March 2004
Telemedicine Clinic in Robib
Report and photos submitted by
David Robertson
On Tuesday,
March 9, 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. Sihanouk
Hospital Center of Hope physician assistant Rithy Chau was also
present to observe and assist at the clinic.
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 that the March Telemedicine
clinic for Robib is now scheduled for Tuesday, 9 March 2004.
We'll have the follow up clinic at 8:00am,
Wednesday, 10 March 2004 (8:00pm, Tuesday, 9 March 2004 in
Boston.)
Best if we could receive your e-mail advice
before this time.
Thanks again for your kind assistance.
Sincerely,
Please reply to David Robertson dmr@media.mit.edu
Dear All:
We'll have the follow up clinic at 8:00am,
Wednesday, 10 March 2004 (8:00pm, Tuesday, 9 March 2004 in
Boston.)
Best if we could receive your e-mail advice
before this time.
Thanks again for your kind assistance.
Sincerely,
David
Telemedicine Clinic in Robib, Cambodia – 9 March 2004
Patient #1: OUNG CHREB,
female, 40 years old, Staff at Robib medical clinic
|
History
of present illness: Forty-year-old
female. We saw this
lady last year (December 2002, attached below.)
We diagnosed her with Dyspepsia and anemia.
We gave her Tums one gram twice daily, multivitamin one
tablet per day, and Folic acid one tablet daily; all meds for
one month. Her
condition got a bit better and then she missed follow up.
After feeling a bit better with these medications, three
months later her condition got worse, all symptoms came up again
presenting with epigastric pain, central chest tightness, throat
burning, sometimes burping and excessive saliva in the morning
like sour taste, dry cough, constipation, poor sleeping, and a
slight headache on and off until now.
Past
medical history: In the last two years she had an abortion.
Family
history: No history of hypertension or diabetes and no heart
disease.
Social
history: Does not smoke or drink alcohol.
Allergies:
None
Review
of system: No weight loss, no fever, no productive cough,
has shortness of breath, no stool with blood, and no limb edema.
Physical
Exam: Looks
stable. Alert and
oriented x 3.
BP: 85/40
Pulse: 72
Resp.: 20
Temp. : 36.5
Weight: 44 kg
Eyes:
Conjunctiva, mild
pale, and no jaundice
Ears, nose, and throat: Unremarkable.
Neck: No lymph
node and no goiter.
Lungs: Clear both
sides.
Heart: Regular
rhythm, no murmur
Abdomen: Soft, flat, not tender, no HSM, and has positive
bowel sound.
Limbs: No edema and no deformity.
Assessment: GERD?
Anemia. Parasitis.
Low blood pressure.
Plan:
May we cover her with these medications?
- Omeprazole,
20 mg two tablets twice daily, for one month
- Multivitamin,
one tablet daily, for one month
- Mebendazole,
100 mg, one tablet twice daily, for three days
- Metoclopramide,
10 mg, one tablet three times daily, for ten days
Please give me any other ideas. |
Telemedicine Clinic in Robib, Cambodia - 12 December 2002
Patient
#6: OUNG CHREB, female, 37
years old, Staff at Robib medical clinic
|
Chief
complaint: Abdominal pain
and sometimes stool with black color on and off for nine months.
History
of present illness: Nine
months ago she got abdominal pain on and off around the
umbilical area accompanied by black stool sometimes, with
weakness and burping. She took some antacids but did not respond at all.
So she came to see us.
Current
medicine: None
Past
medical history: Ten
months ago she had an abortion and lost a lot of blood.
Social
history: Unremarkable
Family
history: Unremarkable
Allergies:
None
Review
of system: Has abdominal
pain, no fever, no cough, no diarrhea, has black stool, has mild
shortness of breath, has palpitations, has headache, has
burping.
Physical exam
General
Appearance: Looks stable.
BP: 90/40
Pulse: 84
Resp.: 22
Temp. : 36.5
Hair,
ears, nose, and throat: Okay.
Eyes: Pale (mild)
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: Okay
Assessment:
Chronic GI bleeding? Gastritis?
Anemia secondary to abortion or GI bleeding? Parasitis?
Recommend:
Can we try with:
-
Famotidine, 40mg, twice
daily, for one month
- Mebendazole,
100mg twice daily, for three days
-
Multivitamin, one
tablet daily for one month
Please
give me any other ideas. |
-----Original Message-----
From: Tan, Heng Soon,M.D.
Sent: Tuesday, March 09, 2004 12:15 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #1: OUNG CHREB, March 2004 Telemedicine, Robib,
Cambodia
I agree she has fairly severe reflux disease.
What are the triggers? Is she facing some stress in her life? Does she
eat late at night? She doesn't smoke or drink, so those are not
contributing factors. Is she sensitive to fatty or spicy foods? She
will benefit from omeprazole, but I would think 20 mg daily would
suffice. After a month's course, she should be instructed to repeat 2
week courses of omeprazole if symptoms recur. If you suspect anemia or
parasites, has that been confirmed by blood test or stool examination?
