Page 37 - Jan-March 2025

HEALTH FEATURE

problem with getting the right diagnosis. There
are “20 causes of fever” out there but too often
they are diagnosed as “malaria and typhoid” and
the experts have to be called in.
So, what are the experts doing? What all physicians
should always be doing. Start with history, then
examination and then relevant lab tests. “Who
where when” is the bedrock of good epidemiology
and good medicine. A lot of medical mistakes
are the result of neglecting the history, not
bothering with a proper examination and instead
going straight to lab tests and hi-tech imaging.
So regardless of what the WHO and CDC find in
Congo it’s important to make sure that when you
or your children have a fever you get the right
diagnosis. A tripod is stable and can’t wobble.
The first leg of the tripod, the first pillar of good
medical care is a proper history. Who where when.
Who: who is the patient? Are they a new arrival,
a child, a tourist or a local office worker? Who
have they been in contact with? Sick children,
refugees, nursing an old lady with TB? Where: have
they been in the lake, have they been visiting the
slums, have they been in Sudan, have they been
nowhere except the office and home in the past
month? Have they been sleeping outside, what
might have bitten or stung them, where have they
been eating? Which restaurant, on the street? In we see everywhere: Covid, flu, RSV, mononucleosis,
the village? When? When was the first symptom, hepatitis. 20 is no exaggeration, but who where
how long did it last, what other symptoms, when when can narrow it down.
was the cough, the diarrhoea, the vomiting? Which
came first? Were they visiting somewhere inside The second leg is examination. Temperature
the incubation period of a disease: 3 to 6 weeks pulse, blood pressure, respiratory rate must be
for bilharzia, 8 days for malaria, 2 days for a flu or measured and recorded. A bare minimum is
Covid? I remember our “oops” moment when we general assessment, check anaemia, jaundice,
found a 40-degree fever and cough in someone lymph nodes, rash. Look in the throat, children
3 days after riding a camel in Dubai. Straight into the ears, listen to the chest, tap and palpate the
isolation. Sample for MERS sent off urgently. It is abdomen. Personally, I found a pulse ox is so
neglect of this first pillar, history, that causes so quick and easy there is no excuse for not doing
many embarrassing mistakes: I can remember a it. The oxygen concentration may well be normal
doctor telling his patients that they see malaria in almost everyone, but if it’s found to be low the
in people from Europe who have been in Uganda next day it’s rather important to know what it was
2 days. Absolutely impossible. Most of those 20 when they came in. Only when we already have
diseases that my old CDC friend told me they a clear idea of what it might be from the history
found in the villages of Acholi in 2010 are not and exam do we go to the third pillar. A typical
going to be found in an office worker in Nakasero. short cut is “What’s wrong? Fever and headache.
I don’t want to be pretentious and list the 20 Do a blood test for malaria and typhoid.” There is
but Leptospirosis, Borellia, Ricketsia, Brucellosis, no place for such negligence in modern medicine.
Coxiella, salmonella, shigella, TB, Bilharzia, 3 or 4 The third pillar is simple quick relevant lab tests.
named arboviruses, are all common enough to The most important tests are out in 10 minutes. A
be seen every week or 2 in travellers and people whole range of expensive tests to look good and
coming back from up country. If they are not listed make money is not good practice, especially if it
in monthly reports it’s probably not because they means they are not giving results until tomorrow.
are not seen, it’s because they are not diagnosed. Sure, take the samples and the tests can be done
Then add on the normal non-tropical fevers that later if necessary; but a blood count, malaria rapid,
urine dip test, rapid bilharzia test, all these take 10

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