January 2003 Telemedicine Clinic in Robib
Report and photos
submitted by David Robertson
On Tuesday,
January 14, 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. Data was transmitted
via the Nicholas and Elaine Negroponte School Internet
link.
The following
day, all patients returned to the Robib Health Clinic. Nurse "Montha"
discussed advice received from the physicians in Boston and Phnom
Penh with the patients.
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
dmr@media.mit.edu
Dear All:
A quick reminder that the next Telemedicine clinic in Robib,
Cambodia takes place this Tuesday, 14 January 2003.
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your kind assistance.
Sincerely,
David
please reply to
dmr@media.mit.edu
Dear All:
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your assistance.
Sincerely,
David
Telemedicine Clinic in Robib, Cambodia
14 January 2003
Patient #1: KONG HAM, female, 35 years
old, farmer
 |
Chief complaint: Upper abdominal
pain on and off the last two months.
History of present illness: Two
months ago she gets upper abdominal pain on and off, pain like
burning, especially after meal. Pain radiates to the back,
sometimes radiates to the whole abdomen, and is accompanied by
excessive saliva in the morning, burping, headache, and blurred
vision as well. She hasn’t consulted with any medical people,
just came to see us directly.
Current medicine: None
Past medical history: Four years ago
she lost a large amount of blood during delivery.
Social history: Unremarkable
Family history: Unremarkable
Allergies: None
Review of system: Has upper
abdominal pain, no cough, no fever, no dyspnea, has stool with
slight blood, no diarrhea, and no chest pain.
Physical exam
General Appearance: Looks
mildly sick.
BP: 100/60
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Neck: No goiter, no JVD, and no lymph node.
Skin: Warm to touch, not pale and no rash.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, and positive bowel sound.
Limbs: Not stiff, no edema, and no pain.
Assessment: Dyspepsia. Chronic GI?
Parasitis?
Recommend: Should we cover her
with Famotidine 40mg per day for 30 days and Mebendazole 100mg
twice daily for three days? Please give me any other ideas.
|
Sounds like gastroesophageal reflux rather than
peptic ulcer disease with recurrent complaint.
Famotidine will be appropriate. After a month therapy she may use it
whenever the pain recurs. There is no reason to suspect parasite
infection since the pain is epigastric rather than central. You
could do stool microscopy to look for ova and parasites if that is
possible.
Tan,
Heng Soon,M.D.
SHCH
reply:
David,
I
agree with your recommendations for famotidine and mebendazole for
the dose and duration you suggest. If symptoms persist, I would
consider and ultrasound or her gallbladder.
Gary
Jacques
please reply to
dmr@media.mit.edu
Dear All:
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your assistance.
Sincerely,
David
Telemedicine Clinic in Robib, Cambodia
14 January 2003
Patient #2: SAO PHAL, female, 55 years
old, follow up patient
 |
Chief complaint: Still weakness,
headache, neck tenderness, sometimes chest pain and shortness of
breath.
History of present illness: We see
this patient every month and have sent her to Kampong Thom
Hospital two times. The first time we saw her, her BP was
220/170. She has diagnosis of DMII, hypertension (stable,) and
PNP. We put her on Diamecrom 80mg per day and Nifedipine 20 mg
per day following the doctor’s prescription from Kampong Thom
Provincial Hospital. Just last month we sent her back to Kampong
Thom Provincial Hospital to evaluate her condition as she was
getting worse day to day. The doctors there said she did not
have DMII at all so they decided to stop her Diamecrom and
Nifedipine. They said she has a mental problem and scheduled
her to come back to Kampong Thom Hospital at the end of this
month. Since stopping her meds three weeks ago, her blood sugar
today is 485mg/dl. Now she also complains of chest pain on and
off, limb numbness and frequency of urination, and blurred
vision.
Physical exam
BP: 100/50
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Lungs: Lungs clear both sides
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, and positive bowel sound.
Limbs: Mild numbness.
Blood sugar: 485 mg/dl
Assessment: Hypertension (stable.) DMII,
PNP, IHD?
