December
2003 Telemedicine Clinic in Robib
Report and photos
submitted by David Robertson
On Wednesday,
December 10, 2003, Sihanouk Hospital Center of Hope nurse Koy
Somontha gave the monthly Telemedicine examinations at the Robib
Health Clinic. David Robertson transcribed examination data and
took digital photos, then transmitted and received replies from
several Telepartners physicians in Boston and from the Sihanouk
Hospital Center of Hope (SHCH) in Phnom Penh.
The following day, all patients returned to the Robib Health
Clinic. Nurse "Montha" dispensed medication to the patients and
discussed advice received from the physicians in Boston and Phnom
Penh.
Following are the e-mail, digital photos and medical advice
replies exchanged between the Telemedicine team in Robib,
Telepartners in Boston, and the Sihanouk Hospital Center of Hope in
Phnom Penh:
Please reply to David Robertson
dmr@media.mit.edu
Dear All:
A quick reminder that the December Telemedicine
clinic in Robib, Cambodia is still scheduled for Wednesday, 10
December 2003.
We'll have the follow up clinic at 8:00am,
Thursday, 11 December (8:00pm, Wednesday, 10 December in Boston.)
Best if we could receive your e-mail advice before this time.
Thanks again for your kind assistance.
Sincerely,
David
PS Vansoeurn, we will drive from Phnom Penh to
Robib on Tuesday, 9 December, hopefully arriving by 5pm.
Please reply to David Robertson <dmr@media.mit.edu>
Our follow up clinic is at 8:00am on Thursday,
11 December 2003 (8:00pm on Wednesday, 10 December 2003 in Boston.)
It is most helpful if we can get your advice by
this time.
Thanks again for your kind assistance.
Telemedicine
Clinic in Robib, Cambodia – 10 December 2003
Patient #1: SOM THOL, male, 50 years
old, Follow up patient
 |
Subject: 50-year-old male returned
for his follow up visit of DMII, PNP and dyspepsia. No new
symptoms, decreased leg numbness from the knee down, is thirsty,
decreased urination, no fever, no cough, no chest pain, no
weight loss, decreased burning sensation on epigastric pain, no
nausea, no vomiting, and no bloody stool.
Object: BP: 100/50, Pulse:
80, Resp.: 20, Temp: 36.5, Weight: 52 kg
- No oropharyngeal lesions, no skin rashes
- Lungs clear both sides, full breath
sound, no crackle, no Rhonchi,
- Heart regular rhythm without murmur.
- Abdomen, mild tenderness on the
epigastric area, no HSM, has bowel sound in all four quadrants
- Legs the same color, left calf still
mild pain but no edema, has strong pedal pulses bilaterally.
Assessment:
- DMII.
- PNP
- Dyspepsia
- Muscle spasm due to Neuropathy?
Plan: Prescribe the following meds for
one month:
- Diamecron, 80 mg, ½ tablet, three
times per day
- Amitriptilline, 25 mg, one tablet,
two times per day
- Famotidine, 40 mg, one tablet daily
- Multivitamin, one
tablet daily
- Paracetemol, 500 mg, four times daily
as needed (for ten days)
Patient will follow up at next month’s
clinic on 06 January 2004. May I draw his blood for lytes, Bun,
creatinine, blood sugar & CBC to do at Sihanouk Hospital Center
of Hope? Kampong Thom Provincial Hospital can’t do lytes, Bun,
creatinine. Please give me any ideas. |
Patient #1: SOM THOL, male, 50 years old,
12/10/03 Follow up
This man is unfortunately dealing with severe
uncontrolled Type 2 diabetes, and will be a real challenge for you.
As you know, prolonged hyperglycemia damages the retina of the eye,
the kidneys, the nerves, and the blood vessels and he can expect
that the following are likely to occur:
-
Damage to the retina from diabetes (diabetic
retinopathy) leading to blindness
-
Damage to the kidneys from diabetes (diabetic
nephropathy) and eventual kidney failure
-
Further foot wounds and ulcers, which
frequently lead to foot and leg amputations.
-
Damage to the nerves in the autonomic nervous
system can lead to paralysis of the stomach (gastroparesis),
chronic diarrhea, and an inability to control heart rate and blood
pressure with posture changes.
-
The formation of fatty plaques inside the
arteries putting him at high risk for heart attack, stroke, and
decreased circulation in the arms and legs.
His leg pain may be due in part to this, but
strong pedal pulses suggest otherwise. Does he have worsening pain
with walking a short distance? If so consider that he may have
peripheral vascular disease and intermittent claudication. If
untreated, peripheral vascular disease can develop complications:
-
Permanent numbness, tingling, or weakness in
legs or feet
-
Permanent burning or aching pain in legs or
feet
-
Gangrene
Remember also, serious short-term problems to
expect in patients like him
include:
-
Infections of any kind
-
Hypoglycemic episodes from too much oral
hypoglycemics
-
Hyperglycemia leading to dangerous episodes:
visual changes, altered mental status (agitation, extreme
lethargy, or confusion), coma, seizures
The main thing for him now is to do whatever he
can to maintain a normal blood sugar. I know this is difficult
without the ability to monitor his blood sugar.
I'd recommend the following:
1. Continue to educate him about his
disease and the importance of preventing further damage
2. Lifestyle: For example, no smoking/alcohol, low fat diet,
3. Medications:
a. Increase his Diamecron if it appears
that he is taking it as you have directed but glucose remains
elevated. (For example increase to 80 mg, 1 tablet, three times per
day).
b. Note that this medication may
eventually not be effective and insulin may be needed. Insulin
however may not be a realistic option for him.
4. Tests: I'd recommend that you get the
labs you suggested. Lytes, BUN, Creatinine, CBC. His urine could
also be checked for protein. These will be helpful in assessing the
presence of any kidney damage from his DM. The random glucose can
give us a snapshot of his glucose control as well.
5. Ideally, having his eyes checked with a
retinal exam, but this may not be considered critical as you weigh
the cost to benefit.
6. Regular follow-up
Best of luck with this unfortunate and very
challenging patient.
Paul Heinzelmann, MD
Massachusetts General Hospital
Dear David and Montha,
Good that his leg
numbness, his urinary frequency and epigastric burning
pain improve.
We would have some
suggestions:
1. Left caft still
tender. According to the attached picture, we see left caft bigger
than right. Last month, deep palpation caused tenderness. Good that
the pulses at the feet are strong. Does he has claudication? Does
stretching his leg cause tenderness? - suggest to bring to Kg. Thom
for US + XRay of Left leg, arterial vs veinous clots, ?mass - the
concerns are the risks of stroke, pulmonary embolism. Agree with
paracetamol for the moment.
Would add ASA 500mg
1/4tab a day.
2. For reason of
compliance - Would do twice daily Diamicron. Glycemia needs to be
done. If FBS>200 mg/dL, then would give Diamicron 80 mg BID. We
think finger stick should be promoted. It can be brought to the
site.
3. Amitriptylline -
would give the 2 tabs at bedtime.
