Medical Missions Outreach
Medical Provider Resource Packet for
Nurses/NPs
Equipment to Bring:
Stethoscope, penlight, pocket otoscope, blood pressure cuff,
drug handbook, calculator, scissors, tape, alcohol swabs, tongue blades (if have access to
get). Nurse practitioners may also include dermatology reference book, Epocrates on
PDA, Tarascon pocket pharmocopeia, Sanford guide to Antimicrobial therapy, handheld
eye charts, ophthalmoscope, reflex hammers, and tuning forks to test hearing. The
pocket size Mosby’s physical examination handbook may also be useful.
For those who do not speak Spanish or the language spoken in the country
sponsoring the medical team, a medical dictionary from English to that language will be
helpful to aid your interpreters.
General Information
 Ask for one specific problem the patient is currently experiencing with which you
can help them today. Very important you or your interpreter limits response back.
Many patients will tell you every problem they ever had.
 Asked focused history questions pertinent only to today’s problem.
 Before the first clinic day, review the list of medications on formulary in the
pharmacy. Familiarize yourself with what class of medication each drug is and
what that drugs treats. Major considerations in prescribing a medication should
also be reviewed. It may be helpful to right info on formulary sheet for easy
reference.
 Daily update what medications are still in formulary.
 For nurses not used to prescribing dosages, remember the pharmacist can figure
dosages if you choose the medication and write what you are treating.
 Remember to include basic teaching concerning diet, exercise, smoking cessation
and weight management in treatment plan for hypertension, diabetics and heart
patients.
 Utilize any patient education handouts provided on each particular trip as
available.
 Examination spaces may not be ideal for thorough physical exams, utilize
symptom descriptions when appropriate in place of physical inspection of
intimate areas.
 Collaborate as necessary with other practitioners. Formulate questions or
uncertainties in plan of care in advance. Also if symptoms or examination
findings are new to you, feel free to have another practitioner examine patient
with you.
 Trust the Lord for daily wisdom. It will amaze you how He calls to remembrance
information you long ago learned.
Pediatric Basics
Human Growth and Development- Normals
 Newborn to two weeks – Well child check
o Strong primitive reflexes- rooting, startle reflex, and Babinski
o Should briefly focus on faces or objects
o Follows face midline
o Lifts head briefly in prone position
o Undifferentiated cry
o Able to suck/swallow/breathe
o Breast feeding recommended for first 4-6 months
o Put baby to sleep on back
o Assessment
 If scale available, measure weight, height and head circumference.
If growth charts available for country the team is in, plot on growth
curve.
 Assess/observe rashes, jaundice, dysmorphic features (skin folds,
ears lower than outer canthus of eye) eyes, eyelids and ocular
mobility.
 Check for red reflex. If absent, have child seen by pediatric MD or
NP on trip.
 Check for heart murmurs. Remember normal for HR to be 124140 at this age.
 Check hips- Ortolani/Barlow maneuvers (see appendage).
 Inspect umbilicus, check for hernias or abdominal. masses
 Palpate femoral pulses.
 Note symmetry of movement, general activity level, and posture.
 Check anterior and posterior fontanels.
 Normal urine output- 6-8 wet diapers a day= adequate hydration
with breast milk or formula. Formula should be iron fortified.
o Mother should be counseled to not smoke and provide smoke free
environment.
o Assess mom for post partum depression
 One month of age
o Follows parent with eyes, recognizes parent’s voice
o Has started to smile
o Able to lift head up when on tummy
o Assessment
 Measure and weigh if available resources
 Anterior and posterior fontanels, check for any skull or head
deformities
 Assess eyes for red reflex, color, clarity, presence of opacities or
clouding of corneas
 Check ears- may be hard to visualize
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Check for heart murmurs
Palpate femoral pulses
Check abdomen for masses and assess umbilical healing
Check hips with Ortolani/Barlow maneuvers
Assess for neurological reflexes, attentiveness to visual and
auditory stimuli
Two months of age
o Attempts to look at parent, smiles
o Consoles and comforts self
o Differentiated cries, and coos
o Holds head up and begins to push up in prone position
o Has consistent head control in supported sitting position
o Newborn reflexes should be decreasing
o Assessment same as above, posterior fontanel may be almost closed or
closed
Four months of age
o Smiles spontaneously
o Babbles expressively and spontaneously
o Elicits social interactions, indicates pleasure and displeasure
o Pushes chest to elbow
o Good head control
o Beginning to roll and reach for objects
o Cereal can be introduced between 4-6 months
o Keep small objects out of reach from the baby
o Assessments- same as above with attention to symmetry of movement,
muscle tone, fontanels and red reflex
Six months of age
o Recognizes faces, babbles, enjoys vocal turn taking
o Responds to own name
o Rolls over and sits
o Stands and bounces
o Rocks back and forth on all fours
o Moves to crawling from prone
o Can introduce cup at this time- limit juice to 2-4 oz per day
o Introduce solids one food at a time
o Continue breast feeding or iron rich formula
o Assess fluoride source
o Assessments as above, primitive reflexes should be faded or gone
completely
Nine months of age
o Stranger apprehension
o Seeks out parents
o Uses repetitive consonants and vowel sounds
o Points out objects
o Gradually increase table foods, provide 3 meals with 2-3 snacks per day
o Assessment- as above. Elicit parachute response
 Twelve months of age
o Plays interactive games
o Hands parent a book when wants a story
o Waves “bye-bye”
o Imitates activities
o Has strong attachment with parent and shows separation anxiety
o Speaks one to two words
o Follows simple directions
o Identifies people on request
o Holds 2 cubes and bangs together
o Stands alone
o Assessment- same as above. Perform cover/uncover test. Check teeth for
caries and staining. For boys check that testes have fully descended.
