|
   
June
2002 Telemedicine Clinic in Robib
Report and photos by David
Robertson
On Thursday, June 27, 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 Dr. Jennifer Hines
of the Sihanouk Hospital Center of Hope (SHCH) in Phnom Penh.
The data was transmitted via the Hironaka School Internet
link. Also
joining us on-line was Dr. Srey Sin, Director of Kampong Thom
Provincial Hospital.
The
following day patients returned to the Robib Health Clinic.
Nurse "Montha" discussed advice received from the
physicians in Boston and Phnom Penh with the patients.
Following
are the e-mail, digital photos and medical advice replies exchanged
between the Telemedicine team in Robib, Telepartners in Boston, and
the Sihanouk Hospital Center of Hope in Phnom Penh:
Please reply to <dmr@media.mit.edu>
Dear All,
Messages regarding the first three patients
today follow. I'll be sending more cases out later this
evening.
Fri. June 28 8am
Telemedicine follow-up clinic
Best for nurse Montha and me to receive e-mail
replies of medical advice by 7:30am on Friday, Cambodia time (8:30pm
on Thursday evening in Boston.)
We cannot transport patients or give medication
without a physician's advice. We are hoping to depart the
village late on Friday morning, stopping first in Kampong Thom, then
continuing to Phnom Penh.
Best regards,
David
Please reply to <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia
27 June 2002
Patient #1: PRUM RETH, female, 45 years old, farmer
|
Follow up patient from May 2002
Telemedicine Clinic
Chief complaint: Still
has palpitations, neck tenderness, headache
Note:
We saw this patient last month.
There was a typo on last month’s exam notes, BP was
stated as 100/80 in May 2002 but in fact it was 160/80.
Montha suggested using Propranolol for her hypertension
but Dr. Jacques didn’t agree because of the typing mistake.
Last month Montha suggested that she had dyspepsia and
mild hypertension. Dr.
Jacques agreed to use Famotidine, 40 mg per day for one
month.
Please check next forwarded message: Last month’s exam
notes on this patient
Review of system: Still
has headache, neck tenderness, shortness of breath sometimes.
Burping decreasing, no vomiting, decreasing epigastric
pain.
Physical exam
General Appearance: looks good
BP: 170/100
Pulse: 88
Resp.: 20
Temp. : 36.5
Hair, eyes, ears,
nose, throat: Okay
Neck: Okay
Lungs: Clear both sides
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound
Limbs: Okay
Assessment: Mild hypertension. Dyspepsia.
Recommend: Should we try Propanolol 40 mg, ¼ tablet
2 times per day for 30 days?
Continue Famotidine 40 mg once per day for one more
month? Do we need to send her to Kampong Thom Hospital for further
evaluation or continue to treat in the village? |
Note: forwarded message attached.
__________________________________________________
Date: Wed, 29 May 2002 18:00:29 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Patient #9: PRUM RETH, Cambodia
Telemedicine, 29 May 2002
To: "Kvedar, Joseph Charles,M.D."
<JKVEDAR@PARTNERS.ORG>,
Graham
Gumley <ggumley@bigpond.com.kh>, KKELLEHER@PARTNERS.ORG,
"Gere, Katherine F." <KGERE@PARTNERS.ORG>,
Jennifer Hines <sihosp@bigpond.com.kh>, gjacques@ucd.net,
Jacques@bigpond.com.kh
Cc:
Bernie Krisher <bernie@media.mit.edu>, dmr@media.mit.edu,
aafc@forum.org.kh, nsothero@yahoo.com, seda@daily.forum.org.kh
please reply to <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia
29 May 2002
Patient #9: PRUM RETH, female, 45 years old, farmer
 |
Chief complaint: Neck tenderness,
dizziness, and palpitations last nine months. Upper abdominal
pain on and off for the last nine months.
History of present illness:
Last nine months she had neck tenderness, dizziness, and
palpitations on and off and accompanied by headache and mild
blurred vision. She also has upper abdominal pain
radiating to chest, pain like burning, gets worse after a
meal. She went got these symptoms, she went to the doctor and
received some medicine, it helped some, but now she has
stopped taking the medication for two months already.
Current medicine: None.
Past medical history: Knew nine
months ago that hypertension diagnosed 180/?
