Work through this case with your small group then read the second case before the full group debrief

Case: a young woman with a neck mass

(adapted from )

A 19-year-old woman in rural Ethiopia presentsto a secondary hospitalwith weakness and neck swelling. She lives a 6-hour bus ride from the facility. She is one of six children and her parents are farmers (estimated income ~3USD/day). Three years ago, she presented to the hospital with submandibular swelling. This was biopsied but pathology consultation took approximately 2 weeks and she missed her follow-up due to her agricultural responsibilities. Her clinical condition worsened, and she developed headache, difficulty swallowing and weight loss. She discontinued her education and her younger sister also had to stop her schooling to care for her. She returned to the hospital one year prior with hematemesis and was told she had metastatic nasopharyngeal carcinoma. The recommended treatment regimen (Cisplatin and 5-FU) costed ~75USD per cycle. There was a possibility that in Addis Ababa, the government would provide those drugs for free but the patient could not afford the transportation or housing for her family in the capital. She left the hospital and returned home.

At the last visit, patient had generalized weakness, nausea, vomiting and weight loss as well as difficulty swallowing and dizziness. Physical exam showed a 10X10cm mass on the left side of her neck and a separate 2x2cm mass inferior to that.

One cycle of treatment was provided from “leftover drugs” unused by other patients. Following this, CT scan revealed a 5.3x2.8 cm enhancing nasopharyngeal mass extending to the first cervical canal space and compressing the spinal cord with complete occlusion of the left carotid artery and jugular vein.

The recommendation for treatment was an extended course of chemoradiotherapy. Radiotherapy is only available in Addis Ababa. One cycle of chemotherapy was obtained free of charge from Addis Ababa as it was transported back personally by a visiting general practitioner. and the patient had good response.However there was a drought/famine and the patient’s family had an extremely insufficient harvest, exacerbating their already difficult financial situation. End of case.

Your task:

  1. What probing questions would you ask/add at this point to help learners incorporate SDH into clinical decision making?
  1. Write a discussion question that encourages learners to think about structural interventions (systems, community, public health policy and advocacy). Think about what you would include in the facilitator guide?
  1. Provide 2-3 SDH-related learning objectives for this case:
  2. (turn over for second case)

Below you will find an actual PBL case in the microbiology course for first year medical students.

Case: Influenza(abbreviated version)

A 31-year old female presents to a community hospital ED with fever of 39 degrees C, non-productive cough, chills, malaise, myalgias and chest congestion for 1 day. She has a history of mild asthma and is 32 weeks pregnant. She works at an engineering firm and says that everyone there has been sick with a cold. Her 3-year-old daughter has also been sick and had to miss 2 days of pre-school in the previous week.

Question for students (do not answer): What is your differential dx based on this information? How is the influenza rapid test different from RVP?

In the ED, she is tachycardic and hypotensive and appears ill. She says that neither she nor her daughter received the flu vaccine. A rapid flu test is done and comes back negative. A chest x-ray is done and no infiltrates are seen. She is started empirically on treatment for community-acquired pneumonia (CAP).

Question for students (do not answer):Is the decision to start antibiotics reasonable?

Despite treatment for presumed CAP, the patient does not improve. She is worried because she hasn’t felt the babymove in the previous 4 hours. She deteriorates further, requiring urgent intubation and c-section. Eventually, a BAL is performed which reveals influenza A and is negative for bacterial infection… End of case.

Your task:

  1. Which risk factors or circumstances would you include in the case to trigger discussion of social determinants of health (SDH)?
  1. Write a discussion question to encourage trainees to think about community based interventions or public health measures related to this case? (think about what you would include in the facilitator guide)
  1. Provide 1-2 SDH-related learning objectives for this case(to supplement the micro learning objectives):