Clinical Notes

 

The readers of my blog have asked me to write more about my work, rather than my walks. As always, I have altered the details to preserve patient confidentiality.

There are few things more dramatic than a patient being brought to the clinic in a state of collapse. The relatives flap around anxiously. The nurses quickly abrogate responsibility to the doctor. Having worked in our local hospital, Raleigh Fitkin Memorial Hospital, my Zimbabwean colleague is highly sceptical of these “dying swans”. After a quick examination, she gets straight to the point, “What’s stressing you, eh?” And often they ‘fess up and talk about how awful their husband has been to them, or how their children don’t take care of them.

Two lads came in last week. They didn’t speak much siSwati, never mind English. The sick one was leaning on his friend and collapsed into a chair.

“His legs are numb,” said the friend. Tell me more.

“They are painful. They are weak. He cannot walk.” When did this happen? “Today.”

The history became more convoluted. The young man was able to walk to work, but his toes hurt. He managed to work from 7am to noon before he collapsed and could not get up. His friend managed to get him into a Kombi and brought him to the clinic. His HIV test was non-reactive.

With difficulty he got up onto the couch. “Can you move your legs?” I asked. “No”

“Where does it hurt?” He bent his leg so he could point to the back of his calf. “Aahh!” said my colleague triumphantly, “You said you can’t move it, then you move it. What is stressing you?”

There were no obvious stressors, so I did a full neurological examination and, apart from equivocal plantar responses, I could find nothing wrong. Although he said he couldn’t move his legs, he was able to push his legs strongly against my hands. He gave inconsistent replies when I did a sensory examination. The spine was normal and there were no signs of meningism.

“And he has been passing blood in his urine for months,” said the friend.

“Didn’t he go to a clinic for treatment?” It transpired that he had had two courses of antibiotics for a urine infection, which hadn’t helped.

Admittedly I was playing for time when I sent him off for a urine test. But I was taking him seriously and his walking seemed to improve markedly. The test indeed showed blood in his urine, with schistosoma haematobium ova seen on microscopy. He had Bilharzia.

A bell rang in my head. Schistosoma eggs can pass from the veins around the bladder into the plexus of veins around the spinal cord. There they produce inflammatory granulomas which can cause odd neurological symptoms. To prove this diagnosis, he should have a scan of his spinal cord, but the treatment is just the same. Praziquantel will kill the schistosomiasis and he should make a full recovery. I asked him to return if his legs became worse, when I could give him some oral steroids.

The next day, a lady was brought into the clinic with her head lolling over the back of the wheelchair. She was making soft, moaning noises. Her husband was very concerned and we managed to get her up the ramp into the treatment room, then onto the examination couch.

The history was that she became unwell last night, feeling generally ill, with headache, irritability and weakness. Rather dramatically, she lost the use of her legs as she got out of the taxi in the clinic car park. Her temperature was elevated at 37.7C and she said she didn’t want to be examined, just to lie down and rest.

I said I had to try to find out what was going on, so I needed to examine her. She rolled onto her back and I swiftly checked her out. I couldn’t find anything wrong. “She needs a drip, doctor,” insisted the husband. My colleague came in and asked her husband to leave. “Is he beating you? Does he have any girlfriends? Is he drinking too much?” she asked. She shook her head in response, but when I asked her to sit up, she slipped slowly off the couch and stretched out on the floor. “Leave me alone,” she said.

We did some blood tests, but nothing abnormal showed up. I prescribed  some paracetamol and oral rehydration solution, then asked a psychosocial counsellor to interview her. Half an hour later, she was feeling much better. “What did you do?” I asked the counsellor. “Oh, she just told me that she was exhausted from preparing the fields and planting all day yesterday in the heat. He husband wanted her to put in another shift today, but she became ill.” Suddenly, it all made perfect sense.

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One of our nurses wearing a red hat as part of her regulation uniform

The relationship between mind and body in dis-ease continues to fascinate me. Occasionally I see patients who have organic mental health problems, such as outright psychosis caused by the anti-HIV drug efavirenz. But I also diagnose obsessive compulsive disorder when I see hand dermatitis caused by excessive washing. I also diagnose patients suffering from major depression and, rarely, dementia.

A 55 year old patient was brought in by a relative because “she is losing her mind.” She was HIV positive but not yet on treatment with anti retroviral drugs. I asked how long this had been apparent and I was told “since Saturday”. But what was she like before Saturday? The relative didn’t know. She hadn’t seen the patient for months and had only come to visit for Christmas last Saturday. The patient lives alone, so there were no independent observers to bear witness. 

