|
   
May
2002 Telemedicine Clinic in Robib
Report and photos submitted by
David Robertson
On Wednesday, May 29, 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. Gary Jacques
of the Sihanouk Hospital Center of Hope (SHCH) in Phnom Penh.
The 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>
Dear all,
Following 4 messages will have nurse Montha's
examination notes and JPG's of the patients from today's clinic.
There are 10 cases, 4 follow now, the rest will
arrive over the next 4-5 hours.
We have our follow up clinic with the patients
tomorrow at 8:00am Cambodia time, Thursday, May 30th (which is
9:00pm on May 29th in Boston.) Answers before this time are
most helpful.
Best regards,
David
Telemedicine
Clinic in Robib, Cambodia
29 May 2002
Patient
#1: KHIM PANNY, female child, 7 years old, (Mother’s name is
ENG THAN)
|
Chief
complaint: Fever and sore throat last five days
History
of present illness: Five
days ago she got high fever, sore throat, and sometimes cough
with a little sputum. Sore throat feels like burning, gets
worse when she drinks ice.
She hasn’t seen a doctor or medical staff at all.
Current
medicine: None.
Past
medical history: Four years ago she had bronchitis.
Two years ago she had Dengue Fever.
Social
history: Unremarkable.
Family history: Unremarkable
Allergies: Unremarkable
Review
of system: Has fever, has cough, no abdominal pain,
positive stool with mucous, no dyspepsia, positive nausea.
Physical exam
General Appearance: looks mildly
sick
Pulse: 128
Resp.: 24
Temp. : 37.5
c
Eyes: No pallor, no jaundice
Ears, nose: Okay
Throat: Positive mild redness, few white spots surrounding
tonsil, tonsil mildly enlarged.
Neck:
Has lymph node on the left side of the neck, positive
mobile, and no pain
Lungs,
Heart, Abdomen: Okay
Limbs: Okay
Assessment: Pharyngitis?
Parasitis? Malnutrition.
Recommend: Should we cover her
with Amoxycillin 250 mg, 3 times per day for 7 days?
And Albendazole? And
Paracetemol 250 mg, 4 times per day for 5 days?
Any other ideas?
|
-----Original Message-----
From: Karen Jacques [mailto:jacques@bigpond.com.kh]
Sent: Wednesday, May 29, 2002 7:45 PM
To: David Robertson
Subject: RE: Patient #1: KHIM PANNY, Cambodia
Telemedicine, 29 May 2002
Regarding Khim Panny:
She sounds like she has strep pharyngitis and I
agree with Amoxicillin 250 tid for 10 days and Paracetemol.
The blood and mucous in the stools suggest possible parasites and
Albendizole also sounds like a good idea. Good job.
Dr. Jacques
> -----Original Message-----
> From: Smulders-Meyer, Olga,M.D.
> Sent: Wednesday, May 29, 2002 8:00 PM
> To: Kelleher, Kathleen M. - Telemedicine
> Subject: RE: Patient #1:
KHIM PANNY, Cambodia Telemedicine, 29 May
> 2002 7 years old
>
> I would indeed start her on Amoxicillin 250 mg tid for 10
days
> to cover streptococcus. This patient is tachycardic, and most
likely very
> dehydrated, so she needs to be rehydrated aggressively, with
plain water.
> To get the fever down, continue with paracetamol q 4-6 hrs.
>
>
> She is also tachypneic, and I wonder whether she might have an
underlying
> pneumonia as well.
>
> if there is a lab in the area I would obtain a CBC, and look at
the WBC,
> as the latter is quite elevated with bacterial infections, and
barely
> elevated with viral URI's.
>
> I would not treat with Abendazole, an
anthelmintic agent, as there is no
> prove that she has such an infection
>
> If she doesn't improve after a few days of antibiotics,
fluids and
> paracetamol, then I would obtain a chest xray to rule out
a pneumonia
> **************************************
Telemedicine
Clinic in Robib, Cambodia
29 May 2002
Patient
#2: LIM NAY, female, 51 years old (housekeeper Sok Nin’s
mother)
 |
Chief
complaint: Upper abdominal pain radiating to lower back on
and off for four months, also muscle pain.
History
of present illness: She
got upper abdominal pain on and off for four months, radiating
to lower abdomen and lower back pain like burning.
