Experiancing El Salvador- Clinic Day #2

Tuesday, January 31st, 2012- Clinic in Las Mesitas
Our second clinic was hosted in a school compound, with the providers set up in the classrooms. This village was in the area affected by the flooding last fall. Due to the increased need for healthcare in this area, members of several surrounding communities were invited to come to the clinic. Interestingly, an increased number of pediatric patients were seen at this clinic.

Prior to going to this clinic site, the national doctor we were working with informed us that there was an increased incidence of renal failure in this area of the country. Recently, she has been working to identify the causes of this condition, as well as things that can be done to identify and slow the progression of the condition in the affected patients. To promote early identification, she has increased her focus on screening patients for diabetes and hypertension. Consequently, she requested that we check finger sticks on all of the adult patients we saw at this clinic.

In looking for causative factors, she has found that parasite treatment medications can become renally toxic if taken frequently. This has become an issue of concern, as parasites are incredibly common and patients have a tendency to be treated frequently. This is also an issue, as patients have access to medications without prescriptions, and will therefore self- treat for parasites. Because of the concerns related to this issue, she no longer treats any of her patients for parasites, unless they have a positive lab slip, and have not been treated within the past six months.

Again, a variety of conditions were presented at this clinic. A number of patients presented with a chief complaint of headaches, while others had chronic cough and cold symptoms. Several patients, both adults and children, were seen and treated for parasites and anemia.
One of our first patients this day was a five year old boy, who weighed 11kg (24.24lbs). He presented at the clinic with his mother with complaints of stomach pain, intermittent fevers, and fatigue. Additionally, his mother had a positive lab slip from a stool sample she had taken to the lab the previous week. The lab slip was negative for any parasites of amoebas, but was positive for a bacterial infection.
As we talked with the mother, and then with Dr. Danielle, we were informed that this child had been severely malnourished last fall, and was actually looking much better. He had been so weak last fall that Daniella had started him on Ensure/protein drinks, and was impressed with how much better he looked. When we charted his height and weight on the growth charts, he was in the 50th percentile for height, but less than the 5th percentile for his weight. Because of his mother’s complaints of him being frequently fatigued, we checked his hemoglobin level, which was 11.4.

Although this particular child was doing better, it was sobering to realize that he represented so many children. Children who are not experiencing life to the fullest. Children who are literally too tired to enjoy their childhood, simply because they do not have access to the nutritious food they need.
One of the other patients we saw at this clinic came in complaining of pain in her right leg and knee. She stated she had been experiencing the pain for about two weeks, but denied any recent trauma to the area. She described the pain as aching, stating it got worse throughout the day. She also noted at times it was difficult to bend her knee. Musculoskeletal exams were difficult due to the setting we were working in, however, we were able to perform a (slightly modified!) anterior drawer test, as well as a Varus and Vulgas test, each of which was negative. The patient did note tenderness on lateral portion of her thigh with palpation, with some areas more tender than others. Based on the exam, it appeared to be a muscle/ligament injury, and not a joint/skeletal injury. Unfortunately, we did not have access to any imaging studies, and could not perform a more extensive exam. Additionally, our treatment was also limited, but we were able to give her an anti-inflammatory for the pain, and some instructions on stretches and exercises that will hopefully strengthen the muscles and help the area to heal.
As we were developing our plan for this patient, I found myself thinking about what we would do if this was a patient we were seeing in the States. Most likely, imaging studies, such as an MRI, would have been ordered. Additionally, a Physical therapy evaluation would have been recommended, and the patient probably would have done physical therapy for the next few weeks. Although access to these additional resources would have been reassuring, we felt confident that our diagnosis and treatment were correct.