HIPAA and You

I went through the ward census the other day writing down information to present. I was anticipating doing case vignettes to give people a sense of what kind of patients I am seeing everyday. However, on reflection, I don’t think that it is fair to post peoples information up for grabs on the internet. I could change the age and sex of the patients, but I think that part of the learning and novelty of the cases here is that people are so young when they present. Also, since I am based on the female side of the ward, it would be a bit transparent to change the sex of the patient. I am starting to think of 65 as old aged. I have heard that the average life expectancy here is 45, which is not surprising given the infant mortality rate and the lack of elderly people that I have been seeing. Eddie, a British registrar volunteer, has a background in geriatrics and hopes to work on outlining an educational curriculum for the PGY’s about geriatrics, but I think he’ll have to adjust his usual age range down, since we have patients who present with end of life issues in their 50’s- 60’s. We still get our share of the 80 year little old ladies that keep falling, but much less frequently than in the states. Admissions for placement are unheard of, since there are no real other options than at home with family.

I have already seen two cases of Stevens Johnson Syndrome, a condition usually caused by medications that causes your skin to ulcerate and fall off; if severe enough, it progresses to Toxic Epidermal Necrolysis. NYY (or HIV+) patients are 40x more likely to get this syndrome. In the states, if they are severe enough or enough of the body is involved, these people would be sent to a burn ward. Even if they weren’t, you would take extreme caution to place them in a safe, sterile environment, since with so much skin loss, they are exceptionally prone to infection and dehydration. Unfortunately here we don’t have those resources; they are kept on the same wards with everyone else, with the septic pneumonia patients, malaria patients, and the lady with that nasty productive cough that makes you very concerned for tuberculosis and wish they would put more masks on people who come in hacking up blood.

Another common chief complaint is ‘body swelling.’ This could mean edema, weight gain, or anasarca depending on who is presenting. Underlying causes, as near as I have come to figuring out, can include heart failure, malnutrition, cirrhosis, or extreme kidney failure. The kidney failure patients are the hardest- we have several that are in their 20’s and are looking like end-stage renal disease, which is unfortunate in that there are no facilities for dialysis outside Kampala, and limited access there. One of the final year PGY’s, John, is interested in nephrology and hopes to expand their ability to care for patients that are end-stage, but it likely won’t come soon enough for the 20 something with diabetes that I am seeing with oliguria (decreased urination) and edema. It could still be schistosomiasis, a form of parasite, so hopefully we’ll actually be able to get some tests to try and figure it out. For body imaging we have an ultrasound available, unless they can pay for an ambulance over to Kampala 5 hours away and afford a CT scan. In the time I have been here I have only seen one CT scan done for a mediastinal mass. Unfortunately that patient could not afford to have a biopsy, so we still don’t know what kind of mass it is. An abdominal ultrasound is quite helpful when you are looking for abdominal lymph nodes, important here because extra-pulmonary tuberculosis is in the differential for most presenting complaints. It seems to be the favorite medical student differential diagnosis, since it can present as just about anything: anemia- could be TB, abdominal pain- could be TB, cough- could be TB, meningitis- could be TB…..Added to this that the diagnostic accuracy of the ZN stain or sputum samples is not great, and we end up treating many people for TB that never have had confirmation of infection, just a sufficiently concerning clinical picture.

Other complaints include palpitations- common since most people here are anemic to one degree or another and I have become blasé about seeing people with hemoglobins of 5 (less than about 13 is abnormal). The residents here are able to tell if people are anemic just by looking at their conjunctiva and comparing their palm color to the patient’s, which doesn’t work as well when you are Caucasian looking at an African’s skin tone… Of course, when the hemoglobin is less than 4 it is pretty clear to look at them and see that they are anemic. We still struggle to make sure patients actually have a blood count drawn before they are transfused, which I would estimate only occurs 70% of the time. Many times, I come in the next morning to see blood hanging and ask the intern what the hemoglobin was, only to be told that the family could not afford the diagnostic tests. In the states, whenever you see someone with iron deficiency anemia you usually make sure that they have had a colonoscopy to look for colonic malignancy- here you deworm them with mebendazole, since hookworm is so commonly the cause for iron deficiency anemia. Of course, we don’t confirm that a low MCV indicates iron deficiency, since we cannot send for iron or ferritin levels easily, but unless they have another clear clinical reason for it you assume that they may have hookworm infection.

Many people also present with fevers of one sort or another; evening fevers, daytime fevers or combinations of both. The differential changes slightly if they have recurrent fevers at one particular time of day. The correlation between fever curve and diagnosis is not exact, to be sure, but there are certain things in the history that make you more suspicious- evening fevers for malaria if the infection is established and the parasites release from the red blood cells in sync, evening fevers for lymphoma, multiple daily fevers for the endocarditis patients, and daily escalating fevers for typhoid (typically described as also having a pulse/ temperature disassociation, with high fevers but a relatively normal pulse). Of course, often we only have suspicion to go on, since many of the tests are not reliably sensitive or specific. Many people have low positive titers for brucellosis, 1+ smears for malaria and oocysts in their stool, but may not have active infections causing their current presentation. Added to the fact that many conformational tests are not available or not affordable for patients makes the practice of medicine here quite challenging.