Robib and Telemedicine

June 2001 Telemedicine Clinic in Robib

Report submitted by David Robertson  

On Wednesday, June 14, 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 Dr. Graham Gumley of the Sihanouk Hospital Center of Hope (SHCH) in Phnom Penh.  The data was transmitted via the Hironaka School Internet link.

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: 

Telemedicine Clinic in Robib, Cambodia – 14 June 2001 

We are looking for e-mail advice on the following patients.  Any patient records or jpgs not sent is intentional (i.e. non-urgent medical case or unnecessary photos.) 

Nurse Montha says the most urgent cases are patient #’s 3, 4, 5, 8, 9, 10, 11, 14, 15, 16, 18 (but answers on any are welcome.)  We will assist transport of patients tomorrow if a physician recommends by e-mail that they be seen at a hospital. 

Morning: 

Patient #1: ENG Nga, male, 51 years old

Chief complaint: Chest tightness, neck tender on and off, cold extremities, thirsty on and off for 3 months.  BP: 120/70 Pulse: 172 Resp.:  20 Temp. :  36.5  Past history: G.I. Bleeding in 1986 Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen:  soft, flat, not tender or painful Bowel sound: positive Skin:  not pale, no rash, no edema Limbs: no stiffness, not swollen, no numbness Urinalysis: Glucose: ++  Assessment: Diabetes.  Ruled out Ischaemic Heart Disease Recommend: Blood tests, EKG, and chest x-ray.

Patient #3: Bin Heng, female, 51 years old

Chief complaint: Shortness of breath, chest tightness, mild fever at night, white sputum, cough on and off for one year.  Epigastric pain last five months.  BP: 120/60 Pulse: 86 Resp.:  24 Temp. :  37.0 Weight: 36 KG  Past history: Unremarkable.  Lost 10 KG during the last year.. Lungs: crackle on the right upper lobe, other side clean Heart: regular rhythm, no murmur Abdomen:  soft, flat, not tender Bowel sound: positive, but epigastric pain Skin:  warm to touch, no edema, not pale Limbs: normal  Assessment: Pulmonary TB?  Dyspepsia.  Recommend: Chest x-ray, blood tests, EKG, examine sputum.

Patient #4: SENG San, female, 10 years old
Father’s name: EM Bour

Chief complaint: Sore throat, fever, all joints painful and swollen last three months.  Cannot walk for the last month.  BP: - Pulse: 176 Resp.:  28 Temp. :  38.7  Past history: not significant Lungs: clear both sides Heart: regular rhythm, no murmur, tachycardia Abdomen:  soft, flat, not tender, no pain Bowel sound: positive Skin:  warm to touch, no rash, mild pale Limb: left foot edema, both palms edema Neck:  Can’t move, small mass size 2 x 2 cm.  Joints:  All joints swollen and stiff. Assessment: Severe pharyngitis, polyarthritis, anemia. Rheumatic Fever?  Recommend:  X-ray all joints, throat culture, EKG, blood tests.

Patient #5: BUN Nareth, female, 38 years old
(supervisor of silk weavers)

Chief complaint: Vaginal bleeding, small amount many times for 10 days.  She has been pregnant for the last three months.  BP: 120/80 Pulse: 68 Resp.:  20 Temp. :  36.5 Past history: 19 months ago had spontaneous abortion. Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen:  soft, flat, not tender, high uterus (about 12 cm) Bowel sound: positive Skin:  mild pale, warm to touch, no edema Assessment: pre-abortion. Recommend: Visit gynecologist (at Kampong Thom Hospital.)

Patient # 8: HONG Kim Hak, male, 4 year old child

Chief complaint: Fever, big head with size increasing day-to-day during the last four years.  BP: - Pulse: 120 Resp.:  24 Temp. :  37.98 Past history: When he was one month old, got high fever and convulsions, then size of his head began to increase.  Mother also mentioned that the child was seen by Kantha Bhopa Hospital previously, they had offered surgery to the child, but she left the hospital against their advice.  She said she regrets her “mistake” and would like to get her child medical attention.  Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen:  soft, flat, not tender, Bowel sound: positive Skin:  warm to touch, no rash, no edema Head: Size 65 cm circumference, fontanel soft with appearance of 5 x 4 cm  Assessment: Hydrocephalie?   Recommend:  CT scan, head x-ray, some blood tests.  Refer to pediatric hospital.

