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Robib and Telemedicine

February 2002 Telemedicine Clinic in Robib

Report and photos submitted by David Robertson

On Wednesday, February 27, 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. Graham Gumley of the Sihanouk Hospital Center of Hope (SHCH) in Phnom Penh. The data was transmitted via the Hironaka School Internet link.

The following morning, February 28, all the patients returned to the Robib Health Clinic. Nurse "Montha" discussed the advice received from the physicians in Boston and Phnom Penh with the patients.

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

Date: Wed, 27 Feb 2002 02:35:19 -0800 (PST)

From: David Robertson <davidrobertson1@yahoo.com>

Subject: Cambodia Telemedicine Clinic text, cases 1-4, 27 February 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

MIME-Version: 1.0

Status: RO

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

Dear all,

Please see attached.

We are going off-line for a few hours to rest the generator. Will e-mail photos and 5 more cases later this evening.

Best regards,

David

To: Telepartners & Sihanouk Hospital Center of Hope (SHCH)

Fr: David Robertson

Date: 27 February 2002

Subject: cases 1-4

Sihanouk Hospital Center of Hope (SHCH) nurse Montha examined the following patients on February 27th at the local health clinic in Robib, Rovieng district, Cambodia. More cases and 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 tomorrow on Thursday, February 28 at 8:00am Cambodia time (8:00pm on February 27 in Boston.) Any advice that could be sent before this time will be most helpful.

We can transport the sickest patients to a hospital (closest is Kampong Thom Provincial Hospital about 3 hours away, or if necessary, at other hospitals that are better equipped 8 hours drive from the village in the capital city of Phnom Penh,) but transport of patients or the distribution 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 – 27 February 2002

Patient #1: SIM ROEUN, female, 15 years old

Chief complaint: Upper abdominal pain for one day.

History of present illness: For one day she has upper abdominal pain like burning. No radiating to anywhere and gets worse after having a meal, better when she bends forward. Better after buying medication at local pharmacy.

Current medicine: Yesterday she took two Maalox tablets.

Past medical history: Malaria and Typhoid fever two years ago.

Social and family history: Does not smoke or drink alcohol. All family members are healthy.

Allergies: None

Review of system: No fever, no cough, positive upper abdominal pain, positive vomiting, positive nausea, negative dyspepsia.

Physical exam: General appearance: looks non-toxic.

BP: 120/70
Pulse: 100
Resp.: 20
Temp. : 36.5

Hair, eyes, ears, nose, throat: Normal.
Neck: No goiter, no lymph node
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, and positive bowel sound.
Limbs: no edema, no pain, no stiffness
Assessment: Dyspepsia, Parasitis?

Recommend: Should we treat her in location? Please let me know what kind of medication.

Patient #2: HOUR SOVANTHA, male, 14 years old, previous Telemedicine patient

Chief complaint: Fever, sore throat, cough with sputum for last three days.

History of present illness: Three days ago he got a sore throat, fever, and cough with sputum. It got worse when he drinks cold beverages with ice. He felt better after his mother gave him Paracetemol purchased at the local pharmacy.

Current medicine: He’s taking one tablet of Paracetemol every six hours.

Past medical history: Three months ago he had pharyngitis. He was treated with Amoxycillin and got better.

Social and family history: Does not smoke or drink alcohol. His father has valvular heart disease, is a Telemedicine patient, and has been following up well for one year with his treatment at Sihanouk Hospital Center of Hope in Phnom Penh.

Allergies: None

Review of system: Has fever, has cough, has sore throat, no upper abdominal pain, no vomiting, no diarrhea, negative dyspepsia.

Physical exam: Looks mildly sick, no respiratory distress.

BP: 100/60
Pulse: 88
Resp.: 20
Temp. : 37

Hair: okay
Eyes: okay, not pale
Ears: okay
Nose: okay
Throat: Red, mild hypertrophy of tonsil
Neck: No goiter, no lymph node
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, and positive bowel sound.
Limbs: no edema, no stiffness

Assessment: Pharangitis, Tonsillitis.

Recommend: Should we treat him in location with antibiotic and give him advice on how to treat this disease? Please let me know what kind of medication.

Patient #3: SOM DIM, female, 60 years old

Chief complaint: All joints painful on and off for three years.

