January 2004
Telemedicine Clinic in Robib
Report and photos
submitted by David Robertson
On Wednesday,
January 7, 2004, Sihanouk Hospital Center of Hope nurse Koy Somontha
gave the monthly Telemedicine examinations at the Rovieng Health
Center. 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 Rovieng Health
Center. 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 David Robertson <dmr@media.mit.edu>
Dear All:
A quick reminder of the Robib, Cambodia
Telemedicine schedule for
January 2004.
Best if we can have your replies by 8:00am on
Thursday (Wed., January
7, 8:00pm in Boston.)
Sincerely,
David
-----
Tue., January 6 - Travel, Phnom Penh to Robib
Wed., January 7, 8:00am - Clinic
Thu., January 8, 8:00am - Follow up clinic (January 7, 8:00pm
in Boston)
Please reply to David Robertson <dmr@media.mit.edu>
Dear All:
Best if we can have your replies in time for
our follow up clinic by 8:00am on Thursday (Wed., January 7, 8:00pm
in Boston.)
Sincerely,
David
Telemedicine Clinic in Robib,
Cambodia – 7 January 2004
Patient #1: THORN KHUN, female, 38 years
old, follow up patient
 |
Subject:
38-year-old female returned for follow up visit for her
hyperthyroidism. She’s taken a Thyroid function test twice; TSH
= 0.02, free T4 = 28 on 13 August 2003; TSH = 0.02, free T4 = 26
on 11 October 2003; tests done at Sihanouk Hospital Center of
Hope. She has been covered with Multivitamin tab once
daily, and Feso4/folic 200/25mg, one tab per day for five
months. She just gave birth on 3 December 2003 at Preah Vihear
Provincial Hospital with normal delivery. Her baby has good
health and was vaccinated for TB. Now she feels back pain,
slight headache, decreasing
palpitations, decreasing
shortness of breath, decreasing vaginal discharge, no fever and
no cough.
Object: BP: 120/70, Pulse:
98, Resp.: 20, Temp. : 36.5, Wt.: 57 kg
- Looks stable.
- Her thyroid gland is not enlarged, no
exophthalmos
- Lungs clear both sides, no crackle, no
wheezing
- Heart regular rhythm without murmur.
- Abdomen: Soft, flat, not tender,
positive bowel sound
- Extremities have no edema and no tremor
Assessment: Hyperthyroidism.
Plan: Prescribe following meds
for one month.
§
Multivitamin tab
once daily
- Feso4/folic 200/25mg, one tab
per day
Suggestion: We want to draw her
blood in the village to test at SHCH to recheck her Thyroid
test. Do you agree? Please give me any other ideas. |
Dear Guys:
Thanks for the
follow-up on this patient. Montha, you did a good job managing her
and I am glad that the baby is healthy. At this point, she is not
clinically hyperthyroid, so I would wait 2-3 months for repeat
thyroid tests. She needs to continue with the vitamins and stay on
a healthy diet.
Thanks.
Jennifer G. Hines,
MD
Medical Director
Sihanouk Hospital Center of HOPE (SHCH)
Street 134, Sangkat Vealvong, Khan 7 Makara
PO Box 2318
Phnom Penh, 3 Cambodia
Phone: 855-23-882-484, ext. 124
Fax: 855-23-882-485
Mobile: 855-11-880-315
Patient #1: THORN KHUN, female, 38 years old,
follow up patient
I am very happy to hear that her delivery went
well and that some of her symptoms have now improved. You have
reported that her last free T4 was 26 and her TSH .02. To make sure
we are dealing with the same units, please submit the units and the
normal ranges you are using.
I am using the following lab ranges:
normal free T4= .8-2.2 ng/dl
normal TSH = .5-5 uU/ml (since 2002 normal TSH =.3-3uU/ml
http://www.aace.com/pub/tam2003/press.php)
If she indeed suffering from hyperthyroidism
(or subclinical hyperthyroidism) by these labs, she remains at
increased risk for cardiac abnormalities and bone loss, and strong
consideration should be given to initiating treatment and restoring
the TSH level to within the normal range.
Recommendations:
1. Educate her about the symptoms of worsening
hyperthyroidism and thyroid storm, and of the need to receive
immediate treatment if symptoms develop.
2. If no worsening of her symptoms occurs, at
minimum, recheck TSH in 6-10 weeks after delivery.
