Week 3

1/23/11

Posted by Olga Lemberg, MD (a third year Pediatrics resident from Kaiser Permanente Oakland serving a global health elective at The Belen Clinic in Cuzco, Peru). 

Unlike many of the prior residents’ inpatient experiences, our ventures into global community health have been comparatively somewhat less intense (for which we are often thankful).  Admittedly, a lot of clinic medicine in the States involves reassurance that one’s child is normal and Peru is no exception. While we have had our fair share of interesting medical cases (e.g. severe balanitis, ezcema herpeticum, labial fusion, congenital torticollis, constitutional growth delay), below are a few unique chief complaints we hear on a daily basis that often simply require some good old TLC to troubleshoot.

Chief complaint #1:  Nocturnal bruxism + sweet tooth

A word about this interesting combination of “symptoms”.  Despite the frequency with which we hear this chief complaint, Amy & I are still confounded.  According to local culture, this is a slam-dunk diagnosis for pinworm infection (i.e. Enterobius Vermicularis) in children.  First, bruxism is said to affect 20-24% of normal healthy children, peaking between the ages of 7-10 yrs old.  Second, last time I checked, kids love sweets. My training has taught me to recognize pruritis ani (i.e. itchy butt), nausea/vomiting or even vulvovaginitis as symptoms of pinworm infection. When (and why?) did grinding your teeth at night and wanting to only eat sweets become pathognomonic for a nematode infection?

Chief complaint #2:

Parent: My child (9 yo male) doesn’t eat, doctor. He just doesn’t want to eat.
Olga: I’m sorry to hear that. When did you notice this change?
Parent: He has been like this his entire life. Doctor, why is it he only likes to eat sweets?
Olga:  Well, we can see from the growth chart that his weight is on the 50th%-ile, as is his height. It appears as if he is growing great.
Parent: But isn’t there an appetite stimulant you can prescribe him?
Olga: No, I’m sorry, but he doesn’t need one.
Parent: Really? But can’t you just prescribe us something to stimulate his appetite? 

For whatever reason, one of the primary companies that makes multivitamins for kids in Peru produces a concoction that contains cyproheptadine (periactin).  The inside pamphlet contains instructions stating it is an appropriate therapy to stimulate an otherwise completely healthy child’s appetite, even toddlers. We have found that parents come to the doctor expecting a prescription for this, despite our efforts at reassurance with the help of a perfectly normal growth chart.  Amy & I have not won this battle.   

Chief complaint #3: “You know, doctor, I’ve noticed my child has smelly feet and sweats a lot. Is that normal?”

Cusqueñian children habitually don several layers of clothing.  The weather in the Andes rapidly changes and accordingly concerned parents will dress their children in multiple layers. The problem is that they never take any of the layers off, even when the sun is blaring (remember, we are at 11,000 ft of elevation).  Parents need prodding to disrobe their kids even when requested for the purposes of a proper physical exam.

As much as I might like to poke fun at some of the local neuroses, it is incredibly touching to witness how much Cusqueñian parents love their children and will do anything to help make their lives better than theirs were, no matter the cost.  Even when parents deposit their children on somebody else’s doorstep, estranged family members will swoop them up and care for them as if they were their own.  One of my patients, a 6-year-old jovial boy, is now being taken care of by his paternal grandmother after his father died from a cirrhotic liver (alcohol-induced) and his mother abandoned him.  His grandma, worried about all aspects of his health, has brought him in to see me 3 times already.  My heart sank when I found out that she spent more than $100 soles (around US$35: an obscenely large sum relative to what is reasonably attainable for them) to get a CBC and Strep probe that I had mentioned in passing might be helpful but was not necessary.  Discussing his normal results in my office, she recounts her “desperation” at the idea that he may have had some unfavorable lab results.