CRANAplus Member and Fellow, Lyn Byers, shares this story outlining the management of a common presentation to remote clinics. Families bring children for a check-up or to address an acute problem. The skill of the RAN is in gathering a comprehensive history, assessing the child, and considering factors that may be contributing to the problems the child is experiencing.
An adult brought a small child to the remote clinic saying she wanted his sores treated. He is four and a half years old. The adult with him says she is his carer and that he is her nephew.
Having established identities, the RAN looks at the child’s history. There is no notable history about the mother’s pregnancy or his birth or postnatal period. There have been multiple presentations for respiratory and ear infections and skin sores. He was anaemic at six months of age and was treated with intramuscular iron injections. Up to date with immunisations and routine child health checks, with the four year old check now due.
Aunty wants her nephew’s skin sores treated, that’s why she brought him in. The RAN wants to know a bit more about the history of the presenting problem, though. Has the child been unwell? Are there any other problems that should be addressed – cough, diarrhoea, fever?
The RAN also wants to explore the child’s general wellbeing and social history. Does he go to the family centre or pre-school? It’s always useful to ask about diet and appetite. If the child attends pre-school, he will be offered at least one main meal there. Knowing if the child attends pre-school also gives the RAN a picture about his socialising patterns – does he have friends at pre-school? Does he like going there?
While collecting some history from the aunty and child, the RAN is also observing the interaction between them, the child’s demeanour and appearance. Giving the family a few minutes to feel comfortable while the RAN asks some questions makes it a lot easier to move on to doing a set of age-appropriate observations, including weight and height. When measurements are plotted on the growth chart, it is clear that this little boy is stunted and has had poor growth for some months. The RAN does a head-to-toe check, looking for medical reasons for the long-term poor growth, as well as assessing the skin sores.
Several medical issues are identified:
• Poor dentition – indicating long-term poor diet and minimal oral hygiene
• Discharging ears – probable chronic suppurative otitis media given his history
• Multiple crusted skin sores – likely impetigo
• A large boil on the left upper thigh
• Poor growth
The child is relatively clean and tidy, seems to have a good rapport with his aunty; his face and scalp are clean, eyes clear, throat and oral mucosa pink and healthy. His chest is clear, abdomen soft and non-tender. He has good muscle tone and is hydrated. There are no obvious developmental concerns. Despite his ear problems, he is talking to his aunt in language, is cooperative and aunty says he can dress himself.
The skin sores are straightforward to treat following local protocols. The main concern is prevention of rheumatic fever, so this child will need an injection of long-acting penicillin, as well as having his sores cleaned and dressed.
Boils generally require incision and drainage to heal, antibiotics are not first line treatment. Ears need treatment following local guidelines, remembering the condition needs to be treated before a meaningful hearing test can be done. The RAN provides education about oral hygiene and diet appropriate to the context. What healthy food does the local shop sell that is within the family budget? Are there any problems with income? Are there any other organisations this family could be offered referral to that can support them?
Having assessed this child, treated the immediate problems while providing health advice, the RAN needs to negotiate when to next see him. This child seems to have had long-term growth problems, evidenced by stunting and poor growth. It may be necessary to collect a faeces sample for parasites.
It would be good if the medical officer could see him on his next visit to the community. The RAN also needs to think about a safety plan: if this child is unwell overnight, can the family get to the clinic? Do they have transport or a means of communication?
The population of very remote communities is young, with high proportions of children to adults. RANs provide comprehensive primary health care. That involves much more than managing the acute problem that presents.
It requires the RAN to be attentive to the presenting problem while opportunistically delivering preventative primary health care.
This case illustrates the importance of holistic assessment, opportunistic screening, and evidence based care guided by local resources, such as the Remote Primary Health Care Manuals or Primary Clinical Care Manual.