Regards,
Jennifer/Bunse
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib,
Cambodia – 10 December 2003
Patient #2: PEN VANNA, female, 37 years
old, follow up patient
 |
Subject: 37-year-old female returned
for follow up visit for her hypertension, DMII and GERD. She
complained of sweating on and off, sometimes dizziness, has dry
mouth, has headache, no blurred vision, no cough, decreased
central chest tightness after a meal, decreased epigastric pain,
no nausea, no bloody stool, no extremity numbness, decreased
urination.
Object: BP: 150/90, Pulse:
86, Resp.: 20, Temp: 36.5, Weight: 60 kg
- Hair, Eyes, Ears, Nose and Throat: Okay
- Neck: No JVD, no lymph node
- Lungs clear both sides, no crackle, no
wheezing
- Heart regular rhythm without murmur.
- Abdomen: Soft, flat with mild burning
sensation at epigastric pain, has bowel sound in all four
quadrants
- Extremities have no edema and no tremor
- She checked blood sugar two days ago at
Preah Vihear Provincial Hospital.
BS =
90mg/dl
Assessment:
- DMII (controlled.) Hypoglycemia?
- Hypertension
- GERD
- Tension Headache
Plan: Continue with:
- Hydroclorothiazide, 50mg,
½ tablet daily
- Stop Diamecrom because she often
gets sweating
- Famotidine, 40 mg twice daily
- Paracetemol, 500 mg, one tablet four
times daily as needed
- Diet sugar and salty food. Exercise.
Please give me any other ideas. |
-----Original Message-----
From: Cusick, Paul S.,M.D.
Sent: Wednesday, December 10, 2003 3:28 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #2: PEN VANNA, December
2003 Telemedicine, Robib, Cambodia
Her BP is not optimally controlled. her target
BP is 130/80.
Her dizziness may be from diuretic or from
hypoglycemia.
Doing a set of orthostatic blood pressure and
pulse readings may help to determine if she is dehydrated. She
should drink at least 2 liters of water daily to preserve a well
hydrated state.
I would check orthostatic BP and HR.
I would see if the sweating and dizziness gets
better off of the diamecrom.
If she is still having these symptoms after one
month off the medication, then it is likely due to dehydration.
Her GERD is controlled.
Optimally, when the source of her
dizziness/sweating is clear, her blood pressure needs to be
lowered.
Good luck,
Paul Cusick
From: "Bunse LEANG"
<tmed1shch@online.com.kh>
To: "David R" <dmr_cambodia@yahoo.com>,
"Gary Jacques" <gjacques@bigpond.com.kh>,
"Jennifer Hines" <sihosp@bigpond.com.kh>,
"Rithy Chau"
<tmed_rithy@online.com.kh>
Cc: <tmed_montha@online.com.kh>,
<aafc@camnet.com.kh>,
"Bernie Krisher" <bernie@media.mit.edu>
Subject: RE: Patient
#2: PEN VANNA, December 2003 Telemedicine,
Robib, Cambodia
Date: Thu, 11 Dec 2003
11:18:47 +0700
Dear
David and Montha,
1. Still
uncontrolled HTN 150/90, is she on HCTZ 25 mg/day? (recommendation
from Dr. Gary on Nov 2003). If you would like to increase to 50
mg/day, this may not do much, and even is not a good option because
of her diabetes (risk of cardiovascular diseases - UpToDate 8.3). We
suggest to keep 25 mg/day of HCTZ and add whether atenolol 25 mg/day
(first option), or ACE inhibitors (for ACE-I lisinopril is good
choice because of availability and once daily, but the use is
complicated - need to stop HCTZ a few days first with ACE-I, then
add later). May add ASA 500 mg 1/4 tab a day.
2.
Because of low dose Diamicron 40 mg/day and she expereinces
hypoglycemic symptoms weith BS = 90 mg/dL, we agree with you to stop
diamicron, but also want to know when the episodes of hypoglycemia
occurs and her diets. Continue diet, exercices and lowering weight.
Have her recheck her BS at Preah Vihear (or you have your One-Touch)
next time. If high BS > 200 mg/dL, may consider metformin.
3. Good
that dyspepsia better. Agree to keep same famotidine.
Regards,
Jennifer/Bunse
Please reply to David Robertson
dmr@media.mit.edu
Telemedicine
Clinic in Robib, Cambodia – 10 December 2003
Patient #3: NGET SOEUN, male, 56 years
old, follow up patient
 |
Subject: 56-year-old male returned
for follow up visit for his Cirrhosis and Ascitis. His previous
symptoms are much improved. Has headache, has blurred vision,
has shortness of breath, no chest pain, no fever, no cough, no
abdominal distension, no edema on both legs, has weakness, has
good appetite, no loss of weight, no bloody or black stool.
Object: BP: 90/60, Pulse: 68,
Resp.: 20, Temp: 36.5, Weight: 42 kg
- Hair, Eyes, Ears, Nose and Throat: Okay
- Neck: Not icteric, no oropharyngeal
lesions, no JVD, and no lymph node.
- Lungs bilateral crackle at lower base
- Heart regular rhythm without murmur.
- Abdomen: Soft, flat, no HSM, has bowel
sound in all four quadrants
- Extremities have no edema and no tremor
Assessment:
- Cirrhosis.
- Ascitis due to Cirrhosis
- Pulmonary congestion due to
Cirrhosis?
Plan: Continue with the same
medications.
- Spironolatone, 50mg, 1/2 tablet
twice daily for 30 days
- Furosemide, 40 mg, 1/2 tablet
daily for 30 days
- Propranolol, 40 mg, 1/4
tablet twice daily for 30 days
- Multivitamin, one
tablet daily for 30 days
- Encourage him to eat two bananas per
day
Return next month for follow up.
Do you agree? |
-----Original Message-----
From: Tan, Heng Soon,M.D.
Sent: Wednesday, December 10, 2003 2:36 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #3: NGET SOEUN, December
2003 Telemedicine, Robib, Cambodia
I'm glad to hear that he remains stable on his
current medications. Were any of my recommendations from last month
carried out? Specifically: 1. Serum electrolytes to check sodium,
potassium, urea and creatinine to monitor renal response.
2. Was it alcoholic, viral hepatitis or
cryptogenic cirrhosis?
3. Has he received appropriate hepatitis A and
B vaccination to prevent superinfection?
Heng Soon Tan, M.D.
Dear David and Montha,
We agree with your
management, great job!
We are unclear why he
has crackles bilateral lower part of the lungs. Could you help him
do a CXR at Kg. Thom and send us the picture?
Regards,
Jennifer/Bunse
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 10 December 2003
Patient #4: SAO CHHOUN, male, 37 years
old, follow up patient
|
Subject: 37-year-old male returned
for follow up visit for his Splenomegalie, muscle strain and
pneumonia? He was sent to Kampong Thom Provincial Hospital last
month for some blood work, abdominal ultrasound, chest x-ray and
AFB. The results as follows:
- Abdominal ultrasound: Showed normal per
attached photo
- X-ray: Showed bronchitis per attached
photo
- AFB: Negative
- Blood results: per attached photo
He still complains of left upper quadrant
and epigastric pain, much improved from his previous symptoms.
Has excessive saliva, no headache, no chest pain, no shortness
of breath, has cough sometimes, no fever, has burning sensation
after a meal, has a good appetite, no weight loss, no black or
bloody stool, and has lower back pain.