She gets worse after meal and gets better when she’s
lying down. When
she felt these signs, she went to the pharmacy and bought an
antacid to take on and off for four months.
Sometimes antacid helps, sometimes not.
Current
medicine: Antacid but unknown brand.
Past
medical history: Unremarkable.
Social
history: Unremarkable.
Family
history: Unremarkable
Allergies:
Unremarkable
Review
of system: No fever, positive vertigo, positive upper
abdominal pain, no dyspepsia, positive nausea, no stool with
blood, no chest pain, no cough.
Physical exam
General Appearance: looks stable
Blood pressure: 90/50
Pulse: 64
Resp.:
20
Temp.
: 36.5
Hair,
eyes, ears, nose, and throat: Okay.
Neck:
No goiter, no lymph node
Lungs,
Heart: Okay
Abdomen:
Negative HSM, no
pain, and no mass, positive bowel sound
Limbs:
Okay
Urine Analysis: Negative
Assessment: Dyspepsia and muscle
pain.
Recommend: Should we cover her
with Tums for one month and Paracetemol for 7 days?
If you agree, please give me correct dosage.
Any other ideas? |
-----Original Message-----
From: Karen Jacques [mailto:jacques@bigpond.com.kh]
Sent: Wednesday, May 29, 2002 8:05 PM
To: David Robertson
Subject: RE: Patient #2: LIM NAY, Cambodia
Telemedicine, 29 May 2002
David,
Peptic disease (ulcer, Gerd, gastritis) is a
common cause of upper abdominal pain. Your review of systems
mentions "no dyspepsia". Her pain gets worse after a
meal so consider cholelithiasis as a possibility. Peptic
disease is often worse with an empty stomach and better after a
meal. I agree with the trial of antacid therapy. Tums
2tablets po qid(ac and hs) would be fine.
or an alternative is Famotidine 20 mg bid for 2
to 4 weeks. If her symptoms worsen or fever or jaundice
develops she should proceed to a local hospital for a gall bladder
ultrasound. Thank you.
Dr. Jacques
> -----Original Message-----
> From: Smulders-Meyer, Olga,M.D.
> Sent: Wednesday, May 29, 2002 8:19 PM
> To: Kelleher, Kathleen M.
- Telemedicine
> Subject: RE:
Patient #2: LIM NAY, Cambodia Telemedicine, 29 May 2002
> 51 years old
>
> healthy 51 y.o woman with dyspepsia.
> Her symptoms are most consistent with
either gastritis, or peptic ulcer
> disease. I would therefore, treat with
anti acids, or if available
> Ranitidine 150 mg BID or Cimetidine 400mg
BID for about 4-6 weeks. I would
> not give her Tylenol, as that just masks
her symptoms . She should be
> advised to eat 4-5 small meals a day,
avoid caffeine and alcohol and
> chocolates.
>
> If her symptoms persist after 4-6
weeks of medical treatment, and she
> continues to have pain, she will
need to get an upper GI, or get an
> endoscopy to r/u
> a persistent Helicobacter Pylori
infection, or worse a malignancy.
> If there is a local lab, I would obtain a
CBC to see if she is anemic.
> if she is anemic, it more likely to be an
underlying malignancy.
>
> Still, she is still pretty young,
and overall in good health. There is no
> report of weightloss, so I would first go
ahead and treat her for
> gastritis, for 6 weeks, see her back, and
if she does not improve work her
> up for H.Pylori antibody (a bloodtest) and
malignancy.
> Gallstones are in the differential as
well, as she experiences her pain
> after meals, so if the upper Gi work up is
negative, she should get an
> ultrasound of the right upper quadrant to
r/u gallstones.
Telemedicine
Clinic in Robib, Cambodia
29 May 2002
Patient
#3: CHHIM SIBORN, female, 27 years old, farmer, patient at May
clinic
Photos taken on 29 May 2002
Examination data from April 23, 2002:
|
Chief
complaint: Palpitations, dizziness and mass on anterior
neck for two years.
History
of present illness: Mass
on anterior neck for two years.
Sometimes feels severe tightness in throat accompanied
by shortness of breath, palpitations and dizziness on and off.
Increased shortness of breath and palpitations when she
walks, decreases when she takes a rest.
Current
medicine: None.
