Актуальная Медицина - The medical practice in a tropical country

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Medicine in the Tropics

The practice of medicine in a tropical country differs in many ways from that in a temperate one.

A major problem arises in the definition of "tropical medicine”.
The expression "tropical diseases” means all diseases occurring in the tropics.
Tropical medicine, as an organized discipline, took off in the 1890s and reached a peak during the first half of the present century.
The major priority at present is to maintain a cadre of physicians well versed in the more "exotic” infections.
The future of the specialty Tropical Medicine is at present uncertain!
But much local teaching and research, local medical societies and examining boards were introduced in Africa.

Clinical Examination
Symptoms and Signs in Tropical Medicine

A: Clinical History:
In tropical medicine, perhaps more than in any other medical specialty, a carefully taken history and search for physical signs are of great importance. It is important to recognize the multiple, often asymptomatic, pathologies that are a frequent feature of disease in a tropical context. Many diseases show a marked geographical variation in incidence. The physicians should be aware of the epidemiology of the disease under consideration. Thus, undercooked meat may transmit a range of infections (tapeworm, trichinellosis, salmonellosis and toxoplasmosis).
STDs are very common in certain parts of the tropics and present with extra-genital manifestations.
HIV in the tropics is transmitted by heterosexual coitus, and should be suspected as a cause or cofactor in virtually any febrile illness.
A history of relevant vaccination should never be used as a reason to exclude any condition from the differential diagnosis, although proven effective vaccination against yellow fever or hepatitis B would virtually eliminate these diseases as a potential cause of ill health.
The presentation of disease is often greatly influenced by cultural factors. A history of malaria from an African patient should not necessarily be taken literally, but rather as being indicative of an acute feverish illness.
B: Specific Symptoms:
Physicians and health care workers practicing in a rural tropical environment are often faced with a large number of patients and have to be pragmatic in their approach to the diagnosis of disease.
When investigational technology is readily to hand the practitioner will usually want to exclude a wider range of likely diseases before committing the patient to therapy.
It is important to compile a relatively short differential diagnostic list based on the patient’s presentation and travel history.
However, many infections can, as part of their repertoire, cause a feverish disease, in which there are no associated features specific enough to allow a firm clinical diagnosis.
It is important to give priority to the diagnosis of conditions that are rapidly progressive or associated with a significant mortality, such as Plasmodium falciparum infection, typhoid or a viral haemorrhagic fever. In the tropics all such patients are given antimalarial drugs automatically, although, depending on the time of year, as few as 5 % of such patients are really infected with malaria.
Offer treatment only after appropriate investigation, unless the patient is in extremis.
The physician’s knowledge of clinical syndromes, disease epidemiology and geographical medicine will often lead to a rapid diagnosis.
Some extra intestinal diseases, such as legionnaires` disease, pneumococcal pneumonia or streptococcal septicemia, can occasionally masquerade as gastroenteritis. Thus, diarrhoea is also a frequent manifestation of certain severe diseases, including measles in malnourished children, and in the acquired immune deficiency syndrome (AIDS).
Yellow eye discoloration may be a presenting symptom, although in many cases it will be detected initially as a clinical sign.
The physician should first of all distinguish between hepatic and hemolytic pathologies by determining the presence or absence of bile in the urine.
In view of the appreciable mortality of the latter conditions, their diagnosis should always be carefully considered.
Haematuria and Dysuria:
The urethral discharge is the patient’s primary complaint in case of STDs then the etiological differential diagnosis should be easy, but a significant discharge is not always found in acute urethritis.
STDs in the male:
- general ulceration;
- inguinal swellings;
- extragenital manifestations are missed (gonococcal pharyngitis)
(In case of inappropriate sexual history)
Most febrile illnesses (malaria, typhoid and dengue fever) are accompanied by the headache.

Physical Examination
General Examination:
The multiple pathology is common within the context of tropical disease, thus the clinician should not be surprised to find physical abnormalities additional to those expected from the primary complaint.
Low body mass due to malnutrition, malabsorption or the cachexia of chronic disease is a common finding. Further examination may also reveal features of vitamin deficiency.
Anemia: Millions of children in the tropics have hookworm infection, making this the most common cause of anaemia, but there are many other possible etiologies that should also be considered. (Table 2.9 p 21)
 Lymphadenopathy: Residents of the tropics are frequently exposed to infectious disease and enlarged lymph nodes are a common finding which doesn’t necessarily indicate continuing pathology.
When the lymph nodes are particularly large or obviously expanding then certain conditions to be considered include tuberculosis, HIV infection, lymphoma (Burkett’s type in Africa), brucellosis and African trypanosomiasis, although virtually any acute infective process may be implicated. Many problems in tropical disease practice may manifest themselves dermatologically and infections of the skin are especially common. 
Even when the primary complaint is not suggestive of abdominal disease, examination of the abdomen can be revealing.
In malaria-endemic areas splenomegaly is a common finding, especially in children – where the spleen often reaches an enormous size. A wide range of other systemic diseases can also cause this sign, in addition to a frequent association with hepatomegaly.
Relative bradycardia, a pulse slower than would be expected for a given fever, is a feature of several infections including typhoid and yellow fever. Tuberculosis is a frequent cause of diseases of respiratory tract, but other etiologies to consider include amoebiasis and helminthic infections.