Object: BP: 120/60, Pulse:
80, Resp.: 20, Temp: 36.5, Weight: 55 kg
- Hair, Eyes, Ears, Nose and Throat: Okay
- Neck: No JVD, no lymph node
- Lungs clear both sides, no crackle, no
wheezing
- Heart regular rhythm without murmur.
- Abdomen: Soft, flat, Splenomegalie about
3cm under costal margin, has bowel sound in all four quadrants
- Extremities have no edema and no tremor
Assessment:
1.
Muscle strain.
2.
Splenomegalie?
3.
Chronic bronchitis?
4.
GERD?
Plan:
- Famotidine, 40 mg tablet daily, for
one month
- Amoxycillin, 500 mg three times
daily, for seven days
- Paracetemol, 500 mg, one tablet four
times daily as needed, for seven days
Please give me any other ideas. |
Interesting case.
I don't think I'd treat him w/ antibiotics at this point as I'm not
convinced of a true bacterial bronchitis. Still no explanation for
the splenomegaly. Differential diagnosis includes chronic infection
(malaria, TB, kala azar, HIV), lymphoma/other malignancy, cirrhosis
though less likely with reportedly "normal" ultrasound. Someone
should verify the results of his lab work as I cannot be sure what I
am looking at, but I presume that his CBC was normal.
I would:
1) plant PPD/mantoux skin test. if positive
would obtain BM/other tissue culture to rule out active TB. AFB
alone may not be sensitive enough.
2) check blood smear to see what his cells
actually look like.
3) check malarial smear
4) check HIV test
5) check hepatitis serology testing for type B
and C.
6) it would probably be too expensive to
consider CT abdomen/chest but this would be something I'd recommend
to folks here.
7) consider bone marrow biopsy for both
microscopic evaluation and culture
for leishmaniasis (kala-azar) and TB.
hope this helps.
J. Benjamin Crocker, M.D.
Internal Medicine Associates 3
WACC 605
15 Parkman Street
Boston, MA 02114
Phone 617 724-8400
Fax 617 724-0331
Email jbcrocker@partners.org
Please note: This email may contain
confidential patient information which is legally protected by
patient-physician privilege. If you are not the intended recipient,
you are hereby notified that any disclosure, copying, or
distribution of this information is strictly prohibited by law. If
you have received this communication in error, please notify us by
telephone at once and destroy any electronic or paper copies. We
apologize for any inconvenience.
From: "Bunse LEANG"
<tmed1shch@online.com.kh>
To: "David R" <dmr_cambodia@yahoo.com>,
"Gary Jacques" <gjacques@bigpond.com.kh>,
"Jennifer Hines" <sihosp@bigpond.com.kh>,
"Rithy Chau"
<tmed_rithy@online.com.kh>
Cc: <tmed_montha@online.com.kh>,
<aafc@camnet.com.kh>,
"Bernie Krisher" <bernie@media.mit.edu>
Subject: RE: Patient
#4: SAO CHHOUN, December 2003 Telemedicine, Robib, Cambodia
Date: Thu, 11 Dec 2003
11:19:48 +0700
Dear
David and Montha,
1. LUQ
abdominal pain with 3 cm splenomegaly below costal margin, and
negative findings on abdominal US, CBC normal, CXR too dark to
interprete. have cough but no fever. The DDx of LUQ abdominal pain
could be MI, left lower lobe pneumonia, left lobe liver abscess,
pyelonephritis, gastritis or splenic enlargement, ruptured or
abscess. He is better compare to last month, so what is his current
medications?
2. If
current meds are what in the Plan list, then with his improvement + epigastric
pain complaints would point towards gastritis. Would continue same
famotidine.
3.
Unlikely that liver abscess, pyelonephritis, splenic abscess due to
1 month without antibiotics.
4. Any
abdominal trauma to the spleen, any anemia?
5. Agree
with amoxicilline.
6. May
empirically give Albendazole 400 mg BID for 5 days. Strongyloides
can give epigastric pain.
Regards,
Jennifer/Bunse
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 10 December 2003
Patient #5: SUM SOKNA, female, 20 years
old
 |
Chief complaint: Pain on all
finger, ankle, knee, wrist, and elbow joints for three months.
Has had dry cough and sore throat on and off for one year.
HPI: 20-year-old female presented
with general joint pain all over the body, especially in the
morning. Sometimes she can’t walk; both knees have been swollen
on and off as well. She also has a dry cough, has sore throat
on and off, has mild fever, has nausea, has weight loss of about
five kg over six months, has good appetite, has shortness of
breath, no chest pain, no palpitations, and no black or bloody
stool.
Past medical history: Unremarkable.
Family history: Unremarkable.
Social history: Does not smoke and does not drink alcohol.
Allergy: None known.
Current medicine: None.
Physical Exam:
BP: 120/60
Pulse: 86
Resp.: 20
Temp. : 37.3
Weight: 44 kg
Object: Alert and oriented x 3
(place, person, and time.)
Hair, eyes, ears, nose, and throat:
Not icteric, has mild redness oropharyngeal but tonsil not
enlarged, no lymph node enlargement, and no pus.
Lungs: Clear both sides, no crackle
and no wheezing.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, has
positive bowel sound all four quadrants, no HSM.
Extremities: All joints no
deformity, no stiffness, no edema, no redness, and has normal
color.
Neuro exam: Unremarkable.
Assessment:
- Poly Arthritis?
- Rheumatoid Fever?
- Chronic Pharyngitis.
Plan: We would like to cover her
with:
- Amoxycillin, 500 mg three times
daily, for seven days
- Ibuprofen, 400 mg, one tablet three
times for 15 days
Follow up at next month’s clinic. If
not better send her to Kampong Thom for some blood work like
Rheumatoid Factor, CBC and ESR. Do you agree? Please give me
any other ideas. |
Kathy,
I do
not have any specific suggestions but question of Rheumatoid
Arthrits does come in my mind She has pink cheeks so wonder if she
also has some kind of skin disorder or secondary to rh fever or what Can they do the blood work before starting the treatment.
How
about just give high dose of Ibuprofen 800mg three times a day and
not give Amoxycillin antibiotics and see the response in 7 days.
Thanks
dinesh
Dear David,
I understand you have already received a
response from another doctor.
I add mine as further consideration.
Paul
Patient #5: SUM SOKNA, female, 20 years old
Chief complaint: Pain on all finger, ankle,
knee, wrist, and elbow joints for three months. Has had dry cough
and sore throat on and off for one year
Thank you for this interesting case.
To start, I think we can deal with these as two
separate problems for now, realizing they may be related.
1. Chronic cough
2. Chronic polyarthritis
1. Chronic cough
In a patient with cough, fever, SOB, wt
loss- we need to consider TB as a possibility.
To evaluate for this, she needs to have
sputum checked for acid-fast bacilli and ideally a chest x-ray. (TB
can affect joints, but usually just one such as a hip or knee)
Other important causes of chronic cough
with fever, wt loss which can also be seen on an x-ray include lung
abscess, paragonimiasis (endemic in Cambodia), fungal infection (histoplasmosis,
and less commonly thoracic actinomycosis ). A rare cause, nocardia,
can also affect the joints, and is seen mostly in patients that are
immune deficient such as HIV. These admittedly are less likely but
offered as causes to consider should she need further work up.
