Elisabeth Hesse’s Blog

2-5-09: TB or not TB…that is the question

First of all, I apologize to Shakespeare for taking his line and
changing it to suit my purposes.  Seeing as he’s dead, though, I
doubt he’ll mind.

The day started with TB rounds, which again went fairly
quickly.  Part of that was because of our decision to split up the
patients and see them individually instead of seeing all of them as a
group, as we typically do during rounds.  Since TB patients are
fairly simple, in terms of decision making (”Keep taking medicine and
stay until your two months are over”), there isn’t much need to see
them as a group.  The only big decision was on a patient I had seen,
with a diagnosis of Pott’s disease (TB of the spine), whom we started
on streptomycin last week, which was already six weeks into his two
months.  He reported some improvement with the streptomycin, but
still wasn’t able to move his legs, so we decided to keep him around
so he’ll get a full month of the new medicine, in hopes that it
really will help him.  Other than that, everything was simple, and so
we had another long break before clinic in the afternoon.

TB clinic is an interesting beast.  Most of the patients probably do
have TB lymph nodes, but before we can make that diagnosis (no lymph
node biopsies here), we have to try them on some other antibiotics
first.  So they get a week of amoxicillin, then come back to be
checked.  Then a week of erythromycin.  Sometimes that gets
accelerated a bit, if they have other symptoms or risk factors, such
as having a cough, or losing weight, or having a family member with
TB.  For kids, there’s a TB score that we use, and if they score
above a 7, you assume TB unless another disease is more likely.  So,
my first two patients got their week of amoxicillin and told to
return in two weeks for a recheck.  My third patient was sent over
because the person who had seen him in outpatient thought he might
have TB spine.  After getting a history, which is never easy in
PNG–a combination of not speaking the right language and the patient
saying what they think the right answer is–I found out that he “did
heavy work” (construction-type work) at a company site for years.  No
fevers, no night sweats, no weight loss, no cough, no enlarged lymph
nodes, just back pain in a man over fifty with a lifetime of manual
labor.  So I diagnosed arthritis and sent him off with some
anti-inflammatories.

We were actually pretty busy in TB clinic, which was a combination of
a family of a TB patient in the ward now (a seven-year-old girl with
eight siblings) decided to all show up in clinic to be checked
despite the nurse having told them to come to the ward in the morning
for that purpose, and a multitude of people who were either not
scheduled, or were scheduled for next week.  The ones who weren’t
scheduled or were scheduled from later who live fairly close were
sent away, and the ones who came from far away were seen.  It’s not
the most equal treatment system in the world, but it’s really the
only way to do it in an area with no good roads and unpredictable
transportation options.  In all, it was about four when we left,
which was far too long to be baking in the clinic house, and the
breeze was a welcome change as I sat out on my veranda and finished
my last book.  Then that breeze turned into a storm right when I was
getting ready to run, so there was no evening run for Manar and I
today.  Hopefully tomorrow the weather will cooperate with out exercise plans.