Pallor may suggest anemia, but anemia is not necessarily always due to
hookworms. I wouldn't worry about her low blood pressure if she is
asymtomatic.
Heng Soon Tan, M.D.
Dear all,
I would suggest to take a deeper history
concerning the constipation. Is this a new fact, change of stool
habits? Could a rectal exam be done to rule out a rectal cancer? If no
suspicion of colorectal malignancy, try Omeprazole, if no improvement
till next month, consider sending her for a gastroscopy.
Thanks
Dr. Cornelia Haener
Dear David, Rithy and Montha,
The patient had black stool and responsed to
famotidine, then did not showed up to the clinic at follow-up. The
symptoms again reappeared, but no black stool. Mild pallor conjunctiva
on exam. BP similar to months ago SBP 85 to 90 mmHg, HR 72. Agree with
your management of omeprazole, metoclopramide, mebendazole and
multivitamine. We would give her 2 months of medication just in case
she missed follow-up again, add FeSO4/folic acid also 2 months. Check
her Hgb if possible. If low, we would like to work-up this anemia.
Regards,
Bunse
Hello David:
Here are some additional comments from the
medical students working with Dr. Tan, along with his edits.
Kathy
> -----Original Message-----
> From: Tan, Heng Soon,M.D.
> Sent: Tuesday, March 09, 2004 5:29 PM
> To: 'Prasad, Paritosh '
> Cc: Kelleher-Fiamma, Kathleen M. - Telemedicine
> Subject: RE: Patient #1: OUNG
CHREB, March 2004 Telemedicine, Robib,
> Cambodia
>
> Kathy:
> Here are the student's [edited] comments.
> HS
>
> Hi Dr. Tan,
>
> Again, thanks for the cases. The current
presentation seems pretty
> consistent with GERD. The prior reports of black stools and
anemia are
> concerning for an upper GI bleed (peptic ulcer), though at a dose
of
> 20mg BID Omeprazole will treat both conditions. With long
standing GERD,
> we might worry about erosive esophagitis as well, though there
doesn't
> appear to be a history of hematemesis. Is it possible to get an
O&P on
> her stool? [I support that--HS] While it appears she has been
treated in the
> past with Mebendazole, it doesn't look like a specific parasite
was ever
> identified. Hookworm's lifecycle from the intestines to the lungs
and down the
> esophagus could give the abdominal discomfort as well as the
> cough, but I think GERD is a more likely etiology [agree--HS].
I'm not sure
> if empirical treatment with Mebendazole is a good idea without
identification
> of the parasite this time, considering she's been treated
previously and
> symptoms have recurred [agreed--HS]; Mebendazole will also
probably make her
> constipation and headache worse in the short term (both are side
effects of
> Mebendazole). And holding off on the antihelminthic while we push
the GERD
> therapy might help us determine the cause of her symptoms. In the
mean time we
> could ask her to think about possible sources of reinfection?
[Endemic if she
> works barefeet in the fields--HS]
>
> Thanks,
> tosh
Please reply to David Robertson dmr@media.mit.edu
Telemedicine Clinic in Robib, Cambodia – 9 March 2004
Patient #2: PEN SAMADY,
male, 36 years old, follow up patient
 |
Chief
complaint: Patient still complains of sore throat.
Subject:
36-year-old
male came for his follow up of Pharyngitis.
He still has mild sore throat and difficulty in
swallowing, sometimes dry cough, and an itchy feeling all over
his body. No
palpitations, no fever, no shortness of breath, no chest pain,
no abdominal pain, and no stool with blood.
Object: Looks stable, alert and
oriented x 3.
BP: 120/80,
Pulse: 84, Resp.:
20, Temp: 36.5,
Weight: 66kg
Eyes, Ears, Nose & Throat: Okay.
Conjunctiva, pink color.Neck: No goiter and no
lymph node.
Lungs: Clear both sides
Heart: Regular rhythm and no murmur.
Abdomen: Soft, flat and not tender.
Limbs: Okay.
Assessment: Post Pharyngitis syndrome.
Rhinitis by allergy.
Hives.
Plan: We would like to cover him with
some medications:
- Nabumetone,
750 mg, one tablet per day, for ten days
- Acetaminophen/Diphenidramine,
500 mg/25mg, one tablet twice daily, for ten days
Please give me any other ideas. |
I would like more information about how his skin
looks. Does he have a rash? Does he have hives? Dry
skin?
Also, does he have any thrush?
I would recommend:
1. Saline gargles
2. Increased fluids
3. Pain relievers (acetaminophen and/or
nabumetone)
4. If he definitely has hives, I would treat more
aggressively with diphenhydramine 25-75 mg every 4-6 hours as needed
to control itching
- 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
Dear David, Rithy and Montha,
Chronic pharingitis, most likely is
non-infectious in origin. Often cause is post-nasal drip from a
sinusitis. Smoking could also be a cause a long with other chemical
irritation. We would advise not to use antibiotics, just
pseudoephedrine 60 mg P.O tid, chlorpheniramine 4 mg tid, paracetamol
(or paracetamol/diphenhydramine 500/25 tid), salt water gargles for 10
days, quit smoking if he does.
