Case #1 – Acute Care, Cardiorespiratory and Neurological

Case #1 – Sonia

Part 1:

Objective

On physical examination Sonia has a fever of 39 degrees C, appears underweight for her size and there is evidence of recent multiple upper extremity injection access sites. She presents with lymphadenopathy. Her chest X-ray (CXR) shows diffuse, bilateral interstitial infiltrates. She is admitted to hospital. The multidisciplinary team receives a referral – “Assess and treat, plan for discharge”

Vital Signs: Respiratory Rate 28, Blood Pressure 105/70, Heart Rate 127 beats per minute, oxygen saturation 94% on 3 litres of oxygen via nasal prongs.

Cardiorespiratory: On auscultation: Decreased breath sounds throughout but particularly to lower lobes bilaterally suggesting decreased air entry. Cough is voluntary, weak, dry and non-productive, and elicits pain. No cardiac murmur.

Musculoskeletal: Complains of pain in the costal margins bilaterally and intercostal muscles are tender on palpation of lower ribs bilaterally.

Mobility & Function: Poor mobility – requires moderate assistance of 1 for all transfers and for ambulation short distances (approximately 5 to 10 metres) to the bathroom.

Activities of daily living (ADL): Assistance of 1 for self-care (dressing and toileting).

Cognition: Oriented to person and place.  She is inconsistent with her orientation to month and year. Appears confused and agitated at times.

Initial laboratory results were consistent with sepsis, and follow-up blood work confirmed Sonia was HIV positive (new diagnosis): CD4 count: 50 cells/mm3 viral load; 500,000 copies/ml blood.

Guiding Questions

1. Given Sonia’s CXR and physical examination findings, what might you think is her diagnosis?

Notes: Bilateral interstitial infiltrates and dry cough could indicate pneumocystis pneumonia (PCP). This is an HIV-Associated condition. Given the new diagnosis of HIV, Sonia’s CD4 count is quite low resulting in her immunocompromised status making her susceptible to opportunistic infections such as PCP.

2. Why do you think Sonia received an HIV test? What are considerations for HIV testing?

Notes: Her history of injection drug use as well as some of her symptoms may suggest she is at risk of HIV infection. When testing, it is important that the “3 C’s” are considered – counselling, consent, and confidentiality. It is important to ensure that Sonia was provided with all the necessary information about testing and consented to the process. It is not explicitly stated in the case whether Sonia was provided with these components surrounding testing.

3. What are some of the (a) impairments, (b) activity limitations and (c) participation restrictions that Sonia is experiencing?

Notes: Consider the physical, cognitive, social, emotional and psychological challenges faced and classify using the International Classification of Functioning (ICF) Framework.

Some examples include:

• Impairments: decreased oxygen saturation, shortness of breath, decreased ventilation to lungs throughout, pain, decreased cognition (lacks orientation to time, confusion and agitation), decreased weight, weakness. Sonia may also experience increased anxiety, uncertainty and stress surrounding the news of her new HIV diagnosis in conjunction with her current medical issues (PCP and sepsis) and potential impairments due to drug withdrawal.
• Activity limitations: decreased mobility, difficulty with ADLs for self-care including dressing and toileting, decreased activity tolerance.
• Participation restrictions: inability to work, decreased financial status, potential risk for losing housing if lack of income support, potential for cultural dislocation from her Indigenous community.

4. What personal and environmental factors might influence Sonia’s disability and ability for discharge?

Notes: She has a history of drug use, which may further exacerbate her health challenges. She appears to have a lack of social support (she lives alone and her family is in a different province). She is concerned about disclosing her HIV status to anyone in her social circle. These challenges raise issues for discharge and her ability to function independently on discharge. Given she is not currently working she may have issues surrounding income support and maintaining independent financial status. She has some support via her drug benefits and Indigenous Affairs coverage. She may also experience cultural dislocation and potential stigma surrounding her diagnosis from the Indigenous community and in relation to her gender.

5. What additional factors should be considered?

• Nutrition: are there any issues regarding weight loss, nutritional habits or other needs (e.g., food security)? Suggest referral to a dietitian. If appropriate and if necessary, discuss options for community food banks, suppers, food boxes and community cooking programs (which also provide social support).
• Review sleep and rest /stress management. If required, follow up with a pamphlet, discussion or referral for good sleep hygiene.
• Determine if the client has a reliable mode of communication to ensure contact with health professionals. Alternatives may include landline, cell phone, leaving messages with a friend or relative who is in regular contact with her.

6. What are some of the short-term and long-term rehabilitation goals for Sonia?

Notes: Consider patient values and preferences, and principles of shared decision-making, when discussing and developing goals. Use the SMART principle (Specific, Measurable, Achievable, Relevant and Time-Bound).

