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Achieved Outcomes

Overview

My main objectives on this elective were to immerse myself in both the medical and cultural environments in Rwanda, maximizing my learning and practical experience. As such, my outcomes were classified into Clinical Skills Development, where I sought to conduct comprehensive examinations on at least 50 patients, into Diagnostic Interpretations, where I wanted to accurately and verifiably diagnose at least 30 cases, as well as perform 10 diagnostically relevant procedures. Thirdly, I wanted to improve my Knowledge of Internal Medicine in the epidemiological context of rural Rwanda by writing up 5 chronic disease cases and 5 infectious disease cases, detailing their management, course, pathophysiology, treatment, and complications, as well as reading broadly and continuing to update my 1000+ strong internal medicine flashcard deck. Last, but certainly not least, I sought to develop my Language Skills and proficiency in Kinyarwanda by mastering key medical vocabulary and achieving fluency through targeted learning assessments of 400 basic words and phrases.

Below is a catalogue of my achievement and exceeding of these outcomes.

1. Clinical Skill Development

Objective: Enhance clinical skills through hands-on patient care.

Measure: Conduct and document comprehensive examinations on atleast 50 patients.

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Examinations

Recorded Examinations

Recorded Examinations

Disease 🏥

Number of Examinations

Malaria 🦟

Pneumonia 🫁

Hypertension ⛲️

Type 1 Diabetes Mellitus 💉

Gastritis 🤢

Peptic Ulcer Disease (PUD) 🌋

Osteoarthritis 🦴

Heart Failure ❤️‍🩹

Hepatitis 🦠

Acute Myeloid Leukemia ⚕️

Reiter's Syndrome 🤕

Liver Cirrhosis 🫀

Renal Stones 🪨

Deep Vein Thrombosis (DVT) 🦵

Appendicitis 🩺

Cholecystitis 🍽️

Acute Pancreatitis 🍾

Congestive Hepatic Failure ❤️‍🩹

Ascites 🌊

Thyroid Nodules 🦋

Breast Mass 🎗️

Cardiomyopathy 🫀

Pericarditis ❤️‍🩹

Bronchitis 🤧

Asthma 😤

Tuberculosis 🦠

Prostate Cancer 🎗️

Urinary Tract Infection (UTI) 🚽

Atrial Fibrillation ❤️‍🩹

Atrial Septal Defect (ASD) 💓

Ventricular Septal Defect (VSD) 💓

Combined ASD and VSD 💓

Hemorrhagic Stroke 🧠

Anemia 🤍

Sepsis 🦠

Type 2 Diabetes Mellitus 🎂

Total

117

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2. Diagnostic Proficiency

Objective: Improve diagnostic interpretation and procedural skills.

Measure: Accurately interpret diagnostics for 30 cases and perform 10 procedures, confirmed by treating doctors at Kibogora hospital.

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Diagnoses

Diagnoses Made

Diagnoses Made

Diagnosis 🏥

Clinical Signs/Presentation

Investigation Used

Specific Result Used

Malaria 🦟

High fever, chills, sweating, headache, myalgia

Clinical Evaluation + Basic Blood Work (FBC)

Positive Rapid Diagnostic Test (RDT) for Plasmodium species

Pneumonia 🫁

Cough, fever, difficulty breathing, chest pain

Clinical Evaluation + Chest X-Ray

Infiltrates visible on Chest X-Ray

Hypertension 💓

Persistent headaches, dizziness, elevated blood pressure

Clinical Evaluation + Basic Blood Work (FBC)

Elevated Blood Pressure readings (e.g., 160/100 mmHg)

Diabetes Mellitus 🩸

Increased thirst, frequent urination, unexplained weight loss

Clinical Evaluation + Basic Blood Work (FBC)

Elevated HbA1c levels (>6.5%)

Gastritis 🤢

Abdominal pain, nausea, vomiting, bloating

Clinical Evaluation + FBC + referral for H. Pylori test

Anaemia on FBC + positive for H. Pylori

Bacterial cellulitis of the foot 🦠

Fever, localized pain, redness, swelling

Clinical Evaluation + Basic Blood Work (FBC)

Elevated White Blood Cell (WBC) count (>10,000/mm³)

Osteoarthritis 🦴

Joint pain, stiffness, decreased range of motion

Clinical Evaluation + X-ray

Joint space narrowing and osteophytes on axial X-ray (knee joint measurements: joint space < 2mm)