3. I would also continue the multivitamins as
long as she is breast feeding.
4. I also see that she is on iron replacement.
Was she anemic? If so, plan for a repeat CBC in the future.
I hope this was helpful.
Thank you for this interesting patient.
Paul Heinzelmann, MD, DTM&H
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib,
Cambodia – 7 January 2004
Patient #2: SOURN SAM ATH, female, 20
years old, village Trapang Reusey
 |
Chief complaint: Right breast mass
for six months.
HPI: 20-year-old single female has
known mass on her right breast for six months by her palpation.
Mass becomes bigger and bigger from day to day. Sometimes she
gets pain on the mass and fever during her strong activities
like carrying heavy things. She has never been to a hospital,
just came to see us.
Past medical history: Unremarkable
Social history: No smoking and no
drinking alcohol.
Family history: Unremarkable.
Allergy: None known.
Current medicine: None.
Review of system: No sore throat, no
weight loss, no cough, no fever, no shortness of breath, and no
abdominal pain.
Object: Looks stable.
BP: 110/50, Pulse: 90,
Resp.: 20, Temp: 36.5, Weight: 49 kg
- Hair, Eyes, Ears, Nose and Throat:
Unremarkable
- Neck: No goiter enlargement.
- Chest: Lungs clear both sides, no
crackle, no wheezing
- Heart regular rhythm without murmur.
- Right breast has one mass, size about 2
x 1 cm, regular edge, smooth, hard and pain when palpable,
moving.
- No lymph node under armpit and neck
- Abdomen: Soft, flat, not tender, and has
positive bowel sound.
- Extremities: Unremarkable.
Assessment: Breast tumor?
Plan: Should we refer her to
Kampong Thom Hospital for ultrasound and consultation with
surgeon? Please give me any ideas. |
Dear Guys:
In this patient, one
must think about infection, benign or malignant tumor. I know that
breast exams are a little challenging for this culture, but it is
good to exam both breasts the same way from the armpit around in
circles to the nipple. We will have to review this exam, which can
be taught to the patients to do on their own. Getting a picture of
the lesion is helpful, too. Where is the mass? Near the nipple?
Near the armpit? What about a nipple discharge? Does she have
lymphadenopathy in the armpit, neck, chest areas?
I agree with your
thought about a surgical evaluation and US of the breast at Kg. Thom
hospital. With the mass movable on palpable, it may be an abscess
and drainage would need to be done. I would not consider
antibiotics here at this time.
Thanks.
Jennifer G. Hines,
MD
Medical Director
Sihanouk Hospital Center of HOPE (SHCH)
Street 134, Sangkat Vealvong, Khan 7 Makara
PO Box 2318
Phnom Penh, 3 Cambodia
Phone: 855-23-882-484, ext. 124
Fax: 855-23-882-485
Mobile: 855-11-880-315
-----Original Message-----
From: Pallin, Daniel Jay,Md,Mph
Sent: Wednesday, January 07, 2004 1:31 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: Hi Kathy - Please forward to Cambodia
Dear Friends,
Sourn Samath has a breast cyst. This is not
a serious problem. It is not a tumor.
The cyst can be drained using an 18-gauge
needle and STERILE TECHNIQUE. If it comes back after that, it can be
drained again or you could refer her to a surgeon.
Please let me know how she does!
Yours truly,
Danny
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Danny Pallin, MD, MPH
Department of Emergency Medicine
Brigham and Women's Hospital NH-122H
Harvard Medical School
75 Francis St., Boston MA 02115
tel: 617-525-6614
fax: 617-264-6848
Dear all,
most likely, this
young patient has a fibroadenoma or breast cyst. Your plan to
send her to Kg Thom
for a surgical consultation is good.
Thanks
Dr. Cornelia Haener
Surgeon, SHCH
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib,
Cambodia – 7 January 2004
Patient #3: OUK SVAY, male, 52 years old
 |
Chief complaint: Whole body edema,
shortness of breath on and off for three months.
HPI: 52-year-old male, married.
Patient has general body edema starting from the face and moving
down to the feet, accompanied by fever, shortness of breath,
abdominal distension, cough, palpitations, poor urine output the
last three months. When he got these symptoms, he went to see a
medical person in the village and they gave him a diuretic and
some unknown drugs for 12 days. The symptoms came down and
stopped while taking these drugs. Two weeks later, all the
symptoms reappeared and sometimes they get worse at night. He
cannot sleep with one pillow and also has a poor appetite and
weakness. So he finally came to see us.
