medical missions outreach- provider resource

8/6/2019 Medical Missions Outreach- Provider Resource

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Medical Missions Outreach

Medical Provider Resource

Packet for Nurses/NPs

Equipment to Bring: Stethoscope, penlight, pocket otoscope, blood pressure cuff,drug handbook, calculator, scissors, tape, alcohol swabs, tongue blades (if have access toget). Nurse practitioners may also include dermatology reference book, Epocrates on

PDA, Tarascon pocket pharmocopeia, Sanford guide to Antimicrobial therapy, handheld

eye charts, ophthalmoscope, reflex hammers, and tuning forks to test hearing. Thepocket size Mosbys physical examination handbook may also be useful.

For those who do not speak Spanish or the language spoken in the country

sponsoring the medical team, a medical dictionary from English to that language will behelpful to aid your interpreters.

General Information Ask for one specific problem the patient is currently experiencing with which you

can help them today. Very important you or your interpreter limits response back.Many patients will tell you every problem they ever had.

Asked focused history questions pertinent only to todays problem.

Before the first clinic day, review the list of medications on formulary in the

pharmacy. Familiarize yourself with what class of medication each drug is and

what that drugs treats. Major considerations in prescribing a medication shouldalso be reviewed. It may be helpful to right info on formulary sheet for easy

reference.

Daily update what medications are still in formulary.

For nurses not used to prescribing dosages, remember the pharmacist can figure

dosages if you choose the medication and write what you are treating.

Remember to include basic teaching concerning diet, exercise, smoking cessation

and weight management in treatment plan for hypertension, diabetics and heart

patients.

Utilize any patient education handouts provided on each particular trip as

available.

Examination spaces may not be ideal for thorough physical exams, utilizesymptom descriptions when appropriate in place of physical inspection ofintimate areas.

Collaborate as necessary with other practitioners. Formulate questions or

uncertainties in plan of care in advance. Also if symptoms or examinationfindings are new to you, feel free to have another practitioner examine patient

with you.


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Trust the Lord for daily wisdom. It will amaze you how He calls to remembrance

information you long ago learned.

Pediatric BasicsHuman Growth and Development- Normals

Newborn to two weeks Well child checko Strong primitive reflexes- rooting, startle reflex, and Babinski

o Should briefly focus on faces or objects

o Follows face midline

o Lifts head briefly in prone position

o Undifferentiated cry

o Able to suck/swallow/breathe

o Breast feeding recommended for first 4-6 months

o Put baby to sleep on back

o Assessment

If scale available, measure weight, height and head circumference.If growth charts available for country the team is in, plot on growth

curve.

Assess/observe rashes, jaundice, dysmorphic features (skin folds,

ears lower than outer canthus of eye) eyes, eyelids and ocularmobility.

Check for red reflex. If absent, have child seen by pediatric MD or

NP on trip.

Check for heart murmurs. Remember normal for HR to be 124-

140 at this age.

Check hips- Ortolani/Barlow maneuvers (see appendage).

Inspect umbilicus, check for hernias or abdominal. masses Palpate femoral pulses.

Note symmetry of movement, general activity level, and posture.

Check anterior and posterior fontanels.

Normal urine output- 6-8 wet diapers a day= adequate hydration

with breast milk or formula. Formula should be iron fortified.

o Mother should be counseled to not smoke and provide smoke free

environment.

o Assess mom for post partum depression

One month of age

o

Follows parent with eyes, recognizes parents voiceo Has started to smile

o Able to lift head up when on tummy

o Assessment

Measure and weigh if available resources

Anterior and posterior fontanels, check for any skull or headdeformities


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Assess eyes for red reflex, color, clarity, presence of opacities or

clouding of corneas

Check ears- may be hard to visualize

Check for heart murmurs

Palpate femoral pulses

Check abdomen for masses and assess umbilical healing Check hips with Ortolani/Barlow maneuvers