More than likely, her sore throat is secondary
to the chronic cough.
2. Chronic polyarthritis
Your thoughts about checking for RA,
CBC and ESR are good, as we can evaluate for more significant
rheumatologic/connective tissue disease (rheumatoid arthritis,
systemic lupus erythematosus, etc) many of which may include
pulmonary symptoms.
Infectious arthritis seems less likely
as her symptoms have been present for 3 months - a long time.
In summary, I agree with your plan. I
might add an ANA blood test, if available, and would do a chest
x-ray to evaluate for some serious causes of chronic cough. The
amoxicillin is of very limited benefit in my opinion.
Thank you for this interesting case.
Paul Heinzelmann, MD
Massachusetts General Hospital
From: "Bunse LEANG"
<tmed1shch@online.com.kh>
To: "David R" <dmr_cambodia@yahoo.com>,
"Gary Jacques" <gjacques@bigpond.com.kh>,
"Jennifer Hines" <sihosp@bigpond.com.kh>,
"Rithy Chau"
<tmed_rithy@online.com.kh>
Cc: <tmed_montha@online.com.kh>,
<aafc@camnet.com.kh>,
"Bernie Krisher" <bernie@media.mit.edu>
Subject: RE: Patient
#5: SUM SOKNA, December 2003 Telemedicine,
Robib, Cambodia
Date: Thu, 11 Dec 2003
11:21:55 +0700
Dear
David and Montha,
We have
some questions. Does she have hair loss? Does she have skin rashes
over her cheeks (sorry the picture is not clear)? Any skin
hyperpigmentation at sun exposed areas? Her mental is OK?
We agree
with your management. We would suggest not to wait to see
improvement until next month, please send her for tests to Kg. Thom,
so that next month we have results and we could give
recommendations. Beside CBC (complete blood count, not the NFL as in
case # 4), ESR, RF, we would add UA, urine microscopy, CXR, and both
hand X-Ray AP.
Regards,
Jennifer/Bunse
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 10 December 2003
Patient #6: DOURNG SUNLY, male, 49 years
old
 |
Chief complaint: Patient complains
of general joint pain, especially both knees and both ankles, on
and off for three years.
HPI: 49-year-old male, district
official, presented with general joint pain on and off for three
years. It originally started from both ankles and then
progressed to both knees, after that radiating to all joints.
Joints are swollen on and off, and accompanied by burning
feeling in knees and ankles, sometimes with redness, and he
cannot walk. In January 2002 he went to Preah Vihear Provincial
Hospital for consultation and was admitted for 12 days. He was
diagnosed with arthritis; they gave him Benzatine, Penicillin
and some painkillers and during that time his symptoms improved
greatly. One month later all the symptoms reappeared and
continue on and off until now. Now he has severe pain on both
knee joints and both ankles, mild swelling on both knee joints
and both ankles, and mild fever and blurred vision sometimes.
Past medical history: He was
admitted to Preah Vihear Provincial Hospital for 12 days in
January 2002.
Family history: Unremarkable.
Social history: Has smoked one pack
of cigarettes per day for 30 years. He drank alcohol for 25
years but stopped two years ago.
Allergy: None known.
Current medicine: Trankal (type of
painkiller,) 1+ per day
Review of system: No sore throat, no
weight loss, has shortness of breath, no cough, has chest pain
sometimes, no abdominal pain, and no black or bloody stool.
Physical Exam:
BP: 110/50
Pulse: 80
Resp.: 28
Temp. : 36.5
Weight: 70 kg
Hair, eyes, ears, nose, and throat:
Not icteric and no lymph node enlargement.
Lungs: Clear both sides, full breath
sound
Heart: Regular rhythm, no murmur
Abdomen: Soft, big belly, has
positive bowel sound all four quadrants, no pain.
Extremities: Both knees and both
ankles mildly swollen, strong pain during bending, no redness,
has normal color, is warm to touch, other extremities okay, has
bilateral pedal pulse.
Neuro Exam:
Unremarkable
Assessment: Poly arthritis?
Plan: I would suggest referring him to
Kampong Thom Hospital for some blood work like CBC, ESR, Aslo,
Rheumatoid Factor, lytes, creatinine, Bun, blood sugar, uric
acid, and x-ray both knees and ankles.
Please give me any other ideas.
Note: I gave him one gram of
Paracetemol to take now. |
Kathy,
I have
reviewd the case , historyu and pictures
It does
sound like Synovits of undetermined itiology
I would
do what has been propsed
Perhaps
aspiration of knee joint fluid and evaluation can be of some value
as well
Some
times it is difficult to come to specific diagnoses so one may have
to treat the synovitis
I would
prefer that he should be started on aspirin small dose to high dose
if stomach does not bother him and see the response.
Perhaps
local support to the joint as a form of rest can be of value as
well.
His feet
and hands are red distally so wonder if he has also Reynaulds' or
some kind of vascular condition as well.
Let me
know what one finds
Thanks
dinesh
Dinesh Patel M.D.
Mass.Gen.Hospital
ACC 510
15 Parkman Street
Boston Mass 02114
617 726 3555
617 726 5349 fax
dgpatel@partners.org
From: "Bunse LEANG" <tmed1shch@online.com.kh>
To: "David R" <dmr_cambodia@yahoo.com>,
"Gary Jacques" <gjacques@bigpond.com.kh>,
"Jennifer Hines" <sihosp@bigpond.com.kh>,
"Rithy Chau" <tmed_rithy@online.com.kh>
Cc: <tmed_montha@online.com.kh>, <aafc@camnet.com.kh>,
"Bernie Krisher" <bernie@media.mit.edu>
Subject: RE: Patient #6: DOURNG SUNLY, December
2003 Telemedicine, Robib, Cambodia
Date: Thu, 11 Dec 2003 11:22:19 +0700
Dear
David and Montha,
We agree
with the paracetamol. He may take it regularly 500-1000 mg qid. Also
agree with the lab tests at Kg. Thom. He is obesis and (?used to be)
drinkers + his left foot picture looked like goutty arthritis.
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib, Cambodia – 10 December 2003
Patient #7: SAO PHAL, female, 56 years
old, follow up patient
 |
Subject: 56-year-old female returned
for follow up visit for DMII, hypertension and GERD. She has
improved much from the previous symptoms but still has
dizziness, has blurred vision, has shortness of breath, has
muscle pain, no fever, no cough, decreasing epigastric pain, no
chest pain, no stool with blood, has good appetite, has gained
two kg of weight, and has increased sensation in feet.
Object: BP: 120/50, Pulse:
80, Resp.: 20, Temp: 36.5, Weight: 60 kg
- Hair, Eyes, Ears, Nose and Throat: No
oropharyngeal lesions
- Neck: No JVD, no enlarged lymph node
- Lungs clear both sides
- Heart regular rhythm without murmur.
- Abdomen: Soft, flat, not tender, has
bowel sound in all four quadrants
- Extremities Unremarkable
- Neuro exam: Unremarkable.
Assessment:
1.
DMII (controlled)
2.
PNP
3.
Hypertension
(controlled)
4.