Throat Pain when swallowing could be from the
pharyngitis itself or esophageal herpes, candidiasis,
malignancy....especially in immunocompromised patients. We would check
whether he is immunocompromised such as diabetes or HIV.
Regards,
Bunse
Please reply to David Robertson dmr@media.mit.edu
Telemedicine Clinic in Robib, Cambodia – 9 March 2004
Patient #3: PRUM SOUR, female, 53 years old, follow up patient
 |
Subject:
53-year-old
female came back for her follow up of pneumonia.
Last month we sent her to Kampong Thom Provincial
Hospital for chest x-ray and AFB check.
The doctor told her that she has pneumonia and her AFB is
negative. After
discharging her from the hospital, the doctor asked her to buy
some Amoxycillin, 500mg twice daily for ten days.
But she only took medication for two and a half days.
This was similar to last month when she did not take all
her medication because she could not afford the full course of
medication. Now her
symptoms still are shortness of breath while working, headache,
sometimes cough with slight sputum.
She has no chest tightness, no fever, no abdominal pain,
and no stool with blood.
Object: Looks stable and oriented x
3.
BP: 120/80,
Pulse: 100, Resp.:
22, Temp: 36.5,
Weight: 62 kg
Eyes, Ears, Nose and Throat: Okay.
Conjunctiva, pink color, no jaundice.
Lungs: Slight wheezing on upper and
lower lobes both sides.
Heart: Regular rhythm and no murmur.
Abdomen: Soft, flat, not tender, has
positive bowel sound, and no HSM.
Limbs: No edema and no deformity.
Assessment: Chronic Asthma? Allergy? Tension
headache.
Plan: May we cover her with the
following?
- Albuterol
Inhaler, two puffs four times daily as needed
- Acetaminophen/Diphenidramine,
500 mg/25mg, one tablet twice daily, for seven days
Please give me any other ideas. |
My differential diagnosis now is bronchitis with
reactive airways or cardiac etiology. When I first saw this case
I thought a cardiac etiology is very likey; bronchitis and wheezing
secondary to that is also possible. A chest x-ray (or a report
of it) and an ECG would be very helpfull. I would give her an
inhaler (albuterol) to use as needed/every 4 hours for shortness of
breath but also give her some anti ischemic meds--if you have a
nitrate (e.g. imdur) or even atenalol I would try that+ an aspirin a
day. She isn't febrile so I wouldn't recommend acetaminophen.
Jonathan Sadeh.
Dear David, Rithy and Montha,
The main complaint is shortness of breath on
exertion. She has cough with sputum sometime. Her sputum AFB last
month are negative. No chest pain, no fever. She was told she had
pneumonia in Kg. Thom provincial hospital (by X-Ray???)last month. She
is overweight by the picture.
We think she may have:
1. PTB - does she has weight loss, night sweat,
low grade fever, neighbor has PTB? What is her CXR look like?.
2. CHF - Does she have cardiomegaly on CXR? Any
chest tightness on exertion? Since she is overweight, we would like to
look at her glycemia and also want to rule out IHD by EKG.
3. Asthma or COPD - does she have history of
asthma? Does she smoke?
While waiting for CXR, glycemia and EKG, we would
try low dose furosemide, say 20 mg AM. If no chest tightness on
exertion and EKG is unremarkable, we may try albuterol and see if
SOBOE and wheeze go away.
If CXR is suspicious, we will follow TB program
protocol - repeat 3 more sputum AFB while putting her on Amoxicilline
500 mg tid for another 7 days.
Regards,
Bunse
Please reply to David Robertson dmr@media.mit.edu
Telemedicine Clinic in Robib, Cambodia – 9 March 2004
Patient #4: SAO PHAL,
female, 56 years old, follow up patient
 |
Subject:
56-year-old female returned (last visit December 2003) for
follow up visit for hypertension, DMII, and PNP.
Her symptoms are improving a lot - no neck tenderness, no
chest pain, no shortness of breath, but she has dizziness, and
sometimes has epigastric pain radiating to sternal chest.
She also has excessive saliva and burping in the morning,
like a sour taste, and a dry cough at night.
Patient gained 4 kg in the last three months.
Object: Looks stable.
BP: 120/80, Pulse:
70, Resp.: 20, Temp:
36.5, Weight:
64 kg
Eyes, Ears, Nose and Throat: Unremarkable
Lungs: Clear both sides.
Heart: Regular rhythm and no murmur.
Abdomen: Soft, flat, not tender, no
HSM, and has positive bowel sound.
Limbs: Decreased numbness and no
joint pain. No
edema.
Urinanalysis: Normal
Assessment:
1.
Hypertension (stable)
2.
DMII & PNP
3.
