Tchadian medical case of the day:

I rounded on medicine today since Odeï is out of town for a few days. Every day I follow his patients on the electronic medical records system and physically walk through the wards and ask Odeï and the nurse how the patients are doing.

So I knew already there was an elderly gentleman admitted for stroke nine days ago. They asked me what could be done when he arrived initially and I talked with them about blood pressure control and aspirin. Of course, the nearest CT is a day's drive away an out of people's budget, so we go with the 85% thrombotic rule and treat everybody with aspirin.

We had also discussed the benefits of a nasogastric tube and started him on feeds and switched him to oral medications a few days ago.

But today was the first day I discussed care at his bedside or examined him or talked with his family and I took the opportunity to delve a bit deeper to confirm his diagnosis.

I looked through the chart again and saw he had received quinine, ceftriaxone, flagyl, vitamins, parasite medications and just about everything else our pharmacy has to offer. And all tests were normal.

So I asked his wife, "Has he said anything?"

"No," she replied, but still smiling.

"Does he move?"

"No."

"Does he eat or drink or swallow?"

"No."

"Does he open his eyes?"

"Oh, yes! Just the day before yesterday he opened them. He's getting better!"

OK, great. So I have a vegetable whom the family believes to be improving and cares enough about for them to be feeding him via nasogastric tube 24/7. This means they won't be eager to take him home to die.

Then I noticed how skinny he was.

"Has he lost weight since coming to the hospital? Are we not putting enough into his nasogastric tube?"

"No, he's always been skinny like this."

"Oh. Um. OK. Does he normally walk around at home?"

"Oh my no. He just sorta scoots around on his bottom."

"Oh? For how long? A couple weeks?"

"For several months probably."

"Like since April?"

"Before then."

I figure I should speed this up. "2013?"

"No. He wasn't walking then either."

"OK. But he was talking and eating before he just recently got sick, right?"

"Oh yes! In fact, he was eating and talking and banging on the ground with his fists when he got sick."

"OK, so then... Wait. Did you just say he was banging on the ground with his fists when this started? Did it start suddenly or gradually?"

"Suddenly. I mean, one moment he was banging on the ground with his fists and quite literally the very next moment, he fell over on the ground."

"Uh. Weird. Was he singing and the ground was his drum?"

"No. I don't believe so."

"OK, was he seizing?"

"What's a seizure?"

"Never mind, was he trying to get your attention? Was he with it? Was he choking?"

"No, silly white guy. He was talking very clearly and loudly and banging on the ground right before he keeled over."

"OK. I need you to help me out. What EXACTLY was he saying the precise moment he fell over?"

"Well, he was in the process of putting a curse on his sister and her children saying they would all die, but he keeled over right at the end just before he could finish the curse."

And... Discuss. I skipped this lecture in residency at Baystate.

Olen Netteburg

Missionarydoctors.blogspot.com

Danae.netteburg@gmail.com

Olen: +235 91 91 60 32
Danae: +235 90 19 30 38

Olen et Danae Netteburg
Hôpital Adventiste de Bere
Boîte Postale 52
Kelo, Tchad
Afrique

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