We now have four clinical officers working at the clinic. There are just two consultation rooms, one with a couch, the other with a massive vaccine fridge instead. The treatment room does have a couch so if no one needs minor procedures, injections, dressings, etc., a clinical officer can work there, too. I had suggested that we might train up one clinical officer to become a de facto pharmacist, but our stock of drugs is so low that it is hardly worth the effort.
A new clinical officer started work this morning. She was very keen and wanted to sit with me as I was teaching another CO, trying to improve her consultation skills. In many cases, the history consists of a few lines – abdominal pain, headache, fever, cough – or something similar, occasionally with a duration. I suppose if your treatment options are extremely limited, why bother delving into the symptoms and signs if you don’t have the drugs to treat the illness you have diagnosed?
But with some effort, we can try some clinical diagnostic reasoning, come up with a plausible diagnosis and construct a management plan.
“OK, you have written abdo pain 2/7, can you tell me more about the pain?” I asked the CO. “The patient has belly ache,” she replied. “Anything else about the pain?” I inquired. “The patient also has headache,” she said. “Let’s stick with the pain. Have you heard of SOCRATES?” I asked. She said she hadn’t but when I wrote it vertically on the page of the patient’s exercise book and said “S stands for site, O stands for…” she said, “Onset.” Ah-ha, she remembered the mnemonic, but this refers to what was happening when the pain first occurred, not when it occurred.
Character of the pain is always difficult because of language, cultural and vocabulary issues. “What about radiation? Does the pain go anywhere?”
The CO wasn’t familiar with the concept of radiation. I gave her some common examples – kidney pain radiates? “To the other side?” “No, to the groin.” Gall bladder pain radiates? “To the groin?” No, to the shoulder tip. I explained about the mystery of dermatomes and their innervation.
A for associated symptoms was easy. Headache.
T for time or duration of the pain, constant or coming/going.
E for exacerbation. What makes it worse, what makes it better.
S for severity, but it is always severe.
The patient had attended a month ago with abdominal pain and headache. A urine test detected a tiny amount of blood and under the microscope, the spiny eggs of schistosoma haematobium. She took some pills for bilharzia, but perhaps this was an incidental finding, because she came back a fortnight later, with the same symptoms. She was treated for gastritis, but this didn’t work either. We needed a Plan C – how about physically examining the patient?
She had tenderness in the right lower quadrant of her abdomen, with a possible mass. We discussed the differential diagnoses and sent her off to the hospital for a sonogram. Hopefully this will give us a treatable cause for her discomfort.
I am trying to get the clinical officers more interested in their patients, to be more patient-centred as GPs are in the UK. Curiosity is a virtue.