Clinical Medicine in Resource-Limited Areas

Clinical Medicine in Resource-Limited AreasAshti Doobay-Persaud M.D.Assistant Professor of MedicineSeptember 19th, 2013Center for Global Health

ObjectivesUnderstanding your settingPractical Guidelines for Primary Care Reasoning without resources- CasesSettings and ResourcesCountryUrban vs. RuralPrimary Care Clinic vs HospitalAvailable Labs and Diagnostic TestingWhat you definitely have:History and Physical Exam SkillsLanguage Dependent

Top Diagnoses at Hillside Clinic and Mobiles - 2011*Primary Care ClinicUpper Respiratory InfectionsAsthmaSkin DiseasesDiarrheaDiabetes and HypertensionSTIsAnemiaAvailable Resources in clinic Vital Signs, one O2 sat monitorUrine HCGFingerstick GlucoseNo Chest XRAY machineImaging 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 permethrinGeneral RulesKeep it Simple (time, # of pills etc.)Consolidate MedicationsDo No HarmQuantity: TriageQuality Care- what we do herePharmacokineticsHorse NOT ZebrasReview: helminths, lice, scabiesOnly treat the patient you have seen

Case #13 yo presents with cough, congestion, fever, sore throat, headache, etc.Slightly tachypneic and tachycardic but well-appearing otherwise, rhinorrhea is present, clear lungs and playing well. Her 2 other siblings have had something similar. + developmental milestonesWhat do you do next, what do you prescribe ? Is there anything else you would like to know on the HPI or PE ?Signs of dehydration, asking if she is eating and drinking well, any fevers go get a thermometer, OP clear- no plaquesTylenol for 2-3 days if fevers, reassurance and can come back if does not improveLook in the ears given ageTB contacts ? Weight loss, night sweats, chest pain /diarrhea concern for staph

*Case #1- RTC 3 days laterNow 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 agoO2 sat: 98%/RAWhat do you do ? Should you have done something differently last time ?Teaching point try not to give too many abx but be aware that sometimes people cannot come back? TB contacts

TB contacts ? Weight loss, night sweats, chest pain /diarrhea concern for staph

Amox po for 5 days, RTC in in 48 to 72 hours if no improvementCan aff azithro after 3 days if doing poorlyIf very concerned can give CTX IV observe for several daysNebs/steroids

*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 RAShe is afebrile and has a chronic cough but no new fevers or coughShe has gotten some inhalers in the past from Belize cityWhat do you do ? Assume we have the same meds here as at home however not in clinicNebs- attach to vehicle, steroids and abx, if O2 sat does not improve may need to drive her to a hospital, +/- abx*What is this?*How do you treat it ?*Scabies Sarcoptes scabieiItchy papules and linear burrows occur in a symmetrical fashion, particularly in skin foldsHead infestation uncommon, except in infants More itchy at nighttime Treatment- Permethrin 5% cream, treatment of clothing/bedding, treat family members *Place clothing in bag for 3 daysWash and dry in the sunRashes- Tropical DermatiditiesBacterialViral ExanthemViralFungalAtopicWhat is this rash?*ImpetigoSuperficial infection of epidermis, often at the site of skin damageGolden-yellow vesicle bursts, then crusts overUsually caused by staph aureus or streptococciTreatment- topical vs. PO antibiotic, soak off crusts