Patient #9, PHENG Roeung, female, 56 years old

Chief complaint: Shortness of breath, tingling of limbs, headache, chest tightness and chest pain. BP: 160/70 Pulse: 160 Resp.:  20 Temp. :  36.5  Past history: One year ago diagnosed with hypertension, BP 185/?. Lungs: clear both sides Heart: regular rhythm, no murmur, HR 160 w/ Tachycardia Abdomen:  soft, flat, no pain Bowel sound: positive Skin:  warm to touch, no rash, no edema Neck: has small mass, size 2 x 2 cm on anterior neck.  Assessment: Toxic goiter?  Mild hypertension.   Recommend:  Blood tests (TSH, T4,) EKG, x-ray, iunogram, BUN, creatinine

Patient #10: PHIM Sichhin, female, 35 years old

Chief complaint: Weakness, palpitations, shortness of breath, sometimes edema all over the body, for the last three years.  BP: 110/60 Pulse: 80 Resp.:  20 Temp. :  36.2 Past history: 10 years ago had malaria but treated well by modern medicine and got resolved.  Lungs: clear both sides Heart: regular rhythm, positive systolic murmur Abdomen:  soft, flat, not tender Bowel sound: positive Skin:  warm to touch, no edema, no rash Urinanalysis: bilirubine +, urobilinogen +  Assessment: Valvular heart disease?  Anemia.   Chronic Hepatitis.  Recommend: Heart ultrasound, some blood test, chest x-ray, EKG.

Patient #11: KONG Ky, female, 72 years old

Chief complaint: Blurred vision, dizziness, palpitations, for one year. Left knee and left ankle, pain for 10 months. BP: 170/80 Pulse: 80 Resp.:  20 Temp. :  36.5  Past history: Five years ago had Pulmonary TB but cured completely with TB medication.  Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen:  soft, flat, not tender Bowel sound: positive Skin:  warm to touch, no edema, no rash Joints: left knee and left ankle joint pain (but no stiffness or swelling)  Assessment: Hypertension?  Left knee and left ankle arthritis.  Recommend:  Some blood tests, chest x-ray, EKG.

Patient #12: SOR Sovanna, female, 41 years old

Chief complaint: Feels burning on chest, palpitations, epigastric pain, sometimes stool blood last five days. BP: 100/60 Pulse: 86 Resp.:  20 Temp. :  36.5 Past history: One year ago had enterogastritis. Lungs: Rhonchi on the left base Heart: regular rhythm, no murmur Abdomen:  positive epigastric pain, not tender, no mass Bowel sound: positive Skin:  mild pale, warm to touch, no edema, no rash  Assessment: Gastritis?  G.I. bleeding?  Rule out bronchitis.   Recommend: Fibroscope, colo check,  some blood tests, chest x-ray.

Patient #13: SOM Nheb, female, 46 years old

Chief complaint: Mass on the right breast for four months, size 4 x 4 cm.  BP: 120/60 Pulse: 80 Resp.:  20 Temp. :  36.5  Past history: Unremarkable. Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen:  soft, flat, not tender Bowel sound: positive Skin:  normal Breast: right has mass, size 4 x 4 cm and mobile.  Assessment: Benign tumor? Breast cyst?   Recommend: Discuss with surgeon for evaluation.

Patient #14: SONG Kheam, male, 70 years old

Chief complaint: Blurred vision for one year, epigastric pain for three months, all toe joints pain and mild swollen on and off for four years.  BP: 170/90 Pulse: 116 Resp.:  20 Temp. :  36.5 Past history: Hypertension two years ago, BP 200/?.    Lungs: Rhonchi on the left base. Heart: regular rhythm, no murmur Abdomen:  soft, flat, not tender Bowel sound: positive Skin:  warm to touch, not pale, no rash Joints: all toes joints positive pain and stiffeness, mild swollen.  Assessment: Hypertension.  Arthritis (all toe joints.)  Dyspepsia.  Rule out Chronic Obstruction Pulmonary Disease (COPD.)   Recommend:  Blood test, chest x-ray, EKG, toes x-ray.

Patient #15: ROS Nheb, male, 74 years old

Chief complaint: Dizziness, headache, blurred vision, neck tender on and off for eight years.  Just got worse five days ago.  BP: 170/80 Pulse: 88 Resp.:  20 Temp. :  36.5 Past history: Knows he had hypertension eight years ago, BP 220/?. Lungs: Rhonchi on both bases, decrease breathing sound Heart: regular rhythm, no murmur Abdomen:  soft, flat, not tender Bowel sound: positive Skin:  warm to touch, not pale, no rash Urinanalysis: Glucose +  Assessment: Hypertension.  COPD?  DMII? Recommend: EKG, some blood test, chest x-ray.