 Fifteen months of age
o Scribbles
o Walks well
o Drinks from a cup
o Hands a book when wants a story
o Indicates wants by pulling/pointing/grunting
o Emphasize dental care
o Assessment- same as above. Observe for stranger avoidance. Anterior
fontanel should be closed (average age of closure is 13 months)
 Eighteen months of age
o Speaks six words
o Points to one body part
o Knows name of favorite books
o Walks up steps
o Runs
o Stacks 2-3 blocks
o Scribbles
o Use spoon/cup without spilling
o Assessments-same as above. Note gait, hand control, arm/spine
movement. Continue to assess red reflex. Cover/uncover test. Observe
for nevi, café au lait spots, birthmarks, bruising.
 Two year old
o Parallel play
o Refers to self as “I” or “me”
o Has at least 50 words
o Used 2-word phrases
o Follows 2 step commands
o Stacks 5-6 blocks
o Makes or imitates horizontal or circular strokes with crayon
o Throws ball overhead
o Jumps, climbs stairs one step at a time
o Screen language acquisition/clarity
o Observe running, scribbling, socialization and ability to follow commands
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o Depending on child, may initiate toilet training
o Assessment- same as above. Calculate BMI if possible.
Three year old
o Play includes other children
o Uses 3-4 word phrases
o Is understandable to others 50% of time
o Points to six body parts
o Knows the correct action for animal or persons
o Copies vertical lines
o Throws ball overhead
o Brushes teeth and dresses with help
o Toilet training
o Assessment- same as above
Four year old
o Listens to story
o Knows first and last name
o Fantasy play
o Knows what to do if tired/cold/hungry
o Speech clearly understandable
o Names four colors
o Plays board games
o Can draw a person with three parts
o Hops on one foot
o Balances on one foot for two seconds
o Builds tower of 8 blocks
o Copies a cross
o Brushes own teeth and dresses self
o Assessment: Same as above. Observe fine/gross motor skills. Language
acquisition. Speech clarity.
Five-six years old
o Balances on one foot, hops, skips, able to tie knot
o Show school readiness skills
o Has mature pencil grip
o Can draw a person with six body parts
o Prints some letters and numbers
o Able to copy squares and triangles
o Names 4 colors
o Counts to ten
o Follows simple directions
o Assessment- same as above. Attempt ophthalmoscopic exam of optic
nerve and retinal vessels. Gait, posture. Assess for scoliosis.
School age children
o Basic head to toe exam
o Assess for scoliosis
o Vision tests, hearing
o Normal social interaction, school performance
Sick Visit
o Ask if child has had fever in last 24 hours
o Ask about irritability, change in activity levels, sleeping patterns, changes in
cry, or changes in play
o Ask how many wet diapers a day. Normal hydration= 6-8 wet diapers a day.
Tears when crying? Give out rehydration handout to formula fed babies.
Breast fed moms should encourage child to feed frequently.
o New rash in last day or two?
o Any other sick family members? Exposures at school or baby-sitters?
o Diarrhea- new onset or chronic? Any blood in stools? Abdominal pain
associated with stools? History of constipation?
o For lethargic children, respiratory wheezing, or high fevers in clinic- refer to
pediatric specialist with team or NP.
General Practice
Upper Respiratory Infections
 Viral illnesses last 7-14 days. Usually by day 7 symptoms are beginning to
improve. Starts with head congestion that loosens and progresses to cough that
moves from dry to moist. If symptoms begin to improve and then worsen or if
symptoms worse after day 7 instead of improving suspect possible bacterial
infection.
