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Ratanakiri and Telemedicine

Telemedicine Clinic Ratanakiri

Provincial Hospital June 2003

Report and photos compiled by Rithy Chau, Telemedicine Physician Assistant at SHCH

On Tuesday, June 24, 2003, Ratanakiri Provincial Hospital (RPH) staff with their Telemedicine(TM) Partners from Sihanouk Hospital Center of HOPE (SHCH) in Phnom Penh, Cambodia and the TelePartners from Boston, USA, launched a Telemedicine clinic. The patients were examined by clinicians from RPH and their data were transcribed along with digital pictures of the patients and data of their illnesses, then transmitted and received replies from their TM partners in Boston and Phnom Penh. SHCH staff (Rithy Chau, PA-C and Somontha Koy, RN) were present during the clinic hours to assist in recording and translating H&P (from French into English) and to monitor and facilitate the data transmission and communication. (There were five additional, new doctors participated in this month TM clinic).

The following day, Wednesday, June 25, 2003, the TM clinic open again to receive the same patient for further evaluation, treatment and management. Clinicians from SHCH discussed briefly case by case with the local (RPH) telemedicine staff concerning patient treatment and management using information/replies received from the TM partners that afternoon. The local medical staff would then followed up with the agreed plan of treatment and management with each patient seen. Finally, the data of the follow-up for patient treatment and management would then be transcribed and transmitted to the PA Rithy Chau at SHCH who compiled and sent for website publishing.

[Please note that the patients’ data collected, transcribed, and communicated were done mostly by the RPH staff and were left in its crude form this time so as for viewers to understand the challenge of medicine practiced in remote, rural setting of Cambodia.]

The followings detail e-mails, digital photos, and replies to the medical inquiries communicated between TM clinic at RPH and their TM partners in Phnom Penh and Boston:

-----Original Message-----

From: Rithy Chau [mailto:tmed_rithy@bigpond.com.kh] i
Sent: Wednesday, June 18, 2003 8:15 AM
To: Nancy Lugn; Bunse Leng; Joseph Kvedar; Kathleen M. Kelleher; Iris
Kedar; Gary Jacques; Jennifer Hines; Heather Brandling Bennett
Cc: Ruth Tootill; SoThero Noun; Bernard Krisher; Somontha Koy; Bunthan;Channarith
Subject: June TM Clinic at Ratanakiri

Dear All,

Please be informed that the next TM clinic at the Provincial Ratanakiri Hospital will be held on Tuesday, June 24, at 8:00 AM local time for one full day. Patient data are expected to be transmitted to those of you in SHCH (Phnom Penh) and Partners (Boston) that evening. Please try to make your replies by noon time the following day, Wednesday, June 25, local time. (As for Boston, the time will be 12 hours behind--i.e. replies ought to be made by midnight of Tuesday, June 24). The patients will be asked to return that afternoon on Wednesday to receive treatments and plan of follow-up or referral.

Thank you for your cooperation and service.

Best Regards,

Rithy

-----Original Message-----
From: Bunthan Hun [mailto:bunthan03@yahoo.com]
Sent: Monday, June 23, 2003 3:24 PM
To: Benard Krisher; Rithy Chau; Noun So Thero; Noun So Thero
Subject: CONFIRM USING CAMINTEL ACCOUNT

Dear all,

During the telemedicine session hold on 23th to 27th of June we can only use the the camintel account by the address: kirihospital@camintel.com and at less CC to kirihospital@yahoo.com.

Thanks alot.

Best regards

Bunthan

-----Original Message-----
From: Kiri Hospital [mailto:kirihospital@camintel.com]
Sent: Monday, June 23, 2003 4:41 PM
To: Ruth Tootill; Paul Heinzelmann; Kathleen M.Kelleher; Ian Tootill; Bunse Leng; Cornelia Haener; Gary Jacques; Heather Brandling-Bennett; Jennifer Hines; Joseph Kvedar; Nancy Lugn; Rithy Chau
Cc: So Thero Noun; Bernard Krisher
Subject: TM clinic in Ratanakiri

Dear all,

Please be informed that the TM clinic at the Ratanakiri Provincial Hospital will be held on Tuesday 24 June,at 8:00 AM local time for one full day. Patient data are transmittet to you in SHCH,and Boston that evening.Please try to make your replies by noon time the following day.

Thank you for your cooparation,

Best regard

Channarith

Ratanakiri Telemedicine Clinic
Tuesday, June 24, 2003

[Please note that due to technical difficulties for the e-mail service in Phnom Penh, Cambodia, the data transmissions were sent without problem to Boston but until able to reach SHCH until re-transmitting the next morning, thus dated Wednesday, June 25, in the AM and addressed to SHCH only.]

-----Original Message-----
From: Kiri Hospital [mailto:kirihospital@camintel.com]
Sent: Wednesday, June 25, 2003 8:46 AM
To: Gary Jacques; Rithy Chau; Jennifer Hines; Bunse Leng
Cc: So Thero Noun; Bernard Krisher
Subject: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient SM#0003)

Ratanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners

Patient: SM#0003, 35F, follow up patient from last month

Chief Complaint: Still palpitation and SOB, right facial edema on and off for 20 days

HPI: this patient we was covered her from last montht with cimetidine200mg 2tab po q12h, Metochlopramide 5mg 1tab po q 6h and Paracetamol 500mg 1 tab po q 6h, all these medications we gave her only 7 days, she got better with these drug, but after stopping taking med the symptoms reuppear like epigastric pain, hiccup, burp and also accompany by palpitation, SOB, blurred vision and muscle pain.

PMH/SH:   same
Social Hx:   same
Allergies:   same
Family Hx:   same

ROS: no fever, no cough, + epigastric pain, + vaginal discharge with white color

PE: VS BP120/80, P 64, R 20, T 37

General Alert and oriented x 4

HEENT OK

Chest Lungs and Heart are unremarkable

Abdomen `soft, flat, no tender, + bowel sound, but left lower quardrant pain during palpable

Musculoskeletal general muscle body pain

Neuro unremarkable

GU refer to GYN ward to exam

Previous Lab/Rx: 6/9/03: Creat 0.6, gluc 137 (fasting), BUN 8.2; 6/19/03: creat 0.3, gluc 110.4, BUN 9.92. Pt. kept on rechecking her lab on her own because she needed to do this whenever she felt bad.

Lab/Rx Requests: None

Assessment:

1. GERD
2. Vaginal cadidiasis
3. Hiccup

Plan:

1. Cimetidine 200mg 2 po bid
2. Metoclopramide 5mg 1 q6h prn for hiccup & nausea
3. Omeprazole 20mg 2 po qhs x 1 mo.
4. Nistatin vag suppository 1 per vaginal qhs x 7d

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

-----Original Message-----
From: Bunse Leang [mailto:tmed1shch@bigpond.com.kh]
Sent: Wednesday, June 25, 2003 1:45 PM
To: Kiri Hospital; Gary Jacques; Rithy Chau; Jennifer Hines
Cc: So Thero Noun; Bernard Krisher
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient SM#0003)

Dear Rithy and Montha,

1. Great that her glycemia is OK without oral hypoglycemic agent. Would be still follow up glycemia from time to time.

2. Since cimetidine, metoclopramide help we would like to continue these, or if omeprazol chosen probably 20 mg daily is enough and no need to add cimetidine.

