Telemedicine @ Ratanakiri Provincial Hospital

Telemedicine Clinic

Ratanakiri Provincial Hospital

April 2003

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

On Monday, April 7, 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 for the first time.  The patients were examined by clinicians from SHCH and RPH and their data were transcribed along with digital pictures of the patients, then transmitted and received replies from their TM partners in Boston and Phnom Penh. 

The following day, the TM clinic open again to receive the same patient for further evaluation, treatment and management.  Clinicians from SHCH discussed case by case with one of the local (RPH) physicians concerning patient treatment and management using information/replies received from the TM partners.  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.
 
[Note:  Due to some technical and mechanical difficulties, only four of the seven patients seen at the opening of the telemedicine clinic at Ratanakiri Provincial Hospital were able to completely transmitted (only one case with photos) with replies from both Boston and Phnom Penh.  These are the patients that we present on the website for this month.  The other patients not presented here will be treated appropriately based on decision made between the local and SHCH medical staff presented at the telemedicine clinic.] 
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 [chaurithy@yahoo.com]
Sent: Saturday, April 06, 2003
To: gjaques@bigpond.com.kh; JKVEDA@PARTNERS.ORG; Kelleher, Kathleen M. - Telemedicine; sihosp@bigpond.com.kh
Cc: ggumley@bigpond.com.kh; bernie@media.mit.edu; KGERE@PARTNERS.ORG; Kedar, Iris,M.D.
Subject: TELEMEDICINE AT Ratanakiri PROVINCIAL HOSPITAL 

Telemedicine Clinic in Ratanakiri, Cambodia
07 April 2003

Patient #1:  Somrith Chanthy, 42F, Bey Srok Village

CC:  Lower back pain x 5 yrs. and leg edema x 5 days    HPI:  42 y.o. woman presented with lower back pain after having an abortion 5 years ago.  Since then back pain progressively worsen without any referred pain.  She was able to ambulate with any assistant.  She said that her "pain and stiffness" were usually worse in the early morning before and after she got out of bed and improved throughout daytime.  For the past 5 days she complained of swelling of both legs with pitting and 3 days later began to have SOB at with exertion. No leg numbness; No dysuria, no N/V, no flank pain, no chest pain, no syncope, no constitutional symtoms.  No fever, no cough, but produced white to yellowish sputum off and on for 2 years; regular mense, no vaginal discharge.   PMH/SH/FH:   abortion 5 yrs ago, IUD x 1 yr. before abortion; +EtOH post-partum as trad. medicine x 5years.   ROS:  unremarkable   PE: ital Signs:          BP:  140/80  P:  80   R:  24    T: 37C   General:   A&O x 3; not tachypneic, freely mobile without assistant   HEENT:  PERRLA; no LN enlargement, no bruit   Chest:  + rales left chest; HRRR no murmur   Abd:  Obese, soft, non-tendered, no organomegaly; no flank pain   M/S:  No gross lesion or deformity, no back tenderness on palpation.  +1-2/4 pitting edema both lower extremities (below knees).   Neuro:  Normal DTRs, motor and sensory intact; good gait    Lab:   some lab test was done 3 months ago in Vietnam and received tx which she finished the meds. 2 weeks ago (Oct. 20, 2002).  WBC 10.5, RBC 4.69, Hb 13.1, Hct 37.5, Plt 328, Creat 0.8, Gluc 5.0, TG 2.6, Chol 5.3, GGT 32, SGOT 52, SGPT 40, uric acid 4.2, Ca 2.1, AFP 2.98, HBsAG negative, Anti-HCV positive.  lower spine (lumbo-sacral) x-ray is unremarkable; abd. u/s was done also and not able to interpreted but digital picture is being sent as attachment.    Assessment:    1.  Pneumonia    2.  TB    3. Renal insufficiency ?    4. Post-surgical (abortion) trauma    5.  HCV infection (resolved?)    Plan:    Tx with Cotrim 480mg 2 tab. p.o. bid x 10 days, Para 500mg 1 tab. p.o. q6hrs prn pain/fever; get AFB sputum smear to rule out TB, repeat some of the lab tests and radiological works, get a thourough GYN exam per local physician at Ratanakiri Provincial Hospital.    Comments:  Any additional advice?  Please send your reply by this evening or by tomorrow morning (Apr 8th, Cambodian time)

 

-----Original Message-----
From: Goldszer, Robert Charles,M.D.
Sent: Monday, April 07, 2003 4:23 PM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE:

This patient most likely has an edema forming disease such as heart failure, cirhosis, or nephrosis. 

