The Case

CASE

Author: Esmeralda Ricks 

26th October 2020 

Clinic Name: VIPE International Clinic, Port Elizabeth 

 Afri-VIPE: A Complex Case in COVID 19 

 

Identifying data:  

Patients name: -Miss Patricia Verloren (fictitious name) 

DOB: - 1984 - 35 year old female, single, two children, boy and girl, age 18 (2002), 7 years - prem baby at 34 weeks (2012).  

Odd jobs; Lives with her children in a shack (informal structure, no electricity, no piped water, one tap shared and an outside toilet - separate from shack) in the backyard of her parents with only the monthly child grant as income. (See social history)  

Community Snapshot: urban based, under-resourced area, high unemployment rate, limited social amenities, high crime rate. Access to health-care: limited 

Publicly funded housing scheme for the under-served 

  

Current medical complaints: 

She visited the clinic yesterday complaining of  

• Burning on micturition (BOM), a greenish vaginal discharge and slight pelvic pain this started 3 weeks ago and has since become worse - vaginal swab was taken 

• Amenorrhea for three months - The test for pregnancy was positive and ultrasound confirmed a 12 weeks intrauterine pregnancy.  

• Known diabetic – HGT (glucose test) -18,6mmol,blood sent for HbA1C (hemoglobin A1C for diabetes) (Values may differ in measurement units between countries): http://www.scymed.com/en/smnxpf/pfxdq210_c.htm 

• She was bitten by a dog on her left lower leg a month ago. – erythematous and mildly fluctuant - getting dressings and got the anti-tetanus injection. 

• She is also complaining of a cough for the last 1 month associated with some weight loss, poor appetite, occasional night sweats and chest pain associated with the coughing. She has SOB (Shortness of breath) with exertion. A CXR (chest X-Ray) was ordered - see below. 

• She has lower back ache and heaviness in both legs 

 

She was followed up today:-  

• Her booking tests reveal a positive RPR - blood sent for titers 

• A positive HIV – Her HIV was first diagnosed during her first pregnancy; She was started on ART (antiretroviral treatment) and took them intermittently until since her second pregnancy 7 years ago i.e. from 2012 when she started to take them more regularly. Blood was sent for full blood count (FBC)/complete blood count (CBC) , CD4 count and viral load - see below 

Past medical history:   

• Known Diabetic on oral medication - doesn’t monitor her own glucose 

• HIV positive (2002) on ART (antiretroviral treatment)- from 2012 - as above 

• Ex PTB (previous pulmonary tuberculosis), 2004,  

  

Past surgical history:  

• Appendicitis 2009; no complications,  

• Caesarian section 2012,  

• Dog bite left lower leg x 1/12 (one month) ago - receiving dressings. 

  

Allergies: 

• Drug allergies - Sulfa drugs  

• NKFA - no known food allergies 

• Denies environmental or latex allergy 

• Allergic to fish and fish products, also in medication 

                  

Medications: 

• Metformin 500mg bd,  

• ART Regimen 1 

  

Immunizations: 

• Normal childhood immunizations including PPD at birth for TB 

  

OBGYN history:  

Ms. Patricia Verloren is a 35-year-old mother of two children, a boy and a girl.   

Gravida 4, para 2 (had a stillbirth in 2010)   

• 1stpregnancy 2002 - normal vaginal delivery 

• 2ndPregnancy - 2010 - stillbirth 7 months 

• 3rdpregnancy - 2012 - Prematurely delivery by C/S cesarean section at 34 weeks gestation for pre-eclampsia; 

• She had a pap smear 12 years ago when invited during the cervical screening campaign. 

• 4thpregnancy - current pregnancy - 12 weeks gestation - RPR and HIV positive + Diabetic 

  

Sexual History: Sexually active, Depo Provera 3 month injectable, but defaulted to contraceptives for 1 year due to heavy bleeding. First pregnancy at the age of 17 was as a result of sexual abuse by a neighbor over a period of five years.  

She has a history of multiple sexual partners. Second child 7 years ago - not seeing the father anymore. 

Now she is RPR positive with a titer of 1:256 and has a vaginal discharge. 

  

Family History: Father with hypertension, Mother has diabetes  relationship with parents are strained due to them failing to support her emotionally when she revealed her sexual abuse as a child. Her relationship with her son (Peter) who is unemployed and verbally and physically abuses her . Her relationship with her 7-year-old daughter, (Sheree who is in Grade 1) is good however she is overprotective at times resulting in Sheree not being able to develop friendships. She  refuses contact between the daughter and the daughter’s father. 

  

Social History: She is currently unemployed and survives on odd jobs and the social grants offered by the government. She stays in a shack that she built in the backyard of her parents’ home. This shack has electricity but she accesses piped water from the tap within the yard and shares this tap with the rest of the other tenants with shacks in this yard. They use a communal pit latrine.  

 

Smoking 10 cigarettes per day, heavy drinker- 6-10 pints of beer a week, and has been referred to a drug and alcohol services/behavioral health services and has not participated in the offered services.  She has a monthly child grant (from the government) and odd jobs as income. She dropped out of school in grade 10 due to the pregnancy and received a child care grant for both her children. She has worked at the local shopping mall as a cleaner in the past but struggled to cope after the daughter’s birth and recent medical problems and resigned. She has few friends and does not belong to any social groups in the community.  

She has been in a relationship with Marvin (34) for the past three months. He is the father of the child she is currently carrying. Marvin works at a local vehicle manufacturing company.  