Many of the goals related to her cardiorespiratory status will be short-term:

• To increase ventilation to lung fields throughout in 1 day as measured by increased breath sounds bilaterally.
• To decrease pain on cough in 1 day as measured by decreased report of pain on visual analogue scale (VAS).
• To ambulate 25 metres with minimal assistance or walker in 1 day.
• To become independent with ADLs (dressing, toileting, bathing) in 1 week.

Long-term rehabilitation goals might revolve around discharge from hospital and include:

1. To ambulate 100 metres independently on discharge from hospital in 1 week.
2. To negotiate stairs independently on discharge from hospital in 1 week.
3. To understand the implications of her new HIV diagnosis (including options for treatment and support services) in 3 months.
4. To return to work as a community support worker as Sonia’s health permits after discharge.
5. To assess Sonia prior to discharge from hospital to determine her eligibility and requirements for home care. If eligible and with sufficient need, home care services should be arranged to start on date of discharge.

7. What rehabilitation treatment strategies might be used to address Sonia’s impairments, activity limitations and participation restrictions?

Notes: Consider patient values and preferences as well as key medical issues when discussing treatment strategies. It is important that the strategies used to address her challenges take into account the ICF. By setting goals that address her impairments, this can lead to improvements in her activity limitations and participation restrictions. Consider using the process of shared decision-making to prioritize treatment choices/strategies and provide rationale. Some treatment interventions to address her short-term goals might include diaphragmatic breathing exercises, splinted cough, functional ambulation with gait aid if needed, strengthening exercises (isometric and concentric), graded ADL practice (e.g., daily reduction of assistance required when bathing and dressing). Consider what elements of rehabilitation may be potentially self-managed by Sonia and what others might require rehabilitation support. She will also potentially need assistance with instrumental ADLs (IADLs) such as shopping initially after discharge. She may also benefit from stair rails, bathing equipment and education about energy conservation techniques.

Record keeping (e.g., tracking of exercise, medications, and other self-management techniques) may help Sonia maintain her goals. If Sonia seems overwhelmed, suggest that she set one goal for the day to provide a purpose for getting up. Additional strategies may include keeping a daily reflection record, especially to identify items for discussion at the next healthcare appointment. All clients should also be encouraged to engage in some type of cognitive activity (e.g., reading, word games, or games on their cell phone).

Some of the interventions to address her long-term goals might include: referrals to social worker and/or HIV physician to address new HIV diagnosis, referral to a vocational rehabilitation specialist to assist with return to work, referral to an addictions counsellor to address substance use and safe injection practices, links to appropriate services to address potential mental health and social support required surrounding her new diagnosis, and links to community-based organizations that may be specific to women and Indigenous communities if available.

8. What types of educational, health promotion, prevention, care, treatment and support materials or information might the team provide for Sonia?

Notes: After Sonia recovers from her PCP pneumonia she will require education surrounding her new HIV diagnosis and referrals to HIV medical care. She will be likely linked to the Infectious Disease specialist at the hospital. She may require psychosocial support to help her deal with the news of her new HIV diagnosis and to navigate the system and choices surrounding treatment options, accessing services, safe injection practices, and health promotional strategies. Any post-test counselling should also include legal issues such as disclosure and prevention of further HIV transmission. Other community links may include Community-based HIV Organizations (CBHO) that are geared towards Indigenous people and women living with HIV. Many people benefit from peer support programs. Examples of the range of peer support content include discussing a new diagnosis, sharing anxieties, support for exercise and other topics. If referral is to a non-HIV peer support program, the program should be screened for policies around discrimination and there should be a discussion as to whether disclosure of HIV status is needed.

9. What other health or social services might Sonia also benefit from having access to? Why?

Notes: Identify other services and providers that might help to address Sonia’s impairments, activity limitations and participation restrictions and the news of her new HIV diagnosis. Consider how you would go about referring to the other service providers and services. Consider the potential barriers that Sonia might encounter in attempting to access these services. How might you advocate with Sonia to enable her to better access the needed services?

• Sonia will need to liaise with an Infectious Disease specialist surrounding her new HIV diagnosis (modes of transmission, available treatment options, etc.) for education and treatment.
• A social worker can assist Sonia to link with further sources for mental and social support, potential links to income support if not working, and help to ensure that she is able to sustain her housing while not currently working.
• A vocational rehabilitation specialist or occupational therapist (OT) to assist with returning to work if/when Sonia is ready.
• Link with a CBHO to learn about support services in Sonia’s area and specifically any resources specific to Indigenous people and women.
• Link with a community-based epilepsy consumer organization to help her to continue to manage the epilepsy that she has been living with for a number of years, in light of her recent HIV diagnosis.

