Alternate Common/Unique Diagnosis

From Guide to YKHC Medical Practices

Practicing Medicine in Bush Alaska—Some ABCs

Category:YKHC Guidelines

Emergency Department

Neonatal

Pediatric

Obstetrics

Outpatient

Abdominal pain

  • This is another very common reason for a visit to the ED. Most of our patients do not have access to fresh fruits and vegetables and reliable safe drinking water and therefore constipation is very common. The nursing staff has standard orders for triage for this problem. We do not have surgeons in Bethel (except for OB related issues) and so all appys need to travel to Anchorage if the surgeon wants to take out the appendix. They can often travel in on a commercial flight if they are stable. If unstable, or if pain can’t be controlled, they will need a medevac.

Injuries/Fractures

  • Please send all x-rays with fractures diagnosed to ANMC orthopedic telerad. This is a paper form you must complete. That allows for non-urgent consultation to take place via the ambulatory clinic. If there is an urgent need, please call ANMC and speak to the on-call ortho doc. They can give you some advice over the phone and, during the day, look at your x-rays.
  • If the patient is a trauma victim, call ANMC surgeon on call. They handle all calls related to trauma, even if the primary injury is orthopedic.

H. pylori

Pathophysiology:
Inheritance:
Demographics:
Signs/Symptoms:
Diagnosis:
Management:
Critical Times for Affected Patients:
Resources:

Hepatitis B

Hepatitis B is common here with the probable major mode of transmission being sexual or close contact. There is a high carrier rate and the “Hepatitis B” program does an excellent job in following AFPs and LFTs to screen for hepatomas bi-annually in these carriers. Children not vaccinated at birth and all Alaskans and health care workers working in Alaska should receive the three part vaccination. Pregnant women who are carriers need to have their HepBeAg tested. If it is positive the child at birth should get the Hep B immunization as well as the immunoglobulin. If the mother is just HepBsAg positive – they do not get the immunoglobulin. If the mother is just HepBsAg positive—they do not get the immunoglobulin—Epidemiology per our State recommendations.

Resources:

HLA-B27

This is frequent in this population with all of its associations (Reiters syndrome, Rheumatoid arthritis, and spondyloarthropathies are much more common here. We manage patients with rheumatic arthritis on Methotrexate with the assistance of ANMC specialist. Remember the labs that need to be done Q 1-2 months – kidney, liver, and blood count – CBC and Comp Chem.

Strep Pharyngitis

This is usually caused by a Group A (strep pyogenes), but can be caused by groups C and G. It usually occurs in children ages 5-10 with peak incidence in the first few years of school. The transmission is through direct contact via respiratory or nasal secretions. There can be food or water borne outbreaks and the incubation period is 2-4 days. We have a great deal of strep throat in the Delta as well as peritonsillar abscesses.

Clinical onset in older children and adults is abrupt onset of ST, HA, malaise and feverish.

The pharynx is usually red and edematous with hyperic/hyperplastic tonsils with white exudate, tender lymphadenopathy, and T>101. Symptoms usually last 3-5 days. It may develop into a peritonsillar abscess – with a enlarged asymmetrical tonsil – exquisitely tender. This may need to be drained by needle aspiration. Exudative pharyngitis in children less than 3 is rarely streptococcal. Type specific antibodies are seen in 4-8 weeks and protect against infection with organisms of the same M-type.

Treatment

Positive strep in a patient with no allergies can be treated with LA bicillin x 1 – with age appropriate dosing. If the family requests PO treatment – it is now recommended to give penicillin – 750mg po Q day x 10 days. You can use the daily dosing to increase compliance.

Evaluate for dehydration – as some of our severely ill patients require IV fluids – as they are so dehydrated due to decreased oral intake from the pain. If a peritonsillar abscess looks likely – it will need to be drained with needle aspiration – using hurricane spray for numbing. Ask for assistance with this as it can be tricky. Be aware that there can many complications from strep – and a review of common complications and management is important.