Social history: Unremarkable
Family history: Unremarkable
Allergies: None
Review of system: No fever, no
diarrhea, positiveburping, no nausea, upper abdominal pain, no
chest pain, no weight loss, no cough
Physical exam
General Appearance: looks good
BP: 100/80
Pulse: 74
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Neck: No lymph node, no goiter
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, positive bowel
sound.
Limbs: okay
Assessment: Mild hypertension. Dyspepsia.
Recommend: Should we refer her to the hospital?
Or cover her in the village with medication like Famolidine
for one month, 40 mg one time per day, and Propranolol 10 mg,
two times per day for one month. If you have any ideas, please
let me know. If you agree with the assessment to treat
with medication in the village, please give me the correct
dosage. |
-----Original
Message-----
From: Goldszer, Robert Charles,M.D.
Sent: Thursday, June 27, 2002 5:45 PM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: Patient #1: PRUM RETH, Cambodia
Telemedicine, 27 June
2002--Previous Patient #9 from May
I am concerned about the thyroid activity in
this patient with palpitations and hypertension. I think it would be
good to start propanolol 40 mg once a day and I think it would be
good to measure blood TSH level.
RCGoldszer
From:
"sihosp" <sihosp@bigpond.com.kh>
To:
"David Robertson" <davidrobertson1@yahoo.com>
References:
<20020627081509.9784.qmail@web10402.mail.yahoo.com>
Subject:
Re: Patient #2: SOR THAVOEUN, text, Cambodia Telemedicine, 27 June
2002
Date:
Thu, 27 Jun 2002 17:52:58 +0700
#1:
Prum Reth, 45 yo Female.
I
think that if your blood pressures are accurate and she does have hypertension,
yes, I would start Propranolol 40mg at 1/4 tablet po twice a day.
This would be a chronic medication, so can the patient afford
and medication
and does she have access to it?
Kg. Thom Hospital would have it on
their formulary.
The famotidine is used with a limit and patient may want
to cut down on tea eat smaller meals more often.
Case # 2
Please reply to <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia
27 June 2002
Patient
#2: SOR THAVOEUN, female, 13 years old,
|
(Computer student @ Hironaka
School, brother works at the pig farm)
Chief
complaint: Edema all over the body on and off.
Headache last 14 days.
Sometimes shortness of breath on exertion last 14
days.
History
of present illness: 14
days ago edema started on and off starting from the face
moving down to the legs, and increased edema when she eats
salty food. When
she got these signs her mother brought her to meet a local
doctor. They gave
her some medicines but she doesn’t know what kind.
During that time she got a little bit better, edema
decreasing and sometimes it was accompanied by shortness of
breath, sometimes on extertion, sometimes jaundice, with
headache and blurred vision.
Current
medicine: She stopped taking the unknown medicine one week
ago but had taken it for 10 days.
Past
medical history: Three years ago she had malaria but got
better with modern medicine treatment.
Social
history: Unremarkable.
Family
history: Unremarkable
Allergies:
Unremarkable
Review
of system: Mild edema all over the body, shortness of
breath on exertion, sometimes jaundice, no cough, no diarrhea,
mild right upper quadrant abdominal tenderness.
Physical exam
General Appearance: looks good
BP: 110/70
Pulse: 72
Resp.: 22
Temp. : 36.5
Hair,
ears, nose, throat: okay
Eyes & Face: Eyes no jaundice, red pink color
Neck: No goiter, no lymph node
Lungs: Clear both sides
Heart: Regular rhythm, no murmur
Abdomen: Mild right upper quadrant tenderness, soft, flat,
positive bowel sound, negative HSM
Limbs: Okay
Weight: 40 kg
Urinanalysis: Urobilinogen +2, Protein +1
Assessment: Hepatitis?
Nephrotic Syndrome?
Recommend: Should refer her to
Kampong Thom Provincial Hospital for evaluation.
Check blood like CBC, Hepatitis, abdominal ultrasound,
lyte, creat., Bun.? Any
other ideas? |
From:
"sihosp" <sihosp@bigpond.com.kh>
To:
"David Robertson" <davidrobertson1@yahoo.com>
Subject:
Re: Patient #2: SOR THAVOEUN, text, Cambodia Telemedicine, 27 June
2002
Date:
Thu, 27 Jun 2002 17:52:58 +0700
#2-
Sor Thavoeun, 13 yo Female
I
am not sure about this patient.