 Continued sinus congestion with facial pain and headaches after day 7 suspect
bacterial sinus infection. Treat with amoxicillin, augmentin, cefdinir, cefprozil,
cefdinir, ciprofloxacin, or levaquin.
 Viral pharyngitis is often present at beginning of viral URI and most common
cause of sore throats. Viral pharyngitis is often associated with a cough. It is not
usually accompanied by high fever for several days, difficulty swallowing, severe
malaise, or stomach upset. Exudative sore throats should have rapid strep and or
mono spot test done. Viral URIs are treated with symptom management.
 Strep A positive- Penicillins, erythromycin, zithromax, clindamycin or
clarithromycin
 Viral bronchitis can persist up to 14 days. Treat with decongestants, mucolytics,
increased fluid intake, and consider use of prn of albuterol inhaler to relieve
tightness.
 Cough > 14 days evaluate for bacterial bronchitis and pneumonia.
 Decreased lung fields or wheezes- have nebulizer treatment given and repeat
assessment listening for crackles, ronchi or increased wheezing. Use percussion
of lung fields and tactile fremitus to aid in diagnosis of pneumonia.
 Treatment of pneumonias/ bacterial bronchitis- Zithromax, Clarithromycin,
doxycycline, augmentin, or respiratory flouroquinolone.
Otitis Media
 Normal tympanic membrane is pearly translucent color, bones are visible, no
bulging of membrane noted, cone light reflex noted, and no fluid bubbles are seen
behind ear drum. External ear cartilage gentle wiggling should not elicit pain.
 Crying can cause ear drum to be red so color of membrane is not always specific.
A non-crying infant or child with a red ear drum is suspicious for otitis media.
 Gray, pussy appearing membranes, cloudy membranes that light reflex and bones
are not easily visualized are suspicious for otitis media.
 Yellow or clear fluid bubbles behind ear drum is indicative more of serous otitis
media. May be related to sinus congestion and Eustachian tube dysfunction.
Might be able to treat with decongestant and Tylenol. Look for other indications
of bacterial infection.
 Otitis media is not common in adults. If present, usually indicative of Eustachian
tube dysfunction. If serous otitis media, treat with decongestants. For chronic
sinus problems or allergies, patient may need allergy medication or nasal steroids
to decrease inflammation in sinuses and allow proper drainage.
 Otitis media is generally treated with amoxicillin, augmentin, cefdinir,
cefpodoxime, cefprozil, cefuroxime axetil, bactrim, and zithromax. Pharmacist
will dose for kids and adult, just provide patient weight for kids and indication for
usage. Also note if child or adult has had an antibiotic for this problem in last
month.
Pain Management
 Team only carries non-narcotic medications
 Tylenol is safe for all patients unless have active liver disease evidenced by
jaundice. Check buccal mucosa and sclera.
 Ibuprofen should be avoided in patients with hypertension, renal disease, or
know gastric ulcers. Medication should also be avoided in pregnant women in
third trimester.
 Teach good posture for lifting, bending, sitting.
 Teach neck and back stretches.
 Ace wraps may be utilized to use as knee supports. Teach how to wrap
correctly without being tight and causing circulation problems below wrap.
Gout
 Painful swelling, inflammation of first metatarsal.
 Treat with NSAIDs unless contraindicated.
 Colchicine 0.6 mg every 1-2 hours during an attack with max dose of six pills per
day.
 Teach patient to avoid alcohol, liver, anchovies, asparagus, shell fish, salmon,
legumes, and sardines as these foods are high in purine and will increase uric acid
production.
 If allopurinol available, consider prophylaxis dose for those suffering with
chronic gout. If first time on allopurinol 300 mg daily, make sure patient takes
NSAIDs or colchicine first.
Hypertension
 Brief health history to check for co-existing morbidities such as diabetes, CAD, or
renal problems.
 Blood pressures should be taken after patient sitting with feet flat on floor.
 Repeat BP after 20 minutes of sitting.
 Goals for treating BPs are much more conservative on these trips due to our
inability to follow up with patients.
 For BPs ranging 140-180/80-99, consider dietary changes such as low fat diet,
sodium restriction of 2Gm per day, exercise, and weight loss as treatment.