History of present illness: Three years ago all joints became painful and she got a dry cough that’s persisted on and off for the last three years. Cough gets worse at night, painful while working and accompanied by chills, sweating at night, weight loss. She got better taking modern medicine but can’t recall name of drug.

Current medicine: None

Past medical history: Five years ago she had severe arthritis in her knee.

Social and family history: Does not smoke or drink alcohol. All family members are healthy.

Allergies: None

Review of system: No fever, has cough, no diarrhea, no vomiting, all joints painful, no abdominal pain, positive shortness of breath occasionally

Physical exam: Looks mildly sick.

BP: 130/60
Pulse: 76
Resp.: 20
Temp. : 36.5

Eyes: mild pale
Ears, Nose & Throat: Normal
Neck: No goiter, no lymph node
Lungs: crackle on all lobes
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, not painful, and positive bowel sound.
Limbs: no edema, not swollen
Joints: Positive pain, mild stiffness on fingers, no redness.
Assessment: Pulmonary TB? Arthritis due to Etio? Malnutrition

Recommend: Refer to Kampong Thom Provincial Hospital for AFB exam, CXR, CBC.

Patient #4: PROM HORN, female, 48 years old, previous Telemedicine patient

Chief complaint: Neck tightness and palpitations last six months. Upper abdominal pain for last six months.

History of present illness: Six months ago she got palpitations and neck tightness on and off, especially when she decreases food intake and does not sleep well. Palpitations stop when she sleeps well. Upper abdominal pain radiating lower gets worse after a meal, gets better when she leans forward.

Current medicine: Cimetidine, one tablet per day, on and off for two weeks.

Past medical history: Malaria four years ago. Typhoid fever two years ago.

Social and family history: Does not smoke or drink alcohol. All family members are healthy.

Allergies: None

Review of system: Has a fever, no cough, no vomiting, neck tightness, upper abdominal pain, nausea, palpitations, no shortness of breath, no weight loss.

Physical exam: Looks non-toxic.

BP: 100/50
Pulse: 80
Resp.: 20
Temp. : 36.5

Hair, Eyes, Ears, Nose & Throat: Normal
Neck: Small goiter in front of neck, size about 4 x 56 cm. No lymph node.
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: positive pain upper abdomen, soft, flat, no mass, positive bowel
sound.
Limbs: no edema, no stiffness, no joints painful
Joints: Positive pain, mild stiffness on fingers, no redness.
Assessment: Simple goiter? Dyspepsia and anxiety.

Recommend: Should we do goiter test (T4, TSH) and cover dyspepsia here?

Date: Wed, 27 Feb 2002 05:39:00 -0800 (PST)

From: David Robertson <davidrobertson1@yahoo.com>

Subject: Cambodia Telemedicine Clinic, correction, case #4, 27 February 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

MIME-Version: 1.0

Status: RO

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

Dear all,

There was a small typo on case #4. Correction is attached.

Best regards,

David

typo in red is corrected below

Patient #4: PROM HORN, female, 48 years old, previous Telemedicine patient

Chief complaint: Neck tightness and palpitations last six months. Upper abdominal pain for last six months.

Neck: Small goiter in front of neck, size about 4 x 56 cm. No lymph node.

Goiter size is 4 x 6 cm

Assessment: Simple goiter? Dyspepsia and anxiety.

Recommend: Should we do goiter test (T4, TSH) and cover dyspepsia here?

Date: Wed, 27 Feb 2002 06:07:20 -0800 (PST)

From: David Robertson <davidrobertson1@yahoo.com>

Subject: Cambodia Telemedicine Clinic text, cases 5-6, 27 February 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

MIME-Version: 1.0

Status: RO

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

Dear all,

Please see attached.

Best regards,

David

To: Telepartners & Sihanouk Hospital Center of Hope (SHCH)

Fr: David Robertson

Date: 27 February 2002

Subject: cases 5-6

Sihanouk Hospital Center of Hope (SHCH) nurse Montha examined the following patients on February 27th at the local health clinic in Robib, Rovieng district, Cambodia.

JPG photos and three more cases follow in later messages.

Thank you again for your kind assistance.

Best regards,

David

Telemedicine Clinic in Robib,
Cambodia – 27 February 2002

Patient #5: CHHIM SAO, male, 8 years old

Chief complaint: Swollen on the right scrotum for one year.