You give a history of edema and dyspnea on exertion over just
two weeks.
Did she have fever, chills, rash, poor urine output before
this?
How much fluids does she take in now and how much urine
does she pass/ day?
Has this changed from before?
Any palpitations, cough, chest tightness?
What is the change, if any, in her weight recently? Do
her clothes, shoes fit normally?
We
need more history to help us.
The PE was unremarkable.
Please try and get
a sense of the chronicity of the problem.
Any previous episodes?
Dies she
have any of the medication left that she took or know who can
identify it for you?
I
wait on your answer.
Jennifer
Dear Jennifer,
Montha's reply in CAPS.
sihosp <sihosp@bigpond.com.kh> wrote:
#2- Sor Thavoeun, 13 yo Female
I am not sure about this patient. You give a history of edema and
dyspnea
on exertion over just two weeks. Did she have fever, chills, rash,
poor
urine output before this?
NO TO ALL.
How much fluids does she take in
now and how much
urine does she pass/ day? Has this changed from before?
NORMAL CONSUMPTION, NORMAL
OUTPUT, NO CHANGE FROM BEFORE.
Any palpitations,
cough, chest tightness?
NONE OF THE ABOVE.
What is the change, if any, in
her weight recently?
SLIGHT WEIGHT GAIN.
Do her clothes, shoes fit normally?
NORMAL BUT OCCASIONALLY CLOTHES
FIT A BIT TIGHT.
We need more history to help us. The PE was unremarkable. Please
try and
get a sense of the chronicity of the problem. Any previous
episodes?
THIS IS A NEW PROBLEM, NOT
CHRONIC, ONLY TWO WEEKS.
Dies
she have any of the medication left that she took or know who can
identify
it for you?
NO MEDICATION LEFT, TYPE UNKNOWN.
I wait on your answer. Jennifer
BEST REGARDS,
DAVID
Dear David:
Dr. Ghaleb Daouk, of MGH Pediatric Nephrology
and I reviewed this patient's history and photos and Dr. Daouk
indicated that Sor Thavoeun should be transported to the hospital
and have a complete work-up by both a nephrologist and an infectious
disease specialist.
With warm regards,
Kathy Kelleher
Case # 3
Please reply to
<dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia
27 June 2002
Patient #3: SEK TIT, male, 66 years old
Follow up patient from May 2002 Telemedicine
Clinic
Insert SEK_TIT_6696.jpg
Chief
complaint: Still complaining about numbness on head, neck
tenderness, dizziness.
Please check next forwarded message: Last month’s exam notes
on this patient
Note: This patient we suspected to have
hypertension and peripheral neuropathy.
Dr. Jacques suggested we cover him with Propranolol 40 mg, ¼
tablet two times per day for 30 days plus Vitamin B1, 250 mg, one
tablet once a day for 30 days.
This patient lives outside of the village of our pilot
project. He was given
the Propranolol from the Sihanouk Hospital Center of Hope allotment
and he purchased the B1 on his own.
The pharmacy in this village does not have Propranolol.
Review
of system: Head numbness, dizziness, neck tenderness, no chest
pain, no vomiting, no diarrhea, and no epigastric pain.
Physical exam
General Appearance: looks well
BP: 190/90
Pulse: 68
Resp.:
20
Temp. :
36.5
Hair,
eyes, ears, nose, throat: Okay
Neck: Okay
Lungs: Clear
both sides
Heart: Regular
rhythm, no murmur
Abdomen:
Soft, flat, not tender, positive bowel sound
Limbs:
Okay
Assessment: Hypertension and peripheral
neuropathy.
Recommend: May we cover him with Propranolol
but increase dose to 20mg twice per day and continue with Vitamin
B1, 250 mg, one tablet once per day, and Aspirin 300 mg 1 tablet 1
time per day, covering all medications for 30 days?
We have told this patient that because he lives outside of
the village of our pilot project, he will have to purchase these
medicines on his own. But may we get him started on medicine from the SHCH
allotment this month and then next month he purchases on his own?
Any other ideas?
