Multisystem cases

Chapter 28 Multisystem cases



Case 28.1



History



Presenting symptoms


Robert, 61-years-old, presents to a medical practice with a history of a recurrent infection in his left ear for 3 months. He has been to the hospital casualty on several occasions and has been given repeated antibiotics and analgesics. There was no preceding respiratory tract infection. Initially, he experienced severe pain and loss of hearing in the left ear. There is no tinnitus. He has been deaf in the right ear since birth. His complaint today is that he is unable to hear well and the pain, although not as severe as first onset, is still unpleasant.


His other problem is a pain in the ribs on his left side, following a fall in his bathroom 2 weeks previously. The pain is present on movement and when he lies on his left side. If he takes a deep breath in, it is also painful.


He says that his general health is good and his weight fluctuates between 65 and 72 kg. He has a morning cough which is productive and his been present for about 2 years. There is no blood in the sputum.


As Robert has not been seen for 10 years a full history and examination is undertaken over two consultations.



Past history


His past history reveals the following: congenital deafness in the right ear; cholecystectomy; left inguinal hernia repair; fracture of a left rib; fracture of a right rib and petit mal epilepsy until the age of 10.



System review



• When Robert climbs a hill he gets short of breath but does not experience chest pain.

• After finding that his vision was blurry, he visited an optometrist. A cataract was found and he was referred to an ophthalmologist. A lens extraction and implantation of an intraocular lens will be performed as soon as a bed becomes available at the public hospital.

• He feels depressed but not suicidal. Robert admits that he had a long history of depression but had never sought treatment, until it was exacerbated following a motor vehicle accident, where his truck was ‘written off’. He states that he has always been ‘uptight’ but was unable to understand why. Three months ago he consulted a doctor at a medical centre and was given Venflaxine, an antidepressant.

• Robert wakes up tired and thinks that he has ‘micro sleeps’ when driving. He is usually very tired by 9 p.m. Occasionally he sleeps during the day. He has always snored heavily. Getting to sleep and remaining asleep has been a problem which he finds has not really changed since being on Venflaxine.

• Robert experiences occasional nocturia and frequency.

• His toes sometimes feel as if they have pins and needles and other times they are ‘burning’.


Lifestyle



• Robert smoked 40 cigarettes per day since the age of 14, but over the last 20 years this has reduced to 20 per day.

• At the first consultation, he admits to drinking 3–4 glasses of wine a day and 1–2 serves of whisky, 6 days a week.

• He lives alone, but does stay at his girlfriend’s home a considerable amount of the time. They argue a lot, especially over his drinking. He has never married and has no children, and finds his girlfriend’s children irritating.

• He was a metallurgist in a copper mine for many years and then became a truck driver.

• He is no longer working due to his motor vehicle accident.


Family history



• Mother died from cancer of the kidney.

• His father is alive and well and in his 80s.

• He has one brother who is alive and very obese.

• He had a brother who died in his 50s from a cancer, the origin of which Robert is unsure. He says his brother had the cancer in his vertebrae and had worked as a printer for many years.


Questions



1. Using the above information, what are the issues that arise from the history? Justify your answer.

2. Why was a full history and examination performed when all Robert came in for was his earache? What are you considering at this stage of your assessment?

3. How do you ask about smoking and alcohol history and why is this relevant in this particular gentleman?

4. How would you examine this patient and what do you expect to find?


Physical examination







































General
Robert’s face is reddened and he has dark circles under his eyes

His clothing is dishevelled

His gait is normal

He has a mild resting tremor but no liver flap

He smells of alcohol, cigarettes and has body odour

His fingernails are yellow and his hands are dirty with dirt under the nails

There is no jaundice or spider naevi
Vitals •Pulse rate/min 80, regular
•Respiratory rate/min 16
•Blood pressure mm Hg 160/90 and at repeat 140/90
•Height (cm) 168
•Weight (kg) 67
•BMI 23.7
•Temperature (degrees C) 36.9
HEENT Ear, nose, throat (ENT)

• The right ear drum is normal

• The left ear is filled with wax and debris, making a clear view of the eardrum impossible

• Hearing bilaterally decreased

• Screening audiometer: no hearing at all frequencies bilaterally

• Nasal septum perforated and deviates significantly to the right

Eyes

• Bilateral lens haziness — bilateral cataracts; right worse than left

• Visual acuity without glasses: right 60/6, left 18/6

• Difficult to visualise fundi
Neck There is no lymphadenopathy
Chest
• Heart sounds are dual and there are no murmurs

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Multisystem cases

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