Not In Our Own Backyards?
by Alexis Eastman

For your perusal, two truncated medical cases, complete with jargon, which is, for the most part irrelevant.

Case 1

CC: Z.M. is a 36 y.o. married woman, P 3-0-0-3, who presents at the clinic with a regular cough and shortness of breath.

HPI: Cough is dry, deep and non-productive. Onset approximately 2 months ago. In past three weeks, Z.M. has experienced increased shortness of breath, and air hunger when supine. Cough now occurs at least once and hour, for several minutes at a time. She is only at the clinic because she can no longer work on her family farm productively. Z.M. states that she must stop to catch her breath every ten to fifteen minutes. She reports no other symptoms – no swelling, pain, itchiness, sputum, or blood. She has not used any OTC cough suppressants because she lives too far from a pharmacy.

PH: All 3 children born at home, now aged 7, 9, and 12. She and husband have a small farm, and sell produce at the local market. She does not know her immunization status. This is her first time at a medical clinic of any sort . She reports no EtOH or tobacco use. She reports NKA, no other health problems in past. Both her parents are deceased, but she does not think any diseases run in the family.

PE: Ht 163 cm, Wt 49 kg, Resp 34, BP 140/92, radial pulse 86 and +3. Upon examination, skin is normal, nasal tissue is pink and normal, no tenderness upon palpation of maxillary sinuses. Pharynx appears normal with no tonsillar swelling. No occipital, post-auricular, pre-auricular, submandibular, submental or supraclavicular nodes present. Axillary nodes present on left side, approximately 2 cm. Lung sounds are wet, and percussion of the lower left lobe was dense.

DX: Suspected carcinoma of the lung. Z.M. cannot be sent for X-ray or biopsy because such services are generally unavailable for her. Will inform patient of what needs to be done for further follow-up, but expected compliance will likely be low. Will refer Z.M. to volunteer social worker for help with financial services.

Case 2

CC: K.V. is a 42 y.o. married woman, P 4-0-0-2, who presents at the clinic with a regular cough and shortness of breath.

HPI: Cough is wet and productive. Onset approximately 2 months ago. In past three weeks, K.V. has experienced increased shortness of breath, and air hunger when supine. Cough now occurs at least once and hour, for several minutes at a time. She is only at the clinic because she can no longer work on her family farm productively. K.V. states that she must stop to catch her breath every ten to fifteen minutes. Occasional blood in sputum. Pain in chest is 2, and dull with no radiations. She has lost 2 kg in the past month, and reports a loss of appetite. She reports one episode of fever and occasional night sweats/chills. She has not used any OTC medications because she lives too far from a pharmacy.

PH: All 4 children born at home, one stillborn, one died age 1, remaining are 16 and 14 y.o. She and husband have a small farm, and sell produce at the local market. She does not know her immunization status. This is her first time at a medical clinic of any sort. She reports no EtOH or tobacco use. She reports NKA, no other health problems in past. Both her parents are deceased, but she does not think any diseases run in the family.

PE: Ht 163 cm, Wt 49 kg, Resp 34, BP 140/92, radial pulse 86 and +3. Upon examination, skin is diaphoretic, nasal tissue is pink and normal, no tenderness upon palpation of maxillary sinuses. Pharynx appears raw but with no tonsillar swelling. No nodes present. Lung sounds are crackling upon inspiration and percussion of the upper right lobe was dense.

DX: Suspected pneumonia or TB. K.V. cannot be sent for X-ray and culture cannot be taken because such services are generally unavailable for her. Will put K.V. on DOT+ as safety measure. Will inform patient of what needs to be done for further follow-up, but expected compliance will likely be low, as no nurse is available to monitor DOT+, and unsure of local resources. Will refer K.V. to volunteer social worker for help with financial services.