Recommend: Should we send her to
Sihanouk Hospital Center of Hope for some blood tests like CBC,
lyte, creat., Bun, glycemie, plus an EKG. I want to verify her
blood work with our hospital. Please give me any other ideas.
|
Exam Data from 12 December 2002:
Patient #1: SAO PHAL, female, 55 years
old, follow up patient
Chief complaint: Still has weakness,
shortness of breath, and chest tightness radiating to upper back.
History of present illness: We have
seen this patient 4-5 times. She has diagnosis of hypertension,
DMII and PNP. We put her on Diamecrom 80mg per day and Nifedipine
20 mg per day following the doctor’s prescription from Kampong Thom
Provincial Hospital. We also followed the ideas of Sihanouk Hospital
Center of Hope but her condition is not better. She gets worse and
worse, her blood sugar has increased every month; last month
255mg/dl, this month 295mg/dl. She also complains of chest
tightness and shortness of breath. Sometimes she faints on the spot
with numbness on the limbs and increased urination as well.
Physical exam
BP: 100/50
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Lungs: Lungs clear.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, no HSM, and positive bowel sound.
Limbs: Mild numbness.
Blood sugar: 295 mg/dl
Assessment: Hypertension (stable.) DMII,
PNP, IHD?
Recommend: I would like suggest
referring her back to Kampong Thom Provincial Hospital for some
blood tests like CBC, lyte, creat., Bun, BS, plus an EKG. Please
give me any other ideas.
Please reply to
dmr@media.mit.edu
We have the follow-up
clinic with the patients on Wednesday morning (8:00am, 27 November
2002, Robib time.) Best if we could receive your e-mail advice
before this time (Tuesday, 8:00pm, 26 November 2002, in Boston.)
Telemedicine Clinic in Robib, Cambodia
26 November 2002
Patient #2: SAO PHAL, female, 55 years
old, follow up patient
Chief complaint: Still has chest
tightness and neck tenderness.
History of present illness: This
patient we have seen many times. She follows up every month for
continuing medication. She has hypertension and DMII. We sent her
to Kampong Thom Hospital, first time in February 2002. The doctor
there agreed to put her on Adalate 20 mg per day and Diamecrom 80 mg
half tablet per day, and Aspirin 150 mg daily. We follow this
prescription every month. Though her condition is a bit better, she
still has chest tightness, sometimes weakness, and frequency of
urination.
Physical exam
BP: 120/80
Pulse: 85
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Lungs: Lungs clear.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, positive bowel sound, and no pain.
Limbs: Okay.
Blood sugar: 255 mg/dl
Assessment: Hypertension (stable.) DMII.
PNP.
Recommend: I would like suggestions
from you. May we put her on the same dose of hypertension medicine
and increase the Diamecrom dose from 40 mg per day to 80 mg per day,
also give her multivitamins, one tab per day, then follow up at next
clinic? Please give me any other ideas.
-----Original Message-----
From: Tan, Heng Soon,M.D.
Sent: Tuesday, January 14, 2003 11:33 AM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: Patient #2: SAO PHAL, Cambodia
Telemedicine, 14 January 2003
Can
we get the blood test results from her previous visits to the
hospital? She must have been tested for electrolytes, renal
function, blood sugar and ekg. What is PNP?
She
has diabetes and it is out of control. So I would have her resume
her Diamicron 80 mg qd.
It
will be useful to get an ekg or better still an exercise or stress
EKG to confirm whether she has coronary artery disease. If Sihanouk
Hospital can do that, then it's worthwhile. Otherwise, one could
empirically treat her for unstable angina with nitroglycerin to see
whether her chest pain is relieved. If it is, then she could start a
beta blocker like metoprolol 25 mg bid, titrating every week to 50
mg bid if necessary to prevent chest pain, while monitoring for
bradycardia [pulse less than 50/m] or orthostatic hypotension.
Tan,
Heng Soon,M.D.