 For BPs ranging 180 or >/100 or > systolic. Lifestyle changes as above and start
low dose medications. JNC-7 recommendations are to start first with thiazide
diuretic (HCTZ) or an ace inhibitor (Lisinopril). Consult formulary for what is
available. Can also use a beta blocker or calcium channel blocker.
o Thiazide diuretics- use cautiously in patients with know gout
o Ace-Inhibitors- use cautiously if know renal disease- serum creatinine>3
on labs brought to you indicate use of other medication
o Beta-blockers- avoid use in patients with asthma or slow heart rates
o Calcium channel blockers- avoid use in patient with active CHF
 Teach patients starting a beta blocker or calcium channel blocker to monitor heart
rate daily before taking medication.
 Teach patients concerning orthostatic hypotension and side effects of meds.
 Check urine for nitrates for known hypertensive patients and newly diagnosed
patients.
 If patient was previously on hypertensive medications, determine what they took
and do they have any left. If medication on formulary or like class of drug,
provide a one month supply of drug as available.
Diabetes
 Difficult to manage on short term trips. Have random finger stick checked as well
as urine for presence of glucose, ketones, or proteins.
 Diabetic education concerning diet, exercise, and weight loss.
 Metformin is standard PO drug for Type II diabetics. However, should not be
used if renal failure or elevated creatinine. Consider Glyburide, Actos, or
Avandia. Will need to check what is on formulary for trip.
 Check for complications of diabetes- vision changes, diabetic neuropathy, and
diabetic ulcers.
 Educate on signs of hypoglycemia and hyperglycemia.
Gastritis/GERD
 Reflux? How often? Positional? Food make better of worse? Any blood in
emesis or stools? Black tarry stools? Presence of parasites?
 Gastric pain and tenderness- burning pain without reflux- evaluate for h-pylori if
test available.
 Treat GERD with Omeprazole or like PPI, Ranitidine or like H2 agonist.
o Omeprazole 20 mg daily for duodenal ulcers, GERD and erosive
esophagitis. Omeprazole 40 mg daily if suspect gastric ulcer.
o Ranitidine 150 mg bid
 Treatment of H-pylori= Prevpac or PPI bid for 10-14 days with Amoxicillin 1Gm
and Clarithromycin 500 mg bid for 10 days.
BPH
 Patient may present with history of disease but out of medication.
 Typical symptoms- increased urinary frequency, difficulty starting stream,
nocturia. Not usually painful to urinate or sense of great urgency.
 Check u/a to make sure not UTI. UTIs not as common in men.
 Make sure no other penile discharge related to STI.
 Ideally a prostate exam should be done to identify enlargement without tenderness
or bogginess. No masses or nodules should be felt. This may not be feasible due
to exam room limitations and provider knowledge of normal prostate.
 Treatments- Flomax 0.4 mg daily- 30 min after same meal daily.
o Proscar 5mg daily.
UTIs
 U/A to confirm or if classic symptoms relieved previously by antibiotic therapy.
 Increase fluid intake.
 Teach methods of cleanliness and voiding post intercourse to decrease UTIs in
women.
 Treatment: Bactrim DS bid x 3 days
 If symptoms of urinary frequency, painful urination, increased urgency, pressure
are associated with fever, chills, back/flank pain, and nausea- Tx for
pyelonephritis- Bactrim DS bid x 14 days, or Cipro 500 mg bid x 7 days.
Gynecology
Differentiating vaginal itch/discharge complaints
 Normal
 White to clear discharge, no itching, no vaginal or pelvic discomfort
 Bacterial Vaginosis
 Thin white, white-gray discharge. More discharge than usual.
 Fishy strong odor to discharge. Patient may complain that odor
worsens after intercourse.
 Itching may or may not be present.
 May have mild vaginal discomfort. Cervix not painful during
intercourse.
 May or may not have painful urination.
 Patient may have recent new sexual partner.
 Symptoms are not related to menstrual cycle.
 If microscopic exam available- patient will have clue cells on saline
wet prep.
 Treatment
o Metronidazole 500 mg bid x 7days (Teach them they MUST avoid alcohol ingestion
during this time and five days after therapy
completed)
 Safe to use in pregnant women after 1st trimester
o Metrondizole vaginal gel- 1 intravaginal application daily x
5days
o Clindamycin 300 mg bid x 7 days or intravaginal clindamycin
2% cream 5 gm at bedtime x 7days (Do NOT use clindamycin
cream in pregnant pts)
 Candidiasis
 White, curdy, “cottage-cheese” like discharge
 No odor present
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Moderate to severe itching and burning with discharge
Painful urination frequently present.
Not usually related to change in sexual partners.
Male partner may have similar symptoms.
Usually positive relationship with menstrual cycle.
Recent antibiotic use common.
Recent attempts to treat itching systemically or locally.
