IDS case – WVSOM-Oct 17^th

26 year old woman presents to your office for an ER follow-up for cough – she’s no better.

Started coughing about 10 weeks ago – seen first in Urgent care for cough for several weeks, productive of purulent sputum – PMH essentially negative, + smoker 1 ppd; diagnosed as “bronchitis” and treated with AMoxil. Seen again 3 weeks later in Urgent – no better -low grade fevers, feeling wiped out and still having hacking cough. Unable too sleep well at night, and getting exhausted – diagnosed as “persistent bronchitis” and switched to Zpak. Seen in ER, 3 weeks later – by now she has missed a couple weeks of work because she’s been coughing, exhausted, losing weight because she can’t eat and intermittent fevers. Chest exam with lots of rhonchi, no rales, and a CXR shows a Right upper chest cavitary pneumonia and she’s treated with Levaquin. A PPD was placed and patient was sent to your office for F/U for PPD reading.

PMH Surg- C/section x’s 2

Medical : anemia with her last pregnancy

SH Unmarried mother of 2 kids, ages 8 and 6; works as a “Hot walker” at Charles Town races for the last 5 years (hot walkers take the horses after they have raced, and walk with them to cool them down); smokes 1 ppd for 10 years

Drinks socially

FH Father – unknown

Mother – died when she was 5yrs, and she was raised by an aunt, with whom she has lost touch - she doesn’t remember anything specific about family’s health

Meds Has been taking lot of Robitussin, antibiotics mentioned in HPI, does not take any Vits or OTC

ROS Heent – having HA’s, usually starting left sided neck and upper back

Sore throat off and on

Hasn’t been able to afford dental care, and can’t remember last time she had seen the dentist

Lungs – see HPI-has felt increasing short of breath in that she runs out of steam

Heart – no palpitations, chest pains

ABD-coughs so hard, she’s been vomiting; has lost her appetite and been unable to eat much – lost 10 pounds since this all begun

MS-diffuse aches and pains in her joints

Neuro – HA’s above; no tremor, jerking

Mental – she’s depressed, starting to wonder if and when she will ever feel normal again – has to get back to work and she’s worried about meeting her bills

PE VS – BP 136/86; P=112; R=26 T=100.8

Gen – you find a crying, distressed young woman – saying something has to change, she can’t go on like this anymore – she feels like she’s dying

HEENT – TM’s ok; eyes ok; multiple carious teeth in poor state of repair-some actually infected; shotty nodes

Lungs – lots of coughing, violent and racking; coarse upper airway sounds – lots of rhonchi – can’t really appreciate rales;

Heart – Reg rhythm, tachycardic, no murmur

Abd – scaphoid and soft; + BS, non-tender

GU-neg

Ext – neg

Skin – small bruise under skin where the PPD was placed – no redness, no induration

Labs – WBC 16,000 with 80 segs, 10 lymphs

` H/H = 10/30, platelets = 675,000

LFT’s – SGOT=54; SGPT=60; GGT=75; Alk Phos=100; TB=1.3

Glucose = 96; lytes=wnl; BUN 34; Creatinine 1.1

CXR – cavitary lesion in Right Upper lobe seen on CXR

Differential: Cavitary pneumonia from anaerobes – source poor dentition

TB – but neg PPD? Why? Could it still be TB

Aspergillis infection-

Questions for other disciplines:

Dental concerns: bad dentition, risk of aspiration pneumonia; does poor dentition increase risk of malnutrition. This woman has no insurance – how can she get her teeth fixed?

Nursing aspects; respiratory isolation – what does it consist of? When is it appropriate to institute it? What else?

Physical therapy; rehab??

Social work; who takes care of family when she’s in hospital? How do you apply for medical assistance?

Pharmacy: meds for TB, anaerobes,fungal