Jessica’s Blog

Wednesday, April 21, 2010

Today was a typical clinic day with rounding in the morning, clinic in the late morning, and clinic all afternoon.  We finished seeing patients and went to the procedure area to help complete the procedures for the day before going home for the evening.

Interesting patients for today:

My four year old inpatient with a cough for the past year had his chest X-ray today (after waiting most of the day for the techs to come in).  It showed atelectasis versus consolidation of the upper right lung field with right shift of the trachea and heart.  There was not pneumothorax, but the lung fields looked hazy.  It may explain his cough and crackles, but I still don’t know what is causing it.  There are old bronchoscopes around and it would be interesting to scope him to see if there is a foreign body, anatomic anomaly, and obtain a sample for AFB testing.

A 10 year girl came in for pain with sitting.  She had a large abscess within her right buttock.  The cheek was visibly larger than the left, hard, warm, and tender.  She had eaten earlier in the day, so we could not use ketamine.  I gave her a little lidocaine and made a 2 cm incision, then Jill and I squeeze out about 2 cups of thick, yellow purulent material.  She said “why, why, why” which is the Ghanaian equivalent of “ow”, but never moved.  Once we were done, she stood up, dressed, and was as cheerful as could be.  The pain tolerance of the people here never ceases to amaze me.  She waved and grinned later and I walked passed her at the end of the day.

A 2 year old came to clinic who was the size of a 6 month old.  She had a mongoloid facies and was significantly developmentally delayed.  She could sit, but could not crawl, stand, or walk.  Her mother had been referred to the nutrition center and she came in for screening labs (blood film for malaria, Hct, and stool O&P) prior to admission.  I think she probably has Down Syndrome, but do not have testing available to prove it.  The specific diagnosis does not matter much in this situation.  I talked with her mother about how she will continue to develop slowly and will not be like her siblings, but how she can still lead a happy life with some extra care.  Right now, her main issue is malnutrition and hopefully she will be able to grow at the nutrition center.

A little boy came in with vesicles and crusts on his left cheek and ear, and an erythematous, vesicular rash on his left index finger.  I think he likely has a herpetic whitlow with secondary impetigo, and I treated the bacterial infection because acyclovir is not on our formulary.  I stopped by the pharmacy later and they dug out one box of acyclovir tablets.  When he return in 5 days, I will prescribe him acyclovir if his lesions have not improved.

A boy came in for follow up for a donkey bite on his upper arm.  The lesion was mostly healed, but one area had induration below a yellow ulcer.  His mother refused an I&D and I discharged him with a second course of antibiotics and instructions to return if it did not heal by the end of the course.

I was seeing a clinic patient when the triage nurse brought in a mother and her son who was in severe respiratory distress.  He was bumped to the front of the line and I pulled out admission orders before completing a history and physical exam.  He was moaning with each breath, febrile, had a distended abdomen, and stared off into space with glassy eyes.  As I finished the orders, Jill walked him to the pediatrics ward and told me his breathing was less noisy by the time he arrived.  A few minutes later, the nurse from the peds ward came to find me in the procedure room to tell me that the patient’s status had changed before any labs were drawn or medications were given.  I changed the orders to expired.

An elderly man was admitted with tetanus and locked jaw.  We stopped by to see him and read about tetanus treatment.  His prognosis is not good.

At the end of clinic, Joyce (head nurse in the clinic) taught us some more Mumpoole phrases including “do you have cough” and “he is my husband” which is used as a joke when talking about one’s young grandson or nephew.  After supper, we took group pictures with all of the baskets from Bolgatonga.  There was a sea of them.  I worked on my talk for our “grand rounds” tomorrow and blogged.  Terry requested the topics of fluids and electrolytes and neonatal resuscitation in a developing country.  Jill called NNR and I’m working to make fluids interesting.  After being here for three weeks and having only D5W, Normal Saline, and D2.5 1/2 Darrows available for the children, I was curious to do some calculations and figure out the best solutions to use.  I just hope the students will be just as excited about salt, sugar, and water tomorrow.

PS - I passed Step 3!!!