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Robib and Telemedicine

January 2002 Telemedicine Clinic in Robib

Report and photos submitted by David Robertson

Date: Wed, 23 Jan 2002 05:15:26 -0800 (PST)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia Telemedicine Clinic text - 23 January 2002
To: JKVEDAR@PARTNERS.ORG, KKELLEHER@PARTNERS.ORG,
Jennifer Hines <sihosp@bigpond.com.kh>, ggumley@bigpond.com.kh
Cc: dmr@media.mit.edu, bernie@media.mit.edu, aafc@forum.org.kh

please reply to <dmr@media.mit.edu>

Thanks again for your help over the holidays lastmonth. The patients here very much appreciate your advice!

To: Telepartners & SHCH
Fr: David Robertson
23 January 2002
Sihanouk Hospital Center of Hope nurse Montha examined the following patients on January 23rd at the local health clinic in Robib, Rovieng district, Cambodia. JPG photos will follow in later messages. We are looking for your e-mail advice and will discuss your reply with these patients in a follow up clinic that begins on Thursday, January 24 at 8:00am Cambodia time (8:00pm on January 23 in Boston.) Any advice that could be sent before this time will be most helpful. We can transport the sickest patients to a hospital (Kampong Thom Provincial Hospital, or if necessary, other hospitals that are better equipped in the capital Phnom Penh,) but transport of patients or the purchase of any medicines is authorized by our program only if a physician advises us to do so.

Thank you again for your kind assistance.

Best regards,

David

Telemedicine Clinic in Robib, Cambodia – 23 January 2002

Patient #1: PROM HORN, female, 48 years old

Chief complaint: Chest tightness, palpitations, difficult to swallow for five months.
BP: 100/40
Pulse: 78
Resp.: 20
Temp. : 36.5

Past history: One year ago she had malaria and was unconscious for two days but was treated well with modern medicine by the medical staff in the Robib clinic.
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, and not painful
Bowel sound: positive
Skin: not pale, no rash, warm to touch
Neck: has a small mass, size about 3 x 3 cm
Limbs: no stiffness, no pain, not swollen
Assessment: Simple goiter? Anxiety.

Recommend: Should we suggest blood tests like TSH, T4?

Patient #2: PROM HEA, female, 38 years old

Chief complaint: All joints painful, coughing up blood with chest pain on and off for five months.

BP: 100/60
Pulse: 80
Resp.: 20
Temp. : 37

Past history: Unremarkable but during the last two years, she lost about 6 kg of weight.
Lungs: both upper lobes crackle, low area is okay.
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, no pain
Bowel sound: positive
Skin: not pale, no rash, warm to touch
Ear, Nose, Throat: normal
Limbs: not swollen, no deformity
Assessment: Pulmonary TB? Musculoskeletal pain. Recommend: Should we refer this patient to Kampong Thom Provincial Hospital for chest x-ray and AFB?

Patient #3: KHIM SOT, male, 65 years old

Chief complaint: All joints painful, on and off for five years. Headache and palpitations for last five days.

BP: R 240/80, L 250/100
Pulse: 80
Resp.: 20
Temp. : 36.5
Past history: Five years ago he was admitted to Preah Vihear Provincial Hospital for one month with diagnosis of polyarthritis. Last year he recalls being diagnosed with hypertension, 170/?. Smoking for 35 years, drinking for 30 years (1/4 litre/day) but stopped drinking for last five years.

Lungs: clear both sides but decreasing breath sound at the base
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, no pain
Bowel sound: positive
Skin: warm to touch, no rash
Neck: no mass, no lymph node
Limbs: swollen on both ankles and both wrists and deformity on all fingers.
Joints: Stiffness on all fingers, difficult to clench a fist.
Urinalysis: Negative
Assessment: Polyarthritis, gout? Severe hypertension.

Recommend: Should we refer him to the hospital for blood tests like BUN, lyte, creat., CBC? Chest x-ray, finger x-ray, EKG.

Patient #4: DEAB CHANNA, female, 13 years old

Chief complaint: Headache, fever, chills, vomiting (3 times yesterday) for two days.

