Chapter 28 Multisystem cases

Case 28.1

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

Issue	Justification
Perforated ear drum or middle ear effusion Reduced hearing	• Recurrent pain and infection in left ear • Congenital hearing loss in right ear • After otitis media, middle ear effusion can occur
Rib fracture secondary to either osteoporosis, osteopenia or tumour	• Localised pain in ribs • Pain in rib worse with inspiration • History of trauma • Family history of cancer • Symptoms of prostate enlargement (possible cancer of the prostate with metastases to bone)
Sleep disorder	• Snores heavily • Nostril blocked • Occasional daytime naps • Micro sleeps while driving (did this cause his accident?) • Getting to and remaining asleep is an issue for him • On antidepressants: depression contributes to sleep problems
Psychological disorder	• He is taking antidepressants (Venflaxine) • Excessive alcohol intake is often seen in depressed or troubled patients • Comments that he has always been uptight for no particular reason
Possible peripheral neuropathy (possibly secondary to alcohol damage or diabetes)	• Pins and needles in toes • Burning feeling in toes
Possible prostatic hypertrophy	• Nocturia • Frequency
Alcohol problems	• Depression • Motor vehicle accident • Frequent falls • May have peripheral neuropathy • Lives alone, never married, troubled relationship • Tremor
Cataracts	• Blurred vision

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?

Of your history taking, 99 % will guide you to what you need to examine in a patient. Frequently, patients present with a ‘calling card’, be it deliberate or subconsciously. Robert has not consulted the practice for 10 years, so one must ask: ‘why does he present now, with a “small” symptom?’ The examination of a patient starts prior to their entry into your consultation room. The therapist observes their appearance and demeanour in the waiting room chair, the manner in which the patient rises from the chair and walks to the room (ie: gait), and how they sit down. Eye contact, or lack thereof, is also noted. Taking note of the person’s self care is also vital.

Robert does not look well, so it is imperative to ensure that he feels comfortable enough to reveal the real reason for his consultation. A full history will allow you to discover what else is happening, both physically and psychosocially, with Robert. Often in healthcare, the holistic approach is forgotten due to time constraints. Poor history taking and examination can have consequences upon a patient’s wellbeing in the long term. By allowing time to tease out all of Robert’s problems (both hidden and overt), the practitioner can enable him to face issues he may not have been fully aware of. Preventative medicine is practised by discovering issues and averting further diseases and complications.

a ear pain

The pain has been present for 3 months, and was initially severe. It was associated with an acute decline in hearing, indicating that the middle ear rather than the external ear was involved. The pain and diminished hearing has persisted, indicating a possibility of a middle ear effusion.

The auditory tube clears secretions, balances the pressure between the middle and external ears and also protects the middle ear. When an effusion occurs due to the inflammatory mediators responding to a bacterial presence, hearing is diminished and there is a possibility of further bacterial infection in this mucin rich medium.^[1]

b rib pain

It is unusual for a man of his age to have multiple fractures and falls. He tells of a previous fracture following a fall, as well as this one where he fell in the bathroom. The practitioner needs to delve deeper into other aspects of his history. How and why did the fall occur? Is his gait abnormal and did he lose balance? In Robert’s case, his gait was abnormal as he had been drinking heavily, as was the case in his previous fall and fractured rib. He may also have osteoporosis or osteopenia.

c sleep disorder

If Robert is not sleeping well, he is predisposed to daytime fatigue and is dangerous on the roads and is not safe operating machinery. The motor vehicle accident he had may have been contributed to by a sleep disorder.

d psychological disorder: depression

One needs to assess the severity of his depression and to see if he is suicidal. Robert had a motor vehicle accident. In men, this may represent a form of attempted suicide.

If he is depressed, he may not have the motivation to gain insight into his multiple problems and therefore be unable to address all his health issues until the depression is addressed appropriately and in a timely manner. Robert may be using alcohol as a form of solace.

e possible peripheral neuropathy

Peripheral neuropathy has multiple causes and these need to be excluded. Further history is required to elucidate the cause of Robert’s peripheral neuropathy by elimination and gathering as much information as possible about the possible cause. He will require tests to eliminate some of the causes.

f prostatic hypertrophy

Robert has some symptoms indicating he may have an enlarged prostate. If he is sleeping poorly, is it because he has to get up at night to pass urine? This contributes significantly to poor sleep quality and thus poor functioning during waking hours. This impacts his ability to work and may be contributing to his depression.

g alcohol problems

Robert has several problems associated with alcohol. Alcohol, when drunk in excess, has consequences that are far reaching. It is very important to ask, in a non-threatening manner, about alcohol.

The CAGE questionnaire was developed by J A Ewing, and this may be used to evaluate how severe the problem is. The questionnaire assists in the recognition by both the practitioner and the patient, that there may be a problem with alcohol.^[2]

h cataracts

If Robert’s vision is impaired it increases his risk of further falls and also impairs his ability to drive. This visual loss may also impact upon his ability to read.

i cough and shortness of breath

Robert is a heavy smoker and may have chronic airways obstruction, peripheral vascular disease or cardiovascular disease as a consequence of damage to his lungs and vascular tree.

