Transcript Clinical Medicine in Resource-Limited Areas

Ashti Doobay-Persaud M.D.
Assistant Professor of Medicine
September 19th, 2013
Center for Global Health
Objectives
Understanding your setting
Practical Guidelines for Primary Care
Reasoning without resources- Cases
Settings and Resources
•Country
•Urban vs. Rural
•Primary Care Clinic vs Hospital
•Available Labs and Diagnostic Testing
•What you definitely have:
•History and Physical Exam Skills
•Language Dependent
Top Diagnoses at Hillside Clinic and Mobiles - 2011
Primary Care Clinic
•Upper Respiratory Infections
•Asthma
•Skin Diseases
•Diarrhea
•Diabetes and Hypertension
•STIs
•Anemia
Available Resources in clinic
•Vital Signs, one O2 sat monitor
•Urine HCG
•Fingerstick Glucose
•No Chest XRAY machine
•Imaging and Referral Centers in the capital→ 3
hours and expensive transportation away
•Rxs available: amoxicillin, azithromycin, cefixime,
CTX, dicloxacillin, TMP/SMX, metronidazole, topical
anti-fungals, albendazole and permethrin
General Rules
 Keep it Simple (time, # of pills etc.)
 Consolidate Medications
 Do No Harm
 Quantity: Triage
 Quality Care- what we do here
 Pharmacokinetics
 Horse NOT Zebras
 Review: helminths, lice, scabies
 Only treat the patient you have seen
Case #1
•3 yo presents with cough, congestion, fever, sore
throat, headache, etc.
•Slightly tachypneic and tachycardic but wellappearing otherwise, rhinorrhea is present, clear
lungs and playing well. Her 2 other siblings have
had something similar. + developmental milestones
•What do you do next, what do you prescribe ? Is
there anything else you would like to know on the
HPI or PE ?
Case #1- RTC 3 days later
•Now she is febrile, tachypneic ( RR 45),
tachycardic and has crackles and wheezing in
one lung field and has a mild fever. She does not
have visible retractions of her chest and can
complete full sentences, she is still playful but
less so compared to three days ago
•O2 sat: 98%/RA
•What do you do ? Should you have done
something differently last time ?
Case # 2
•In a rural village and a 78 yo F who cooks by the
fire daily presents with wheezing, tachypnea and is
unable to complete full sentences, her O2 sat is
80% on RA
•She is afebrile and has a chronic cough but no new
fevers or cough
•She has gotten some inhalers in the past from
Belize city
•What do you do ? Assume we have the same meds
here as at home however not in clinic
What is this?
Scabies
• Sarcoptes scabiei
• Itchy papules and linear burrows occur in a
symmetrical fashion, particularly in skin folds
• Head infestation uncommon, except in infants
• More itchy at nighttime
• Treatment- Permethrin 5% cream, treatment of
clothing/bedding, treat family members
Rashes- Tropical Dermatidities
•Bacterial
•Viral Exanthem
•Viral
•Fungal
•Atopic
What is this rash?
Impetigo
• Superficial infection of epidermis, often at the
site of skin damage
• Golden-yellow vesicle bursts, then crusts over
• Usually caused by staph aureus or streptococci
• Treatment- topical vs. PO antibiotic, soak off
crusts
Tinea Infections
• Tinea pedis (athlete’s foot)
• Topical antifungals usually effective
• Tinea cruris (jock itch)
• Topical antifungals
• Tinea corporis (ring worm)
• Topical antifungals usually effective
• Tinea capitis
• Oral antifungals
• May progress to kerion (immune response to fungus)
4 days of non-bloody diarrhea.
What are your follow-up questions ?
What are you looking for on exam?
Warning Signs
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Fever
Significant abdominal pain
Blood or pus in stools
> 6 stools per day
Severe dehydration
Ability to take po
Elderly or very young
Duration > 7 days
WHO Guidelines for Assessing Hydration
• Condition: Well, restless, lethargic, or
unconscious
• Eyes: Normal or sunken
• Thrist: None, drinks eagerly, or unable
• Turgor: Goes back immediately or slowly
Diarrhea
What are the causes of Non-Bloody
Diarrhea ?