BP: 100/60
Pulse: 126
Resp.: 20
Temp. : 39.4
Past history: One year ago, she had malaria, but was treated with modern medicine by the medical staff in local health clinic.

Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, and not tender
Bowel sound: positive
Skin: warm to touch, no rash, not pale
Limbs: Okay, no stiffness, not painful, not swollen
Urinalysis: urobilinogen: +
Malaria Test: Plasmodium falciparum + (blood test done by local clinic staff)
Assessment: Malaria.
Recommend: Should we refer her to Kampong Thom Provincial Hospital for blood tests like Malaria & CBC?

Note: Patient will immediately start treatment in the village with malaria medication given by local medical clinic staff.

Patient #5: CHAN HAT, male, 44 years old (boss of the pig farm)

Chief complaint: Has hemorrhoid in anus approx. 20 years. Difficult to pass stool on and off for about five years.

BP: 120/80
Pulse: 80
Resp.: 20
Temp. : 36.5
Past history: Unremarkable.
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, and not tender
Bowel sound: positive
Neck: okay
Limbs: okay
Skin: normal to touch, no rash, not pale
Anus: has soft mass around it, painful when doing rectal exam
Assessment: Hemorrhoids.

Recommend: Refer him to the hospital to discuss with surgeon?

Patient #6: CHHIM KIM YOEUN, female, 41 years old

Chief complaint: Palpitations, weakness, dizziness for about three months. Productive cough, chest pain sometimes for approx. six months.

BP: 110/70
Pulse: 80
Resp.: 20
Temp. : 36.5
Past history: Unremarkable, but lost weight, approx. 10 kg, during last six months

Lungs: crackle on both lobes
Heart: regular rhythm, no murmur.
Abdomen: soft, flat, not tender, no pain.
Bowel sound: positive
Skin: warm to touch, no rash, not pale
Neck: No mass, no lymph node
Limbs: not stiff, no pain, not swollen
Assessment: Pulmonary TB? Bronchitis? Malnutrition.

Recommend: Should refer her to Kampong Hospital for chest x-ray, AFB and some blood tests like CBC?

Patient # 7: PROM AM, female, 68 years old

Chief complaint: Weakness and upper abdominal pain on and off for about two months.

BP: 170/60
Pulse: 60
Resp.: 20
Temp. : 36.5
Past history: Unremarkable
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, mild upper abdominal pain
Bowel sound: positive
Skin: not pale, mild dehydration, no rash
Neck: no mass, not stiff
Limbs: not swollen, no deformity
Assessment: Mild hypertension? Malnutrition, Dyspepsia.

Recommend: Should we encourage her to improve her diet (low salt, low fat) and encourage her to drink more clean water? Cover her with antacid and keep observing her next month? Or refer her to the hospital this trip for some blood tests?

Patient # 8: VORNG REN, female, 39 years old

Chief complaint: Headache, palpitations, sometimes chest tightness for two years.

BP: 120/80
Pulse: 100
Resp.: 20
Temp. : 36.5
Past history: Unremarkable
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, no pain
Bowel sound: positive
Skin: warm to touch, no rash, not pale
Neck: no mass, not stiff, no lymph node
Limbs: not swollen, no deformity
Assessment: Tension headache. Anxiety.

Recommend: Should we give her some advice about how to release anxiety and cover her with some medication available locally like Paracetemol ?

Patient # 9: SAO PHAL, female, 55 years old

Chief complaint: Chest tightness, neck tightness, difficult to swallow on and off for one year.

BP: 150/70
Pulse: 110
Resp.: 20
Temp. : 36.5
Past history: In 1984 she was admitted to Rovieng clinic for seven days with malaria diagnosis and treated well with modern medicine.

Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, no pain
Bowel sound: positive
Skin: warm to touch, no rash, not pale
Neck: not stiff, but has small mass, size about 3 x 3 cm
Limbs: not swollen, not stiff
Assessment: Toxic goiter?
Recommend: Should we refer her to the hospital for blood test like TSH or T4?