History of present illness: One year ago he got right scrotum hypertrophy, especially when he runs, but it decreases in size when he is lying down. It’s not painful.

Current medicine: None.

Past medical history: Unremarkable.

Social and family history: Unremarkable.

Allergies: None

Review of system: No fever, no cough, no abdominal pain.

Physical exam: Looks healthy.

Pulse: 100
Resp.: 24
Temp. : 36.5
Hair, eyes, ears, nose, throat: Normal.
Neck: No lymph node
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, positive bowel sound, no mass.
Limbs: okay
Genitals: Right scrotum increased in size, three times larger than the left side, and soft.
Assessment: Right hernia

Recommend: Refer to Khantha Bhopa Children’s Hospital for consultation with surgeon.

Patient #6: CHEAV PHALLA, female, 12 years old

Chief complaint: Convulsions two or three times per day, on and off for one year.

History of present illness: For one year she got convulsions on and off and contractions over the whole body. After that she got cyanosis all over the body and became unconscious for ten minutes. After massage, she became completely awake and felt as usual. Convulsions are worse when she has abdominal pain. Sometimes her father takes her to a local doctor in the village but the doctor has no idea how to treat this condition.

Current medicine: She doesn’t use any modern or traditional medicine.

Past medical history: When she was three years old, she had convulsions and was unconscious for three days. After that she was healed until she was 11 years old.

Social and family history: Unremarkable

Allergies: None

Review of system: No fever, no cough, no vomiting, has abdominal pain, negative dyspepsia.

Physical exam: Looks healthy.

BP: 100/50
Pulse: 90
Resp.: 20
Temp. : 36.5

Hair, eyes, ears, nose, throat: Normal.
Neck: No lymph node, no sign of goiter
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, positive bowel sound, no pain.
Limbs: no edema, no stiffness, no pain
Assessment: Epilepsy? Parasitis?

Recommend: Should we refer her to pediatric hospital for evaluation?

Date: Wed, 27 Feb 2002 07:59:47 -0800 (PST)

From: David Robertson <davidrobertson1@yahoo.com>

Subject: Cambodia Telemedicine Clinic text, cases 7-9, 27 February 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

MIME-Version: 1.0

Status: RO

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

Dear all,

Please see attached. As it's getting late and the generator needs to be shut down, photos for these last three cases will have to follow tomorrow (but hoping you can do the evaluations without them.)

Best regards,

David

To: Telepartners & Sihanouk Hospital Center of Hope (SHCH)

Fr: David Robertson

Date: 27 February 2002

Subject: cases 7-9

Sihanouk Hospital Center of Hope (SHCH) nurse Montha examined the following patients on February 27th at the local health clinic in Robib, Rovieng district, Cambodia.

These are the last cases for this month. JPG photos for these last three cases will have to follow tomorrow morning.

Thank you again for your kind assistance.

Best regards,

David

Telemedicine Clinic in Robib,
Cambodia – 27 February 2002

Patient #7: THAI SOKVY, female, 6 year old child

Chief complaint: Convulsions three to four times per day for last five months.

History of present illness: For last five months she gets convulsions on and off for three to four times per day. Contractions over the whole body and cyanosis. After that she becomes unconscious for about one minute. After massage, she became completely awake most of the time. She gets worse when she plays a lot. Her father took her to a local doctor in the village but the doctor cannot resolve this problem.

Current medicine: None.

Past medical history: When she was one year old, she got high fever, vomiting, and then was unconscious for one night.

Social and family history: Unremarkable.

Allergies: Father says she has an allergy but doesn't know the kind of medicine.

Review of system: No fever, no cough, no dyspepsia, no vomiting, but has abdominal pain

Physical exam: Looks healthy.

Pulse: 112
Resp.: 24
Temp. : 36.5

Hair, eyes, ears, nose, throat: Normal.
Neck: No lymph node
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, positive bowel sound
Limbs: no edema, no stiffness, and no pain
Assessment: Epilepsy? Parastis?

Recommend: Should we refer her to pediatric hospital for evaluation?

Patient #8: CHHIM MAN, female, 60 years old

Chief complaint: Blurred vision, dizziness, neck tender, tremor, on and off for five years.

