or there is something impeding the sound of normal alveolar air movement from reaching the examiners ears (eg: fluid in the pleural cavity).

8. Can you now narrow your differential diagnosis?

Chronic bronchitis and a possible bronchial carcinoma.

9. Why were the following specifically looked for:

a clubbing

May occur with bronchial carcinoma.

b swelling of head and neck

If Anthony has a malignancy arising in his lung, there may be mediastinal lymphadenopathy. This may be large enough to cause pressure on the superior vena cava, thus resulting in congestion of the veins of the head and neck and subsequent oedema (due to the increase in blood hydrostatic pressure in the veins and capillaries of the head and neck).

c lymphadenopathy

Bronchial carcinoma may result in cervical lymphadenopathy.

10. Anthony is referred to a medical practitioner. What investigation is required first? Why?

A chest X-ray is required to detect any shadows which may represent a tumour, and to confirm the presence of bilateral effusions.

11. What are the possible causes of the appearance of the X-ray?

There is a large, non-calcified lesion in the lower lobe of the left lung, neoplastic in nature.

12a What is the most likely diagnosis?

Lung carcinoma.

b What further investigations are now likely to be performed? Why?

• Baseline studies, including a full blood count and biochemistry (including liver function tests).

• MRI or CT for further inspection of the chest X-ray abnormalities.

• Bronchoscopy would often be performed in order to biopsy the tumour, and allow for histological identification.

• Bone scans may be used to assess for the presence of any bony metastases.

• Other tests may be indicated to investigate the possibility of metastases in specific body parts.

13. There are many different possible presentations of this condition, depending on its site of origin, local spread and eventual dissemination. For each of the following sets of symptoms and signs which can occur with this disease, state the information that it can impart.

a development of a hoarse voice

Spread of the tumour to the recurrent laryngeal nerve (or possibly vocal cord, but less likely).

b development of stridor

Spread of the tumour to the upper airways.

c oedema of face and upper limb, visible veins seen on chest and distended neck veins, redness or cyanosis of face

Spread of the tumour to involve the superior vena cava.

d miosis, anhidrosis and partial ptosis of eyelid

Spread of the tumour to involve the cervical sympathetic chain (causing Horner’s syndrome).

e headaches, changes in personality, seizures or altered mental state

Metastatic spread to the brain.

f occipital headaches, ataxia, vertigo, neck stiffness

Involvement of the meninges and/or brainstem from metastases.

g bone pain (eg: sudden onset of back pain with associated tenderness on palpation)

Presence of bony metastases.

h weakness and sensory changes in upper limb

Brachial plexus involvement or spinal cord compression.

i dysphagia and/or coughing exacerbated by swallowing

Compression of the oesophagus by the tumour, or the possibility of a fistula developing between the airways and the digestive tract.

j stabbing chest pain exacerbated by inspiration

Spread of the tumour to the pleura.

k development of ‘Cushingoid’ type features

Possibility of a paraneoplastic syndrome (some lung cancers secrete hormones; eg: ACTH).

l gradual onset of proximal muscle weakness, especially in lower limb

Lambert-Eaton myasthenic syndrome (a rare paraneoplastic syndrome, predominantly associated with small cell carcinoma).

m development of jaundice and ascites

Presence of liver metastases.

Case 38.3

1. Using only this information, list the possible causes of Walt’s symptoms, and justify your answer:

a sudden onset of upper back pain

• The suddenness of the pain suggests a compression fracture of a thoracic vertebra (worse with movement and with breathing).

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