Date: Wed, 23 Jan 2002 17:00:04 -0800 (PST)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: missed appointments - 2 SHCH Telemedicine patients
To: Jennifer Hines <sihosp@bigpond.com.kh>, ggumley@bigpond.com.kh
Cc: dmr@media.mit.edu, bernie@media.mit.edu, aafc@forum.org.kh

please reply to <dmr@media.mit.edu>

Dear Dr. Hines,

With your permission, may we bring 2 patients to Phnom Penh that would visit SHCH first thing tomorrow morning? These patients had follow up appointments at SHCH but were unable to travel the last few days. patient CHHAY CHANTY, 38 yrs. old, female diagnosed with diffuse goiter and dyspepsia missed 23 January follow up appointment no money for travel patient YIN HUN, 66 yrs. old, female diagnosed with hypertension missed 22 January appointment Every member of her family is seriously ill and all have been hospitalized at different times in the last year as Telemedicine referrals. She felt she had no choice but to stay home to take care of her sick husband plus has no money for travel.

We have told both patients that they cannot miss any future SHCH appointments.

Thanks for your help,

David

Date: Wed, 23 Jan 2002 17:25:00 -0800 (PST)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia January 2002 Telemedicine replies
To: aafc@forum.org.kh
Cc: dmr@media.mit.edu

please reply to <dmr@media.mit.edu>
Good Morning Thero,

We did not hear back from SHCH this morning. Dr. Gumley is in the USA and Dr. Jennifer Hines told nurse Montha she would be answering our e-mail this time. Would you mind calling her with a polite reminder. The phone number at the hospital is 023-982603. Montha says somebody at that number should be able to locate Dr. Hines. You might even ask them for her hand phone and call Dr. Hines directly. Please e-mail me back so that I can let nurse Montha and the patients know what time we will be hearing from her this morning.

Thanks for your help,

David

From: "sihosp" <sihosp@bigpond.com.kh>
To: <dmr@media.mit.edu>
Subject: RE: Robib Clinic---SHCH replies
Date: Thu, 24 Jan 2002 16:42:35 +0700

Hi David and Montha:

Here are my thoughts and questions concerning the patients that you have written about this time---

#1: Prom Horn, 48 yo F: I am gathering from the history and the physical that this lady does not have signs of clinical hyperthyroidism. How long has she noticed, if she did, swelling in the neck? Does anyone else in the family have a similar problem? You don't mention weight loss, sweats, increased appetite, etc. She may have anxiety, but she also has difficulty swallowing. Is it getting worse? If so, that may be an indication for a surgeon to see. Thyroid tests need not be done emergently here.

#2: Prom Hea, 38 yo F: This is a very common presentation for TB. Kg. Thom Hospital should be a national TB site, so she should get sputums done there. CXR is not in the national guidelines for TB, so I would rule that out first before spending resources on other tests.

#3: Khim Sot, 65 M: Clearly he has hypertension and this should be addressed now. He has a smoking history and advanced age, so he is at significant risk for heart disease. I would consider starting a beta blocker on him like propranolol 10mg BID and an ASA. His joints reflect polyosteoarthritis. Using NSAIDs may be of some benefit, although in small amounts---You did not give me any history of flares of pain, redness, swelling of joints that come and go and so I am not sure this is gout. In men, gout usually is seen in the larger joints like the knee and elbows, while women have more disease of the fingers and toes. The great toe, is of course, the most common site of gout in both sexes.

#4: Deab Channa, 13 F: I agree to treat the malaria. Hopefully, her mucous membranes are not pale or her urine dark. Her nausea and vomiting could also be typhoid fever, which we see a lot with malaria. I would observe and keep in good fluid balance.

#5: Chan Hat, 44 M: You may want the surgeons to see his hemorrhoids and in the meantime, have him soak in warm soapy water (sitz bath). He should be eating fruits and vegetables as high fiber in the diet in order to keep the bowels soft and moving.

#6: Chhim Kim Yoeun, 41 F: This lady also is a good candidate for having TB. I would rule this out as above.