Patient #16: SENG Sovann, male, 14 month old child

Chief complaint: Mass on the nose since he was born.  Size 4 x 3 cm and painful.  BP: - Pulse: 120 Resp.:  26 Temp. :  36.5  Past history: Unremarkable. Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen:  soft, flat, not tender, no mass. Bowel sound: positive Skin:  warm to touch, not pale, no rash Nose: Mass, size 4 x 3 cm, mild tender and pain, not moving.  Assessment: Tumor?  Menigosele?   Recommend: Nose x-ray, CT scan, refer to Kantha Bhopa Children’s Hospital.

Patient #17: ROS Chhiv, female, 51 years old

Chief complaint: Elephant foot for the last ten years.  BP: 120/80 Pulse: 100 Resp.:  22 Temp. :  36.5   Past history: Unremarkable.  One year ago malaria clinic took photo of her foot and ran in a Cambodian newspaper in Phnom Penh asking for medical help with no response.   Lungs: normal Heart: normal Abdomen:  soft, flat, not tender Bowel sound: positive Skin:  warm to touch, feels numbness on the right leg, not pale Leg: Right leg feels tight and thick, sometimes gets painful.  Assessment: Bilariossis? Recommend: Refer to hospital for evaluation, check stool microscopic, some blood tests.

Patient #18: SREY Somaly, female, 44 years old

Chief complaint: Mass on the right upper abdomen, cough with sputum for five days.  BP: 170/80 Pulse: 100 Resp.:  22 Temp. :  36.5  Past history: Unremarkable. Lungs: crackle on upper both sides Heart: regular rhythm, no murmur Abdomen:  soft, flat, small mass on the right quadrant, size 4 x 4 cm and mobile Bowel sound: positive Skin:  warm to touch, no edema, no rash, not pale, sweat at night, weight loss Assessment: Abdominal tumor?  Pulmonary TB?   Recommend: Abdominal ultrasound, some blood test, chest x-ray, examine sputum.

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

To: "David Robertson" <davidrobertson1@yahoo.com>

Cc: "David Robertson" <dmr@media.mit.edu>

Subject: RE: Resend: Robib, Cambodia - Telemedicine Clinic - 14 June - message 1

Date: Fri, 15 Jun 2001 07:13:01 +0700

Message-ID: <NEBBLOHAEIHDALAOKLDEAEDCCEAA.ggumley@bigpond.com.kh>

MIME-Version: 1.0

Content-Type: multipart/mixed;

  boundary="----=_NextPart_000_0016_01C0F56A.9D31D0C0"

X-Priority: 3 (Normal)

X-MSMail-Priority: Normal

X-MimeOLE: Produced By Microsoft MimeOLE V5.00.2919.6600

Status: RO  

Dear David and Montha,  

Replies attached -- brief due to time crunch, but practical.  

Great work!  

Dr. Graham Gumley

SHCH, Phnom Penh  

Patient #1: ENG Nga, male, 51 years old

Chief complaint: Chest tightness, neck tender on and off, cold extremities, thirsty on and off for 3 months.

Assessment: Diabetes.  Ruled out Ischaemic Heart Disease

Recommend: Blood tests, EKG, and chest x-ray. 

SHCH: Agree with plan above. Should be referred to Kampong Thom Referral Hospital for work up.  

We clearly need a significant donation of Urine test strips for patients like this. In the absence of a Lab within hours of the village these multi function strips are vital.  

Abbott now make a hand held device that will give us accurate readings on many blood parameters, including Glucose, with only a small blood sample. Perhaps we may be able to source a donation of one of these in time to help such needy people.  

Patient #3: Bin Heng, female, 51 years old

Chief complaint: Shortness of breath, chest tightness, mild fever at night, white sputum, cough on and off for one year.  Epigastric pain last five months.

Assessment: Pulmonary TB?  Dyspepsia.

Recommend: Chest x-ray, blood tests, EKG, examine sputum. 

SHCH: Agree with this assessment. Should be seen at Kampong Thom Referral Hospital for above investigation.  

We will be meeting with the National TB Center (CENAT) next week in Phnom Penh and I will discuss improved approaches to TB prevention and management in remote areas such as this,  

Patient #4: SENG San, female, 10 years old

Father’s name: EM Bour

Chief complaint: Sore throat, fever, all joints painful and swollen last three months.  Cannot walk for the last month.