History of present illness: Five years ago she got dizziness, neck tender, blurred vision on and off, accompanied by headache and chest pain on the pericardial radiating to left chest. Worse when she walks or works hard. She rarely has gone to meet local medical staff.

Current medicine: She has used traditional medicine for five years to release dizziness and neck tenderness.

Past medical history: Unremarkable.

Social and family history: Does not smoke. Drank alcohol but stopped two years ago.

Allergies: None

Review of system: No fever, no cough, no abdominal pain, no dyspepsia, positive neck tenderness, positive dizziness.

Physical exam: Looks okay. (David noticed head shaking fairly continuously.)

BP: 150/90
Pulse: 92
Resp.: 20
Temp. : 36.5

Hair, eyes, ears, nose, throat: Normal.
Neck: No goiter, no lymph node
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender, no mass, and positive bowel sound.
Limbs: no edema, no pain, no stiffness, but positive tingling
Assessment: Mild hypertension? Parkinson's Disease? Ischaemic heard disease?

Recommend: Should we refer her to the hospital for some blood tests like Uree, creat, bun, & EKG?

Patient # 9: SAM MAO, female, 58 years old

Chief complaint: Palpitations, blurred vision, chest tightness for one year.

History of present illness: One year ago she got palpitations, blurred vision, chest tightness with a dull radiating to upper abdominal area. It gets worse when she walks and lasts for four or five minutes accompanied by sweats and cold extremities. She gets better when she rests. When she gets signs like this she went to meet the staff of the local medical clinic that gave her some medication but she had no response to the drug.

Current medicine: None

Past medical history: Malaria two years ago.

Social and family history: Does not smoke or drink alcohol. Family history is unremarkable.

Allergies: None

Review of system: No fever, no cough, no abdominal pain, positive shortness of breath sometimes, positive chest tightness, no diarrhea.

Physical exam: Looks mildly sick.

BP: 110/60
Pulse: 66
Resp.: 20
Temp. : 36.5

Hair, Eyes, Ears, Nose & Throat: Normal
Urinalysis: Negative
Neck: No lymph node, no goiter
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, no mass, not tender, positive bowel sound.
Limbs: no edema, no stiffness, and no pain
Joints: Positive pain, mild stiffness on fingers, no redness.
Assessment: Anxiety, vertigo? Rule out ischaemic hear disease

Recommend: EKG or some medications. Cover vertigo in local area.

From: "Graham Gumley" <ggumley@bigpond.com.kh>

To: "David Robertson" <davidrobertson1@yahoo.com>, <JKVEDAR@PARTNERS.ORG>,

<KKELLEHER@PARTNERS.ORG>, "Jennifer Hines" <sihosp@bigpond.com.kh>

Cc: <dmr@media.mit.edu>, <bernie@media.mit.edu>, <aafc@forum.org.kh>

Subject: RE: Cambodia Telemedicine Clinic text, cases 1-6, 27 February 2002

Date: Wed, 27 Feb 2002 22:46:54 -0800

MIME-Version: 1.0

Status: RO

Dear David,

Great work you and Montha again.

Good evaluations, clear written communication and helpful pictures.

My replies attached.

Regards.

Graham

Patient #1: SIM ROEUN, female, 15 years old

Chief complaint: Upper abdominal pain for one day.

Assessment: Dyspepsia, Parasitis?

Recommend: Should we treat her in location? Please let me know what kind of medication.

SHCH: What was the response to the Maalox? This is important to know. If a quick and good response then should continue that medication.

(Montha: What is the list of medicines that you have?)

Patient #2: HOUR SOVANTHA, male, 14 years old, previous Telemedicine patient

Chief complaint: Fever, sore throat, cough with sputum for last three days.

History of present illness: Three days ago he got a sore throat, fever, and cough with sputum. It got worse when he drinks cold beverages with ice. He felt better after his mother gave him Paracetemol purchased at the local pharmacy.

Assessment: Pharangitis, Tonsillitis.

Recommend: Should we treat him in location with antibiotic and give him advice on how to treat this disease? Please let me know what kind of medication.

SHCH: Should have a course of antibiotic. (What do you have with you?) Amoxycillin would do fine … for 10 days.

