Dear Telepartners & SHCH,

Attached in the following three mesasges are text and photos of patients seen this morning in Robib, Cambodia. Nurse Koy Somontha will examine more patients this afternoon, and all patients will be seen again tomorrow morning to discuss your e-mail recommendations.

We have a helicopter leaving the village in 2 hours, bound for Phnom Penh. If you think any of the
patients should be seen at Sihanouk Hospital, it would be very easy to send people from the village with the helicopter as it has several empty seats.

Will check e-mail again in 90 minutes, and also first thing tomorrow. Our clinic tomorrow begins at 8:00am Monday, Cambodia time (8:00pm Sunday in Boston,) so it would be ideal to receive a reply by that time.

Thanks again for your help.

Sincerely,

David

Telemedicine Clinic in Robib, Cambodia
AM, 22 April 2001

Patient #1: Chuum Sokhon, male, 43 years old

Chief complaint: body weakness, leg pain after falling from a tree 20 years ago BP: 100/50 Pulse: 68 Resp.: 20 Temp. : 36.5 Past history: 20 years ago had a foot operation at Kompong Thom Lungs: clear Heart: normal Abdomen: normal Bowel sound: normal Skin: not pale, no edema Leg: left heel has a wound, size 4 x 6 cm, wound has been open for 20 years, leg is difficult to move Assessment: old left ankle fracture Recommend: Refer patient to hospital for x-ray and meet surgeon for evaluation

Patient #2: Kim Heang, female, 37 years old

Chief complaint: palpitations, headache and anterior mass on the neck for one year BP: 100/60 Pulse: 100 Resp.: 20 Temp. : 36.5 Past history: malaria two years, treated at a private clinic Lungs: clear Heart: regular rhythm, no murmur Abdomen: normal Bowel sound: positive Skin: not pale, no edema, no jaundice Neck: has anterior mass, size 6 x 8 cm Assessment: toxic goiter? and anxiety disorder Recommend: Refer patient to hospital for blood test, (T3, T4)

Patient #3: Prom Ma Ly, female, 47 years old

Chief complaint: mass on anterior neck, left side, size 8-10 cm, for 7 years Plus palpitations and weakness off and on for 7 years. BP: 130/80 Pulse: 120 Resp.: 20 Temp. : 37 Past history: not significant Lungs: clear both sides Heart: regular rhythm, no murmur, but tachycardia Abdomen: soft, flat Bowel sound: positive Skin: not pale, no edema, neck has mass on anterior, left side, size 8-10 cm Assessment: toxic goiter? Recommend: Refer patient to hospital for blood test, (T3, T4)

Patient #4: Tith Hon, female, 43 years old

Chief complaint: Palpitation, headache, numbness on both legs, chest tightness for 7 months BP: 150/70 Pulse: 140 Resp.: 22 Temp. : 37 Past history: not significant Lungs: clear both sides Heart: regular rhythm, no murmur, but tachycardia Abdomen: soft, flat, and not tender Bowel sound: positive Skin: warm to touch, no edema, not pale Urinalysis: normal Assessment: mild hypertension, ischaemic heart disease? Recommend: Refer patient to hospital for blood test, chest x-ray, EKG

Patient #5: Sok Lim, male, 80 years old

Chief complaint: chest pain on and off for 2 months. Feels burning on both soles of his feet and shortness of breath for about 3 years. BP: 140/80 Pulse: 88 Resp.: 20 Temp. : 37 Past history: not significant but smoked a lot for 60 years, still smokes 10 sticks per day Lungs: bronchitis on left lower lobe Heart: regular, no murmur Abdomen: soft, flat Bowel sound: positive Skin: warm to touch, no edema, not pale Urinanalysis: protein: +, bilirubin: + Assessment: Chronic obstruction pulmonary disease? Ischaemic heart disease? Recommend: Refer patient to hospital for EKG, chest x-ray, and blood tests

Patient #6, So On female, 74 years old

Chief complaint: Productive cough (yellow color for one month,) chest pain, palpitations on and off for 2 years BP: 140/60 Pulse: 68 Resp.: 24 Temp. : 37 Past history: Three years ago, a cart for carrying rice, press on her chest. She was admitted in a district hospital for 15 days. Lungs: bronchitis on left side Heart: regular, no murmur Abdomen: soft, flat Bowel sound: positive Skin: warm to touch, no edema, not pale Assessment: Bronchitis ruled out Pulmonary TB Recommend: Refer patient to hospital for x-ray, select sputum for gram stain A & B

Date: Sun, 22 Apr 2001 02:43:40 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: helicopter arriving PP with 4 patients 5:00 PM tonight
To: Nuon So Thero <012911859@mobitel.com.kh>,
Graham Gumley <ggumley@bigpond.com.kh>, sihosp@bigpond.com.kh
Cc: Bernard Krisher <bernie@media.mit.edu>, Seda <seda@daily.forum.org.kh>,
dy@rural.forum.org.kh, dmr@media.mit.edu, aafc@forum.org.kh

Dear Thero,

Dy is on the helicopter that departed Robib at 4:00pm with 4 Telemedicine patients plus 4 family members, total of 8 people from Robib (plus Dy.) Bernie said to put them up at the trainee house. There is one spare bedroom, and Bernie said maybe something can be arranged with garage space. They should be fed at the trainee house.