Past medical history: Unremarkable
Social history: Drank alcohol for 35
years (one litre per day) but just stopped five months ago.
Smoking for 40 years, about seven sticks per day.
Family history: Unremarkable.
Allergy: None known.
Current medicine: Used a diuretic
and unknown modern drugs during the last two months.
Review of system: No sore throat,
has dry cough, no chest pain, no fever, has shortness of breath,
no abdominal pain but mild distension, no stool with blood.
Physical Exam: Looks stable and
oriented x 3 (place, time and person.)
BP: 140/100, Pulse: 84,
Resp.: 28, Temp: 36.5, Weight: 49 kg
- Hair, Ears, Nose and Throat:
Unremarkable. Eyes: Mild pale and not yellow
- Neck: Has JVD 3cm and no goiter
enlargement.
- Lungs slight crackle on both sides at
the base, decreasing breath sound at right base
- Heart regular rhythm, has murmur 1/3 at
apex.
- Abdomen: Soft, mild distension, has
positive bowel sound, Hepathomegalie 4cm under costal
diaphragm.
- Extremities: Both legs +4 pitting edema.
- Urinanalysis: Protein +2.
Assessment:
- Valvular heart disease? MR? CHF?
- Liver cirrhosis?
- CRF?
- Lung congestion?
- Anemia due to Etio?
Plan: I would like to refer him to
Kampong Thom Hospital for:
- EKG
- Abdominal ultrasound
- Some blood work like CBC, lytes,
creat., Bun, liver function, chest x-ray.
Please give me any other ideas. |
Dear Montha:
This patient has
signs of congestive heart failure----peripheral edema, pulmonary
congestion, orthopnea (cannot lie flat in the bed) with poor urine
output. Heart failure can be caused by right heart dysfunction,
which could cause the elevated neck veins and enlarged liver; or
left sided heart dysfunction, causing peripheral edema and fluid in
the lungs. Your patient has all of these symptoms. The other
possible etiology is renal failure of multiple causes. We don't
know if he has ischemic heart disease, hypertensive heart disease or
metabolic heart disease with this alcohol history. Does his breath
smell bad? Uremia causes bad breath and is a sign of severe renal
failure.
I agree that he
should be better evaluated and put on chronic medications for his
condition. You did not say that he was cyanotic, so he may be
oxygenating well enough for the time being. I think you should
refer him to Kg. Thom hospital for a good Hx. And PE, electrolytes,
Cr, CXR and EKG. The other tests may not be as important for the
time being. The patient should stop smoking. I suspect that he
needs to be on diuretics, ASA, fluid restriction, minimum for his
problem.
Thanks.
Jennifer G. Hines,
MD
Medical Director
Sihanouk Hospital Center of HOPE (SHCH)
Street 134, Sangkat Vealvong, Khan 7 Makara
PO Box 2318
Phnom Penh, 3 Cambodia
Phone: 855-23-882-484, ext. 124
Fax: 855-23-882-485
Mobile: 855-11-880-315
-----Original Message-----
From: Crocker, J.Benjamin,M.D.
Sent: Wednesday, January 07, 2004 12:44 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #3: OUK SVAY - January 2004, Robib, Cambodia,
Telemedicine
Very unfortunate. Differential diagnosis
includes cardiac disease (CHF, ischemic cardiomyopathy,
new/worsening or ischemic valvular disease, post-infectious
myocarditis, less likely pericardial disease), renal disease (acute
and now worsening renal failure or glomerularnephropathy/nephritis,
leading to periorbital and generalized edema), perhaps on top of a
compromised liver given his long ETOH history and enlarged liver (?hypoalbuminemia).
