1. Chief Complaints by Type Patient Demographics and Clinic Details
Providing Primary Care in Spiti Valley as Student Doctors
Vatsal Bhatt1; Deborah Chen1 and Nicholas Colazzo1
1Graduate School of Biomedical and Health Sciences, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ 08854
Introduction
Typical Case Presentation
Patient Statistics
(n = 1,147)
From June 22 to July 8, 2015, a team of 3 students from Rutgers Robert Wood Johnson Medical School (RWJMS) joined a team from the Himalayan Health Exchange (HHE) to provide healthcare access to the underserved people of Spiti Valley, in the Inner Himalayas. The team set up 9 temporary clinics and treated 1,147 patients.
This travelogue presents their learning experience: immersing themselves as student doctors in an unfamiliar culture and merging education with health care initiatives while limited by resources and language barriers. It includes an outline of a typical case seen frequently at clinic.  
CC: “Pain, itching, and watery eyes that gets worse in the sun”
HPI: Patient is a 47 year old male presenting with visual acuity changes, lacrimation, and itching of the eyes. Symptoms have been worsening for the past few months and are worst when the patient is outside. There is no history of similar symptoms. Patient is not on any medication and claims that symptoms are temporarily alleviated by splashing face with water. Patient is a farmer by trade in the Himalayas. He spends most of the day outside and symptoms are significantly interfering with his work.
Social History: Patient is a father of 3 healthy children and lives with his spouse. He lives at high altitudes in the Himalayas and is a farmer by trade. He spends most of his day outside working in the fields. He does not smoke and denies any illicit drug use. Patient and his family are vegetarian and his diet consists mostly of lentils and beans that can be grown locally.
Relevant ROS:
Constitutional: (+) weight loss, decreased appetite, lethargy (-) fevers/chills
Neuro: Blurry vision with lacrimation (-) tinnitus, aphasia, seizure, headache, ataxia, numbness
HEENT: (-) trauma (+) watery, itchy eyes with blurred vision
GI: Nausea without vomiting. (+) abdominal pain (-) diarrhea, constipation, hematochezia
Rheum: (+) Back pain (-) swelling, erythema, warmth in joints
Physical Exam:
Vitals: 98.3ºF 77BPM 14RR
General Appearance: NAD, undernourished
Eyes: PERRLA, EOMI. Visual acuity 20/70 bilaterally. Bilateral nasal pinguecula extending to the
corneo-scleral margin. Bilateral nasal pterygia extending to the corneo-scleral margin.
ENT: Poor dentition with missing teeth, no dentures. Normal ear canal; tympanic membrane intact.
Normal nares. No redness or discharge in throat
Cardiac: No murmurs, rubs, gallops
Lung: Clear to auscultation bilaterally. No wheezing, rhonchi, rales
Abdomen: Doughy abdomen. Normal bowel sounds with no masses. No hepatosplenomegaly
Lymph: Normal lymph nodes
Assessment and Plan:
Pterygium w/ pinguecula – treat with eye drops to alleviate irritation. Provide sunglasses to
protect from UV and dust. If vision changes progress, patient should go to hospital.
2) Worms – Given patient's history of weight loss and lethargy, combined with prevalence of worms
in the region, patient and his family should be treated with Albendazole 400mg, one dose.
Chief Complaints by Type
66% of patients had ENT complaints
42.7% of patients had eye complaints
19.6% of patients had GI complaints
Top 3 GI Complaints:
GERD (n=43, 3.7% of pts)
constipation (n=34, 3.0% of pts)
stomach pain (n=29, 2.5% of pts)
16.6% of patients had MSK complaints
Top 3 MSK Complaints:
back pain (n=41, 3.6% of pts)
osteoarthritis (n=32, 2.8% of pts)
nonspecific (n=23, 2.0% of pts)
11.4% of patients Lost to Follow-Up
(left clinic without checking out) 1
Methods
Each clinic was set up the morning of clinic day at a temporary site, using tarp, rope, and travel tables to make a registration table and 9 clinical stations: triage, 2 adult medicine, 2 pediatric, ophthalmology, OB/GYN, OMT, and pharmacy. Each station held 1 physician, 4-5 students, and 1 translator. Students were assigned to stations for 1-day shifts such that every student worked each station type at least once.
Upon arrival, patients checked in at registration to report a chief complaint (CC), and were given a blank paper record that would accompany them through the visit. Patients proceeded to triage, where vitals (BP, HR, temperature, visual acuity, and pediatric height and weight) were recorded before directing patients to the appropriate clinical station based on CC.
Students at clinical stations took histories and performed physicals with the assistance of interpreters, then presented findings along with a proposed assessment and plan to the team physician. After physician counsel, students educated patients on appropriate topics, wrote a SOAP note on the record, then patients proceeded to pharmacy to retrieve prescribed medication and supplies (toothbrushes, sunglasses, false tears), and check out of clinic.
Patient Demographics and Clinic Details
Summary
Three weeks were spent in the Inner Himalayan region serving 7 different communities
Students performed histories, physicals, and determined appropriate plans for patients with the help of a translator before presenting cases to attending physicians for approval
Students provided preventative health education to patients and gained massive amounts of clinical experience
Patient population seen demonstrated a primary need for preventative eye care and education on UV protection. Other common needs: nutritional education, worm treatment, and MSK pain relief
Top 3 Eye Complaints:
pterygium (n=202, 17.6% of pts)
visual acuity (n=104, 9.1% of pts)
nonspecific (n=64, 5.6% of pts)
Name of the Clinic
# of Patients
Additional Details
Clinic Day 1
Gui
137
Several soldiers guarding the Indo-Tibetan border came in for treatment
Clinic Day 2
Sumra 73
Clinic Day 3
Tabo (Serkong School)
305
This was a middle school equivalent in Tabo where we saw about 300 kids who came in mostly for well checks. We gave out tooth brushes and educated kids on the importance of hygiene
Clinic Day 4
Poh 75
Clinic Day 5
Mani 70
Clinic Day 6
Dhankar Monastery 60
Predominantly served monks.
Clinic Day 7
Rangrik Day 1 80
Clinic Day 8
Rangrik Day 2
120
Clinic Day 9
Pongmo Nunnery
Nuns constituted the primary patient population of this clinic. The clinic was followed with a lecture given by the head nun about life as a nun.
Conclusions
Regional access to healthcare is very limited and education in conjunction with preventative health is the best way to maintain overall population health
Spiti Valley is a neglected region of India without government support or financial aid to build a permanent healthcare solution; traveling clinics are a good temporary measure to satisfy the healthcare needs of the population until a permanent solution is established
This mission trip provides annual opportunities for medical professional students to gain clinical, cultural, and service experience
Program Contact Info:
*Eye complaints with n < 9 were reported as “other”
Supported by the Office of Global Health, Rutgers Robert Wood Johnson Medical School
This table highlights specific information about our 9 clinic days. Details include the name of the clinic sites and the number of patients seen at each clinic.