Patient #3: SOM DIM, female, 60 years old

Chief complaint: All joints painful on and off for three years.

History of present illness: Three years ago all joints became painful and she got a dry cough that’s persisted on and off for the last three years. Cough gets worse at night , painful while working and accompanied by chills, sweating at night, weight loss. She got better taking modern medicine but can’t recall name of drug.

Assessment: Pulmonary TB? Arthritis due to Etio? Malnutrition.

Recommend: Refer to Kampong Thom Provincial Hospital for AFB exam, CXR, CBC.

SHCH: Agree with above assessment and recommendation.

Patient #4: PROM HORN, female, 48 years old, previous Telemedicine patient

Chief complaint: Neck tightness and palpitations last six months. Upper abdominal pain for last six months.

Assessment: Simple goiter? Dyspepsia and anxiety.

Recommend: Should we do goiter test (T4, TSH) and cover dyspepsia here?

SHCH: This sounds like a good plan. Did she have an ECG previously to assess the palpitations? Have you seen evidence of palpitations/heart beat irregularities? Certainly T4 TSH would be helpful to sort this out, particularly if there is some concern re anxiety.

Patient #5: CHHIM SAO, male, 8 years old

Chief complaint: Swollen on the right scrotum for one year.

History of present illness: One year ago he got right scrotum hypertrophy, especially when he runs, but it decreases in size when he is lying down. It’s not painful.

Assessment: Right hernia.

Recommend: Refer to Khantha Bhopa Children’s Hospital for consultation with surgeon.

SHCH: This could be a hernia or a hydrocoele.

What do you think of the red area in the R Groin?

Is it tender or inflamed? Is there any drainage?

Referral to KB or NPH will be good. It is not urgent if the swelling is not painful or tender, so transportation at this time is optional.

Patient #6: CHEAV PHALLA, female, 12 years old

Chief complaint: Convulsions two or three times per day, on and off for one year.

Assessment: Epilepsy? Parasitis?

Recommend: Should we refer her to pediatric hospital for evaluation?

SHCH: I agree that she should be referred to KB and brought down this trip.

From: "Graham Gumley" <ggumley@bigpond.com.kh>

To: "David Robertson" <davidrobertson1@yahoo.com>, <JKVEDAR@PARTNERS.ORG>,

<KKELLEHER@PARTNERS.ORG>, "Jennifer Hines" <sihosp@bigpond.com.kh>

Cc: <dmr@media.mit.edu>, <bernie@media.mit.edu>, <aafc@forum.org.kh>

Subject: RE: Cambodia Telemedicine Clinic text, cases 7-9, 27 February 2002

Date: Thu, 28 Feb 2002 08:03:13 -0800

MIME-Version: 1.0

Status: RO

Reply from Dr. Gumley.

SHCH

Patient #7: THAI SOKVY, female, 6 year old child

Chief complaint: Convulsions three to four times per day for last five months.

Assessment: Epilepsy? Parasitis?

Recommend: Should we refer her to pediatric hospital for evaluation?

SHCH: Requires referral to Pediatric hospital for eval.

Patient #8: CHHIM MAN, female, 60 years old

Chief complaint: Blurred vision, dizziness, neck tender, tremor, on and off for five years.

Assessment: Mild hypertension? Parkinson's Disease? Ischaemic heart disease?

Recommend: Should we refer her to the hospital for some blood tests like Uree, creat, bun, & EKG?

SHCH: Agree. Repeat her BP check today. If her symptoms are current could go to KT with you. If longstanding and not currently present this could be advised and facilitated more electively.

Patient # 9: SAM MAO, female, 58 years old

Chief complaint: Palpitations, blurred vision, chest tightness for one year.

Assessment: Anxiety, vertigo? Rule out ischaemic heart disease/

Recommend: EKG or some medications. Cover vertigo in local area.

SHCH: In this age group Ischeaemic Heart Disease needs to be evaluated. This patient should go to KT for assessment/ECG etc.

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

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

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

Cc: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>

Subject: FW: Patient #3: SOM DIM

Date: Wed, 27 Feb 2002 15:46:22 -0500

MIME-Version: 1.0

Status: RO

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

From: Patel, Dinesh G.