SCHC
reply:
Restart the diamecrom 80mg/day and place her on an aspirin 1 tablet
per day. I am surprised the blood pressure is low off her
antihypertensive medication but lets
not restart
nifedipine now. I agree she needs an EKG and lab workup. Send her
to the hospital for that. (If she can make the trip to SHCH that
would be great) --Gary Jacques
please reply to
dmr@media.mit.edu
Dear All:
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your assistance.
Sincerely,
David
Telemedicine Clinic in Robib, Cambodia
14 January 2003
Patient #3: SOM THOL, male, 49 years
old, follow up patient
 |
Chief complaint: Wound on the left
sole for last four days, and still numbness on the limbs, and
sometimes epigastric pain.
History of present illness: We see
this patient every month and follow up on his monthly diabetic
medication. He has a diagnosis of DMII and PNP. We cover him
with Diamecrom 80mg twice daily and Vitamin B1 250 mg daily
following the doctors’ e-mail advice. Four days ago he got
burnt by fire on the left sole, size of wound is about 4 x 3 cm,
wound gets more painful day to day, looks pale on wound, and
oozing comes out. Besides this new problem he complains of limb
numbness and epigastric pain after a meal. His blood sugar is
493mg/dl after a meal today.
Physical exam
BP: 90/40
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound, and
has epigastric pain.
Limbs: Mild numbness and on the left
sole has a wound, size of wound is about 4 x 3cm.
Blood sugar: 493 mg/dl (after meal)
Assessment: DMII. PNP. Dyspepsia?
Left sole wound infection.
Recommend: Should we cover him
with the same medication and add cloxacilline 500mg four times
daily for ten days and Tums, 1 gram three times daily for 30
days. Clean wound every day and keep restricting sweet
diet. Please give me any other ideas.
|
From: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>
To: 'David Robertson' <davidrobertson1@yahoo.com>,
"Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>,
"Qureshi, Abrar A.,M.D." <AQURESHI@PARTNERS.ORG>
Cc: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>,
"Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>
Subject: RE: Patient #3: SOM THOL, Cambodia
Telemedicine, 14 January 2003
Date: Tue, 14 Jan 2003 14:31:36 -0500
Hello,
The gentleman has several problems.
-
Burn, L foot. This type of wound
is very serious in a diabetic, and proper treatment is essential
to preserving this patient’s limb. It is not clear that he has an
infection, but I would certainly treat him as if he does. If this
is an infection, he at risk for developing osteomyelitis (bone
infection), which could be life threatening. I recommend the
following:
-
-
Incision and drainage of the
lesion under sterile conditions, un-roofing what appears to be a
blister
-
-
Cloxacillin 500mg PO QID is a
good choice to cover the most likely organisms, staph or strep. It
would be preferable, however, to also cover gram negative bacteria
and anaerobes. If you have a second generation cephalosporin and
flagyl that would cover all organisms we are worried about.
-
-
It is imperative that he keep
his foot clean. It needs to be washed once a day, covered with a
topical antibiotic such as bacitracin, and covered with a dry
sterile dressing. Perhaps you can teach him to do this in the
village. Please emphasize how important this will be to preserving
his limb.
-
Limb numbness. The ddx include
peripheral neuropathy due to diabetes, which is most likely, but
Hansen’s disease and HIV are possibilities.
-
Diabetes. His blood sugar is quite
high, placing him at risk for the many complications of diabetes,
including poor wound healing. Is he taking his diamecrom? I am not
familiar with this medication, but it should either be increased
or he should be started on another diabetes medication.
Restricting sweets and simple carbohydrates is essential.
-
Epigastric pain. Gastritis or
peptic ulcer related pain are most likely. Tums is a good choice.
If pain does not remit famotidine would be the next step.
-
PLEASE HAVE HIM FOLLOW-UP AT THE
NEXT CLINIC.
I hope this helps.
Sincerely,
Iris Kedar, M.D.
