Monday, 3 October 2011

The patients that made me look foolish/ Eating humble pie

The patients that made me look foolish/ Eating humble pie

27th September 2011:

On todays ward round we saw young girl that Aj and me saw in OPD on the 20th. This is the girl that we felt had HIV complicated by PCP but had to persuade the clinical officer that this was a possibility. She now has been diagnosed as HIV positive and her chest x-ray was indicative of PCP. So an accurate diagnosis by Aj and I but not a great one for the girl. Poor kid :(. But this accurate diagnosis was more than balanced out by a complete diagnostic fail...

When we were sitting down waiting for the doctor this morning we saw a girl walk past on her way to the loo with the bizzarest gait I have ever seen. There's no way I could describe this walk accurately but it involved weird rhythmic arm motions and head movements as well on occasion. Her balance appeared poor and she looked in risk of falling over. We immediately went to look at her notes to see what her diagnosis was and were shocked to see there was nothing about her walk in her notes. We alerted the doctor to her walk and the lack of notation as soon as he arrived on the ward, and he then discussed the patient a bit with the nurse in Swahili before telling us the cause of her walk was psychological. Having seen so many patients recently who were diagnosed as their illness being "psychological" without adequate investigation I was outraged at this and struggled a bit to not make it obvious. I listed off all the possible causes of chorea (jerky involuntary movements that are "dance like" and usually effect the head, face and limbs) as this is what I thought maybe the girls walk could be and was saying to him he should refer her to a neurologist if that is possible here. He laughed at the idea and said he was very experienced in this condition and she was a student and probably wanted to be sent home to her family so it was psychological. I was pretty scornful about this to be honest but I decided to keep quiet and wait till we saw the patient before saying anymore.

Halfway through the ward round the doctor pointed out that a different girl of about 18 was walking up the ward with exactly the same bizarre walk and told us she was from the same school as the first patient... this was a bit suspicious but I was still thinking that maybe one of the patients could be actually ill and the other one just copying her friend for time off school as well. However when we saw the patient it was obvious that the doctor was actually right, as both girls were not particularly brilliant actors and kept bursting into fits of laughter. Plus allegedly they both developed this inability to walk normally very suddenly in addition to abdomen pain at the same time the day before. Not the most convincing story, maybe next time they should just fake a headache. Not a psychological illness either I reckon, just plain bog standard skivealitus. Oh dear, sometimes you have to eat humble pie and laugh at yourself!

The doctor was aware of this but his management plan for the patients was still to keep them in hospital and give them valium. He said the condition would not go away if he sent them back to school…. Well it’s no wonder the teenagers here fake this weird walk a lot (for one of the girls this was the second time she had) if each time they do they get admitted to hospital and given valium! Unfortunately after debating the diagnosis for so long with him I think I had somewhat ruined my credibility for arguing that they should be discharged and not kept in hospital.

In other news

Sadly the patient I talked about yesterday with tetanus has already passed away :(. Lots of horrible diseases here and not all of them are tropical. Stay up to date with your tetanus vaccinations!

Halfadoc x

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