Heart Failure ❤️‍🩹

Shortness of breath, edema, fatigue

Clinical Evaluation + Chest X-Ray + echocardiogram

Enlarged cardiac silhouette on Chest X-Ray; clinical oedema in legs, crackles on auscultation and Reduced ejection fraction (EF < 40%) on Echocardiogram

Hepatitis 🦠

Jaundice, fatigue, abdominal pain, dark urine

Clinical Evaluation + Basic Blood Work (FBC)

Elevated Liver Function Tests (LFTs: AST, ALT)

Acute Myeloid Leukemia ⚕️

Fatigue, frequent infections, easy bruising

Clinical Evaluation + Basic Blood Work (FBC)

Elevated and abnormal blast cells in Full Blood Count (FBC) smear

Reiter's Syndrome 🤕

Joint pain, conjunctivitis, urethritis

Clinical Evaluation + Basic Blood Work (FBC)

Elevated ESR and CRP levels + clinical picture

Liver Cirrhosis 🧑‍🦲

Fatigue, jaundice, ascites, spider angiomas

Clinical Evaluation + Ultrasound

Nodular, small liver surface and with signs of liver disease

Deep Vein Thrombosis (DVT) 🦵

Leg swelling, pain, redness

Clinical Evaluation + Ultrasound

Presence of thrombus in deep veins on Ultrasound (lack of compressibility on Doppler ultrasound)

Appendicitis 🩺

Right lower quadrant pain, fever, nausea

Clinical Evaluation + Ultrasound

Abdominal guarding + McBurney’s point tenderness + target sign on ultrasound

Pancreatitis 🩺

Upper abdominal pain radiating to the back, nausea, vomiting

Clinical Evaluation + serum lipase

Elevated serum lipase x3

Congestive Hepatic Failure ❤️‍🩹

Jaundice, hepatomegaly, edema

Clinical Evaluation + Ultrasound

Hepatic vein congestion and hepatomegaly on Ultrasound

Ascites 🌊

Abdominal distension, weight gain, discomfort

Clinical Evaluation + Ultrasound

Free fluid in the abdominal cavity on Ultrasound (4 cases)

Thyroid Nodules 🦋

Neck swelling, difficulty swallowing, thyroid dysfunction

Clinical Evaluation + Ultrasound

Thyroid nodules visualized with varying echogenicity (e.g., hypoechoic with irregular margins)

Breast Mass 🎗️

Palpable lump, breast pain, nipple discharge

Clinical Evaluation + Ultrasound

Hypoechoic mass with irregular margins on Ultrasound

Cardiomyopathy 🫀

Fatigue, shortness of breath, palpitations

Clinical Evaluation + Ultrasound

Enlarged heart chambers and impaired systolic function on Ultrasound (e.g., left ventricular end-diastolic diameter > 55mm)

Pericardial Effusion ❤️‍🩹

Chest pain, dyspnea, muffled heart sounds

Clinical Evaluation + Ultrasound

Fluid accumulation around the heart on Ultrasound (e.g., echo-free space > 20mm)

Bronchitis 🤧

Persistent cough, mucus production, wheezing

Clinical Evaluation + Chest X-Ray

Increased bronchial markings and possible peribronchial cuffing on Chest X-Ray + clinical picture

Asthma 😤

Wheezing, shortness of breath, chest tightness

Clinical Evaluation + Chest X-Ray

Hyperlucent areas and possible flattening of the diaphragm on Chest X-Ray

Tuberculosis 🦠

Chronic cough, night sweats, weight loss, hemoptysis

Clinical Evaluation + Chest X-Ray

Upper lobe infiltrates and possible cavitation on Chest X-Ray + positive TB GeneXpert

Prostate Cancer 🎗️

Difficulty urinating, hematuria, lower back pain

Clinical Evaluation

Noduler prostate on DRE, with urinary retention and frequency + tingling in toes and lumbar back pain

Urinary Tract Infection (UTI) 🚽

Dysuria, frequency, urgency, suprapubic pain

Clinical Evaluation + Basic Blood Work (FBC) + Urine Dipstix

Positive leukocytes and nitrites on urine dip stix.