Most severe neurological diseases are also infectious in origin:
Neck stiffness is normally a reliable sign in the early diagnosis of bacterial meningitis. Although cerebral malaria may also cause severe neck stiffness, this is usually the sole alternative diagnosis to primary meningeal infection in an endemic area.
The distinction between cerebral malarial and bacterial meningitis in children can be a difficult problem in endemic areas. Even when a firm diagnosis of malaria has been established, the child’s unconsciousness may in fact be due to associated hypoglycemia.
Musculoskeletal system:
• Myopathy caused by the retroviruses HIV and HTLV-1 is increasingly recognized.
• Tuberculosis and brucellosis are frequently implicated, and salmonellae are a particular problem in children with sickle cell disease.
• Conjunctiva infection may be caused by a primary ophthalmic condition but can also be related to systemic disease such as leptospirosis and typhus.
Vocabulary:

To differ [`dǐfə] – відрізнятися; to take off [`teǐk of] – починати шлях;
temperate – [`tempǐrǐt] помірний пояс; to maintain [meǐn`teǐn] – підтримувати;
to arise [ə`ra ǐz ] – поставати; well versed [wel`və:st] – добре інформований,
definition [dǐfǐ`nǐ∫n] – визначення; uncertain [ǎn`sə:tən] – непевний;
expression [ǐks`pre∫n] – вираження; research [rǐ`zə:t∫] – дослідження;
societies [sə`saǐətǐz] – товариства, гуртки; boards [`bo:dz] – кафедри; manifestations [mənǐfǐs`teǐ∫nz] – прояви; search for [`sə:t∫fo:] – пошук;  
coitus [`kəυǐtəs] – спарювання; feature [`fi:t∫ə] – риса; cofactor [kəυ`fæktə] – споріднений фактор;
variation in incidence [vərǐ`eǐ∫n ǐn`ǐnsǐdəns] – зміни у числі хворих;  
literally [`lǐtərəlǐ] – буквально; 
undercooked meat [ǎndə`ku:kt`mi:t] – недоварене м’ясо;  
rather [`rα:ðə] – швидше як; 
rural environment [`ru:rl ǐn`vaǐərəmǐnt] – сільське середовище;  
investigational [ǐnvestǐ`geǐ∫nl] – дослідницький;
to be readily to hand [bi:`redǐlǐ tə`hænd] – наявна під руками;  
 to commit to [kəm`mǐt] – піддавати до;
to exclude [ǐks`klu:d] – виключати; to compile [kəm`pa ǐl ] – оформити, скласти;
range [`ræŋdз] – ряд; repertoire [`repə`twα:] – репертуар;
appropriate [ə`prəυprǐət] – правильний; extremis [ǐks`tri:mǐs] – крайність;
legionnaires’ disease [`lǐdзǐnərǐs dǐ`zi:z] – хвороба легіонерів;  
inguinal [`ǐngwǐnl] – паховий;
to be detected [bi:dǐ`tektǐd] – розпізнаватись;  
helminthic infections [hel`mǐnθǐk ǐn`fek∫nz] – гельмінтичні інфекції;
discharge [dǐs`t∫α:dз] – виділення;  
appreciable [ə`pre∫ǐəbl] – значний, помітний;
to be accompanied [bi:ə`kα:mpənǐd] – супроводжуватися;  
bile [`ba ǐl ] – білок, жовч, білірубін;


Questions:

1. What is the general specific practice of medicine in a tropical country?
2. Do physicians have the major priority in the tropics? Why?
3. Should the physicians be aware of the epidemiology of tropical diseases? How?
4. What are the characteristics of disease influenced by the cultural factors?
5. What is so important while diagnosing the infectious disease in the tropics?
6. How shall we start the treatment and investigations?
7. What shall we take into account in case of primary and secondary diagnosis?
8. What are the symptoms of disease in case of multiple pathology

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