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

The current recommendation for both men and women, to reduce the risk of alcohol-related disease, is two standard drinks on any day. Drinking no more than four standard drinks on a single occasion reduces the risk of alcohol-related injury on that occasion.^[3]

When taking a history, it is important not to appear to be judgmental. Asking directly about alcohol intake is important. You will not always receive an answer that is true, but watching the manner in which a patient divulges information through body language and eye contact is helpful.

Ask about what type of drink the person enjoys drinking, and what quantity do they have. Whether they drink alone or in company is often very relevant. Quantifying is important.

Asking about when they start drinking is also useful and using the CAGE questionnaire may be of assistance.^[2] There are four questions asked:

C have you ever felt you needed to cut down your drinking?

A have you ever been annoyed when someone suggests that you drink too much?

G have you felt any guilt about your drinking?

E have you ever drunk in the morning → eye opener.

There are other tools as well, including AUDIT (alcohol usage disorder identification test) in which more specific questions are asked regarding how often and how much the person drinks as well as checking for harmful drinking, including no recall of previous night’s events.

A standard drink is 10g of pure alcohol (see the table below).

Type of drink	Quantity	Standard drinks
Beer full strength	Glass (285ml) middie	1.1
Beer full strength	Glass (425 ml) schooner	1.6
Beer full strength	Bottle (375ml) or can (375ml)	1.4
Wine sparkling	Glass (150ml ) restaurant serve	1.4
Wine red	Glass (150ml ) restaurant serve	1.6
Wine white	Glass (150ml ) restaurant serve	1.4
Spirits full strength	Bottle ready to drink 5% alc vol(330ml)	1.2
Spirits full strength	Glass (30ml) 40% spirit nip	1
Spirits full strength	Can (375ml) full strength pre mix 5% alc vol	1.5

(Source: adapted from the Australian Government Department of Health and Aging: Reduce Your Risk: New National Guidelines for Alcohol Consumption)^[3]

Robert’s drinking is actually causing him harm and needs to be addressed to prevent further damage and perhaps reverse some of the damage. His alcohol intake may be a consequence of his depression , so addressing this is also important because if discussion about cessation occurs, addressing the underlying depression is vital.

Once the results from the tests are back, it is easier to show the patient the results and indicate that they are caused by alcohol excess, and that it is vital to seek assistance in reducing his further risks by decreasing alcohol intake.

Cirrhosis and end-stage liver disease can also be associated with a higher risk of hepatocellular carcinoma.

Robert’s fingers are cigarette stained. Questioning about smoking should include when the patient commenced smoking and how many cigarettes are smoked daily. It is also prudent to ask how much is spent on cigarettes and/or tobacco products weekly as this has some use in discussing cessation. Readiness to cease smoking and discussing previous attempts to do so are important, because unless someone is really ready to quit, it will be very difficult to do so.

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

Examination	Justification
General observation	• Does he smell of alcohol and/or cigarettes at the time of consultation? If he smells of alcohol at 2 p.m., this may indicate alcohol dependence • Does he have good personal hygiene?
Blood pressure	He has not had a check-up for a long time. Measuring blood pressure is a basic part of any examination as hypertension is silent until a patient experiences the consequences such as cardiovascular, cerebrovascular and renal disease. Alcohol is known to raise blood pressure
Chest and lymph nodes	He is a smoker and has a risk of chronic airway limitation. Commonly there is hyperinflation of the chest, decreased breath sounds, decreased expansion of the chest, hyperresonance to percussion and prolonged expiration in advanced disease
Peripheral arteries	Checking for patency of the peripheral vessels in a smoker can reveal whether there has been vascular damage
Hands	• Nicotine staining from cigarettes indicates heavy use • Check for cyanosis of the nail bed: this indicates how severe respiratory or cardiovascular disease is • Check for tremor and also check for cog-wheeling to exclude Parkinson’s disease
Abdomen and look for signs of chronic liver disease	• Check for liver enlargement and/or tenderness indicating liver disease • Check for spleen enlargement. Cirrhosis of the liver causes portal hypertension which in turn causes splenomegaly • Check for ascites (chronic liver disease) • Check for jaundice • Check for spider naevi (chronic liver disease) • Check for ‘liver flap’ also known as asterixis (chronic liver disease) • Check for conjunctival pallor — he may have anaemia if he is bleeding from oesophageal varices
Neurological examination	• Check for reflexes, power, sensation and tone, as he may have peripheral neuropathy • Check cerebellum — indicates if there is damage caused by alcohol • Need to assess the above to see if he has a neurological deficit causing risk for falls and also risk due to decreased mental capacity from chronic alcohol abuse
Ears	He presents with change in hearing. Need to assess why Audiometry screening is required to assess both ears
Nose	Check for anatomical abnormalities that may cause snoring and possible sleep disruption
Eyes	• Check vision and look at fundi • Check for cataracts and fundal abnormalities such as macular degeneration and exudates • Individuals with visual disturbances are at a risk for falls Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Eating disorders, substance abuse and behavioural disturbances in adolescence Fever in infancy and childhood Pain in adolescence Miscellaneous cases in adolescence Acute back pain Upper limb pain Stay updated, free articles. Join our Telegram channel Tags: Cases in Differential Diagnosis for the Physical and Manipulativ Dec 26, 2016 \| Posted by admin in MANUAL THERAPIST \| Comments Off on Multisystem cases Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access