3. Vaginal discharge: very good to refer for exam. Any plan in the future to do it ourselve?

Sincerely,

Jennifer/Bunse

-----Original Message-----

From: Kelleher-Fiamma, Kathleen M., Telemedicine
[mailto:KKELLEHERFIAMMA@PARTNERS.ORG]
Sent: Wednesday, June 25, 2003 9:43 AM
To: 'kirihospital@yahoo.com'; 'kirihospital@camintel.com';
'tmed_rithy@bigpond.com.kh'

Cc: Lugn, Nancy E.; Brandling-Bennett, Heather A.
Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic

(Patient SM#0003)

> -----Original Message-----

> From: Kvedar, Joseph Charles,M.D.
> Sent: Tuesday, June 24, 2003 10:06 PM
> To: Kelleher-Fiamma, Kathleen M., Telemedicine
> Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic
> (Patient SM#0003)

> This patient definitely appears to be suffering from dyspepsia (for
> example: GERD, gastritis, ulcer, H. pylori). It appears that the medicine
> has helped and re-starting her on these medications seems reasonable.

> The new symptoms muscle pain, blurred vision, SOB are difficult to
> attribute to dyspepsia however. If palpitations and SOB are continuing:
> Consider an EKG and chest x-ray to further evaluate if palpitations and
> SOB persist
> Consider Medications:
> It appears that the new symptoms started after she stopped the
> medications, so not likely the cause, but it should be noted that possible
> side effects of Cimetidine include: irregular heartbeat. Taking too much
> Cimetidine can cause: nausea, vomiting, diarrhea, increased saliva
> production, difficulty breathing, and a fast heartbeat.
> Too much omeprazole can cause: drowsiness, seizures, shortness of breath,
> and decreased body temperature.
> I am assuming she is not on any other medications such as lipid lowering
> agents...they are notorious for causing muscle pain and can cause blurred
> vision - as can some commonly prescribed antihypertensives,
> anti-depressants.

> Finally, allergy to nearly any medicine can cause facial swelling and SOB.
>

Joseph C. Kvedar, M.D.

-----Original Message-----
From: Kiri Hospital [mailto:kirihospital@camintel.com]
Sent: Wednesday, June 25, 2003 8:47 AM
To: Gary Jacques; Rithy Chau; Jennifer Hines; Bunse Leng
Cc: So Thero Noun; Bernard Krisher
Subject: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient DP#0007)

Ratanakiri Provincial Hospital Telemedicine Clinic with
Sihanouk Hospital Center of HOPE and TelePartners

Patient: DP#0007 53F Village II

Chief Complaint: Epigastric pain, lower abdominal pain.

HPI: 53y/f with epigastric pain for 3 months,hiccup,nausea,abdominal pain like burning and radiating to the back and complaint of lower abdominal pain sensation burning urine, moderate fever.she sought at private clinic with some medicine(metronidazol,ceftriaxone ,omeprazol)but symtome are slightly relieved.

PMH/SH: Ectopic pregnancy in 1978,Gastric ulcer in 2000(treated in Viet Nam)

Social Hx:  smoke,Drink
Allergies:   NKA
Family Hx:  unremarkable
ROS:

PE: BP 100/60mmHg , P 75/mn , R 20 ,T 38c

General she look like sick

HEENT noon icteric.noon oropharyngeal legion

Chest clear BS bilateral

-HRRR :without mummur

Abdomen   -Tenderness at epigastric pain and lower abd pain
                   -no hepato splenomegali
                  -Active BS
                 -Abdominal scar about 10cm

Musculoskeletal unremarkable

Neuro unremarkable

GU unremarkable

Rectal: Anal sphinter normal

Previous Lab/Rx:

Lab/Rx Requests:
CBC,ECHO abd,urine analyse
(WBC 4200/mm3 ,NFL 58,08,34,02,00)
-Proteine and glucose negative,few epitelial cell,Cystis?

Assessment: - Gastric ulcer?
-Cystitis?

Plan: Shall we give

         1/ cimetidine 400mg 1tab BID (4week)
        2/ Metoclopramid 10mg 1tabTID (5days)
        3/Ciprofoxacine 500mg 1tab BID (5days)
        5/Paracetamol 500mg 1tab TID (5days)

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

-----Original Message-----
From: Kelleher-Fiamma, Kathleen M., Telemedicine [mailto:KKELLEHERFIAMMA@PARTNERS.ORG]
Sent: Wednesday, June 25, 2003 10:04 PM
To: tmed_rithy@bigpond.com.kh; camintel; Kirihospital
Cc: Brandling-Bennett, Heather A.; Lugn, Nancy E.
Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient DP#0007)

The finalized consultation for this patient is attached.

Many thanks,

Kathy

This patient does seem to be suffering from
1. dyspepsia (for example: GERD, gastritis, ulcer, H.Pylori)
2. Urinary tract infection. However, with her complaints of pain into the
back, pyelonephritis should be considered - particularly with fever and
nausea.

The medications you have her on seem quite appropriate, but if you suspect
pyelonephritis, the Ciprofloxacin course should be extended to 7-10 days
I am unable to interpret the abdominal ultrasound (ECHO).

Joseph C. Kvedar, M.D.

Ratanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners

Patient: CP#0008 39F ,IV village

Chief Complaint: H/A, bluring vision and neck tension x 2 mo

HPI: 39F with no PMH presented with HA , blurring vision and neck tension x 2mo. HA and blurry vision internittenly. Rigth upper arm pain,sob intermittenly,pain a scalp and tinnitus;did not sleep well, No congh,no fever,Q G I conplant.P T was seen at RPH 3d ago and nifedipine 20mg 1/2 tab bid and KCL 600 mg 1/2 tab gd, furosenide 40 mg 1/2 tab gd BP 3d ago was 160/100 . Norelief from tx above.