Alternatively, this could all be related to
worsening liver disease. Dobut primary infectious process, doubt
primary heme process (anemia w/ high output CHF). Lung congestion
very likely due to CHF +/- pulmonary effusions. Does he have
ascitic fluid wave or asterixis? The response to diuretics and
improvement in orthopnea suggests CHF or liver disease. Body
swelling more suggestive of right sided CHF so would expect JVP to
be more than just 3cm.
agree with transfer to hospital for further
evaluation to
1) r/o active ischemia
2) assess cardiac function, would check echocardiogram to look for
LV function/valvular function
3) assess liver status and renal status -- check LFT's, renal
function, 24 hr urine protein to r/o nephrotic syndrome. check
hepatitis serologies (as hepatitis and etoh can lead to faster
cirrhosis development).
labs: ekg (cardiac enzymes if suspect new
ischemic changes), lytes, renal function, urinalysis, liver enzymes,
albumin, PT, bilirubin (is he icteric? i can't tell by picture),
hepatitis serology, chest x-ray, echocardiogram, and abdominal
ultrasound (to assess both hepatic and renal architecture) to
start.I would admit someone in this state here in the U.S.
if CHF -- needs diuretics, likely
ace-inhibitors, other BP meds (betablocker) dependent on EF. good BP
control and eval for CAD. if liver disease, need to r/o infectious
hepatitis, consider spironolactone/lasix combination. ETOH
cessation a MUST!!! Cigarette cessation a MUST!!! if renal disease
-- diuretics, ace inhibitors (if renal function and potassium can
tolerate), renal
consultation....
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.
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib,
Cambodia – 7 January 2004
Patient #4: NGET SOEUN, male, 56 years
old, follow up patient
 |
Chief complaint: Still weakness.
Subject: 56-year-old male returned
for follow up visit for his Cirrhosis and Ascitis. His previous
symptoms are much improved. Has weakness, decreased blurred
vision, no cough, no chest pain, no fever, no abdominal
distension, has good appetite, no black stool, has cramping
muscles on both legs, and has normal urination.
Object: BP: 110/70, Pulse:
80, Resp.: 20, Temp: 36.5, Weight: 40 kg
- Hair, Eyes, Ears, Nose and Throat:
Unremarkable.
- Neck: No goiter enlargement.
- Lungs clear both sides.
- Heart regular rhythm without murmur.
- Abdomen: Soft, flat, no abdominal
distension, has bowel sound.
- Extremities have no edema but calves are
cramping.
Assessment:
- Cirrhosis (stable.)
- Ascitis (resolved.)
- Hypokalenia due to Furosemide?
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, 1/2
tablet twice daily for 30 days
- Multivitamin, one
tablet daily for 30 days
- Potassium, 600mg, two tablets twice
daily for 30 days
Please give me any other ideas. |
Dear Montha:
For this patient, I
would stop his Furosemide and give only KCL 600mg 2 tabs QD for the
next 3 days and then stop, too. I agree with maintaining all of his
medications the same. I would be good for the patient to stay on a
fluid restriction and watch the amount of protein that he eats. I
would suggest that he eat meat 2-3 times/week and focus on fruits,
vegetables and rice. He needs to be active and do stretch muscles
daily.
As you know,
furosemide can cause hypokalemia and Spirolactone can cause
hyperkalemia. We don't want him to get too dry at this point, but
to try and maintain a certain weight and fluid balance for good
balance in his electrolytes, as well. He may be a little low in
magnesium, which he can also lose while on diuretics. Good sources
of magnesium come from nuts, peas, beans, and leafy green
vegetables.
Thanks,
Jennifer G. Hines,
MD
Medical Director
Sihanouk Hospital Center of HOPE (SHCH)
Street 134, Sangkat Vealvong, Khan 7 Makara
PO Box 2318
Phnom Penh, 3 Cambodia
Phone: 855-23-882-484, ext. 124
Fax: 855-23-882-485
Mobile: 855-11-880-315
> -----Original Message-----
> From: Tan, Heng Soon,M.D.
> Sent: Wednesday, January 07, 2004 5:48 PM
> To: Kelleher-Fiamma, Kathleen M. -
Telemedicine
> Subject: RE: Patient #4: NGET SOEUN -
January 2004, Robib, Cambodia,
> Telemedicine
>
> That sounds great. If there is no further
edema, you could hold the lasix
> and potassium and use it periodically like
once a week if his weight
> increases again. Monitoring weight twice a
week will be critical.
> Heng Soon
>
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib,
Cambodia – 7 January 2004
Patient #5: SOM DEUM, female, 64 years
old, follow up patient
 |
Chief complaint: Still both
shoulders have joint pain, and still has knee pain.
