You are a medical student doing a rotation in the emergency department of a large, inner-city hospital.
Rasa is a 31-year old single, mother of two. She speaks limited English. She presents to the emergency department accompanied by Yulia, a public health nurse, who is acting as a translator. Yulia is concerned because Rasa has a persistent cough and has lost a lot of weight over the last several months.
Through Yulia, Rasa reports having a 2-week history of persistent, productive cough. There is no blood in the sputum (hemoptysis). She feels short of breath when walking up stairs. There is no chest pain. She feels feverish at times, but has not checked her temperature. She reports losing about 30 pounds over the last few months (originally 130 lbs, currently 100 lbs) and feeling increasingly tired.
Rasa is anxious to get home to her children who are being watched by a friend. She is not concerned about the cough and thinks it is likely the ‘flu’. She assumes the weight loss is due to not feeling like eating, and isn’t concerned because it means she doesn’t spend as much money on groceries. She only came to the emergency department because Yulia insisted.
Rasa has been relatively well her entire life. She has had 2 vaginal deliveries of healthy term babies. She had her appendix out as a child. She is unsure about vaccinations - she hasn’t had any since she was a teen - but thinks she got one for tuberculosis as an infant.
Rasa is a non-smoker. She consumes the occasional alcoholic drink when paid for by customers.
No prescription medications.
No use of herbals.
She gets the odd acetaminophen for headaches from the street health service.
None known drug allergies.
Rasa is a single parent and has 2 children. She does not have a partner. Rasa lives in an apartment with several other women and children.
Rasa is an illegal immigrant to Canada and does not have a health card, she sometimes uses the street health service because they do not require a health card.
Rasa is originally from Lithuania and has a high school education. She came to Canada about 10 years ago with the promise of work as a housekeeper. The housekeeping job never existed, and when Rasa arrived, she was given the choice of being turned over to the police as an illegal immigrant or working in the sex trade until she paid back the “debt“ she owed for travel and housing.
She has no family in Canada other than her children, Rasais very close with the other women with whom she lives.
Rasa does not believe her family has had a lot of health problems. She is unsure how they are doing now.
On exam, Rasa appears cachectic and older than her stated age. She appears unwell, but is in no acute distress.
Temperature: 39.3 Celsius
Heart rate: 105
Respiratory rate: 24
Oxygen saturation: 91% on room air
Weight: 45.5 kg
There is no lymphadenopathy. Ears, nose and throat are unremarkable.
Heart sounds are normal. No extra sounds and no murmurs are heard.
There are decreased breath sounds bilaterally. You find it tough to hear because Rasa keeps coughing but wonder if you can hear a faint wheeze..
The rest of the physical examination is unremarkable.
Her fever comes down and she feels abit better, but her saturations do not improve despite the use of brinchodilators.
Complete blood count (CBC) returns with a low normal white blood cell count. There is a mild microcytic anemia.
Chest x-ray shows diffuse bilateral interstitial opacification. There are no cavitary lesions. There is no hilar lymphadenopathy.
Sputum for culture and sensitivity, including acid-fast bacilli, is pending.
You suspect Rasa has pneumonia. You are concerned about her lowish oxygen saturation and suggest admitting her to hospital for antibiotics, bronchodilators and observation. You discuss your plan with Rasa. However, Rasa refuses to come into hospital. She is concerned about her children being without her overnight. Yulia asks if she could just get prescription for an oral antibiotic.
You believe Rasa is competent to make treatment decisions. You concede a prescription for an oral antibiotic, which Yulia can obtain through public health. You tell Rasa to return to the emergency department if she gets worsening shortness of breath, or is not starting to feel better in the next few days.
Late the next day, you receive a call from the microbiology lab regarding Rasa’s sputum results. Rasa has Pneumocystis carnii pneumonia (PCP). The microbiologist suggests Rasa have an HIV test and CD4 count.