GERD
Plan: Continue same medication
for another month plus add some others:
- Diamecrom,
80 mg, ½ tablet daily (for one month)
- Amitriptilline,
25mg, ½ tablet three times daily (for one month)
- Hydroclorothiazide,
50mg, ½ tablet daily (for one
month)
- Aspirin,
300mg, ¼ tab daily (for one month)
- Ranitidine,
75 mg, two tablets twice daily (for one month)
- Metoclopramide,
10mg, one tablet twice daily (for
ten days)
Note:
We would like to try the above for one month.
If all symptoms not improving, we would like to switch to
Omeprazole. Please
give me any other ideas. |
-----Original Message-----
From: Tan, Heng Soon,M.D.
Sent: Tuesday, March 09, 2004 12:58 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #4: SAO PHAL, March 2004
Telemedicine, Robib, Cambodia
I agree she has esophageal reflux disease. What
are the triggers? Is she facing some stress in her life? Does she eat
late at night? She doesn't smoke or drink, so those are not
contributing factors. Is she sensitive to fatty or spicy foods?
If she coughs at night, propping up the head of
the bed by 6 inches may avoid nocturnal reflux. She will benefit from
ranitidine. 300 mg at night is an alternative way to dose her. After a
month's course, she should be instructed to repeat 2 week courses of
ranitidine if symptoms recur. Of course if response is incomplete,
omeprazole will be more effective. With her diabetes, I would advise
her not to gain any more weight.
Heng Soon Tan, M.D.
Dear David, Rithy and Montha,
Do you have any info on her blood sugar? We
cannot comment on whether we should stay on same dose Diamicron.
I would be sleepy all day if I take amitripyline
tid. For her PNP, bedtime should be OK.
We think she is on famotidine long enough and
still not better, we would switch it now to omeprazole, if still not
better after 1 month, she needs endoscopy. If better, continue another
month. Metoclopramide should be tid or qid.
Have a nice day,
Bunse
Please reply to David Robertson dmr@media.mit.edu
Telemedicine Clinic in Robib, Cambodia – 9 March 2004
Patient #5: SOM DEUM,
female, 64 years old, follow up patient
 |
Subject:
64-year-old female returned for follow up visit for her
Polyarthritis and malnutrition.
Her symptoms are improving a lot; less painful on all her
joints, increased walking, no joint swelling, no shortness of
breath, no fever, no abdominal pain, no stool with blood, no
cough and her weight has increased 5 kg.
Object: Looks stable, alert and
oriented x 3.
BP: 100/50,
Pulse: 70, Resp.:
20, Temp: 36.5,
Weight: 49 kg
Hair, Eyes, Ears, Nose and Throat: Unremarkable
Lungs: Clear
Heart: Regular rhythm and no murmur.
Abdomen: Soft, flat, not tender, no
HSM, and has positive bowel sound.
Joints: No swelling, no stiffness,
but still has mild pain on both knees.
Assessment: Polyarthritis. Malnutrition.
Plan: May we continue with the
following:
- Nabumetone,
750mg, one tablet daily for one month
- Multivitamin,
1 tablet
daily
for one month
Please give me any other ideas. |
-----Original Message-----
From: Crocker, Jonathan T., M.D.
Sent: Tuesday, March 09, 2004 11:27 AM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #5: SOM DEUM, March 2004 Telemedicine, Robib,
Cambodia
Re: Som DEUM
Fantastic! Glad to hear that response to NSAID
has been good and tolerated well.
Continue NABUMETONE with food daily, and if symptoms continue to
improve, you might think about cutting back to AS NEEDED dosing.
No other recommendations.
Best,
Jon Crocker, M.D.
Dear David, Rithy and Montha,
The patient is better on the treatment. We agree
with your suggestion.
Keep taking NSAID with meal.
Regards,
Bunse
Please reply to David Robertson dmr@media.mit.edu
Telemedicine
Clinic in Robib, Cambodia – 9 March 2004
Patient #6: THORN KHUN, female, 38 years old, follow up patient
 |
Subject:
38-year-old female returned for follow up visit for her
hyperthyroidism and neck headache.
Her symptoms are improving a lot; decreasing
palpitations, decreasing shortness of breath, decreasing eye
fatigue, but she still has slight neck tenderness.
Object: Looks stable, alert and
oriented x 3.
BP: 100/70,
Pulse: 80, Resp.:
20, Temp. :
36.5, Wt.: 55 kg
Hair,
eyes, ears, nose, and throat: Unremarkable.
Neck:
Her goiter the same
size, not enlarged.
Lungs:
Clear.
Heart:
Regular rhythm and
no murmur.
Abdomen:
Soft, flat, not tender, no HSM, and has positive bowel
sound.
Limbs:
No edema.
Assessment:
1.
Hyperthyroidism with three months of breast-feeding baby.
2.
Tension headache.
Plan: Continue with following
meds:
§
Multivitamin tab once daily, for one month
- Feso4/folic
200/25mg, one tab per day, for one month
- Paracetemol,
one tablet four times daily, for seven days
We
want to draw her blood in the village to recheck TSH of her
Thyroid test at Sihanouk Hospital Center of Hope.
Please give me any other ideas.