Subject: 64-year-old female returned
for follow up visit of Polyarthritis. Her previous symptoms are
improving, but still painful on her shoulder joint and knee
joint. She has no cough, no fever, no nausea, no shortness of
breath, no chest pain, and has poor appetite, no abdominal pain,
and no stool with blood.
Object: Looks stable.
BP: 110/60
Pulse: 98
Resp.: 20
Temp. : 37
Weight. : 34 kg
Hair, eyes, ears, nose, and throat:
Unremarkable.
Neck: No JVD and no goiter.
Lungs: Clear both sides, no crackle.
Heart: Regular rhythm, no murmur.
Abdomen: Soft, flat, not tender, and
has positive bowel sound.
Joints: Shoulder joints painful when
moving, but no swelling or redness. Knees get painful during
moving as well, mild warming on both sides but no swelling.
Finger joints mildly stiff and hard to move in the morning.
Assessment: Polyarthritis.
Malnutrition.
Plan: Could we continue giving
the same drugs like the last four months?
- Aspirin, 500mg, twice daily
for one month
- Multivitamin, 1 tablet
daily
for one month
- Chloroquine, 300mg, ½ tablet
daily for one month.
Please give me any other ideas. |
Dear Montha:
Does this patient
have symmetric joint pain and decreased movement? Have you ever sent
a picture of her hands? Next time I would show us both her hands.
I think that she has chronic osteoarthritis and perhaps you may want
to try something other than ASA for her problem.
We have a medication
here called Nabumetone 500mg that can be used in this patient for
polyarthritis. I suppose that RA is still in the differential
diagnosis, but I suspect that the chloroquine is not very useful for
her.
We can give you some
Nabumetone to try with her next time. I would suggest that you try
any other NSAID like Ibuprofen or Naproxen for the time being.
Ibuprofen dosing could be 200mg twice daily with food. I would stop
the chloroquine. Naproxen dosing would be 220mg twice daily with
food.
Let's try this
temporary option and we will supply her with Nabumetone to try next
month.
Thanks.
Jennifer G. Hines,
MD
Medical Director
Sihanouk Hospital Center of HOPE (SHCH)
Street 134, Sangkat Vealvong, Khan 7 Makara
PO Box 2318
Phnom Penh, 3 Cambodia
Phone: 855-23-882-484, ext. 124
Fax: 855-23-882-485
Mobile: 855-11-880-315
With regards to this patient I would check an
ESR, Rhematoid Factor, ANA, and CBC to rule out a systemic arthritis
like Rheumatoid Arthritis or Lupus. If possible, discontinue the
Aspirin and give her Ibuprofen 600mg up to TID as needed, WITH FOOD
and continue the Chloroquine.
Regards,
Jon Crocker, M.D.
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib,
Cambodia – 7 January 2004
Patient #6: EM SOKLEY, female, 25 years
old
 |
Chief complaint: Patient still
complains of epigastric pain and nausea.
Subject: 25-year-old female came
for follow up visit with Gerd and Parasitis. Last month we
covered her with Tums, 1 gram twice daily for one month, and
Mebendazole, 100 mg twice daily for three days. Her symptoms
improved just a little bit but still has nausea, epigastric
pain, excessive saliva, less diarrhea, has hiccups after a meal,
no fever, no cough, no shortness of breath, no chest pain, and
no weight loss.
Object: Looks stable. Alert and
oriented x 3 (place, person, and time.)
BP: 110/70, Pulse: 80,
Resp.: 20, Temp: 36.5, Weight: 40 kg
Hair, eyes, ears, nose, and throat:
Unremarkable
Neck: No enlargement and no JVD
Heart: Regular rhythm, no murmur
Lungs: Clear both sides, no crackle
Abdomen: Soft, flat, not tender, has
epigastric pain, has positive bowel sound all four quadrants.
Extremities: Unremarkable
Assessment:
- Gerd, PVD?
- Malnutrition
Plan: We would like to change
from:
- Tums to Omerprazole 20 mg one tablet
twice daily for one
month
- Multivitamin, one
tablet daily for one month
Please give me any other ideas. |
Dear David and
Montha,
Not better with
Tums. Also heart-burn, nausea.
1. How about her
menstruation? Please check if she is pregnant.
2. Possible GERD.
Agree with your omeprazole 20 mg daily. We would add metoclopramide
5-10mg tid to qid, sleep with bed elevated, avoid chocolate, avoid
sleep right after meal, avoid wearing clothes too tight, not to be
obesis.