Dy should take these people to Sihanouk Hospital tomorrow morning and ask for Dr. Gumley. Dy should stay with these people until nurse Montha and I return to Phnom Penh on Tuesday night. Bernie said they can be transported to Sihanouk in the Mercedes van.

I will assist arranging their transport home to Robib by visiting the trainee house Tuesday night. Maybe everyone can return to Robib by share taxi on Wednesday morning (possibly with the mother and baby after their Monday Calmette visit as well.) This gives them two days for exam and tests at Sihanouk Hospital. Bernie said Dr. Gumley is arranging for the people to not
wait on line as they are in a "research" category.

Mr. Bunrong might help at the airport tonight with transport to the trainee house. If you see this
message in time and have Bunrong's mobile #, please call him now. Otherwise, you may want to call and alert the trainee house that they have visitors arriving soon.

Bernie asked that Dy and you please keep us informed via e-mail (copy Bernie, DMR, Dy's e-mail address, Hironaka School address.) Please let us know if there are any problems tonight, and what happens at Sihanouk Hospital tomorrow.

Thanks for your help,

David

From: "Graham Gumley" <ggumley@bigpond.com.kh>
To: "David Robertson" <davidrobertson1@yahoo.com>
Subject: Re: Telemedicine - AM Exams - 22 April - Robib, Cambodia
Date: Sun, 22 Apr 2001 21:13:35 +0700

Dear David,

Thanks for the details.

Attached are my replies.

We will see the patients tomorrow.

I did not yet get detail on which particular patients these were that arrived.

Regards.

Graham

Reply from Dr. Graham Gumley, Sihanouk Hospital Center of HOPE.
Replies in RED.

Telemedicine Clinic in Robib, Cambodia
AM, 22 April 2001

Patient #1: Chuum Sokhon, male, 43 years old
Chief complaint: body weakness, leg pain after falling from a tree 20 years ago
Assessment: old left ankle fracture
Recommend: Refer patient to hospital for x-ray and meet surgeon for evaluation

Weakness likely to be due to neurological injury 20 years ago and unlikely to be remediable, however the ankle injury may be suitable for help … do we have a photo of this open wound? Pending review of this …. The next step would be an x-ray to allow evaluation of the bone injury and ? infection.

The difficulty of the leg moving … is it related to the heel wound, or is there muscle stiffness? The latter would be die to the remote head injury and would not respond to available measures. (Physical Therapy may help, but would require many treatments for a limited gain)

Patient #2: Kim Heang, female, 37 years old
Chief complaint: palpitations, headache and anterior mass on the neck for one year
Assessment: toxic goiter? and anxiety disorder
Recommend: Refer patient to hospital for blood test, (T3, T4)

Agree with this assessment and recommendation. I think this should be suitable for Kampong Thom workup … although if surgery is requires they may need to refer to PP. A period of medical therapy is likely to be required even if surgery is eventually needed.

The anxiety disorder, if present, is likely to be related to any hyperthyroidism present.

Patient #3: Prom Ma Ly, female, 47 years old
Chief complaint: mass on anterior neck, left side, size 8-10 cm, for 7 years
Plus palpitations and weakness off and on for 7 years.
Assessment: toxic goiter?
Recommend: Refer patient to hospital for blood test, (T3, T4)

Agree with this assessment and recommendation. I think this should be suitable for Kampong Thom workup … although if surgery is requires they may need to refer to PP. A period of medical therapy is likely to be required even if surgery is eventually needed.

Patient #4: Tith Hon, female, 43 years old
Chief complaint: Palpitation, headache, numbness on both legs, chest tightness for 7 months
Assessment: mild hypertension, ischaemic heart disease?
Recommend: Refer patient to hospital for blood test, chest x-ray, EKG

What is the area of Numbness in the legs? Is it in a stocking distribution or irregular?

Perhaps describe the type of chest tightness … is there shortness of breath, sweating or faintness associated with it? What initiates it? What relieves it?

Is there a goiter?

Otherwise …. agree with the recommendation.

I think this should be suitable for Kampong Thom Hospital.

Patient #5: Sok Lim, male, 80 years old
Chief complaint: chest pain on and off for 2 months. Feels burning on both soles of his feet and shortness of breath for about 3 years.
Assessment: Chronic obstruction pulmonary disease? Ischaemic heart disease?
Recommend: Refer patient to hospital for EKG, chest x-ray, and blood tests

Agree with this assessment and recommendation. I think this should be suitable for Kampong Thom Hospital.

Patient #6, So On female, 74 years old
Chief complaint: Productive cough (yellow color for one month,) chest pain, palpitations on and off for 2 years
Assessment: Bronchitis ruled out Pulmonary TB
Recommend: Refer patient to hospital for x-ray, select sputum for gram stain A & B

Agree with this assessment and recommendation. I think this should be suitable for Kampong Thom Hospital.

Has there been weight loss, night sweats or close exposure to TB?
Have any Antibiotics been used so far?

Date: Sun, 22 Apr 2001 23:41:30 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia AM Telemedicine Clinic - 22 April - patient #1
To: Graham Gumley <ggumley@bigpond.com.kh>,
"Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>,
KKELLEHER@PARTNERS.ORG, sihosp@bigpond.com.kh
Cc: bernie@media.mit.edu, aafc@forum.org.kh, ruth_tootill@bigpond.com.kh,
lfpurple@bigpond.com.kh

1 photo file and 1 text file attached.