Note:
Her baby is still healthy. |
Patient #6: THORN KHUN, female, 38 years
old, follow up patient
Thank you for the interesting case. I am
happy to hear that she is improving somewhat. My advice remains
the same as last month, so I have included that below with slight
modification.
Best Wishes
Paul Heinzelmann, MD
PS. I might suggest that we develop some kind of
unique medical record number for each patient. That will make
archiving their cases a bit easier for us.
Just a suggestion.
Patient #2: THORN KHUN, February 2004
Telemedicine, Robib, Cambodia
Thank you for this follow up case. Again, I
recommend checking her thyroid function (TSH, T4) and repeating a CBC
now as it has been at least 6-8 weeks since her delivery. Please
send those results when they become are available.
Please also send the normal range of values you
are using for the thyroid tests).
I suspect that she has been hyperthyroid but
is improving somewhat.
Her persistant headache with blurred vision is
somewhat troubling. I assume that has improved as well? She
would benfit from an ophthalmic exam to look at her optic nerves for
papilledema if her headache persists with blurred vision.
My recommendations
1. Check TSH and T4 now. Report values and normal
ranges to us when they are recieved.
2. CBC
3. Ophthalmologic eye exam to check for
papilledma if headache persists with blurred vision
4. Continue the multivitamins as long as she is
breast feeding
5. Continue paracetemol if it helps with headache
but dont ignore persistant headache
Thank you
Paul Heinzelmann, MD
Dear David, Rithy and Montha,
Agree with TSH check, also would check her
hemoglobin in order to stop MTV and FeSO4. Agree with Paracetamol for
headache, inform her about her thyroid status noe so that she feels
relieve.
Regards,
Bunse
Dear Jennifer/ Bunse,
About six cases were sent per David this
afternoon and some more will be sent later. If you have time,
you can go ahead and reply now. Here is a case which was follow
up at SHCH, but I think that instead of having here returning to SHCH
for more F/U she can receive medication from Montha here since he may
have enough left over from another patient to give her until he return
next month (i.e. if you agree with my plan below):
Pheng Roeun, 58F, from Robib TM clinic has been
scheduled to returned to SHCH on 17/03/04 for follow-up on her
hyperthyroid condition. She was lasted seen at SHCH on 27/01/03
per Dr. Lou Lay and since her free T4 was slightly elevated (T4=27)
was was restarted on Carbimazole 5mg 1 po bid. Her past history
at SHCH showed that she was dx and tx with Carbimazole 5mg 1 po tid
since 27/09/01 and reduced to 1 po bid on 14/01/02 and 1 po qd on
23/09/02 and she was stopped due to medication ran out at SHCH on
25/10/02 and restarted back on 31/01/03.
Finally, the doctor stopped her carbimazole (and
propranolol) on 19/08/03 due to free T4 = 17 (10/08/03).
However, her sx recurred with BP 160/80 P 120 R 20 on 26/12/03.
Her T4 was checked on 20/01/04 again and found to
be 27. Dr. Lay started her back on Carbimazole 5mg 1 po bid.
As for my opinion, this patient may need a
maintanance dose of Carbimazole 5 mg 1 po qd is enough (plus
Propranolol 40mg 1/4 po bid) and recheck her free T4 again in
1-2 months (total 3 mos after medication retstarted). Her vital
sx is normal BP 120/60, P80, R22 and without any new sx. She
said that she would be happy not to travel back to SHCH if she does
not need to. What is your opinion on this?
Regards,
Rithy
Dear Rithy:
This is the problem in treating any of these
patients with chronic diseases so far away. We end up dealing
with a woman who needs care there and not here and will be lost to
follow up again when she cannot travel. When was her follow up
down here supposed to be? I think that she should try and keep
that appointment. You could keep her on Propranolol only for now
and this drug she can buy in the private pharmacy up there when she
runs low and chooses not to come back to SHCH for care. The
carbimazole is harder to come by up there and maybe she could get away
with just the beta blocker, given the mild elevation of T4 when she is
off of all medications.
My recommendation---put on propranolol 40 mg, 1/4
tab. PO BID x 30 days and ask her to follow up with us at SHCH, if she
wants to or just stay on the beta blocker that she can buy up there in
the future.
Thanks. Jennifer
Please reply to David Robertson dmr@media.mit.edu
Telemedicine Clinic in Robib, Cambodia – 9 March 2004
Patient #7: NGET SOEUN, male, 56 years old, follow up patient
 |
Subject:
56-year-old
male returned for follow up visit for his Cirrhosis.
His previous symptoms are much improved.
He has no shortness of breath, no palpitations, no cough,
no chest tightness, no abdominal distension or pain, no stool
with blood, has a good appetite, has no limb edema but has
weakness sometimes.
Object: Looks stable
BP: 90/40,
Pulse: 68, Resp.:
20, Temp: 36.5,
Weight: 40 kg
Hair, Eyes, Ears, Nose and Throat: Unremarkable.
Neck: Has no goiter, no JVD, and no
lymph node.
Lungs: Clear both sides.
Heart: Regular rhythm without
murmur.
Abdomen: Soft, flat, not tender, no
HSM, has bowel sound.
