Robib and Telemedicine

September 2002 Telemedicine Clinic in Robib

Report and photos submitted by David Robertson

On Tuesday, September 24, 2002, Sihanouk Hospital Center of Hope nurse Koy Somontha gave the monthly Telemedicine examinations at the Robib Health Clinic. David Robertson transcribed examination data and took digital photos, then transmitted and received replies from several Telepartners physicians in Boston and from Dr. Gary Jacques, of the Sihanouk Hospital Center of Hope (SHCH) in Phnom Penh. Data was transmitted via the Hironaka School Internet link.
The following day, all patients returned to the Robib Health Clinic. Nurse "Montha" discussed advice received from the physicians in Boston and Phnom Penh with the patients.

Following are the e-mail, digital photos and medical advice replies exchanged between the Telemedicine team in Robib, Telepartners in Boston, and the Sihanouk Hospital Center of Hope in Phnom Penh:

Date: Mon, 23 Sep 2002 03:09:29 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Reminder, Cambodia Telemedicine, 24 September 2002
To: JKVEDAR@PARTNERS.ORG, KKELLEHER@PARTNERS.ORG,
"Gere, Katherine F." <KGERE@PARTNERS.ORG>, ggumley@bigpond.com.kh,
Karen Jacques <jacques@bigpond.com.kh>
Cc: dmr@media.mit.edu, "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>,
Jennifer Hines <sihosp@bigpond.com.kh>, aafc@forum.org.kh,
Bernie Krisher <bernie@media.mit.edu>, telemedicine_cambodia@yahoo.com

Please reply to dmr@media.mit.edu
Hello from Robib, Cambodia.

A quick reminder that the next Telemedicine Clinic in Robib, Cambodia is this Tuesday, 24 September 2002. I'll send out the cases in a few batches on Tuesday (hopefully late morning, late afternoon, and in the evening, Cambodia time.)

We have the follow-up clinic with the patients on Wednesday morning (8:00am, 25 September 2002, Robib time.) Best if we could receive your e-mail advice before this time (Tuesday, 9:00pm, 24 September 2002, in Boston.)
Thanks again for your help.
Best regards,
David

Date: Mon, 23 Sep 2002 21:12:04 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia Telemedicine, 24 Sept. 2002, Patient # 1, NGET SOEUN, male, 59 years old
To: JKVEDAR@PARTNERS.ORG, KKELLEHER@PARTNERS.ORG,
"Gere, Katherine F." <KGERE@PARTNERS.ORG>, ggumley@bigpond.com.kh,
gjacques@ucd.net, jacques@bigpond.com.kh
Cc: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>,
Jennifer Hines <sihosp@bigpond.com.kh>, aafc@forum.org.kh,
Bernie Krisher <bernie@media.mit.edu>, dmr@media.mit.edu,
telemedicine_cambodia@yahoo.com
Please reply to dmr@media.mit.edu
Telemedicine Clinic in Robib, Cambodia - 24 September 2002

Patient #1: NGET SOEUN, male, 59 years old, farmer

From: "Gary Jacques" <gjacques@ucd.net>
To: "David Robinson" <dmr@media.mit.edu>
Subject: RE patient 1:Nget Soeun
Date: Tue, 24 Sep 2002 14:06:48 +0700
Importance: Normal

Yes, precisely. You may start patient on an antacid if you have one available. The hospita;l might also consider an upper GI series to rule out peptic ulcer disease or tumor. --Gary Jacques

From: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>
To: 'David Robertson' <davidrobertson1@yahoo.com>
Cc: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject: RE: Cambodia Telemedicine, 24 Sept. 2002, Patient # 1, NGET SOEUN
, male, 59 years old
Date: Tue, 24 Sep 2002 12:53:09 -0400

Hi,
My recommendations follow.
1. Dyspepsia. DDx include GERD and peptic ulcer disease.
- check h. pylori
- famotidine 20 mg po BID
- avoid spicy foods, coffee, chocolate, peppermint, all of which can exacerbate GERD
2. Scrotal mass. DDx does include a hernia, suggested by increase in size with exertion. However, this needs further evaluation to rule-out other causes including a malignancy.
- ultrasound
- surgery evaluation
3. Abnormal lung exam. CXR reasonable.
Thanks.
Sincerely,
Iris Kedar, M.D.

Date: Mon, 23 Sep 2002 21:13:54 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia Telemedicine, 24 Sept. 2002, Patient # 2, PEN VANNA, female, 37 years old
To: JKVEDAR@PARTNERS.ORG, KKELLEHER@PARTNERS.ORG,
"Gere, Katherine F." <KGERE@PARTNERS.ORG>, ggumley@bigpond.com.kh,
gjacques@ucd.net, jacques@bigpond.com.kh
Cc: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>,
Jennifer Hines <sihosp@bigpond.com.kh>, aafc@forum.org.kh,
Bernie Krisher <bernie@media.mit.edu>, dmr@media.mit.edu,
telemedicine_cambodia@yahoo.com
Please reply to dmr@media.mit.edu

Telemedicine Clinic in Robib, Cambodia
24 September 2002

Patient #2: PEN VANNA, female, 37 years old, teacher

Chief complaint: She has limb numbness, frequency of urination, and sometimes chest tightness radiating to upper back, on and off for six months. History of present illness: For six months patient has had chest tightness and frequency of urination, chest pain like burning, sometimes get worse during nighttime, better after a massage on chest. Pain radiates to upper back, lasting 20 minutes per occurrence, and it happens once per day. She gets these symptoms accompanied by headache, dizziness, blurred vision, and limb numbness and sweating. Current medicine: Paracetemol, 1 gram per day, for one month. Past medical history: In 1995, she had Typhoid Fever. Social history: Unremarkable Family history: Unremarkable Allergies: Solucamp, in 1993. Review of system: Has chest tightness, has dizziness, has headache, no diarrhea, has upper abdominal pain, no fever, no stool with blood, no dyspnea, and no cough. Physical exam General Appearance: Looks well. BP: Left = 160/100, Right = 180/120 Pulse: 80 Resp.: 20 Temp. : 36.5 Hair, eyes, ears, nose, and throat: Okay. Lungs: Clear both sides. Heart: Regular rhythm, no murmur Abdomen: Soft, flat, not tender, positive bowel sound, and no mass. Limbs: Not swollen, not stiff, mild numbness on the soles. Blood Sugar: 185mg/dl Urinalysis: Glucose +3, Urobilinogen +2. Assessment: Mild Hypertension, DM Type II, Ischaemic heart disease? Recommend: Can we try medication that we have in the village like: - Propranolol, 20mg daily, for one month - Diamecrone, 40mg daily, for one month - Paracetemol, 500mg, four times per day, for one month Or should we send her to Kampong Thom Hospital to evaluate her and do some blood work like lyte, create, Bun, CBC, and Chest x-ray and EKG?

From: "Gary Jacques" <gjacques@ucd.net>
To: "David Robinson" <dmr@media.mit.edu>
Subject: Patient pen vanna
Date: Tue, 24 Sep 2002 14:15:04 +0700
Importance: Normal

This patient should be sent to a medicine clinic for diagnostic evaluation.
She has possible symptoms of diabetes or cystitis.
she has elevated blood pressure on one exam but needs repeat to confirm.
Unclear cause of chest tightness. Needs MD to evaluate.
Thanks --Gary

From: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>
To: 'David Robertson' <davidrobertson1@yahoo.com>
Cc: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject: RE: Cambodia Telemedicine, 24 Sept. 2002, Patient # 2, PEN VANNA,
female, 37 years old
Date: Tue, 24 Sep 2002 12:37:34 -0400

Hi,
This patient has several problems and should be transported to Kampong Thom Hospital. My recommendations follow:
1. Diabetes with associated peripheral neuropathy.
- I am not familiar with diamecrone, but if this is a diabetes agent that is fine, she needs some medication to control her blood sugar
- Chem7 to check blood glucose and evaluate renal function
- other basic diabetes care includes eye exam and foot exam
2. Hypertension. Her diastolic blood pressure is quite high. I would not treat her with a beta-blocker as this can mask symptoms of hypoglycemia. A better choice is a an ACE inhibitor, which can slow the progression of renal disease in a diabetic.
3. Chest pain. The ddx include musculoskeletal, supported by the improvement with massage; hearburn, supported by the burning nature and the fact that it is worse at night. The radiation to the back brings up an aortic dissection, but this is less likely given the pain is not acute onset or sharp, and she does not have >30mm Hg differential in blood pressure in opposite arms. Ischemic chest pain is possible.
- EKG
- CXR
- Ibuprofen 600mg TID with food for possible musculoskeletal component of pain
I hope this helps. Thanks.
Sincerely,
Iris Kedar, M.D.

Date: Tue, 24 Sep 2002 00:42:57 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia Telemedicine, 24 Sept. 2002, Patient # 3, CHEUY PO, male, 18 months old, TEXT
To: JKVEDAR@PARTNERS.ORG, KKELLEHER@PARTNERS.ORG,
"Gere, Katherine F." <KGERE@PARTNERS.ORG>, ggumley@bigpond.com.kh,
gjacques@ucd.net, jacques@bigpond.com.kh
Cc: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>,
Jennifer Hines <sihosp@bigpond.com.kh>, aafc@forum.org.kh,
Bernie Krisher <bernie@media.mit.edu>, dmr@media.mit.edu,
telemedicine_cambodia@yahoo.com
Please reply to dmr@media.mit.edu
 

Telemedicine Clinic in Robib, Cambodia
 24 September 2002

Patient #3: CHEUY PO, male, 18 months old, child. Mother is SREY TAING KEA

From: "Gary Jacques" <gjacques@ucd.net>
To: "David Robinson" <dmr@media.mit.edu>
Subject: Cjeuy po
Date: Tue, 24 Sep 2002 15:08:07 +0700
Importance: Normal

I have no picture of this child or the swelling. Could be a hematoma.
Concerned about the h/o of fever.Send him to a pediatric hospital for
evaluation. Thanks, Gary

From: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>
To: 'David Robertson' <davidrobertson1@yahoo.com>
Cc: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>,
"Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>
Subject: RE: Cambodia Telemedicine, 24 Sept. 2002, Patient # 3, CHEUY PO,
male, 18 months old, TEXT
Date: Tue, 24 Sep 2002 17:57:31 -0400

Hi,
This boy needs to be hospitalized for his growing left sided mass and dyspnea. His mass is likely an accumulation of blood given the time course. I worry about a pneumothorax as well given his dyspnea and respiratory rate despite a reported normal lung exam. I recommend the following:
- Chest x-ray to r/o pnuemothorax or hemothorax
- spine and pelvis x-rays to rule-out other fractures given the significant fall
- Abdominal CT is preferable, alternatively abdominal ultrasound to rule-out causes of bleeding to include a renal laceration, splenic laceration, or soft tissue hematoma
- careful monitoring of his blood pressure and respiratory status
- paracematol as you are doing for his pain
I hope this helps.
Sincerely,
Iris Kedar, M.D.

Date: Tue, 24 Sep 2002 00:48:23 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia Telemedicine, 24 Sept. 2002, Patient # 4, THAT SAROEUN, female, 42 years old
To: JKVEDAR@PARTNERS.ORG, KKELLEHER@PARTNERS.ORG,
"Gere, Katherine F." <KGERE@PARTNERS.ORG>, ggumley@bigpond.com.kh,
gjacques@ucd.net, jacques@bigpond.com.kh
Cc: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>,
Jennifer Hines <sihosp@bigpond.com.kh>, aafc@forum.org.kh,
Bernie Krisher <bernie@media.mit.edu>, dmr@media.mit.edu,
telemedicine_cambodia@yahoo.com
Please reply to dmr@media.mit.edu

Telemedicine Clinic in Robib, Cambodia
 24 September 2002

Patient #4: THAT SAROEUN, female, 42 years old, farmer

From: "Gary Jacques" <gjacques@ucd.net>
To: "David Robinson" <dmr@media.mit.edu>
Subject: That Saroeun
Date: Tue, 24 Sep 2002 15:18:44 +0700
Importance: Normal

Agree with your assessment of pharyngitis. Treatment with amox 500mg t.i.d. for 10 days is fine and follow up to make sure symptoms resolve.
Thanks -Gary

From: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>
To: 'David Robertson' <davidrobertson1@yahoo.com>
Cc: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject: RE: Cambodia Telemedicine, 24 Sept. 2002, Patient # 4, THAT SAROE
UN, female, 42 years old
Date: Tue, 24 Sep 2002 12:00:03 -0400

Hi,
I agree that bacterial pharyngitis is likely diagnosis given the timing, associated low-grade fever, and erythema/exudate on throat. However, the description of white plaques on the tongue also raises the question of thrush.

I would treat either with amoxicillin for 10 days as you suggest, or with penicillin 500mg three times a day X 10 days. Paracetamol is fine for symptoms. The importance of treatment is to cover strep and prevent complications including rheumatic fever.

If anyone else in the family or close contacts develops a sore throat they should be treated empirically as well with antibiotics.

If her symptoms do not improve I would consider treatment for thrush with a topical azole such as clotrimazole troches or nystatin.
Thanks.
Sincerely,
Iris Kedar, M.D.

Date: Tue, 24 Sep 2002 02:59:51 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia Telemedicine, 24 Sept. 2002, Patient # 5, YIM PHON, male, 66 years old
To: JKVEDAR@PARTNERS.ORG, KKELLEHER@PARTNERS.ORG,
"Gere, Katherine F." <KGERE@PARTNERS.ORG>, ggumley@bigpond.com.kh,
gjacques@ucd.net, jacques@bigpond.com.kh
Cc: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>,
Jennifer Hines <sihosp@bigpond.com.kh>, aafc@forum.org.kh,
Bernie Krisher <bernie@media.mit.edu>, dmr@media.mit.edu,
telemedicine_cambodia@yahoo.com
Please reply to dmr@media.mit.edu

Telemedicine Clinic in Robib, Cambodia
24 September 2002

Patient #5: YIM PHON, male, 66 years old, farmer

Chief complaint: Has weakness and shortness of breath on and off for last six months. History of present illness: Six months ago he got shortness of breath and weakness on and off. Shortness of breath increases when he walks or works, better when he rests or sleeps. He got these symptoms over six months accompanied by 3-4 kg weight loss, headache, and blurred vision. His first medical attention for these problems was when he came to see us. Current medicine: None. Past medical history: Two years ago he had pulmonary TB. He was admitted to Preah Vihear Provincial Hospital for five months, covered with TB medication for five months, and then discharged. Social history: Smoking for 40 years, drinking for 25 years, and quit both two years ago. Family history: Unremarkable Allergies: Penicillin. Review of system: No chest pain, no cough, has shortness of breath, has mild fever, no stool with blood, no abdominal pain, and sometimes sweats at night. Physical exam General Appearance: Looks skinny. BP: 140/80 Pulse: 84 Resp.: 28 Temp. : 36.5 Hair, ears, nose and throat: Okay. Eyes: Mild pale. Lungs: Crackle both sides from top to lower. Heart: Regular rhythm, no murmur Abdomen: Soft, flat, not tender, positive bowel sound, and no mass. Limbs: Okay. Assessment: Pulmonary TB relapse? Malnutrition. Recommend: Should we refer him to Kampong Thom Hospital for chest x-ray, CBC, and AFB exam?

From: "Gary Jacques" <gjacques@ucd.net>
To: "David Robinson" <dmr@media.mit.edu>
Subject: yim phon (pt#5)
Date: Wed, 25 Sep 2002 08:53:53 +0700
Importance: Normal
I agree. Send him to the hospital for CXR, Sputum exam, CBC, other work up
as needed. --Gary Jacques

From: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>
To: 'David Robertson' <davidrobertson1@yahoo.com>
Cc: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject: RE: Cambodia Telemedicine, 24 Sept. 2002, Patient # 5, YIM PHON,
male, 66 years old
Date: Tue, 24 Sep 2002 21:15:30 -0400

I agree that the first step should be exam at Preah Vihear Provincial Hospital for a Tb work up.

Joseph C. Kvedar, MD
Director, Partners Telemedicine
Vice Chair, Department of Dermatology
Harvard Medical School
Two Longfellow Place, Suite 216
Boston, MA 02114
voice 617-726-4447
fax 617-228-4609

Date: Tue, 24 Sep 2002 03:02:07 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia Telemedicine, 24 Sept. 2002, Patient # 6, SOM YOEUN, female, 46 years old
To: JKVEDAR@PARTNERS.ORG, KKELLEHER@PARTNERS.ORG,
"Gere, Katherine F." <KGERE@PARTNERS.ORG>, ggumley@bigpond.com.kh,
gjacques@ucd.net, jacques@bigpond.com.kh
Cc: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>,
Jennifer Hines <sihosp@bigpond.com.kh>, aafc@forum.org.kh,
Bernie Krisher <bernie@media.mit.edu>, dmr@media.mit.edu,
telemedicine_cambodia@yahoo.com
Please reply to dmr@media.mit.edu
 

Telemedicine Clinic in Robib, Cambodia
 24 September 2002

Patient #6: SOM YOEUN, female, 46 years old, midwife at health clinic

Chief complaint: Upper abdominal pain on and off for three months. History of present illness: Three months ago patient got upper abdominal pain on and off, pain like cramping, increased pain during early morning and gets better after taking medication like Cimetidine. On and off she gets these symptoms accompanied by nausea, excessive saliva, and headache. Current medicine: Cimetidine on and off for one week. Past medical history: Unremarkable Social history: Unremarkable Family history: Unremarkable Allergies: Unremarkable Review of system: Has abdominal pain, no chest pain, and no shortness of breath, has burping, no diarrhea, no fever, no cough, and has nausea. Physical exam General Appearance: Looks well. BP: 100/60 Pulse: 80 Resp.: 20 Temp. : 36.5 Hair, eyes, ears, nose, and throat: Okay. Skin: Warm to touch, no rash. Lungs: Clear both sides. Heart: Regular rhythm, no murmur Abdomen: Soft, flat, no mass, and positive bowel sound. Limbs: Okay. Assessment: Dyspepsia, gastritis. Recommend: Can we cover her with medication like: - Famotidine, 40mg, twice daily, for thirty days. Please give me any other ideas.

From: "Gary Jacques" <gjacques@ucd.net>
To: dmr@media.mit.edu
Subject: patient #6
Date: Tue, 24 Sep 2002 20:00:46 -0700

I agree with your assessment. Give trial of cimetidine 400mg b.i.d for
four weeks. If new symptoms such as fever develop she would need to see the
nearset hospital for further evaluation. --Gary Jacques

From: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>
To: 'David Robertson' <davidrobertson1@yahoo.com>
Cc: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject: RE: Cambodia Telemedicine, 24 Sept. 2002, Patient # 6, SOM YOEUN,
female, 46 years old
Date: Tue, 24 Sep 2002 21:16:56 -0400

I agree with Montha that the best initial course would be Famotidine for 30 days.

Joseph C. Kvedar, MD
Director, Partners Telemedicine
Vice Chair, Department of Dermatology
Harvard Medical School
Two Longfellow Place, Suite 216
Boston, MA 02114
voice 617-726-4447
fax 617-228-4609

Date: Tue, 24 Sep 2002 03:09:26 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia Telemedicine, 24 Sept. 2002, Patient # 7, PEN SAMADY, male, 36 years old
To: JKVEDAR@PARTNERS.ORG, KKELLEHER@PARTNERS.ORG,
"Gere, Katherine F." <KGERE@PARTNERS.ORG>, ggumley@bigpond.com.kh,
gjacques@ucd.net, jacques@bigpond.com.kh
Cc: "Kedar, Iris,M.D." <IKEDAR@PARTNERS.ORG>,
Jennifer Hines <sihosp@bigpond.com.kh>, aafc@forum.org.kh,
Bernie Krisher <bernie@media.mit.edu>, dmr@media.mit.edu,
telemedicine_cambodia@yahoo.com
Please reply to dmr@media.mit.edu