Assess for neurological reflexes, attentiveness to visual andauditory stimuli

Two months of age

o Attempts to look at parent, smiles

o Consoles and comforts self

o Differentiated cries, and coos

o Holds head up and begins to push up in prone position

o Has consistent head control in supported sitting position

o

Newborn reflexes should be decreasingo Assessment same as above, posterior fontanel may be almost closed or

closed

Four months of age

o Smiles spontaneously

o Babbles expressively and spontaneously

o Elicits social interactions, indicates pleasure and displeasure

o Pushes chest to elbow

o Good head control

o Beginning to roll and reach for objects

o Cereal can be introduced between 4-6 months

o Keep small objects out of reach from the baby

o Assessments- same as above with attention to symmetry of movement,

muscle tone, fontanels and red reflex

Six months of age

o Recognizes faces, babbles, enjoys vocal turn taking

o Responds to own name

o Rolls over and sits

o Stands and bounces

o Rocks back and forth on all fours

o Moves to crawling from prone

o Can introduce cup at this time- limit juice to 2-4 oz per dayo Introduce solids one food at a time

o Continue breast feeding or iron rich formula

o Assess fluoride source

o Assessments as above, primitive reflexes should be faded or gone

completely

Nine months of age

o Stranger apprehension


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o Seeks out parents

o Uses repetitive consonants and vowel sounds

o Points out objects

o Gradually increase table foods, provide 3 meals with 2-3 snacks per day

o Assessment- as above. Elicit parachute response

Twelve months of ageo Plays interactive games

o Hands parent a book when wants a story

o Waves bye-bye

o Imitates activities

o Has strong attachment with parent and shows separation anxiety

o Speaks one to two words

o Follows simple directions

o Identifies people on request

o Holds 2 cubes and bangs together

o

Stands aloneo Assessment- same as above. Perform cover/uncover test. Check teeth for

caries and staining. For boys check that testes have fully descended.

Fifteen months of age

o Scribbles

o Walks well

o Drinks from a cup

o Hands a book when wants a story

o Indicates wants by pulling/pointing/grunting

o Emphasize dental care

o Assessment- same as above. Observe for stranger avoidance. Anterior

fontanel should be closed (average age of closure is 13 months)

Eighteen months of age

o Speaks six words

o Points to one body part

o Knows name of favorite books

o Walks up steps

o Runs

o Stacks 2-3 blocks

o Scribbles

o Use spoon/cup without spilling

o Assessments-same as above. Note gait, hand control, arm/spinemovement. Continue to assess red reflex. Cover/uncover test. Observefor nevi, caf au lait spots, birthmarks, bruising.

Two year old

o Parallel play

o Refers to self as I or me

o Has at least 50 words

o Used 2-word phrases


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o Follows 2 step commands

o Stacks 5-6 blocks

o Makes or imitates horizontal or circular strokes with crayon

o Throws ball overhead

o Jumps, climbs stairs one step at a time

o Screen language acquisition/clarityo Observe running, scribbling, socialization and ability to follow commands

o Depending on child, may initiate toilet training

o Assessment- same as above. Calculate BMI if possible.

Three year old

o Play includes other children

o Uses 3-4 word phrases

o Is understandable to others 50% of time

o Points to six body parts

o Knows the correct action for animal or persons

o

Copies vertical lineso Throws ball overhead

o Brushes teeth and dresses with help

o Toilet training

o Assessment- same as above

Four year old

o Listens to story

o Knows first and last name

o Fantasy play

o Knows what to do if tired/cold/hungry

o Speech clearly understandable

o Names four colors

o Plays board games

o Can draw a person with three parts

o Hops on one foot

o Balances on one foot for two seconds

o Builds tower of 8 blocks

o Copies a cross

o Brushes own teeth and dresses self

o Assessment: Same as above. Observe fine/gross motor skills. Language

acquisition. Speech clarity.

Five-six years oldo Balances on one foot, hops, skips, able to tie knot

o Show school readiness skills

o Has mature pencil grip

o Can draw a person with six body parts

o Prints some letters and numbers

o Able to copy squares and triangles


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o Names 4 colors

o Counts to ten

o Follows simple directions

o Assessment- same as above. Attempt ophthalmoscopic exam of optic

nerve and retinal vessels. Gait, posture. Assess for scoliosis.

School age childreno Basic head to toe exam

o Assess for scoliosis

o Vision tests, hearing

o Normal social interaction, school performance

Sick Visit

o Ask if child has had fever in last 24 hours

o Ask about irritability, change in activity levels, sleeping patterns, changes in

cry, or changes in play

o Ask how many wet diapers a day. Normal hydration= 6-8 wet diapers a day.

Tears when crying? Give out rehydration handout to formula fed babies.Breast fed moms should encourage child to feed frequently.

o New rash in last day or two?

o Any other sick family members? Exposures at school or baby-sitters?

o Diarrhea- new onset or chronic? Any blood in stools? Abdominal pain

associated with stools? History of constipation?

o For lethargic children, respiratory wheezing, or high fevers in clinic- refer to

pediatric specialist with team or NP.