“Do you think you are losing your mind?” I asked her.

“Yes. I am going mad. I keep forgetting things. I forget where I am going and I get lost. I get confused.”

I told her I didn’t think she was going mad, but I was concerned that something was affecting her thinking. My working hypothesis was that she had mild cognitive impairment and needed more assessment. But here, the buck stops with me; there are no specialist psychogeriatricians in Swaziland. So I started trying to work out how to adapt the mini mental state examination to a Swazi context.

Is she oriented in time and place? “Where are you now?” “In hospital.”

Well, many patients call this a hospital, but it is just a clinic, with no inpatient beds.

“What is the date?” “Near Christmas.” “And the year?” “2016”, nearly right.

I showed her three objects, which she was able to identify correctly.

I had a brainwave and asked her who was the monarch. “King Mswati.” I’d have been surprised if she had said Queen Elizabeth II.

“And the prime minister?” “Don’t know.” A better answer would have been Dlamini, as this is the commonest surname in Swaziland.

Serial sevens next. “Take seven away from a 100 and what do you have left?” “A lot.”

I am not sure if innumeracy is evidence of dementia. Neither is illiteracy. She couldn’t sign her name, never mind draw two interlocking pentagons. And asking her to repeat a cryptic phrase which had been translated into siSwati wasn’t going to work either.

She clearly had some insight that something was not right. She wasn’t depressed, this was not pseudo-dementia of depression. There were no signs of syphilis or hypothyroidism. I wondered if this was early dementia, possibly related to HIV. Her relative said that she had been coughing, had lost some weight and had been sweating at night, so I felt we needed to rule out tuberculosis. And of course, TB can affect the brain insidiously, too.

If she tests positive for TB, we will treat this for a couple of weeks, then start treatment for HIV, choosing a drug regime which penetrates into the cerebrospinal fluid, in case this is early HIV encephalitis. If she tests negative, she will need to be seen and assessed regularly to detect any change or deterioration. Watchful waiting.

In previous posts, I have written about Nigerian holy water which is reputed to have special healing powers. Last week I saw two patients with pneumonia, both of whom had the sticky label from the holy water bottle attached to their chest. Listening with my stethoscope I could hear the rasping rub of pleurisy exactly where the label had been attached. I should write this up in a learned clinical journal as “Ian’s Sign” for my 15 minutes of medical fame.

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I saw five patients with HONK (hyperosmolar non-ketotic hyperglycaemia) last week. This is rather more than usual. Perhaps the seasonal feasting and overindulgence was to blame? Two ladies were newly diagnosed with type 2 diabetes, so I am always on the alert for unusual presentations of diabetes.

One gogo, who was attending for review and treatment of hypertension, told me that she felt tired (this is common in persons taking a beta blocker) and her joints have been playing up (hydrochlorthiazide increases the risk of gout). She had a dry cough (she is also taking an ACE inhibitor, which causes cough). Then she said her vision was blurred today.

This sparked my interest. What could this be? Why just today? Fluctuating blood glucose levels can alter visual acuity because of the osmotic effect on the eyeball fluid. Or was there something else going on? Cataracts, chronic open angle glaucoma, macular degeneration wet or dry?

I spent five minutes checking her vision. I looked inside her eye with an ophthalmoscope. It all seemed normal apart from my needing to alter the lens in the scope to get a clear view of the retina.

“All I can find is that you need spectacles,” I said.

“Yes, I know that. I left them at home today. That’s why I can’t see properly.”

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6 Replies to “Clinical Notes”

  1. After my mother had a stroke, the doctor asked the standard U.S. mental status questions–date, year, who’s the president? “I can’t remember his name,” my mother said, “but I do remember that he’s a son of a bitch.”

    1. I’d score that correct.
      When the GP asked my grandfather the MMSE questions, he said, “I wish you had let me know you were coming and I would have found out the answers for you.”

  2. What a shame – I really enjoy the variety of topics and enjoy reading about the country around you. Some cracking photos of the flowers and views. Hope you had a good Christmas Ian – all the best for 2016.

    1. Jo, in 22 hours you will be able to see a bumper edition of flowers from the Malolotja National Park. The reserve covers 4,447 acres of mountain wilderness on Swaziland’s north western border with South Africa.

  3. I laughed!! I love the flowers but find it odd to laugh at them! Thanks for your lovely descriptions Ian…. and the laughter. Have a fun filled New Year and hoping you get some rest, relaxation and good food… ON TIME!! Hattie

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