Regards,
Bunse/Jennifer
-----Original Message-----
From: Crocker, J.Benjamin,M.D.
Sent: Wednesday, January 07, 2004 12:27 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #6: EM SOKLEY - January
2004, Robib, Cambodia, Telemedicine
Yes change to omeprazole twice daily. The
epigastric tenderness is concerning for peptic ulcer (duodenal or
gastric). Any way to check H. Pylori antibody status? If persistent
symptoms, or weight loss, or melena or dysphagia, despite PPI
therapy, she warrants an endoscopy. Avoid NSAIDs, dietary
irritants. I would also guaiac her stool and check CBC. If
positive guaiac or anemic, consider endoscopy earlier.
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.
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib,
Cambodia – 7 January 2004
Patient #7: YEM PHALA, male, 55 years
old, follow up patient
 |
Subject: 55-year-old male returned
for follow up visit of stable hypertension and muscle pain
(sciatica?) His symptoms are much improved, less dizziness,
decreasing headache, no shortness of breath, no chest pain, no
cough, no abdominal pain, and has left muscle pain from hip to
thigh, especially during walking. Ten days ago he went to Siem
Reap for a spinal x-ray. The doctor says he has a problem with
L4, film attached.
Object: Looks stable, alert and
oriented x 3..
BP: 130/70
Pulse: 86
Resp.: 20
Temp. : 36.5
Weight. : 77 kg
Hair, eyes, ears, nose, and throat:
Unremarkable.
Neck: No goiter and no JVD
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, and has positive bowel
sound all quadrants.
Limbs: Unremarkable
Assessment:
1.
Stable Hypertension.
2.
Muscle pain on left leg (sciatica?)
Plan: May we continue with the same drugs
for another month?
- Propranolol, 40 mg, 1/4 tablet twice
daily
- Aspirin, 500 mg, 1/4 tablet
daily
- Vitamin B1, 250 mg daily
|
Dear David and
Montha,
There are
osteophytes noted L4-L5 on lateral view, but we cannot see AP view
clearly. Exercises, lowering weight, and some pain killer PRN, like
paracetamol would do fine.
Good job, agree with
the continuation of propranolol.
Regards,
Bunse/Jennifer
-----Original Message-----
From: Cusick, Paul S.,M.D.
Sent: Wednesday, January 07, 2004 1:47 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #7: YEM PHALA - January
2004, Robib, Cambodia, Telemedicine
His hypertension is well controlled at present.
I cannot see significant abnormality in L4
except for some disc space narrowing and degenerative disc disease.
I would continue his current medications. I am
not sure why the B12 is being used. I would teach him some
stretching exercises for his back and apply a warm wet towel to his
leg and lower back twice daily for pain reduction.
Paul Cusick, M.D.
Dear all,
it is very difficult
to evaluate these X-rays on the computer screen. Could you
bring the X-rays to
Phnom Penh, so that I can have a look at them?
Thanks
Dr. Cornelia Haener
Surgeon, SHCH
Please reply to David
Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib,
Cambodia – 7 January 2004
Patient #8: CHAN SENG, male, 68 years
old
| |
Chief complaint: Patient complains
of shortness of breath, abdominal distension, and cough for four
months.
HPI: 68-year-old male married
farmer patient has abdominal distension, shortness of breath and
productive cough the last ten days. In the last four months,
all symptoms get worse day to day and are accompanied by edema
both legs, poor sleeping, palpitations, poor urination, and
epigastric pain, so he went to see a local medical person. They
covered him with some unknown drugs such as a diuretic,
antibiotic, and vitamins via IM, IV or PO for four months. His
symptoms release some. Now he still has abdominal distension,
shortness of breath and palpitations so he came to see us.
Past medical history: Malaria in the
last six months but completely treated.
Social history: Drank alcohol
50ml/day for 20 years. Smoking for about 50 years, four sticks
per day. But now he has stopped smoking for four months and
alcohol for four years.
Family history: Unremarkable.
Allergy: None known.
Current medicine: Was covered with
some unknown diuretic, antibiotic, and vitamins for four
months.
Review of system: No sore throat,
weight loss of about 10 kg during four months, has mild fever,
has shortness of breath, has palpitations, has chest pain
sometimes, has productive cough, has abdominal distension, and
no stool diarrhea.