Note: forwarded message attached.
__________________________________________________
Date: Wed, 29 May 2002 17:57:24 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Patient #8: SEK TIT, Cambodia
Telemedicine, 29 May 2002
To: "Kvedar, Joseph Charles,M.D."
<JKVEDAR@PARTNERS.ORG>,
Graham
Gumley <ggumley@bigpond.com.kh>, KKELLEHER@PARTNERS.ORG,
"Gere, Katherine F." <KGERE@PARTNERS.ORG>,
Jennifer Hines <sihosp@bigpond.com.kh>, gjacques@ucd.net,
Jacques@bigpond.com.kh
Cc:
Bernie Krisher <bernie@media.mit.edu>, dmr@media.mit.edu,
aafc@forum.org.kh, nsothero@yahoo.com, seda@daily.forum.org.kh
please reply to <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia
29 May 2002
Patient #8: SEK TIT, male, 66 years old,
farmer
 |
Chief complaint: Weakness,
dizziness. Both feet have numbness on and off for three
months.
History of present illness:
For three months he has weakness, dizziness, and sometimes
neck tenderness accompanied by blurred vision and numbness all
over both feet. These symptoms develop when he walks and
get better when he rests. After he got these signs he
purchased medication at the drug store like anti-hypertension
medicine taking on and off for one month. He stopped
medication two months ago.
Current medicine: Traditional
medicine.
Past medical history: Two years
ago hypertension diagnosed 150/?
Social history: Has smoked and
drank alcohol for 30 years.
Family history: Unremarkable
Allergies: None
Review of system: Has
dizziness, no cough, no chest pain, has diarrhea, no vomiting,
no nausea, no fever, no dyspepsia
Physical exam
General Appearance: looks
non-toxic
BP: 170/90
Pulse: 78
Resp.: 20
Temp. : 36
Hair, eyes, ears, nose, throat: Normal.
Neck: okay
Lungs: clear both sides
Heart: decreasing regular rhythm, no murmur
Abdomen: soft, flat, not tender, positive bowel
sound.
Limbs: numbness both feet, no deformity
Assessment: Hypertension (mild)
and PNP (Peripheral neuropathy)
Recommend: Should we cover him
with Propranolol 10 mg, two times per day and Vitamin B1, 250
mg, one tab per day? Should we refer him to the
hospital? Please give me any ideas. |
-----Original
Message-----
From: Goldszer, Robert Charles,M.D.
Sent: Thursday, June 27, 2002 5:48 PM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: Patient #3: SEK TIT, Cambodia
Telemedicine, 27 June 2002
I think it would be fine to increase the
propanolol to 40 mg, 1/2 pill twice a day. I would plan to see him
at your next visit in 3-4 weeks if possible, or have him seen by
another nurse or physician.
RCGoldszer
From:
"sihosp" <sihosp@bigpond.com.kh>
To:
"David Robertson" <davidrobertson1@yahoo.com>
Subject:
Re: Patient #3: SEK TIT, Cambodia Telemedicine, 27 June 2002
Date:
Thu, 27 Jun 2002 18:03:14 +0700
Hi
David:
About
Sek Tit. This man has
systolic hypertension and looks like a smoker. He
is on propranolol at 10mg twice a day, but I am concerned about
increasing the dose with the heart already in the 60's.
Beta blockers will be
safe down to a heart rate of roughly 60.
You may want to try 10mg three times
a day or keep the same propranolol dosing and add HCTZ 50mg, 1/2
tablet once a day. He
should be able to buy this in the private pharmacy.
Not
furosemide, but a thiazide diuretic.
If we have this, we can give both for
30 days. Chronic meds.
have to be gotten through the patient.
He
should stop smoking.
Thanks.
Jennifer
Case # 4
Please reply to <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia
27 June 2002
Patient #4: CHAN
SIVUTHA, female, 50 years old, nurse at Robib health clinic
 |
Chief
complaint: Upper abdominal pain, right chest tightness,
numbness on both hands and both legs for 30 days.
History
of present illness: Right
chest tightness for 30 days, persistent pain like dullness not
radiating to anywhere, and last three hours and especially at
night she gets better when she takes Paracetemol.
