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October
2002 Telemedicine Clinic in Robib
Report and photos submitted by
David Robertson
On Thursday, October 24, 2002,
Sihanouk Hospital Center of Hope nurse Koy Somontha gave the monthly
Telemedicine examinations at the Robib Health Clinic.
David Robertson transcribed examination data and took digital
photos, then transmitted and received replies from several
Telepartners physicians in Boston and from the Sihanouk Hospital
Center of Hope (SHCH) in Phnom Penh.
Data was transmitted via the Hironaka School Internet link.
The
following day, all patients returned to the Robib Health Clinic.
Nurse "Montha" discussed advice received from the
physicians in Boston and Phnom Penh with the patients.
Following are the e-mail, digital photos and
medical advice replies exchanged between the Telemedicine team in
Robib, Telepartners in Boston, and the Sihanouk Hospital Center of
Hope in Phnom Penh:
Please reply
to dmr@media.mit.edu
Hello from
Robib, Cambodia.
A quick
reminder that the next Telemedicine Clinic in Robib, Cambodia is this
Thursday, 24 October 2002. I'll send out the cases in a few
batches (hopefully late morning, late afternoon, and in the evening on
Thursday, Cambodia time.)
We have the
follow-up clinic with the patients on Friday morning (8:00am, 25
October 2002, Robib time.) Best if we could receive your e-mail
advice before this time (Thursday, 9:00pm, 24 October 2002, in
Boston.)
Thanks again
for your help.
Best regards,
David
Telemedicine
Clinic in Robib, Cambodia - 24 October 2002
Patient
#1: LENG HAK, male, 67 years old, farmer
 |
Chief
complaint: Has headache, dizziness, and blurred vision on
and off for last three years.
History
of present illness: Three
years ago he got headache, dizziness, and blurred vision,
developing day to day. These
symptoms got better when he took some antihypertension medicine.
He got these symptoms accompanied by weakness, neck
tenderness and sometimes vomiting. He went back to the local
doctor and they gave him some medicine for hypertension but
he’s still not better so he came to see us.
Current
medicine: Nifedipine, 10 mg twice per day for two weeks but
he stopped ten days ago.
Past
medical history: He got malaria in 1962, but completed
treatment with modern medicine.
Social
history: Smoked cigarettes and drank alcohol for fifty
years, but quit drinking alcohol about two years ago.
Family
history: Unremarkable
Allergies:
None
Review
of system: Has no fever, no cough, no abdominal pain, has
headache, has blurred vision, has dizziness, no chest pain, and
no dyspepsia.
Physical
Exam:
General Appearance: Good
BP: Left: 220/120, Right:
230/110
Pulse: 100
Resp.: 20
Temp. : 36.5
Hair,
eyes, ears, nose, and throat: Okay.
Neck: No goiter, no
lymph node.
Lungs: Clear both
sides but decreasing breath sound on left side.
Heart: Regular
rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound, and
no HSM.
Limbs: No stiffness, no edema, no joint pain.
Urinalysis: Normal
Assessment: Severe Hypertension.
Recommend: Should we refer him to
Kampong Thom for blood tests like creat., lyte, BUN, plus CBC
and a chest x-ray? |
From: "Graham
Gumley" <ggumley@bigpond.com.kh>
To: "'David
Robertson'" <davidrobertson1@yahoo.com>
Cc: "'Gary
Jacques'" <gjacques@bigpond.com.kh>
Subject: RE: patient
#1, LENG HAK, Cambodia Telemedicine, 24 October 2002
Date: Fri, 25 Oct
2002 11:15:42 +0700
Importance: Normal
Apologies for the
delayed replies ... multiple reasons.
For this patient:
Agree with plan for referral for Hypertension
workup.
Telemedicine
Clinic in Robib, Cambodia - 24 October 2002
Patient
#2: MUY VUN, male, 36 years old, teacher
 |
Chief
complaint: Patient has had palpitations and shortness of
breath, on and off, for the last eight months.
History
of present illness: Eight
months ago patient got palpitations and shortness of breath, on
and off. Symptoms developed during working and lying down, got better
when he took some medicine.
When he got these signs he went to Siem Reap to consult
with a doctor there who gave him some unknown medication.
His condition only got a little bit better so he came to
see us. Besides palpitations and shortness of breath, he also has
dizziness and sweating.
Current
medicine: Used an unknown medication for four months, and
stopped one month ago.
Past
medical history: Unremarkable
Social
history: Drank alcohol and smoked for 18 years but stopped
both two years ago.
Family
history: Unremarkable
Allergies:
None.
Review
of system: Has no fever, has a dry cough, no abdominal pain,
and no chest pain, has dizziness, has mild dyspepsia.
Physical
Exam:
General Appearance: Looks good.
BP: 110/70
Pulse: 80
Resp.: 24
Temp. : 36.5
Hair,
eyes, ears, nose, and throat: Okay.
Lungs: Clear both
sides.
Heart: Irregular
rhythm, no murmur.
Abdomen: Soft, flat, not tender, positive bowel sound, and
no HSM.
Limbs: No edema and no joint pain.
EKG: Done in Siem Reap on 13 May 02,
shows HR = 66, T invert on Lead V4 and AVR many places on Leads
V1, V2, V3 and others not clear.
Other, not clear P wave.
Assessment: Atrial Fibrillation
secondary to Etio? Valvular
heart disease? Left
Ventricle hypertrophy?
Recommend: Should we refer him to
Kampong Thom for blood tests like creat., lyte, BUN, EKG, plus
CBC, a chest x-ray and reevaluation? |
> -----Original Message-----
> From:
Mudge, Gilbert
Horton,Jr.,M.D.
> Sent: Thursday, October 24, 2002 4:32
PM
> To: Kelleher, Kathleen M. -
Telemedicine
> Subject: RE:
patient #2, MUY VUN, Cambodia Telemedicine, 24 October
> 2002
>
> I have reviewed the data supplied on the
patient below. This includes the
> clinical history, physical exam, CBC,
urinalysis, and EKG. The EKG was
> performed on May 13, 2002. The major
abnormality noted is on the EKG.
> This reveals atrial flutter-fibrillation,
but in addition, also shows
> severe right ventricular hypertrophy.
There is extreme right axis
> deviation and a prominent R wave in VI, all
consistent with severe right
> ventricular hypertrophy. This pattern
of EKG abnormality is most
> consistent with advanced rheumatic mitral
stenosis, or perhaps congenital
> heart disease; I suspect the former
diagnosis based on EKG alone. The
> patient requires further evaluation with
Chest X-ray and echocardiogram.
> Cardiac Catheterization may be required.
Although there are few finding on
> physical exam, the EKG abnormalities are
sufficiently abnormal to warrant
> full and complete evaluation. Ultimate
therapy will depend on the
> echocardiogram findings. Please to not
hesitate to contact me if I can be
> of further assistance.
>
From: "Graham
Gumley" <ggumley@bigpond.com.kh>
To: "'David
Robertson'" <davidrobertson1@yahoo.com>
Cc: "'Gary
Jacques'" <gjacques@bigpond.com.kh>
Subject: RE: patient
#2, MUY VUN, Cambodia Telemedicine, 24 October 2002
Date: Fri, 25 Oct
2002 11:17:45 +0700
Importance: Normal
SHCH
Reply;
Agree
with plan for referral for workup as described.
Graham
Gumley.
Telemedicine
Clinic in Robib, Cambodia - 24 October 2002
Patient
#3: SOM MAN, female, 51 years old, farmer
|
Chief
complaint: neck tightness and mass on anterior neck for two
years.
History
of present illness: Two
years ago she developed a mass on the anterior neck plus neck
tightness. Mass
increased in size day to day for two years.
She got these symptoms accompanied by difficulty in
swallowing, dizziness, and palpitations, so she came to see
us.
Current
medicine: None.
Past
medical history: None.
Social
history: No smoking but she’s drank small amounts of
alcohol on and off for two years.
Family
history: Unremarkable
Allergies:
None
Review
of system: Has no cough, no fever, no abdominal pain, no
diarrhea, no dyspepsia, and has dizziness.
Physical
Exam:
General Appearance: Looks good
BP: 120/80
Pulse: 88
Resp.: 20
Temp. : 36.5
Hair,
eyes, ears, nose, and throat: Okay.
Neck: Has goiter,
size 3 x 3 cm, and mobile.
Lungs: Clear both
sides.
Heart: Regular
rhythm, no murmur
Abdomen: Soft, flat, not tender, and positive bowel sound.
Limbs: A little bit of tremor, no stiffness, no edema, and
no joint pain.
Assessment: Hyperthyroidism? Simple goiter?
Recommend: Should we draw blood
here for T4, TSH, T3 and send to our hospital?
Follow up the test results next trip?
Please give me any other ideas. |
From: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>
To: "List, James Frank,M.D.,Ph.D." <JLIST@PARTNERS.ORG>
Cc: 'David Robertson' <davidrobertson1@yahoo.com>,
"Kelleher,
Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject: FW: patient #3, SOM MAN, Cambodia
Telemedicine, 24 October 2002
Date: Thu, 24 Oct 2002 16:24:54 -0400
Hi
Jim,
Thanks
for consulting on this case. Please respond to all and your
recommendations will be sent to Cambodia.
The
website for this project is www.villageleap.com.
The site has a telemedicine link with previous cases.
Good
luck studying for the boards.
Iris
From: "List, James Frank,M.D.,Ph.D."
<JLIST@PARTNERS.ORG>
To: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>
Cc: ''David Robertson' ' <davidrobertson1@yahoo.com>,
"Kelleher,
Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject: RE: patient #3, SOM MAN, Cambodia
Telemedicine, 24 October 2002
Date: Thu, 24 Oct 2002 17:14:56 -0400
Recommendations:
The patient should have thyroid function tests
sent, and, if found to be hyperthyroid, she should be treated
medically until definitive therapy can be arranged. She does not sound
severely thyrotoxic, so follow-up of results in a couple of weeks to
as long as a month or two is acceptable with the caveat that should
her symptoms worsen, she would need more immediate attention. It may
be helpful to treat the patient with beta-blockers at low dose (e.g.
atenolol 25 mg per day) until results are back, on the assumption that
she is hyperthyroid.
Comments:
The patient's complaint of palpitations and the
finding of tremor are compatible with but not diagnostic of
thyrotoxicosis. To establish the diagnosis, a TSH should be sent. If
suppressed, T4, T3, and, if available, T3 resin uptake should be
added. If the TSH is a first generation test (i.e. if it does not
discriminate low normal from suppressed values), then the T4 and T3
should be sent at the same time as the TSH.
If the patient is found to have thyrotoxicosis
(low TSH, high T4 and T3), then the likely etiologies in the setting
of a goiter for 2 years are toxic nodule(s) or Graves' disease. A T3
to T4 ratio in excess of 20:1 favors the latter diagnosis. The level
of T3 and T4 will also help determine what steps to take next.
Usually, antithyroid drugs such as propylthiouricil or methimazole
would be given along with beta-blockers to treat the thyrotoxicosis
until the patient could have definitive therapy with radioactive
iodine or surgery. Often, beta blocker therapy alone will ameliorate
the symptoms of mild to moderate hyperthyroidism.
In the setting of a growing neck mass, thyroid
carcinoma must also be considered. No nodules were mentioned in the
physical examination. If the patient is found not to have
thyrotoxicosis, an ultrasound of the neck and biopsy of any large
nodules would be helpful here. If any palpable nodules are present,
they could be biopsied even without ultrasound evaluation.
An 123I scan and uptake would also be quite
helpful in identifying the etiology of hyperthyroidism and in
identifying cold nodules (which are more likely to contain cancer).
The described mass does not sound big enough to
cause anatomic obstruction of the thoracic inlet; however, there could
be significant retrosternal extension, and the patient's dizzyness and
neck tightness could represent symptoms of compression. A
Pemberton's maneuver may help evaluate this. In this maneuver, the
patient raises her hands above her head. Resulting facial flushing is
a sign of thoracic inlet obstruction, and an indication for further
evaluation - starting with a chest X-ray - and consideration of
surgical removal.
James F. List, M.D., Ph.D.
From: "Graham
Gumley" <ggumley@bigpond.com.kh>
To: "'David
Robertson'" <davidrobertson1@yahoo.com>
Cc: "'Gary
Jacques'" <gjacques@bigpond.com.kh>
Subject: RE: patient
#3, SOM MAN, Cambodia Telemedicine, 24 October 2002
Date: Fri, 25 Oct
2002 11:19:30 +0700
Importance: Normal
SHCH
reply:
Agree
with tests as recommended.
Graham
Gumley
Telemedicine Clinic in Robib,
Cambodia - 24 October 2002
Patient
#4: SOURN VOEUN, female, 52 years old
 |
Chief
complaint: Sore mouth for two months.
Weakness and fever on and off for two months.
History
of present illness: She
has sore throat, weakness, and fever developing from day to day
for two months, increased pain in mouth during eating.
After that, she went to the local health center,
discussed with medical staff, and they gave her antibiotics to
take for three days and she stopped taking the medication 10
days ago and came to see us.
Current
medicine: Antibiotics for three days, stopped the medication
10 days ago.
Past
medical history: Unremarkable
Social
history: Does not smoke and does not drink alcohol.
Family
history: Unremarkable
Allergies:
None
Review
of system: Has mild fever, no vomiting, no abdominal pain,
has diarrhea, no chest pain, no cough, and no stool with
blood.
Physical exam
General Appearance: Looks mildly
thin.
BP: 110/60
Pulse: 94
Resp.: 20
Temp. : 36.7
Hair,
ears, and nose: Okay.
Eyes: Mild pale but
not yellow.
Throat: Pink color, no hypertrophy of tonsil.
Mouth: Has small wound at right upper gum.
Lungs: Clear both
sides.
Heart: Regular
rhythm, no murmur.
Abdomen: Soft, flat, not tender, and positive bowel sound.
Limbs: Okay.
Assessment: Sore mouth secondary to
right upper gum infection.
Vitamin deficiency?
Parasitis?
Recommend: Should we try
Amoxycillin, 500 mg three times daily, for ten days, plus
multivitamins, one tablet daily for ten days, and Albendazole,
100mg twice daily for three days? Please give me any other ideas. |
> -----Original Message-----
> From:
Troulis, Maria
> Sent: Thursday, October 24, 2002 4:02
PM
> To: Kelleher, Kathleen M. -
Telemedicine
> Subject: RE:
patient #4, SOURN VOEUN, Cambodia Telemedicine, 24
> October 2002
>
> I would recommend the amocillin or
doxycycline. If no resolution in 48hrs.
> she should be reevaluated at a larger
center. Also, if patient is febrile,
> has malaise or other systemic issues- she
must be evaluated at larger
> center.
From: "Gary
Jacques" <gjacques@bigpond.com.kh>
To: "David
Robinson" <dmr@media.mit.edu>
Cc:
"Telemedicine Project" <davidrobertson1@yahoo.com>
Subject: pt 4 : Sourn
Voeurn
Date: Fri, 25 Oct
2002 12:55:32 +0700
Importance: Normal
Agree you your
initial plan. If no relief of fever, send for lab work-up
including malaria
smear, CBC ==Gary
Telemedicine Clinic in Robib,
Cambodia - 24 October 2002
Patient
#5: CHHOURN EART, female, 26 years old, farmer
 |
Chief
complaint: Upper abdominal pain for two months.
History
of present illness: Two
months ago she got upper abdominal pain accompanied by nausea,
excessive saliva, pain like cramping in epigastric area
radiating to her back. She
has increased pain after a meal sometimes and decreased pain
after using an antacid given to her by local medical staff in
the village. But
her condition is still on and off so she decided to come see
us.
Current
medicine: None.
Past
medical history: One month ago she was admitted to the local
Rovieng Health Center for one week.
They said she had gastritis.
Social
history: Unremarkable
Family history: Unremarkable
Allergies: None
Review of system: No fever, no cough, no chest pain, has
diarrhea sometimes, no dyspepsia, no stool with blood, and has
upper abdominal pain.
Physical exam
General Appearance: Looks good
BP: 100/60
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair,
eyes, ears, nose, and throat: Okay.
Neck: No goiter and
no lymph node.
Lungs: Clear both
sides.
Heart: Regular
rhythm, no murmur
Abdomen: Soft, flat, not tender, and positive bowel sound.
Limbs: No stiffness and no joint pain.
Assessment: Dyspepsia, Parasitis?
Recommend: Should we
cover her here with some medications like Famotidine, 40 mg once
daily for one month, plus Albendazole 100mg twice daily for
three days? Please
give me any other ideas. |
> -----Original Message-----
> From:
Fairchild, David
Grandison,M.D.
> Sent: Thursday, October 24, 2002 4:01
PM
> To: Kelleher, Kathleen M. -
Telemedicine
> Subject: RE:
patient #5, CHHOURN EART, Cambodia Telemedicine, 24 October
> 2002
>
> My response:
>
> If the patient has not had any weight loss,
I agree with plan to treat with
> Famotidine, 40 mg once daily for one month,
plus Albendazole 100mg twice daily
> for three days.
> However, if the patient has had weight loss
over the past 6 months of more
> than 5 Kg, then I recommend an upper
gastrointestinal endoscopy or
> radiographic study.
>
> David Fairchild, MD
>
From: "Graham
Gumley" <ggumley@bigpond.com.kh>
To: "'David
Robertson'" <davidrobertson1@yahoo.com>
Cc: "'Gary
Jacques'" <gjacques@bigpond.com.kh>
Subject: RE: patient
#5, CHHOURN EART, Cambodia Telemedicine, 24 October 2002
Date: Fri, 25 Oct
2002 11:23:36 +0700
Importance: Normal
SHCH
Reply:
Agree
with this plan.
Graham
Gumley
Telemedicine Clinic in Robib,
Cambodia - 24 October 2002
Patient
#6: CHAN KEN, male, 17 years old, student
 |
Chief
complaint: Swollen and painful on both scrotums, and fever
for the last two days.
History
of present illness: Two
days ago he developed a fever, swelling, and pain on both
scrotums, pain increasing during high fever and walking.
Sometimes he has the chills.
After getting these symptoms he came to see us
immediately.
Current
medicine: Paracetemol, two grams per day for two days.
Past
medical history: Last year he got malaria but was treated
well with modern medicine.
Social
history: Unremarkable
Family
history: Unremarkable
Allergies:
None
Review
of system: Has fever, no cough, no chest pain, no abdominal
pain, no stool with blood, and no dyspepsia.
Physical exam
General Appearance: Looks mildly
sick.
BP: 90/40
Pulse: 120
Resp.: 24
Temp. : 38.7
Hair,
eyes, ears, nose, and throat: Okay.
Neck: Has no mass
and no lymph node.
Lungs: Clear both
sides.
Heart: Regular
rhythm, no murmur
Abdomen: Soft, flat, not tender, and positive bowel sound.
Limbs: Okay
Genital: Both scrotums swollen, painful, hot to touch, and
red.
Assessment: Orchitis?
Rule out malaria (tested negative at local clinic two
days ago.)
Recommend: Should we
cover him with Cloxxicillin 500 mg four times daily for ten
days? And Paracetemol 500 mg four times daily for five days.
Please give me any other ideas. |
> -----Original Message-----
> From:
Kim, Samuel H.,M.D.
> Sent: Thursday, October 24, 2002 3:55
PM
> To: Kelleher, Kathleen M. -
Telemedicine
> Subject: RE:
patient #6, CHAN KEN, Cambodia Telemedicine, 24 October
> 2002
>
> He needs an ultrasound of his scrotum
looking for epididymo-orchitis or
> testicular torsion. Also, besides
Malaria, other parasitic diseases such
> as Schistosomiasis should be ruled out.He
should be covered with broad
> spectrum antibiotics. So he should be
seen at a hospital.
>
> Dr. Sam Kim
From: "Graham
Gumley" <ggumley@bigpond.com.kh>
To: "'David
Robertson'" <davidrobertson1@yahoo.com>
Cc: "'Gary
Jacques'" <gjacques@bigpond.com.kh>
Subject: RE: patient
#6, CHAN KEN, Cambodia Telemedicine, 24 October 2002
Date: Fri, 25 Oct
2002 11:25:13 +0700
Importance: Normal
SHCH
Reply:
This
patient will need hospital admission for IV antibiotics and
observation.
Graham
Gumley
Telemedicine Clinic in Robib,
Cambodia - 24 October 2002
Patient
#7: PEN VANNA, female, 37 years old
Follow up patient from September 2002
Please see last month’s data that
follows in another message.
History of
present illness: We
sent this patient to Kampong Thom Hospital last month.
We think she has mild hypertension and DMII, and possibly
ischaemic heart disease? We
sent the Boston and SHCH opinions to Kampong Thom Hospital with the
patient last month. The
doctors in Kampong Thom say she has no signs of our diagnosis and sent
her back to the village. Now
the patient is back to see us again.
Physical exam
BP: 160/100
Pulse: 80
Resp.: 20
Temp. : 36.5
Blood sugar: 255mg/dl
Assessment: We still think she has mild
hypertension, DMII, and IHD?
Recommend: Please give me any
other ideas for this patient.
Please
reply to dmr@media.mit.edu
Telemedicine Clinic in Robib,
Cambodia - 24 September 2002
Patient
#2: PEN VANNA, female, 37 years old, teacher
Chief
complaint: She has limb numbness, frequency of urination, and
sometimes chest tightness radiating to upper back, on and off for six
months.
History of
present illness: For
six months patient has had chest tightness and frequency of urination,
chest pain like burning, sometimes get worse during nighttime, better
after a massage on chest. Pain radiates to upper back, lasting 20
minutes per occurrence, and it happens once per day.
She gets these symptoms accompanied by headache, dizziness,
blurred vision, and limb numbness and sweating.
Current
medicine: Paracetemol, 1 gram per day, for one month.
Past
medical history: In 1995, she had Typhoid Fever.
Social
history: Unremarkable
Family
history: Unremarkable
Allergies:
Solucamp, in 1993.
Review of
system: Has chest tightness, has dizziness, has headache, no
diarrhea, has upper abdominal pain, no fever, no stool with blood, no
dyspnea, and no cough.
Physical exam
General Appearance: Looks well.
BP: Left = 160/100, Right
= 180/120
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair,
eyes, ears, nose, and throat: Okay.
Lungs: Clear both sides.
Heart: Regular rhythm, no
murmur
Abdomen: Soft, flat, not tender, positive bowel sound, and no
mass.
Limbs: Not swollen, not stiff, mild numbness on the soles.
Blood Sugar: 185mg/dl
Urinalysis: Glucose +3, Urobilinogen +2.
Assessment: Mild Hypertension, DM Type II,
Ischaemic heart disease?
Recommend: Can we try medication that we
have in the village like:
- Propranolol,
20mg daily, for one month
-
Diamecrone, 40mg daily, for one month
- Paracetemol,
500mg, four times per day, for one month
Or should we send her to Kampong Thom Hospital to
evaluate her and do some blood work like lyte, create, Bun, CBC, and
Chest x-ray and EKG?
This
patient should be sent to a medicine clinic for diagnostic evaluation.
She has possible symptoms of diabetes
or cystitis. she has elevated blood pressure on one exam but needs
repeat to confirm. Unclear cause of chest tightness. Needs MD to
evaluate.
Thanks
--Gary
From: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>
To: 'David Robertson' <davidrobertson1@yahoo.com>
Cc: "Kelleher, Kathleen M. -
Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject: RE: Cambodia Telemedicine, 24 Sept.
2002, Patient # 2, PEN VANNA,
female, 37 years old
Date: Tue, 24 Sep 2002 12:37:34 -0400
Hi,
This
patient has several problems and should be transported to Kampong Thom
Hospital. My recommendations follow:
1.
Diabetes with associated peripheral neuropathy.
-
I am not familiar with diamecrone, but if this is a diabetes agent
that is fine, she needs some medication to control her blood sugar
-
Chem7 to check blood glucose and evaluate renal function
-
other basic diabetes care includes eye exam and foot exam
2.
Hypertension. Her diastolic blood pressure is quite high. I would not
treat her with a beta-blocker as this can mask symptoms of
hypoglycemia. A better choice is a an ACE inhibitor, which can slow
the progression of renal disease in a diabetic.
3.
Chest pain. The ddx include musculoskeletal, supported by the
improvement with massage; hearburn, supported by the burning nature
and the fact that it is worse at night. The radiation to the back
brings up an aortic dissection, but this is less likely given the pain
is not acute onset or sharp, and she does not have >30mm Hg
differential in blood pressure in opposite arms. Ischemic chest pain
is possible.
-
EKG
-
CXR
-
Ibuprofen 600mg TID with food for possible musculoskeletal component
of pain
I
hope this helps. Thanks.
Sincerely,
Iris
Kedar, M.D.
-----Original Message-----
From: Kelleher, Kathleen M. - Telemedicine
Sent: Thursday, October 24, 2002 2:04 PM
To: Kedar, Iris,M.D.
Subject: FW: patient #7, PEN VANNA, Cambodia Telemedicine, 24
October 2002
Hello Dr. Kedar:
Here is a follow up case for a patient whose case you reviewed in
September. Please call with any questions or comments.
Kathy
-----Original Message-----
From: Kedar, Iris,M.D.
Sent: Thursday, October 24, 2002 3:44 PM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: patient #7, PEN VANNA, Cambodia Telemedicine, 24
October 2002
Hello,
It
is not clear what the opinion was of the doctors at Kampong Thom
Hospital. I am also not clear on what the patient's current symptoms
are, and whether she has been treated for anything. Given the
objective findings, she very likely has diabetes and hypertension. A
random blood sugar of >200 mg/dl, repeated of another occasion,
confirms diabetes. High blood pressure must be confirmed on 3
occasions, and today she has her second elevated reading.
-
Diamecrone is fine for diabetes if that is what you have
-
Again, I would suggest an ACE inhibitor or diuretic in a hypertensive
patient who likely has diabetes; if there is no other alternative a
beta-blocker such as propranolol is fine.
I
hope this helps.
Sincerely,
Iris
Kedar, M.D.
Agree with your
diagnosis. You can instruct patient on a low salt, diabetic diet
in the meantime. Send your documentation with the patient (your blood
pressure reading on several occasions, her random blood sugar levels).
If still no response at local hospital, try the next available one.
--Gary
Telemedicine Clinic in Robib,
Cambodia - 24 October 2002
Patient
#8: SOR SOPHY, female, 30 years old, farmer
 |
Chief
complaint: Epigastric pain for the last three months.
History
of present illness: Three
months ago she developed epigastric pain on and off accompanied
by nausea in the morning and excessive saliva, pain like
cramping, increased pain when not eating, decreased pain after a
meal, so she came to see us.
Current
medicine: None.
Past
medical history: None.
Social
history: Unremarkable
Family
history: Unremarkable
Allergies:
None
Review
of system: Has headache, has nausea, and has abdominal pain
at epigastric area, no cough, no dyspnea, and no stool with
blood.
Physical exam
General Appearance: Looks good
BP: 90/50
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair,
eyes, ears, nose, and throat: Okay.
Neck: No goiter and
no lymph node.
Lungs: Clear both
sides.
Heart: Regular
rhythm, no murmur
Limbs: No stiffness and no joint pain.
Assessment: Dyspepsia.
Recommend: Should we
cover her with an antacid like Tums, 500 mg three times daily
for two month. Please give me any other ideas. |
From: Kedar, Iris,M.D.
Sent: Thursday, October 24, 2002 4:29 PM
To: 'David Robertson'
Cc: Kelleher, Kathleen M. - Telemedicine
Subject: RE: patient #8, SOR SOPHY, Cambodia Telemedicine, 24
October 2002
Hello,
I agree that this woman has some sort of
dyspepsia. The epigastric pain is concerning for an ulcer, it is
reassuring that she has no blood in her stool. Does she have abdominal
pain upon palpation? Are there any masses? Assuming no
masses, I would recommend famotidine for one month and ask her to
follow-up to see if she is feeling better. If they do h. pylori blood
testing this would also be useful, and if positive would involve
several medications for treatment.
I
hope this helps.
Sincerely,
Iris
Kedar, M.D.
From: "Graham
Gumley" <ggumley@bigpond.com.kh>
To: "'David
Robertson'" <davidrobertson1@yahoo.com>
Cc: "'Gary
Jacques'" <gjacques@bigpond.com.kh>
Subject: RE: patient
#8, SOR SOPHY, Cambodia Telemedicine, 24 October 2002
Date: Fri, 25 Oct
2002 15:05:47 +0700
Importance: Normal
SHCH
Reply:
Agree
with this plan.
Graham
Gumley
Follow up Report, Friday, October 25, 2002
Per
e-mail advice of the physicians in Boston and Phnom Penh, the
following patients were given medication found in the village or
donated by Sihanouk Hospital Center of Hope:
May
2001 Patient: SOM THOL, male, 48 years old
September
2001 Patient: CHOURB CHORK, male, 28 years old
January
2002 Patient: SAO PHAL, female, 55 years old
September
2002 Patient: PEN SAMADY, male, 36 years old
Patient
#4: SOURN VOEUN, female, 52 years old
Patient
#5: CHHOURN EART, female, 26 years old, farmer
Patient
#7: PEN VANNA, female, 37 years old
Patient
#8: SOR SOPHY, female, 30 years old, farmer
Blood
was taken from the following patients in the village for testing at
Sihanouk Hospital Center of Hope in Phnom Penh:
- July
2002 Patient #7: CHHIM KENG, female, 45 years old
- Patient
#3: SOM MAN, female, 51 years old, farmer
Because
of the long travel time and limited medical facilities outside of
Phnom Penh, the blood is collected in the village, stored in an ice
cooler, then driven to Kampong Thom Provincial Hospital where it is
“spun” and returned to the ice cooler for the rest of the journey
to Sihanouk Hospital in Phnom Penh.
This month the drive was a little more than seven hours not
including Hospital and lunch stops. We were able to save the two patients a very long bumpy
ride from the village to the city.
Per
e-mail advice of the physicians in Boston and Phnom Penh, the
following patients were given transport or assistance in getting to
the hospital:
Transported
on 25 October and admitted to
Kampong Thom Provincial Hospital:
- September 2002 Patient #1: NGET SOEUN, male, 59 years old,
farmer
- Patient #2: MUY VUN, male, 36 years old, teacher
- Patient #6: CHAN KEN, male, 17 years old, student
Transport
arranged on 27 October to Sihanouk Hospital Center of Hope in Phnom
Penh:
- Patient
PHIM SICCHIN, female,
35 years old, previous Telemedicine patient for medical
check-up and refill of medication at SHCH
- Patient
PROM CHHIM, male, 63
years old, previous Telemedicine patient for medical
check-up and refill of medication at SHCH
- Patient
YIN HUN, female,
66 years old, previous Telemedicine patient for medical check-up
and refill of medication at SHCH
Transport
arranged
for 27 October
to
Calmette Hospital Cardiology Center in Phnom Penh:
- Patient PHIM SOPHAN, male, 14 year old child, previous
Telemedicine patient (February 2001) for medical check-up and
refill of heart medication
Transport
arranged
for 7 November
to
Calmette Hospital Cardiology Center in Phnom Penh:
- Patient PHIM SOPHAN, male, 14 year old child, previous
Telemedicine patient (February 2001) for echocardiogram, other
tests and evaluation for his heart condition
Transport
was arranged for 29 October and the patient admitted to
Kampong Thom Provincial Hospital:
- Patient
#1: LENG HAK, male, 67 years old, farmer
Transport
arranged for 21 November to Sihanouk Hospital Center of Hope in Phnom
Penh:
- Patient CHAY CHANTHY, female,
38 years old, previous Telemedicine patient, for medical
testing and refill of medication at SHCH
Transport
arranged
for 13 November
to
Kantha Bhopa Children’s Hospital in Phnom Penh:
- Patient SENG SAN, female, 13 year old child, Telemedicine
patient (June 2001,) for medication and chronic care for
polyarthritis.
Transport
arranged
for 24 November
to
Calmette Hospital Cardiology Center in Phnom Penh:
- Patient CHHEM LYNA, female, 2 year old child, previous
Telemedicine patient (February 2001) for medical check-up and
refill of heart medication
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