Extremities: No edema, no
deformity
Assessment: Cirrhosis
Plan: Continue with the same medications
for another month.
- Spironolatone,
50mg, 1/2 tablet daily
- Propranolol,
40 mg, 1/2 tablet twice daily
- Multivitamin,
one tablet daily
- Furosemide,
40 mg, 1/2 tablet daily
Please give me any other ideas. |
-----Original Message-----
From: Tan, Heng Soon,M.D.
Sent: Tuesday, March 09, 2004 1:02 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #7: NGET SOEUN, March 2004
Telemedicine, Robib, Cambodia
Congratulations on a good clinical response! He
should be monitored with serum electrolytes, renal function tests
every 3 months to avoid electrolyte imbalances that could cause
weakness or cardiac arrhythmia.
Heng Soon Tan, M.D.
> -----Original Message-----
> From: Tan, Heng Soon,M.D.
> Sent: Tuesday, March 09, 2004 5:32 PM
> To: 'Prasad, Paritosh '
> Cc: Kelleher-Fiamma,
Kathleen M. - Telemedicine
> Subject: RE:
Patient #7: NGET SOEUN, March 2004 Telemedicine, Robib,
> Cambodia
>
> Kathy:
> Here are the student's [edited] comments.
> HS
>
>
> Hi Dr. Tan,
>
> Again, thanks for the forwards. The pt in
the case below seems to be
> doing well. He seems to be ascites free
right now, so it probably
> wouldn't pay to change his diuretic regimen.
But theoretically; what
> would you think about going up on the
Spironolactone and down on the
> Furosemide[worth trying considering that he
is on such low doses, he may very
> well continue to do well just on
spironolactone alone. Furosemide could be
> used whenever needed to supplement diuretic
action--HS]. Yes hyperkalemia
> might be a risk but we would better maximize
on spironolactone's inhibition of
> the hyperaldosteronism of
> portal hypertension. Otherwise, besides salt
and water restriction to
> minimize ascites, and protein restriction to
minimize hepatic
> encephalopathy he seems to be well. (Has he
ever had any signs of
> hepatic encephalopathy before?)[No--HS]. It
would also be good to check his
> orthostatics just to make sure he's not
intravascularly depleted. [Good
> suggestion. Checking BUN/Creatinine and
electrolytes will be critical
> too--HS].
>
> thanks,
> tosh
>
Dear Guys in the Province---
I will answer questions for patients 7-11 and
Bunse will handle the first 6 for SHCH. I hope the weather is
nice and that your time there is going well.
#7-Nget Soeun, 56 male---
This man has chronic cirrhosis and at this point,
appears to be stable. The goal of all patients is to stabilize them on
a medication regimen and then maintain them on the least amount of
medications possible. In this case, I would stop the furosemide,
which was needed when he was volume overloaded, but may not be needed
now. I would continue Propranolol 40mg 1/2 po BID; spirolactone
50mg 1/2 po daily and MVI 1 po daily. Next month, you may want
to access the need for propranolol at that dose. Changes in
medications should be done in stages to allow the patient to get used
to the change and so one will know what changes may affect the patient
for the better or for worse.
Please reply to David Robertson dmr@media.mit.edu
Telemedicine Clinic in Robib, Cambodia – 9 March 2004
Patient #8: PEN VANNA, female, 38 years old, follow up patient
 |
Subject:
38-year-old female returned for follow up visit for her
stable hypertension, dyspepsia, and DMII?
Her symptoms have much improved, now decreased muscle
pain, decreased dizziness, no blurred vision, no neck
tenderness, has slight headache, no cough, but still feels
burning on the sternal chest pushing up to the mouth, has
excessive saliva and sour tasting burping in the morning, no
abdominal pain, and has no stool with blood.
Patient gained 4 kg since her last visit in December
2003.
Object: Looks stable.
BP: 140/90,
Pulse: 70, Resp.:
20, Temp: 36.5,
Weight: 64 kg
Hair, Eyes, Ears, Nose and Throat:
Unremarkable
Lungs: Clear both sides.
Heart: Regular rhythm without
murmur.
Abdomen: Soft, flat, not tender, no
HSM, and has bowel sound.
Limbs: Okay
Urinanalysis: Negative
Assessment:
- Stable
Hypertension
- GERD
- DMII?
- Tension
headache.
Plan: We would like to cover her
with some medications for the next month like:
- Hydroclorothiazide,
50mg, ½ tablet daily
- Aspirin,
500 mg, ¼ tablet daily
- Omeprazole,
20 mg twice daily
- Paracetemol,
500 mg, one tablet four times daily as needed
- Keep
her on a restricted sweets and restricted salt diet.
Please give me any other ideas. |
-----Original Message-----
From: Cusick, Paul S.,M.D.
Sent: Tuesday, March 09, 2004 5:16 PM
To: Kelleher-Fiamma, Kathleen M. - Telemedicine
Subject: RE: Patient #8: PEN VANNA, March 2004 Telemedicine, Robib,
Cambodia
Thank you for the information.