She also has upper abdominal pain especially after meal
and accompanied by burping and excessive saliva, numbness both
legs and hands. Decreasing
upper abdominal pain when she took Almac.
Current
medicine: Almac, Paracetemol for seven days.
Past
medical history: Unremarkable.
Social
history: Does not smoke, does not drink alcohol.
Family
history: Her husband died in 2000 because of severe
pneumonia.
Allergies:
Penicillin
Review
of system: No fever, no cough, right chest tightness, no
nausea, no vomiting, has burping, has epigastric pain, has
diarrhea sometimes.
Physical exam
General Appearance: looks stable
BP: 100/60
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair,
eyes, ears, nose, and throat: Okay
Neck: Okay
Lungs: Clear both sides
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound
Limbs: Okay
Urinalysis: Negative
Assessment: Muscle Pain.
Dyspepsia, Anxiety?
Recommend: Should we cover her
with Tums 500 mg, 3 times per day for 30 days?
And Paracetemol 500 mg, 4 times per day for 10 days?
Exercise every day. |
From:
"sihosp" <sihosp@bigpond.com.kh>
To:
"David Robertson" <davidrobertson1@yahoo.com>
Subject:
Re: Patient #4: CHAN SIVUTHA, Cambodia Telemedicine, 27 June 2002
Date:
Fri, 28 Jun 2002 10:16:36 +0700
#4
Chan Sivutha- the nurse
Her
symptoms seem nonspecific to me.
Montha, remember that onset and timing of
symptoms are important. Did her symptoms come on quickly or
gradually? Does it limit any of her activities?
On PE, does she have tenderness in the area
of her chest pain?
Is this reproducible?
If
she has point tenderness to the chest that you can make happen again
and again,
this is chest wall pain.
Tylenol, heat, Tiger balm or similar, should
be tried.
We
do not have anymore TUMS to give to you on your trip, so you should
use it
wisely.
If the patient can get Almac, that is okay to continue.
Anyone with
access to medications, should buy them on their own.
You should save your
meds for those who have no other source of medicines.
Case # 5
Please reply to <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia
27 June 2002
Patient
#5: DY SAMOEUN, female, 30 years old, farmer
 |
Chief
complaint: Epigastric pain for three days
History
of present illness: Three
days ago she got severe epigastric pain like dullness
radiating to lower back accompanied by burping, vomiting and
sometimes nausea. Gets better when she takes antacid, worse
after a meal.
Current
medicine: Antacid and an unknown antibiotic for three
days.
Past
medical history: Malaria in 2001.
Social
history: Does not smoke, does not drink alcohol.
Family
history: Unremarkable.
Allergies:
None.
Review
of system: No fever, no cough, has epigastric pain, no
chest pain, has stool with mucous, has burping, has vomiting,
no shortness of breath.
Physical exam
General Appearance: looks mild
sick
BP: 100/50
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair,
eyes, ears, nose, and throat: Okay
Neck: Okay
Lungs: Clear both sides
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound
Limbs: Okay
Assessment: Dyspepsia.
Parasitis?
Recommend: Can we cover her with
Famotidine 40 mg once per day for 30 days?
And Mebendazole 100 mg, 2 times per day for 3 days?
Please give me any other ideas.
|
Hello David:
Please find the response of Dr. Kvedar below.
Kathy
-----Original Message-----
From: Kvedar, Joseph Charles,M.D.
Sent: Thursday, June 27, 2002 5:00 PM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: Patient #5: DY SAMOEUN, Cambodia
Telemedicine, 27 June 2002
I believe it makes sense to empirically treat
with antihelminthics as Montha has suggested. If this is not
effective, I would suggest a course of antacid therapy. I
would send her to hospital for evaluation if she has fever, bloody
diarrhea, or bloddy emesis.
From:
"sihosp" <sihosp@bigpond.com.kh>
To:
"David Robertson" <davidrobertson1@yahoo.com>
Date:
Fri, 28 Jun 2002 10:16:36 +0700
#5-
Dy Samoeun 30 yo. F
For
symptoms less than 1 week, I would not use famotidine.
You could give TUMS
for five days at a time. These
symptoms are acute and very well could be
related to parasites or other organisms.
I agree with the mebendazole and
limited TUMS use. Someone
with chronic abdominal symptoms may need famotidine
course, but I don't think in this case, we need to use.