She should have a 1) chest xray because of edema and rales on exam, 2) urinalysis to check for protein in urine, 3)Complete abdomen and pelvic ultrasound to evaluate for fluid in the abdomen, liver size, and vein obstruction. 

She will likely need diuretic therapy, hopefully in low dose

She should be on a low salt diet and try to keep legs elevated until tests can be performed to make a complete diagnosis. 

These tests are not emergency but should be done soon. 

THANK YOU 

Robert C Goldszer MD

Partners Health Care

-----Original Message-----
From: Kelleher, Kathleen M. - Telemedicine
Sent: Monday, April 07, 2003 11:39 AM
To: Goldszer, Robert Charles,M.D.
Subject: FW:

______________________________________________________________________________________

08 April 2003, 0800 am at Ratanakiri Provincial Hospital, Telemedicine Clinic:  Discussion and agreement between Director of RPH and SHCH (Dr. Gary Jaques and Rithy Chau, PA-C). 

Patient will receive treatment with Cotrim and paracetamol as planned for her suspected pneumonia.  She will have a sputum test done to rule out TB and have some other lab works such as Chemistry, BUN, Creatinine as well as a chest x-ray and abdominal/pelvic ultrasound at the Ratanakiri Hospital.  A local doctor will perform a more thorough GYN exam also before the ultrasound of the pelvic if there is any suspicion of abnormality.  Follow-up in one month.

-----Original Message-----
From: Phay SOM [mailto:kirihospital@yahoo.com]
Sent: Monday, April 07, 2003 9:09 AM
To: gjaques@bigpond.com.kh; JKVEDA@PARTNERS.ORG; Kelleher, Kathleen M. - Telemedicine; sihosp@bigpond.com.kh
Cc: ggumley@bigpond.com.kh; bernie@media.mit.edu; KGERE@PARTNERS.ORG; Kedar, Iris,M.D.
Subject: TELEMEDICINE AT Ratanakiri PROVINCIAL HOSPITAL Pt #2 KHUN
 

Telemedicine Clinic in Ratanakiri, Cambodia
07 April 2003

Patient #2: Khun, 57 yo male

CC:  2 year history of dizziness and fatigue     HPI:  patient has dizziness withtu vertigo preciupitated by rapoid head movement and orthostasis. No tinnitus, no headache. Patient also has exertioanl shortness of breath and chestpain, Symptoms have been stable over the last two years. PMH/SH/FH:      half pack perday smoking, heavy ETOH. Sytpped two years ago. Unemployed. ROS:  PE:  Vital Signs:          BP:    140/88  P:    72  R: 20  T: General:   Normal HEENT:  Normal, without bruits Chest:  Clear CV: Clear RRR, no murmurs Abd:  Normal M/S:  Normal Neuro:  Normal Lab: Assessment:    Rule out ischaemic heart disease and anaemia Plan:    Stop smoking, Chest Xray and HCT (ECG unavailable) Comments:

Please send all replies to Rithy Chau, MPH, MHS, PA-C at RithyChau_12@hotmail.com.