#7: Prom Am, 68 F: When does this lady get abdominal pain? Is it around eating? How often? Does her pain radiate anywhere? She may have dyspepsia and H. pylori disease is very common here. I would agree to use antacids for 4 weeks and reassess. I would also try maybe HCTZ for the blood pressure. Her heart rate is already low, so beta blockers should not be used.

#8: Vorng Rin, 39 F: These symptoms sound very non-specific and in the setting of negative findings, I would reassure the patient and trying paracetamol is fine.

#9: Sao Phal, 55 F: Again, this patient may have thyroid disease, but is not clinical that symptomatic. One thing to try is propranolol 10mg BID that will impact the thyroid and the blood pressure. If she has signs of a growing mass in the neck that is compressing, she should go and get assessed at Kg. Thom hospital.

One question that we have is the possibility of sending samples of blood here to SHCH and following up next month in the clinic up there. None of these patients, except the ones with acute illnesses, need urgent care, so they could return with labs. I will speak to our lab about this option. If we can do it, it would save some money and effort getting the patients down here and easier to follow up at Kg. Thom Hospital. Syna in the lab here tells me that we can draw blood for chemistry, thyroid tests, but you must draw the blood on the last day that Montha is there so that the sample is the freshest. This is just n idea.

Thanks. Jennifer

From: consultsinfo@partners.org

To: <dmr@media.mit.edu>

Subject: Partners Online Specialty Consultations Case - Opinion Provided
Date: Wed, 30 Jan 2002 09:54:18 -0700
Importance: Normal
X-OriginalArrivalTime: 30 Jan 2002 16:54:18.0466 (UTC)
Status: RO

Dear Dr. David Robertson,

The opinion has been provided in your Partners Online Specialty Consultations case.

Click on the following link to display the case.
https://econsults.partners.org/

Partners Online Specialty Consultations Form

From: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>

To: "'davidrobertson1@yahoo.com'" <davidrobertson1@yahoo.com>,

"'dmr@media.mit.edu" <dmr@media.mit.edu>

Subject: FW: Patient #6: CHHIM KIM YOEUN, female, 41 years old

Date: Wed, 27 Feb 2002 17:26:19 -0500

X-Mailer: Internet Mail Service (5.5.2650.21)

Status: RO

Here's one from last month

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

> From: Ryan, Edward T.,M.D.

> Sent: Tuesday, January 29, 2002 1:11 PM

> To: Kelleher, Kathleen M. - Telemedicine

> Subject: RE: Patient #6: CHHIM KIM YOEUN, female, 41 years old

> She could have 10000 things wrong with her. Ideally would want CBC, AFB,

> but would probably treat first with a simple antibiotic for bronchitis

> (bactrim, TMP-SMZ or Erthromycin), if no improvement could send for

> additional studies.

> Edward T. Ryan, M.D., DTM&H

> Tropical & Geographic Medicine

> Massachusetts General Hospital

> Harvard Medical School

> Contact information:

> Division of Infectious Diseases

> Jackson 504

> 55 Fruit Street

> Boston, MA 02114 USA

> Administrative Tel: 617-726-3815/6175

> Administrative Fax: 617-726-7416

> Laboratory Tel: 617-724-3743

> Outpatient Appointments/Clinical Issues Tel: 617-724-1934

> Outpatient Appointments/Clinical Issues Fax: 617-726-7653

> Email: etryan@partners.org (best)

> Email 2: etryan@helix.mgh.harvard.edu

From: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>

To: "'davidrobertson1@yahoo.com'" <davidrobertson1@yahoo.com>,

"'dmr@media.mit.edu'" <dmr@media.mit.edu>

Subject: FW: Patient # 9: SAO PHAL, female, 55 years old

Date: Wed, 27 Feb 2002 17:28:25 -0500

X-Mailer: Internet Mail Service (5.5.2650.21)

Status: RO

Another from last month

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

> From: Daniels, Gilbert H.,M.D.

> Sent: Tuesday, January 29, 2002 1:16 PM

> To: Kelleher, Kathleen M. - Telemedicine

> Subject: RE: Patient # 9: SAO PHAL, female, 55 years old

> Hi Kathy - should have a blood test - if hyperthyroid needs surgery or

> radioactive iodine (if available). If not hyperthyroid - needs biopsy - if

> available.