SCHC
reply: Agree with your medication choices except I would add ofloxin
400mg bid if you have it. This person is at risk of complications
and needs to have the wound and blood supply to the foot evaluated
by a physician. Send to regional hospital or SHCH for eval. --Gary
Jacques
please reply to
dmr@media.mit.edu
Dear All:
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your assistance.
Sincerely,
David
Telemedicine Clinic in Robib, Cambodia
14 January 2003
Patient #4: HENG SOK, female, 34 years
old, farmer
 |
Chief complaint: Epigastric pain on
and off for more than one month, getting worse the last three
days.
History of present illness: For
more than one month she has epigastric pain on and off. Just
three days ago she got severe abdominal pain on the epigastric
area, pain like cramping not radiating to anywhere. Pain
increases after meal and is accompanied by burping, nausea, and
excessive saliva in the morning, vertigo, and weakness. She has
never seen a doctor at all, just came to see us.
Current medicine: None
Past medical history: None
Social history: None
Family history: None
Allergies: None
Review of system: Has upper
epigastric pain, no cough, no stool with blood, no chest pain,
no fever, no diarrhea, and no shortness of breath.
Physical exam
General Appearance: Looks
well
BP: 90/50
Pulse: 120
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Neck: No goiter, no lymph node and no JVD.
Skin: Not pale, warm
to touch, and no rash.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound.
Limbs: Okay
Assessment: Dyspepsia, Parasitis.
Recommend: Should we cover her
with some medicines like:
- Tums, 1 gram,
three times per day, for one month
- Mebendazole,
100mg twice daily, for three days
Please give me any other ideas.
|
-----Original Message-----
From: dsands@bidmc.harvard.edu [mailto:dsands@bidmc.harvard.edu]
Sent:
Tuesday, January
14, 2003 2:13 PM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: Patient #4: HENG SOK, Cambodia Telemedicine, 14
January 2003
Impression: This is most likely gastroesophageal reflux disease but
other possibilities include biliary colic (gallstones), peptic ulcer
disease, pancreatitis, gastrointestinal malignancy, and I suppose
parasitic infestation. Has the patient had any weight loss? If so
it might make me concerned about a gastrointestinal malignancy. Any
melena or blood in the stool? That would support malignancy or
bleeding ulcer.
Plan:
-
Elevate head of bed
-
Avoid caffeine, chocolate,
caffeine, alcohol
-
Do not recline for 2 hours after
meals
-
Magnesium hydroxide (Maalox or
Mylanta) 30 cc qid as needed
-
Empiric treatment with mebendazole
as you suggest
-
If not improved within few weeks,
try avoiding fatty foods
-
If still not improved or if any
weight loss or fever send CBC, amylase, liver function tests,
helicobacter pylori titer, abdominal ultrasound
-
If ultrasound negative for stones,
can add ranitidine 150 mg PO bid
-
Danny Daniel Z. Sands, MD, MPH V: (617)
667-1510
___/
Center for Clinical Computing F:
(810) 592-0716
(__
Beth Israel Deaconess Medical Center
___)
Harvard Medical School
http://cybermedicine.caregroup.harvard.edu/dsands
SCHC
reply: Agree with plans. Evaluate gallbladder with ultrasound if
symptoms don't resolve after treatment. --Gary Jacques
please reply to
dmr@media.mit.edu
Dear All:
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your assistance.
Sincerely,
David
Telemedicine Clinic in Robib, Cambodia
14 January 2003
Patient #5: SEK LONN, male, 63 years
old, Farmer
 |
Chief complaint: Patient complains
that both legs have had numbness on and off for one year and has
had epigastric pain on and off more than one year.
History of present illness: For
more than one year this patient has had epigastric pain on and
off, pain like cramping, not radiating to anywhere, especially
pain increases after meal. Patient also has burping and
excessive saliva in the morning. Both legs have numbness and
weakness. He cannot walk a long distance. This patient has
never seen a medical doctor so he came to see us.
Current medicine: None
Past medical history: None
Social history: Does not drink alcohol but has smoked for
over forty years.
