First half of OPD

OPD week mon tues half of wed

The OPD, out patient department is where every patient starts out in th hospital. It is mostly walk ins as ambulances are only used for motor accidents and transferring patients from clinics to hospitals or vies versa. Most patients are driving, taxi, walking, etc. the outpatient department has a admission desk and waiting area where you will be directed to the dr offices, dental, optics, OPD surgery, OPD obsentrics/gynaecology, skin disease ward, ctc(care treatment centre) for TB and HIV, or sent to the clinic for health insurance claims.

I started off with Dr.moses' office taking in patients.
Patient 1
Young male, a 4 week old arm injury previously X-ray and cast applied, however he removed the cast himself and is now back complaining of pain. Dr to send him for a new X-ray to compare to old, likely then discharged.

Patient2
Diabetic patient with lower limb and finger numbness, hasn't been taking her Medes for 2 weeks. Sent for blood glucose test and BP, new prescriptions given.

Patient 3
Older gentleman in wheelchair, has had CVA since 2010, complaining of pains, irritation, painful swallowing, cough, diarrhea, has a skin deformity on his arm.
Patient BP taken, prescribed antibiotics for infection and given a cream for skin irritation.

Patient 4
Patient coming in complaining of pains and weakness. Diagnosed soft tissue injuries, patient came with police report after being beaten. Dr fills out form describing findings, pain relief tablets given.

Patient 5
Child with club foot since birth, dr palpates, soft, tender, painful. Given some prescriptions, not sure exactly what for.

Patient 6
Older lady complaining of painful swallowing and hyper salivation, with visual inspection and palpating of neck sent to the dental ward. Depending of findings will be sent back to us.

Patient 7
Middle aged man with a lump on the lower right back, soft no tender palpation, also complains of painful urination. Sent to surgical ward to check and drain fluids from lump.

Patient 8
Middle aged,lady, complains of weakness, weight loss, sent to PITC (provider initiated counselling and testing) for HIV or similar testing.

Patient 9
Young male, history of pain in right foot and trauma throughout 2014, sent for X-ray of foot and ankle joint.

Patient 10
Child with difficulty breathing, seems like pneumonia, given 5 day course of antibiotics, with no improvement told to come back after course.

Patient 11
Baby, also pneumonia, admitted for 24hr with 1 day course of injected antibiotics, then to be discharged given a 5 day course with instructions to return.

Patient 12
Older lady, cough, sometimes bloody, sent for chest X-ray.

Was told I would be switching offices to join Dr.Mpena but her office was empty, instead I was lead out of the ward to the road out front with dr Mpena standing beside 2 pickup trucks. She told me to put on gloves and go into the first pickup truck. There was a blue grocery bag and she told me to expose what was inside. In the bag were 2 bloody shirts or large rags and I mostly expected to find some body part inside... However what I discovered was a aborted fetus maybe 8 inches long bloody and gooey it sort of look like some small alien, smelt horrible... Not quite what I was expecting after an hour in OPD............ After telling her what it was she sent me to the next pickup with a scene straight out of every mobster movie. A rolled up rug with what had to be a body inside. Again I was told to unwrap it and tell her what it was. So I exposed the body of an old man and told her it was a dead body. She then asked me how I would determine if it was dead. I explained I can check for verbal and physical responses if I expect unconsciousness and check breathing and circulation as well as for rigor mortis. She stared expecting lay at me so I did as I just explained going to check pulse and respiratory rates, or the absence there of. Instantly I felt how hard the body was and I realized why they call bodies stiffs, I really needed no more than that but I checked pulse breathing and determined death. So I touched a dead body, nothing I've done before, weird experience not sure how I felt about that. I then escorted the bodies to the morgue.

After my little adventure I went back for some more patients in the dr office.

Pt13
Old diabetic lady with swollen hands and a small cut on her pinky. Hands where non-soft and tender on palpation, sent to surgical ward for incision to drain pus, daily dressings, and to wait for her BGL to come down(currently 17.0 mmol/L)

Pt14
Patient presented with rough bumps starting at pelvis and getting sparser leading up to breasts, before we could finish the patient I was sent to the CTC, the ward for the immune compromised.

Was told dr would come back to me after a half hour, though she never did, I ended up staying we the dr in th CTC until he was out of patients.

The ward was explained to me, the reception desk acts as a bit of a triage/ distribution centre. Patients are sent to education seminars and counselling sessions for living with HIV every time they have to come to the CTC. Then they sent to drs for appointments to get their ARV drugs, antiretroviral. ARV must be taken at the same time every day for them to be effective. Adherence problems are the biggest cause of complications, with patients missing their doses, or patients taking them at wrong or different times. Patients come in frequently after thir diagnosis with HIV but the visits are made less frequent. Going from 1 week to 2 to 4 to 2 months to 6 months and th every 6 months. They are questioned about their health, symptoms and occasionally they get their CD4% rechecked. Cd4 being a certain measurement of their white blood cell levels. If cd4 isn't consistently rising each check the dr has to determine if this is due to immunological reasons, resistance development, or adherence problems.