PMH/SH:

Social Hx: No snoke,No ETOH,RN c RPH

Allergies: NKDA

Family Hx: Husband smoke

ROS: urinate 500cc/d x 3mo,befor tx

PE: BP 130/80 P 80 R 22 T 37 Wt 50kg

General Ax Ox3

HEENT unremarkable

Chest symmetrical, BS clear both side , no rales , no rhonchu

Abdomen soft non tendered no organomegaly no mass in abdomen

Musculoskeletal unremarkable

Neuro unremakable

Previous Lab/Rx: none

Lab/Rx Requests: EKG done not get interpreted
tot chol 135,2 gluc 96,8 chem, pending creat 0,8 TG pending

Assessment: 1 possible HTN
2 Tention HA

Plan:   1 Nifédipine 20mg 0,5cp x 2 per day
           2 Furosémide 40mg 0,5cp per day
           3  Kcl 600mg 0,5mg per day

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

-----Original Message-----
From: Bunse Leang [mailto:tmed1shch@bigpond.com.kh]
Sent: Wednesday, June 25, 2003 2:41 PM
To: Kiri Hospital; Gary Jacques; Rithy Chau; Jennifer Hines
Cc: So Thero Noun; Bernard Krisher
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient CP#0008)

Dear Rithy and Montha,

What are her vital signs now after nifedipine? Some patient may have more headache after nifedipine. Probably better to add paracetamol. Since there are flipped T in V1 through V4 we would add atenolol and ASA. Again Furosemide does not have place in HTN treatment. Would be nice to distribute the 7th report of JNC on HTN.

Regards,

Jennifer/Bunse

-----Original Message-----
From: Kelleher-Fiamma, Kathleen M., Telemedicine [mailto:KKELLEHERFIAMMA@PARTNERS.ORG]
Sent: Wednesday, June 25, 2003 1:48 AM
To: tmed_rithy@bigpond.com.kh; camintel; Kirihospital
Cc: Lugn, Nancy E.; Brandling-Bennett, Heather A.; 'ph2065@yahoo.com'
Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient CP#0008)

-----Original Message-----
From: Tan, Heng Soon,M.D.
Sent: Tuesday, June 24, 2003 1:33 PM
To: Kelleher-Fiamma, Kathleen M., Telemedicine
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient CP#0008)

Hypertension could explain most of her symptoms. EKG showed non specific ST T wave changes. No left ventricular hypertrophy. Since her current meds are not effective to lower her BP to 120/80, consider switching to this combination:

Hydrochlorthiazide 25 mg qd instead of lasix.

Continue KCl 600 mg qd only if she has hypokalemia.

Atenolol 50-100 mg qd or Lisinopril 5-20 mg qd instead of nifedipine.

Heng Soon, M.D.

Ratanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners

Patient: LE#0009, 43M,

Chief Complaint: Drink a lot , pass urine many times on and off for 2 years

HPI: He has known DMII for 2 years , last year he went to VietNam , the doctors diagnosed him with DMII , they gave he him some medicines like Metformine 850 mg 1t. q.12 , after taking that medicine his symptom decreased,urination decreased. From March 2003 he went to Hope Center with complaination of passing urine many times and thirsty very much again ,he had also body weakness,bleured vision.He was given The Glibenclamide 5mg 2t. AM ,1t. PM by doctors At Hope Center his condition was better but not definited because 3 months later his symptome occured again,he still has chest tightness, limb numness and increase urination, sometime has SOB and dry throat

PMH/SH: DMII

Social Hx: He is married , no smoking cigarette ,no drinking alcohol

Allergies: none

Family Hx: his grand father die because of DMII

ROS: blurred vision, SOB, chest tighteness, upper abdominal pain , no feverm no cought, no palpitation, no diarrhea

PE:

General BP: 100/80mmHg, P: 70/min, R: 18/min and look stable

HEENT eye: pupils react to light
others unremarkable

Chest -heart: no murmur
- lungs : clear both side (no wheezing)

Abdomen soft, flat, no tender, no HSM, BS positif

Musculoskeletal none

Neuro   orientation normal
           sensation intact
             reflex normale
             motor function normale

GU
Previous Lab/Rx:

Lab/Rx Requests: Cholesterol: 74,2mg/dl
                               Glycémie :360,2mg/dl
                               Créatinine :1,4mg/dl
                               Glucosurie : +++
                               EKG:

Assessment:

DMII

Plan:

-Metformin 850mg : 1tablet 2 times per day and Glibenclamide 5mg: 2tablets morning, 1tablet evening

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

-----Original Message-----

From: Kelleher-Fiamma, Kathleen M., Telemedicine

[mailto:KKELLEHERFIAMMA@PARTNERS.ORG]

Sent: Wednesday, June 25, 2003 1:52 AM

To: tmed_rithy@bigpond.com.kh; camintel; Kirihospital

Cc: Lugn, Nancy E.; 'ph2065@yahoo.com'; Brandling-Bennett, Heather A.

Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic

(Patient LE#0009)

-----Original Message-----

From: List, James Frank,M.D.,Ph.D.

Sent: Tuesday, June 24, 2003 1:37 PM

To: Kelleher-Fiamma, Kathleen M., Telemedicine

Cc: 'kirihospital@yahoo.com'

Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient

LE#0009)

In summary, the patient has polydipsia, polyuria, hyperglycemia, and glycosuria. He also has chest pain (duration and quality not described) and dyspnea (also not further described).

EKG shows sinus rhythm with possible small ST segment elevations in inferior leads.

Assessment and Recommendations:

1) Without further history, it is hard to know what to make of the chest pain and dyspnea. Given the cardiogram, there is certainly concern for an evolving inferior MI if these symptoms are acute. If this is the case, would give an aspirin 325 mg and admit to hospital for cardiac care.

2) The patient is likely to fail even maximal oral therapy for diabetes, especially now that he is in a metabolically decompensated state. He should be started immediately on an insulin regimen. Begin a 70:30 mix of NPH:regular insulin at 0.3 units per kg before breakfast and 0.15 units per kg before dinner. Monitor sugars and increase doses as needed - the patient will likely need to increase his dose over the first few days. When he has returned to normal blood sugar levels, he may then experience a decrease in insulin requirement.

James F. List, M.D., Ph.D.
Molecular Endocrinology
Endocrine Associates
Massachusetts General Hospital

-----Original Message-----
From: Kiri Hospital [mailto:kirihospital@camintel.com]
Sent: Wednesday, June 25, 2003 8:48 AM
To: Gary Jacques; Rithy Chau; Jennifer Hines; Bunse Leng
Cc: So Thero Noun; Bernard Krisher
Subject: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient NH#00010)

Ratanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners

Patient: NH#00010 49 F, III Village

Chief Complaint: Chest pain and palpitation on exertion,gastic pain off and on x 1mo.

HPI: 49 year old wonan with previous episode of HTN during past one month, she was treated with antihypertension drugs (Unknown ),traditional drugs at private clinic and at home. She felt better with those meds, but 1 mo. ago she presented with sharp chest pain off and on,palpitation,SOB, dizziness, scalp numbness when sleeping; burning epigastric pain which radiated to LUQ of abd. occasiunally.,no N/V, no burried vision.

PMH/SH: Eclampsia in 1975 , no smoking ,no Etou,FH uremakarble.