General PracticeUpper Respiratory Infections

Viral illnesses last 7-14 days. Usually by day 7 symptoms are beginning toimprove. Starts with head congestion that loosens and progresses to cough that

moves from dry to moist. If symptoms begin to improve and then worsen or if

symptoms worse after day 7 instead of improving suspect possible bacterialinfection.

Continued sinus congestion with facial pain and headaches after day 7 suspect

bacterial sinus infection. Treat with amoxicillin, augmentin, cefdinir, cefprozil,cefdinir, ciprofloxacin, or levaquin.

Viral pharyngitis is often present at beginning of viral URI and most common

cause of sore throats. Viral pharyngitis is often associated with a cough. It is not

usually accompanied by high fever for several days, difficulty swallowing, severe

malaise, or stomach upset. Exudative sore throats should have rapid strep and ormono spot test done. Viral URIs are treated with symptom management.

Strep A positive- Penicillins, erythromycin, zithromax, clindamycin orclarithromycin

Viral bronchitis can persist up to 14 days. Treat with decongestants, mucolytics,

increased fluid intake, and consider use of prn of albuterol inhaler to relievetightness.


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Cough > 14 days evaluate for bacterial bronchitis and pneumonia.

Decreased lung fields or wheezes- have nebulizer treatment given and repeat

assessment listening for crackles, ronchi or increased wheezing. Use percussionof lung fields and tactile fremitus to aid in diagnosis of pneumonia.

Treatment of pneumonias/ bacterial bronchitis- Zithromax, Clarithromycin,

doxycycline, augmentin, or respiratory flouroquinolone.Otitis Media

Normal tympanic membrane is pearly translucent color, bones are visible, no

bulging of membrane noted, cone light reflex noted, and no fluid bubbles are seenbehind ear drum. External ear cartilage gentle wiggling should not elicit pain.

Crying can cause ear drum to be red so color of membrane is not always specific.

A non-crying infant or child with a red ear drum is suspicious for otitis media.

Gray, pussy appearing membranes, cloudy membranes that light reflex and bones

are not easily visualized are suspicious for otitis media.

Yellow or clear fluid bubbles behind ear drum is indicative more of serous otitismedia. May be related to sinus congestion and Eustachian tube dysfunction.

Might be able to treat with decongestant and Tylenol. Look for other indicationsof bacterial infection.

Otitis media is not common in adults. If present, usually indicative of Eustachiantube dysfunction. If serous otitis media, treat with decongestants. For chronic

sinus problems or allergies, patient may need allergy medication or nasal steroids

to decrease inflammation in sinuses and allow proper drainage.

Otitis media is generally treated with amoxicillin, augmentin, cefdinir,

cefpodoxime, cefprozil, cefuroxime axetil, bactrim, and zithromax. Pharmacist

will dose for kids and adult, just provide patient weight for kids and indication forusage. Also note if child or adult has had an antibiotic for this problem in last

month.

Pain Management

Team only carries non-narcotic medications

Tylenol is safe for all patients unless have active liver disease evidenced by

jaundice. Check buccal mucosa and sclera.

Ibuprofen should be avoided in patients with hypertension, renal disease, or

know gastric ulcers. Medication should also be avoided in pregnant women in

third trimester.

Teach good posture for lifting, bending, sitting.

Teach neck and back stretches.

Ace wraps may be utilized to use as knee supports. Teach how to wrap

correctly without being tight and causing circulation problems below wrap.Gout

Painful swelling, inflammation of first metatarsal.

Treat with NSAIDs unless contraindicated.

Colchicine 0.6 mg every 1-2 hours during an attack with max dose of six pills per

day.


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Teach patient to avoid alcohol, liver, anchovies, asparagus, shell fish, salmon,

legumes, and sardines as these foods are high in purine and will increase uric acidproduction.

If allopurinol available, consider prophylaxis dose for those suffering with

chronic gout. If first time on allopurinol 300 mg daily, make sure patient takes

NSAIDs or colchicine first.Hypertension

Brief health history to check for co-existing morbidities such as diabetes, CAD, or

renal problems.

Blood pressures should be taken after patient sitting with feet flat on floor.

Repeat BP after 20 minutes of sitting.

Goals for treating BPs are much more conservative on these trips due to ourinability to follow up with patients.

For BPs ranging 140-180/80-99, consider dietary changes such as low fat diet,

sodium restriction of 2Gm per day, exercise, and weight loss as treatment.