Atrial Fibrillation ❤️‍🩹

Irregular heartbeat, palpitations, fatigue

Clinical Evaluation + ECG

Irregularly irregular heartbeat on ECG

Atrial Septal Defect (ASD) 💓

Shortness of breath, fatigue, palpitations

Clinical Evaluation + Ultrasound

Atrial septal defect visualized on echocardiogram

Ventricular Septal Defect (VSD) 💓

Heart murmur, failure to thrive (in children), shortness of breath

Clinical Evaluation + Ultrasound

Ventricular septal defect visualized on echocardiogram

Combined ASD and VSD 💓

Mixed symptoms of ASD and VSD, including both atrial and ventricular signs

Clinical Evaluation + Ultrasound

Presence of both atrial and ventricular septal defects on echocardiogram

Anemia 🩸

Fatigue, pallor, shortness of breath

Clinical Evaluation + Basic Blood Work (FBC)

Low hemoglobin and hematocrit levels on FBC (10 cases)

Sepsis ⚕️

High fever, confusion, rapid breathing, hypotension

Clinical Evaluation + Basic Blood Work (FBC)

Elevated lactate and WBC count on FBC

Total Diagnoses 📝

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Procedures Performed

(Note: this outcome was written before we had to switch our elective from the Kigali Military Hospital (Tertiary) to Kibogora Hospital (District), and was therefore written in anticipation of having access to the resources and patient volume of a tertiary hospital (lumbar puncture, chest drain, pleural taps etc.). The only diagnostic procedures performed at Kibogora (in addition to the point of care ultrasound device that I brought with) where blood draws, and as such, I’ve listed them here.

Diagnostic Procedures Performed

Diagnostic Procedures Performed

Procedure

Number Performed

Blood draws 🩸

Abdominal Ultrasound 🐬

Echocardiogram 🫀

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3. Knowledge of Internal Medicine

Objective: Broaden understanding of chronic and infectious diseases.

Measure: Write up 5 chronic disease cases and 5 infectious disease cases, detailing their management, course, pathophysiology, treatment, and complications.

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Process

These write-ups were made with the assistance of the AI note-taking tool (

HALO⁠

) that took all my notes and formatted them for me while I saw each patient.

Chronic Disease Cases

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Case 1: Hypertension

Patient Information:

Name: Jean-Pierre Uwimana

Age: 58

Sex: Male

Occupation: Farmer

Location: Rural village near Gisenyi, Rwanda

Presenting Complaint: Jean-Pierre presented with persistent headaches and occasional dizziness over the past two months.

History: Jean-Pierre reported a gradual onset of intermittent headaches, primarily in the mornings. He also experienced episodes of dizziness, especially when standing up quickly. No history of chest pain, palpitations, or visual disturbances was noted. He has a family history of hypertension; his father suffered from high blood pressure.

Clinical Findings:

Vital Signs: BP 160/100 mmHg, HR 88 bpm, RR 18/min, Temp 37°C

General Examination: Alert, oriented, no acute distress

Cardiovascular: Regular rhythm, no murmurs

Respiratory: Clear lung fields

Abdominal: Soft, non-tender, no hepatosplenomegaly

Neurological: No focal deficits

Investigations:

Basic Blood Work:

Complete Blood Count (CBC): Normal

Electrolytes: Within normal limits

Blood Glucose: Fasting blood sugar elevated at 130 mg/dL (mg/dL was used in Rwanda’s labs, as opposed mmol/L in SA)

Ultrasound: Renal ultrasound showed no abnormalities

Chest X-Ray: Normal

Diagnosis: Essential Hypertension

Pathophysiology: Hypertension is a chronic condition characterized by persistently elevated arterial blood pressure. It results from a complex interplay of genetic, environmental, and lifestyle factors leading to increased peripheral vascular resistance and/or increased cardiac output.

Management:

Lifestyle Modifications:

Dietary salt restriction

Regular physical activity

Weight loss

Stress management techniques

Pharmacotherapy: Initiated on an ACE inhibitor (e.g., Enalapril) to manage blood pressure

Follow-Up: Scheduled for regular BP monitoring and follow-up visits every month

Course: Over the next three months, Jean-Pierre adhered to the prescribed lifestyle changes and medication regimen. His blood pressure gradually decreased to 140/90 mmHg. He reported fewer headaches and improved overall well-being.

Complications: If left uncontrolled, hypertension can lead to complications such as stroke, myocardial infarction, kidney failure, and retinopathy. Early detection and management are crucial to prevent these adverse outcomes.

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Case 2: Type 2 Diabetes Mellitus

Patient Information:

Name: Amina Ndayisaba

Age: 52

Sex: Female

Occupation: Teacher

Location: Rural district near Kigali, Rwanda

Presenting Complaint: Amina presented with increased thirst, frequent urination, and unexplained weight loss over the past three months.

History: Amina reported a progressive increase in thirst and the need to urinate more frequently, especially at night. She also noticed a 10 kg weight loss without changes in diet or physical activity. No history of blurred vision, neuropathy, or recurrent infections was noted. Her mother has a history of diabetes.