She has stable bp (could be a bit better) with a
low salt diet.
Sounds like brackish taste and symptoms are GERD.
continue prilosec and a low acid diet (avoid orange juice, coffee.)
Thank you.
Paul Cusick, M.D.
#8-Pen Vanna, 38F
This lady keeps getting the label of questionable
diabetes. Why? What evidence do you have that she is or is
not a diabetic? Many of our older patients with hypertension may
be at risk of having impaired glucose tolerance (IGT) and would be at
a higher risk of getting diabetes and atherosclerotic cardiovascular
disease in the future. How does this patient fit that profile?
What about this stomach problem? What does she eat in her diet, how
often does she eat and how late does she eat in the day? Does
she have burning in the chest after every meal or is it with certain
foods or other circumstances? If she had gained weight, she may
have a good appetite and not have problems that stop her from eating.
GERD is certainly a possibility and using omeprazole empirically is a
very common treatment to begin with. I agree to start omeprazole
20mg BID and I would hold the ASA, which can aggravate symptoms,
possibly. I would also continue the HCTZ 25mg QD and the paracetamol,
PRN.
Please reply to David Robertson dmr@media.mit.edu
Telemedicine
Clinic in Robib, Cambodia – 9 March 2004
Patient #9: SOM THOL,
male, 50 years old, Follow up patient
 |
Subject:
50-year-old male returned for his follow up visit of DMII, PNP,
dyspepsia and left foot wound infection.
His previous symptoms are improving; decreased frequency
of urination, no chest pain, no dizziness, no fever, no cough,
decreased epigastric pain, no diarrhea, has a weight gain of 3
kg, decreased numbness at extremities.
Results of blood test done last month at
Sihanouk Hospital Center of Hope:
- NA+
133 mmol/l
- K+
6.3 mmol/l
- Bun.
1.3 mmol/l
- Creat.
69 umol/l
- BS
= 9 mmol/l
Object: Looks stable
BP: 110/60,
Pulse: 80, Resp.:
20, Temp: 36.5,
Weight: 57 kg
Hair, Eyes, Ears, Nose and Throat: Okay.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur.
Abdomen: Soft, flat, not tender, no
HSM, has bowel sound.
Limbs: Left foot wound healing and
he’s able to walk very well.
Assessment:
- DMII
& PNP
- Dyspepsia
- Hyperkalemia
(due to blood hemolisis)
- Left
foot wound completely healed
Plan: Continue with the following meds
for one month:
- Diamecron,
80 mg, ½ tablet, three times per day
- Amitriptilline,
25 mg, one tablet, two times per day
- Aspirin,
300 mg, 1/4 tablet daily
- Ranitidine,
75 mg, one tablet twice daily
|
Patient #9: SOM THOL, male, 50 years old, Follow
up patient
Greetings. I am so happy to hear about his
improvement with his foot and in general. I am surprised the
wound is already healed, but that is reassuring. I assume he is
not limping.
I suspect you had the BUN and creatinine values
reversed. A BUN of 69 is a high and his creatinine is just
outside normal range, so I would suspect at least some loss of kidney
function due to his diabetes. (This is important to
consider with a patient on any long term antibiotics.) We are
assuming his hyperkalemia is due to hemolysis. Does he have any
recent prior recorded potassium levels? In my opinion, it warrents
re-checking. My suspician is that he now has diabetic
nephropathy leading to his increased BUN, and his mildy elevated
creatinine. This makes a high potassium less likely due to
hemolysis If available, an easy way to see if a high potassium is
real, is to look for peaked or tented T waves on an EKG.
Assessment:
1. DMII & PNP
2. Dyspepsia
3. Hyperkalemia (?hemolysis vs
renal insufficiency)
4. Elevated BUN (dehydration?
....suggests diabetic nephropathy to me)
4. Left foot wound completely healed
Recommendations:
1. continue meds , but I would consider
avoiding Aspirin if he has ongoing dyspepsia. It can also worsen any
kidney problems. Risks may be greater than any
benefit, and you should consider.
2. recheck Potassium (and/or get ECG and look for
peaked or tented T waves to verify if elevated K is actually
high)
3. If possible do UA dip and look for protein -
this too suggests loss of kidney function.
4. If it hasnt been done, a rectal exam checking
for occult blood and a CBC are needed in patients with dyspepsia,
especially if on Aspirin.
5. Regular follow up
Best of luck with this complicated patient.
Sincerely,
Paul Heinzelmann, MD
#9 Som Thol, 50 male
It is very helpful to at least show us a picture
of the healed foot wound and to continue to educate about closed toed
shoes that don’t fit tightly, inspecting and cleaning the feet with
warm soap and water daily and to always walk around with foot
protection. I agree with your treatment plan to continue all
medications as before.
Please reply to David Robertson dmr@media.mit.edu
Telemedicine Clinic in Robib, Cambodia – 9 March 2004
Patient #10: KHUN NAVOEUN, female, 21 years old, follow up patient
|
Subject:
21-year-old
female follow up case with lichen planus returned.
