July 14, 2009

A correction on the census for yesterday: we so closer to 175 patients in Wellness Clinic.  I slept in this morning because I felt unwell yesterday, very light-headed and Dr. Stoltz instructed me to sleep in this morning, so I did.  I got up at 8:30 am!  It certainly felt good to do so.   

I went to the wards first before going to Wellness Clinic to see how the lady with the undiagnosed problem was doing.  When I entered the female ward, ward #2, I immediately asked Dr. Matlala about her.  He sadly shook his head and said she did not make it through the night.  I will ask if we can get a post mortem to find the cause of her death.

Today, the patient with the big heart (cardiomegaly) was still not doing well so I asked if there was an echocardiographer at Jubilee to do an echo on this lady’s heart.  The answer was no, but we can send her to George Mukhari  Hospital.  I asked for if an electrocardiogram machine was available.  Dr Ramasod said she had never seen one in Jubilee hospital!  So we called George Mukhari Hospital and asked to speak to the cardiologist on call.  Dr Ramasod said the first available date was August 15!  I asked to speak to the cardiologist on call, so we called back.  I explained this lady had a heart the size of a melon in her chest and just three weeks ago it was normal.  I had to do everything I could to get them to grant the request.  So late this afternoon she left by ambulance to have her echocardiogram.  Hopefully she will be back tomorrow or the day after and we should know what is going on.  Then it was off to the intensive care unit with Dr. Isila to see a 69 year old gentleman that Dr. Matlala had admitted during the night with a presumptive diagnosis of diabetic ketoacidosis.  It was plain to see his problem was severe respiratory distress.  He was hypotensive with a systolic pressure of 80 mm Hg. and a diastolic pressure of 39 mm Hg. (80/39).  His temperature was 39.8 degrees C.  He had been in the hospital two weeks ago with a diagnosis of asthma and HIV.  CD4 and viral loads were drawn but he was discharged before these results were seen.  Now he is back and in acute respiratory distress and responding only to painful stimuli.  I listened to his chest and there were crackles in every lobe.  We stopped his amoxicillin and started him on Bactrim per nasogastric tube since there was no IV bactrim available in the hospital.  Next it was off to Casualty (emergency room) to see a 44 year old male who had a CVA (stroke) in 2004 but had suffered a seizure during the night and now was confused.  A lumbar puncture was performed and family was counseled re HIV testing, then he was admitted to the ward. 

Next it was to Wellness Clinic where we saw a total of 170 for the day.  I left at 3:00 and went by the mall to get some mouthwash and a saline nasal spray for myself and then here to the guesthouse, exhausted!

 July 15, 2009

It is hump day!  I was off bright and early this morning getting to Jubilee Hospital at 8:00 am.  Wednesdays are rather slow days and most of the clinic patients are here for government grant signatures so they can get their money (much like our Social Security/Welfare).  Of course, we have to make sure their labs are in order, et cetera.  Several very interesting cases were seen: one was la lady who was five months pregnant who was still on efavirenz.  Efavirenz is very teratogenic causing central nervous system malformations.  Dr Stoltz told me that most of these babies are born “dumb”.  So we changed her regimen to Kaletra since she had a very high CD4 cell count and switching her to nevirapine could have disposed her to severe hepatic toxicity. 

Another interesting patient (and the first Caucasian) was D.D.J.  He is a 36 year old brought by his mother to Jubilee after his initial diagnosis of HIV and AIDS defining PCP pneumonia was made in another hospital.  He was discharged from the hospital and said he felt great!  He was able to walk but how quickly things can change!  Now he is wheelchair ridden and unable to ambulate.  He has developed deep pressure wounds on his buttock, left hip, left ankle and heel.  He was referred to surgery for debridement. 

Then there was this 76 year old whose wife passed away twenty five years ago.  He is HIV (+) but is stable on his regimen.  His wife’s family told him he was such a good husband to their daughter/sister that they gave him the youngest daughter as his consort!  He wanted to have her checked for HIV because, if she was (+) like he was, he could “stop using condoms.  I am having sex with her four times every day”!  To myself I said, “Lucky him”.