Bloody Diarrhea ?
Remember your setting
Diarrhea
• Non-Bloody:
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Preformed toxin: Food poisoning
Viral: Rotavirus, norovirus
Bacterial: E coli, cholera
Parasites: Giardia, cryptosporidium
Diarrhea
• Bloody
• Bacterial: Campylobacter, Salmonella, Shigella, E
coli
• Parasite: E. histolytica
Diarrhea Treatment
• If no warning signs & patient taking PO supportive care
• If moderate dehydration - oral rehydration
solution (ORS)
• Antibiotic treatment: For inflammatory
diarrhea w/ warning signs or Giardia
• Cholera/Shigella
Reasoning without Resources
Case 1: Ascites
Case 2: Leg Edema
Case 1: Question 1
•“Frame” Key features of the HPI
•Age
•Duration of symptoms
•Lack of pain, jaundice or constitutional sx
•+ JVP, HJR WITHOUT edema
•No evidence of preceding exertional dyspnea
Case 1: Question 2
•Physical Exam findings:
•General: barefoot, torn clothing
•Normal BP without pulsus, benign fundi
•No thrush
•Increased JVP and HJR
•Summation Gallup
•Holosystolic Murmur@LSB
•Kussmaul’s sign
Case 1: Question 2
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Ascites+RV failure
No RV Lift (not hyperdynamic)
Clear Lungs, normal PMI, no MR murmur
No edema → next question
What is the DDX of Ascites without edema ?
Case 1: Question 3
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DDX Ascites without edema:
○ Malignant Ascites
○ TB Peritonitis
○ Ascites due to RV Failure can have no
edema in certain disease states
Case 1: Question 4
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UA: proteinuria
EKG: R atrial enlargement
without RV or LV Hypertrophy or LAE
Differential Diagnosis:
Painless Ascites with high CVP and no edema
● Malignant Ascites
● TB Peritonitis
● Cardiac Ascites:
○ Constrictive Pericarditis :? underlying cause,
what next test could confirm this if available
○ Mitral Stenosis
○ Hyperthyroid Cardiomyopahty
○ Restrictive Cardiomyopathy
EMF: Endomyocardial Fibrosis
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most common restrictive CM in the world
centered in E.Africa (rural SW Uganda)
>25% cases of CHF
widespread endocardial fibrosis → rigid ventricles
and a non-dilated heart, often murmurs due to the
tethering of valve apparatus
Patchy geographical and ethnic distribution
Nigeria, India, Brazil, Columbia, Sri Lanka and Middle
East
EMF: Endomyocardial Fibrosis
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Poverty as risk factor
Unknown etiology
Like Loeffler Endocarditis →
hypereosinophilic syndromes ?damage by
eosinophils due to multiple episodes of
parasitic infection
Other theories: nutrient, micronutrient
imbalance and gnetics
Case 2: Question 1
 Age and location
 Recent death of partner
 NON-pitting Bilateral Edema
 Temporal relation of swelling to skin lesions
 Painless Lymphadenopathy
Case 2: Question 2
 DDX:
 Filarial Elephantiasis
 Fungal Infection
 Chronic Renal Failure
 Congestive Heart Failure
 Chronic Liver Failure
 Chronic Venous Stasis
 Kaposi Sarcoma
Case 2: Testing
 Urine Dip:
 Spec Grav: 1.015, (-)
nitrites/WBCs/RBCs/protein, no casts,
glucose or ketones
 HIV rapid  (+)
 Creatinine wnl
Narrow our Differential
 DDX:
 Filarial Elephantiasis
 Fungal Infection
 Chronic Renal Failure
 Congestive Heart Failure
 Chronic Liver Failure
 Chronic Venous Stasis
 Kaposi Sarcoma
? Kaposi’s Sarcoma
 Stage 4 AIDS
 CD4 count
 Any other AIDS defining diagnoses
 Pregnancy Test
 Skin Scraping with KOH
 Punch Biopsy
 Look for Visceral Involvement
 Test Child and all partners
 R/o STIs, TB
Treatment
 HAART
 Chemotherapy, Surgical Excision
 Demanding Resources: Tertiary Care hospital if
available