*Tinea Infections Tinea pedis (athletes foot)Topical antifungals usually effective Tinea cruris (jock itch)Topical antifungalsTinea 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?*FebrileAble to take poFebrileTears, mucous membranes, skin turgorMental statusHow many stools per day Warning SignsFeverSignificant abdominal painBlood or pus in stools> 6 stools per daySevere dehydrationAbility to take poElderly or very youngDuration > 7 days*WHO Guidelines for Assessing HydrationCondition: Well, restless, lethargic, or unconsciousEyes: Normal or sunkenThrist: None, drinks eagerly, or unableTurgor: Goes back immediately or slowly *DiarrheaWhat are the causes of Non-Bloody Diarrhea ?Bloody Diarrhea ?Remember your settingDiarrheaNon-Bloody:Preformed toxin: Food poisoningViral: Rotavirus, norovirusBacterial: E coli, choleraParasites: Giardia, cryptosporidium*DiarrheaBloodyBacterial: Campylobacter, Salmonella, Shigella, E coliParasite: E. histolytica*Diarrhea TreatmentIf no warning signs & patient taking PO - supportive careIf moderate dehydration - oral rehydration solution (ORS)Antibiotic treatment: For inflammatory diarrhea w/ warning signs or GiardiaCholera/Shigella*Cholera: Doxy/AzithroHigh Mortality is 2/2 dehydration pt over5 with severe and rapid dehydration CholeraReasoning without ResourcesCase 1: AscitesCase 2: Leg EdemaCase 1: Question 1Frame Key features of the HPIAgeDuration of symptomsLack of pain, jaundice or constitutional sx+ JVP, HJR WITHOUT edema No evidence of preceding exertional dyspneaCase 1: Question 2Physical Exam findings:General: barefoot, torn clothingNormal BP without pulsus, benign fundiNo thrushIncreased JVP and HJRSummation GallupHolosystolic Murmur@LSBKussmauls signCase 1: Question 2Ascites+RV failureNo RV Lift (not hyperdynamic)Clear Lungs, normal PMI, no MR murmurNo edema next questionWhat is the DDX of Ascites without edema ?Case 1: Question 3DDX Ascites without edema:Malignant AscitesTB PeritonitisAscites due to RV Failure can have no edema in certain disease statesmakes hepatic etiologies much much less likelyconstrictive pericarditis and restrictive CM 2 most relevant in the DDX

Case 1: Question 4

UA: proteinuriaEKG: R atrial enlargement without RV or LV Hypertrophy or LAE

Differential Diagnosis:

Painless Ascites with high CVP and no edemaMalignant AscitesTB PeritonitisCardiac Ascites:Constrictive Pericarditis :? underlying cause, what next test could confirm this if availableMitral StenosisHyperthyroid CardiomyopahtyRestrictive Cardiomyopathy

EMF: Endomyocardial Fibrosismost common restrictive CM in the worldcentered in E.Africa (rural SW Uganda)>25% cases of CHFwidespread endocardial fibrosis rigid ventricles and a non-dilated heart, often murmurs due to the tethering of valve apparatusPatchy geographical and ethnic distributionNigeria, India, Brazil, Columbia, Sri Lanka and Middle EastEMF: Endomyocardial FibrosisPoverty as risk factorUnknown etiologyLike Loeffler Endocarditis hypereosinophilic syndromes ?damage by eosinophils due to multiple episodes of parasitic infectionOther theories: nutrient, micronutrient imbalance and gneticsCase 2: Question 1Age and locationRecent death of partnerNON-pitting Bilateral EdemaTemporal relation of swelling to skin lesionsPainless LymphadenopathyCase 2: Question 2DDX:Filarial ElephantiasisFungal InfectionChronic Renal FailureCongestive Heart FailureChronic Liver FailureChronic Venous StasisKaposi Sarcoma

Case 2: TestingUrine Dip:Spec Grav: 1.015, (-) nitrites/WBCs/RBCs/protein, no casts, glucose or ketonesHIV rapid (+)Creatinine wnlNarrow our DifferentialDDX:Filarial ElephantiasisFungal InfectionChronic Renal FailureCongestive Heart FailureChronic Liver FailureChronic Venous StasisKaposi Sarcoma

? Kaposis SarcomaStage 4 AIDSCD4 count Any other AIDS defining diagnosesPregnancy TestSkin Scraping with KOH Punch BiopsyLook for Visceral InvolvementTest Child and all partners R/o STIs, TB TreatmentHAARTChemotherapy, Surgical ExcisionDemanding Resources: Tertiary Care hospital if available