Nicholas Comninellis

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Can You Correctly Care For These Three Patients?

Test Your Skills


Low-resource, cross-cultural healthcare will test your skills to the extreme. Begin by eliminating the options of comprehensive laboratory testing, advanced imaging, or even specialty consultations. Would you be able to care for these three patients correctly?


1. You are volunteering at a safety net clinic in Oklahoma City and seeing Erasto – a sixteen-year-old refugee newly arrived from Somalia. He has cough, weight loss, poor appetite and vague but increasing abdominal pain. On questioning you learn that in his Somali home safe drinking water is a luxury and sanitation is in disarray. On exam Erasto has an oral temperature of 38.8, respirations of 30, and capillary refill time of 5 seconds. His abdomen is tense and diffusely tender. You are considering the possibility of typhoid fever. Which ONE of the following statements about typhoid fever is TRUE?


A. Salmonella typhi is transmitted by ingestion of contaminated food or water.

B. Typhoid fever almost always causes diarrhea.

C. Typhoid fever commonly presents as an acute illness.

D. Typhoid vaccination is quite effective.

E. Typhoid fever can be readily differentiated on clinical examination from other infectious diseases, such as mononucleosis and infectious hepatitis.


Carefully consider before selecting your answer. The correct response is A. Although typhoid fever does not frequently cause diarrhea, it shares many of the risk factors associated with diarrheal diseases and is usually transmitted by fecal-oral ingestion of contaminated food or water. Typhoid should be considered in persons with non-acute, persistent, unexplained fever and GI symptoms, especially diarrhea and abdominal pain. Diagnosis is often challenging. The differential diagnosis includes malaria, infectious hepatitis, enteric fever syndrome (due to Yersinia enterocolitica, Y. pseudotuberculosis, or Campylobacter), atypical pneumonia, mononucleosis, bacterial endocarditis, tuberculosis, and brucellosis. Common complications include intestinal hemorrhage and perforation, with osteomyelitis and endocarditis occurring less commonly. Typhoid vaccination is available, but it is of marginal effectiveness.


2. You are in the Middle Eastern nation of Jordan caring for Anas, a 2-year-old child whose family just escaped the bloodshed in Syria. Anas is alert, temperature is 38 degrees C, respirations are 30 per minute, pulse is 90 bpm, and blood pressure is unobtainable. He has extreme muscle wasting throughout, reddish hair discoloration, and loss of adipose tissue with no peripheral edema. Your first priority in managing this child with acute protein-energy malnutrition (PEM) is which ONE of the following:


A  Treatment of coexisting medical illnesses

B  Provision of high-concentration protein supplement

C  Administration of micronutrient supplements

D  Immediate refeeding

E  Correction of hydration and acid-base alterations


The appropriate answer to this question may not be the most intuitive. The correct answer is E. The management of acute protein-energy malnutrition (PEM) can be separated into two stages. The first stage is stabilization: to immediately correct hydration and acid-base alterations. The second stage is refeeding. This can begin as soon as medical problems are reasonably stable and rehydration is complete. It may be necessary to begin initial refeeding slowly in persons who have advanced PEM or kwashiorkor because of damage to the intestinal mucosa. During the period of renutrition, micronutrient supplements and attention to any coexisting medical illnesses may also be indicated.


3. You are in Cambodia, southern Asia, seeing Solyna, a twenty-one-year-old lady, who suddenly developed fever, vomiting, severe headache, and pain on moving her eyes. On physical examination you note that Solyna is lethargic, has generalized lymph node enlargement and a slow heart rate relative to her fever of 39 degrees. Your initial differential diagnosis is broad: influenza, dengue, typhoid fever, mononucleosis, malaria.  You Giemsa stain her blood smears but you do not identify any ring-like Plasmodium parasites that would suggest malaria. You initiate intravenous fluids and antipyretics. Over the next hours Solyna develops hypothermia, severe abdominal pain, decreased mental status, and bleeding from her gums and nose. You now suspect dengue – an arbovirus infection. Which ONE of the following is a characteristic of severe dengue fever?


A  Leukocytosis with increased band forms

B  Increased urinary output

C  Abnormal vascular permeability with spontaneous bleeding

D  Predictable improvement in response to gamma globulin infusion

E  Decreasing hematocrit


This case requires careful attention to detail in the history and physical exam. The correct answer is C. Key criteria for diagnosis of severe dengue fever are abnormal vascular permeability with spontaneous bleeding, fever, and low platelet count. Leukopenia (low white blood cell count), increasing hematocrit, and decreased urinary output commonly accompany severe dengue fever. Gamma globulin is of no therapeutic benefit.


Practicing in the absence of comprehensive laboratory testing, advanced imaging, and specialty consultations provokes understandable anxiety in most medical care professionals. But you can learn to provide quality care within such parameters, especially when you develop such skills under the watchful attention of an experience supervisor. INMED International Medicine, Nursing and Public Health Training Sites are designed to assist you in developing such prized, life-saving skills.


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