L.T.
Resources consulted for this case, unless otherwise stated:
Gaetz S, Donaldson J, Richter T, & T Gulliver (2013): The State of Homelessness in Canada 2013. Toronto: Canadian Homelessness Research Network Press.
Greenaway C, Khan K, & Schwartzman K (2013): Chapter 13: Tuberculosis surveillance and screening in high-risk populations. Canadian Tuberculosis Standards – 7th Edition. Canadian Thoracic Society and The Public Health Agency of Canada.
L.T. is a 53-year-old recent immigrant from India who comes to your walk-in clinic today at his wife’s prompting. For three months, he has felt tired and generally unwell, has had progressive weight loss, and has a worsening cough. He has also been experiencing fevers, night sweats, and occasional hemoptysis. He has a 20-pack-year smoking history, no significant medical history, takes no medications, and has not seen a doctor since his immigration medical check. He received the BCG vaccine as a child and has never had an HIV test. L.T. and his family of four lived in a shelter for a few months after arriving in Canada. Recently, they moved into a cramped, two-bedroom apartment that they share with another family of three to share costs. L.T. is worried about providing for his family and that they may lose the apartment if he cannot find a job.
Gaetz S, Donaldson J, Richter T, & T Gulliver (2013): The State of Homelessness in Canada 2013. Toronto: Canadian Homelessness Research Network Press.
Greenaway C, Khan K, & Schwartzman K (2013): Chapter 13: Tuberculosis surveillance and screening in high-risk populations. Canadian Tuberculosis Standards – 7th Edition. Canadian Thoracic Society and The Public Health Agency of Canada.
L.T. is a 53-year-old recent immigrant from India who comes to your walk-in clinic today at his wife’s prompting. For three months, he has felt tired and generally unwell, has had progressive weight loss, and has a worsening cough. He has also been experiencing fevers, night sweats, and occasional hemoptysis. He has a 20-pack-year smoking history, no significant medical history, takes no medications, and has not seen a doctor since his immigration medical check. He received the BCG vaccine as a child and has never had an HIV test. L.T. and his family of four lived in a shelter for a few months after arriving in Canada. Recently, they moved into a cramped, two-bedroom apartment that they share with another family of three to share costs. L.T. is worried about providing for his family and that they may lose the apartment if he cannot find a job.
Question 1: How would you define L.T.’s housing status? Describe a link between housing and health status.
- L.T. is currently at risk of experiencing homelessness (two-bedroom shared apartment, not employed and financial strain). Prior to moving to the apartment, L.T. and his family’s housing status would be categorized as “emergency sheltered”.
- Any unstable housing situation can be linked with individuals’ vulnerability, which can influence all aspects of their health (e.g. physical, mental, psychosocial)
Question 2: What are some important diagnoses you need to rule out and what social risk factors does he have?
o Immigration medical exams are conducted in an effort to identify (and treat) active TB cases.
o Between 18-51% of individuals experiencing homelessness in Canada have positive TB skin tests, most of whom
have latent TB infection (LTBI). LTBI People with LTBI experiencing some form of homelessness may be more likely
to progress to active TB for a variety of reasons (e.g. medical comorbidities like HIV and diabetes may not be
well-controlled, lower LTBI treatment completion rates)
- Tuberculosis (immigration from TB-endemic country, lived in a shelter, crowded housing, unknown HIV status, unknown results of his immigration medical check)
o Immigration medical exams are conducted in an effort to identify (and treat) active TB cases.
o Between 18-51% of individuals experiencing homelessness in Canada have positive TB skin tests, most of whom
have latent TB infection (LTBI). LTBI People with LTBI experiencing some form of homelessness may be more likely
to progress to active TB for a variety of reasons (e.g. medical comorbidities like HIV and diabetes may not be
well-controlled, lower LTBI treatment completion rates)
- Lung cancer (smoking history)
- HIV infection
At this time, you decide to order a chest x-ray to assess for evidence of pulmonary tuberculosis or lung cancer, an HIV test, and some basic bloodwork.
Question 3: List three things about L.T.’s current living situation that you need to take into consideration when planning further investigations and follow-up for L.T.
- At risk for losing his housing
- Limited financial resources
- Potential difficulty contacting L.T. and/or ensuring he can attend appointments. Confirm address and contact numbers, including emergency contacts.
- Crowded housing puts others at risk if he has active tuberculosis
You were able to arrange a chest x-ray for the same day as L.T.’s initial appointment and a follow up appointment for him with you later this week. Your clinic provided him with tickets for public transportation for these.
The radiologist at the lab calls you the next day and faxes over L.T.’s report: it is positive for infiltrates and cavitary lesions in the right upper lobe. This plus his symptoms are indicative of pulmonary tuberculosis.
The radiologist at the lab calls you the next day and faxes over L.T.’s report: it is positive for infiltrates and cavitary lesions in the right upper lobe. This plus his symptoms are indicative of pulmonary tuberculosis.
Question 4: What are your next steps in managing L.T.’s likely diagnosis?
o Assistance with arranging treatment (e.g. directly observed therapy)
o Assistance with patient education and contact tracing and TB screening (individuals recently exposed to L.T. – e.g.
in his apartment, the shelter – will need appropriate screening for TB)
- Arrange for bacteriological confirmation (e.g. specimen collection for Acid Fast Bacilli smear and culture)
- Start discussion and education about tuberculosis with L.T. (diagnosis, treatment, how drug resistance occurs, importance of adherence and isolation requirements)
- Ensure L.T. knows he will not have to pay for his TB medications (active and latent TB treatment medications are publicly funded)
- Contact public health for:
o Assistance with arranging treatment (e.g. directly observed therapy)
o Assistance with patient education and contact tracing and TB screening (individuals recently exposed to L.T. – e.g.
in his apartment, the shelter – will need appropriate screening for TB)
- If available in your community, other options for treatment and monitoring include referring L.T. to a comprehensive TB treatment clinic or to a physician with TB experience
- Consider a referral to a social worker or community work who could assist L.T. with his housing and employment concerns, to see how he is managing with treatment
- Follow up on results of HIV test
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greenaway_2013_ch._13_high_risk_populations.pdf | |
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