GERD
Plan: Continue same medication
for another month:
- Diamecrom, 80 mg, ½
tablet daily
- Amitriptilline, 25mg, ½ tablet twice
daily
- Famotidine, 40 mg twice daily
- Hydroclorothiazide, 50mg,
½ tablet daily
- Aspirin, 500mg, ¼ tab daily
Patient to return next month for follow
up. Do you agree? |
-----Original Message-----
From: Tan, Heng Soon,M.D.
Sent:
Wednesday,
December 10, 2003 3:06 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #7: SAO PHAL, December 2003
Telemedicine, Robib, Cambodia
Diabetes
Can
you monitor glycosylated hemoglobin or
fingerstick fasting blood
sugar, otherwise how would you know that the diabetes is well
controlled? She looks slightly overweight and may be gaining weight
because of excessive caloric intake. Has she received dietary advice
on keeping food intake to 1800 calories a day, adjusted to the level
of physical activity? Perhaps switching from diamicron to metformin
500 mg bid or metformin XL 1g qd may continue to control diabetes
without further weight gain.
Hypertension
Does
she really have hypertension? The blood pressure looks very good.
You may want to monitor her without meds for a month. If she does
need hypertensive meds, lisinopril, an ACE inhibitor, will control
blood pressure and protect kidneys from progression to diabetic
renal failure.
Blurred vision
Is there any obvious cataract on
direct illuminination examination of the eye lens? Can she read the
vision chart? If the blurred vision is chronic, I would suspect
cataract or visual refraction problem. If it is transient, it may be
related to hyperglycemia. Can her fingerstick fasting blood sugar
be measured? As for treatment, are you able to perform refraction to
prescribe eye glasses?
GERD
If GERD is controlled, famotidine 40mg
qd will suffice and be better for compliance.
Peripheral neuropathy
Amitriptyline can be given 25 mg
once a day will be better for compliance.
Heng Soon, M.D.
From: "Bunse LEANG" <tmed1shch@online.com.kh>
To: "David R" <dmr_cambodia@yahoo.com>,
"Gary Jacques" <gjacques@bigpond.com.kh>,
"Jennifer Hines" <sihosp@bigpond.com.kh>,
"Rithy Chau" <tmed_rithy@online.com.kh>
Cc: <tmed_montha@online.com.kh>, <aafc@camnet.com.kh>,
"Bernie Krisher" <bernie@media.mit.edu>
Subject: RE: Patient #7: SAO PHAL, December
2003 Telemedicine, Robib, Cambodia
Date: Thu, 11 Dec 2003 11:23:06 +0700
Dear
David and Montha,
Like in
patient # 1, we would do amitriptylline at bedtime only (2 tab),
HCTZ maximum 25 mg a day in DM II (so decrease it), ASA 500mg 1/4tab
daily, and check her BS.
About
dyspepsia, the treatment is 2 months, unless frequent relapse. Would
stop famotidine.
We are
not sure why SOB. Could you help her having EKG and CXR at Kg.
Thom?
Regards,
Jennifer/Bunse
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 10 December 2003
Patient #8: EM SOKLEY, female, 25 years
old
 |
Chief complaint: Patient complains
of epigastric pain for two months, diarrhea on and off for two
months.
HPI: 25-year-old female farmer gets
epigastric pain, like a burning sensation, especially after a
meal. She feels something come up to her chest and then
excessive saliva and nausea in the morning. She also has
diarrhea on and off, comes at the same time as epigastric pain
and is accompanied by weakness and palpitations. At the
beginning of the symptoms two months ago she bought some antacid
medicine at the local pharmacy; it helped her for four days but
because of lack of finances she could not afford to buy any more
and stopped using it, now all the symptoms have returned.
Past medical history: Unremarkable.
Family history: Has three children;
her husband is a farmer.
Social history: Does not smoke and
does not drink alcohol.
Allergy: None known.
Current medicine: Use traditional
medicine for more than one month.
Review of system: No sore throat,
weight loss of about three kg, no cough, no fever, no chest
pain, has palpitations, has epigastric pain, and no black or
bloody stool.
Physical Exam: Alert and
oriented x 3 (place, person, and time.)
BP: 110/60, Pulse: 90,
Resp.: 20, Temp: 37, Weight: 40 kg
Hair, eyes, ears, nose, and throat:
No oropharyngeal lesions, not icteric
Neck: No JVD, and no enlarged lymph
node
Heart: Regular rhythm, no murmur
Lungs: Clear both sides, no crackle
and no wheezing.
Abdomen: Soft, flat, not tender, has
positive bowel sound all four quadrants.
Extremities: No edema, no deformity
Assessment:
- Dyspepsia
- Parasitis?
- Malnutrition
Plan: Should we cover her with
some medications like:
- Tums, 1 gram twice daily for one
month
- Multivitamin, one
tablet daily for one month
- Mebendazole, 100 mg twice daily, for
three days
Please give me any other ideas. |
presumptive dx: GERD with possible PUD.
I am concerned with the 3 kg wt loss
considering she only weighs 40 kg, and this should be monitored
carefully. The post prandial pain may be indicative of ulcer
disease. An H2 blocker (like zantac) or proton pump inhibitor (like
omeprazole) would be best in this situation. If CBC to rule out
anemia and liver enzymes are available, they should be checked. If
H. Pylori status is not known or cannot be done (antibody test), she
could even be treated empirically for H. Pylori eradication (if
medicaiton available) w/ omeprazole 20mg bid, amoxicillin 500mg bid,
clarithromycin 500mg bid for 10 days to 2 wks. If symptoms persist
would consier Barium UGI series or endoscopy for further evaluation
of peptic ulcer disease. She should elevate the head of her bed at
night and avoid caffeinated beverages, even hot beverages before
bed, and other foods which may exacerbate GERD symptoms.
If parasitic infection is of concern, would
check stool O&P prior to treating.
hope this helps.
J. Benjamin Crocker, M.D.
Internal Medicine Associates 3
WACC 605
15 Parkman Street
Boston, MA 02114
Phone 617 724-8400
Fax 617 724-0331
Email jbcrocker@partners.org
Please note: This email may contain
confidential patient information which is legally protected by
patient-physician privilege. If you are not the intended recipient,
you are hereby notified that any disclosure, copying, or
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apologize for any inconvenience.
Date: Thu, 11 Dec
2003 10:07:33 +0700
From: ruth_tootill@online.com.kh
To: David R <dmr_cambodia@yahoo.com>
Subject: Re: Patient
#8: EM SOKLEY, December 2003 Telemedicine, Robib, Cambodia
Dear David,
I think your
management plan is appropriate.
Ruth
From: "Bunse LEANG"
<tmed1shch@online.com.kh>
To: "David R" <dmr_cambodia@yahoo.com>,
"Gary Jacques" <gjacques@bigpond.com.kh>,
"Jennifer Hines" <sihosp@bigpond.com.kh>,
"Rithy Chau"
<tmed_rithy@online.com.kh>
Cc: <tmed_montha@online.com.kh>,
<aafc@camnet.com.kh>,
"Bernie Krisher" <bernie@media.mit.edu>
Subject: RE: Patient
#8: EM SOKLEY, December 2003 Telemedicine,
Robib, Cambodia
Date: Thu, 11 Dec 2003
11:23:20 +0700
Dear
David and Montha,
We agree
with your management, follow-up next month. If better continue Tums
one more month to complete 2 months total. If not better switch to
Famotidine.