Past
medical history: Ten years ago she had Typhoid Fever.
Social
history: No smoking and does not drink alcohol.
Family
history: Unremarkable
Allergies:
None
Review
of system: No fever, no cough, no vomiting, no diarrhea,
no epigastric pain, weight loss of five kg over the last year.
Physical exam
General
Appearance: look non-toxic
BP: 100/60
Pulse: 90
Resp.: 24
Temp. : 36.5
Hair,
eyes, ears, nose, throat: Normal.
Neck: Has goiter, size about 6 x 5 cm.
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender, positive bowel sound.
Limbs: mild tremor, no edema
Joints: okay
Assessment:
Hyperthyroidism? Anxiety?
Recommend: May we draw blood in
the village for thyroid test at SHCH, and then see her next
clinic? |
April 24,
2002 Dr. Gumley recommended:
SHCH
Reply: Agree with your assessment and plan. Draw blood for CBC/Thyroid
function tests and see next visit.
Following exam data on 29 May 2002:
This is a follow up patient from last month.
Chief
complaint: Still
neck tightness and palpitation.
Physical exam
General Appearance: looks non-toxic
Blood pressure: 120/60
Pulse: 90
Resp.: 20
Temp. : 36.5
Hair,
eyes, ears, nose, throat: Normal.
Neck: Has goiter, size about 5 x 6 cm, no lymph node
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender, no mass, positive bowel sound.
Limbs: okay
Assessment: Simple goiter.
Recommend: Should we refer her to our
hospital, Sihanouk Hospital Center of Hope, for discussion with
surgeon? Any other ideas?
Note: This
patient from last month’s trip thought she had toxic goiter.
Dr. Graham asked to take blood for goiter tests TSH and T4.
Results were “normal.”
TSH = O, 51 ulu/ml
T4 = 12 pml/l
Her goiter still develops day-to-day.
Kampong Thom Provincial Hospital cannot take care of goiter
cases at all. Please
give me your best idea how to manage this case.
Non-toxic goiter can still cause symptoms from
local mass effect. Also, thyroid function can fluctuate with
time. I agree with your recommendation to refer to our
surgeons at SCHC for consultation. Is there adequate iodine in
the diet in her province? Thank you.
Dr. Jacques
Telemedicine
Clinic in Robib, Cambodia
29 May 2002
Patient
#4: NGOUN SOKHOM, female, 40 years old
 |
Chief
complaint: Cold extremities. Sometimes chest tightness on
and off for three years.
History
of present illness: She
has cold extremities and chest tightness on and off for three
years, accompanied by vertigo, weakness, and muscle pain,
chest tightness sometimes radiating to upper back.
She gets worse chest tightness during the night, in the
daytime is okay. When
she got signs per above she went to the local medical clinic
and received some medicine.
She doesn’t know the name of the drug; it helped a
little bit.
Current
medicine: None.
Past medical history: In 1983 she had Malaria.
Social history: Unremarkable
Family history: Her mother died of severe Pharyngitis.
Allergies: None
Review
of system: No fever, no cough, no diarrhea, positive
muscle pain, positive chest tightness, positive cold
extremities, no stool with blood, positive stool with mucous,
no weight loss, no nausea, no chest pain
Physical exam
General Appearance: looks
non-toxic
BP: 90/50
Pulse: 68
Resp.: 20
Temp. : 36.5
Hair,
eyes, ears, nose, and throat: Okay.
Neck: no goiter, no lymph node
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender, positive bowel sound, no pain or mass
Assessment:
Anxiety? Parasites.
Muscle Pain.
Recommend: Should we cover her
with Paracetemol for 7 days and Mebendazole for three days and
educate her how to release anxiety? |
Anxiety sounds quite possible, but I would like
more information before reaching a conclusion. Does she
describe feelings of anxiety? Is there any shortness of breath
or other repiratory symptoms associated with the chest tightness?
On physical exam what is her affect? Does she look
anxious or depressed? It's hard to tell from her photo.
With this being a three year duration, I think we can try your
suggestions and observe in follow up. If she has shortness of
breath, orthopnea, or other respiratory symptoms I would like to see
a chest xray. Also, what did her extremities look like on
physical exam? Thank you
Dr. Jacques
> -----Original Message-----
> From: Goldszer, Robert Charles,M.D.
