Cheryl grew up in rural Idaho in a large extended family and enlisted as a private in the army just after she finished her third year in high school. After basic training, she was first deployed to Iraq and subsequently to Afghanistan for active combat duty. Traveling en route to Ghorak base in southern Afghanistan, Cheryl's Humvee made contact with an explosive device, throwing Cheryl from the vehicle and causing massive injuries to both legs. She sustained [Page 74]a blow to the head as well and lost consciousness for 30 minutes. As a result of serious injuries, Cheryl was taken to the intensive care unit of the closest military hospital by medevac. After she underwent surgery, Cheryl was informed by her physician and social worker that in order to save her life, both of her legs had to be amputated below the knee. To the delight of her medical team, Cheryl's reaction to this news was not extreme.

Over the 10-month course of her rehabilitation, Cheryl was fitted with different types of prostheses, none of which restored her ability to run and engage in sports. She also experienced phantom pain in her right leg, a condition in which pain is experienced in a body part that is no longer present. Following her honorable discharge from the army, Cheryl traveled to a university medical center several states away, where she was accepted into an experimental prosthetics program. She was fitted with two below-the-knee robotic prosthetics that are controlled by sensors. While she did well in her mobility training, Cheryl had a hard time with simple mathematical calculations, and her friends and family remarked that Cheryl's affect seemed vacant compared to how she was prior to her accident. Cheryl was referred to a social worker for counseling for suspected depression. The social worker, who had extensive experience with clients who had head injuries, referred Cheryl for neurological and neuropsychological testing. Cheryl's MRI scan detected injury to the frontal cortex, the region of the brain that controls affect.

Case Study 3.2 A Diabetes Diagnosis for Jenna

Jenna, a 12-year-old Franco American girl who lives in rural Maine, was doing well in school, riding in pony club in the summer, and alpine ski racing in the winter. The youngest of three children, Jenna also worked on her parents' blueberry farm, raking berries to earn spending money. Like many girls her age, Jenna had a sweet tooth, but her parents watched her nutrition, making sure that she was adequately nourished. Drinking sufficient fluids each day was easy for Jenna because it seemed that she was always thirsty for water. But when Jenna started losing weight and engaging in more afternoon napping, Jenna's parents were concerned that she could be exhibiting an eating disorder. They made an appointment with their family health provider.

On the morning of her appointment, Jenna did not come down from her bedroom. Because it was very unusual for her not to join her family at the breakfast table, her parents became alarmed and immediately went upstairs to find Jenna sitting on her bed, still in her nightgown, which was drenched with perspiration. Jenna was confused and unable to answer simple questions with correct responses. Jenna's parents immediately took her to the local community hospital.

In the emergency department (ED), after some blood work, a doctor diagnosed Jenna with type 1 diabetes. The ED social worker referred Jenna to a hospital social worker, who is helping her with her new insulin pump, a small computerized device that is programmed to deliver insulin to the fatty tissue under the skin. Jenna hates to draw blood daily so the social worker has put her on the waiting list to test out a new cell phone app, Epic Health, which she can use to measure blood glucose levels by placing her finger over the camera device.

Case Study 3.3 Melissa's HIV Diagnosis

Melissa's "perfect life" has just fallen apart. As a young urban professional who grew up in a middle-class suburb in New York, Melissa had always dreamed of a big wedding at her parents' country club, and her dreams were about to come true. All the plans had been made, invitations sent out, bridesmaids' dresses bought and measured, and her wedding dress selected. All that remained was finalizing the menu and approving the flower arrangements. Because Melissa and her fianc, Ashish, planned to have children soon after their marriage, she went to her physician for a physical exam two months prior to the wedding. Following common practice, the doctor asked Melissa for permission to conduct an HIV test.

One week following the physical, the doctor's office called and asked Melissa to return for repeat blood work and a follow-up visit. At the appointment, Melissa learned that she was positive for HIV. Melissa's physician started her on daily medication to prevent the disease from exacerbating and advised her not to engage in unprotected intercourse.

Melissa had no history of illicit drug use and was relatively conservative in her intimate relationships, having only one partner besides her fianc. She recalled that this man did not share much about his history.

[Page 75]After couples counseling, Melissa and Ashish decided to proceed with their marriage and their desire to have children. The social worker referred them to an HIV pregnancy clinic to explore their options. At that time, they learned that there are ways to fulfill their desire to have children and minimize the risks of transmitting HIV to Ashish and their babies.

Case Study 3.4 HIV, Thomas's Hero

Thomas is a 6-year-old boy who lives with his parents. When he turned 3, he was diagnosed with leukemia. New research and experimental treatments are indicating that one's own immune system can be used to fight and cure certain cancers, leukemia being one of them. The HIV virus has been manipulated as a hunter, one that can ferret out and eliminate cancer cells and activate one's own immunity, particularly in the blood. Thomas continued to fail, showing no positive responses to conventional treatments. After consultation with his pediatric social worker, his parents decided to enroll him in an experimental program in which HIV was a primary treatment agent. Thomas underwent the preparation of T-cell protection and then was treated with the modified HIV virus (chimeric antigen receptor T-cell therapy). Now, at age 6, there is no evidence of cancer in his body.

Case Study 3.5 Louise and Stewart, Huntington's, Obesity, and Cardiovascular Disease

Louise is an 81-year-old Jewish woman who lives on the west coast of Florida in her own apartment. At the age of 49, Louise was diagnosed with Huntington's disease, a genetically transmitted neurodegenerative condition affecting all aspects of function, including musculoskeletal integrity, cognition, self-care, speech, and mood. Until the age of 70, Louise was able to walk with the assistance of a rollator (a wheeled walker), to engage in social interactions, and to do light chores in the house. As her disease progressed, she became increasingly limited in mobility, fine motor skills, speech, and swallowing. Her husband, Stewart, who was grossly obese and thus unable to provide full care for Louise, found an agency that brought Haitian families into the United States to provide care for elders. Anne, the 39-year-old caregiver, came to work at Louise's home each day, sometimes bringing her 10-year-old daughter with her. When Louise's husband died suddenly of a massive heart attack, Anne and her daughter moved into the guest bedrooms of Louise's home. Anne's daughter has graduated from undergraduate school and plans to go on for her master's degree in social work. Anne remains with Louise at home, despite Louise's son's attempt to put his mother in a nursing home. Louise's daughter, now in her early 60s, has Huntington's but benefits from the new drugs to reduce symptoms and from her exercise regimen that has been empirically shown to reduce the rate of neural degeneration.

1. What was most memorable about and/or what you learned in the reading above?