Clinical Findings:

Vital Signs: BP 130/85 mmHg, HR 78 bpm, RR 16/min, Temp 36.8°C

General Examination: Thin build, no acute distress

Cardiovascular: Regular rhythm, no murmurs

Respiratory: Clear lung fields

Abdominal: Soft, non-tender, no hepatosplenomegaly

Neurological: No focal deficits

Investigations:

Basic Blood Work:

Fasting Blood Glucose: 160 mg/dL

HbA1c: Not available due to resource limitations

Chest X-Ray: Normal

Ultrasound: Abdomen ultrasound revealed fatty liver changes

Diagnosis: Type 2 Diabetes Mellitus

Pathophysiology: Type 2 Diabetes Mellitus is characterized by insulin resistance and relative insulin deficiency, leading to hyperglycemia. Chronic hyperglycemia results from impaired insulin signaling and glucose uptake by tissues.

Management:

Lifestyle Modifications:

Dietary counseling focusing on carbohydrate control

Regular physical activity

Weight management

Pharmacotherapy: Initiated on Metformin to improve insulin sensitivity

Monitoring: Regular blood glucose monitoring and periodic follow-up for HbA1c assessment when available

Course: Amina was educated on the importance of diet and exercise. Over six months, her blood glucose levels improved, and she stabilized her weight. She experienced a reduction in thirst and urination frequency.

Complications: Uncontrolled diabetes can lead to microvascular complications (retinopathy, nephropathy, neuropathy) and macrovascular complications (cardiovascular disease). Early intervention is essential to mitigate these risks.

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Case 3: Osteoarthritis

Patient Information:

Name: Claude Mugenzi

Age: 65

Sex: Male

Occupation: Retired

Location: Rural area near Butare, Rwanda

Presenting Complaint: Claude presented with chronic knee pain and stiffness, especially in the mornings, persisting for the past year.

History: Claude reported gradual onset of knee pain, which worsens with activity and improves with rest. He experiences morning stiffness lasting about 30 minutes. No history of trauma or systemic symptoms such as fever or weight loss. He has a history of repetitive knee use during farming activities.

Clinical Findings:

Vital Signs: BP 125/80 mmHg, HR 72 bpm, RR 16/min, Temp 36.7°C

Musculoskeletal Examination:

Knees: Bilateral swelling, decreased range of motion, crepitus on movement, no redness or warmth

Other Systems: Unremarkable

Investigations:

Basic Blood Work:

CBC: Normal

Inflammatory Markers (ESR, CRP): Within normal limits

Ultrasound: Joint space narrowing, osteophyte formation, and synovial thickening in both knees

Chest X-Ray: Normal

Diagnosis: Osteoarthritis of the Knees

Pathophysiology: Osteoarthritis is a degenerative joint disease characterized by the breakdown of cartilage, subchondral bone changes, and synovial inflammation. It leads to joint pain, stiffness, and reduced function.

Management:

Lifestyle Modifications:

Weight reduction to decrease joint load

Low-impact exercises (e.g., walking, swimming)

Pharmacotherapy:

NSAIDs for pain management

Topical analgesics as needed

Physical Therapy: Strengthening exercises to support joint stability

Follow-Up: Regular monitoring of symptoms and joint function

Course: Claude was advised on weight management and engaged in regular low-impact exercises. His pain decreased, and his mobility improved over six months. He reported better quality of life and increased ability to perform daily activities.

Complications: Osteoarthritis can lead to significant disability, decreased mobility, and reduced quality of life. Chronic pain may result in psychological issues such as depression and anxiety. Early intervention can slow disease progression and manage symptoms effectively.

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Case 4: Heart Failure

Patient Information:

Name: Marie Uwimana

Age: 70

Sex: Female

Occupation: Homemaker

Location: Rural vicinity of Rwamagana, Rwanda

Presenting Complaint: Marie presented with progressive shortness of breath, especially during exertion, and swelling in her lower limbs over the past six months.

History: Marie reported increasing difficulty in breathing during daily activities and noticeable swelling in her ankles and feet. She experiences fatigue and reduced exercise tolerance. No history of chest pain or palpitations. She has a history of hypertension and was previously diagnosed with a myocardial infarction two years ago.