 Child Support Grant (Publicly Support Funding):  

Activities of daily living: Her doctors have recommended that she lives a healthier lifestyle and includes physical activity as part of her daily routine.  While Patricia is keen to start exercising, she cannot afford gym fees and would like to explore cost effective avenues. Furthermore, she is concerned about exercising while her legs feel heavy and swollen.  She has a garden where she grew and sold vegetables for extra money; however, with her leg swelling due to the dog bite she has not been able to tend to it. 

  

Psychiatric history: Patricia was diagnosed with postpartum depression after the birth of her daughter. She received antidepressants for 6 months.  has noticed that in the last few weeks she has been struggling to sleep and doesn’t eat much. She often finds herself crying and worried about her future. At times she fantasizes about going to sleep and never wakes up but worries about her daughter if she was to die. Her son’s abuse has left her fearful and anxious.  She smokes to calm herself and consumes alcohol to help her sleep. On days where she feels overwhelmed by her emotions and her son has been physically abusive, she will take 3 Paracetamol/Stilpane/Analgesic tablets. 

  

On Examination 

Vitals: BP 110/ 70mmHG, Pulse- 102bpm, Resp 24 bpm, Weight - 80 kgs (has recently lost weight, previous weight 100 kgs), Height -156cm, BMI – 32,9 kg/m2, waist – 100cm, hip 115cm 

Temp 38, 5ºĆ, HGT -18,6mmol, HB- 9,5gm%,  

(look up equivalent values in your country) http://www.scymed.com/en/smnxpf/pfxdq210_c.htm 

General: Looks pale and ill;  oedema 1+ lower legs; No Jaundice, cyanosis , clubbing , spider naevi or splinter haemorrhages noted. 

  

HEENT:  

• Head normal; No neck stiffness; No lymphadenopathy felt./ inguinal lymphadenopathy due to wound of dog bite  

• No evidence of oral candidiasis or Kaposi sarcoma  

• Eyes- vision normal as reported by the patient. Not formally tested. 

• Ears- No ear discharge noted 

• Nose- Yellowish nasal discharge, with nasal flaring 

• Throat- inflamed, but no enlarged tonsils 

  

Cardiovascular: Heart sound normal but tachycardia present 102/min; Regular. 

Respiratory: Air entry equal bilaterally, resonance with percussion except in right & left upper lobes- minimally dull; Bilateral rhonchi on auscultation  

Abdomen: Soft; Mild lower abdominal tenderness especially over old cesarean scar and suprapubic; No hepatosplenomegaly 

Vaginal Examination -profuse greenish discharge; Uterus enlarged +/- 12 weeks; Mobile; Mild excitation tenderness. ; No vaginal warts or other lesions noted; Pap smear not done due to the discharge and  pregnancy. 

Musculoskeletal: grade 1 oedema, lower limbs,  

Septic dog bite 2 cm x 3 cm left lower leg with discomfort on lateral rotation of left leg due to pain in left groin from enlarged tender lymph nodes. 

Exaggerated lumbar lordosis, decreased hamstring flexibility 

Neurologically:- Normal level of consciousness; Oriented for time, place and person; Appears anxious with slight tremor; Speech normal; Cranial nerves intact; Motor and sensory function normal. 

  

Labs results (students may need to look up normal values) http://www.scymed.com/en/smnxpf/pfxdq210_c.htm 

• FBC (Full blood count)/WBC (white blood count) – White Blood Cell Count 4, 5 ; Differential - Neutrophils 50% ; Monocytes 30% ; Eosinophils 2% ; Basophils 1% ;  

• Hb 10,mg/dl ; MCV = 80 ; Platelets 200 ; Pending: HbA1C, eGFR 

• CD4 = 250  

• VL (viral load) – Pending 

• ESR = 100mm/hr  ; CRP - 20 

• RPR - 1:256 

• HbA1C - 8,9 

  

Chest X-RAY:  

 With a previous history of PTB pulmonary tuberculosis, AP CXR is the primary modality for confirmation of positive results of the blood or skin test. Also, the lungs should be evaluated for scar tissue from the previous PTB infection and the extent of the new infection. 

Chest X-RAY:  

• Old scarring right upper lobe. Cavitation and increased reticular and nodular marking left upper lobe. 

• Pulmonary infiltrates – consolidation in left upper zone with a thick wall air filled cavity 

• Enlarged lymph nodes at the aorto-pulmonary window. 

• Dense nodular densities present in right hilar region 

• Multiple small calcifications in right mid and lower lung zones – calcified granulomas 

• Right cardiophrenic angle not visible 

Differential diagnosis – (Recurrent) PTB  

  

Mantoux test- weakly positive 10mm. 

  

Assessment   

Medical Issues 

1. 35 year old G4P2M1 - 12/52 pregnant with previous C/S x 1 for preeclampsia at 34 weeks with last pregnancy 

2. RPR +ve - active syphilis 

3. HIV +ve on ARVS - not well controlled 

4. NIDDM on Metformin 500mg bd - not well controlled 

5. Active TB (tuberculosis) on History , ESR elevated and on CXR (chest Xray) - questionable multi-drug resistant TB - previous TB 11 years ago 

6. Infected dog bite left leg with enlarged inguinal lymph nodes - not improving on dressings x 1/12 

7. Vaginal discharge –RPR positive  

8. Previous history of postpartum depression 

 

Social Issues 

 

She does not interact with her community members due to her social anxiety.  

Lifestyle issues 

 Suffers from depression due to unemployment and socio-economic status. 

Patients have resorted to begging for food close to the end of the month as the grant money and money received for odd jobs does not cover their monthly expenses. 

Plan of management:- to be completed by participants