Monday, September 3, 2012

Patient Care Challenges

Today was a long day.

We started rounding about 0830, and there were plenty of challenging cases to keep us busy. (Details slightly altered to protect patient privacy). One HIV positive adult had stopped going to her appointments and was no longer taking her life-saving antiretroviral drugs (ARVs).  She was now weak, unable to speak, febrile, hypotensive, and rigid, mostly at the neck. She was also having seizures, and abnormal changes in her eye movements (nystagmus and hippus). I'm pretty sure that she has advanced meningitis, along with severe HIV/AIDS. We started her on treatment for bacterial meningitis as well as for toxoplasmosis, a parasitic infection that can cause a tumor-like mass to grow in the brain. We were able to drive to another hospital and drop off her blood sample for a test that looks for fungus that could be growing in her brain. The test result showed that she doesn't have that infection, so I held off on performing a lumbar puncture, also known as a spinal tap. If she has a pressure-building mass in her brain, either caused by toxoplasmosis, tuberculosis, or cancer, we could cause her brain to herniate if we remove spinal fluid. She is very, very sick.

Another patient has been confused for weeks, as well as having fevers, tender swollen joints, and skin breakdown from being in bed too long without proper care. We pulled fluid from her knee that had some bacteria, and I'm wondering if she has bacteria in her blood that are depositing in her joints.

Another patient came in with what looked like a simple case of diarrhea. He developed acute onset vomiting, weakness, and confusion while in the hospital. The Kenyan clinicians astutely ordered a blood test for malaria, even though his first test had shown no malaria parasites in his blood. He now had evidence of malaria, but also had signs of severe dehydration. When we left at the end of the day, he still had a fast heartbeat, but he looked much better than he had in the morning.

Another man with a foot infection caused by diabetes is waiting to be operated on. His infection had been so advanced that the small toe had to be removed when cleaning the infection. Now, with the bacteria affecting more of his foot, he'll have to go to the operating theatre (as they say here) for further amputation. Diabetes, as I've mentioned before in this blog, is affecting more and more people in Africa, and will be a much worse problem in the future.

The save for the day was the case of a man with HIV who came in with severe headache and weakness. It turns out that he had been diagnosed with a brain infection caused by the yeast called cryptococcus at a different hospital but left during the course of his treatment. Treatment for this severe infection can last for weeks in the hospital, and then for over a year at home, and it's common for patients to get frustrated with the costs and hassles of staying in the hospital. Thankfully, he came back into medical care, and we were able to start the antifungal medicine again. Without treatment, this infection is 100% fatal. After 3 days of treatment over the weekend, he was feeling significantly better. I have high hopes.

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