Social Hx: unremakarble

Allergies: none

Family Hx: unremakarble

ROS: no cough, no fever, + SOB, + HA, + Dizziness, + palpitation, + epigastric pain, no stool with blood

PE: BP 140/80 P 60 R T 37.5 Wt

General look good, no jaundice, no pale, alert and oriented

HEENT unremarkable

Chest -Clear both sides

- Systolic murmur? + JVD

- Tachycardia.

Abdomen -Soft,non tendered,no mass,active B S

- no organomegaly

Musculoskeletal unremmkable

Neuro unremmkable

Previous Lab/Rx:

Lab/Rx Requests: premiers ECG(30/5/03) cherst X Ray (20/6/03 )

June 23, 2003 FBG 180.5 mg/dL, June 24, 2003 FBG 192.3 mg/dL, Creat 0.6

Assessment: HTN

-left ventricular Hypertrophy?

-Gastritis.

- Aorta insufficiency?, Aorta stenosis ?

Plan: 1- Atenolol (50mg) 1/2 tablet po q24 H x 10days

2-cimetidine (400 mg ) 1tablet po qhs

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

----- Original Message -----

From: Bunse Leang

To: Kiri Hospital

Sent: Friday, June 27, 2003 10:13 AM

Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient NH#00010 & SP#00011)

Dear Rithy and Montha:

First, I want to remind you to keep a standard reporting approach for all answers, if you do a full PE. What I mean is that if you do a neuro exam, please include: cranial nerves, sensory (pinprick, joint position sense, simple touch), gross motor strength and reflexes. Also, all cases should have full vital signs. Some of the cases sent this time, including those with HTN, do not have vitals. You should also do blood pressures in both arms on HTN cases that are new. Also, getting weights and heights on diabetics is helpful for the calculation of body, mass index (BMI). This helps with possible medication choices. The last thing is to characterize the chief complaints better. Please, if you say "headache," please tell us how often, where it and and things like the quality of the HA and association with other symptoms. Is the headache dull, unilateral, diffuse, throbbing, etc.

Now, for the cases that are left. Concerning Patient NH #00010, it is not clear about things in her history or PE. What is dizziness? Does she become dizzy after breathing long and fast? Does her heart race? How often? Constantly or with exertion? In the PE, you state a systolic murmur. Rithy, what is the quality of this finding and where in the chest is it located? Does it radiate? You must be able to understand the sounds in the chest to help with a CV diagnosis. Aortic insuff., for example, is a diastolic murmur at the aortic area, not a systolic murmur.

Based on what you have written to us, we find that she has palpitations, dizziness, SOB, and epigastric burning. She has a history of HTN, but we don't know the vitals today, so I would take vitals and if hypertensive, atenolol is fine to use because she has LVH on EKG, which would benefit from a beta blocker. You other complaints may be associated with this problem, and the dyspepsia is nonspecific and perhaps just giving an H2 blocker will help. The follow-up is in 10 days. Will she be eligible for more meds then?

Patient SP#00011 is the lady with signs of a goiter and hyperthyroidism and headache. Please document a neuro exam, including a full cranial nerve exam. This lady had blurred vision, but I don't know what that means. Blurred vision to patients can mean things like double vision, cloudy vision, fuzziness of vision all the way to blind spots. What is the case of this woman? She may have Grave's Disease because her picture shows a diffuse goiter. You tell us there is a mass in the right neck, but this is hard to see because both sides look swollen.

If you feel that the HA may be due to hyperthyroidism or a vascular type cause, propranolol is a good choice to give to the patient while waiting for test results. You may just get away with paracetamol because she does not really appear that symptomatic.

I hope that this helps. Thanks. Jennifer

-----Original Message-----
From: Kelleher-Fiamma, Kathleen M., Telemedicine [mailto:KKELLEHERFIAMMA@PARTNERS.ORG]
Sent: Wednesday, June 25, 2003 1:46 AM
To: tmed_rithy@bigpond.com.kh; camintel; Kirihospital
Cc: Lugn, Nancy E.; Brandling-Bennett, Heather A.; 'ph2065@yahoo.com'
Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient NH#00010)

This patient is having cardiac ischemia and all her symptoms are likely related to that. The ECG from May 20 shows an infarcted anterior-septal region and ST elevations in V2/V3 suggestive of an active infarct. If she is having symptoms of chest pain and shortness of breath, I would give her a 325mg aspirin, 25mg of atenalol and send her to a hospital ASAP. If she cannot/would not go, then aspirin, atenalol to keep heart rate below 60 and nitroglycerin as needed would be my recommendation.

Jonathan Sadeh, M.D.

Ratanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners

Patient: SP#00011, 47F, Banlung town

Chief Complaint: Vertigo 1year and mass on the front neck 20years

HPI: For 20 years ago she feels pain on the neck, headache, right mass progress increase on the front neck and making her difficult to breath. One year before she come hospital she had palpitation, headache, chest tightness , blurredd vision, extremeties tremor, no syncope, insomnia, no cough.

PMH/SH:   none
Social Hx:   she's married, non smoking, no drinking alcohol
Allergies:   none
Family Hx:   none
ROS:

PE:

General BP 110/60mmHg, P 112/min, R20/min, T 1,50m, Wt 41kg mild elevate HR regular rythm no diaphonetic, no tachypnea

HEENT mass on the right side on anterior neck about 5x4x2cm mobile diffuse thyroid no bruit, pink conjunctive, no exophthalmos, tinitus right ear

Chest clear BS both sides, mild elevate HR, regular rythm, no murmur

Abdomen no organomegaly, BS positif no tenderness, soft, not distended

Musculoskeletal unremarkable

Neuro motor and sensory intact

Previous Lab/Rx: none

Lab/Rx Requests: CBC/diff, T4, T4, EKG, Neck ultrason, Chest XR

Assessment: 1. Hyper thyroidism

2. Tumor of neck

3. Mild Tachycardia

Plan: - Propanonol10mg 1cp x 3 per day

- Bromazépam6mg 1/4cp morning, 1/4cp evening, 1/2cp at night

- If elevated T4 , low TSH I would like give her Carbimazole 5mg 1cp x 2 per day and recheck T4, TSH in 2 weeks

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

----- Original Message -----

From: Bunse Leang

To: Kiri Hospital

Sent: Friday, June 27, 2003 10:13 AM

Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient NH#00010 & SP#00011)

Dear Rithy and Montha:

I hope that this helps. Thanks. Jennifer

-----Original Message-----
From: Kelleher-Fiamma, Kathleen M., Telemedicine [mailto:KKELLEHERFIAMMA@PARTNERS.ORG]
Sent: Wednesday, June 25, 2003 1:49 AM
To: tmed_rithy@bigpond.com.kh; camintel; Kirihospital
Cc: Lugn, Nancy E.; 'ph2065@yahoo.com'; Brandling-Bennett, Heather A.
Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic (patient SP#00011)

-----Original Message-----
From: Goldszer, Robert Charles,M.D.
Sent: Tuesday, June 24, 2003 1:35 PM
To: Kelleher-Fiamma, Kathleen M., Telemedicine
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (patient SP#00011)

It appears that this patient does have hyperthyroidism by clinical criteria

She should be evaluated with the blood tests you suggested and should also include a sedimentation rate and a TSH.