A photo of the foot wound per Dr. Gumley's request and
resend of that text.

UPDATE: We will stay in the village to meet yesterday's AM & PM Telemedicine patients tomorrow morning to discuss any e-mail advice that may arrive from Boston or Phnom Penh today or tonight (or overnight.)

Patients have been requested to return to the Robib clinic on 24 April, 8:00am (Cambodia time,) 8:00pm Monday night Boston time. We will hold the short followup clinic from 8:00-9:00am. If patients are referred to Kompong Thom or Phnom Penh, we will try to facilitate their transport tomorrow morning, then leave the village approx 10:00am.

Several more patients were seen today. Photos and exam data will be sent in the next few days in the hope that urgent cases can be handled by e-mailing the village school. Less urgent cases will be followed up at the May 18 clinic in Robib.

Telemedicine Clinic in Robib, Cambodia
AM, 22 April 2001

Patient #1: Chuum Sokhon, male, 43 years old

Chief complaint: body weakness, leg pain after falling from a tree 20 years ago BP: 100/50 Pulse: 68 Resp.: 20 Temp. : 36.5 Past history: 20 years ago had a foot operation at Kompong Thom Lungs: clear Heart: normal Abdomen: normal Bowel sound: normal Skin: not pale, no edema Leg: left heel has a wound, size 4 x 6 cm, wound has been open for 20 years, leg is difficult to move Assessment: old left ankle fracture Recommend: Refer patient to hospital for x-ray and meet surgeon for evaluation

From: "Graham Gumley" <ggumley@bigpond.com.kh>
To: "David Robertson" <davidrobertson1@yahoo.com>
Subject: RE: Cambodia AM Telemedicine Clinic - 22 April - patient #1
Date: Mon, 23 Apr 2001 17:13:06 +0700

Please see attached file.

Thanks.

The four patients who came down yesterday are all being seen and assessed.

Graham Gumley

Thanks for the photograph.

These are difficult to treat and sometimes require amputation.

X-ray evaluation is needed "AP and Lateral Left Heel, including ankle and foot".

I can evaluate the films in Phnom Penh, or, preferably in Preah Vihear in May when I come up.

Thanks
Graham Gumley

Date: Sun, 22 Apr 2001 18:48:43 -0700 (PDT)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: Cambodia PM Telemedicine Clinic - 22 April
To: Graham Gumley <ggumley@bigpond.com.kh>,
"Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>,
KKELLEHER@PARTNERS.ORG, sihosp@bigpond.com.kh
Cc: bernie@media.mit.edu, aafc@forum.org.kh, ruth_tootill@bigpond.com.kh,
lfpurple@bigpond.com.kh

Dear Telepartners and SHCH:

Following e-mail messages with attached text and photos are the nine patients seen during the 22 April afternoon Telemedicine clinic in Robib, Cambodia. The patients are returning to the clinic at 1:00pm today (in approx. the next 4 hours) for follow up advice.

Thanks in advance.

Sincerely,

David

Telemedicine Clinic in Robib, Cambodia
PM, 22 April 2001

Correction: AM Patient #4: Tith Hon, is 49 years old

Patient #1: Bun Norm, female, 48 years old

Chief complaint: both lower abdominal pain and feel burning when passing urine, weakness for 3 months, and vaginal discharge off and on for 2 years. BP: 60/40 Pulse: 100 Resp.: 28 Temp. : 36.5 Past history: 3 months ago admitted to Rovieng District Hospital with vaginal bleeding. Past 2 weeks, major bleeding. Lungs: clear Heart: regular rhythm, small murmur at apex Abdomen: soft, flat, positive around umbilical area and both lower abdomen Bowel sound: positive Skin: warm to touch, pale: ++, no edema, very skinny Assessment: Gastro intestinal bleeding, salphingite, and malnutrition, anemia secondary to etio, blood transfusion? Recommend: Refer patient to hospital for colo check, blood test, abdominal ultrasound, and vaginal exam PATIENT LEFT IN HELICOPTER TO PHNOM PENH AT 4:00PM

Patient #2: Prom Chhim, male, 63 years old (grandfather of earlier Telemedicine patient Phim Sophan)

Chief complaint: upper abdominal pain, burp on and off for six months BP: 110/50 Pulse: 88 Resp.: 20 Temp. : 36.5 Past history: admitted at private hospital for approx. 10 days about 3 months ago Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen: epigastric pain, old scar on abdomen Bowel sound: normal Skin: not pale, no edema, warm to touch Assessment: Dyspepsia, gastritis Recommend: Fibroscope? Advice from Boston & Phnom Penh. Treat patient in village?

Patient #3: Deab Srey Touch, female, child, 4 years old

Patient #4: Sum Phat, male, 78 years old

Chief complaint: Upper abdominal pain, weakness, and cough with white sputum for one year. BP: 100/50 Pulse: 80 Resp.: 24 Temp. : 36.5 Past history: Five years ago, had malaria, was treated well by local medicine. More than 50 years, has been drinking alcohol and smoking a lot. Lungs: Rhonchit on both sides Heart: regular rhythm, no murmur Abdomen: positive epigastric pain, not tender, soft, flat, warm to touch Bowel sound: normal Skin: very skinny, turgor, no edema, warm to touch Assessment: Bronchitis, secondary to smoking. Rule out pulmonary TB and Chronic obstruction pulmonary disease. Malnutrition, dehydration, dyspepsia. Recommend: Refer patient to hospital for chest x-ray, blood test, collect sputum for gram stain

Patient #5, Tith Yem, female, 63 years old

Chief complaint: Dizziness, difficulty breathing, and upper abdominal pain for ten months BP: 110/60 Pulse: 100 Resp.: 24 Temp. : 36.5 Past history: not significant Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen: soft, flat, positive epigastric pain Bowel sound: positive Skin: mild dehydration, not pale, no edema, warm to touch Assessment: Dyspepsia, malnutrition, and mild dehydration Recommend: Refer patient to hospital for blood tests.

Patient #6, Tith Vorn, female, 33 years old

Chief complaint: Headache, dizziness, and sometimes convulsions two times per week for three months BP: 90/60 Pulse: 80 Resp.: 20 Temp. : 36.5 Past history: not significant Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen: soft, flat Bowel sound: positive Skin: not pale, no edema, warm to touch Assessment: Epilepsy? Anxiety? Recommend: Refer patient to hospital, blood tests

Patient #7, Kong Naro, female, 51 years old

Chief complaint: Lower back pain, upper abdominal pain for one year. Nausea in the morning, diarrhea two times per week for five months. BP: 120/60 Pulse: 72 Resp.: 20 Temp. : 36.5 Past history: In 1995, had Typhoid fever and was well treated by traditional local medicine. One year ago, she had abdominal ultrasound one time and showed kidney stone, size unknown. Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen: soft, flat Bowel sound: positive Skin: not pale, no edema, warm to touch Assessment: Kidney Stone? Dyspepsia? Recommend: Refer patient to hospital for abdominal ultrasound and stool microscopic, and patient should drink a lot of clean water.

Patient #8, Beng San, male, 41 years old

Chief complaint: Both ankles, pain and mild swelling for three years. Piece of boom on the right clavicle bone and right mandible bone area for ten years. BP: 130/60 Pulse: 76 Resp.: 20 Temp. : 36.5 Past history: Fall down from house (height 4.5 meters) three years ago. Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen: soft, flat Bowel sound: positive Skin: warm to touch, no rash, swollen on the feet, puncture scar near the clavicle. Urinalysis: normal Assessment: Arthritis both ankles. Piece of boom on left clavicle. Recommend: Refer patient to hospital for x-ray on clavicle, blood tests, and discussion with surgeon.

Patient #9, Prom Choruy, female, 36 years old (Patient seen at her home)

Chief complaint: headache, confusion, left side weakness in extremities. BP: 150/90 Pulse: 104 Resp.: 20 Temp. : 37 Past history: Hypertension. BP was 230/?. Was admitted at Preah Vihear Provincial Hospital and was treated well by modern medicine. Before second delivery five months ago, got edema on both feet. Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen: soft, flat, no mass and not tender Bowel sound: positive Skin: warm to touch, no rash, no edema Legs: Left leg weakness, no reaction, negative Bakenskie. Right leg is okay. Assessment: Stroke (left side) due to Hypertension. Heclamsia secondary to hypertension. Recommend: Refer patient to hospital for chest x-ray, blood tests, EKG

From: "Graham Gumley" <ggumley@bigpond.com.kh>
To: "David Robertson" <dmr@media.mit.edu>
Subject: Reply from SHCH
Date: Mon, 23 Apr 2001 16:46:57 +0700

Please see attached file.

Graham Gumley

Reply from Dr. Graham Gumley, Sihanouk Hospital Center of HOPE.
Replies in RED.

Telemedicine Clinic in Robib, Cambodia
PM, 22 April 2001

Correction: AM Patient #4: Tith Hon, is 49 years old

Patient #1: Bun Norm, female, 48 years old
Chief complaint: both lower abdominal pain and feel burning when passing urine, weakness for 3 months, and vaginal discharge off and on for 2 years.
Assessment: Gastro intestinal bleeding, salphingite, and malnutrition, anemia secondary to etio, blood transfusion?
Recommend: Refer patient to hospital for colo check, blood test, abdominal ultrasound, and vaginal exam
PATIENT LEFT IN HELICOPTER TO PHNOM PENH AT 4:00PM

Will see in Phnom Penh.
To avoid duplication of resource use is there a way to easily arrange for a copy of the Medical Record from the District Hospital to be sent to us at the Sihanouk Hospital Center of HOPE?

Patient #2: Prom Chhim, male, 63 years old (grandfather of earlier Telemedicine patient Phim Sophan)
Chief complaint: upper abdominal pain, burp on and off for six months
Assessment: Dyspepsia, gastritis
Recommend: Fibroscope? Advice from Boston & Phnom Penh. Treat patient in village?

Was the old scar from Surgery? If so …. Do we know what it was?
Has there been evidence of bleeding? Are the conjunctivae or lips pale?
Is there any information from the Private Hospital?
I think that if there has not been bleeding or weight loss, and if there is no mass palpable on abdominal exam a course of antacid taken regularly would be wise with review of progress at next visit.

Perhaps a Gastroscopy may be needed in the future.

Patient #3: Deab Srey Touch, female, child, 4 years old
Chief complaint: scar on chin, on abdomen, and on left groin after burning by fire 4 months ago
Assessment: Serious burn scarring
Recommend: Refer patient to hospital. Suggest patient be referred to Kantha Bopha.
Should be discussed with surgeon to remove scar.

Agree with above assessment and plan, although NPH an option if KB not possible.

Patient #4: Sum Phat, male, 78 years old
Chief complaint: Upper abdominal pain, weakness, and cough with white sputum for one year.
Assessment: Bronchitis, secondary to smoking. Rule out pulmonary TB and Chronic obstruction pulmonary disease. Malnutrition, dehydration, dyspepsia.

Recommend: Refer patient to hospital for chest x-ray, blood test, collect sputum for gram stain

Agree with above assessment and plan. Referral to Kampong Thom or Preah Vehear seems appropriate.

Patient #5, Tith Yem, female, 63 years old
Chief complaint: Dizziness, difficulty breathing, and upper abdominal pain for ten months
Assessment: Dyspepsia, malnutrition, and mild dehydration
Recommend: Refer patient to hospital for blood tests.

Agree with above assessment and plan. Referral to Kampong Thom or Preah Vehear seems appropriate.

Patient #6, Tith Vorn, female, 33 years old
Chief complaint: Headache, dizziness, and sometimes convulsions two times per week for three months
Assessment: Epilepsy? Anxiety?
Recommend: Refer patient to hospital, blood tests

What is the nature of the "convulsions"?
Agree with need for Medical evaluation, initial tests as noted, but likely will need Phnom Penh evaluation if convulsions are due to epilepsy. Adult onset convulsions may be the presenting sign of Brain Tumor.

Patient #7, Kong Naro, female, 51 years old
Chief complaint: Lower back pain, upper abdominal pain for one year.
Nausea in the morning, diarrhea two times per week for five months.
Assessment: Kidney Stone? Dyspepsia?
Recommend: Refer patient to hospital for abdominal ultrasound and stool microscopic, and patient should drink a lot of clean water.

Agree with above assessment and plan. Referral to Kampong Thom or Preah Vehear seems appropriate.

Patient #8, Beng San, male, 41 years old
Chief complaint: Both ankles, pain and mild swelling for three years. Piece of boom on the right clavicle bone and right mandible bone area for ten years.
Assessment: Arthritis both ankles. Piece of boom on left clavicle.
Recommend: Refer patient to hospital for x-ray on clavicle, blood tests, and discussion with surgeon.

Agree with above assessment and plan. Referral to Kampong Thom or Preah Vihear seems appropriate.
Did this all date from the fall? Are the dates accurate? 4.5 meters is a big fall … bound to cause some residual problems … check the dates of the three and ten year time scales.
Was there another accident ten years ago?
The three bone or joint situations could all come from the fall, with fractures that have perhaps healed leaving arthritis in the ankles.
In any event x-rays will be of help.

Patient #9, Prom Choruy, female, 36 years old (Patient seen at her home)
Chief complaint: headache, confusion, left side weakness in extremities.
Assessment: Stroke (left side) due to Hypertension. Heclamsia secondary to hypertension.
Recommend: Refer patient to hospital for chest x-ray, blood tests, EKG

Agree with above assessment and plan. Referral to Kampong Thom or Preah Vihear seems appropriate.

We could know more about the Headache. Is it constant or intermittent; what relieves it; is there any photophobia; is it global or one sided?
Is the patient confused now? How severe?
What treatment is the patient receiving for the Hypertension?

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject: FW: Cambodia Project
Date: Mon, 23 Apr 2001 16:06:43 -0400

>> -----Original Message-----
> From: Patel, Dinesh G.
> Sent: Monday, April 23, 2001 3:37 PM
> To: Kelleher, Kathleen M., PHS - Telemedicine
> Subject: RE: Cambodia Project
>
> Kathleen,
> Here is my evaluation on two patients limited
> based on what I have from them
>
> Patient #8, Beng San, male, 41 years old 4/22/01 PM CLINIC
> 985-988 jpg
>
> Difficult to opine on this data
> Let us have x-rays
> and than we can talk abouit it
> Sedimentation rate and x rays would help us as well
> I do not know what is in his cheek-- mandible
> area. Collar bone area not clear
> but can have acromioclavicular joint subluxation.
> Ankle sweling can be from traumatic , infectious
> or rheumatoid type problem.
> Let us have all data and we wil respond later.
> *********************************
> Chum Sokhon
> Patient #1: Chuum Sokhon, male, 43 years old 4/22/01 AM CLINIC
> 944 jpg
> Traumatic injury to the ankle , foot and fixed
> deformity together with heel
> ulcer. It appears that he may have injured knee
> or hip as well
> Let us get x rays of ankle , foot, knee and hip to
> see what has ben happening
> unless the physical exam is normal for the knee
> and hip.
> Why is he weak !!
>
> Let me Have X Ray on both patients and we will
> give opinion . Perhaps
> surgeon can send me information as well about the
> ulcer and movements of foot
> and ankle and knee and hip exam
> thanks
> dinesh
>
> Dinesh G. Patel, M.D. F.A.C.S.
> Chief of Arthroscopic Surgery
> Massachusetts General Hospital
> Assistant Clinical Professor
> Orthopaedic Surgery
> Harvard Medical School
>
> Wang Ambulatory Care Unit 510
> 15 Parkman Street
> Boston, MA 02114
> Phone:(617)726-3555
> Fax: (617)726-5349
> Patel.Dinesh@MGH.Harvard.Edu

