First day in the clinic

Yesterday was my first official day working in the Clinica Familiar Luis Angel Garcia (CFLAG), and it was great. I worked with an incredible doctor, Dr. Herrera, and we saw patients from 7 AM to 2 PM without stopping. We saw a wide variety of patients, from asymptomatic patients with CD4 counts as high as 834 (a normal level for a person without HIV) to very sick, cachectic patients that required admission to the hospital. We admitted 2 patients to the hospital yesterday - one was a man with cough and weight loss for the past three months. He was so weak that he could barely walk. He was seen in the clinic last week, and had taken 3 sputum samples to the lab since then to rule out tuberculosis. All of his sputum samples were negative for tuberculosis, so Dr. Herrera peformed a bone marrow biopsy in the clinic to look for disseminated Histoplasmosis or miliary tuberculosis, then walked him to the Emergency room for admission to the hospital. The second was a woman also with cough and weight loss, as well as headache, neck pain, and dizziness. She previously weighed 125 lbs, but now weighs 80 lbs. She came in asking to be admitted, saying that she could not go on like this. After performing a fundoscopic exam to ensure that she did not have papilledema, I performed a lumbar puncture. Sure enough, the cerebrospinal fluid (CSF) came pulsating out. This makes the diagnosis of cryptococcal meningitis highly likely, since it is known to produce elevated opening pressures. The apparatus needed to measure CSF opening pressure is not available here, so you have to go by the speed and quantity of the fluid. After the lumbar puncture, we walked her to the Emergency room to be admitted as well.

And for the trivia question of the day - this rash belongs to a 62 year old male with AIDS. His CD4 count is less than 200. He has had it for about a month, and it itches like crazy. He scratches it all night long, and pours lemon juice on it during the day to take away the itch. The distribution of the rash includes bilateral lower legs, bilateral forearms, lower back, buttocks, and a few small lesions on the abdomen: