Report and photos
submitted by David Robertson
On Friday,
November 21, 2003, Sihanouk Hospital Center of Hope physician
assistant Rithy Chau 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.
On November 22, all of this month’s
patients returned to the Robib Health Clinic. Rithy Chau
discussed advice with the patients received via e-mail from the
physicians in Boston and Phnom Penh.
Dr. Joseph Kvedar,
Nancy Lugn from Telepartners of Boston, MA visited Cambodia and
were on hand in Robib to observe this month’s clinic.
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>
We will be sending six cases tonight, four
more cases will go out tomorrow morning.
The follow up clinic will be on Saturday
morning, November 22 at 9:00am Cambodia time (November 21 @ 9:00pm
in Boston.) Please reply before this time if possible. Thanks
again for your kind assistance.
Telemedicine Clinic in Robib,
Cambodia – 21 November 2003
Patient #1: THORN KHUN, female, 38 years old,
follow up patient
 |
Subject: Patient returned for
follow up visit for check-up for her pregnancy and possible
symptoms of hyperthyroidism? Her previous TSH = 0.02, free T4
= 28, on 13 August 2003 and TSH = 0.02, free T4 = 26, on 11
October 2003 done at SHCH. Patient said that she was feeling
better but still experienced palpitations off and on, mild
heartburn, and felt a little gassy. Otherwise, no vaginal
discharge, weight has been increasing, and baby is kicking.
Generally doing well.
Object: No enlarged neck mass
on thyroid, no exophthalmos; chest exam clear breath sound, no
crackles, no Rhonchi, heart regular rhythm without murmur. No
extremity edema.
BP: 138/88
Pulse: 88
Resp.: 18
Temp. : 36.5
Wt.: 67 kg
Assessment: Pregnancy of nine
months. Dyspepsia secondary to pregnancy.
Plan: Multivitamin
tab once daily, Tums 4 times daily, and Feso4, folic acid 200,
25mg, one tab per day, all meds for 30 days.
Comments:
Patient had ultrasound done at the Preah Vihear Hospital and reading
normal, male fetus due 5 December 2003 +/- ten days. She can
have her blood drawn again in two to three months after
delivery for TSH (only) to reevaluate her thyroid function;
otherwise she can follow up as needed.
Do you agree? |
Good morning,
Gentlemen and Nancy:
Once again, we
find that we are late in the replies to you. Please excuse my
delay. Gary will answer some of your queries and I will cover the
rest. I hope that Rithy is doing better and is pushing a lot of
fluids during the trip.
Thanks for you
great work. Have a great day.
Jennifer
My responses:
#1: Thorn Khun,
38yo F with pregnancy and hyperthyroidism. She sounds like things
are going well with the pregnancy and I agree to continue to
monitor and give no meds other than the MVI and TUMS. We are
keeping her a little hyperthyroid for the good of the developing
fetus. Good job in her understanding of the situation enough so
she does not treat herself with other medications from somewhere
else. The more serious situation is hypothyroidism and we would
have had to treat that to help her and the baby. I agree with
your follow-up. We look forward to hearing that she had a safe
delivery.
Thank you for the
update on this interesting patient. I have read her prior
history.
To summarize:
This is a 38 year
old female in her final month of pregnancy, and that as of last
month continues to have laboratory evidence of hyperthyroidism,
and occasional episodes of palpitations, in addition to mild
dyspepsia. It was apparently decided to avoid treating her with
medications in the past, and over the past three months her
original neck mass has reduced to the point where it is no longer
palpable and is no longer tender. OB ultrasound has shown that the
baby is doing well.
It is very
reassuring that she seems to be improving, however, we should
remember that because of her apparent hyperthyroidism, she remains
at a higher risk for thyroid storm, severe preeclampsia, preterm
delivery, heart failure, and possibly, miscarriage. Her age also
puts her at increased risk of complications. Low birth weight in
neonates also can occur.
[Information about
thyroid storm: A rare but serious complication of hyperthyroidism.
Diagnosis is based on a combination of signs and symptoms: fever,
tachycardia out of proportion to the fever, altered mental status
(nervousness, restlessness, confusion, seizures), vomiting,
diarrhea, and cardiac arrhythmia. An inciting event (e.g.,
surgery, infection, labor, delivery) may be identified. Untreated
thyroid storm can result in shock, stupor, and coma. Serum-free
triiodothyronine (FT3), FT4, and TSH levels help confirm the
diagnosis, but treatment should not be delayed for test results. A
standard series of drugs is used to treat thyroid storm:
propylthiouracil or methimazole; saturated solution of potassium
iodide or sodium iodide; dexamethasone; and phenobarbital. General
supportive measures, such as oxygen, antipyretics, and appropriate
monitoring, are also important. Unless deemed necessary, delivery
during thyroid storm should be avoided.]
Also, patients with
hyperthyroidism (and subclinical hyperthyroidism) remain 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 if this
hyperthyroid state persists after her delivery.
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 an option, she
should deliver her baby within a medical facility.
3. If no worsening
of her symptoms occurs, at minimum, recheck TSH in 6-10 weeks
after delivery.
I hope this was
helpful. I look forward to any updates on her or her infant's
condition as needed.
Thank you.
Paul Heinzelmann, MD
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib, Cambodia – 21 November 2003
Patient #2: THO CHANTHY, female, 36 years
old, follow up patient
 |
Subject: Patient with diagnosis of
hyperthyroidism returned for follow up visit. She has been
taking Carbimazole, Propranolol, and Aspirin regularly; her
symptoms of palpitations, tremor and poor appetite have been
improving with medications, sleep is better, and she has
gained some weight. No new symptoms and no other problems.
Patient ran out of medication about ten days ago.
Object: Has exophthalmos, thyroid
enlargement (same size as before,) no neck bruit. Chest exam
with clear breath sound, HR = 80, regular rhythm, +2 systolic
murmur heard over apex. No extremity edema.
BP: 136/78
Pulse: 80
Resp.: 16
Temp. : 36.5
Weight: 52kg
Assessment: Hyperthyroidism.
Plan: Continue with same medications:
- Carbimazole, 5mg, one tablet three
times daily
- Propranolol, 40mg, 1/4 tablet twice
daily
- Aspirin, 300mg, 1/4 tablet
daily
- Multivitamin, one tablet daily
Next month Nurse Montha will draw her
blood for both TSH and T4.
Do you agree? |
SHCH reply:
This hyperthyroid
patient now on medical treatment is clinically improved without
physical exam evidence of hyperthyroidism. It would be helpful in
the future to record when her current treatment was initiated. I
agree with continuing current medications and rechecking the
thyroid studies in one month.
Gary Jacques, M.D.
> -----Original
Message-----
> From: Tan, Heng
Soon,M.D.
> Sent: Friday,
November 21, 2003 2:49 PM
> To: Kelleher-Fiamma,
Kathleen M. - Telemedicine
> Subject: RE:
Patient #2: THO CHANTHY, female, 36 years old
>
> Hyperthyroidism
> How long has she
been on treatment? It sounds like she is now euthyroid on
> maintenance
therapy. I would titrate the carbimazole dose between 5-15 mg to
> maintain euthyroid
state. Medicine can be given bid for a total of 12 months
> after achieving
euthyroid state.
>
> Exophthalmos
> If she has any
chemosis or double vision, she should be referred to an
> ophthalmologist
for surgery.
>
> HS
> -----Original
Message-----
> From: Tan, Heng
Soon,M.D.
> Sent: Friday,
November 21, 2003 2:53 PM
> To: Kelleher-Fiamma,
Kathleen M. - Telemedicine
> Subject: RE:
Patient #2: THO CHANTHY, female, 36 years old
>
> One other thought.
> She may not need
to take propranolol if she is euthyroid, unless she is
> taking it for
hypertension. By the way, I can see from her picture that
> the proptosis is
quite mild and benign.
> HS
Please reply to David Robertson <dmr@media.mit.edu>
We will be sending six cases tonight, four
more cases will go out tomorrow morning.
The follow up clinic will be on Saturday
morning, November 22 at 9:00am Cambodia time (November 21 @ 9:00pm
in Boston.) Please reply before this time if possible. Thanks
again for your kind assistance.
Telemedicine Clinic in Robib, Cambodia – 21 November 2003
Patient #3: SOM THOL, male, 50 years old,
Follow up patient
 |
Subject: Patient returned for follow up
visit, diagnosed with DMII and PNP. He has been out of
medications for 2-3 days now, no new symptoms, has left leg
numbness from knee down, is thirsty and urinates frequently.
No fever, no weight loss; still has mild epigastric pain off
and on with burning sensation; no black or bloody stool. Does
not smoke or drink alcohol. No foot sore.
Object: No oropharyngeal lesions, no skin
rashes, chest exam with clear breath sound, no crackles, no
Rhonchi, heart regular rhythm without murmur. Bowel sound in
all four quadrants, no HSM, has slight tenderness in
epigastric region on deep palpation. No leg edema, numbness
pattern remains the same below the knees on both sides, has
mild left calf pain on deep palpation, good pedal pulses
bilaterally. Urinalysis dipstick glucose 4+.
BP: 94/58
Pulse: 104
Resp.: 16
Assessment:
- DMII.
- PNP.
- Muscle spasm.
- Dyspepsia.
Plan: Prescribe the following meds for
the next 30 days:
- Diamecron, 80 mg, ½ tablet, three
times per day
- Amitriptilline, 25 mg, one tablet, two
times per day.
- Famotidine, 40 mg, one tablet daily
- Multivitamin tablet twice
daily
- Paracetemol, 500 mg, four times daily
Patient to return for next month’s clinic
on 10 December 2003. Recommend giving him an additional
week’s supply of meds for this patient. Gave him two tablets
of Paracetemol, 500 mg now. Any ideas or comments? |
Good morning,
Gentlemen and Nancy:
Thanks for you
great work. Have a great day.
Jennifer
#3: Som Thol, 50M
Please remember
that UA is a poor monitor for DM. One can have blood glucose
in the range or 250-350 and not have it spill into the urine. It
depends on the renal and other metabolic states of the patient.
It is difficult that we do not have fingerstick there for such
patients. This is a difficult situation because he needs chronic
drugs and if Telemedicine does not come as scheduled each month,
he was be lacking. I agree with an extra week of medications for
this reason. He needs a diet history taken and it would be good
to encourage multiple meals with decreasing rice (1/3-`1/2 cup)
per meal if that is his main source of calories. We should be
promoting more leafy green vegetables that have a lower
carbohydrate amount, but rich in vitamins and water. He needs to
also drink 2 liters of good water per day, even if he is not
thirsty. I agree with renewing his medications as you have
stated.
Patient #3: SOM THOL,
male, 50 years old
This patient is
obviously a very poorly controlled diabetic with multiple serious
complications including diabetic neuropathy (peripheral and
autonomic neuropathy): (I do recall sending a detailed reply
with recommendations in the recent past, though I don't see
it on the website. I wonder of it was received.
If so, those
recommendations are likely still useful.)
Autonomic neuropathy
is a group of symptoms caused by damage to nerves supplying the
internal body structures that regulate functions such as blood
pressure, heart rate, bowel and bladder emptying, and digestion.
Other symptoms
typical of diabetic neuropathy also include the following, and can
be expected:
· Numbness
· Tingling
Decreased sensation to a body part
· Loss of sensation to a body part or area
· Diarrhea
· Constipation
· Loss of bladder control
· Impotence
· Facial drooping
· Vision changes
· Dizziness
· Weakness
· Swallowing difficulty
· Speech impairment
· Muscle contractions
Assessment:
1. DMII poorly
controlled
2. PNP
3. Autonomic neuropathy
Some suggetions:
1. Tighter control
of glucose- which may be difficult as we don't have HgbA1Cs or
even glucose readings.
2. Small, frequent
meals; sleeping with the head elevated; may help with GI symptoms.
3. Topical pain
creams (capcacin)
4. Regular follow
up for exams, screening
Best,
Paul Heinzelmann, MD
Massachusetts
General Hospital
Please reply to David Robertson <dmr@media.mit.edu>
We will be sending six cases tonight, four
more cases will go out tomorrow morning.
The follow up clinic will be on Saturday
morning, November 22 at 9:00am Cambodia time (November 21 @ 9:00pm
in Boston.) Please reply before this time if possible. Thanks
again for your kind assistance.
Telemedicine Clinic in Robib, Cambodia – 21 November 2003
Patient #4: NGET SOEUN, male, 56 years old,
follow up patient
 |
Subject: Patient returned for follow up
visit for his Cirrhosis and Ascitis problem. He ran out of
medication 10 days ago. He said his symptoms were much
improved with less distended abdomen, no more leg edema;
sometimes has shortness of breath after walking one kilometer;
increased appetite and has gained some weight.
Object: Not icteric, no oropharyngeal
lesions, no JVD, no bruit. Chest exam with bilateral coarse
crackles lower lung fields, heart regular rhythm without
murmur. Active bowel sound, slight distension of abdomen, has
4cm shifting dullness on percussion; no hepathomegalie. No
extremity edema.
BP: 100/68
Pulse: 76
Resp.: 18
Temp. : 36.5
Weight: 42 kg
Assessment:
- Cirrhosis.
- Ascitis secondary to Cirrhosis
- Pulmonary congestion secondary to
Cirrhosis
Plan: Continue with the same medications.
- Spironolatone, 50mg, 1/2
tablet twice daily for 30 days
- Furosemide, 40 mg, 1/2 tablet
daily for 30 days
- Propranolol, 40 mg, 1/4 tablet
twice daily for 30 days
- Multivitamin, one
tablet daily for 30 days
Return next month for follow up
and give one week extra supply of medication. Do you agree? |
SHCH Reply:
I agree with your
management. This note makes no mention of any lab monitoring. If
they have not been checked in the last several months, please
check electrolytes, BUN, creatinine at time of next visit.
Gary Jacques, M.D.
> -----Original
Message-----
> From: Tan, Heng
Soon,M.D.
> Sent: Friday,
November 21, 2003 2:59 PM
> To: Kelleher-Fiamma,
Kathleen M. - Telemedicine
> Subject: RE:
Patient #4: NGET SOEUN, male, 56 years old
>
> Cirrhosis ascites
> He sounds stable
on his current medications and can be continued as is.
> Ideally,
electrolytes to check sodium, potassium, urea and creatinine will
> help monitor renal
response. Monitoring weight clinically is useful. Watch
> out for
encephalopathy from GI bleed or excessive meat intake. By the way,
> was it alcoholic,
viral hepatitis or cryptogenic cirrhosis? Has he
> received
appropriate hepatitis A and B vaccination to prevent
> superinfection?
> HS
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 21 November 2003
Patient #5: SAO PHAL, female, 55 years old,
follow up patient
 |
Subject: Patient returned for follow up
visit for her hypertension and DMII with PNP. She has no new
complaint except her eyesight is getting worse with blurry
vision. Still has epigastric pain on and off, heartburn, bad
taste in mouth in the morning, excessive burping, no bloody or
black stool, still has “burning sensation” on her lower
extremities, decreased thirst, frequency of urination and not
eating so much.
Object: No oropharyngeal lesions, fundi
unable to exam, no JVD, clear breath sound, no crackles, no
Rhonchi, heart rate regular rhythm without murmur, abdomen
soft, active bowel sound, no HSM, mildly obese, no extremity
edema, good pulses, no numbness. Urinalysis dipstick within
normal limit.
BP: 115/78
Pulse: 80
Resp.: 16
Temp. : 36.5
Weight: 58 kg
Assessment:
1.
DMII (ontrolled)
2.
Hypertension
(controlled)
3.
Peripheral neuropathy
4.
GERD
Plan: 30 days supply of the
following meds:
- Diamecrom, 80 mg, ½
tablet daily
- Nifedipine, 20mg daily
- Aspirin, 300mg, ¼ tab daily
- Amitriptilline, 25mg, ½ tablet twice
daily
- Famotidine, 40 mg twice daily
Patient to return next month for follow
up. Give her one extra week supply of meds. Do you agree? |
Good morning,
Gentlemen and Nancy:
Thanks for you
great work. Have a great day.
Jennifer
#5: Sao Phal, 55F
This lady, as
stated above, may actually not have great diabetic control. We
need more information about that, but a diet history and
increasing exercise for definite weight loss would be important.
I agree with the famotidine for the dypepsia, but I would also
consider switching her BP medications from nifedipine to HCTZ
25mg po QD. Nifedipine can cause acid reflux because it relaxes
the gastroesophageal sphincter. Her blood pressure is not that
significant, so switching to something else may improve those
symptoms. I would keep the rest of the meds the same.
> -----Original
Message-----
> From: Tan, Heng
Soon,M.D.
> Sent: Friday,
November 21, 2003 2:34 PM
> To: Kelleher-Fiamma,
Kathleen M. - Telemedicine
> Subject: RE:
Patient #5: SAO PHAL, female, 55 years old
>
> Blurred vision
> Is there any
obvious cataract on direct illuminination examination of the eye
> lens? Can she read
the vision chart? If the blurred vision is chronic, I would
> suspect cataract
or visual refraction problem. If it is transient, it may be
> related to
hyperglycemia. Can her fingerstick fasting blood sugar be
measured?
> As for treatment,
are you able to perform refraction to prescribe eye glasses?
>
> GERD
> If famotidine is
ineffective, do you have omeprazole? Using metoclopramide
> supplements may
also enhance the effects of famotidine.
>
> Peripheral
neuropathy
> Amitriptyline can
be given 25 mg once a day. You could increase to 50 mg qd to
> see whether it
will be more effective. Otherwise try carbamazepine 200 mg bid.
>
>
> HS
Please reply to David Robertson <dmr@media.mit.edu>
Following is the last case we will be sending
tonight, four more cases will go out tomorrow morning.
The follow up clinic will be on Saturday
morning, November 22 at 9:00am Cambodia time (November 21 @ 9:00pm
in Boston.) Please reply before this time if possible. Thanks
again for your kind assistance.
Telemedicine Clinic in Robib,
Cambodia – 21 November 2003
Patient #6: PEN VANNA, female, 37 years old,
follow up patient
 |
Subject: Patient returned for follow up
visit for her hypertension and DMII; she complained of central
chest tightness off and on for one month, especially after
having a heavy meal, excessive burping, and epigastric pain.
Has headache and sometimes dizziness, her other previous
symptoms were much improved, ran out of medication one week
ago.
Object: No oropharyngeal lesions, no JVD,
chest exam shows clear breath sound, heart rate regular rhythm
without murmur, abdomen unremarkable, no leg edema.
Urinalysis dipstick within normal limit.
BP: 158/116
Pulse: 80
Resp.: 16
Temp. : 36.5
Weight: 61 kg
Assessment:
- Hypertension
- DMII
- GERD
Plan: 30 days supply of the
following meds:
- Diamecrom, 80 mg, ½
tablet daily
- Propranolol, 40mg, ½ tablet twice
daily
- Famotidine, 40 mg twice daily
- Diet & exercise
Patient to return next month for follow
up. Give her one extra week supply of meds. Gave Propranolol
40mg ½ tablet now and another ½ tablet for bedtime. Will
recheck BP tomorrow morning. Do you agree? |
SHCH Reply:
I try to be
careful with using beta blockers such as propranol in diabetics
because they can mask (hide) the symptoms of hyperglycemia.
Often beta
blockers are less effective in women as well. If she has no
contraindications, let's try HCTZ 25mg once per day if available.
An ACE inhibitor if available would also be a good choice.
I agree with the
rest of your plans. Can we check a blood sugar by finger stick
next time? (specify fasting or random) Labs such as electrolytes,
glucose and creatinine should be checke a few times per year at
least.
Gary Jacques, M.D.
Would agree that she
needs medications for hypertension and recheck to determine if
blood pressure is effectively maintained below 130 systolic and 80
diastolic.
continue treatement
for diabetes mellitus type 2 and GERD.
Please reply to David Robertson <dmr@media.mit.edu>
Thanks again for your kind assistance.
Telemedicine Clinic in Robib, Cambodia - 21 November 2002
Patient #7: MUY VUN, male, 36 years old,
follow up patient
 |
Subject: Patient returned for follow up
visit for his problem of congenital heart disease. He has
been treated with Digoxin 0.25 mg ½ tablet per day and Aspirin
300 mg ¼ tablet per day. He said that the medication was
helping him with his symptoms of shortness of breath,
palpitations, no syncope, no headache, no dizziness, no chest
pain, and he stopped smoking and drinking alcohol one year
ago.
Object: Has JVD and it disappeared at
45-60 degree angle of head elevation; chest clear breath
sound, no crackles, no Rhonchi; normal heart rate with
irregular rhythm, no thrill, opening snap heard over aortic
and mitral areas with +1-2 grade diastolic murmur. No
clubbing, no cyanosis, no extremity edema. Good pedal pulses.
BP: 105/70
Pulse: 64
Resp.: 18
Temp. : 36.5
Weight: 64 kg
Assessment:
- Congenital heart disease with AS and
MS?
- A-fib.
Plan:
1.
Digoxin 0.25 mg ½ tablet per day
- Aspirin 300 mg ¼ tablet per day
Patient to return next month for follow
up. Give him one extra week supply of medication.
Do you agree? |
Good morning,
Gentlemen and Nancy:
Thanks for you
great work. Have a great day.
Jennifer
#7: Muy Vun, 36 M
with CHD.
I would continue
his current meds. He may have mitral stenosis with atrial
fibrillation and just by maintaining a lower heart rate to give
more effective contractility to his heart seems to have stabilized
him. He may need diuretics in the future should his conditions
worsen. I would continue all current meds and give extra to him,
as you have suggested.
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib, Cambodia – 21 November 2003
Patient #8: KHAN NAVOEUN, female, 21 years
old
 |
Chief complaint: Itchy rashes on arms and
legs for nine years.
Subject: HPI. 21-year-old female, cleft
lip (from birth) presented with complaint of itchy rashes on
both legs and arms. Initially, the lesions appeared when she
was 12 years old, and during the last two years they appeared
on her arms and left flank with “small bumps” and when she
scratched them they became scaly and excoriated. No fever, no
oral problem, no difficulty swallowing, no shortness of
breath, no cardiopulmonary complaint, no GI complaint. No
cough, no sputum production.
Past medical history: Repaired cleft lip
(1982) at Preah Vihear Provincial Hospital.
Family history: None.
Social history: Does not smoke or drink
alcohol.
Allergy: Penicillin (rashes.)
Review of system: Five-month-old baby,
irregular menses with little blood flow.
PE: Alert & oriented x 3.
BP: 128/68
Pulse: 84
Resp.: 16
Temp. : 36.5
Weight: 44 kg
Hair, eyes, ears, nose, and throat: No
oropharyngeal lesions, no enlarged lymph node.
Chest: Clear breath sound without
crackles or rhonchi; heart regular rhythm without murmur.
Abdomen: Soft, not tender, and no HSM.
Extremities: Plaque-like lesions ranging
from less than 1cm to 3-4cm with scales and excoriations in
random pattern over both legs and arms and left anterior
flank; mild erythema. Trunk, face, palms, soles, and scalp
spared.
Neuro: Unremarkable.
Assessment:
1.
Lichen planus.
2.
Sacchoidosis?
Plan:
1.
Topical steroid (bethamethasone or
hydrocortisone cream if available locally.)
2.
If not improved with topical steroid,
send her for chest x-ray and some blood work at Kampong Thom? |
SHCH:
I would add
psoriasis to the differential diagnosis in a patient with chronic
scaly plaques more on the extensor surfaces of the extremities.
I agree with a
trial of topical steroids and would expect to see some improvement
without complete resolution.
Gary Jacques, M.D.
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib, Cambodia – 21 November 2003
Patient #9: SAO CHHOUN, male, 37 years old
 |
Chief complaint: Left upper quadrant
abdominal pain off and on for three months.
Subject: HPI. 37-year-old male with
past medial history of malaria five years ago presented with
complaint of left upper quadrant abdominal pain off and on for
three months. No fever, no headache, no nausea and vomiting,
no shortness of breath, no syncope, no tinnitus, no myalgia,
no arthralgia; has cough with “greenish sputum” off and on for
one week, has sore throat for one week also. Good appetite,
no black or bloody stool. The left side pain occurred after
he did heavy lifting for one full day unloading a truck.
Past medical history: Malaria five years
ago; accident injury – loss tip of middle finger on left
hand.
Family history: Father died of TB at 45
years old.
Social history: Heavy drinker of
alcohol, smokes three packs per day for the last five years.
Allergy: No known drug allergy.
BP: 110/64
Pulse: 84
Resp.: 16
Temp. : 37.5
Hair, eyes, ears, nose, and throat: Not
icteric, pink conjunctiva; no oropharyngeal lesions; no lymph
node enlargement.
Chest: Clear breath sound, heart regular
rhythm without murmur.
Abdomen: Soft, positive bowel sound all
quadrants, has splenomegaly (two finger breadth below costal
margin) with mild tenderness on palpation.
Neuro: Unremarkable
Malaria smear negative 21 November 2003
Assessment:
1.
Splenomegaly.
2.
Muscle strain?
3.
Pneumonia?
4.
Rule out TB.
Plan:
1.
Send him to Kampong Thom Hospital for
CBC, chest x-ray and abdominal ultrasound?
2.
Paracetemol, 500 mg, one to two times
daily for pain
3.
Ofloxocine, 200mg, two tablets twice
daily for seven days.
Follow up next month? |
Good morning,
Gentlemen and Nancy:
Thanks for you
great work. Have a great day.
Jennifer
#9 Sao Chhoun,
37M
I am not quite
clear on the history of this man. What is the quality of his left
upper quadrant pain? When does it come on and what makes it
better? If this musculoskeletal pain or is it internal?
Musculoskeletal
pain will produce more of a sharp quality of pain that comes on
with movement or direct palpation. Rithy, is this visceral pain?
Pain with palpation of the spleen? I am not sure of the
significance of this finding.
His respiratory
symptoms could just be from a bronchitis and as you may know, the
organisms will likely be Gram negative because of his smoking
history.
Ruling out TB is
okay, but his course is short and he likely has a bacterial
infection.
I agree with your
management--Ofloxacin 400mg BID for 10 days; paracetamol 500mg 1-2
po Q6h, prn for pain and fever; stop smoking and alcohol intake;
and getting a
CXR, US of abdomen and CBC are all appropriate.
Please reply to David Robertson <dmr@media.mit.edu>
This is the final case we will be sending
this month.
The next Telemedicine Clinic in Robib,
Cambodia will be on Wednesday,
December 10, 2003.