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject: FW: Cambodia Project
Date: Mon, 23 Apr 2001 16:25:59 -0400

> -----Original Message-----
> From: Kazemi, Homayoun,Md
> Sent: Monday, April 23, 2001 4:18 PM
> To: Kelleher, Kathleen M., PHS - Telemedicine
> Subject: RE: Cambodia Project

> -----Original Message-----
> From: Kelleher, Kathleen M., PHS - Telemedicine
> Sent: Monday, April 23, 2001 3:15 PM
> To: Kazemi, Homayoun,Md
> Subject: Cambodia Project
>
> Dear Dr. Kazemi:
>
> Thank you very much for participating in this program.

> ***************************
> Patient #4: Sum Phat, male, 78 years old
> Chief complaint: Upper abdominal pain, weakness, and cough with white
> sputum for one year.
> Assessment: Bronchitis, secondary to smoking. Rule out pulmonary TB and
> Chronic obstruction pulmonary disease. Malnutrition, dehydration,
> dyspepsia.
> Recommend: Refer patient to hospital for chest x-ray, blood test, collect
> sputum for gram stain

> [Kazemi, Homayoun,Md] Case #4. Agree with assessment
> &recommendations. Patient may well need a course of broad spectum
> antibiotics. If the chest film shows a mass, then
> cancer of the lung should
> be ruled out in view of patient's smoking history.
>
> *************************************

> Patient #6, So On female, 74 years old
> Chief complaint: Productive cough (yellow color for one month,) chest
> pain, palpitations on and off for 2 years
> Assessment: Bronchitis ruled out Pulmonary TB
> Recommend: Refer patient to hospital for x-ray,
> select sputum for gram stain A & B

> [Kazemi, Homayoun,Md] Case #6. Again
> recommendations seem
> appropriate.Since bronchi are heard only on the left
> side, then most likely
> the major abnormalities on the chest film are on
> that side also.

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject: FW: Cambodia Project
Date: Mon, 23 Apr 2001 16:39:17 -0400

> -----Original Message-----
> From: Sheridan, Robert L.,M.D.
> Sent: Monday, April 23, 2001 2:49 PM
> To: Kelleher, Kathleen M., PHS - Telemedicine
> Subject: RE: Cambodia Project
>
> Kathy:
>
> This child has a relatively minor problem, but we could certainly help
> her, either here or there, depending on how you wanted to set it up.
> After approval by the board, the Shrine Hospital would do this gratis,
> although they would want ...
> 1) transportation paid by a third party.
> 2) a parent or guardian to come with and stay with the child.
> 3) the assurance that the child did not have another problem requiring
> expensive care that we cannot provide (eg we cannot do or fund cardiac
> surgery).
>
> Let me know how you would like to proceed.
>
> Rob Sheridan

> -----Original Message-----
> From: Kelleher, Kathleen M., PHS - Telemedicine
> Sent: Monday, April 23, 2001 2:32 PM
> To: Sheridan, Robert L.,M.D.
> Subject: Cambodia Project
>
> Dear Dr. Sheridan:
>
> Thank you very much for agreeing to participate in our program. Below you
> will find the brief history of the child as well as some photographs.
> Please feel free to contact me with any questions
> or comments. According to the history that I received 7 photos were sent,
> but I only received four. I think that they are sufficient.
>
> ********************
>
> Patient #3: Deab Srey Touch, female, child, 4 years old
> Chief complaint: scar on chin, on abdomen, and on left groin after burning
> by fire 4 months ago
> Skin: scar on chin, left groin and abdomen. Not pale, warm to touch.
> Assessment: Serious burn scarring
> Recommend: Refer patient to hospital. Suggest patient be referred to
> Kantha Bopha.
> Should be discussed with surgeon to remove scar.
>
> << File: deab_961.jpg >> << File: deab_962.jpg
> << File: deab_963.jpg
> << File: deab_964.jpg >>

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject: FW: Cambodia Project
Date: Mon, 23 Apr 2001 16:51:44 -0400

Hi David:

I am forwarding an additional note for patient: Deab Srey Touch.

If transportation can be arranged for the patient and she meets the other
requirements as stated in Dr. Sheridan's response then her treatments could be
done free of charge. It would be wonderful to see this happen for the patient.

Kathy

> -----Original Message-----
> From: Sheridan, Robert L.,M.D.
> Sent: Monday, April 23, 2001 4:43 PM
> To: Kelleher, Kathleen M., PHS - Telemedicine
> Subject: RE: Cambodia Project
>
> Kathy:
>
> Initially we could release and graft the scars limiting motion (or wound still
> unhealed). It would be highly likely that she would need subsequent
> procedure(s) as she grew.
>
> Rob
>
> -----Original Message-----
> From: Kelleher, Kathleen M., PHS - Telemedicine
> Sent: Monday, April 23, 2001 2:54 PM
> To: Sheridan, Robert L.,M.D.
> Subject: RE: Cambodia Project
>
> Thank you very much for the quick reply. Could you briefly state what
> procedures the child would have to undergo either at the Shrine or in
> Cambodia?

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject: FW: Cambodia Project
Date: Mon, 23 Apr 2001 16:55:03 -0400

> -----Original Message-----
> From: Isselbacher, Eric Michael,M.D.
> Sent: Monday, April 23, 2001 4:44 PM
> To: Kelleher, Kathleen M., PHS - Telemedicine
> Subject: RE: Cambodia Project
>
> See my comments highlighted below.
> ________________
> Eric M. Isselbacher, MD
> Mass. General Hospital, 15 Parkman St., WAC-469, Boston, MA 02114
> Tel: 617-724-1994 / Fax: 617-724-0289
>
> -----Original Message-----
> From: Kelleher, Kathleen M., PHS - Telemedicine
> Sent: Monday, April 23, 2001 4:36 PM
> To: Isselbacher, Eric Michael,M.D.
> Subject: Cambodia Project
>
> Thank you again for your participation. I hope that you feel better
> soon.
>
> ************************'
>
> Patient #4: Tith Hon, female, 43 years old
> Chief complaint: Palpitation, headache, numbness on both legs, chest
> tightness for 7 months
> Assessment: mild hypertension, ischaemic heart disease?
> Recommend: Refer patient to hospital for blood test, chest x-ray, EKG
>
>
> I agree. She needs an EKG to assess the etiology of her tachycardia and
> to look for evidence of other cardiac pathology. She should have renal
> function and her hematocrit checked. There should be follow up of her
> hypertension.
> Eric M. Isselbacher, M.D.
>
> *********************************************************
>
> Patient #5: Sok Lim, male, 80 years old
> Chief complaint: chest pain on and off for 2 months. Feels burning on
> both soles of his feet and shortness of breath for about 3 years.
> Assessment: Chronic obstruction pulmonary disease? Ischaemic heart disease?
> Recommend: Refer patient to hospital for EKG, chest x-ray, and blood tests
>
> I agree. He needs an EKG, chest x-ray, and complete blood work. I would
> also check a set of simple pulmonary function tests, if possible.
> Eric M. Isselbacher, M.D.
>

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Cc: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>
Subject: 4/22/01 AM & PM clinic updates
Date: Mon, 23 Apr 2001 17:15:18 -0400

Dear David:

Here is a summary of the cases that you sent today:

4/22/01 AM Clinic

#1 completed by Dr. Dinesh Patel
#2 still open
#3 still open
#4 completed by Dr. Eric Isselbacher
#5 completed by Dr. Eric Isselbacher
#6 completed by Dr. Homayoun Kazemi

4/22/01 PM Clinic
#1 still open
#2 completed by Dr. Raymond Chung
#3 completed by Dr. Robert Sheridan
#4 completed by Dr. Homayoun Kazemi
#5 still open
#6 still open by Dr. Kenneth Sassower
#7 completed by Dr. Stephen Dretler
#8 completed by Dr. Dinesh Patel
#9 still open

***********************
Kathy Kelleher
Senior Remote Consultation Coordinator
Partners Telemedicine
Two Longfellow Place, Suite 216
Boston, MA 02114
Phone: 617-726-1051
Fax: 617-228-4608
Page: 617-724-5700 x28976
http://telemedicine.partners.org

To: davidrobertson1@yahoo.com, robibtech@yahoo.com
CC: bernie@media.com.kh, aafc@forum.org.kh, schlemme@daily.forum.org.kh
Date: Tue, 24 Apr 2001 08:59:36 +0700
Subject: Examination
From: dy@daily.forum.org.kh (Meng Dy)

Dear Mr.David and teachers

I brought the 4 patiens to the Hope hospital yesterday to have an examination from 10AM till 6:30PM. The result coming as follow:

1/ Mr. Nung Kemcheang, robib school director has been examed and got some medicines, but the doctor asked me to bring him to have an test blood today at Hope hospital, then send him to have an heart X-ray at Culmet hospital this morning too. The doctor at the Hope hospital asked him to come back to see him on April 30, 2001 after the heart X-ray coming.

2/ Miss Ngourn Sokheang learning in 6 grade at Robib Primary school and she is living in Thnot Mlou village, has an goiter on her neck, but the doctor said she can go home to cure at the Provincial hospital.

3/ Mrs Chem Neang, living in Keng village, already did an examination and got some medicines. The doctor asked me to bring her to have heart X-ray this morning too and the doctor asked her
to come again to see the doctor on April 26, 2001 after the heart X-ray finished.

4/ Mrs Bun Nam, living in Bak Kdong village, already did an examination and got some medicines. She is going to have blood test today as well.

**** Please tell their families at Rovieng that they are here no problem with the stay, food and we are taking care of them. 

Best regards,

Meng Dy

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject: FW: Cambodia AM Telemedicine Clinic - 22 April - patient #1
Date: Tue, 24 Apr 2001 08:36:00 -0400

-----Original Message-----
From: Patel, Dinesh G.
Sent: Monday, April 23, 2001 6:06 PM
To: Kelleher, Kathleen M., PHS - Telemedicine
Subject: RE: Cambodia AM Telemedicine Clinic - 22 April - patient #1

Kathleen,
This is second patient with heel ulcer picture.
On the picture it also appears that he has had some surgery in ankle I suspect that he has fixed foot and ankle plantar flexed deformity with tight achilles tendon and may be due to traumatic ankle problem as wellhe has develped this non healing ulcer on the heel. 
does he have diabetes most important for this patient is to take care of soft tissue deep ulcer.
I suspect if he gets frequent debriedements , antibiotics and rest in cast as a first step it would be positive movements. It is possible that bone is exposed as well. After frequent debridenments if it does not look better than one may have to look at bony part as well. Nice to know how far is bone invloved any how . have them take xrays of foot and ankle to make sure about osteomylitis and the status of ankle as well peripheral vasulature need to be seen as well I think it would be better for this to be evaluated by plastic surgeon as well. In short what one needs
Xray of foot and ankle status of diabetes status and peripheral blood supply Does he have charcoats problem loss of sensitivity from neurological condition or else

Thanks
Dinesh

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject: FW: Cambodia Project
Date: Tue, 24 Apr 2001 08:37:31 -0400

> -----Original Message-----
> From: Sassower, Kenneth,M.D.
> Sent: Monday, April 23, 2001 6:29 PM
> To: Kelleher, Kathleen M., PHS - Telemedicine
> Subject: RE: Cambodia Project
>
> In light of a clinical history of recurrent episodic behaviors of unclear
> etiology, and in addition to the aforementioned hospital admission for
> purpose of evaluation and diagnostic and laboratory testing, it would also
> be recommended for this patient to undergo a routine scalp EEG study
> during wakefulness, drowsiness and natural sleep. This will help in the
> assessment of a potential seizure disorder; i.e., in particular, a complex
> partial seizure disorder, which may manifest with neuro-behavioral
> manifestations and recurrent bouts of dizziness. In addition, a MRI study
> of the brain, both with and without gadolinium administration, is also
> suggested, as it would offer high-resolution imaging of cortical areas,
> grey and white matter interface, and posterior fossa structural anatomy in
> this patient with a history of recurrent bouts of "dizziness" and
> headaches. Please feel free to contact our Department of Neurology and
> Division of Clinical Neurophysiology as additional pertinent medical
> information becomes available, and as the clinical need arises. Thank you
> for your cooperation and consideration. Respectfully yours, - Kenneth C.
> Sassower, M.D.; Division of Clinical Neurophysiology; Department of
> Neurology; Massachusetts General Hospital; Bigelow 1256; Boston,
> Massachusetts 02114.
> -----Original Message-----
> Patient #6, Tith Vorn, female, 33 years old
> Chief complaint: Headache, dizziness, and sometimes convulsions two times
> per week for three months
> Assessment: Epilepsy? Anxiety?
> Recommend: Refer patient to hospital, blood tests
> ***********************

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject: FW: Cambodia Project
Date: Tue, 24 Apr 2001 08:38:09 -0400

> -----Original Message-----
> From: Dretler, Stephen P.,Md
> Sent: Monday, April 23, 2001 6:27 PM
> To: Kelleher, Kathleen M., PHS - Telemedicine
> Subject: RE: Cambodia Project
>
> It would be helpful to know which side the kidney stone was on...if the
> patient had any blood in her urine...if there was any pain to palpation in the
> flank and which side it was on.....and of course, if the new ultrasound showed
> any stones (and their size) and whether there was any hydronephrosis seen by
> the ultrasound.
>
> -----Original Message-----
> From: Kelleher, Kathleen M., PHS - Telemedicine
> Sent: Monday, April 23, 2001 4:09 PM
> To: Dretler, Stephen P.,Md
> Subject: Cambodia Project
>
> Dear Dr. Dretler:
>
> Thank you very much for your participation in this project. Below you will
> find the clinical history that we discussed as well as a photograph of the
> patient. I am available at the phone numbers below if you have any questions
> or comments.
>
> ********************************************
> Patient #7, Kong Naro, female, 51 years old
> Chief complaint: Lower back pain, upper abdominal pain for one year.
> Nausea in the morning, diarrhea two times per week for five months.
> Past history: In 1995, had Typhoid fever and was well treated by traditional
> local medicine.
> One year ago, she had abdominal ultrasound one time and showed kidney stone,
> size unknown.
> Assessment: Kidney Stone? Dyspepsia?
> Recommend: Refer patient to hospital for abdominal ultrasound and stool
> microscopic, and patient should drink a lot of clean water.
>

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject: FW: one patient
Date: Tue, 8 May 2001 11:56:27 -0400

Hello David:

Below you will find the response to case #9. I apologize for not sending a response prior to today. I was under the impression that I only had one day to complete the cases and was informed by Dr. Kvedar that I should try and complete them in one day, but if cases were sent the next day
that would be acceptable.

Best wishes,

Kathy

> Case# 9
> 37 year old with left leg weakness history of hypertension during pregnancy.
> If the onset of weakness was very rapid (happening in minutes) I would worry
> about a stroke event.
> Would make sure that patient did not have bleeding into the brain from high
> blood pressure.
> If patient could get head computed tomogram (CT) this would answer whether
> this is a stroke from lack of oxygen versus stroke from bleeding.
> Colin McDonald MD
> Neurosurgical Intensive Care Unit
> Massachusetts General Hospital