Telemedicine Clinic in Robib, Cambodia
24 September 2002

Patient #7: PEN SAMADY, male, 36 years old, teacher

Chief complaint: Productive cough for one month and left chest tightness on and off for one year. History of present illness: For one year he's had left chest tightness on and off, pain in localized area not radiating to anywhere, pain like dullness, sometimes like burning. It last about less than one hour. It happens every day, gets more pain when he walks or works and gets better when he relaxes. He gets these symptoms accompanied by cough with sputum, sweats at night, neck tenderness, and left side headache. He's had about five kg weight loss over the last year. Current medicine: Unknown medication for one week. Past medical history: In 1995 he got malaria until he became unconscious, then completed treatment with modern medicine. Social history: Does not smoke but drinks alcohol. Family history: His sister has DM Type II. Allergies: Unremarkable Review of system: Has chest tightness, has headache, has shortness of breath, has productive cough, but no fever, no diarrhea, and no abdominal pain. Physical exam General Appearance: Looks well. BP: 120/60 Pulse: 88 Resp.: 24 Temp. : 37.3 Hair, eyes, ears, nose, and throat: Okay. Neck: No JVD and no goiter. Lungs: Crackle at 2/3 of left side, no chest deformity. Heart: Regular rhythm, no murmur Abdomen: Soft, flat, not tender, positive bowel sound, and no mass. Limbs: Okay. Assessment: Left lung pneumonia, muscle pain. Rule out PTB? Recommend: Can we cover her with medication like: - Amoxycillin, 500mg, three times daily, for ten days. - Paracetemol, 500mg, four times daily, for ten days. Or do we refer him to hospital for chest x-ray, sputum, gram stain, and AFB check?

From: "Gary Jacques" <gjacques@ucd.net>
To: dmr@media.mit.edu
Subject: Patient #7, Pen Samady
Date: Tue, 24 Sep 2002 20:09:22 -0700

I would not give ampicillin emperically, but would send to the apppropriate
hospital to rule out Tb with a CXR, Sputum stains etc. --Gary
Jacques

From: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>
To: 'David Robertson' <davidrobertson1@yahoo.com>
Cc: "Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject: RE: Cambodia Telemedicine, 24 Sept. 2002, Patient # 7, PEN SAMADY
, male, 36 years old
Date: Tue, 24 Sep 2002 21:20:51 -0400

Because the symptoms are so long lasting, and have not had any apparent acute change, and because he is not febrile, I would not cover him with the antibiotics and pain reliever. I would favor sending him for a work up to hospital for chest x ray, sputum gram stain and afb testing

Joseph C. Kvedar, MD
Director, Partners Telemedicine
Vice Chair, Department of Dermatology
Harvard Medical School
Two Longfellow Place, Suite 216
Boston, MA 02114
voice 617-726-4447
fax 617-228-4609

Date: Tue, 24 Sep 2002 03:16:40 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia Telemedicine, missed appointment, Patient PROM CHHIM
To: ggumley@bigpond.com.kh, gjacques@ucd.net, jacques@bigpond.com.kh
Cc: Jennifer Hines <sihosp@bigpond.com.kh>, aafc@forum.org.kh,
Bernie Krisher <bernie@media.mit.edu>, dmr@media.mit.edu,
telemedicine_cambodia@yahoo.com
Please reply to dmr@media.mit.edu
24 September 2002

Dear Dr. Jacques,

Patient PROM CHHIM, male, 63 years old, missed his follow up appointment on August 5th. We have been following this patient for 18 months or so. His SHCH paperwork is attached. The patient is unemployed and his family is very poor; he did not have any money for travel in August and was afraid to ask for help.

Three other family members that we have been following in the Telemedicine program are also sick, and two of them are scheduled for follow up at SHCH on October 28. (His grandson visits Calmette Cardiology on October 29.) I try to coordinate patients to travel and share accommodations together whenever possible to save the Telemedicine program money.

May we send PROM CHHIM to SHCH on early morning of October 28 with his other family members?

Sincerely,

David

From: "Gary Jacques" <gjacques@ucd.net>
To: dmr@media.mit.edu
Subject: Prom Chhim
Date: Tue, 24 Sep 2002 20:52:13 -0700
Yes, send him to SCHC igaryn Oct with his paperwork and a note that fast
track should facilitate his being seen. Thanks,

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