Imagine: you are the single provider manning a rural clinic in Northern Tanzania along the shore of Lake Victoria. You are one of only a handful of physicians in the entire region and you have minimal access to diagnostics or therapeutics. Your clinic does not have any power. Your diagnostics include: urinalysis, urine pregnancy, CBC and rapid tests for HIV, syphilis, and malaria. You have 2 nurses, one of whom acts as a translator (from Swahili to English). You are armed primarily with your intellect, knowledge of local disease processes, and your keen sense of intuition.

Case #1

13 year old male with no significant PMH presents with 3 days of fever, cough, chest pain, and intermittent nose bleeds. He denies nausea, vomiting, diarrhea, or abdominal pain. His cough is non-productive. No sick contacts.

T 39.1C HR 98 BP 110/70 RR 16 weight 40kg

Gen: Mildly ill-appearing; skin warm to touch

HEENT: PERRL, EOMI, Mild conjunctival pallor; Oropharynx clear, no erythema or lesions

C/V: S1S2 present, borderline tachycardia, regular rhythm, no murmurs

Resp: No resp distress, good air movement. Diffuse mild expiratory wheezing.

Abd: Soft, nt/nd. +Splenomegaly. Lower spleen edge palpated 2-3 finger-breadths below L costal margin

Skin/Ext: No edema or rash.

What’s the most likely diagnosis?

Case #2

28 year old female G4P3 at approximately 14 weeks gestational age who presents with several weeks of dysuria, lower abdominal pain, and fever. No hematuria. No diarrhea or blood/mucus in stool. Reports feeling weak but denies dizziness or syncope.

T 39.3C HR 110 BP 120/80 RR 12 weight 55kg

Gen: Appears uncomfortable but not in acute distress.

HEENT: PERRL, EOMI. Significant conjunctival pallor. Oropharynx clear.

C/V: S1S2 present, tachycardic, no murmurs.

Resp: CTAB, no crackles/wheezes

Abd: Mild periumbilical tenderness. No rebound/guarding. No masses palpated.

+FHT (~140 bpm)

Urinalysis negative.

What’s the most likely diagnosis?

Quick Hits

Case #3

57 year old female with PMH HIV & currently active TB presents with 3 days of dizziness and palpitations and discovered to be febrile with splenomegaly and significant anemia (Hb<3.0). What’s the diagnosis?

Case #4

14 month old male with no significant PMH presents in acute distress w/ fever, lethargy, poor feeding, tachycardia, tachypnea (RR>60), and anemia (Hb 5.5) whom you immediately refer to the main hospital but dies en route. What’s the diagnosis?