For BPs ranging 180 or >/100 or > systolic. Lifestyle changes as above and start

low dose medications. JNC-7 recommendations are to start first with thiazidediuretic (HCTZ) or an ace inhibitor (Lisinopril). Consult formulary for what is

available. Can also use a beta blocker or calcium channel blocker.

o Thiazide diuretics- use cautiously in patients with know gout

o Ace-Inhibitors- use cautiously if know renal disease- serum creatinine>3

on labs brought to you indicate use of other medication

o Beta-blockers- avoid use in patients with asthma or slow heart rates

o Calcium channel blockers- avoid use in patient with active CHF

Teach patients starting a beta blocker or calcium channel blocker to monitor heart

rate daily before taking medication.

Teach patients concerning orthostatic hypotension and side effects of meds. Check urine for nitrates for known hypertensive patients and newly diagnosed

patients.

If patient was previously on hypertensive medications, determine what they tookand do they have any left. If medication on formulary or like class of drug,

provide a one month supply of drug as available.

Diabetes

Difficult to manage on short term trips. Have random finger stick checked as well

as urine for presence of glucose, ketones, or proteins.

Diabetic education concerning diet, exercise, and weight loss.

Metformin is standard PO drug for Type II diabetics. However, should not be

used if renal failure or elevated creatinine. Consider Glyburide, Actos, orAvandia. Will need to check what is on formulary for trip.

Check for complications of diabetes- vision changes, diabetic neuropathy, and

diabetic ulcers.

Educate on signs of hypoglycemia and hyperglycemia.

Gastritis/GERD

Reflux? How often? Positional? Food make better of worse? Any blood in

emesis or stools? Black tarry stools? Presence of parasites?


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Gastric pain and tenderness- burning pain without reflux- evaluate for h-pylori if

test available.

Treat GERD with Omeprazole or like PPI, Ranitidine or like H2 agonist.

o Omeprazole 20 mg daily for duodenal ulcers, GERD and erosive

esophagitis. Omeprazole 40 mg daily if suspect gastric ulcer.

o Ranitidine 150 mg bid Treatment of H-pylori= Prevpac or PPI bid for 10-14 days with Amoxicillin 1Gm

and Clarithromycin 500 mg bid for 10 days.

BPH

Patient may present with history of disease but out of medication.

Typical symptoms- increased urinary frequency, difficulty starting stream,nocturia. Not usually painful to urinate or sense of great urgency.

Check u/a to make sure not UTI. UTIs not as common in men.

Make sure no other penile discharge related to STI.

Ideally a prostate exam should be done to identify enlargement without tendernessor bogginess. No masses or nodules should be felt. This may not be feasible due

to exam room limitations and provider knowledge of normal prostate.

Treatments- Flomax 0.4 mg daily- 30 min after same meal daily.

o Proscar 5mg daily.

UTIs

U/A to confirm or if classic symptoms relieved previously by antibiotic therapy.

Increase fluid intake.

Teach methods of cleanliness and voiding post intercourse to decrease UTIs in

women.

Treatment: Bactrim DS bid x 3 days

If symptoms of urinary frequency, painful urination, increased urgency, pressure

are associated with fever, chills, back/flank pain, and nausea- Tx forpyelonephritis- Bactrim DS bid x 14 days, or Cipro 500 mg bid x 7 days.

GynecologyDifferentiating vaginal itch/discharge complaints

Normal

White to clear discharge, no itching, no vaginal or pelvic discomfort

Bacterial Vaginosis

Thin white, white-gray discharge. More discharge than usual.

Fishy strong odor to discharge. Patient may complain that odor

worsens after intercourse.

Itching may or may not be present. May have mild vaginal discomfort. Cervix not painful during

intercourse.

May or may not have painful urination.

Patient may have recent new sexual partner.

Symptoms are not related to menstrual cycle.

If microscopic exam available- patient will have clue cells on salinewet prep.


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Treatment

o Metronidazole 500 mg bid x 7days-

(Teach them they MUST avoid alcohol ingestion

during this time and five days after therapy

completed)

Safe to use in pregnant women after 1st trimestero Metrondizole vaginal gel- 1 intravaginal application daily x

5days

o Clindamycin 300 mg bid x 7 days or intravaginal clindamycin

2% cream 5 gm at bedtime x 7days (Do NOT use clindamycin

cream in pregnant pts)

Candidiasis

White, curdy, cottage-cheese like discharge

No odor present

Moderate to severe itching and burning with discharge

Painful urination frequently present.

Not usually related to change in sexual partners.

Male partner may have similar symptoms.

Usually positive relationship with menstrual cycle.

Recent antibiotic use common.