Regards,
Jennifer/Bunse
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 10 December 2003
Patient #9: REAM SREY BORN, female, 23
years old
 |
Chief complaint: Patient complains
of fever and abdominal pain on and off for one month.
HPI: 23-year-old female farmer has
abdominal pain, especially around umbilical area, pain radiating
to chest, especially after a meal. During the start of
abdominal pains she also had a fever of around 39-40 degrees
accompanied by headache, stool with mucus, abdominal distension
as well. She went to a private local clinic and was treated
with some unknown medication that didn’t help her at all and her
symptoms still appear.
Past medical history: Unremarkable.
Family history: Has one child.
Social history: Does not smoke and
does not drink alcohol.
Allergy: None known.
Current medicine: None.
Review of system: No sore throat, no
weight loss, no cough, has a fever, no chest pain, has pain in
umbilical area, no black or bloody stool, has poor appetite, and
has nausea.
Physical Exam: Alert and
oriented x 3
BP: 100/60, Pulse: 90,
Resp.: 20, Temp: 38, Weight: 44 kg
Hair, eyes, ears, nose, and throat:
Not icteric and no oropharyngeal lesions.
Neck: No JVD, and no enlarged lymph
node
Lungs: Clear both sides, no crackle
and no wheezing.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, has
mild pain on umbilical area, has positive bowel sound all four
quadrants and much more active, no HSM.
Extremities: Unremarkable
Malaria test: Negative on 6 December
2003.
Assessment:
- Typhoid Fever?
- GERD?
- Parasitis?
Plan: We would like to cover her
with:
- Gatifloxacine, 40 mg once daily, for
ten days
- Famotidine, 40 mg once daily, for 30
days
- Mebendazole, 100 mg twice daily, for
three days
- Paracetemol, 500 mg, one tablet four
times daily as needed, for five days
|
Patient #9: REAM SREY BORN, female, 23 years
old
Thank you for this
interesting patient.
Your thought of
Typhoid fever seems appropriate as fever, headache and abdominal
distention are typical - particularly in the abscence of
diarrhea. As you know, this can become quite serious.
Blood and/or stool
culture/smear may not be practical at this, in which case, simply
treating it for possible Typhoid seems reasonable. Cipro 500 BID
for ten days is reasonable but gatifloxacin may be good
alternative. (other option azithromycin 1 5 po qd x 5 days)
The mebendazole
would treat intestinal worms such as ascaris.
Finally, GERD , or
H. pylori are important considerations.
I would concur and
agree with your plan, but be prepared to consider other causes if
diarrhea develops or symptoms worsen. (ie Giardiasis, etc.)
Thank you for this
interesting patient.
Paul Heinzelmann,
MD
Massachusetts General
Hospital
Date: Thu, 11 Dec
2003 10:04:59 +0700
From: ruth_tootill@online.com.kh
To: David R <dmr_cambodia@yahoo.com>
Subject: Re: Patient
#9: REAM SREY BORN, December 2003 Telemedicine, Robib, Cambodia
Dear David,
Thanks for your
letter.
I think your
management is appropriate. The temperature is more against GERD.
The only other
possible diagnosis I would think of is a liver abscess - probably
amebic. However, your treatment would cover this, but may need to
be prolonged for three weeks.
Yours sincerely,
Ruth Tootill
From: "Bunse LEANG"
<tmed1shch@online.com.kh>
To: "David R" <dmr_cambodia@yahoo.com>,
"Gary Jacques" <gjacques@bigpond.com.kh>,
"Jennifer Hines" <sihosp@bigpond.com.kh>,
"Rithy Chau"
<tmed_rithy@online.com.kh>
Cc: <tmed_montha@online.com.kh>,
<aafc@camnet.com.kh>,
"Bernie Krisher" <bernie@media.mit.edu>
Subject: RE: Patient
#9: REAM SREY BORN, December 2003 Telemedicine, Robib, Cambodia
Date: Thu, 11 Dec 2003
11:25:09 +0700
Dear
David and Montha,
We have
some questions. Does she have dysuria? Does she have tenesmus? Does
she have vaginal discharge? Any vaginal exam?
We agree
with your management. If tenesmus or vaginal discharge, we would add
metronidazole 500 mg TID for 5 days.
Regards,
Jennifer/Bunse
Sorry for delay in
responding. was unable to get to email yesterday afternoon. Agree
typhoid possible. would also rule out pregancy/ectopic/PID. Agrre
with regimen. Doubt the mebendazole will do much. Good luck,
Edward T. Ryan,
M.D., DTM&H
Tropical & Geographic Medicine Center
Division of Infectious Diseases
Massachusetts General Hospital
Jackson 504
55 Fruit Street
Boston,
Massachusetts 02114 USA
Administrative
Office Tel: 617 726 6175
Administrative Office Fax: 617 726 7416
Patient Care Office Tel: 617 724 1934
Patient Care Office Fax: 617 726 7653
Email: etryan@partners.org or ryane@helix.mgh.harvard.edu
The information
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is prohibited. If you received this email in error, please contact
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Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 10 December 2003
Patient #10: THO CHANTHY, female, 36
years old, follow up patient
 |
Subject: 36-year-old female came to
follow up her hyperthyroidism. Her previous symptoms have
improved a lot. Now she has less blurred vision, decreased
shortness of breath, decreased palpitations, no tremors, better
appetite, weight gain of one kg, and better sleeping as well.
Object: BP: 100/60, Pulse:
68, Resp.: 20, Temp: 36.5, Weight: 53 kg
Hair, eyes, ears, nose, and throat:
Has exophthalsis (bilateral,) other areas okay.
Neck: Same size as before, has
enlarged thyroid.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, no HSM, has
positive bowel sound all four quadrants.
Extremities: No edema and no tremor
Assessment: Hyperthyroidism.
Plan: Continue with same medications for
another month:
- Carbimazole, 5mg, one tablet three
times daily
- Propranolol, 40mg, 1/4 tablet twice
daily
- Aspirin, 300mg, 1/4 tablet
daily
- Multivitamin, one tablet daily
|
Draw her blood for both TSH and T4 to
test at SHCH.
Do you have any other ideas or comment?
-----Original Message-----
From: Crocker, Jonathan T., M.D.
Sent:
Wednesday,
December 10, 2003 4:14 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #10: THO CHANTHY, December 2003
Telemedicine, Robib, Cambodia
Importance: High
Good
Morning,
It would
be helpful to know what her presenting symptoms were and what the
presumed diagnosis was. For example do you think this was classic
Graves' disease? Does she have multiple nodules on exam. Is there
any reason that she could not have a radioactive iodine uptake scan
(ie is she breast feeding or is she pregnant, available, cost)? It
would help confirm your diagnosis as to what's causing the
hyperthyroidism. I would suggest checking T3 levels and T4
levels. If you have piror T3 and T4 levels, sometimes calculating
their ratio can help suggest a cause -- ie Graves' disease you see
ratio T3:T4 > 20 ng/dl or ug/dl or > 0.3 molar.
Patients
should have thyroid funciton tested each 4-6 weeks. Initial TSH for
several months may be misleading becasue it is suppressed by
hyperthyroidism, so it's important to follow T4 and T3 during the
first several months. When the TSH rises to the normal range, then
follow only the T4 and TSH, no need to measure T3. Usually have to
treat for several years with thionamide therapy, but can be stopped
anytime if pt proceeds with radioiodine treatment or surgery.