Family history: None
Allergies: None
Review of system: Has upper
epigastric pain, no cough, no fever, no chest pain, no shortness
of breath, and has constipation.
Physical exam
General Appearance: Looks
well
BP: 130/80
Pulse: 84
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Neck: No goiter, no lymph node and no JVD.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound.
Limbs: Okay but on both legs decreasing reflex on both sides
when we do neuro test.
Assessment: Dyspepsia. Weakness in both
legs due to Vitamin B1 deficiency.
Recommend: Should we cover him
with some medicines like:
- Tums, 1 gram,
three times per day, for one month
- Vitamin B1,
250mg twice daily, for one month
Please give me any other ideas. |
Hello,
My assessment of this gentleman’s
problems follow:
-
Dyspepsia. Likely related to GERD, possibly peptic ulcer disease,
or non-ulcer dyspepsia. Tums is reasonable and if pain does not
improve I would try famotidine. Do you have any thoughts on why
so many people in the village seen to have epigastric pain? Is h.
pylori prevalent to your knowledge?
-
Leg
numbness, weakness. The differential diagnosis is broad. Certainly
thiamine deficiency could cause this and supplementation is
reasonable. I would ask for more detailed history and exam:
-
-
what does he have difficulty
doing, eg. Getting up from a chair
-
-
is there weakness on exam? If
so it is proximal or distal?
-
-
Is there impaired sensation
on exam?
-
-
Which reflexes are
diminished?
-
Smoking. I would strongly encourage smoking cessation, informing
the patient about the risks of lung cancer, heart disease, and
peripheral vascular disease.
Please
have this patient follow-up next week, and hopefully with more
information we can have a neurologist give a thoughtful response.
I hope
this helps.
Sincerely,
Iris
Kedar, M.D.
SHCH
reply: This patient may have a peripheral neuropathy which has many
possible causes. I agree with your medications. If you have a
multiple vitamin that would be good to add. If patient is no better
he will need lab evaluation. --Gary Jacques
please reply to
dmr@media.mit.edu
Dear All:
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your assistance.
Sincerely,
David
Telemedicine Clinic in Robib, Cambodia
14 January 2003
Patient #6: HUY YIM, female, 49 years
old, Farmer
 |
Chief complaint: Patient complains
of neck tenderness, poor sleeping, weakness, shortness of
breath, and epigastric pain on and off for one year.
History of present illness: For one
year this patient has had shortness of breath during walking,
and neck tenderness on and off accompanied by headache,
epigastric pain, dizziness, weakness, palpitations, and
excessive saliva. These signs increase when she has poor sleep
and get better when she took some unknown medicine bought at a
private pharmacy.
Current medicine: None
Past medical history: None
Social history: None
Family history: None
Allergies: None
Review of system: Has mild shortness
of breath, no fever, no cough, no chest pain, and no stool with
blood.
Physical exam
General Appearance: Looks
well
BP: 140/70
Pulse: 100
Resp.: 22
Temp. : 36.5
Hair, eyes, ears, nose, and throat: Okay.
Neck: No goiter, no lymph node and no JVD.
Skin: Mild pale, warm to touch, and no rash.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound, and
has epigastric pain.
Limbs: Okay.
Assessment: Dyspepsia. Parasitis.
Malnutrition, anxiety?
Recommend: Should we cover her
with some medicines like:
- Tums, 1 gram,
three times per day, for one month
- Multivitamin,
one tablet per day for one month
- Mebendazole,
100mg twice daily for three days.
Please give me any other ideas. |
The
differential diagnosis includes chronic diseases like anemia (from
parasites, iron deficiency, B12 deficiency) causing weakness,
dyspnea on exertion, or malignancy; heart disease causing epigastric
pain, SOB, fatigue; dyspepsia causing epigastric pain; but also
things like depression--when I see someone complaining of so many
different things that don't seem to be connected, I think of
depression or of the complaints being somatic in nature. Maybe try
to narrow it down--what is the thing that bothers her the most? What
is the nature of the headaches; of the neck pains; what did she take
that made it better (maybe get the bottle--was it an anti-acid,
nitroglycerin?).
