The Clinical Officer training and experience leads to a broad skill set. They may see 30-50 patients a day, or more, and in these clinic sessions they may be presented with a wide range of conditions, seeing both adults and children. Generally, there are no scheduled appointment times; instead things operate more on a first-come-first-served basis. A typical rural health centre will serve a population of about 10,000 patients and cover a radius of approximately 30km, so the clinics may be very busy, especially in the rainy season. The Clinical Officers provide Primary Care services primarily, but as well as having to manage patients in the clinic based setting they may also be presented with emergencies that they need to stabilise before referring onwards. Dental problems, obstetric cases and trauma may also present to the Clinical Officers as a first point of care.
Excerpt taken from the Standard Treatment Guidelines, Zambian Ministry of Health
THE CASE
A Clinical Officer contacted us to discuss a 69-year old man who had presented with swollen legs (leg oedema). He told us that the patient was normally fit and well until the symptoms started a few days ago. He attached a photo with the referral to illustrate the nature and extent of the swelling. He described the swelling as ‘pitting’, meaning that an indentation remains for a time after the skin is pressed; this is important because the causes of non-pitting versus pitting oedema are different. Similarly, it was helpful that he told us that both legs were affected because the underlying causes we think about differ if only one leg is swollen. The patient’s observations were stable. He had been started on an antibiotic and a water tablet. On this occasion little further history was provided and the Clinical Officer did not frame a specific question. Clearly he had been considering various possible causes but there was something he was unsure about and he needed help moving forwards.The Virtual Doctor provided a very clear discussion of the most common causes of leg swelling. They started by suggesting that in a man of 69-years old, heart failure would be an important cause of this presenting symptom. The volunteer described how asking about chest pain and breathlessness was important when considering this as a diagnosis. They went on to suggest features the Clinical Officer should look for on examination of the cardio-respiratory system to help support this diagnosis, such as clinical signs of distended neck veins or ‘crackles’ when he listened to the lungs. They then gave some recommendations about management of heart failure should this prove to be the working diagnosis. This included continuing the water tablets but also adding further medication. Next the Virtual Doctor went on to offer alternative possibilities. Could the swelling be caused by liver failure? Excessive alcohol consumption would make this more likely and thus they suggested asking specifically about alcohol intake. They described the signs of chronic liver disease to look for on examination such as reddened palms, altered nail shape, ‘spider-shaped’ blood vessels across the chest wall and so on. Again clear advice was provided on managing the swelling in this context. Knowing that access to tests would be limited the volunteer tried to encourage the Clinical Officer to gather as much information as possible from clinical skills alone. However, they recommended doing a urine dipstix if possible to check for urinary protein loss as this can be another cause of leg swelling. They also mentioned that dietary deficiency of protein can be a contributing factor to oedema and suggested noting the patient’s nutritional status. The doctor highlighted that a review of a patient’s medication list is always important; side effects of drugs can often contribute to the presenting complaint. In this case they noted that the antibiotic could (rarely) cause oedema. On review of the details and the photo, the volunteer judged that there was no sign of skin infection (no redness and no signs of a fever). They recommended that the antibiotic should be stopped. Finally, they went on to highlight that another important cause of leg swelling can be ‘dependent oedema’; it is not caused by any underlying pathology but the swelling tends to get worse as the day goes on. They stressed that it was important to ensure that the patient had been thoroughly evaluated for other causes before reaching this conclusion. They described how this condition is best managed by elevating the legs when sitting down and pointed out that if water tablets are used this should only be for short term symptomatic relief. The Virtual Doctor had helped to create a differential diagnosis list and had given the Clinical Officer the tools to help him make judgement decisions in his ongoing management. This is just a very simple example of a problem we might be asked to consider. Sometimes the case can be even more complex. The patient may present with a multitude of symptoms and together with the Clinical Officer we need to sort through and priotise their problems and see if we can find a unifying diagnosis. For example the patient with chronic chest pain, weight loss, cough and headaches in the setting of abnormal liver function tests. Or the patient with joint pain, vomiting, fevers and dizziness. A clinical discussion applying the ‘science of probability and art of uncertainty’ can sometimes reveal the diagnosis. In this way we hope not only to support the Clinical Officers but also to improve patient care.