Acceptance of disability

Contributed by Dr Jean Watkins, a sessional GP in Hampshire.

Large bowel fistula

Eight years earlier this woman had undergone extensive surgery for an adenocarcinoma of the colon (Dukes level 2). At the time there was evidence of invasion of the peritoneum and metastases to the regional lymph nodes. The block excision of the transverse colon, portion of the stomach and long loop of the jejunum was seen to be largely palliative.

The patient had survived but had had to come to terms with this constantly leaking fistula with all its discomforts, pain and antisocial effects.

Bilateral inguinal herniae

At the age of 88, this man had not even mentioned the increasing problem with his hernia, feeling that it 'was just one of those things one must put up with'.

Anxious to avoid surgery he had opted for a truss in the early stages. Unfortunately he had found this uncomfortable and had discarded it. Recent constipation had made the situation worse.

He preferred to leave well alone but was aware that he should seek help quickly if he developed acute pain with symptoms suggesting strangulation of the hernia.

Gout

This elderly woman had been diagnosed with gout some years before. The initial flares had been treated with colchicine, so she had continued to deal with any exacerbations with this drug, and adjusted her diet by reducing her intake of pyrine-rich foods such as meat and fish.

Now, at the age of 91, gouty tophi affected all of her fingers leading to great difficulty in turning the key in her front door.

Her situation was reviewed, her uric acid level checked and she was started on a daily dose of allopurinol.

Onychogryphosis

Some patients seem to be too tolerant of disability. This 90-year-old woman lived alone. For the past 18 months she had considered herself housebound because wearing shoes and walking were too painful due to an overgrowth of her toenail.

Onychogryphosis may follow sudden injury or gradual damage to the nail over the years. Treatment involves cutting and filing the nail. In some cases the nail may be removed but, unless the nail matrix is destroyed, there will be re-growth of the nail and recurrence of the problem.

Recurrence is less likely if phenol is applied after removal of the nail.

Neurofibromatosis

At the age of 12, this woman had noticed a number of soft, fleshy pedunculated lumps on her trunk. Her GP had also remarked that she had a number of pigmented patches (cafe au lait patches) and suspected that this was a problem of neurofibromatosis.

The patient had been adopted and had no knowledge of her family history. An MRI scan was used to assess the soft tissue extent of the disease and any other involvement of the neurological system.

Genetic studies suggested that it was related to the dominantly inherited gene NF-1.

Ectopia vesicae

Ectopia vesicae is a distressing congenital abnormality in which there is non-development and failure of closure of the bladder, with inevitable leakage of urine from it. Plastic closure of the bladder is recommended in the first few days of life; however the achievement of continence is problematic.

As in this case, transplantation of the ureter into an isolated ileal loop may overcome this problem. This woman was happily married but, as she had been unable to achieve a pregnancy for seven years, was embarking on IVF.

Mycosis fungoides

This patient was only 41 but 15 years ago she had had to come to terms with a diagnosis of mycosis fungoides. The early patch stage progressed to thickened itchy plaques that had been kept under control with a variety of treatments including topical steroids, phototherapy and radiotherapy.

She was shocked when several large ulcerating lumps started to appear. This one in the axilla caused her particular problems with rubbing and soreness but more distressing for her were the similar lumps that had developed on her face and forehead.

Multiple sclerosis

Independence is important to us all. To this woman, the installation of an environmental control system had made all the difference to her life. Her symptoms of MS had gradually deteriorated over the years from minor incapacity to reliance on a wheelchair and then to a life confined to bed.

The system allowed her to control some things herself, such as an alarm if she needed help, open the door if she wished to admit a caller, make calls on the telephone and choose TV and radio programmes. To her, this made all the difference

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