For now,
I would ask more questions regarding chronic disease, like weight
loss, loss of appetite, fevers, night sweats; maybe weigh her today
and again on the next visit (in a few weeks). If you can get a
hematocrit, that would be good to evaluate anemia. I would
prescribe an anti-acid (for dyspepsia symptoms) and a multivitamin
(includes iron and B12) and have her return in a few weeks.
Please
email back with more questions, follow up.
Jonathan
Sadeh ,
M.D.
SHCH reply: Agree with medications. Not
sure why short of breath. Would recommend CBC, maybe CXR if symptoms
don't resolve soon. __Gary Jacques
please reply to
dmr@media.mit.edu
Dear All:
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your assistance.
Sincerely,
David
Telemedicine Clinic in Robib, Cambodia
14 January 2003
Patient #7: SOK THON, female, 30 years
old, Farmer
 |
Chief complaint: Patient complains
of epigastric pain on and off for two months.
History of present illness: For two
months she has epigastric pain on and off, pain like cramping,
just on epigastric area not radiating to anywhere, accompanied
by burping and weakness. She gets more pain after a meal and
feels better after taking an antacid like Tums. Because patient
lacks money, she discontinued taking Tums a long time ago and
can only takes it during increased pain. So she came to see us.
Current medicine: None
Past medical history: None
Social history: None
Family history: None
Allergies: None
Review of system: No fever, no
dyspnea, no cough, no chest pain, no stool with blood, no
diarrhea, and has epigastric pain.
Physical exam
General Appearance: Looks
well
BP: 130/80
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Neck: No goiter, no lymph node and no JVD.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound, and
mild epigastric pain.
Limbs: No edema, no stiffness and no deformity.
Assessment: Dyspepsia. Parasitis.
Malnutrition.
Recommend: Should we cover her
with some medicines like:
- Tums, 1 gram,
three times per day, for one month
- Multivitamin,
one tablet per day for one month
- Mebendazole,
100mg twice daily for three days
Please give me any other ideas. |
-----Original Message-----
From: dsands@bidmc.harvard.edu [mailto:dsands@bidmc.harvard.edu]
Sent: Tuesday, January 14, 2003 2:43 PM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: Patient #7: SOK THON, Cambodia Telemedicine, 14
January 2003
I'm
not quite sure why you said she had malnutrition. Has she had
weight loss? Did she look thin? I am concerned if her condition is
causing her to lose weight.
Did
she have any vomiting? Is she eating well? Can you test her stool
for blood?
Impressions:
She
has dyspepsia. Most likely she has gastroesophageal reflux, peptic
ulcer disease, non-ulcer dyspepsia. Possibly pancreatitis,
gastrointestinal malignancy, parasitic disease, viral
gastroenteritis. Since this is the second case of this I received
today, I wonder if there is an epidemic, suggesting a parasitic
infestation or helicobacter pylori infection.
Plan:
- If she has been losing
weight since she's been ill, I would transport her to hospital for
blood tests, abdominal ultrasound.
-
Elevate head of bed
-
Avoid caffeine, chocolate,
caffeine, alcohol
-
Do not recline for 2 hours after
meals
-
Magnesium hydroxide (Maalox or
Mylanta) 30 cc qid as needed
-
Empiric treatment with mebendazole
as you suggest
-
If not improved within few weeks,
try avoiding fatty foods
-
If still not improved or fever send
CBC, amylase, liver function tests, helicobacter pylori titer,
abdominal ultrasound
-
If ultrasound negative for stones,
can add ranitidine 150 mg PO bid
If this patient can't
afford an antacid, it's going to be hard to get her to feel better,
unless she responds to behavioral therapy (#2,3,4,7). If she is
indeed malnourished then a multi vitamin won't really help that
much.