Clinical Findings:

Vital Signs: BP 150/95 mmHg, HR 90 bpm, RR 20/min, Temp 36.9°C

General Examination: Overweight, pitting edema in both lower limbs

Cardiovascular:

Elevated jugular venous pressure

S3 heart sound audible

No murmurs detected

Respiratory: Bilateral basal crackles on auscultation

Abdominal: Mild hepatomegaly, no ascites

Other Systems: Unremarkable

Investigations:

Basic Blood Work:

CBC: Mild anemia

Electrolytes: Normal

Chest X-Ray: Cardiomegaly with pulmonary congestion

Ultrasound: Echocardiography revealed reduced ejection fraction (calculated with Butterfly, so questionable accuracy)

Diagnosis: Chronic Heart Failure (Systolic Dysfunction)

Pathophysiology: Heart failure occurs when the heart is unable to pump sufficient blood to meet the body’s metabolic demands. In systolic dysfunction, there is impaired ventricular contraction leading to reduced ejection fraction and increased ventricular filling pressures.

Management:

Pharmacotherapy:

ACE inhibitors to reduce afterload

Beta-blockers to decrease heart rate and improve cardiac output

Diuretics (e.g., Furosemide) to manage fluid overload

Lifestyle Modifications:

Sodium restriction

Fluid management

Weight monitoring

Monitoring: Regular follow-up for symptom assessment and medication adjustment

Course: Marie was initiated on a combination of ACE inhibitors, beta-blockers, and diuretics. She was educated on dietary modifications and adherence to medication. Over six months, her symptoms improved significantly with reduced edema and better exercise tolerance.

Complications: Untreated heart failure can lead to worsening renal function, liver congestion, arrhythmias, and increased mortality. Timely management is essential to improve prognosis and quality of life.

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Case 5: Liver Cirrhosis

Patient Information:

Name: Josephine Mukamana

Age: 60

Sex: Female

Occupation: Artisan

Location: Rural area near Musanze, Rwanda

Presenting Complaint: Josephine presented with fatigue, abdominal discomfort, and jaundice over the past four months.

History: Josephine reported persistent fatigue, a dull ache in the upper right abdomen, and yellowing of the skin and eyes. She also experienced episodes of itching and noticed dark urine. No history of significant alcohol consumption, but she has a history of chronic hepatitis B infection diagnosed five years ago.

Clinical Findings:

Vital Signs: BP 130/85 mmHg, HR 85 bpm, RR 18/min, Temp 37°C

General Examination: Jaundice, pallor, and mild hepatosplenomegaly

Abdominal Examination:

Hepatomegaly

Splenomegaly

Ascites present

Other Systems: No focal neurological deficits

Investigations:

Basic Blood Work:

CBC: Mild anemia, thrombocytopenia

Liver Function Tests (LFTs): Elevated AST, ALT, bilirubin levels

Ultrasound: Nodular liver surface, signs of portal hypertension (e.g., enlarged spleen, varices)

Chest X-Ray: Normal

Diagnosis: Liver Cirrhosis

Pathophysiology: Liver cirrhosis is the end stage of chronic liver disease characterized by fibrosis, regenerative nodules, and architectural distortion of the liver. It results in impaired liver function and portal hypertension, leading to systemic complications.

Management:

Pharmacotherapy:

Antiviral therapy for hepatitis B to reduce viral load

Diuretics (e.g., Spironolactone, Furosemide) for ascites management

Beta-blockers to prevent variceal bleeding

Lifestyle Modifications:

Alcohol abstinence

Nutritional support

Monitoring: Regular follow-up for liver function, screening for hepatocellular carcinoma

Complications Management: Therapeutic paracentesis for refractory ascites, prophylaxis for spontaneous bacterial peritonitis

Course: Josephine was started on antiviral therapy and diuretics. She was advised on dietary sodium restriction and monitored regularly. Over six months, her ascites decreased, and her liver function stabilized. She was educated on recognizing signs of complications and the importance of adherence to treatment.

Complications: Cirrhosis can lead to variceal hemorrhage, hepatic encephalopathy, renal dysfunction, and hepatocellular carcinoma. Early detection and comprehensive management are crucial to improving outcomes.

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Infectious Disease Cases

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Case 1: Malaria

Patient Information:

Name: Emmanuel Kamara

Age: 35

Sex: Male

Occupation: Farmer

Location: Rural village near Rulindo, Rwanda

Presenting Complaint: Emmanuel presented with high fever, chills, and sweats for the past three days.

History: Emmanuel reported sudden onset of high-grade fever with chills and sweating. He also experienced headache, myalgia, and malaise. No history of vomiting, diarrhea, or respiratory symptoms. He lives in a malaria-endemic area and works outdoors during dusk and dawn.

