1. Clinical Medicine in Resource-Limited Areas
Ashti Doobay-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 ?
Signs of dehydration, asking if she is eating and drinking well, any fevers – go get a thermometer, OP clear- no plaques
Tylenol for 2-3 days if fevers, reassurance and can come back if does not improve
Look in the ears given age
TB contacts ? Weight loss, night sweats, chest pain /diarrhea – concern for staph *

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 ?
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 improvement
Can aff azithro after 3 days if doing poorly
If very concerned can give CTX IV observe for several days
Nebs/steroids *

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
Nebs- attach to vehicle, steroids and abx, if O2 sat does not improve may need to drive her to a hospital, +/- abx *

13. What is this?
How do you treat it ? *

14. *

15. 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
Place clothing in bag for 3 days
Wash and dry in the sun *

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) Tinea cruris (jock itch)
Topical antifungals usually effective
Tinea cruris (jock itch)
Topical antifungals
Tinea corporis (ring worm)
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
4 days of non-bloody diarrhea. What are your follow-up questions ? What are you looking for on exam?
Febrile
Able to take po
Tears, mucous membranes, skin turgor
Mental status
How many stools per day *

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 ?
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
Cholera: Doxy/Azithro
High Mortality is 2/2 dehydration
pt over5 with severe and rapid dehydration → Cholera *

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
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 Ascites without 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
makes hepatic etiologies much much less likely
constrictive pericarditis and restrictive CM 2 most relevant in the DDX

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 Loeffler Endocarditis → 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  (+)
Creatinine wnl

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