Clinical Medicine in Resource-Limited Areas

1. Clinical Medicine in Resource-Limited Areas AshtiDoobay-Persaud M.D. Assistant Professor of Medicine September 19th, 2013 Center for Global Health

2. Objectives Understanding your setting Practical Guidelines for Primary Care Reasoning without resources- Cases

3. 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

4. Top Diagnoses at Hillside Clinic and Mobiles - 2011

5. Primary Care Clinic • Upper Respiratory Infections • Asthma • Skin Diseases • Diarrhea • Diabetes and Hypertension • STIs • Anemia

6. 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

7. 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

8. Case #1 • 3 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 milestones • What do you do next, what do you prescribe ? Is there anything else you would like to know on the HPI or PE ?

9. 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 ?

11. 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

13. What is this?

15. Scabies • Sarcoptesscabiei • 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

16. Rashes- Tropical Dermatidities • Bacterial • Viral Exanthem • Viral • Fungal • Atopic

17. What is this rash?

18. 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

22. 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)

23. 4 days of non-bloody diarrhea.What are your follow-up questions ?What are you looking for on exam?

24. Warning Signs • 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

25. 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

26. Diarrhea • What are the causes of Non-Bloody Diarrhea ? • Bloody Diarrhea ? • Remember your setting

27. Diarrhea • Non-Bloody: • Preformed toxin: Food poisoning • Viral: Rotavirus, norovirus • Bacterial: E coli, cholera • Parasites: Giardia, cryptosporidium

28. Diarrhea • Bloody • Bacterial: Campylobacter, Salmonella, Shigella, E coli • Parasite: E. histolytica

29. 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

31. Reasoning without Resources • Case 1: Ascites • Case 2: Leg Edema

32. 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

33. 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

34. Case 1: Question 2 • Ascites+RV failure • No RV Lift (not hyperdynamic) • Clear Lungs, normal PMI, no MR murmur • No edema → next question • What is the DDX of Asciteswithout edema ?

35. Case 1: Question 3 • DDX Ascites without edema: • Malignant Ascites • TB Peritonitis • Ascites due to RV Failure can have no edema in certain disease states

36. Case 1: Question 4 • UA: proteinuria • EKG: R atrial enlargement • without RV or LV Hypertrophy or LAE

37. 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

38. EMF: Endomyocardial Fibrosis • 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

39. EMF: Endomyocardial Fibrosis • Poverty as risk factor • Unknown etiology • Like LoefflerEndocarditis → hypereosinophilic syndromes ?damage by eosinophils due to multiple episodes of parasitic infection • Other theories: nutrient, micronutrient imbalance and gnetics

40. Case 2: Question 1 • Age and location • Recent death of partner • NON-pitting Bilateral Edema • Temporal relation of swelling to skin lesions • Painless Lymphadenopathy

41. Case 2: Question 2 • DDX: • Filarial Elephantiasis • Fungal Infection • Chronic Renal Failure • Congestive Heart Failure • Chronic Liver Failure • Chronic Venous Stasis • Kaposi Sarcoma

42. Case 2: Testing • Urine Dip: • Spec Grav: 1.015, (-) nitrites/WBCs/RBCs/protein, no casts, glucose or ketones • HIV rapid  (+) • Creatininewnl

43. Narrow our Differential • DDX: • Filarial Elephantiasis • Fungal Infection • Chronic Renal Failure • Congestive Heart Failure • Chronic Liver Failure • Chronic Venous Stasis • Kaposi Sarcoma

44. ? 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

45. Treatment • HAART • Chemotherapy, Surgical Excision • Demanding Resources: Tertiary Care hospital if available