10. What issues might Sonia need you to help her advocate for?

Notes: Sonia will probably need assistance to connect with the necessary services needed in order to help her deal with her new diagnosis; including a primary care physician familiar with HIV. She will need assistance to access rehabilitation at an outpatient facility (healthcare centre or outpatient hospital clinic) if needed. Eventually, she will need assistance to access vocational rehabilitation if/when Sonia would like to return to work. The challenge will be linking to all the above health providers and community organizations in a way that is driven by Sonia and not overwhelming in light of the multitude of medical and social issues that she is dealing with, preferably services specifically geared towards Indigenous women to address any potential forms of cultural dislocation or stigma.

Part 2:

Part 2: Four months later…

Presenting Problem / Background

Sonia was discharged from hospital after her first admission and linked with an HIV primary care physician and started antiretroviral therapy (ART). During that time, she got behind in paying her rent, lost her apartment and moved into a women’s shelter. She has not yet returned to work.  She is greatly troubled by her HIV diagnosis and was unable to follow up with recommended health professionals because her cell phone account was cancelled due to non-payment.

Four months later, Sonia presented to the ER by ambulance from a detox centre with uncontrolled seizures. The ER doctors administered her anti-seizure medication. Sonia recovered well enough to be sent back to the women’s shelter. Within 12 hours, she presented to the same ER again with seizures.

Subjective

Sonia has been largely non-adherent with her HIV and antiepileptic medications and doctor’s appointments due an increase in her substance use, compounded by her housing situation and lack of a phone. She has a pay-as-you-go cell phone but can’t afford to add minutes to it. She states that she is overwhelmed by all her health issues and needs help getting back on her feet.

Objective

CT imaging revealed positive findings. A serum cryptococcal antigen test confirmed that Sonia has cryptococcal meningoencephalitis (now her second AIDS-defining illness).

She has advanced HIV disease with a viral load of >500,000 copies RNA/ml and a CD4 of 1 cell/mm3. She also shows elements of wasting (86-94 pounds).

Sonia was admitted to hospital and ordered high doses of antifungals (Amphotericin B followed by Fluconazole).

She quickly became unresponsive with very high blood pressure. When she woke, she suffered from severe dysphagia, dysarthria, cognitive deficits (biting off PICC line x2), slurred speech, unsteady gait (numerous falls) and decreased sensation to right hand and forearm (she drops things frequently as she is right handed). She is inconsistent with her orientation to person, place and time.

According to the Speech-Language Pathology (SLP) report, Sonia was noted to chew her food for a “significantly long period of time”. The final comments were to “downgrade diet to DAT (diet as tolerated) with thin fluids”. The use of straws was recommended with Sonia, and she was monitored for throat clearing. OT and PT assessments were requested.

Guiding Questions

1. What is cryptococcal meningoencephalitis?

Notes: AIDS-defining illness, neurological condition.

2. What are some of the (a) impairments, (b) activity limitations and (c) participation restrictions that Sonia is experiencing?

Notes: Consider the physical, cognitive, social, emotional and psychological challenges faced and classify using the ICF Framework.

Some examples include:

• Impairments: any problem with body structure or function (e.g., dysphagia, dysarthria, decreased cognition, slurred speech, decreased balance, decreased sensation to right hand and forearm, decreased strength potentially in right hand and arm).
• Activity limitations: decreased mobility, decreased ability to swallow, reduced ability to grip, falls.
• Participation restrictions: diminished financial status, drug benefits, homeless, not working.

3. What personal and environmental factors might influence Sonia’s disability and ability for discharge?

Notes: Her ongoing history of drug use which may further exacerbate her health challenges, potential lack of social support, drug benefits and Indigenous Affairs coverage, her diminished financial status, her homelessness, potential stigma experienced from her Indigenous community.

4. What additional factors should be considered?

• Determine if the client has a reliable mode of communication to ensure contact with health professionals. Alternatives may include landline, cell phone, leaving messages with a friend or relative who is in regular contact.
• Determine adherence with medications (HIV and other). Adherence may be improved with blister packs or a record-keeping technique (e.g., phone alarm).

5. What are some of the rehabilitation goals for Sonia?

Notes: Consider patient values and preferences, and principles of shared decision-making, when discussing and developing goals. Use the SMART principle.

1. To be able to be oriented to person, place and time in 3 days.
2. To be able to ambulate independently with gait aid 100 metres in 1 week.
3. To be able to carry out ADL tasks (dressing, bathing, toileting) independently in 1 week.
4. To be able to swallow pill medications safely without need for crushing pills in 1 week.
5. To be able to swallow soft-textured foods and thin fluids safely with supervision in 1 week.
6. To be able to speak intelligibly with assistance from a communication partner in 3 days.