______________________________________________________________________________________ 

-----Original Message-----
From: Sadeh, Jonathan S.,M.D.
Sent: Monday, April 07, 2003 11:11 AM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: TELEMEDICINE AT Ratanakiri PROVINCIAL HOSPITAL Pt #2 KHUN

The differential diagnosis of dizziness is long but along with chest pain and shortness of breath we may be able to narrow it a bit.  Coronary disease is certainly high on the list--if he gets the CP on exertion I would try to give him some nitroglycerin as needed for the pain and if he does respond to it that is suggestive of coronary disease.  Positional dizziness is possible also since you describe it happening with rapid head movement--meclazine can be effective for that if you have it available.  Lung disease of any sort but specifically COPD in a long time smoker can certainly make him dizzi and short of breath--a chest x-ray would be helpful and smoking cessation is definitely important; bronchodilators like albuterol can be helpful if that is suspected.  Anemia from any cause (?liver disease from heavy alcohol history) is also possible and a hematocrit check would make that diagnosis.

-----Original Message-----
From: Kelleher, Kathleen M. - Telemedicine
Sent: Monday, April 07, 2003 9:20 AM
To: Sadeh, Jonathan S.,M.D.
Subject: FW: TELEMEDICINE AT Ratanakiri PROVINCIAL HOSPITAL Pt #2 KHUN

________________________________________________________________________________________

08 April 2003, 0800 am at Ratanakiri Provincial Hospital, Telemedicine Clinic:  Discussion and agreement between Director of RPH and SHCH (Dr. Gary Jaques and Rithy Chau, PA-C). 

Patient will have a CXR and EKG done to rule out any cardiomyopathy or ischemic heart disease; also get Hb and Hct lab works to rule out anemia.  All will be done locally.  Advise patient to stop smoking and return for follow-up next month.

________________________________________________________________________________________

-----Original Message-----
From: Phay SOM [mailto:kirihospital@yahoo.com]
Sent: Monday, April 07, 2003 9:13 AM
To: gjaques@bigpond.com.kh; JKVEDA@PARTNERS.ORG; Kelleher, Kathleen M. - Telemedicine; sihosp@bigpond.com.kh
Cc: ggumley@bigpond.com.kh; bernie@media.mit.edu; KGERE@PARTNERS.ORG; Kedar, Iris,M.D.
Subject: TELEMEDICINE AT Ratanakiri PROVINCIAL HOSPITAL #3 Ooch Yiev

________________________________________________________________________________________

Telemedicine Clinic in Ratanakiri, Cambodia
07 April 2003

Patient #3:  Ooch Yiev, 53 yo female O Seanglea Village

CC:  Both knee pain for twoi years and epigastric pain for two years.  HPI:  Pain and swelliing both knees for two years. No other joint invoilvement. She received steroin injectioon X 4 over the past year. No fever of chills. Pain worse after the day. Recently has left heel pain at night beforte bed. Epigastric pain for tewo years during meals ( off and on) Has polyuria, polydypsian, polyphagia, increasing weight for over six months. No chest p[ain or shortness of breath. No palpitations or syncopy. Bowels normal. No blood or mucus. PMH/SH/FH:  Unremarkable ROS:  Unremarkable PE:  Vital Signs:          BP:    132/89  P:  58   R:  18    T: General:   Alert oriented. Obese.  HEENT:  Unremarkable  Chest:  Clear BS Bilat. Decrease heart rate, mild. Irrregular rhythm. Abd:  Unremarkable M/S:  Unremarkable  Neuro:  Unremarkable  Lab: Assessment:    Dyspepsia, Possible DM 2, Joint pain --? Plan:    Famotidine 40mg qhs, Urine glucose, Give paracetamol 500 mg q 6hr prn pain. Comments:

Please send all replies to Rithy Chau, MPH, MHS, PA-C at RithyChau_12@hotmail.com.

-----Original Message-----
From: Sadeh, Jonathan S.,M.D.
Sent: Monday, April 07, 2003 10:29 AM
To: Kelleher, Kathleen M. - Telemedicine
Subject: RE: TELEMEDICINE AT Ratanakiri PROVINCIAL HOSPITAL #3 Ooch Yiev

A few issues to address:

Knee pain: most likely arthritic pain; paracetamol 3-4 times a day as needed is good.

Epigastric pain:  dyspepsia related to reflux or ulcer is most likely; famotidine is a good idea but would also recommend dietary modifications like avoiding fatty foods, coffee, chocolates, mints and eating smaller more frequent meals as apposed to larger less frequently.  Maalox or other anti acids when she gets symptoms are also effective.