If she has hyperthyroidism then medical treatment could be used until she can see an endocrinologist to decide if she needs radioiodine treatment or surgery.

The propanolol is a good idea to control symptoms.

RCGoldszer , M. D.

-----Original Message-----
From: Kiri Hospital [mailto:kirihospital@camintel.com]
Sent: Wednesday, June 25, 2003 8:45 AM
To: Gary Jacques; Rithy Chau; Jennifer Hines; Bunse Leng
Cc: So Thero Noun; Bernard Krisher
Subject: Ratanakiri Provincial Hospital Telemedicine Clinic (patient KT#00012)

Ratanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners

Patient: KT#00012, 43F, Banlung Town

Chief Complaint: Head ache, blurred vision, OSB and neck tension on and off for 7 years

HPI: 43 years old with weakness, head ache, neck tension, bleurred vision and pass urine many times, she was treated with Tenormine 50mg po everyday and Migragine 500mg po everyday at private clinic, it was progressively relieveed and just 3 months later she presents with head ache on and off again,blurred vision, tireness, palpitation, Polyuria 4 times per night,

PMH/SH: unremarkable

Social Hx: no smoke, no EtOH

Allergies: NKDA

Family Hx: none

ROS: None

PE: BP170/110, P 88, R 22, T 37.5

General A&O x3

HEENT unremarkable (the three round marks on her forehead were due to a Cambodian traditional “cupping” to help relieved her HA; her body was also marked with long stripes of ecchymoses due to “coining,” a very common practice of Cambodian traditional healing.)

Chest clear BS both sides,

HRRR and no murmur

Abdomen soft, no tenderness, + BS, no mass, NO organomegaly

Musculoskeletal unremarkeble

Neuro unremarkeble

Previous Lab/Rx:

Lab/Rx Requests: EKG( HR 80, regular rhythm,T flat on lead I, AVL,V1 and T invert on lead V2, V3, V4, V5,V6), lytes(2 mmol/dl),for BUN andCreat, TG, UA not evalable

June 24, 2003 Creat 0.6, K 4.0, uric acid 5.2, UA trace protein & pH 5.0.

Assessment: 1, HTN

2, Ischemia heart dz

3,Anxiety?

Plan: Atenolol 50mg 1/2 tab po bid

Paracetamol 500mg 1 tab q 6h

ASA 500mg 1/4 tab po qd

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

-----Original Message-----
From: Bunse Leang [mailto:tmed1shch@bigpond.com.kh]
Sent: Wednesday, June 25, 2003 1:02 PM
To: Kiri Hospital; Gary Jacques; Rithy Chau; Jennifer Hines
Cc: So Thero Noun; Bernard Krisher
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (patient KT#00012)

Dear Rithy and Montha,

1. HTN: agree with atenolol and aspirin. Please check her glycemia, if normal would add HCTZ. Adjust dose of drugs to reach BP goal < 140/90.

2. HA: agree with paracetamol.

3. Polyuria: how much urine? Only at night? Any other med taken at night? Would do UA, Urine microscopy, lytes, renal functions and kidney ultrasound.

Regards,

Jennifer/Bunse

-----Original Message-----
From: Kelleher-Fiamma, Kathleen M., Telemedicine [mailto:KKELLEHERFIAMMA@PARTNERS.ORG]
Sent: Wednesday, June 25, 2003 1:53 AM
To: tmed_rithy@bigpond.com.kh; camintel; Kirihospital
Cc: Lugn, Nancy E.; Brandling-Bennett, Heather A.; 'ph2065@yahoo.com'
Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic (patient KT#00012)

-----Original Message-----
From: Goldszer, Robert Charles,M.D.
Sent: Tuesday, June 24, 2003 1:43 PM
To: Kelleher-Fiamma, Kathleen M., Telemedicine
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (patient KT#00012)

1. Blood pressure is too high and needs to be treated. The Atenolol is a good idea. Her dose should be doubled from what it is currently

2. What are the round marks on her skin? Is this done by her, or family, or practitioner?

3. She should have pressure measured again in 2-3 weeks

4. She should have urinalysis as you requested, as well as evaluation of kidney function

RCGoldszer , M.D.

-----Original Message-----
From: Kiri Hospital [mailto:kirihospital@camintel.com]
Sent: Wednesday, June 25, 2003 8:44 AM
To: Gary Jacques; Rithy Chau; Jennifer Hines; Bunse Leng
Cc: So Thero Noun; Bernard Krisher
Subject: Ratanakiri Provincial Hospital Telemedicine Clinic (patient SR#00013)

Ratanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners

Patient: SR#00013 , 28 years old, male, village I

Chief Complaint: Head ache, Dizziness, poor sleepy(during night time)

HPI: It happended 10 years ago, afer loosing the moto bike, he feels afraid and wanted staying far away from relatives, dark place, before those sings uppear, he was treated with Chinese, Khmer traditional medications, but thoses symptoms still remain and accompanny by head ache, dizziness, so his family bring him to our Hospital.

PMH/SH: unremarkeble

Social Hx: no smoking, no alcohol

Allergies: none

Family Hx: unremarkable

ROS: none

PE: VS BP 110/70, P 70, R 16, T 36.5, Wt 57kg

General look stable

HEENT Head: scare on the forehead( by accident)

Eye: normal, no pale, no jaundice

Ear: feel earinging on the right side and deaf on the letf side

Nose: both sides stiffness

Throat: OK

Chest Lungs clear both sides, no crakle, no wheezing

Heart RRR and no murmur

Abdomen soft, flat, no tender, +SB, no HSM, no mass

Musculoskeletal unremarkable

Neuro unremarkable

Previous Lab/Rx:

Lab/Rx Requests:

Assessment: Tension head ache or mental problem( mood changed from previous trauma)

Plan: 1 conseling the patient

2 family and community support

3 health education

4 Paracetamol 500mg 1 tab po q6h

5 Diazepam 5mg 1tab po qd before bed time

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

Dear Rithy and Montha,

We agree with you on counselling, family and community support, and paracetamol. We would refer him to a psychiatrist and an ENT for his ears problems. If not available, we would switch diazepam to amitriptyline, start with 12.5 mg q HS.