> Assume these are unofficial consults

> GIl

From: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>

To: "David Robertson (E-mail 2)" <dmr@media.mit.edu>,

"David Robertson (E-mail)" <davidrobertson1@yahoo.com>

Subject: FW: Patient #1: PROM HORN, female, 48 years old

Date: Wed, 27 Feb 2002 17:40:33 -0500

Status: RO

This 48 year old female patient should have a blood test - if hyperthyroid, she

needs surgery or radioactive iodine (if available). If not hyperthyroid - she

needs biopsy - if available.

GIl Daniels, M.D

> Chief complaint: Chest tightness, palpitations, difficult to swallow for five

> months.

> Assessment: Simple goiter? Anxiety.>

> Recommend: Should we suggest blood tests like TSH, T4

From: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>

To: "'davidrobertson1@yahoo.com'" <davidrobertson1@yahoo.com>,

"'dmr@media.mit.edu'" <dmr@media.mit.edu>

Subject: FW: Patient # 9: SAO PHAL, female, 55 years old

Date: Wed, 27 Feb 2002 17:41:12 -0500

Status: RO

Another from last month

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

> From: Daniels, Gilbert H.,M.D.

> Sent: Tuesday, January 29, 2002 1:16 PM

> To: Kelleher, Kathleen M. - Telemedicine

> Subject: RE: Patient # 9: SAO PHAL, female, 55 years old

> Hi Kathy - should have a blood test - if hyperthyroid needs surgery or

> radioactive iodine (if available). If not hyperthyroid - needs biopsy - if

> available.

> GIl

From: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>

To: "David Robertson (E-mail 2)" <dmr@media.mit.edu>,

"David Robertson (E-mail)" <davidrobertson1@yahoo.com>

Subject: FW: Patient #4: DEAB CHANNA, female, 13 years old

Date: Wed, 27 Feb 2002 17:43:30 -0500

Status: RO

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

From: Kelleher, Kathleen M. - Telemedicine

Sent: Tuesday, January 29, 2002 12:33 PM

To: Kelleher, Kathleen M. - Telemedicine

Subject: FW: Patient #4: DEAB CHANNA, female, 13 years old

Would only refer to hospital if fails malaria treatment at community level or if becomes complicated (seizures, coma, etc).

Edward T. Ryan, M.D.

Chief complaint: Headache, fever, chills, vomiting (3 times yesterday) for two days.

Past history: One year ago, she had malaria, but was treated with modern medicine by the medical staff in local health clinic.

Urinalysis: urobilinogen: +

Malaria Test: Plasmodium falciparum + (blood test done by local clinic staff)

Assessment: Malaria.

Recommend: Should we refer her to Kampong Thom Provincial Hospital for blood tests like Malaria & CBC?

Note: Patient will immediately start treatment in the village with malaria medication given by local medical clinic staff.

From: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>

To: "David Robertson (E-mail 2)" <dmr@media.mit.edu>,

"David Robertson (E-mail)" <davidrobertson1@yahoo.com>

Subject: FW: Patient #2: PROM HEA, female, 38 years old

Date: Wed, 27 Feb 2002 17:43:52 -0500

Status: RO

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

From: Kelleher, Kathleen M. - Telemedicine

Sent: Tuesday, January 29, 2002 12:31 PM

To: Kelleher, Kathleen M. - Telemedicine

Subject: FW: Patient #2: PROM HEA, female, 38 years old

I would be concerned for pulmonary TB. Agree with CXR and AFB. Brochiectasis is also possible, and is sarcoid, Wegener's, lupus pneumonitis. Statistically, TB is most likely. Would check CXR and AFB.

Edward T. Ryan, M.D.

Chief complaint: All joints painful, coughing up blood with chest pain on and off for five months.

Assessment: Pulmonary TB? Musculoskeletal pain.

Recommend: Should we refer this patient to Kampong Thom Provincial Hospital for chest x-ray and AFB?

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