Case # 6
Please reply to <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia
27 June 2002
Patient #6: HEM VANNOU, female, 51 years old
 |
Chief
complaint: Weakness, upper abdominal pain, and dizziness
on and off for two months, dry cough on and off for three
months.
History
of present illness: Dry
cough on and off for three months and mild fever at night.
Weight loss step by step, about 10 kg, over three
months. Sometimes
sweats at night. She
also has upper abdominal pain especially after meal radiating
to back. She gets
these signs accompanied by weakness and dizziness. She has never been to a doctor.
Current
medicine: None.
Past
medical history: Unremarkable.
Social
history: Does not smoke, does not drink alcohol.
Family
history: Her son-in-law has pulmonary TB and lives with
her.
Review
of system: Dry cough, mild fever, sweating, weight loss,
vomiting, burping, dizziness, no diarrhea, has chest
tightness.
Urinalysis:
Urobilingen ++
Physical exam
General Appearance: looks skinny
BP: 100/50
Pulse: 120
Resp.: 22
Temp. : 36.5
Hair,
eyes, ears, nose, throat: Okay
Neck: No goiter, no lymph node
Lungs: Crackle on right side upper lobe, decreasing breath
sound at both
bases.
Heart: Regular rhythm, no murmur, Tachycardia.
Abdomen: Soft, flat, not tender, positive bowel sound
Limbs: Okay
Assessment: Pulmonary TB? Dyspepsia, Malnutrition.
Recommend: Should we refer to
Kampong Thom Provincial Hospital for evaluation like chest
x-ray, AFB examination, and some blood tests like CBC.
Please give me any other ideas. |
Hi David:
Dr. Kvedar's
response is below.
Thank you for the referrals.
-----Original Message-----
From: Kvedar, Joseph Charles,M.D.
Sent: Thursday, June 27, 2002
5:15 PM
To: Kelleher, Kathleen M. -
Telemedicine
Subject: RE: Patient #6: HEM
VANNOU, Cambodia Telemedicine, 27 June 2002
I agree that all findings are
consistent with pulmonary tb and that work up focused
on this condition is the best course.
From:
"sihosp" <sihosp@bigpond.com.kh>
To:
"David Robertson" <davidrobertson1@yahoo.com>
Date:
Fri, 28 Jun 2002 10:16:36 +0700
#6-
Hem Vannou 51 yo F---send to rule out TB.
Note: forwarded message attached.
From:
"Kelleher, Kathleen M. - Telemedicine" KKELLEHER@PARTNERS.ORG
To: "David Robertson (E-mail 2)" <dmr@media.mit.edu>,
"David
Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject: FW: Patient #6: HEM VANNOU, Cambodia
Telemedicine, 27 June 2002
Date: Thu, 27 Jun 2002 17:17:44 -0400
Hi David:
Dr. Kvedar's response is below.
Thank you for the referrals.
-----Original Message-----
From: Kvedar, Joseph Charles,M.D.
Sent: Thursday, June 27, 2002 5:15 PM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: Patient #6: HEM VANNOU, Cambodia
Telemedicine, 27 June 2002
I agree that all findings are consistent with
pulmonary tb and that work up focused on this condition is the best
course.
Case # 7
Please reply to <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia
27 June 2002
Patient #7: SOK NOEUN, female, 38 years old, farmer
 |
Chief
complaint: Sore throat and throat tightness on and off for
two months. Epigastric pain for three months.
History
of present illness: Two
months ago on and off she got sore throat and throat
tightness, increasing pain during drinking, ice, and salty or
fatty food, decreasing pain with the use of Paracetemol.
She gets these symptoms accompanied by mild fever,
headache, dizziness, and epigastric pain. She’s never gone to meet a medical doctor.
Current
medicine: None.
Past
medical history: Unremarkable.
Social
history: Does not smoke and does not drink alcohol.
Family
history: Unremarkable
Allergies:
None
Review
of system: Mild fever, throat soreness and tightness, no
vomiting, has nausea, no chest pain, no diarrhea, has
epigastric pain.
Physical exam
General Appearance: Looks
non-toxic.
