Clinic today was an eye-opening experience. We started with rounds in the morning where we met a woman who presented overnight with what appeared to be a stroke. She had a right-sided headache and a left-sided facial, lateral palsy, and extremity paralysis that appeared to have worsened overnight. Differentials included hemorrhagic/ischemic stroke, abscess formation, cerebral edema, or an infectious process. In the United States, she most likely would have received a non-contrast CT scan and subsequent tPA if found to be ischemic and within 3-4.5 hours of onset. However, this would cost 10,000 shillings ($100 US dollars) and be of little use based on time-frame for the top differential of stroke. It could help diagnose an infectious process, but the family decided that the distance and cost would be too much of a burden. Additionally in the long run, management and treatment would not change for stroke with or without the CT scan. This patient’s situation was unfortunate, as her breathing, speaking, and swallowing was affected. Long term management would include continued perfusion of the brain, physical and occupational therapy, and palliative care. The second patient on rounds was a young three-year old who was admitted overnight for malaria and UTI. After quinine, dextrose, ceftriaxone, and an overnight stay in the clinic, she appeared like a different child. For other communities, this child would have either had to commute 5-8 hours to a local hospital or wait out the infections at home. However, having the clinic in the local community allowed for rapid recovery and a discharge in less than 24 hours.
The remainder of the day was spent seeing patients in the day clinic. We had a family present with cyclical fevers and chills, decreased appetite, and generalized fatigue. Only the four-year-old in the family of three tested positive with the rapid malaria test; however, it was decided to treat the entire family. When the clinical signs point toward a diagnosis and laboratory tests do not match, it is important to remember sensitivity and specificity. The rapid malaria test is better if found positive, but if found negative, malaria cannot be ruled out. It also only tests for one strand (plasmodium falciparum) so ovale/vivax strains cannot be ruled out. We decided to save the time and resources used for a blood smear and treat the entire family and have them return for follow-up. This is a common occurrence in a low-resource community and a cost-effective strategy toward treatment of malaria. We also treated a woman with herpes zoster, and advised her to stay away from children, sick adults, and those with HIV. The lesion was the typical dermatome pattern and the patient was experiencing extreme pain to palpation. Acyclovir and follow-up was encouraged for her. Finally we were able to see a few simpler cases of cellulitis, otitis media, ringworm, and eczema. It’s always so rewarding seeing how grateful patients are for just a tube of anti-fungal medication or a 5-day antibiotic course. It’s the little things like this that we don’t appreciate as much in the United States and can be grateful for.