Dysentery won't stop Dr Robert

,So the ... Frequent ..pooping recurred.

Q2h bathroom trips.

So at first I was gonna sleep it off and let my intestinal epithelium shed itself and miss clinic but I woke up with a renewed passion, showered and hopped on a bodaboda (motorcycle) to catch the gang at clinic. 

As usual, Dr Jan had procured business for me. 

Going through the patients

1. Following up my friend  with ISS/ AIDS with pyrexia of unknown origin ( like FUO) who's doing quite well. 

2. 60 something old female with new diagnosis if chf . Dr Jan asked me to appreciate her physical exam findings and wanted to know if I had additional questions. So I found out that someone had " given her medicine that made her pee more " which I interpreted as diuretics aka someone knew she was fluid overloaded. Then I examined her . Pertinent findings: JVD, cardiac wheeze, crackles to halfway up posterior lungs , irregular heart rate and rhythm , ascites, bilateral pitting leg edema , significant dyspnea while lying supine. So I theorized that she is in chf exacerbation with underlying afibb either from dilation or may have thrown her into chf. Interestingly , she did admit to occasional palpitations while at home.  So we managed her as best we could , uganda style. 80 ,g iv lasix, started aspirin/ digoxin / beta blocker / aspirin and hoped for the best . 

3. 60 something old male with cirrhosis/hepatomegaly of unclear etiology and possibly nephrotic syndrome . In short, he hasn't gotten better in 6 days and we don't know what he has. We reviewed years of his paper records and weird labs like an albumin of 0.7 in the past ( which dr jan thinks is lab error from shady reagents in Mbale ). So I proposed he gets a proper chemistry and liver function tests..which can only be done in Kampala , the capital . Given his age and proteinuria , he probably needs a kidney biopsy . And to add to the fun, he needs a liver biopsy for this "cirrhosis ". So...the family asked us for an estimate for these things and we guessed about 1 million shillings which is about   435 US dollars . This is a significant burden on a family and after a meeting realized we can't do this today. So I suggested we empirically treat with high dose steroids and told him there was maybe a 10% chance this work. My quick lit search showed that there is maybe a 50% remission rate . The morphology of nephrotic syndromes is so varied and relapse is relatively common. 

4.  Poor soul of a lady with cervical cancer with likely hips mets. She just came in for pain management and unfortunately lives by herself.

5.  My copd/asthmatic / interstitial lung dz lady returned with chest tightness. Kind of humorously , she appeared to be completely normal when nobody was watching her. 

6.  Last patient of the day, triaged from the front. A 40 something year old male with known cirrhosis comes in with massive ascites. He pretty much looked 9 months pregnant. In short, we found out that we had been a cirrhotic since 2007 and was previously well controlled on diuretics and abstaining from alcohol. However, as of 2011, he went back to alcohol, specifically waragi, which is a type of homemade gin. 

http://en.wikipedia.org/wiki/Waragi

So basically, Dr Jan asked me to set up another paracentesis and even better, walk the clinical officer through my custom setup. Here's some before and after pics with CAPUT MEDUSA!

So prior to me leaving, we were about 7 liters out. I knew we'd probably get close to 10 liters (pending by holding) given his 11kg weight increase from prior weights. 

All in a days work :).  And now the clinical officer is officially certified by yours truly , hahahaha

Last thing,  I wanted to know about the source of the loud dog barking next door to my hotel/casa and I spotted my new friend from across the balcony. 

Kinda reminded my of the beast from Sandlot.

http://villains.wikia.com/wiki/Beast_(The_Sandlot)