BP: 140/90
Pulse: 80
Resp.: 20
Temp. : 37
Hair,
eyes, ears, nose: Okay|
Throat: Mild redness, some pus at left side of tonsil,
but both tonsils no hypertrophy.
Neck: No goiter, no lymph node
Lungs: Clear both sides
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound, no
HSM.
Limbs: Okay
Assessment: Chronic Pharyngitis, dyspepsia.
Recommend: Should we cover her
with Amoxycillin 500 mg, 3 times per day for 10 days?
And Famotidine, 400 mg, one tablet daily for 30 days? And Paracetemol 500 mg, 4 times per day for 7 days? |
Hello David:
Dr. Kvedar's response is below.
Feel free to contact us with any additional
questions/comments.
Kathy
-----Original Message-----
From: Kvedar, Joseph Charles,M.D.
Sent: Thursday, June 27, 2002 5:24 PM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: Patient #7: SOK NOEUN, Cambodia
Telemedicine, 27 June 2002
I agree with the empiric coverage with
amoxicillin and famotidine, but am not sure that paracetamol would
add much value. I think the others should do the trick.
From:
"sihosp" <sihosp@bigpond.com.kh>
To:
"David Robertson" <davidrobertson1@yahoo.com>
Date:
Fri, 28 Jun 2002 10:16:36 +0700
#7-
Sok Noeun 38 yo F
I
agree with the Amoxicillin for the pharyngitis, as well as the paracetamol.
Use of famotidine here is not needed.
She needs to push fluids.
The pus from the infected tonsil can cause dyspepsia and
nausea. This
should get better when we treat the tonsil.
Case # 8
Please reply to <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia
27 June 2002
Patient #8: CHOURN CHANTY,
female, 35 years old, farmer
 |
Chief
complaint: Headache, dizziness, chest tightness on and off
for one month. Upper abdominal pain for two weeks.
History
of present illness: She
has chest tightness like stabbing on the pericardial area
radiating to the lower chest, lasts for five or six minutes at
a time, happens twice a day, accompanied by headache and
dizziness. She
gets better after taking Paracetemol.
She also has epigastric pain like burning, increased
pain before a meal, better after a meal, pain not radiating to
anywhere.
Current
medicine: None.
Past
medical history: In 1993 she had malaria.
Social
history: Does not smoke and does not drink alcohol.
Family
history: Unremarkable
Allergies:
None
Review
of system: Mild local chest tightness, no shortness of
breath, no diarrhea, no vomiting, has nausea, has epigastric
pain, no fever.
Physical exam
General Appearance: looks well
BP: 130/80
Pulse: 80
Resp.:
20
Temp. : 37
Hair,
eyes, ears, nose, and throat: Okay
Neck: No lymph node, no goiter
Lungs: Clear both sides
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound
Limbs: Okay
Assessment: Dyspepsia, muscle
pain. Rule out
ischaemic heart disease.
Recommend: Cover her with
Famotidine 40 mg, one time per day for 3 days.
And Paracetemol 500 mg, 4 times per day for ten days?
Any other ideas? |
Hi David:
Please find Dr. Kvedar's response below.
Kathy
-----Original Message-----
From: Kvedar, Joseph Charles,M.D.
Sent: Thursday, June 27, 2002 5:28 PM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: Patient #8: CHOURN CHANTY,
Cambodia Telemedicine, 27 June 2002
I would go ahead with the famotidine, but
again, would not encourage paracetamol because it may mask something
more serious. I would also do a careful exam of the
costochondral junctions to rule out chostochondritis. If one or more
costochondral junctions are tender, I'd add a nsaid to the
therapeutic mix.
From:
"sihosp" <sihosp@bigpond.com.kh>
To:
"David Robertson" <davidrobertson1@yahoo.com>
Date:
Fri, 28 Jun 2002 10:16:36 +0700
#8-
Chourn Chanty 35 F
This
lady has localized, sharp chest tightness on the left chest.
This could
be chest wall pain
or even pericarditis.
Does she have a friction rub
on exam?
How about point tenderness on the chest wall from palpation? If
so, really NSAIDS, like aspirin would be good for the inflammation.
If she
is having dyspepsia, the medications could be given with food.
If this is
not possible, give paracetamol.
Your
physical findings or history do not point to ischemia. |
