Case Presentation 1

Case 1

25 yo female with no PMH presents with convulsions. She has been in her usual state of health until the day of presentation. She has spent the day travelling on a bus from the Rift Valley to Karatina. She states she packed her own food and did not eat anything offered to her on the bus. On arrival to Karatina she had a convulsion as described by the fellow travellers. Patient was admitted and was witnessed in hospital to have several more convulsions that started with facial spasms and generalized to tonic clonic convulsions. The convulsion lasted for "a while" and was broken by giving 30mg of diazapam slow IV push. Patient returned to baseline and was noted to have brusing on her tongue.

ROS: + for HA on and off for the past month, relieved with paracetomal. No HOB, no blurriness of vision. Otherwise negative.

PMH:-

FMH:-for epilepsy

Social: Denies EtOH, tobacco, drug use.

Medications :none

Allergies: NFDA

PE: T36.7 P80 R20 BP: 140/60

General: Well developed African female, NAD

Head: ATNC

Eyes: Conjunctiva pink, sclera anicteric, PERRL, EOMI

Neck: No menignismus, Fullness of R thyroid with no appreciable nodules.

CV: RRR, no MRG; peripheral pulses present, symetric; cap refill <2sec

Resp:LCTAB

GI: AB S/NT/ND/BS+

MS: FROM

Skin: No rashes/bruises/lesions

NEURO: CNII-XII intact; sensation intact B/L; strength is 5/5 throughout; no dysmetria; abulation without difficulty; A&Ox3

A/P: 25yo with new onset convulsions

Obtain full Hemogram, UEC's and Pregnancy Test. Order CT head for masses/bleeding. Admit for observation. Diazapam PRN for seizures, PCM for headaches. Re-eval in AM.

Discussion:

This was an interesting case for me, not because of the medical aspects itself, but it brings up some important social issues. As is probably evident in the case, Kenyan's don't really use the term seizures, but convulsions. It's really a minor difference, but there are many of these language problems I've run into during rounds. They tend to call congestive heart failure (CHF) congestive cardiac failure (CCF). Fevers are hotness of body (HOB). A basic metabolic profile (BMP) is equivalent to a urea, electrolytes, and creatinine (UEC). They are very subtle differnece and it's not difficult to adapt, but they use abbreviations as commonly as we do and I feel I slow down discussion some by asking what each of these mean.

As mentioned above, the patient had an enlarged thyriod that was picked up on physical exam. After more discussion with the patient we found out that it was evaluated several years ago at an outside hospital. She was told then that she needed her thyroid taken out. This I actually seemed very familiar to me. I can't count the times that patients have been told they needed a procedure, a scan, an xray, or just follow-up and haven't- either because they were scared or just couldn't afford it. Strangely, I felt reassured that somehow all people are alike.

The patient did very well and had no more seizures throughout her hospital stay. However, the CT was never performed for 2 reasons. One was that she was afraid of what the scan might due to her. The other was that she and her family could not afford the test. While many of the service Tumutumu provides are cost-reduced (such as medications, laboratory tests, and meals) any of the tests obtained outside of the hospital (such as CT's, MRI's, Ultrasounds, and EGD's) are paid for in advance by the patient. Ultrasounds cost about 2,000 shillings (about $25 US) and CT's cost about 10,000 ($126). Although that doesn't sound like much but the average salary in Kenya is $730 US. Often patients have to call family and friends to help come up with the money. Often this can delay the test (and often diagnosis) by days.

Our patient ultimately decided that she did not want the test and wanted to be discharged home. This comes up alot here and seems to be to be a real contrast to how we practice in the US. Here in Kenya, if patients want to stay, the doctors are not really apt to forcing them out. If they want to go, there is no discussion on leaving against medical advice and documenting risks as we would in the US, patients are just discharged. That's not to say that the patients aren't informed, it's just that there isn't much malpractice out here to worry about.

I really hope that the patient does well, and hope that she follows up in clinic. I think many patients are lost to follow-up because of distance, time, and cost. I guess like many things out here in Kenya, it's out of our hands.