Tuesday, June 12, 2012

Major sign I’m missing the lifestyle back in the US: so we were talking about the foods we were craving, which is probably too early to discuss (it’ll just make us miserable).  Ironically but not surprisingly, I had a dream last night that I was eating chicken quesadillas and that they were really good.  I don’t really eat these very often either… and if anything actually, what I’m craving are apples, watermelon, and other fruits not here (bananas, pineapple, and mangoes are part of the daily routine here instead).  It’s also probably some of the chloroquine talking (which is the anti-malaria prophylaxis that we’re taking), as one of the side effects is hallucinatory dreams.  I can’t say I’ve been hallucinating thankfully but I have really bizarre, vivid dreams, some of which I can’t remember but I do wake up feeling like I had something crazy going on in my head overnight.  Is that weird?

We just had our first torrential downpour for the first time since we’ve been here.  It’s supposed to be rainy season now, so it was surprising it hadn’t rained until now.

2 of the chickens also decided to hide under the porch during the rainstorm.

Clinic work here is absolutely incredible as I’ve already mentioned before.  Though, I desperately miss EMR’s already.  It’s so difficult to read these charts sometimes (aside from them being in French).  Friday, I was in the cardiology adult outpatient clinic with Dr. K, a friend of Dr. Pearlmutter’s who came down for the week.  He’s a hysterical guy who just hung around with us , but he’s obviously a great clinician and very knowledgeable.  He teaches a summer course at Hopkins on tropical medicine, so he gave talks on tetanus, rabies, malaria, cholera, and filariasis.  They were a lot of fun to learn about although you need thousands of bites to get filariasis, well, let’s face it.  Among anyone in my group to get it, it’ll probably be me haha.  Kidding, mosquito bites actually have been decreasing significantly now that I wear pants to sleep.  My old ones are fading, though they now look like old bruises.  Hopefully they go away, but at least they’re not taking up half my leg now.

Anyway, he let me take the lead completely, having me sit in the doctor’s chair in the middle, and he just sat on the side to provide guidance.  I was absolutely terrified at first, but this was probably the most informative clinical experience I’ve had.  I was forced to think by myself for the most part on the questions to ask, make a differential, etc.  Dr. Dupee would be happy to know that one of the six patients I saw in the morning actually had a case of chronic cough!  I just had a homework assignment in CAP (where we work in primary care once a week), where Dr. Dupee asked us to look up the 5 most common causes of chronic cough.  It turned out that the patient had both gastric-esophageal reflux disease and was on enalopril, an ACE inhibitor for hypertension, 2 of the 5 most common causes.  I was actually able to do the differential diagnosis by myself!  She wasn’t getting anything for the acid reflux, so I decided to prescribe her ranitidine (Zantac) to see if the cough would go away and to treat the acid reflux anyway.  If it didn’t, I told her to come back so that we could change her medication which could also be the cause.  Pretty much every patient had hypertension, so I got some practice asking cardiac history questions and doing a full cardiac exam.

Weekends and afternoons in general are very lazy.  Proof?  Dr. K sleeping on the porch.

All of Sunday though, I was without internet because unbeknownst to any of us, we each have a weekly bandwidth limit.  I was freaking out the entire time that my computer was dying, and that I’d be wifi-less for 5 weeks.  Then I found out about the limit, got it reset because none of us knew.  My dedication as a Celtics fan and streaming Game 6 probably did it for me.  No more Facebook either so I can reserve my bandwidth for Gmail, Skyping, and blogging!

Yesterday, I worked with another one of the American internists visiting for the week.  We were mostly in the adult inpatient clinic and saw some crazy cases and pathologies.  I heard my first S3, S4 gallop, saw a ton of CHF patients with edema, 2 severe cases of diabetic ketoacidosis who would normally be in the ICU in the US with IV insulin and monitoring (not here though), JVD, a patient with severe hepatomegaly (we could feel her liver 10 cm below her costal margin/rib, and for any of us, you can barely feel it below the ribs so yeah, it’s huge).

I’ll discuss a couple of really interesting cases I think everyone will find interesting.  Patient 1, I believe late 20s female who recently came out of a diabetic coma.  Her family claims she didn’t have diabetes previously, so likely she had gestational diabetes.  Her blood glucose is now 106, and she’s out of the coma.  Though she can speak, her language is unclear.  Unfortunately, she had given birth to an 8 month old stillborn child.  We ordered a Chem7 and CBC on her since we needed to monitor her electrolytes with her continuing diabetes, as well as her blood sugar.  After checking her labs in the afternoon, it said her blood sugar was 36 which is absolutely nuts, when the glucometer said 106.   We think though that the lab results were messed up because the blood sample probably sat around for a while, and so then the red blood cells start eating up the sugar.  The tests were repeated today, so not sure of the results today.  Anyway, when we came back, she had a seizure where her BP was 175/152 during the seizure.  Her eyes were completely fixed to the left, she was febrile.  No one ‘s really sure why she had the seizure, but in case, they prescribed her IV diazepam (Valium) for the seizure.  Word today though is that her family can’t afford any of the medications, so I don’t really know what the hospital can do at that point if she continues to have a fever, uncontrollable blood sugar, and is seizure-prone.  It’s so sad that this is such a common case here, where people don’t take medications that they need because they just can’t afford them.

Patient 2 is a 21 year old female patient who delivered her child on May 15.  8 days after delivery, she slipped into this coma-like state.  For 16 days now, she’s awoken but she’s in this bizarre, altered mental status.  Her eyes are open, but she doesn’t speak, doesn’t respond to command, doesn’t go to the bathroom, doesn’t eat, and doesn’t stand up.   Her jaw is as if she has lock-jaw, really weird.  Her eyes are not completely fixed to the left, but she doesn’t move them beyond the normal position (like she doesn’t ever look right).  She also has hyperreflexia, and a Babinski reflex which would suggest upper motor neuron lesions.  Yet, there is something really strange about her.  During Patient 1’s seizure, we all could swear that the patient was watching the doctors and nurses the entire time, and if you motion your hand as if to shake her hand, she kind of motions her hand forward but that’s it.  She didn’t have any signs of frontal lobe lesions.  One of the physicians here thinks she could have extreme post-partum depression because she has seen something crazy like this before, a bleed in her brain, or a post-partum thrombosis (blood clot) in her brain.

Started part of my water sanitation project today!   I’ll provide information about that later though including the results I get.

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