Thanks again for your kind assistance.
Telemedicine Clinic in Robib, Cambodia – 21 November 2003
Patient #10: CHHOURN SOKHON, male, 45 years
old
 |
Subject: Follow up patient from May 2002
came in complaining of left heel wound from puncture injury of
bamboo debris in 1979. In 1993, he went to Preah Vihear
Hospital and got wound care, but not healed because he “walked
around too much.” He was seen by nurse Montha through our
Telemedicine Clinic in Robib in May 2002 and was sent to
Kampong Thom Hospital for surgical wound care and debridement;
wound became better; but the wound was not completely healed
due to not following doctor’s instructions. Now he has
returned for help. No fever, no groin swelling. Has used
penicillin frequently.
Object: Open wound, necrotic with
draining pus, tenderness involving tendon and possibly bone;
limping gait and shortened Achilles tendon (?) good pedal
pulse; no cellulitis; foul smell, shotty left inguinal lymph
node without tenderness.
BP: 104/68
Pulse: 80
Resp.: 16
Temp. : 36.5
Weight: 40 kg
Assessment: Left open heel wound with
possible osteomyelitis.
Plan:
- Paracetemol, 500 mg, two tablets daily
for pain.
2.
Can we refer him to Sihanouk Hospital
Center of Hope orthopedic surgeon for aggressive debridement
and IV antibiotics? If you agree, can we bring him back to
Phnom Penh this trip and take him to SHCH on Monday morning? |
SHCH Reply:
I agree that this
chronic wound most likely involves underlying osteomyelitis. Yes,
you may bring him to SHCH for aggressive treatment.
I will forward
pictures to our surgeons.
Gary Jacques, M.D.
Please reply to David Robertson <dmr@media.mit.edu>
Dear Dr. Jacques and Dr. Hines,
We received your replies on all the cases,
thanks so much.
We should be leaving the village in another
hour, and hope to be back to Phnom Penh by 9:00pm or so.
Today we will be transporting two patients
plus two relatives to look after them.
Rithy will inform Montha; the patients will
come to SHCH on Monday.
Best regards,
David
Follow up Report, Monday, 24 November 2003
Per e-mail
advice of the physicians in Boston and Phnom Penh, four patients
from this month’s clinic and several follow up case 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 #2: THO CHANTHY, female, 36 years
old, follow up patient
Patient #3: SOM THOL, male, 50 years old,
follow up patient
Patient #4: NGET SOEUN, male, 56 years old,
follow up patient
Patient #5: SAO PHAL, female, 55 years old,
follow up patient
Patient #6: PEN VANNA, female, 37 years old,
follow up patient
Patient #7: MUY VUN, male, 36 years old,
follow up patient
Patient #8: KHAN NAVOEUN, female, 21 years
old
Patient #9: SAO CHHOUN, male, 37 years old
Patient #10: CHHOURN SOKHON, male, 45 years
old
October 2003 Patient: YEM PHALA, male, 55
years old
Transported to Phnom Penh on 22 November
2003 by the Telemedicine team for an appointment at Sihanouk
Hospital Center of Hope:
October 2002 Patient: LENG HAK, male, 68
years old
Patient #10: CHHOURN SOKHON, male, 45 years
old
Transport & lodging arranged for 28
November 2003 follow up appointment at Sihanouk Hospital Center of
Hope in Phnom Penh:
April 2003 Patient: PROM NORN, female, 52
years old
Transport arranged to Kampong Thom
Provincial Hospital on 22 November 2003 by the Telemedicine team:
Patient #9: SAO CHHOUN, male, 37 years old
Transport & lodging arranged for 28
November 2003 follow up appointment at Kantha Bhopa Children’s
Hospital in Phnom Penh:
June 2001 Patient: SENG SAN, female,
13-year-old child
The next Telemedicine Clinic in Robib,
Cambodia will be on Wednesday,
December 10, 2003.