Possible DM: obviously checking a blood sugar (by finger stick) is the best but checking the urine is a reasonable alternative as well; other possible cause is hypothyroidism but would need a TSH blood level check.

Irregular rhythm: you mentioned that on your exam, ?atrial fibrillation.  I would recheck that and if it really is irregular it is very well controlled but would require further evaluation; would give an aspirin a day until it is evaluated by ECG.

-----Original Message-----
From: Kelleher, Kathleen M. - Telemedicine
Sent: Monday, April 07, 2003 9:20 AM
To: Sadeh, Jonathan S.,M.D.
Subject: FW: TELEMEDICINE AT Ratanakiri PROVINCIAL HOSPITAL #3 Ooch Yiev

08 April 2003, 0800 am at Ratanakiri Provincial Hospital, Telemedicine Clinic:  Discussion and agreement between Director of RPH and SHCH (Dr. Gary Jaques and Rithy Chau, PA-C). 

Patient will be treated with Cimetidine 400 BID; UA dipstick for urine glucose, hematocrit, and EKG will be done locally at Ratanakiri Hospital.  No aspirin given until dyspepsia/gastritis problem resolved.  Follow-up in one month.

-----Original Message-----
From: Phay SOM [mailto:kirihospital@yahoo.com]
Sent: Monday, April 07, 2003 9:09 AM
To: gjaques@bigpond.com.kh; JKVEDA@PARTNERS.ORG; Kelleher, Kathleen M. -Telemedicine; sihosp@bigpond.com.kh
Cc: ggumley@bigpond.com.kh; bernie@media.mit.edu; KGERE@PARTNERS.ORG; Kedar, Iris,M.D.
Subject: TELEMEDICINE AT Ratanakiri PROVINCIAL HOSPITAL Pt #4 CHOURN BOTH

Telemedicine Clinic in Ratanakiri, Cambodia
07 April 2003

Patient #4:  Chourn Both, 48 yo female CC:  Dizziness and oligourea for 15 days. HPI:  For 15 days has had neck tension with dizziness, nausea, oligourea and extremity oedema. Palpitaion and fatigue. Shortness of breath. PMH/SH/FH:  Nephrotic Syndrome??? ROS:  Unremarkabkle PE:  Vital Signs:          BP: 150/100   P:  98   R:      T: General:   Unremarkabkle EENT:  Unremarkabkle Chest:  Unremarkabkle Abd:  Unremarkabkle M/S: Lower extremity oedema Neuro:  Unremarkabkle Lab:    Assessment:    Nephrotic Syndrome ???? Plan:    Need urine dipstick for protein. Cholesterol. BUN Creat and chemistry. (unavailable in this province) Treatment:    1. Prednisolone 40mg  daily, for 30 days                     2. Furosimide 40 mg BID, for 10 days                     3. KCl, 300 mg 1-2 tabs per day, 10 days                     4. Atenolol 50 mg QD am Comments:

 -----Original Message-----
From:   Steele, David J.R.,M.D. 
Sent:   Monday, April 07, 2003 11:28 PM
To:     Kelleher, Kathleen M. - Telemedicine
Subject:        RE: TELEMEDICINE AT Ratanakiri PROVINCIAL HOSPITAL  #4 Chourn Both,

<<Renal Associates Telemedicine Case 4-7-03.doc>>

-----Original Message-----
From:   Kelleher, Kathleen M. - Telemedicine
Sent:   Monday, April 07, 2003 11:33 AM
To:     Steele, David J.R.,M.D.
Subject:        FW: TELEMEDICINE AT Ratanakiri PROVINCIAL HOSPITAL  #4 Chourn Both,

Thank you very much Dr. Steele:
 
Here is the case that we discussed earlier.  Please feel fee to contact me if you have any questions or comments.
 