Next,  a 31 year old who was started on HAART one month ago.  Now he could not breathe.  I put my stethoscope on his chest and noted dramatically diminished breath sounds on the right.  Chest x-ray confirmed a complete white-out of the right lung.  This is either a pleural effusion or exudates and he will have to have it drained.  This is Immune Reactivation Inflammatory Syndrome (IRIS).  When a person with a very low CD4 count is started on HAART, their immune system comes back to life.  IRIS describes a collection of inflammatory disorders associated with paradoxical worsening of preexisting infectious processes.  Preexisting infections in individuals with IRIS may have been previously diagnosed and treated or they may be subclinical and later unmasked by the host’s regained capacity to mount an inflammatory response.

There was this very attractive young lady who came because her nails had become discolored, almost a chocolate brown.  Drs.Tom and Mabuse thought it was a fungal infection, but I took a look and said “this lady is on AZT, isn’t she?”  We looked and sure enough, she was.  She was offered a change in her regimen but she was doing so well with a CD4 in the 600’s, she declined saying she would rather keep the nails as they were.  I agreed with her.

Then there was the 11 year old girl who had been on TB treatment for over a year and her cough was getting worse.  Chest x-ray one month ago showed bilateral pneumonia.  She was still coughing very deeply, as was her mother who denied she had TB.  But her father had TB.  Dr. Tom was rather rushed and only refilled her HIV medications.  I pressured him that this little girl could have multi drug resistant tuberculosis (MDR TB).  He said he would see her in a month and if no better, would refer her for further testing.

Elizabeth, a 39 year old lady whose husband worked out of the Province and obviously slept around, brought HIV home to Elizabeth.  When she got sick, she went to be checked for HIV in April 2008 and was started on HAART.  Husband came home, found the HIV medications, beat her up and threw away her meds accusing her of unfaithfulness.  She has been without medications since July, ’08.  Today she is in the clinic with a fractured right arm where he had beat her up again.  Fortunately, he is now in jail and the ARV’s can again be started. 

 I could go on and on and on…but I won’t.  Needless to say, the state of HIV/AIDS/TB in South Africa is in crisis and there are no easy solutions.   BTW, a post mortem (autopsy) on the lady with the unknown disease was not possible; the family could not afford it.  Dr. Matlala opined that the lady had gone to an herb doctor before coming to see us at Jubilee.  It is very common for these people to seek medical help only as a last resort when the herb doctor and the church have failed.  There are churches here in South Africa who discourage people from seeking medical help saying “there is no such thing as HIV.  It is only a demon possessing you.”  How sad!

July 16, 2009

Today started off with a bang!  By noon we had seen over 100 in Wellness Clinic.  In addition, I made ward rounds and a medicine consult surgical ward with Dr. Ramasod on a patient with severe anemia.  I was sorry to have Dr. Matlala move to Casualty from the medicine ward.  I was just getting to have a good working relationship with him and Dr. Ramasod.  The  young man with the right lung white-out from yesterday with IRIS had his thoracic tap and walked into the office saying “God is great”!  It is so nice to see such gratitude.  The lady is still not back from the George Mukhari Hospital.  Her echocardiogram was scheduled for this afternoon at 3:00 o’clock.  Hopefully we will have her and a report back by tomorrow.

July 17, 2009

This morning’s lecture was on HIV-associated Peripheral Neuropathy.  It was well attended and well received by the hospital staff.  Wellness Clinic was slower than I have seen it in these two weeks since I have been here.  However, we have managed to see an average of approximately 150 patients each day this week; today’s census has brought the average down substantially.  I made hospital rounds again with Dr. Ramasod and Dr. Matlala’s replacement, Dr. Ohaju.  It seems most of the ward problems are in the female ward.  Of course, by far more women seek medical attention than do the men… typical!  My lady with the huge heart is still at George Mukhari Hospital and the echo still has not been done!  I am sure it will be next week before she gets the echocardiogram.  At least she has been started on treatment: HAART and TB.