Best
regards,
Dr.
Crocker
From: "Bunse LEANG" <tmed1shch@online.com.kh>
To: "David R" <dmr_cambodia@yahoo.com>,
"Gary Jacques" <gjacques@bigpond.com.kh>,
"Jennifer Hines" <sihosp@bigpond.com.kh>,
"Rithy Chau" <tmed_rithy@online.com.kh>
Cc: <tmed_montha@online.com.kh>, <aafc@camnet.com.kh>,
"Bernie Krisher" <bernie@media.mit.edu>
Subject: RE: Patient #10: THO CHANTHY, December
2003 Telemedicine, Robib, Cambodia
Date: Thu, 11 Dec 2003 11:25:45 +0700
Dear
David and Montha,
Good,
patient improves. Agree with T4 check (no need TSH) in SHCH. No need
MTV.
Regards,
Jennifer/Bunse
Fri, 12
Dec 2003 06:37:25 -0500
"Dr. Srey
Sin" <012905278@mobitel.com.kh>
"Bernie
Krisher" <bernie@media.mit.edu>, seda@bizdaily.forum.org.kh, aafc@camnet.com.kh
Robib Telemedicine patients admitted last night
Please reply to David Robertson
dmr@media.mit.edu
Dear Dr. Srey Sin,
The following two attachments are the Telemedicine patient notes
from Nurse Montha, and the return advice of the physicians in Boston
and Phnom Penh, for the two patients we brought to Kampong Thom
Provincial Hospital last night.
Thank you for helping these patients.
Best regards,
David Robertson
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 10 December 2003
Patient #5: SUM SOKNA, female, 20 years
old
|
|
Chief complaint: Pain on all
finger, ankle, knee, wrist, and elbow joints for three months.
Has had dry cough and sore throat on and off for one year.
HPI: 20-year-old female presented
with general joint pain all over the body, especially in the
morning. Sometimes she can’t walk; both knees have been swollen
on and off as well. She also has a dry cough, has sore throat
on and off, has mild fever, has nausea, has weight loss of about
five kg over six months, has good appetite, has shortness of
breath, no chest pain, no palpitations, and no black or bloody
stool.
Past medical history: Unremarkable.
Family history: Unremarkable.
Social history: Does not smoke and
does not drink alcohol.
Allergy: None known.
Current medicine: None.
Physical Exam:
BP: 120/60
Pulse: 86
Resp.: 20
Temp. : 37.3
Weight: 44 kg
Object: Alert and oriented x 3
(place, person, and time.)
Hair, eyes, ears, nose, and throat:
Not icteric, has mild redness oropharyngeal but tonsil not
enlarged, no lymph node enlargement, and no pus.
Lungs: Clear both sides, no crackle
and no wheezing.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, has
positive bowel sound all four quadrants, no HSM.
Extremities: All joints no
deformity, no stiffness, no edema, no redness, and has normal
color.
Neuro exam: Unremarkable.
Assessment:
- Poly Arthritis?
- Rheumatoid Fever?
- Chronic Pharyngitis.
Plan: We would like to cover her
with:
- Amoxycillin, 500 mg three times
daily, for seven days
- Ibuprofen, 400 mg, one tablet three
times for 15 days
Follow up at next month’s clinic. If
not better send her to Kampong Thom for some blood work like
Rheumatoid Factor, CBC and ESR. Do you agree? Please give me
any other ideas. |
Kathy,
I do
not have any specific suggestions but question of Rheumatoid
Arthrits does come in my mind
She has
pink cheeks so wonder if she also has some kind of skin disorder or
secondary to rh fever or what
Can they do the blood work before starting the treatment.
How
about just give high dose of Ibuprofen 800mg three times a day and
not give Amoxycillin antibiotics and see the response in 7 days.
Thanks
dinesh
Dear David,
I understand you have already received a
response from another doctor.
I add mine as further consideration.
Paul
Patient #5: SUM SOKNA, female, 20 years old
Chief complaint: Pain on all finger, ankle,
knee, wrist, and elbow joints for three months. Has had dry cough
and sore throat on and off for one year Thank you for this
interesting case.
To start, I think we can deal with these as two
separate problems for now, realizing they may be related.
1. Chronic cough
2. Chronic polyarthritis
1. Chronic cough
In a patient with cough, fever, SOB, wt
loss- we need to consider TB as a possibility.
To evaluate for this, she needs to have
sputum checked for acid-fast bacilli and ideally a chest x-ray. (TB
can affect joints, but usually just one such as a hip or knee)
Other important causes of chronic cough
with fever, wt loss which can also be seen on an x-ray include lung
abscess, paragonimiasis (endemic in Cambodia), fungal infection (histoplasmosis,
and less commonly thoracic actinomycosis ). A rare cause, nocardia,
can also affect the joints, and is seen mostly in patients that are
immune deficient such as HIV. These admittedly are less likely but
offered as causes to consider should she need further work up.
More than likely, her sore throat is secondary
to the chronic cough.
2. Chronic polyarthritis
Your thoughts about checking for RA,
CBC and ESR are good, as we can
evaluate for more significant
rheumatologic/connective tissue disease (rheumatoid arthritis,
systemic lupus erythematosus, etc) many of which may include
pulmonary symptoms.
Infectious arthritis seems less likely
as her symptoms have been present for 3 months - a long time.
In summary, I agree with your plan. I
might add an ANA blood test, if available, and would do a chest
x-ray to evaluate for some serious causes of chronic cough. The
amoxicillin is of very limited benefit in my opinion.
Thank you for this interesting case.
Paul Heinzelmann, MD
Massachusetts General Hospital
From: "Bunse LEANG"
<tmed1shch@online.com.kh>
To: "David R" <dmr_cambodia@yahoo.com>,
"Gary Jacques" <gjacques@bigpond.com.kh>,
"Jennifer Hines" <sihosp@bigpond.com.kh>,
"Rithy Chau"
<tmed_rithy@online.com.kh>
Cc: <tmed_montha@online.com.kh>,
<aafc@camnet.com.kh>,
"Bernie Krisher" <bernie@media.mit.edu>
Subject: RE: Patient
#5: SUM SOKNA, December 2003 Telemedicine,
Robib, Cambodia
Date: Thu, 11 Dec 2003
11:21:55 +0700
Dear
David and Montha,
We have
some questions. Does she have hair loss? Does she have skin rashes
over her cheeks (sorry the picture is not clear)? Any skin
hyperpigmentation at sun exposed areas? Her mental is OK?
We agree
with your management. We would suggest not to wait to see
improvement until next month, please send her for tests to Kg. Thom,
so that next month we have results and we could give
recommendations. Beside CBC (complete blood count, not the NFL as in
case # 4), ESR, RF, we would add UA, urine microscopy, CXR, and both
hand X-Ray AP.
Regards,
Jennifer/Bunse
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 10 December 2003
Patient #6: DOURNG SUNLY, male, 49 years
old
|
|
Chief complaint: Patient complains
of general joint pain, especially both knees and both ankles, on
and off for three years.