- Danny
Daniel Z. Sands, MD, MPH V: (617) 667-1510
___/
Center for Clinical Computing F:
(810) 592-0716
(__
Beth Israel Deaconess Medical Center
___)
Harvard Medical School
http://cybermedicine.caregroup.harvard.edu/dsands
SHCH
reply: Agree with plans. She may have H. pylori and benefit from an
eradication regimen if she has funds or access to that (SHCH) --Gary
Jacques
please reply to
dmr@media.mit.edu
Dear All:
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your assistance.
Sincerely,
David
Telemedicine Clinic in Robib, Cambodia
14 January 2003
Patient #8: KY CHHENG LAN, female, 29
years old
 |
Chief complaint: Patient complains
of sneezing and headache on and off for three years.
History of present illness: Three
years ago this patient started sneezing and got headaches,
sometimes gets pain in her nose and it has a bad smell as well.
She went to the pharmacy and bought some unknown medication to
take but sneezing continued, so she came to see us.
Current medicine: None
Past medical history: None
Social history: None
Family history: None
Allergies: None
Review of system: Has no fever, no
diarrhea, no dyspnea, no cough, no chest pain, and no stool with
blood.
Physical exam
General Appearance: Looks
well
BP: 100/70
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair, eyes, and ears: Okay.
Nose: Mild pain in nostrils.
Throat: Mild redness but no pain. Tonsil is not enlarged.
Neck: No goiter, no lymph node and no JVD.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, and positive bowel sound.
Limbs: No edema and no stiffness.
Assessment: Sneezing due to allergy.
Pharyngitis and Rhinitis due to allergy? Anxiety?
Recommend: Should we cover her
with some medicines like:
- Allergine,
5mg, twice daily for one week
- Paracetemol,
500mg, four times daily for one week
Please give me any other ideas. |
-----Original Message-----
From: Sadeh, Jonathan S.,M.D.
Sent: Tuesday, January 14, 2003 3:40 PM
To: Kedar, Iris,M.D.
Cc: Kelleher, Kathleen M. - Telemedicine
Subject: RE: Patient #8: KY CHHENG LAN, Cambodia
Telemedicine, 14 January 2003
Allergies seem like a very likely diagnosis in a young woman who is
otherwise well. Would ask more on when does it get worse, exposures
that make it worse (animals, birds, cats, seasons, cold weather);
does she have any infectious symptoms to suggest sinusitis--fevers,
pain around sinuses, thick secretions. If no infectious symptoms
are suspected, I would treat with an anti-histamine (I assume that
is what Allergine is) and try to avoid the triggers of her
allergies, if possible.
Please
email with other questions/follow up.
Jonathan
Sadeh ,
M.D.
SHCH
reply: Agree with your plans. --Gary Jacques
please reply to
dmr@media.mit.edu
Dear All:
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your assistance.
Sincerely,
David
Telemedicine Clinic in Robib, Cambodia
14 January 2003
Patient #9: TITH SREY, male, 75 years
old
 |
Chief complaint: Patient complains
of epigastric pain on and off for three years.
History of present illness: For
three years this patient has had epigastric pain on and off,
pain like burning, radiating to whole abdomen, pain increases
after meal, pain decreases after taking antacid like Tums. He
gets these symptoms accompanied by burping and sometime
abdominal distension. This patient has never seen a medical
doctor so he came to see us.
Current medicine: None
Past medical history: None
Social history: Does not drink alcohol but has smoked for
sixty years.
Family history: None
Allergies: None
Physical exam
General Appearance: Looks
well
BP: 140/70
Pulse: 68
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Neck: No goiter, no lymph node and no JVD.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, mild epigastric pain, and
positive bowel sound.
Skin: Warm to touch, not pale, and no rash.
Limbs: Okay.
Assessment: Dyspepsia, Parasitis?
Recommend: Should we cover him
with some medicines like:
- Tums, 1 gram,
three times per day, for one month
- Mebendazole,
100mg twice daily for three days.
Educate him for smoking risk.
Please give me any other ideas. |
He
should be referred to the hospital for UGI endoscopy
or xrays.