Clinical Findings:

Vital Signs: BP 120/80 mmHg, HR 100 bpm, RR 18/min, Temp 39°C

General Examination: Febrile, dehydrated

Respiratory: Clear lung fields

Cardiovascular: Tachycardia, no murmurs

Abdominal: Soft, non-tender

Other Systems: No focal deficits

Investigations:

Basic Blood Work:

Full Blood Count (FBC): Hemoglobin 12 g/dL, WBC 9,000/mm³, platelets 150,000/mm³

Rapid Diagnostic Test (RDT): Positive for Plasmodium falciparum

Chest X-Ray: Normal

Ultrasound: Not indicated

Diagnosis: Uncomplicated Plasmodium falciparum Malaria

Pathophysiology: Malaria is caused by Plasmodium parasites transmitted through Anopheles mosquito bites. P. falciparum is the most severe form, capable of causing cerebral malaria and multi-organ failure. The parasite multiplies within red blood cells, leading to hemolysis and anemia.

Management:

Antimalarial Therapy:

Artemisinin-based combination therapy (ACT), e.g., Artemether-Lumefantrine

Supportive Care:

Oral rehydration solution (ORS) for dehydration

Antipyretics (e.g., Paracetamol) for fever

Monitoring: Regular follow-up to ensure resolution of symptoms and prevent complications

Course: Emmanuel was treated with ACT and supportive measures. His fever subsided within three days, and he regained his strength by the end of the treatment course. No complications were observed.

Complications: Severe malaria can lead to cerebral involvement, acute respiratory distress syndrome (ARDS), renal failure, and death. Prompt diagnosis and appropriate treatment are essential to prevent these outcomes.

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Case 2: Pneumonia

Patient Information:

Name: Grace Uwimana (this turns out to be a very common surname in Rwanda)

Age: 28

Sex: Female

Occupation: Nurse

Location: Rural health center near Gitarama, Rwanda

Presenting Complaint: Grace presented with cough, fever, and difficulty breathing for the past week.

History: Grace reported a persistent cough productive of yellowish sputum, high fever, and increasing shortness of breath. She also experienced chest pain that worsens with breathing and occasional wheezing. No history of smoking or chronic respiratory disease.

Clinical Findings:

Vital Signs: BP 130/85 mmHg, HR 110 bpm, RR 22/min, Temp 38.5°C

General Examination: Alert but in respiratory distress

Respiratory:

Increased work of breathing

Bilateral crackles on auscultation

Dullness to percussion in the right lower lobe

Cardiovascular: Tachycardia, no murmurs

Abdominal: Soft, non-tender

Investigations:

Basic Blood Work:

FBC: Elevated WBC count at 15,000/mm³ with neutrophilia

Chest X-Ray: Consolidation in the right lower lobe

Ultrasound: Not indicated

Diagnosis: Community-Acquired Pneumonia (Right Lower Lobe)

Pathophysiology: Pneumonia is an infection of the lung parenchyma, commonly caused by bacteria such as Streptococcus pneumoniae. It leads to inflammation, alveolar filling with exudate, impaired gas exchange, and respiratory distress.

Management:

Antibiotic Therapy:

Empirical antibiotics, e.g., Amoxicillin or a combination of Beta-lactam and Macrolide

Supportive Care:

Oxygen therapy if hypoxemic

Hydration and rest

Antipyretics for fever

Monitoring: Regular assessment of respiratory status and response to treatment

Course: Grace was started on empirical antibiotics and received supportive care. Her symptoms improved over seven days, with resolution of fever and cough. A follow-up chest X-ray showed clearing of the consolidation.

Complications: Pneumonia can lead to sepsis, lung abscesses, pleural effusion, and acute respiratory distress syndrome (ARDS). Early diagnosis and appropriate antibiotic therapy are crucial to prevent these complications.

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Case 3: Tuberculosis

Patient Information:

Name: Pascal Mugisha

Age: 45

Sex: Male

Occupation: Miner

Location: Rural region near Nyagatare, Rwanda

Presenting Complaint: Pascal presented with a persistent cough, night sweats, and weight loss over the past two months.

History: Pascal reported a chronic cough lasting more than three weeks, with hemoptysis on occasion. He also experienced night sweats, significant weight loss (approximately 8 kg), and fatigue. He has a history of exposure to TB through a family member diagnosed with the disease.

