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 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 *

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 *

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 *

What is this? How do you treat it ? *

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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 *

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) 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) *

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 *

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 *

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 ? Remember your setting

Diarrhea Non-Bloody: 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 Cholera: Doxy/Azithro High Mortality is 2/2 dehydration pt over5 with severe and rapid dehydration → Cholera *

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 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 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

Case 1: Question 4 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 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 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