Pt15
Diagnosis starting cd4 39%, after 6 month of ARV cd4 747% patient to be retested for current levels.

Pt16
Feb 2013, 247, June. 2013, 407 February 2014. 344
Checking current levels, will then question patient about adherence and possible testing about immunological changes.

Pt17
5yr ago 224
2.5 yr ago 209
Received counselling about drinking and drug use
Last year 481
Current 484

Pt18
May 2014 30
One month later 30
Checking current.

Pt 19
June 2008 cd4 6
2012 335
2014 394
Current 268
Lost 5kg in last couple months(~10% body weight) showing signs of TB and oth infections.

Pt 20
2011 cd4 41
2012 189
2013 272
2014 269
Based on his talks with the patient he expects poor adherence to be the main cause of no continued increase. Talks to patient frustratedly about importance and rig time of taking drug.

Pt21
No left leg, 2012 851
Current 913

Pt 22
2010 147
2011 121
2013 210
2014 187
I noticed a typo on his sheet where his age and eight were both listed as his age. Dr attributes patients cd4 problems to alcohol use causing missed doses.

Dr never showed up so I walked back to the offices in OPD.

Pt 23
Middle aged make, BP 160/80 sent to medical OPD ward.

Pt 24
Lower abdominal pain, genital skin rashes, diagnosed with PID and discharged with prescription antibiotics for PID

Pt25
Young middle aged man, has trouble keeping head up, subdued talking and responses, rapid respiratory and heart rates, pale, edemic. Possible heart/kidney disease/failure. Sent to internal medicine ward.

Pt26
Middle aged man with infertility. Long talk with dr, nothing really of note.

Pt27
Male 6 yo, malariA, sent for stool sample for other parasite checks.

28
Young girl can't straighten arm after falls down 2 days prior. Sent for X-ray.

29
Old lady with back pain, prominent spine disks, swelling, painful urination, sent for X-ray of lumbar spine.

End of the day, went home, no new students this week so Monday after no one was pretty free and relaxed.

Tuesday

Dr Moses gave me a lesson on diabetes. Was good, not goons write about it,though.

Pt1
Woman submitting a medical investigation form for someone else. Not sure what it entailed.

Pt 2
Woman in wheel chair, BP,test first thing as seems standard in OPD for chairs.
Recent HIV diagnosis, cd4 oct 181, early nov 110, current 181
Pepper white jaundice eyes, weightloss, frequent diarrhoea 7-8* a day! lower extremity pitting edema, heart failure! gradual onset of pain in legs increasing in severity over last 2 weeks. BP 100/60
6 different prescriptions given.

Pt3
Pain on left side, BP test 110/80 fever, throat pain, headache, median gastric pain, increases with hunger, most food relives pain but gassy foods increase pain. Expected peptic ulcer disease, given 4 prescriptions.

Pt4
Male in 40s timid low voice, slow to respond, red eyes, most questions met blankly. Has HIV taking ARV, vomiting and diarrhea, prescribed strong antibiotic and given a oral hydration solution. Told to stay on his ARV.

Pt5
Woman with lower abdominal pain, painful urination, 3 months no menstruation. Sent for a urinary pregnancy test. Came back negative, diagnosis urinary tract infection, given antibiotics.

Pt6
Mother with infant. Edema of right leg, painful on palpation sent for X-ray. Upon questioning the mother cause is found to be mother and father having a fight, mother tried to grab baby away from father and dropped him... When X-ray came back shown to have mid shaft femur fracture, to be admitted to surgical award.

Pt7
Male submitting a diagnostic investigation form for his pregnant wife who is in th dental clinic.

Pt8
17 year old woman in wheel chair. BP 110/80 can stand but slow and difficult, walks to examination table. History of lower abdominal pain, no clear and whitish vaginal discharge, on examination diagnosis is vaginal candidiasis. A fungal infection.

Pt9
20 year old female, history of lower abdominal pain, painful urination, PV discharge whitish recently turning red, on examination find red discharge and 2 small vaginal lacerations, urinary analysis ordered to check for syphilis and UTI. Syphilis comes back negative.

Pt10
Female history if lower abdominal pain, PV discharge, painful urination, on examination find coloured discharge and vaginal lacerations, dr diagnoses vaginal candidiasis and UTI.

Dr comments that it is like gynaecology day in OPD for some reason, i didn't expect so many vaginas until I was in obstetrics and gynaecology next week.

Pt11
Older lady in wheel chair, hemoglobin levels at 7.8 normal level 12.0 moderate anemia, large mass on pelvic X-ray, unsure of what it is, will go to surgical ward tomorrow for identification and possible surgery.