Clinical Findings:

Vital Signs: BP 125/80 mmHg, HR 95 bpm, RR 20/min, Temp 37.8°C

General Examination: Cachectic appearance, pallor

Respiratory:

Decreased breath sounds in the upper lobes

Presence of crackles and occasional wheezes

Cardiovascular: Tachycardia, no murmurs

Abdominal: Soft, non-tender

Investigations:

Basic Blood Work:

FBC: Mild anemia

Chest X-Ray: Upper lobe infiltrates with cavitation

Sputum Analysis: Acid-Fast Bacilli (AFB) positive on Rapid Diagnostic Test

Diagnosis: Pulmonary Tuberculosis

Pathophysiology: Tuberculosis is caused by Mycobacterium tuberculosis, primarily affecting the lungs. It spreads through airborne droplets. The bacteria establish infection in the alveoli, leading to granuloma formation, caseous necrosis, and cavitation, which facilitates transmission.

Management:

Antitubercular Therapy:

Initiate a four-drug regimen (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol) for two months, followed by Isoniazid and Rifampicin for four months

Supportive Care:

Nutritional support

Monitoring for drug side effects

Infection Control: Isolation until non-infectious

Follow-Up: Regular monitoring of treatment adherence and response

Course: Pascal was started on the antitubercular regimen and provided with nutritional support. His symptoms gradually improved over the course of treatment, with weight stabilization and reduction in cough frequency. Sputum samples became negative for AFB after two months of therapy.

Complications: Untreated TB can lead to extensive lung damage, dissemination to other organs (extrapulmonary TB), and increased mortality. Drug-resistant TB poses significant treatment challenges. Adherence to therapy is essential to prevent resistance and ensure cure.

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Case 4: Sepsis

Patient Information:

Name: Louise Nshimiyimana

Age: 50

Sex: Female

Occupation: Market vendor

Location: Rural community near Kibuye

Presenting Complaint: Louise presented with high fever, confusion, and rapid breathing for the past two days.

History: Louise reported sudden onset of high fever, chills, and confusion. She also experienced rapid breathing and a feeling of extreme fatigue. No history of recent travel or known infections. She has a history of chronic osteoarthritis managed with NSAIDs.

Clinical Findings:

Vital Signs: BP 90/60 mmHg, HR 120 bpm, RR 30/min, Temp 39.5°C

General Examination: Altered mental status, tachypneic, signs of dehydration

Respiratory: Rapid breathing, clear lung fields

Cardiovascular: Tachycardia, weak pulse, no murmurs

Abdominal: Soft, non-tender

Other Systems: No obvious source of infection identified

Investigations:

Basic Blood Work:

FBC: Elevated WBC count at 18,000/mm³ with neutrophilia

Blood Cultures: Pending (resource limitations)

Chest X-Ray: No consolidation or infiltrates

Ultrasound: Abdominal ultrasound to rule out intra-abdominal sources revealed no abnormalities

Diagnosis: Sepsis of Unknown Origin

Pathophysiology: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It leads to systemic inflammation, widespread vasodilation, increased vascular permeability, and potential multi-organ failure.

Management:

Immediate Interventions:

Antibiotic Therapy: Empirical broad-spectrum antibiotics (e.g., Ceftriaxone and Metronidazole)

Fluid Resuscitation: Intravenous fluids (e.g., Normal Saline) to address hypotension and dehydration

Supportive Care: Oxygen supplementation if needed

Monitoring:

Vital signs frequently

Assessment for signs of organ dysfunction

Source Control: Identify and manage the source of infection when possible

Course: Louise was promptly started on antibiotics and received aggressive fluid resuscitation. Her blood pressure stabilized, and mental status improved over the next 48 hours. No specific source of infection was identified, but continued monitoring ensured timely intervention if complications arose.

Complications: Sepsis can progress to septic shock, acute respiratory distress syndrome (ARDS), acute kidney injury, and disseminated intravascular coagulation (DIC). Early recognition and management are critical to improve survival rates.

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Case 5: Hepatitis B

Patient Information:

Name: Daniel Rwabizambuga

Age: 40

Sex: Male

Occupation: Taxi driver

Location: Rural outskirts of Kibogora

Presenting Complaint: Daniel presented with fatigue, jaundice, and right upper quadrant abdominal pain for the past month.

History: Daniel reported gradual onset of fatigue, yellowing of the skin and eyes, and intermittent pain in the right upper quadrant of the abdomen. He denied alcohol use, recent travel, or exposure to known hepatitis cases. He had a previous diagnosis of chronic hepatitis B infection three years ago but was lost to follow-up.