Object: Looks skinny. Alert and
oriented x 3.
BP: 90/40, Pulse: 126,
Resp.: 28, Temp: 37, Weight: 55 kg
Hair, ears, nose, and throat:
Unremarkable Eyes: Not pale
Neck: Has JVD about 8 cm. No
goiter.
Lungs: Crackle on the 1/3 left lobe,
other side okay.
Heart: Irregular rhythm, no murmur,
Tachycardia
Abdomen: Mild distension, soft, has
positive bowel sound all four quadrants, Hepathomegalie about
5cm under costal.
Extremities: +2 pitting edema, and
no deformity
Urinanalysis: Protein +2,
Urobilonogen +2
Assessment:
- Cirrhosis?
- Ascitis due to Cirrhosis?
- Heart arrhythmia (PVC?) Valvular
heart disease?
- CHF?
- PTB?
- Malnutrition.
Plan: We would like to refer him to
Kampong Thom Hospital for EKG, abdominal ultrasound, chest
x-ray, and blood work like CBC, lytes, Bun, creat, and liver
function.
Do you agree with this plan? Please
give me any other ideas. |
Dear David and
Montha,
Interesting case.
Could be multiple problems like you mention.
Agree with you for
referral to Kg. Thom, please make a good referral, adding also
sputum AFB. Because he is alcoholic, it is OK with us to give high
dose vit B1 and MTV in the meantime, like in case 3.
Regards,
Bunse/Jennifer
> -----Original Message-----
> From: Tan, Heng Soon,M.D.
> Sent: Wednesday, January 07, 2004 6:22 PM
> To: Kelleher-Fiamma, Kathleen M. -
Telemedicine
> Cc: 'Chang, Ann Lee'
> Subject: RE: Patient #8: CHAN SENG -
January 2004, Robib, Cambodia,
> Telemedicine
>
> It sounds like he is in biventricular heart
failure by history and physical
> exam, perhaps in atrial fibrillation. The
etiology is not obvious. Did he have
> coronary artery disease? Was he hypertensive
previously? A reliable cardiac
> exam that confirms no murmurs will exclude
valvular heart disease. It does not
> sound like he has cor pulmonale from advanced
emphysema. Perhaps he has
> idiopathic dilated cardiomyopathy.
>
> It will be worthwhile to exclude pulmonary
tuberculosis, but by itself, it
> does not explain the heart failure. However
tuberculous chronic pericardial
> effusion with tamponade should be considered.
I don't think he has cirrhosis
> since you describe hepatomegaly. Furthermore
you do not describe jaundice and
> other skin stigmata of cirrhosis. More likely
he has liver congestion and even
> ascites from heart failure. Of course leg
edema could be aggravated by
> nutritional deficiency. I wonder about the
proteinuria. He may have concurrent
> renal disease with nephrotic syndrome
aggravating leg edema.
>
> So to sort these out, I agree he needs:
> A detailed cardiac exam to look for
paradoxical pulse, pulse volume, pattern
> of irregular pulse, to examine neck vein
pulsations, determine cardiac apex,
> right ventricular heave, intensity of heart
sounds, presence of S3 or S4
> gallops, and heart murmurs may help sort out
the differential diagnosis.
>
> Lab tests to include CBC to exclude anemia.
> Renal function [BUN, Creatinine, albumin] and
repeat urine to check for
> nephritis and nephrotic syndrome.
> TSH and T4 to exclude thyroid disease.
>
> EKG to confirm atrial fibrillation. Q waves
may confirm coronary artery
> disease. There may be changes of chamber
enlargement. Low voltages may raise
> possibility of dilated cardiomyopathy or
pericardial tamponade.
> Echocardiogram to check heart size, wall
contractility, valvular function and
> exclude pericaridal effusion.
> Chest xray to exclude pulmonary tuberculosis,
check heart size and confirm
> heart failure. A globular heart would raise
possibility of pericardial
> tamponade.
>
> In the meantime, he would benefit from a
small dose of lasix and potassium,
> while monitoring his vital signs to avoid
hypotension.
>
> Heng Soon
>
Please reply to David Robertson <dmr@media.mit.edu>
Dear All:
This is our last case for this month. Thank
you so much for your earlier replies on the other cases.