Pt12
Skinny oldish man, very distended abdomen, liver sclerosis, no pitting edema in legs, sent for abdominal ultrasound. Since there is only 2 ultrasound machines Iringa he will be transferred to one of,the clinics that has one, the hospital doesn't.

Pt13
Right ear pain, no abnormalities found on exam, diagnosis otitis media given a prescription.

Pt 14
Teenage male, pain of left arm after falling, sent for xray of wrist.

Pt15
Older couple, male has past of difficulty breathing, just in for a medical checkup, sent to medical OPD.

Pt16
Middle aged couple in, long discussion, secondary infertility(have had pregnancy, no longer able)

Pt17
Older lady in wheelchair, unable to walk. Pains of left hip joint starting 2 weeks prior, gradual onset increasing in severity, pain is localized and continuous with no aggravating or reliving factors. Patient is pail and jaundice, joint is swollen and tender, sent to surgical ward.

Pt18
Female in 20s, has typhoid, filling out a work sickness absentee sheet.

Pt19
Male brought in on stretcher, conscious but 0/4 alert and oriented, confused, erratic head movement, rapid blinking, no verbal responses, sent over from a health clinic, 6 hours ago he fell down and lost consciousness, BGL comes back in range, dr suspects severe malaria. Relative comes in and reports patient complained of weakness prior to event. BP comes in at 90/50, eyes jaundice, face pale, sent to internal medicine ward.

Sent to other dr as dr Moses needed lunch,

Pt20
63'year old male, complaining of pain of left side after falling down. On exam dr says the pain is to be expected, no signs of trauma, given some anti pain tablets.

Pt 21
The last case of the day was unfortunately a suspected rape case. Mother in with 14 year old daughter. Mother says daughter didn't come home the night before. Dr does a vaginal exam checking for broken hymen, bruising, bleeding, etc. based on the pain of the patient, some blood, and depth her finger went in that the patient had been a virgin before being raped. She then had a long talk with the mother and daughter and eventually father when he came in.

Tuesday finished

Given a lesson by dr impena on abdominal investigations. Visual inspection, palpation, percussion, and auscultation. Breaking down the sections of the abdominal into 9, General started ending points etc.

Pt 1
Middle aged woman, doctor does breast exam, checks eyes, and takes history. Diagnosis is a respiratory tract infection. Given antibiotics.

Pt2
Lady in wheel chair, patient complains of heartbeat awareness, hypertension, headache,weakness, difficulty breathing, and doctor comments that she looks quite visibly Ill. Admitted to icu.

Pt 3
20 yr old female complaining lower abdominal pain. Referred tqo different ward for further analysis.

Pt4
Baby, checked hands eyes feet tempura true(38C) do a malaria test. Palling, fever, vomiting, cries during urination, baby well until 2 days prior. Babies symptoms increase at night, baby seems weaker in the morning, frequent diarrhea. Dr suspects dehydration and other possibilities. When given water baby drinks very eagerly... Sunken and jaundiced eyes. Admitted to paediatric ward, to be administered 3 satchels of ORS, paediatric zinc, gentamicin injection, paracetamol syrup. Maybe another prescription or two.

I then headed to the OPD minor theatre. Child injured from motor accident, I was lead to believe it would be serious but ended up being quite minor when I arrived. Small abrasions on left knee, laceration above left eyebrow, abrasions across right leg, arm tied and squeezed for IV fluids, failed, switched arms. Success.

In the waiting room for the theatre was another patient. Middle aged man, sort of fat, quite big, covered in burns. Lots of lost and peeling skin. Looks like thin shrink wrap that's been warped and is no longer tight but peeling... Burns across legs up to groin including full thigh, burns across abdomen and arms and shoulders. Large saline IV. Man shudders with every breath and every action of the nurses but manages to never cry out or flinch too bad. Nurses cutting away and peeling off all the affected skin across the arms and shoulders, after peeling nurses unravelled dampened gauss and placed over the peeled arms and shoulders one piece at a time until completely covered by a couple layers. His shorts were pulled off and his underwear cut away, the peeled and cut the legs and left thigh of skin, repeating the process of watered down gaussing. The right thigh they kept the skin on after stretching it back over th thigh. They had to drain some fluid from the skin that had pooled underneath it before they pulled it over that thigh.

Antonio the Italian doctor/nurse came in and took over the show but not after knocking over the chair and some bottles of saline that were in front of th entrance. He seemed a little confused at the nurses using normal saline and seemed to want cooled or iced water. He brought some of his own gauss that was in a roll instead of in pads and used it to finish up the legs. He would gauss dry and then pour water over instead of soaking the gauss first. Once he had all burns wrapped a full bottle of saline was again poured over everything. He was then stood up and put on a dry blanket and wheelchaired himself out.