Clinical Findings:

Vital Signs: BP 135/85 mmHg, HR 85 bpm, RR 18/min, Temp 37.2°C

General Examination: Jaundice, mild hepatomegaly

Abdominal Examination:

Hepatomegaly palpable 4 cm below the right costal margin

No ascites

Other Systems: Unremarkable

Investigations:

Basic Blood Work:

CBC: Mild leukopenia

Liver Function Tests (LFTs): Elevated AST, ALT, bilirubin

HBsAg: Positive

Ultrasound: Liver ultrasound showed nodular surface, signs of chronic liver disease, and no focal lesions

Chest X-Ray: Normal

Diagnosis: Chronic Hepatitis B with Exacerbation

Pathophysiology: Hepatitis B virus (HBV) infection can lead to chronic liver disease, including cirrhosis and hepatocellular carcinoma. Chronic infection results from the inability to clear the virus, leading to ongoing liver inflammation, fibrosis, and eventual liver dysfunction.

Management:

Antiviral Therapy:

Initiate antiviral agents such as Tenofovir or Entecavir to suppress viral replication

Supportive Care:

Nutritional support

Monitoring liver function and viral load

Preventive Measures:

Vaccination of close contacts

Education on transmission prevention

Follow-Up: Regular monitoring of liver function tests and ultrasound to assess disease progression

Course: Daniel was started on antiviral therapy and received counseling on liver health and medication adherence. Over three months, his liver function tests showed improvement, and his symptoms of fatigue and jaundice subsided. He was re-engaged with the healthcare system for ongoing management.

Complications: Chronic hepatitis B can progress to cirrhosis, liver failure, and hepatocellular carcinoma. Regular monitoring and antiviral therapy are essential to manage the disease and prevent severe complications.

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4. Language Skills Improvement

Objective: Enhance Kinyarwanda language proficiency.

Measure: Complete medical vocabulary tests in Kinyarwanda before and after the elective.

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Process

I used OpenAI’s o1 model to create a flashcard deck of foundational Kinyarwandan words separated into the following headings:

Greetings and Basic Phrases 🫱🏼‍🫲🏽

Personal Information 💁🏻‍♀️

Common Expressions 🙌🏼

Medical Phrases 👨🏼‍⚕️

Directions and Locations 🗺

Time Expressions ⏱

Travel and Shopping 🛍

Food and Drink 🍔

Miscellaneous Phrases for Building Sentences 📚

Pronouns 👨‍👩‍👧‍👦

Common Verbs 🏃🏻‍♀️

Useful Adjectives 🙊

Useful Adverbs 👉🏼

Numbers (1-10) 💯

Days of the Week 📆

I then imported these into Remnote (my preferred flashcard software) and optimised the spaced repetition algorithm to ensure that I’d mastered every card within one month (Nov 2024)

The full document of all of the words can be found

here⁠

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A screenshot of one of the chapters of my Kinyarwanda flashcard deck

A screenshot of one of the chapters of my Kinyarwanda flashcard deck

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⁠
Results

My control score: taken on 28 Oct 2024: 3.5% (most of which was guess work based on similar sounding Xhosa words)

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My final score for this vocabulary test: taken on 28 Nov 2024: 100% (safe to safe this approach works well)

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Achieved Outcomes

Overview

1. Clinical Skill Development

⁠⁠ Examinations

2. Diagnostic Proficiency

⁠ Diagnoses

⁠ Procedures Performed

3. Knowledge of Internal Medicine

⁠⁠ Process

Chronic Disease Cases

⁠⁠ Case 1: Hypertension

⁠⁠ Case 2: Type 2 Diabetes Mellitus

⁠⁠ Case 3: Osteoarthritis

⁠⁠ Case 4: Heart Failure

⁠⁠ Case 5: Liver Cirrhosis

Infectious Disease Cases

⁠⁠ Case 1: Malaria

⁠⁠ Case 2: Pneumonia

⁠⁠ Case 3: Tuberculosis

⁠⁠ Case 4: Sepsis

⁠⁠ Case 5: Hepatitis B

4. Language Skills Improvement

⁠ Process

⁠ Results

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⁠
Examinations

⁠
Diagnoses

⁠
Procedures Performed

⁠
⁠
Process

⁠
⁠
Case 1: Hypertension

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Case 2: Type 2 Diabetes Mellitus

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Case 3: Osteoarthritis

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Case 4: Heart Failure

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Case 5: Liver Cirrhosis

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⁠
Case 1: Malaria

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Case 2: Pneumonia

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Case 3: Tuberculosis

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Case 4: Sepsis

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Case 5: Hepatitis B

⁠
Process

⁠
Results