> Sent: Wednesday, May 29, 2002 6:04 PM
> To: Kelleher, Kathleen M.
- Telemedicine
> Subject: RE:
Patient #4: NGOUN SOKHOM, Cambodia Telemedicine, 29 May
> 2002 40 years old
>
>
> 1. Do you agree with assessment?
> 2. Do you recommend any additional
testing?
> 3. Should the patient be transported to
hospital rather than be treated in
> the village?
>
> It sounds most like anxiety to me. Patient
can be treated in village.
> How about anxiety management or medication
and antacids for stomach and
> back pain. If persists or if patient
develops other symptoms such as
> fever, weight loss, bloody diarrhea I
would culture stools and then treat.
> If diarrhea and stools are very bad at
present, I would treat with anti
> parasite medication. This might help the
muscle aches also.
> RCGoldszer
>
Telemedicine
Clinic in Robib, Cambodia
29
May 2002
Patient
#5: TACH SOPHAR, male, 29 years old, farmer
|
Chief
complaint: Piece of boom on left hand, left shin, 2 cm
under left clavicle, for seven years, painful on and off.
History
of present illness: Seven
years ago he got piece of boom on left hand, left shin, and
under left clavicle. Now
it is getting painful and includes fever, vertigo, headache
and sometimes feels burning on these old scars, especially on
the left shin. It
is severely painful when he walks.
In 1995 he was admitted to a hospital in Phnom Penh;
they didn’t remove piece of boom, just cured wound.
Current
medicine: None.
Past
medical history: Had malaria in 1996.
Social
history: Unremarkable
Family
history: Unremarkable
Allergies:
None
Review
of system: Has fever, no cough, no diarrhea, no chest
pain, no abdominal pain.
Physical exam
General Appearance: look non-toxic
BP:
100/60
Pulse: 68
Resp.: 20
Temp. : 37
Hair,
eyes, ears, nose, throat: Normal.
Neck: No goiter, no lymph node.
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender, no mass, negative HSM
Limbs: Left hand has soft mass, size about 4 x 2 cm, not
mobile. Left shin has small scar, painful but not swollen
Assessment:
Left hand mass due to piece of boom.
Left shin old scar due to piece of boom.
Under left clavicle mass due to piece of boom.
Recommend: Should we refer him
to Kampong Thom Hospital to discuss with surgeon? |
I agree that Mr. Tach Sophar should consult a
surgeon as soon as possible to evaluate and rule out abcess or
osteomyelitis. Thank you.
Dr. Jacques
> -----Original Message-----
> From:
Mora, Bassem
> Sent: Wednesday, May 29, 2002 7:01 PM
> To: Kelleher, Kathleen M.
- Telemedicine
> Subject: Cambodia
Patient
> Importance: High
>
> I would recommend having the patient seen
in a hospital to have the
> boom-related mass removed from the arm.
I would also suggest a chest
> radiograph and plain radiograph of the
left lower leg to evaluate the two
> other masses. The pain associated
with the left leg mass raises concerns
> about local inflammation that could lead
to fracture of the bone in this
> region.
>
> John C. Wain, MD
> Associate Visiting Surgeon
> Massachusetts General Hospital
>
>
> Kathy,
> I am sending this from another mailbox
because mine is currently full. That
> is the reason for the high priority.
Sorry about any confusion. John Wain
Telemedicine
Clinic in Robib, Cambodia
29 May 2002
Patient
#6: TOURN TIT, male, 8 year old child, Mother is KIM LAM
 |
Chief
complaint: Fever, abdominal pain, watery diarrhea last six
days
History
of present illness: Four
days ago he got high fever, abdominal pain, and diarrhea three
times per day. After
four days of eating mangoes, his mother brought him to the
health center, they gave him some medicine, but she doesn’t
know the name of the drug.
Now that there’s diarrhea, abdominal pain has
developed.
Current
medicine: Paracetemol 500mg two times per day for two
days.
Past
medical history: June 2001 he had Typhoid Fever.
Social
history: Unremarkable
Family
history: Unremarkable
Allergies:
None
Review
of system: Has fever, diarrhea, abdominal pain and
distension. No nausea, no cough, no vomiting, no dyspepsia.