Regards,

Jennifer/Bunse

-----Original Message-----
From: Kelleher-Fiamma, Kathleen M., Telemedicine [mailto:KKELLEHERFIAMMA@PARTNERS.ORG]
Sent: Wednesday, June 25, 2003 1:47 AM
To: tmed_rithy@bigpond.com.kh; camintel; Kirihospital
Cc: Lugn, Nancy E.; Brandling-Bennett, Heather A.; 'ph2065@yahoo.com'
Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic (patient SR#00013)

-----Original Message-----
From: Tan, Heng Soon,M.D.
Sent: Tuesday, June 24, 2003 1:22 PM
To: Kelleher-Fiamma, Kathleen M., Telemedicine
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (patient SR#00013)

Sounds like he may have a generalized anxiety disorder with somatic symptoms of headache, dizziness and insomnia. It seems unlikely that a relatively minor incident of losing his motorcycle could cause an acute traumatic stress disorder. It may be more likely that he has an underlying anxiety disorder with agarophobia. Consider treating with fluoxetine 20 mg qd instead of diazepam for long term use.

Heng Soon , M.D.

-----Original Message-----
From: Kiri Hospital [mailto:kirihospital@camintel.com]
Sent: Wednesday, June 25, 2003 8:49 AM
To: Gary Jacques; Rithy Chau; Jennifer Hines; Bunse Leng
Cc: So Thero Noun; Bernard Krisher
Subject: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient KS#00014)

Ratanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners

Patient: KS#00014, 27F, Village VI

Chief Complaint:
SOB, palpitation

HPI: 27 yo female who has been hypertention for one year now the patient complaint palpitation, SOB on exertion , tention of the neck accompany the headache, cough non productive BP:200/120mmHg, P: 100/min, sought help at referal hospital with some medacine: Atenolol25mg qd, Furosémid 40mg qd, Kcl 1tb qd, during one week and then we check chest xray EKG which showed abnormally

PMH/SH: Alcohol negatif, no cigarette

Social Hx: unremarkable

Allergies: NKA

Family Hx: unremarkable

ROS:

PE: vital sign BP: 160/100mmHg, P: 80/min, R: 22/min, T: 36,5 c

General look well

HEENT unremarkable

Chest sound clear are both sides no rale, no ronchus
HR irregular no murmur appreciated

Abdomen soft no tender no hepatosplenomegalie

Musculoskeletal unremarkable

Neuro normal

Previous Lab/Rx:

Lab/Rx Requests: EKG : LVH positif, ST abnormality inverted V5 V6 chest XRay--pending

Assessment:

-hypertention

-valvular heart disease

-left ventricular hypertrophy

-ischémia

Plan:

-Atenolol 25mg 0,5tb qd

-Furosémide 40mg 1tb qd

-KCl 600mg 1tb qd

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

-----Original Message-----
From: Bunse Leang [mailto:tmed1shch@bigpond.com.kh]
Sent: Wednesday, June 25, 2003 10:08 AM
To: Kiri Hospital; Cornelia Haener; Ruth Tootill; Nancy Lugn; Heather Brandling-Bennett; Gary Jacques; Rithy Chau; Joseph Kvedar; Jennifer Hines; Kathy Kelleher; Paul Heinzelmann
Cc: So Thero Noun; Bernard Krisher
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient KS#00014)

Dear Rithy and Montha,

1. Hypertension: I agree with atenolol. May need to increase, maximum 100 mg daily. Furosemide has no place in the treatment of hypertension (HTN). I would switch to hydrochlorothiazide, start with 12.5 mg P.O daily, maximum 50 mg daily. I would replace KCl with banana, orange...She is young probably need to check the cause of HTN. In SHCH, nephritis and primary hyperaldosteronism are the 2 frequent causes of secondary HTN, so would check electrolytes, urine microscopy and kidney US. Since there are a lot of cases with HTN, I attach the 7th report of JNC on HTN.

2. Cough non productive: need more history, how long? any post nasal drip? nasal discharged? other medication like ACE-inhibitor..

Jennifer/Bunse

-----Original Message-----
From: Kelleher-Fiamma, Kathleen M., Telemedicine [mailto:KKELLEHERFIAMMA@PARTNERS.ORG]
Sent: Wednesday, June 25, 2003 1:01 AM
To: 'kirihospital@yahoo.com'; 'kirihospital@camintel.com'; 'Rithy Chau'
Cc: 'ph2065@yahoo.com'; Brandling-Bennett, Heather A.; Lugn, Nancy E.
Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient KS#00014)

-----Original Message-----
From: Mudge, Gilbert Horton,Jr.,M.D.
Sent: Tuesday, June 24, 2003 12:38 PM
To: Kelleher-Fiamma, Kathleen M., Telemedicine
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient KS#00014)

I have reviewed the available data. This young female presents with apparent systolic and diastolic hypertension, and has left ventricular hypertrophy with strain on EKG, significant cardiomegaly on Chest x-ray. I cannot rule out coarctation of the aorta on chest x-ray. I would have the following thoughts:

1. Echocardiogram to rule out intrinsic aortic valve disease and to assess left ventricular function. The LV wall thickness should also be established.

2. Renal function studies. Creatinine, blood urea. Urinanalysis, with protein determination

3. Consider renal artery studies. Is renal ultrasound possible ?

4.If these studies were unrevealing, I would initiate aggressive antihypertensive therapy, including vasodilation ( Hydralazine, ACE inhibitors, or ARB therapy). Lasix might be replaces with thiazide diuretic.She will need ACE or ARB therapy to control the BP if no alternative etiologies are identified.

Thank you. G.H.Mudge, MD

Ratanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners

Patient: CS#00015, 48M, Village II

Chief Complaint: body weakness, pass urine many times, thirsty,poor sleepy on and off for 5 years

HPI: he has known DMII for five years, was dignosed by Calmett hospital Dr, they gave him some medications like diamecron 80mg 1tab po q 12h, but his condition not better, he still has increase thirsty, increase amount of urination and loose weight. Just May of 2002 the symptom like polyurie, polydysia, chest tightnes reuppear more and more, he went to consult with NGO, Dr there cover him with Apoglyburide 5mg 1 tap po q6h his condition feels a little bit better.

PMH/SH: unremarkable

Social Hx: none

Allergies: none

Family Hx: none

ROS: no fever, no head ache, no cough, + left chest tightness, + SOB, no diarrhea, + weakness, + bleured vision, + limbs numbness.

PE: VS BP 120/114, P 114, R 14, T 37, wt 63kgs

General look none toxic

HEENT unremarkable

Chest lungs :clear both sides, decrease breath sound at right lower lobe, Egophony

Heart: RRR and no murmur

Abdomen soft, flat , no tender, no mass,+ BS and no HSM

Musculoskeletal unremarrkable

Neuro Alert and oriented x 4

sensation, motor and reflex are normal

Previous Lab/Rx: Total Cholesterole 106mg/dl, Creat 0.9mg/dl, fasting blood sugar 386mg/dl, Triglycerides 301.6mg/dl, BUN 15,14mg/dl, SGOT 23,3u/L, SGPT 115u/L, these tests checked on 20, Janaury, 2003

Lab/Rx Requests: EKG, CXR, Creat, BUN, BS, lytes, UA, Total Cholesterol, CBC

Assessment: DMII, Ischemie Heart Disease?, Right Pleural Effusion?