Sent: Wednesday, February 27, 2002 3:41 PM

To: Kelleher, Kathleen M. - Telemedicine

Subject: RE: Patient #3: SOM DIM

**********************************

Kathleen,

I have reviewed the available information including three pictures

I do not see any evidence of Rheumatoid in her hands

It appears that the patient has osteoarthritis . The suggestion to get necessary tests such as they have advised is reasonable. The treatment can be started WITH ANTI-INFLAMMATORY MEDICINE LOCAL HEAT AND EXERCISES. It may be that one should start anti-inflammatory medicine, good nutrition first. If the symptoms do not resolve than one can get x-rays and appropriate tests

thanks

dinesh

-----------------------------------------------------------

Kathy Kelleher

Senior Remote Consultation Coordinator

Partners Telemedicine

Two Longfellow Place, Suite 216

Boston, MA 02114

Phone: 617-726-1051

Cell: 617-838-5083

Fax: 617-228-4608

Page: 617-724-5700 x28976

http://telemedicine.partners.org

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

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

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

Cc: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>

Subject: RE: Patient #7: THAI SOKVY

Date: Wed, 27 Feb 2002 16:02:12 -0500

MIME-Version: 1.0

Status: RO

Hi David:

Here is Dr. Sassower's response. We did not receive the photos of patients 7-8-9, but I think that this response shows that the clinical summary can certainly paint us a good picture of our patients.

Kathy

*************************

This is a 6 year-old female child with a history of suspected generalized tonic-clonic convulsive motor activity dating back to one month of age. These generalized convulsions are said to be associated with facial cyanosis, and a relatively brief post-ictal period. Although most generalized tonic-clonic convulsions have a more prolonged post-ictal recuperative period, it is perhaps most prudent to consider either primary or secondarily generalized convulsions as likely diagnostic entities (i.e., given the history of associated facial cyanosis), with cyanotic breath-holding spells a somewhat less likely consideration (i.e., given the presence of increased motor tone, rather than diffuse hypotonia, as an accompanying clinical feature). In light of these diagnostic considerations, an EEG study, performed during wakefulness, drowsiness and natural sleep, would be the primary neuro-diagnostic study of choice. If the EEG results suggest a partial seizure disorder with secondary generalization (i.e., by virtue of focal interictal EEG spike discharges), a neuro-imaging study (either in the form of an MRI of the Brain, or, if not available at the regional health center, a CT Scan of the Head) would then be suggested. In light of the somewhat less likely possibility of a cyanotic breathholding spell, a careful history regarding potential precipitants of these events (usually a pronounced period of crying) might offer additional clinical benefit. Please feel free to contact me with regards to any seizure-related questions; i.e., should the EEG demonstrate any focal or generalized epileptiform discharges. Thank you for allowing me to share in the medical care of this young child. Respectfully yours, - Kenneth C. Sassower, M.D.; Division of Clinical Neurophysiology; Department of Neurology; Massachusetts General Hospital.

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

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

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

Cc: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>

Subject: FW: Patient #6: CHEAV PHALLA

Date: Wed, 27 Feb 2002 16:19:38 -0500

MIME-Version: 1.0

This is a 12 year-old female child with a one year-history of suspected generalized convulsions, with associated diffuse facial and body cyanosis. If we are to assume that the generalized convulsion at three years of age represents a similar epileptic process, the fact that she was reportedly "unconscious" for three days during early childhood is of some clinical concern; i.e., given a propensity for what may be either continuous generalized seizures of a non-convulsive variety, or a markedly prolonged post-ictal state. With a suspected clinical diagnosis of primary versus secondarily generalized epilepsy, an EEG study, performed during wakefulness, drowsiness and natural sleep, would be the primary neuro-diagnostic study of choice. If the EEG results suggest a partial seizure disorder with secondary generalization (i.e., by virtue of focal interictal EEG spike discharges), a neuro-imaging study (either in the form of an MRI of the Brain, or, if not available at the regional health center, a CT Scan of the Head) would then be suggested. Please feel free to contact me with regards to any seizure-related questions; i.e., should the EEG demonstrate any focal or generalized epileptiform discharges. Thank you for allowing me to share in the medical care of this young child. Respectfully yours, - Kenneth C. Sassower, M.D.; Division of Clinical Neurophysiology; Department of Neurology; Massachusetts General Hospital.