Gastric symptoms at his age is concerning for gastric cancer
presenting
as
ulcer. So response to antacids does not ensure that it is not
malignancy.
Does he
have nausea, vomiting or weight loss to suggest gastric outlet
obstruction?
Tan,
Heng Soon,M.D.
SHCH
reply: Agree with your plans. --Gary Jacques
please reply to
dmr@media.mit.edu
Dear All:
We sent nine cases this month.
We'll have the follow up clinic at 8:00am, Wednesday 15 January
(8:00pm, Tuesday, 14 January in Boston.) Best if we could receive
your e-mail advice before this time.
Thanks again for your assistance.
Sincerely,
David
Follow up Report, Wednesday, 15 January 2003
Per e-mail
advice of the physicians in Boston and Phnom Penh, the following
patients were given medication that came from the pharmacy in the
village or was donated by Sihanouk Hospital Center of Hope:
May 2001 Patient: SOM THOL, male, 49
years old
September 2001 Patient: CHOURB CHORK,
male, 28 years old
October 2002 Patient: MUY VUN, male, 36
years old
October 2002 Patient: PEN VANNA, female,
37 years old
Patient #1: KONG HAM, female, 35 years
old, farmer
Patient #2: SAO PHAL, female, 55 years
old, follow up patient
Patient #4: HENG SOK, female, 34 years
old, farmer
Patient #5: SEK LONN, male, 63 years
old, Farmer
Patient #6: HUY YIM, female, 49 years
old, Farmer
Patient #7: SOK THON, female, 30 years
old, Farmer
Patient #8: KY CHHENG LAN, female, 29
years old
Patient #9: TITH SREY, male, 75 years
old
Per e-mail advice of the
physicians in Boston and Phnom Penh, the following patients were
given transport or assistance in getting to the hospital:
Transported by
David and Montha to Kampong Thom Provincial Hospital on Wednesday,
15 January:
- Patient #3: SOM THOL, male, 49 years
old, follow up patient
Transport
arranged
for 21
January to
Sihanouk Hospital Center of Hope in Phnom Penh:
- Patient NOUNG KIM CHHANG, male, 46 years
old, Telemedicine patient (February 2001,) for medication and
chronic care.
Transport
arranged
for 31
January to
Sihanouk Hospital Center of Hope in Phnom Penh:
- Patient PHENHG ROEUN, female, 56 years
old, Telemedicine patient (August 2001,) for medication and
chronic care.
Transport
arranged for 4
February to
Sihanouk
Hospital Center of Hope in Phnom Penh:
§
Patient #2:
SAO PHAL, female, 55 years old, follow up patient
Transport
arranged
for 4
February to
Calmette Cardiology Hospital in Phnom Penh:
- Patient PHIM SOPHAN, male, 13 years old,
Telemedicine patient (February 2001,) for medication and chronic
care.
Transport
arranged
for 4
February to
Sihanouk Hospital Center of Hope in Phnom Penh:
- Patient YIN HUN, female, 60 years old,
Telemedicine patient (July 2001,) for medication and chronic care.
Transport
arranged for 4 February to Sihanouk Hospital Center of Hope in Phnom
Penh:
§
Patient PHIM
SICCHIN, female, 30 years old, Telemedicine patient (June 2001,) for
medication and chronic care.
Transport
arranged
for 13
February to Kantha
Bhopa Children’s Hospital in Phnom Penh:
- Patient SENG SAN, female, 13 year old
child, Telemedicine patient (June 2001,) for medication and
chronic care for Polyarthritis.
Transport
arranged
for 14
February to
Sihanouk Hospital Center of Hope in Phnom Penh:
- Patient CHHAY CHANTTY, female, 30 years
old, Telemedicine patient (June 2002,) for medication and chronic
care.
Transport
arranged
for 25
February to
Calmette Cardiology Hospital in Phnom Penh:
- Patient CHHEM LYNA, female, 2 year old
child, Telemedicine patient (February 2001,) for medication and
chronic care.