Physical exam
General Appearance: looks sick
BP: 100/60
Pulse: 112
Resp.:
24
Temp.
: 37.3
Hair,
ears, nose, throat: Okay.
Eyes: Mild pale, no jaundice, mild
sunken eye.
Neck:
No lymph node, no pain
Lungs:
clear both sides, no crackle
Heart:
regular rhythm, no murmur
Abdomen:
mild
distension, soft, mild pain around umbilical, positive
bowel sound, negative HSM
Limbs:
okay
Assessment: Thyphoid
fever? Parasitis?
Food Poisoning? Malnutrition. Rule
out malaria.
Recommend:
Should we treat him with:
-
ORS, one bag diluted with clear water, one
liter, drink as needed
-
Ofloxacine, 200 mg, two times per day for ten
days
-
Albendazole, 100 mg, one time per day for three
days
-
Paracetemol, 500 mg, three times per day for
three days
If you have any idea, please let me know.
I think this patient should have CBC test but can’t
do here in the village. I
want to try medication listed above first.
Okay? |
I agree with your assessment and treatment
including dosages. Please caution his mother carefully to take Tourn
Tit to the hospital for additional evaluation if his condition
worsens--if he is unable to keep oral medicine and fluids down,
mental status changes, worsening abdominal pain etc.
Thank You.
Gary Jacques M.D.
I would prefer not to use Ofloxacin in this
pediatric patient. If you have
Clotrimoxasol you may give one and a half tsp
po bid for 10 days.
Otherwise, give Paracetamol and Mebendazole and
fluids. Server was down
last night for this communication and for
patient #7. Thanks Dr. Jacques
> -----Original Message-----
> From: Goldszer, Robert Charles,M.D.
> Sent: Wednesday, May 29, 2002 6:09 PM
> To: Kelleher, Kathleen M.
- Telemedicine
> Subject: RE:
Patient #6: TOURN TIT, Cambodia Telemedicine, 29 May
> 2002
>
> Your plan sounds very reasonable to me. It
sounds like this person has
> bacterial gastroenteritis. I agree with
adding the antibacterial
> medication and hydration. If child
can not take oral fluids and
> nourishment they should go to hospital.
>
> ORS, one bag diluted with clear water, one
liter,
> drink as needed
> - Ofloxacine, 200 mg, two times per day
for ten days
> - Albendazole, 100 mg, one time per day
for three days
> - Paracetemol, 500 mg, three times per day
for three
> days
>
> Robert C Goldszer
Telemedicine
Clinic in Robib, Cambodia
29 May 2002
Patient
#7: HOURT SAM BATH, male, 9 year old child
 |
Chief
complaint: Fever, abdominal pain, diarrhea two times per
day for last four days
History
of present illness: Four
days ago he got high fever, abdominal pain, and diarrhea two
times per day. After
he ate some food and fruit, his mother brought him to the
health center, medical staff gave him some medicine, but
mother doesn’t know the name of the drug.
Now diarrhea, fever, abdominal pain still appear.
Current
medicine: Paracetemol 500mg two times per day for two
days.
Past
medical history: In 1999 he had Dengue Fever and Malaria.
Social
history: Unremarkable
Family
history: Unremarkable
Allergies:
None
Review
of system: Has fever, diarrhea, abdominal pain.
No nausea, no vomiting, no cough.
Physical exam
General Appearance: looks mild
sick
BP: 90/60
Pulse: 84
Resp.:
20
Temp.
: 37.5
Hair,
eyes, ears, nose, throat: Okay.
Lungs:
clear both sides
Heart:
regular rhythm, no murmur
Abdomen:
soft,
flat, not tender, positive bowel sound
Limbs:
okay
Assessment:
Parasitis? Food
Poisoning? Malnutrition. Rule out Typhoid Fever and Malaria.
Recommend:
I think this patient should do CBC and stool exam
but can’t do in the village.
May we treat him with:
-
Ofloxacine, 200 mg, three times per day for ten
days
-
Paracetemol, 500 mg, two times per day for five
days
-
Albendazole, 100 mg, one time per day for three
days
-
ORS as needed
If you have any idea, please let me know. |
From:
"Karen Jacques" <jacques@bigpond.com.kh>
To:
"David Robertson" <davidrobertson1@yahoo.com>
Cc:
<Dmr.@media.mit.edu>
Subject:
RE: Patient #7: HOURT SAM BATH, Cambodia Telemedicine, 29 May 2002
Date:
Thu, 30 May 2002 08:32:52 +0700
Importance:
Normal
I
would not like to use Ofloxacin in children, (please see my addendum
to patient
#6 Tourn Tit as well).
