The first time newFNP saw positive cerebellar findings in a chronic alcoholic, she thought that the patient had misunderstood her instructions. Not that rapid alternating movements (RAM) are so hard to describe, especially as newFNP always demonstrates said movements, but -- you know -- maybe the patient just missed the boat.
Monday, November 29, 2010
In retrospect, she shouldn't have been surprised. This patient was a middle-aged man who walked as though he was an epileptic zombie. Yeah, that gait ataxia is a good first clue. (This video of a professional man in pleated Dockers-style pants demonstrated a pretty great example of ataxic gait and, frankly, is kind of hilarious.)
Yet, newFNP was astonished to see the floppy-fish movements of the RAM. When she moved on to finger-nose-finger (at a arm's length away of course -- any yayhoo with half a cerebellum can make reasonable contact as less than full extension), she felt lucky to have left the room unblinded. She didn't even conduct a Romberg as she felt concern for the patient's safety.
That was about a year ago when newFNP was in the research clinic. That patient did not matriculate into the study.
Today, however, she had a patient in his mid-40's who began drinking at the age of 12 when his drinking buddy was his father. Having just been released from jail, he came to see newFNP to refill his diabetes meds. The last time she saw him, newFNP noted that he smelled of alcohol. This time, he lacked the aroma but exhibited the slurred speech one might note with acute intoxication. The dysarthria reminded her of her patient with cerebellar ataxia some time ago. His neuro exam confirmed newFNP's suspicion of cerebellar injury.
Now, newFNP loves her wine. And her mojitos. And her Maker's Mark with ginger ale. Wait -- where was newFNP going with this??
Ah yes, alcoholism is truly devastating. This man cannot work, he is in and out of jail and his father died from the disease that is killing him as well. The last two times newFNP assessed his readiness to change his drinking behavior, he was very clear and straightforward -- not ready, not yet. Since leaving jail this time, he has been drinking very little. He states it's time to get straight.
It's just too frigging bad that his cerebellum has been pickled before he came to that decision. Perhaps he will see some improvement if he can achieve some sustained abstinence. Until then, newFNP gives him his multi-vitamins. Today he got prenatal vitamins -- they were all newFNP had to give.
For other clinicians and students out there who need help getting substance abusing patients into care, the SAMHSA Treatment Locator is super helpful.