Recent attempts to treat itching systemically or locally.

No cervical pain with intercourse.

May have external itching and redness of labia.

Microscopic exam- positive KOH for buds

Treatment

o Fluconazole 150 mg PO x 1 dose. Safe in pregnancy.

o Intravaginal Miconazole, Clotrimazole, daily applications 7-14days

Trichomonas Vaginitis

Yellow, green, frothy, adherent discharge, often in large amounts

Frothy, bubbling discharge

Vaginal vulvar pain

Foul odor but not fishy

May or may not have mild itching

Painful urination

Patient will often report new sexual partners or suspicion of partner

cheating Treatment

o Metronidazole 500 mg bid x 7days- avoid alcohol use during

course of treatment and five days after ( Do not use in 1st

month of pregnancy)

o Treat the partner as well- Metronidazole 2 Gms PO one single

dose

Gonorrhea/Chlamydia Symptoms (Possible PID)


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Pelvic pain and pressure- suspect PID

Painful intercourse internally not just vaginal irritation- suspect PID

May or may not have itching

Mild to moderate odor to discharge for some pts, may not have odor

May or not have painful urination

History of new sexual partner or multiple partners Sexual partner often has symptoms as well- should be evaluated and

treated as well if possible

Treatment

o Doxycycline 100 mg PO bid for 14 days ( Unsafe in pregnancy

and possibly lactation) and Metronidazole 500 mg bid for 14

days

Dermatology

Basic Wound Care If wound is dry, make it wet. If wound is wet, make it dry.

Give supplies to keep wound clean and dressed.

Utilize Ace wraps for light compression in patients without cellulites or CHF,check distal pulses before using compression wraps.

Cellulitis surrounding wounds or infected wounds- Keflex, Bactrim,

daptomycin, augmentin, or zithromax. Cipro effective if suspected bone

involvement.

Lice

Consult formulary for what shampoos we have available.

Scabies

Rash generally found in webspace of hands, wrists, front of elbows, knees, ankles,web spaces in between toes, axillae, around waist, genitals, and buttocks, and may

spread onto arms and trunk as progresses untreated. Burrows noted in rash.Classically reports increased itching at night.

Tx: All sheets, linens, and clothes patient uses must be washed.

Premetherin 5% cream- apply from chin to toes and leave on 8-10 hours. Thenshower off. Repeat treatment in one week. Safe in all patients > 2mos old.

May need to prescribe medium dose steroid cream for itching. Rash will persist

for several weeks but itching should cease after 2-3 weeks.

Eczema

Teach good hygiene and moisturization of the skin with baby oils and

moisturizers. Oatmeal powder baths may be helpful.

Patients may also present with allergic rhinitis symptoms

Poorly defined erythematous patches, papules or plaques with or without scale.

Pruritic. Skin appears puffy. Chronic eczema may have lichenification from

scratching. Rash occurs on face, neck, trunk, hands, antecubital spaces, back ofknees, shoulders, thighs and calves. Spares feet and buttocks area.


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Depending on age of patient and severity of eczema, confer with another

practitioner if a corticosteroid cream should be prescribed. Severe cases may needsteroid cream and antibiotic to treat for localized staph skin infections.

Psoriasis

Classic lesions are sharply marginated erythematous papule or plaque with

silvery-white scales. Occurs on scalp, behind ears, palms, nails, arms, back of elbows, arm pits, lower

back, front of knees, soles of feet, buttock, and perigenital areas. Usually spares

face, back of hands, and light exposed areas.

The location and severity of psoriasis will determine type of treatment.

Mild scalp psoriasis can be treated with ketoconazole shampoo followed by

betamethasone 1% lotion.

Moderate strength corticosteroid creams/lotions are usual treatment for psoriasis

on elbows, knees and feet. Confer with another practitioner concerning

appropriate treatment for location and severity of psoriasis.

Recommend spending time in sun in short durations.

Acne

Teach good hygiene.

Refer to formulary for acne washes available on trip. Most topical medications

we dont carry other than benzyl peroxide washes. Po medications requireextensive tests before treatment. Refer to local dermatologist.

Appendix of Images


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Infantile Eczema- Picture taken from Fitzpatricks Color Atlas and Synopsis of ClinicalDermatology


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Follicular eczema in dark skin- Picture also taken from Fitzpatricks Manual

Scabies


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Psoriasis- Images from Fitzpatricks manual


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Barlow-Ortolani Maneuvers to check Hips

Picture from Mosbys Guide to Physical Examination 6th ed.

medical missions outreach- provider resource

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