Sincerely,
David
Telemedicine Clinic in Robib,
Cambodia – 7 January 2004
Patient #9: KHAN NAVOEUN, female, 21
years old, follow up patient
 |
Subject: 21-year-old female follow
up case with lichen planus and sacchoidosis? She was covered
with Bethamethazone cream for one and a half months, her
symptoms improved a little bit, but she still feels itchy on
both calves with some black old scars and on the right thumb.
No fever, no cough, no GI problem, no pulmonary problem.
Object: Looks stable
Hair, eyes, ears, nose, and throat:
Unremarkable
Lungs, heart, abdomen: Unremarkable
Extremities: Both shins have some
old black scars
Assessment:
1.
Lichen planus.
2.
Sacchoidosis?
Plan: Please give me some other ideas.
Or let me continue the same drug for another month.
1.
Topical steroid (bethamethasone.) |
Dear David and
Montha,
I have discussed
this case with my colleague, Dr. Lavath, who have more experience in
Derma. The patient could also have prurigo nodularis.
You may want to
replace with a more potent steroid ointment Clobetasol. If severely
itch and active nodules, a short course of oral steroid could also
try. Start her with 50 mg prednisolone and devrease 5 mg every 3
days till gone. Stay on same ointment.
She may get benefit
from UV of the sun. A shorter trouser like skirt would do fine.
Have a nice day!
Bunse
Follow up Report, Friday, 9 January 2004
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 #3: OUK SVAY, male, 52 years
old. Nurse Montha was concerned this patient might not survive the
three and a half hour pick-up truck ride from the village to the
hospital in Kampong Thom. But the prospect of remaining in the
village was worse. Nurse Montha gave him medication via IV before
we departed the health center. The patient seemed to be in critical
condition with the earlier described symptoms plus increased
difficulty in breathing (no oxygen is available at the Rovieng
health center.) He was kneeling on the ground outside the health
center gasping for air. Fortunately he survived the trip to the
hospital and was taken to Kampong Thom Provincial Hospital by the
Telemedicine team on Thursday, 8 January 2004. He was admitted to
stabilize his condition and underwent testing.
Patient #8: CHAN SENG, male, 68 years
old. Transported to Kampong Thom Provincial Hospital by the
Telemedicine team on Thursday, 8 January 2004. He was admitted for
testing.
Following patient went to the follow up clinic and agreed to
have her breast cyst examined at Kampong Thom Provincial Hospital.
But she left the clinic saying she wanted to go to the market and
would return shortly. Unfortunately she did not return in time for
the Telemedicine team’s departure:
Patient #2: SOURN SAM ATH, female, 20
years old, village Trapang Reusey
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: THORN KHUN, female, 38 years
old, follow up patient
Patient #3: OUK SVAY, male, 52 years old
Patient #4: NGET SOEUN, male, 56 years
old, follow up patient
Patient #5: SOM DEUM, female, 64 years
old, follow up patient
Patient #6: EM SOKLEY, female, 25 years
old
Patient #7: YEM PHALA, male, 55 years
old, follow up patient
Patient #9: KHAN NAVOEUN, female, 21
years old, follow up patient
November 2003 Patient: MUY VUN,
male, 36 years old, follow up patient
December 2003 Patient: PEN VANNA, female, 37 years old,
follow up patient
December 2003 Patient: SAO PHAL, female, 56 years old, follow
up patient
December 2003 Patient: THO CHANTHY, female, 36 years old,
follow up patient
December 2003 Patient: SOM THOL, male, 50 years old, follow
up patient
December 2003 Patient: SUM SOKNA, female, 20 years old,
follow up patient
Transport arranged for two follow up appointments in late January 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.
November 2003 Patient CHHOURN
SOKHON,
male, 45 years
old. He returned to the Telemedicine clinic this month. Amazingly,
his foot wound, open for more than 20 years, is beginning to fill in
and heal. Nurse Montha inspected the patient’s wound and advised him
to keep cleaning the wound daily and to return to the Telemedicine
clinic if there were any complications.
The schedule for the next Telemedicine
Clinic in Robib:
Mon. February 9 - Travel - Phnom Penh to Robib
Tue. February 10 - Clinic
Wed. February 11 - Morning follow up clinic.
Travel - Robib to Phnom Penh with a stop at Kampong Thom Provincial
Hospital.