Plan: Chlorpropramide 250mg 01tab po qd

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

-----Original Message-----
From: Bunse Leang [mailto:tmed1shch@bigpond.com.kh]
Sent: Wednesday, June 25, 2003 1:35 PM
To: Kiri Hospital; Gary Jacques; Rithy Chau; Jennifer Hines
Cc: So Thero Noun; Bernard Krisher
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient CS#00015)

Dear Rithy and Montha,

1. Diabetes Mellitus: Is he currently on glyburide 5 mg q 6 hrs? If so, his diabetic is not controlled. We do not like to use chlorpropramide due to its frequent side effects. If glyburide is not available, we would switch to glibenclamide (CLAMID 5 mg from Malaysia is cheap 70 riels a tablet and is readily available). Would start 5 mg TID and follow his blood sugar, goal FBS 120-180 mg/dl. If above that add Metformin. I attach lecture handout on Diabetes for Sothnikum Training Project. Please educate his diet, exercise. We would like also to hear info on weight and height. Are his feet numbness severe? He should clean and check his feet regular at night time, and he probably need amitriptyline to help the numbness. Would add ASA 75 mg daily, and fibrate or statin if affordable.

2. HTN: would use captopril start 6.25 mg BID, increase to reach goal < 130/80 in DM. Check his baseline renal functions now and 1 week later to see if captopril can be used or not.

3. Right pleural effusion? would repeat CXR.

Regards,

Jennifer/Bunse

-----Original Message-----
From: Kelleher-Fiamma, Kathleen M., Telemedicine [mailto:KKELLEHERFIAMMA@PARTNERS.ORG]
Sent: Wednesday, June 25, 2003 1:41 AM
To: tmed_rithy@bigpond.com.kh; camintel; Kirihospital
Cc: Lugn, Nancy E.; Brandling-Bennett, Heather A.
Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient CS#00015)

-----Original Message-----
From: Mudge, Gilbert Horton,Jr.,M.D.
Sent: Tuesday, June 24, 2003 12:44 PM
To: Kelleher-Fiamma, Kathleen M., Telemedicine
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (Patient CS#00015)

I have reviewed the available information. There is a small right pleural effusion, but I cannot make out any other abnormalities. The clinical presentation is most consistent with hyperglycemia and Diabetes Mellitus, and based upon the available information, I would favor institution of insulin therapy.

Ratanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners

Patient: SK#00016, 50F, Village I

Chief Complaint: SOB and chest pain, palpitation

HPI: 50yo F women with previous episode of pulmonary TB and Hight blood pressure during one years. Her symtoms appeared to be resolved. Recently she presents the complaint of SOB, blurry vision, HA, palpitation, and epigastric burning pain which radiated to chest, beeching off and on, cough .

PMH/SH: unremarkable

Social Hx: no smoking, traditional alcohol off and on.

Allergies: PNC V

Family Hx: unremarkable

ROS: palpitation, HA, Blurry vision, cough

PE:

General BP: 160/120mmHg, P: 84/min, T: 37,5 C

HEENT

Chest

-Left lung creakle

-Tachycardia

-regular rythm

-no murmur

Abdomen

-small mass in right upper quadrant

-soft

-no organomegaly

Musculoskeletal unremarkable

Neuro unremarkable

Previous Lab/Rx:no

Lab/Rx Requests: chest XRay, EKG, Cholesterol

Assessment:

-Hypertention

-Gastritis

-Bronchitis

Plan: I would give these medecine:

-Atenolol50mg 1tb po qh for 10 days

-Cimetidine 400mg 1tb po q12 for 10 days

-Erythromycin 250mg 3tb po q6 for 10 days

Comments/Notes:

Please send all replies to kirihospital@yahoo.com, kirihospital@camintel.com, and cc: to tmed_rithy@bigpond.com.kh.

-----Original Message-----
From: Bunse Leang [mailto:tmed1shch@bigpond.com.kh]
Sent: Wednesday, June 25, 2003 1:13 PM
To: Kiri Hospital; Gary Jacques; Rithy Chau; Jennifer Hines
Cc: So Thero Noun; Bernard Krisher
Subject: RE: Ratanakiri Provincial Hospital Telemedicine Clinic (patient SK#00016)

Dear Rithy and Montha,

1. HTN: We agree with you on atenolol. Since BP that high, we would add HCTZ 12.5 mg daily.

2. Epigastric burning radiate to chest with belching and cough: could be gastroesophageal reflux disease (GERD), but should evaluate cough separately. I also attach articles "diagnosis and treatment of cough" from NEJM, part of cough lecture handouts for Sothnikum Training project and 7th report of JNC on HTN. For GERD, I would switch cimetidine to omeprazol 20 mg daily, metoclopramide 5 mg P.O TID, avoid coffee, tea, and sleep with bed elevated. Treat for at least 2 months.

3. We are not sure about the cause of cough and lung crackles. Please give more history as stated in previous reply and in the journal article attached. We are afraid that this erythromycin dose may make the patient nauseated, dizzy..., probably better to stop.

4. Small mass at RUQ: probably an ultrasound needed.

Have a nice day,

Jennifer/Bunse

-----Original Message-----
From: Kelleher-Fiamma, Kathleen M., Telemedicine [mailto:KKELLEHERFIAMMA@PARTNERS.ORG]
Sent: Wednesday, June 25, 2003 1:43 AM
To: tmed_rithy@bigpond.com.kh; camintel; Kirihospital
Cc: Lugn, Nancy E.; 'ph2065@yahoo.com'; Brandling-Bennett, Heather A.
Subject: FW: Ratanakiri Provincial Hospital Telemedicine Clinic (patient SK#00016)

She needs to control her blood pressure with combination of atenolol and low salt diet. recheck bp and blurry vision in 7-10 days.

If she has sputum production or fever or chills with cough, it is reasonable to treat a bronchitis with erythromycin, however, vast majority of upper respiratory infections are viral in nature. Given the finding of crackles in the left lung base, it is reasonable to use erythromycin. Here in the US, we usually give 500mg bid or 333mg tid.

she has symptoms of gastritis or dyspepsia. it is not clear what the RUQ mass represents. is it superficial or is it deep to palpation? An H2 blocker like cimetidine and a diet low in citric acid or spicy foods or caffeine is adviseable.