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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>

Cc: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>

Subject: FW: Patient #5: CHHIM SAO

Date: Wed, 27 Feb 2002 17:46:52 -0500

MIME-Version: 1.0

Status: RO

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

> From: Schnitzer, Jay J.,M.D.

> Sent: Wednesday, February 27, 2002 5:43 PM

> To: Kelleher, Kathleen M. - Telemedicine

> Cc: Hovasse, Catherine

> Subject: RE: Patient #5: CHHIM SAO

> Dear Kathy,

> From the description of the case and the photos, it is my opinion that all of

> the information is highly suggestive of an inguinal hernia in this young

> child, and in my medical opinion, he should be sent to the hospital for

> consultation with a surgeon and possible corrective surgery.

> Thank you very much.

> Sincerely,

> Jay Schnitzer

> Jay J. Schnitzer, M.D., Ph.D.

> Pediatric Surgical Services

> Massachusetts General Hospital, WRN 1159

> 55 Fruit Street

> Boston, MA 02114-2696

> Tel: (617) 724-1602

> Fax: (617) 726-5057

> Email: jschnitzer@partners.org

> Email: schnitzer.jay@mgh.harvard.edu

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

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

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

Cc: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>

Subject: FW: Patient #1: SIM ROEUN

Date: Wed, 27 Feb 2002 19:54:25 -0500

MIME-Version: 1.0

Status: RO

Hi David:

I'll keep watching for the remaining consults.

Kathy

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

> From: Kleinman, Ronald E.,M.D.

> Sent: Wednesday, February 27, 2002 5:54 PM

> To: Kelleher, Kathleen M. - Telemedicine

> Subject: RE: Patient #1: SIM ROEUN

> Her symptoms sound quite compatible with a gastritis. I think she can be

> treated locally with more intensive antacid therapy - either an H2 blocker

> such as cimetidine or ranitidine or more agressive treatment with Maalox (2

> tablets 2 hours after every meal and at bedtime) for a period of 3 weeks.

> Before starting, if they have a microbiology lab, they could examine a stool

> specimen for the presence of blood and parasites. Her resting pulse is a bit

> high and so a blood count with hemoglobin and hematocrit would be reasonable.

> The fact that her abdomen isn't tender and she can eat, suggests that

> pancreatitis isn't the problem. REKleinman

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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>

Cc: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>

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

Date: Thu, 28 Feb 2002 09:02:06 -0500

MIME-Version: 1.0

X-Mailer: Internet Mail Service (5.5.2650.21)

Status: RO

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

From: Goldszer, Robert Charles,M.D.

Sent: Wednesday, February 27, 2002 11:28 PM

To: Kelleher, Kathleen M. - Telemedicine

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

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Does not sound like hospitalization is necesary. Possible diagnosis

1. Moderate Hypertension

2. Peptic Ulcer disease

3. Irritable Bowel syndrome

SUGGEST:

1. Low salt diet for blood pressure

2. Antacids for abdomen discomfort

3. Oral hydration

Testing if there is rapid heart beat or bleeding or fever

RCGoldszer

++++++++++++++++++++++++++++++++++++++

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>

Cc: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>

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

Date: Thu, 28 Feb 2002 09:04:57 -0500

MIME-Version: 1.0

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

From: Goldszer, Robert Charles,M.D.

Sent: Wednesday, February 27, 2002 11:33 PM

To: Kelleher, Kathleen M. - Telemedicine

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

**************************

Possible Diagnosis:

1) Tension headaches

2) Angina

3) Other cause of chest tightness

Suggest:

1) aspirin 325 mg, one a day

2) Beta blocker treatment such as propanolol 10 mg twice a day to start.

This might decrease chest discomfort and headache

If chest discomfort persists, suggest stress test.

RCGoldszer

++++++++++++++++++++++++++++++++++++++

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>

Cc: "Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>

Subject: FW: Patient #4: PROM HORN

Date: Thu, 28 Feb 2002 09:07:01 -0500

MIME-Version: 1.0

Status: RO

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

From: Goldszer, Robert Charles,M.D.