She is improving a lot with Ciclopirox applied twice
daily but still feels itchy in some places.
She has no fever, no cough, no respiratory distress, no
GI complaints and no secondary infection.
Object: Looks stable
Hair,
eyes, ears, nose, and throat: Normal
Lungs,
heart, abdomen: Normal
Skin:
Old scars of lichen planus on both arms.
Assessment: Lichen planus.
Plan: Continue with the same drug for
another month:
§
Ciclopirox gel, 0.77%, increase dose and apply
three times daily |
I saw this lady in person when we were in Robib.
I would suggest a more potent topical steroid. I am not sure
what is available. Choices included fluocinonide, clobetasol or
halobetasol. If only betamethasone is available, that is ok too.
She should soak the skin in cool water for 20-30 minutes at night,
apply the ointment to the lesions and wrap them for one hour with
something occlusive like plastic food wrap.
By the way, I don't think there is any evidence
for sarcoidosis in this case.
Joseph C. Kvedar, MD
Director, Partners Telemedicine
Vice Chair, Department of Dermatology
Harvard Medical School
Two Longfellow Place Suite 216
Boston, MA 02114
617-726-4447 (phone)
617228-4609 (fax)
The information transmitted in this email is
intended only for the person or entity to which it is addressed and
may contain confidential and/or privileged material. Any review,
retransmission, dissemination or other use of or taking of any action
in reliance upon, this information by persons or entities other than
the intended recipient is prohibited. If you received this email in
error, please contact the sender and delete the material from any
computer.
#10 Khun Navoeun 21 female
Lichen Planus is a chronic condition, so when the
patient is pretty much asymptomatic, she does not need to continue
daily use of topical agents.
Only when symptomatic. I agree with
increasing the use of Ciclopirox, as needed. These lesions will
not likely disappear entirely, but can fade a bit when not excoriated.
I defer to my dermatology colleagues in
Boston.
Please reply to David Robertson dmr@media.mit.edu
Telemedicine Clinic in Robib,
Cambodia – 9 March 2004
Patient #11: MUY VUN,
male, 37 years old, follow up patient
 |
Subject:
37-year-old male patient returned for follow up visit for
his valvular heart disease (MS/MR Afib.)
Last three weeks he has been coughing up blood, increased
shortness of breath, increased palpitations, and increased fever
so he went to Kampong Thom to meet a doctor and they found he
had pneumonia. They gave him some medication and now he is
getting healed, all symptoms gone.
He has no shortness of breath, no palpitations, no cough,
no GI complaints and no edema on extremities.
Object: Looks stable.
BP: 100/60,
Pulse: 84, Resp.:
20, Temp: 36.5,
Weight: 61 kg
Hair, Eyes, Ears, Nose and Throat: Okay.
Neck: No JVD.
Lungs: Clear both sides.
Heart: Irregular rhythm, no murmur.
Abdomen: Soft, flat, not tender, has
bowel sound, and no HSM.
Limbs: No edema.
Assessment:
- Valvular
heart disease (MS, MR) and A-fib.
Plan:
Continue following medications for another month:
1.
Digoxin 0.25 mg ½ tablet per day
- Aspirin
300 mg ¼ tablet per day
Please give me any other ideas. |
Hemoptysis in the setting of MS in an ominous
sign--it is related to increased pulmonary pressures and is a clear
indication for a valve replacement.
Obviously, the best thing for this patient is to
go to a hospital where this can be fixed. If that is not
possible, I would STOP THE ASPIRIN and try to diuris with lasix to
lower pulmonary pressures. It may be secondary to a pneumonia
but the mortality from MS with hemoptysis is so high you have to have
him evaluated in a hospital.
Jonathan Sadeh.
#11-Muy Vun 37 male
For this gentleman, did he get a chest x-ray in
the process of diagnosing the pneumonia? If he did, it is nice
to document where the finding of pneumonia was seen. How long
ago did he have this problem?
I agree with continuing his current medications
as before.
That is it from me. Thanks. Jennifer
Follow up Report, Thursday, 11 March 2004
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: OUNG CHREB, female, 40 years old, Staff at Robib medical
clinic
Patient #2: PEN SAMADY, male, 36 years old, follow up patient
Patient #3: PRUM SOUR, female, 53 years old, follow up patient
Patient #4: SAO PHAL, female, 56 years old, follow up patient
Patient #5: SOM DEUM, female, 64 years old, follow up patient
Patient #6: THORN KHUN, female, 38 years old, follow up patient
Patient #7: NGET SOEUN, male, 56 years old, follow up patient
Patient #8: PEN VANNA, female, 38 years old, follow up patient
Patient #9: SOM THOL, male, 50 years old, follow up patient
Patient #10: KHUN NAVOEUN, female, 21 years old, follow up patient
Patient #11: MUY VUN, male, 37 years old, follow up patient
December 2003 Patient: THO CHANTHY, female, 36 years old, follow up
patient
September 2001
Patient: PHENG ROEUNG, female,
58 years old
[English Version][Khmer
Version]
|