If you have clotrimazole, you can give one and
a half teaspoons po bid for 10 days instead.
Otherwise, let's just treat
with Mebendazole, fluids, and Paracetamol.
As with the previous patient,
please advise his family to take him to a nearby hospital if his
condition deteriorates--specifically, if he is unable to keep
medicine or fluids down, worsening abdominal pain, mental status
changes, etc.
Thanks.
Gary
Jacques, M.D.
> -----Original Message-----
> From: Goldszer, Robert Charles,M.D.
> Sent: Wednesday, May 29, 2002 6:06 PM
> To: Kelleher, Kathleen M.
- Telemedicine
> Subject: RE:
Patient #7: HOURT SAM BATH, Cambodia Telemedicine, 29 May
> 2002
>
> It sounds like either a parasite or
bacterial gastroenteritis.
> I agree with plans for continuing
anti-parasite treatment and adding
> Ofloxacine, 200 mg, three times per day
for ten days.
>
> If patient can not take oral fluids he
should go to hospital.
> RCGoldszer
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. |
From:
"Karen Jacques" <jacques@bigpond.com.kh>
To:
"David Robertson" <davidrobertson1@yahoo.com>
Cc:
<mdr@media.mit.edu>
Subject:
RE: Patient #8: SEK TIT, Cambodia Telemedicine, 29 May 2002
Date:
Thu, 30 May 2002 09:29:39 +0700
Agree
with your assessment.
The Propranolol dose could be 20 mg bid and
titrated
upwards on subsequent visits.
An EKG and chest xray would be
helpful
when available.
Listen for carotid bruits.
If stools are heme
negative,
and he is no longer drinking, consider adding aspirin 75 mg po qd.
thank
you Dr. Jacques
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, positive burping, 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. |
Agree with Famotidine 40 mg qd. for one month.
No need to start Propranolol with the blood pressure that you
obtained. Follow up next visit. Thanks
Dr. Jacques
please reply to <dmr@media.mit.edu>
Dear all,
The last case for this month's Telemedicine
clinic follows. Thanks again for your help.
Best regards,
David
-----
Telemedicine
Clinic in Robib, Cambodia
29 May 2002
Patient
#10: KIM SARO, female, 47 years old, farmer
 |
Chief
complaint: Upper abdominal pain on and off for last seven
months. Cold extremities and chest tightness on and off for last two
months.
History
of present illness: Two
months ago she got cold extremities and chest tightness, not
radiating to anywhere, tightness like a dull feeling.
She also has upper abdominal pain like burning,
radiating, especially after meal, and accompanied by burping.
When she got these symptoms she went to buy some
medication at the drugstore (antacid) which helped sometimes.
Current
medicine: Antacid (brand unknown) one tablet one time per
day for five months on and off.
Past
medical history: In 1996, Malaria.
Social
history: Unremarkable
Family
history: Unremarkable
Allergies:
None
Review
of system: No fever, no nausea, no diarrhea, no sweat, but
has chest tightness, has cold extremities, no cough, has
burping and has epigastric pain.
Physical exam
General Appearance: looks stable
BP: 90/50
Pulse: 80
Resp.:
20
Temp.
: 36.5
Hair,
eyes, ears, nose, throat: Normal.
Neck:
no goiter, no lymph node
Lungs:
clear both sides
Heart:
regular rhythm, no murmur
Abdomen:
soft, flat, not tender, positive bowel sound,
positive epigastric pain.
Limbs:
okay
Assessment:
Anxiety. Muscle
pain. Dyspepsia.
Recommend: Should we cove her
with antacid like Tums, 500 mg three times per day for 30 days
and Paracetemol, 500 mg four times per day for seven days?
Any other ideas? |
Tums 1 to 2 tablets 4 times a day (2 hours
after each meal and at bedtime).
Paracetamol 1 tablet every 4 hours as needed
for pain. see her back in
follow up in one month. Thanks Dr.
Jacques
|