No cervical pain with intercourse.
May have external itching and redness of labia.
Microscopic exam- positive KOH for “buds”
Treatment
o Fluconazole 150 mg PO x 1 dose. Safe in pregnancy.
o Intravaginal Miconazole, Clotrimazole, daily applications 7-14
days
Trichomonas Vaginitis
 Yellow, green, frothy, adherent discharge, often in large amounts
 Frothy, bubbling discharge
 Vaginal vulvar pain
 Foul odor but not fishy
 May or may not have mild itching
 Painful urination
 Patient will often report new sexual partners or suspicion of partner
cheating
 Treatment
o Metronidazole 500 mg bid x 7days- avoid alcohol use during
course of treatment and five days after ( Do not use in 1st
month of pregnancy)
o Treat the partner as well- Metronidazole 2 Gms PO one single
dose
Gonorrhea/Chlamydia Symptoms (Possible PID)
 Pelvic pain and pressure- suspect PID
 Painful intercourse internally not just vaginal irritation- suspect PID
 May or may not have itching
 Mild to moderate odor to discharge for some pts, may not have odor
 May or not have painful urination
 History of new sexual partner or multiple partners
 Sexual partner often has symptoms as well- should be evaluated and
treated as well if possible
 Treatment
o Doxycycline 100 mg PO bid for 14 days ( Unsafe in pregnancy
and possibly lactation) and Metronidazole 500 mg bid for 14
days
Dermatology
Basic Wound Care
 If wound is dry, make it wet. If wound is wet, make it dry.
 Give supplies to keep wound clean and dressed.
 Utilize Ace wraps for light compression in patients without cellulites or CHF,
check distal pulses before using compression wraps.
 Cellulitis surrounding wounds or infected wounds- Keflex, Bactrim,
daptomycin, augmentin, or zithromax. Cipro effective if suspected bone
involvement.
Lice
 Consult formulary for what shampoos we have available.
Scabies
 Rash generally found in webspace of hands, wrists, front of elbows, knees, ankles,
web spaces in between toes, axillae, around waist, genitals, and buttocks, and may
spread onto arms and trunk as progresses untreated. Burrows noted in rash.
Classically reports increased itching at night.
 Tx: All sheets, linens, and clothes patient uses must be washed.
 Premetherin 5% cream- apply from chin to toes and leave on 8-10 hours. Then
shower off. Repeat treatment in one week. Safe in all patients > 2mos old.
 May need to prescribe medium dose steroid cream for itching. Rash will persist
for several weeks but itching should cease after 2-3 weeks.
Eczema
 Teach good hygiene and moisturization of the skin with baby oils and
moisturizers. Oatmeal powder baths may be helpful.
 Patients may also present with allergic rhinitis symptoms
 Poorly defined erythematous patches, papules or plaques with or without scale.
Pruritic. Skin appears puffy. Chronic eczema may have lichenification from
scratching. Rash occurs on face, neck, trunk, hands, antecubital spaces, back of
knees, shoulders, thighs and calves. Spares feet and buttocks area.
 Depending on age of patient and severity of eczema, confer with another
practitioner if a corticosteroid cream should be prescribed. Severe cases may need
steroid cream and antibiotic to treat for localized staph skin infections.
Psoriasis
 Classic lesions are sharply marginated erythematous papule or plaque with
silvery-white scales.
 Occurs on scalp, behind ears, palms, nails, arms, back of elbows, arm pits, lower
back, front of knees, soles of feet, buttock, and perigenital areas. Usually spares
face, back of hands, and light exposed areas.
 The location and severity of psoriasis will determine type of treatment.
 Mild scalp psoriasis can be treated with ketoconazole shampoo followed by
betamethasone 1% lotion.
 Moderate strength corticosteroid creams/lotions are usual treatment for psoriasis
on elbows, knees and feet. Confer with another practitioner concerning
appropriate treatment for location and severity of psoriasis.
 Recommend spending time in sun in short durations.
Acne
 Teach good hygiene.
 Refer to formulary for acne washes available on trip. Most topical medications
we don’t carry other than benzyl peroxide washes. Po medications require
extensive tests before treatment. Refer to local dermatologist.
Appendix of Images
Infantile Eczema- Picture taken from Fitzpatrick’s Color Atlas and Synopsis of Clinical
Dermatology
Follicular eczema in dark skin- Picture also taken from Fitzpatrick’s Manual
Scabies
Psoriasis- Images from Fitzpatrick’s manual
Barlow-Ortolani Maneuvers to check Hips
Picture from Mosby’s Guide to Physical Examination 6th ed.