a few days seems like a lifetime

I'm a few days behind online but writing down anything and everything that comes to mind! The next three posts will be for each missed day...

Saturday, February 20th, 2010
After hours of preparation I presented my big case during Dhaka Medical College Hospital's verison of a Morbidity and Mortality session. My case was one of biliary atresia, which is when the bile ducts are basically blocked by a progressive fibrosing process. This causes progressive jaundice and clay colored stools in babies almost immediately. Because this is such a quickly progressing disease it is really important to catch it early on and convene surgically, hopefully within the first two months of life or the child may suffer drastically. THe case I presented was a case of missed Biliary Atresia by the Pediatric Medicine team, which was referred to pediatric surgery a bit too late to intervene...the childs family decided not to go forth with surgical management because of the poor prognosis and within a few years the child will probably pass away of fulminant liver failure.

Here's the twist, I presented this case after having read the history of present illness taken on admission by the pediatric medicine team and then that which was recorded by pediatric surgery...the lesson I wanted to impart was the documentation by both parties was HORRENDOUS. Not only was the actual physical finding of jaundice left out but all the dates were mixed up, the patient's file was an absolute mess and not all of the labwork was even recorded. Furthermore, retrieving a file like this is very difficult b/c the patients' files are rolled up and tied together by a piece of string and dumped in a file room. Also, the actual admission records kept by the nurses are terrible as well b/c some patients' intake information is either incorrect or missing all together....This has been very frustrating for me..i dont think i'll ever complain about any hospital filing/medical record system in the U.S. every again.

After the presentation I spent the rest of the day in the Pediatric Medicine ward...a veritable breeding ground for respiratory illness...about 60% of the patients in the ward are admitted with the diagnosis of bronchiolits/Pneumonia as it is the season here as well. Some of the more interesting cases I saw today were Acute Disseminated EncephaloMyelitis...Long name for an autoimmune disease that attacks the spinal cord and brain causing paralysis, difficulty with speech, etc. The patient presented with paraplegia, personality changes, difficulty with speech, involuntary urination. The MRI showed multiple lesions in the brain as well as thickening of the spinal cord (reaction to autoimmune attack).

Another patient-about 6 y.o. female, all smiles, with a skeletal deformity of the Right upper limb leaving her wrist in constant flexion and with one less digit, as well as stunted growth. Furthermore this child has findings of a heart defect(s) called Tetralogy of Fallot...a syndrome in which four things have to present together, Pulmonary valve stenosis (narrowing), Right Ventricular Hypertrophy, an Overriding Aorta, and ventricular septal defect. I could actually make out the murmur for the septal defect, the echo showed hypertrophy, pulmonary stenosis and the overriding aorta along with the vsd. Clinically, the child had signs of clubbing(hyperacute angle between nailbed and nail), which is often seen with disease of decreased oxygen perfusion although the exact cause is unknown....but like I said, with all of this..the child was smiling and laughing and playing with the child she was sharing her bed with (since there are usually two children to a bed).

I also saw three cases of Nephrotic Syndrome (protein losing disease of the kidneys which leads to massive swelling)...all three children presented first with swollen eyes, then swollen belly and then swollen legs..basically complete anasarca (full body edema).

The most astounding case though...the 5 y.o. with active T.B....Child presented with chronic cough, PPD that was placed was blatantly obvious, chest xray showed evidence of T.B....I mean I know it's a problem here but I was just really sad to see T.B. in such small child--The conditions in which most of these patients live or work or both is a breeding ground for any communicable disease..T.B. probably the leading infectious disease of them all.