6. What rehabilitation treatment strategies might be used to address Sonia’s impairments, activity limitations and participation restrictions?

Notes: Consider patient values and preferences when discussing treatment strategies. Consider the process of shared decision-making when prioritizing treatment strategies. It is important that the strategies used to address her challenges take into account the ICF. By setting goals that address her impairments, this can lead to improvements in her activity limitations and participation restrictions. Some treatment interventions might include stretching exercises, strengthening exercises, functional ambulation, balance retraining, practice with functional ADL tasks such as bathing, dressing, eating, cognitive retraining, diet texture modifications, feeding training, articulation exercises.

Record keeping (e.g., tracking of exercise, medications, and other self-management techniques) may help the client to maintain her goals. If Sonia seems overwhelmed, suggest that she set one goal for the day to provide a purpose for getting up. Additional strategies may include keeping a daily reflection record, especially to identify items for discussion at the next healthcare appointment. All clients should also be encouraged to engage in some type of cognitive activity (e.g., reading, word games, or games on their cell phone).

7. What types of educational health promotion, prevention, care, treatment and support materials or information might the team provide for Sonia?

Notes: After Sonia recovers from her cryptococcal meningoencephalitis she will require much support to help her with housing and getting back onto HIV and antiepileptic medications. She will likely be linked to the Infectious Disease specialist at the hospital again and other community-based supports to help her deal with her homelessness (which will have an impact on her ability to store and adhere to her HIV and antiepileptic medications). Other community links may include a CBHO, particularly if there is a local organization geared towards Indigenous peoples and women living with HIV.

8.What other health or social services might Sonia also benefit from having access to? Why?

Notes: Identify other services and providers that might help to address Sonia’s impairments, activity limitations and participation restrictions and the news of her new HIV diagnosis.
Consider how you would go about referring to the other service providers and services. Consider the potential barriers that Sonia might encounter in attempting to access these services. How might you advocate with Sonia to enable her to better access the needed services?

Sonia would benefit from a referral to:

• An infectious disease specialist to review her current status and update recommendations for care.
• An addictions counsellor may help her address her increased substance use and provide education on safe injection practices.
• A social worker that can assist Sonia to link with further sources for mental and social support, and potential links to income support. A social worker can also help to explore housing options given her new state of homelessness, either a shelter (if needed in the short-term) or a form of supportive housing.
• A dietitian to assist with nutritional requirements and referral to an SLP to continue with speech and swallowing re-assessment and treatment.
• PT and OT to continue with improving grip, mobility, balance, strength, cognition, and functional ADLs.
• A vocational rehabilitation specialist to assist with returning to work if/when Sonia is ready.
• Link with CBHOs to learn about support services in Sonia’s area and specifically any resources specific to Indigenous people and women. Accessing a CBHO with a good peer support or support coordinator and/or peer buddy program can help her navigate the system of rehabilitation.
• Link with community-based epilepsy consumer organization to help her to continue to manage the epilepsy that she has been living with for a number of years, in light of her recent HIV diagnosis.

9. What issues might Sonia need you to help her advocate for?

Notes: Sonia may require continued advocacy support to address housing issues, income support and hopefully return to work (consider part-time return to work or alternative duties).

Medical Management – Infectious Disease Specialist Recommendations for Sonia Part 1

Assessment: Sonia more than likely has PCP, but could also have non-PCP pneumonia, fungal infection, tuberculosis (TB), and endocarditis with septic emboli to the lungs. She is a very high-risk individual for adverse health outcomes.

Plan:

Management of Acute Illness:

• Acute resuscitation/supportive care: IV fluids, broad-spectrum antibiotics with coverage for PCP. Sputum culture with direct fluorescent antibody (DFA), blood cultures, and echocardiogram would be warranted.
• Airborne isolation and sputum for Acid-Fast Bacillus (AFB) given high risk for TB as well. If negative patient should have a follow up TB skin test once acute illness is resolved.
• Monitor and treat for substance withdrawal.
• Consult infectious diseases team or local HIV specialist (if available) for assistance with linking up with local resources.
• Consult PT, OT and social work as patient seems significantly deconditioned and may require increased supports or rehabilitation prior to discharge home.

Long-term Management:

• Initiate ART and ensure follow up with a local family physician who is HIV-trained or with an infectious diseases specialist for regular blood work, medication assessment, and support.
• Addictions counselling, consider follow up with a local psychologist to manage not only addictions but also the new diagnosis of HIV.
• Education about HIV and risks of transmission.
• Ensure patient has been assessed for concomitant blood-borne illnesses such as Hepatitis B and Hepatitis C.