CASE 12
George, a frequent visitor to your emergency department, is generally in a state of total intoxication. He is 55 years old and has lived on the streets for as long as you can remember. In winter he stays overnight in a local shelter. When you see him tonight he looks quite ill and has obviously lost a significant amount of weight compared with when you saw him last (˜2 to 3 months ago). He admits he has chronic night sweats and a persistent cough with some whitish-yellow sputum. He has no history of diabetes, and indeed his blood sugar, even now, is within the normal range of 5 to 8 mmol/dL. He is unaware of any obvious acute presentation of a febrile illness and admits to a general lethargy over the past 2 to 4 weeks. There is no history of travel out of the city (including to local farms). He is currently afebrile but certainly does not look well. Blood work is unremarkable, with the exception of a modest increase in neutrophils. His chest radiograph shows significant consolidation in the lower lobes and evidence of an infectious process (inflammation) in the upper zones also (Fig. 12-1). In room air, his oxygen saturation is only 89% (normal 97% to 100%), and he is not a cigarette smoker.