HPI: 49-year-old male, district
official, presented with general joint pain on and off for three
years. It originally started from both ankles and then
progressed to both knees, after that radiating to all joints.
Joints are swollen on and off, and accompanied by burning
feeling in knees and ankles, sometimes with redness, and he
cannot walk. In January 2002 he went to Preah Vihear Provincial
Hospital for consultation and was admitted for 12 days. He was
diagnosed with arthritis; they gave him Benzatine, Penicillin
and some painkillers and during that time his symptoms improved
greatly. One month later all the symptoms reappeared and
continue on and off until now. Now he has severe pain on both
knee joints and both ankles, mild swelling on both knee joints
and both ankles, and mild fever and blurred vision sometimes.
Past medical history: He was
admitted to Preah Vihear Provincial Hospital for 12 days in
January 2002.
Family history: Unremarkable.
Social history: Has smoked one pack
of cigarettes per day for 30 years. He drank alcohol for 25
years but stopped two years ago.
Allergy: None known.
Current medicine: Trankal (type of
painkiller,) 1+ per day
Review of system: No sore throat, no
weight loss, has shortness of breath, no cough, has chest pain
sometimes, no abdominal pain, and no black or bloody stool.
Physical Exam:
BP: 110/50
Pulse: 80
Resp.: 28
Temp. : 36.5
Weight: 70 kg
Hair, eyes, ears, nose, and throat:
Not icteric and no lymph node enlargement.
Lungs: Clear both sides, full breath
sound
Heart: Regular rhythm, no murmur
Abdomen: Soft, big belly, has
positive bowel sound all four quadrants, no pain.
Extremities: Both knees and both
ankles mildly swollen, strong pain during bending, no redness,
has normal color, is warm to touch, other extremities okay, has
bilateral pedal pulse.
Neuro Exam:
Unremarkable
Assessment: Poly arthritis?
Plan: I would suggest referring him to
Kampong Thom Hospital for some blood work like CBC, ESR, Aslo,
Rheumatoid Factor, lytes, creatinine, Bun, blood sugar, uric
acid, and x-ray both knees and ankles.
Please give me any other ideas.
Note: I gave him one gram of
Paracetemol to take now. |
Kathy,
I have
reviewd the case , historyu and pictures
It does
sound like Synovits of undetermined itiology
I would
do what has been propsed
Perhaps
aspiration of knee joint fluid and evaluation can be of some value
as well
Some
times it is difficult to come to specific diagnoses so one may have
to treat the synovitis
I would
prefer that he should be started on aspirin small dose to high dose
if stomach does not bother him and see the response.
Perhaps
local support to the joint as a form of rest can be of value as
well.
His feet
and hands are red distally so wonder if he has also Reynaulds' or
some kind of vascular condition as well.
Let me
know what one finds
Thanks
dinesh
Dinesh Patel M.D.
Mass.Gen.Hospital
ACC 510
15 Parkman Street
Boston Mass 02114
617 726 3555
617 726 5349 fax
dgpatel@partners.org
From: "Bunse LEANG" <tmed1shch@online.com.kh>
To: "David R" <dmr_cambodia@yahoo.com>,
"Gary Jacques" <gjacques@bigpond.com.kh>,
"Jennifer Hines" <sihosp@bigpond.com.kh>,
"Rithy Chau" <tmed_rithy@online.com.kh>
Cc: <tmed_montha@online.com.kh>, <aafc@camnet.com.kh>,
"Bernie Krisher" <bernie@media.mit.edu>
Subject: RE: Patient #6: DOURNG SUNLY, December
2003 Telemedicine, Robib, Cambodia
Date: Thu, 11 Dec 2003 11:22:19 +0700
Dear
David and Montha,
We agree
with the paracetamol. He may take it regularly 500-1000 mg qid. Also
agree with the lab tests at Kg. Thom. He is obesis and (?used to be)
drinkers + his left foot picture looked like goutty arthritis.
Follow up Report, Friday, 12 December 2003
Per e-mail advice of the physicians in Boston and Phnom Penh,
two patients from this month’s clinic agreed to go to the hospital:
Patient #5: SUM SOKNA, female, 20 years old, was taken to
Kampong Thom Provincial Hospital by the Telemedicine team on
Thursday, 11 December 2003. She has been admitted for tests.
Patient #6: DOURNG SUNLY, male, 49 years old, was taken to
Kampong Thom Provincial Hospital by the Telemedicine team on
Thursday, 11 December 2003. This patient was in a lot of pain by
the time he arrived at the hospital and could not walk on his own so
we moved him from the truck to the admitting area on a stretcher.
This patient lives outside of Robib village and will take care of
all of his own health care costs.
Per
e-mail advice of the physicians in Boston and Phnom Penh, patients
from this month’s clinic and several follow up cases were given
medication from the pharmacy in the village or medication that was
donated by Sihanouk Hospital Center of Hope:
Patient #1: SOM THOL, male, 50 years old, follow up patient
Patient #2: PEN VANNA, female, 37 years old, follow up
patient
Patient #3: NGET SOEUN, male, 56 years old, follow up patient
Patient #4: SAO CHHOUN, male, 37 years old, follow up patient
Patient #7: SAO PHAL, female, 56 years old, follow up patient
Patient #8: EM SOKLEY, female, 25 years old
Patient #9: REAM SREY BORN, female, 23 years old
Patient #10: THO CHANTHY, female, 36 years old, follow up
patient
November 2003 Patient: MUY VUN, male, 36 years old
November 2003 Patient: THORN KHUN, female, 38 years old
October 2003 Patient: YEM PHALA, male, 55 years old
May 2003 Patient: SOM DEUM, female, 63 years old
November 2003 Patient CHHOURN SOKHON, male, 45 years old,
returned to the Telemedicine clinic this month after last month’s
trip to Sihanouk Hospital. Nurse Montha inspected and cleaned the
patient’s wound. The patient was advised to keep cleaning the wound
daily and to return to the Telemedicine clinic next month.
Transport arranged for 26 December 2003 follow up appointment at
Sihanouk Hospital Center of Hope in Phnom Penh:
September 2001 Patient: PHENG ROEUNG, female, 58 years old
This patient will stay with one of her relatives in Phnom Penh.
Transport & lodging arranged for 2 January 2004 follow up
appointment at Sihanouk Hospital Center of Hope in Phnom Penh. We
have been following this patient’s heart condition since the very
first Telemedicine clinic:
February 2001 Patient: NOUNG KIM CHHANG, male, 50
years old
Transport & lodging was arranged last month for a 28 November 2003
follow up appointment at Kantha Bhopa Children’s Hospital in Phnom
Penh. Normally this child receives a penicillin injection for her
polyarthritis condition and returns back to the village the next day
but the doctors at Kantha Bhopa decided to admit her. She is still
in the hospital as of this date:
June 2001 Patient: SENG SAN, female, 13-year-old child
Transport & lodging was arranged last month for a 28 November 2003
follow up appointment at Calmette Cardiology Hospital in Phnom
Penh. We have been following this child’s heart condition since the
very first Telemedicine clinic. Previously too weak, and now three
and a half years old, she just recently started walking:
February 2001 Patient: CHHEM LYNA, female,
3-year-old child
The next Telemedicine Clinic
in Robib, Cambodia will be on Tuesday, January 7, 2004.