Kathy

MASSACUSETTS GENERAL HOSPITAL MGH Renal Associates GRB 1003, 55 Fruit Street Boston, MA 02114 Tel: 617 726 5050 Fax: 617 724 1122  E-mail: dsteele@partners.org

HARVARD MEDICAL SCHOOL David J R Steele MD Director Outpatient Services, MGH Renal Unit Instructor in Medicine Harvard Medical School

March 7^th, 2003 

Patient:  Chourn Both 

The patient is 48 years old patient with Nephrotic Syndrome and hypertension. We are told that she is presenting with two weeks of oliguria. She is complaining of shortness of breath, dizziness, nausea and fatigueability.  

While we have some information there is a lot more we need to know. 

Information which would be relevant for a complete history:

-         Duration of Nephrotic Syndrome and amount of proteinuria if previously quantified

-         Is Hematuria present?

-         Duration of hypertension

-         Did it precede the onset of Nephrosis?

-         Has it worsened recently?

-         Previous documentation of BUN, Creatinine and Renal indices

-         Has the urine sediment been examined and if so what are the characteristics?

-         Where there any precipitating events surrounding the onset of oliguria two weeks ago

-         Where diuretics increased?

-         Where there any other medication changes?

-         Does the patient use Non steroidal anti-inflammatory agents (NSAID’s)?

-         Does she take aspirin?

-         Has she been on and Angiotensin converting enzyme inhibitor (ACEI)?

-         Has she recently received antibiotics?

-         Has she been exposed to radiocontrast? 

In terms of her previous history we need to know:

-         Is she diabetic?

-         Has she been exposed to Hepatitis?

-         Is there a history of tropical illnesses such as malaria?

-         Has she had a blood transfusion?

-         What is her HIV status?

-         Is there a history of IV drug use?

-         Is there a history of malignant disease? 

Is there a Family history of renal disease? 

Her review of systems should detail whether or not there are symptoms of cardiac disease. For instance has she had chest pain; does she have dyspnea on exertion, paroxysmal nocturnal dyspnea, or orthopnea. Respiratory symptoms to note are whether she has had a cough or hemoptysis. From the GI standpoint we need to rule out symptoms or a history of liver disease. Does she have loin pain? Does she have nocturia? Are there any signs of an arthritic process? Has she had evidence of a skin rash? 

On examination there are details to explore:

-         Is she orthostatic?

-         What is the level of her JVP?

-         Is there any evidence of upper respiratory tract disease?

-         Does she have adenopathy?

-         Does she have evidence of a pleural effusion?

-         Are the heart sounds normal; are there murmurs to suggest valvular heart disease; does she have a pericardial rub?

-         Evidence of liver disease and documentation of the liver span is important to note

-         Is the spleen enlarged?

-         How extensive is her edema? 

Finally lab data:

-         Chest X-Ray and EKG

-         Renal Labs

-         What is the level of her renal function. If BUN and Creatinine are elevated what is the rate of rise?

-         Electrolytes. Is there an increased or narrowed anion gap?

-         A report of urinalysis and a microscopic review of urine sediment

-         Are there any casts present?

-         Serological data if available would be important

-         Hepatitis serologies

-         HIV serology

-         ANA

-         Rheumatoid factor

-         Complement studies i.e. C3 and C4 levels

-         ANA titer

-         Serum Protein Electrophoresis; Urine for Bence Jones Protein

-         Ultimately a Renal Biopsy may be useful if available 

Based on the information received so far and assuming that the patient does have documentation of nephrotic range proteinuria and in the absence of the above requested information we are able to assume the following at this stage: 

-         her presentation suggests a combination of nephrotic and possibly nephritic syndrome (if she has hematuria and because we are assuming she is hypertensive as a result of her renal disease)

-         certain of her symptoms although non specific are concerning for progressive renal failure (fatigue; nausea; oliguria)

-         we should not forget that both primary cardiac disease and liver disease can present with oliguria, progressive edema, rising BUN and Creatinine and non nephrotic range proteinuria  

The differential diagnosis for her renal disease would include:

-         Primary Renal Diseases

-         IgA Nephropathy

-         Focal segmental glomerulosclerosis

-