Ashti Doobay-Persaud M.D. Assistant Professor of Medicine September 19 th, 2013 Center for Global Health.

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Ashti Doobay-Persaud M.D. Assistant Professor of Medicine September 19 th, 2013 Center for Global Health Slide 2 Objectives Understanding your setting Practical Guidelines for Primary Care Reasoning without resources- Cases Slide 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 Slide 4 Top Diagnoses at Hillside Clinic and Mobiles - 2011 Slide 5 Primary Care Clinic Upper Respiratory Infections Asthma Skin Diseases Diarrhea Diabetes and Hypertension STIs Anemia Slide 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 Slide 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 Slide 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 ? Slide 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 ? Slide 10 Slide 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 Slide 12 Slide 13 What is this? Slide 14 Slide 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 Slide 16 Rashes- Tropical Dermatidities Bacterial Viral Exanthem Viral Fungal Atopic Slide 17 What is this rash? Slide 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 Slide 19 Slide 20 Slide 21 Slide 22 Tinea Infections Tinea pedis (athletes 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) Slide 23 4 days of non-bloody diarrhea. What are your follow-up questions ? What are you looking for on exam? Slide 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 Slide 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 Slide 26 Diarrhea What are the causes of Non-Bloody Diarrhea ? Bloody Diarrhea ? Remember your setting Slide 27 Diarrhea Non-Bloody: Preformed toxin: Food poisoning Viral: Rotavirus, norovirus Bacterial: E coli, cholera Parasites: Giardia, cryptosporidium Slide 28 Diarrhea Bloody Bacterial: Campylobacter, Salmonella, Shigella, E coli Parasite: E. histolytica Slide 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 Slide 30 Slide 31 Reasoning without Resources Case 1: Ascites Case 2: Leg Edema Slide 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 Slide 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 Kussmauls sign Slide 34 Case 1 : Question 2 Ascites+RV failur e No RV Lift (not hyperdynamic) Clear Lungs, normal PMI, no MR murmur No edema next question What is the DDX of Ascites without edema ? Slide 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 Slide 36 Case 1: Question 4 UA: proteinuria EKG: R atrial enlargement without RV or LV Hypertrophy or LAE Slide 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 Slide 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 Slide 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 Slide 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 Slide 41 Case 2: Question 2 DDX: Filarial Elephantiasis Fungal Infection Chronic Renal Failure Congestive Heart Failure Chronic Liver Failure Chronic Venous Stasis Kaposi Sarcoma Slide 42 Case 2: Testing Urine Dip: Spec Grav: 1.015, (-) nitrites/WBCs/RBCs/protein, no casts, glucose or ketones HIV rapid (+) Creatinine wnl Slide 43 Narrow our Differential DDX: Filarial Elephantiasis Fungal Infection Chronic Renal Failure Congestive Heart Failure Chronic Liver Failure Chronic Venous Stasis Kaposi Sarcoma Slide 44 ? Kaposis 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 Slide 45 Treatment HAART Chemotherapy, Surgical Excision Demanding Resources: Tertiary Care hospital if available