Good Luck

Paul Cusick, MD

Wednesday, June 25, 2003

Follow-up Report for Ratanakiri TM Clinic

One patient (seen in May 2003) returned for this month TM clinic. The other 10 patients seen were new to the TM clinic at Ratanakiri Provincial Hospital (RPH). Per advice sent by Boston TelePartners and Phnom Penh Sihanouk Hospital Center of HOPE, the following patients were managed and treated per local medical staff:

[Please note that the practice of dispensing medications at RPH for all patients is limited to a maximum of 7 days treatment with expectation of patients to return for another week of supplies if needed be. This practice allows clinicians to monitor patient compliance to taking medications and to follow up on drug side effects, changing of medications, new arising symptoms especially in patients who live away from the town of Banlung and/or illiterate.]

Two patients from last month TM clinic were referred to SHCH for further evaluations. Patient CC#0002, 39F, Village I, was seen by surgical doctors at SHCH and was examined with confirmation of abdominal US of the mass to be an unusual, but normal right kidney mobile as if floating. No surgery was done. Patient was reassured of the unusual situation, but normal structure of her kidney and advised patient to keep watch if there would be future sign of severe abdominal pain due to possible twisting or strangulation. She was sent home with tx of a vaginal yeast infection. Patient NS#0006, 16F, Village I, was seen by SHCH clinicians for further evaluation of her hyperthyroidism with exophthalmos. She was referred to Takeo eye clinic for a thorough check up of her eyes and found to be normal except for her exophthalmos problem. SHCH gave her a short course of high dose prednisolone 40mg po bid x 2 weeks, then ween her down the next 1.5 months. She was premedicated with Albedazole 400mg po bid x 5d to eradicate any superinfection of parasites before the steroid was started. She is still taking Carbimazole 5mg to 1 tab po q12h for her hyperthyroidism and TFT will be checked within a month in PP and to be followed at SHCH.

Patient SM#0003, 35F, Village III

Final assessment: 1) Dyspepsia/GERD 2) Hiccup

This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows:

Omeprazole 20mg 2 tab po qd x 30d (can be bought at the market)
Metochlopramide 5mg 1 tab po q6h PRN hiccup

This patient was seen last month at the TM clinic and was treated only for one week with some alleviation but not resolved and did not take any medication since. Thus, her symptoms became worsen mildly. She has been doing FBG on her own at least 4 times more with BUN and creatinine at the Rhinehart Lab and all results showed within normal limit. She is no longer being dx with DM II. If her GERD symptoms improve with omeprazole then her physician will continue this regimen for at least another two weeks. If not improving, look into getting ECG and plain CXR. Gyn exam including microscopic revealed negative result for any infection.

Patient DP#0007, 53F, Village II

Final assessment: 1) Dyspepsia 2) Pyelonephritis 3) Hiccup

This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows:

Metronidazole 250mg 2 tab po bid x 14d
Amoxicilline 500mg 2 tab po bid x 14d
Omeprazole 20mg 1 tab po bid x 14d (can be bought at the market)
Ciprofloxacine 500mg 1 tab po bid x 10d
Metochlopramide 10mg 1 tab po tid x 5d

After eradication of H. pylori omeprazole will continue to be given 20mg qd x 2 months.

Patient CP#0008, 39F, Village IV

Final assessment: 1) HTN 2) Tension HA

This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows:

Atenolol 50mg 1 tab po qd x 7d
HCTZ 25mg 1 tab po qd x 7d (can be bought at the market)

Patient LE#0009, 43M, Banlung Town

Final assessment: 1) DM II (uncontrolled)

This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows:

Glibenclamide 5mg 2 tab po in AM, 1 tab po in PM as directed per SHCH physician (can be bought at the market)
ASA 500mg ¼ tab po qd x 7d

Patient was seen at SHCH for his DM II problem previously and missed his appointment. He was urged to go back to continue to be seen at SHCH and advised strongly not to miss further appointment with his doctor there at SHCH.

Patient NH#00010, 49F, Village III

Final assessment: 1) HTN 2) Ischemic Heart Disease 3) LVH 4) Dyspepsia

This patient received all medications from RPH pharmacy as follows:

Cimetidine 400mg 1 tab po qd x 10d
Atenolol 25mg 1 tab po qd x 7d
ASA 500mg ½ tab po qd x 7d
NTG sl prn for CP is not available.

Patient SP#00011, 47F, Banlung Town

Final assessment: 1) Hyperthyroidism? 2) Neck tumor 3) Mild tachycardia 4) Insomnia

This patient received all medications from RPH pharmacy as follows:

Propranolol 10mg 1 tab po tid x 10d
Diazepam 5mg 1 tab po qd x 10d

Patient KT#00012, 43F, Banlung Town

Final assessment: 1) HTN 2) HA

This patient received all medications from RPH pharmacy as follows:

Atenolol 50mg 1 tab po bid x 7d
ASA 500mg ¼ tab po qd x 7d
Paracetmol 500mg 1 tab po tid prn HA

Patient SR#00013, 28M, Village I

Final assessment: 1) Generalized anxiety disorder 2) HA

This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows:

Fluoxetine 25mg 1 tab po qd x 15d (can be bought at the market)
Multivitamine 1 tab po qd x 15d
Paracetmol 500mg 1 tab po tid prn HA
Counseling, health education, and family/community support

Patient KS#00014, 27F, Village VI

Final assessment: 1) HTN 2) Valvular heart disease 3) LVH

This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows:

Atenolol 50mg 1 tab po qd x 7d
ASA 500mg ¼ tab po qd x 7d
HCTZ 25mg 1 po qd x 7d (can be bought at the market)

Patient CS#00015, 48M, Village II

Final assessment: 1) DM II 2) Mild right pleural effusion 3) Elevated diastolic BP

This patient was prescribed with medications from RPH pharmacy (otherwise indicated) as follows:

Glibenclamide 5mg 1 tab po tid x 10d (can be bought at the market)
ASA 500mg ¼ tab po qd x 7d

Patient SK#00016, 50F, Village I

Final assessment: 1) HTN 2) Pneumonia 3) Dyspepsia

This patient received all medications from RPH pharmacy as follows:

Atenolol 50mg 1 tab po qd x 10d
Erythromycin 500mg po bid x 10d
Cimetidine 400mg 1 tab po bid x 10d

The next Ratanakiri TM Clinic will held on Wednesday and Thursday, July 23-24, 2003

Telemedicine Clinic Ratanakiri

Provincial Hospital June 2003

Ratanakiri Telemedicine Clinic Tuesday, June 24, 2003

Follow-up Report for Ratanakiri TM Clinic

Patient SM#0003, 35F, Village III

Patient DP#0007, 53F, Village II

Patient CP#0008, 39F, Village IV

Patient LE#0009, 43M, Banlung Town

Patient NH#00010, 49F, Village III

Patient SP#00011, 47F, Banlung Town

Patient KT#00012, 43F, Banlung Town

Patient SR#00013, 28M, Village I

Patient KS#00014, 27F, Village VI

Patient CS#00015, 48M, Village II

Patient SK#00016, 50F, Village I

Ratanakiri Telemedicine Clinic
Tuesday, June 24, 2003