Sent: Wednesday, February 27, 2002 11:43 PM

To: Kelleher, Kathleen M. - Telemedicine

Subject: RE: Patient #4: PROM HORN

See response below:

RCGoldszer

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Impression:

1. Possible hypothyroidism or thyroiditis

2. Possible gall bladder or pancreas disease

SUGGEST:

1. Blood tests: TSH, cbc, amylase, lipase, electrolytes because of palpitations

2. X ray such as ultrasound or ct scan should be considered of gall bladder and pancreas,

3. Treatment might include thyroid hormone, or antibiotics, depending on the test results.

RCGoldszer

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Follow up report on 28 February 2002

Per advice of the physicians in Boston and Phnom Penh, the following patients were given transport or assistance in getting to the hospital.

transported on 28 February to Kampong Thom Provincial Hospital:

Patient SOM DIM, female, 60 years old
Patient CHHIM MAN, female, 60 years old

transported on 28 February to Calmette Hospital Cardiology Center in Phnom Penh:

Patient PHIM SOPHAN, male, 14 year old child, previous Telemedicine patient (February 2001,) for medical check-up and refill of heart medication

transported on 28 February to Kantha Bhopa Children's Hospital in Phnom Penh:

Patient CHHIM SAO, male, 8 year old child, admitted for hernia surgery

transported on 28 February to Sihanouk Hospital Center of Hope in Phnom Penh:

blood taken from Patient PROM HORN, female, 48 years old

This is a new addition to the program, the nurse taking blood samples. The hope is that collecting blood in the village will cut down on the number of lengthy and expensive trips to the hospital for these poor patients. The blood was collected shortly before our departure from the village, put on ice, then driven approximately three hours to Kampong Thom Provincial Hospital. Kampong Thom's lab kindly "spun" the blood sample, it was put back on ice, and then the blood was driven another four hours to Phnom Penh's Sihanouk Hospital Center of Hope. Depending on the type of blood test required, we are hoping some future blood samples will only need to travel as far as the provincial hospital, otherwise more sophisticated testing is available in Phnom Penh.

transport arranged for 7 March to Phnom Penh:

Patient CHAY CHANTHY, female, 38 years old, previous Telemedicine patient, for medical check-up and testing at SHCH

transport arranged for 12 March to Phnom Penh:

Patient SENG SAN, female, 12 years old, previous Telemedicine patient for medical check-up and refill of medication at Kantha Bhopa Children's Hospital

transport arranged for 20 & 29 March to Phnom Penh:

Patient PHENG ROEUNG, female, 56 years old, previous Telemedicine patient for medical check-up, testing, and medication refill at SHCH

Medication donated by Sihanouk Hospital Center of Hope was given to the following patients:

Patient #1: SIM ROEUN, female, 15 years old

Patient #2: HOUR SOVANTHA, male, 14 years old

Patient CHHAM PHAM, female, 31 years old, previous Telemedicine patient (supplies given to follow up on chronic gunshot wound)

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The following two Telemedicine patients from January,2002, SAO PHAL and MEAK NATH, were discharged after being admitted and treated at Kampong Thom Provincial Hospital. The patients visited us at the local Robib health clinic and claimed they had been sent home from the hospital without any medication or prescription. Nurse Montha and I visited the hospital in Kampong Thom and the physician on duty said both patients "escaped" from the hospital without taking their prescriptions with them (though I must note that both patients had discharge papers from the hospital.) We asked the doctor in charge to please write the prescriptions and I forwarded to the patients in Robib by e-mail via the village school's Internet link.

Date: Fri, 1 Mar 2002 02:39:55 -0800 (PST)

From: David Robertson <davidrobertson1@yahoo.com>

Subject: prescription for SAO PHAL

To: Hironaka school <robibtech@yahoo.com>

MIME-Version: 1.0

Status: RO

Dear Vansoeurn,

Please find attached the prescription for SAO PHAL. Nurse Montha says that it's no longer necessary to buy the first item on the list, the "Glucose," but please purchase the other three items.

Thanks again,

David

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Date: Fri, 1 Mar 2002 02:45:42 -0800 (PST)

From: David Robertson <davidrobertson1@yahoo.com>

Subject: prescription for MEAK NATH

To: Hironaka school <robibtech@yahoo.com>

MIME-Version: 1.0

Status: RO

Dear Vansoeurn,

Please find attached the prescription for MEAK NATH.

Thanks again for your help.

Best regards,

David