Assessment: Severe pharyngitis, polyarthritis, anemia. Rheumatic Fever?

Recommend:  X-ray all joints, throat culture, EKG, blood tests. 

SHCH: Agree with above plan. This child will need referral to KB who have the necessary equipment/testing for this condition.  

Patient #5: BUN Nareth, female, 38 years old

Chief complaint: Vaginal bleeding, small amount many times for 10 days.  She has been pregnant for the last three months.

Past history: 19 months ago had spontaneous abortion.

Assessment: pre-abortion.

Recommend: Visit gynecologist (at Kampong Thom Hospital.) 

SHCH: Agree with above assessment and plan.  

Patient # 8: HONG Kim Hak, male, 4 year old child

Chief complaint: Fever, big head with size increasing day-to-day during the last four years.

Assessment: Hydrocephalie?

Recommend:  CT scan, head x-ray, some blood tests.  Refer to pediatric hospital. 

SHCH: Agree with above plan. This child will need referral to KB who have the necessary equipment/testing for this condition.  

Can you tell us more about the child’s current motor function, mental capacity and development?  

I am sure that Kuntha Bopha will be familiar with the decision made previously by the mother, since this happens so often in this undereducated and frequently illiterate population.  

Patient #9, PHENG Roeung, female, 56 years old

Chief complaint: Shortness of breath, tingling of limbs, headache, chest tightness and chest pain.

Assessment: Toxic goiter?  Mild hypertension.

Recommend:  Blood tests (TSH, T4,) EKG, x-ray, iunogram, BUN, creatinine 

SHCH: Were medications prescribed for the ? Hypertension once diagnoses a year ago?  Are they being taken?  

The respiratory rate is not high. Ask more about the “shortness of breath”. Is it at rest, while lying down, only on exertion or unpredictable?  

I see again that we would do well to have a small portable ECG machine to aid in your evaluation.  

Patient #10: PHIM Sichhin, female, 35 years old

Chief complaint: Weakness, palpitations, shortness of breath, sometimes edema all over the body, for the last three years.

Assessment: Valvular heart disease?  Anemia.   Chronic Hepatitis.

Recommend: Heart ultrasound, some blood test, chest x-ray, EKG. 

SHCH: Referral to Kampong Thom would be wise to begin these investigations.  

(Cardiac surgery will soon be available in Phnom Penh)  

Patient #11: KONG Ky, female, 72 years old

Chief complaint: Blurred vision, dizziness, palpitations, for one year.

Left knee and left ankle, pain for 10 months.

Past history: Five years ago had Pulmonary TB but cured completely with TB medication.

Assessment: Hypertension?  Left knee and left ankle arthritis.

Recommend:  Some blood tests, chest x-ray, EKG. 

SHCH: Cataracts are a common cause of visual impairment in Cambodia. Is there an eye camp anticipated in the area sometime soon? 

Tell us more about the dizziness and re-measure the BP a few times today.  

Patient #12: SOR Sovanna, female, 41 years old

Chief complaint: Feels burning on chest, palpitations, epigastric pain, sometimes stool blood last five days.

Assessment: Gastritis?  G.I. bleeding?  Rule out bronchitis.

Recommend: Fibroscope, colo check,  some blood tests, chest x-ray. 

SHCH: Initial investigations could be arranged at Kampong Thom. Endoscopy usually is best available at Calmette Hospital in Phnom Penh

Patient #13: SOM Nheb, female, 46 years old

1522-26 jpg

Chief complaint: Mass on the right breast for four months, size 4 x 4 cm.

Assessment: Benign tumor? Breast cyst?

Recommend: Discuss with surgeon for evaluation. 

SHCH: This mass requires evaluation and probable biopsy with Histpathology.  

Eval. And surgery available at KT.  Discuss with Director maens of ensuring adequate Histopath examination.  

Patient #14: SONG Kheam, male, 70 years old

1530-34 jpg

Chief complaint: Blurred vision for one year, epigastric pain for three months, all toe joints pain and mild swollen on and off for four years.

Assessment: Hypertension.  Arthritis (all toe joints.)  Dyspepsia.  Rule out Chronic Obstruction Pulmonary Disease (COPD.)

Recommend:  Blood test, chest x-ray, EKG, toes x-ray.

SHCH: Agree with assessment.  

Re measure BP today.  

These conditions do not appear urgent, although in need of basic care. Is there a means for such patients to arrange no urgent transport to KT for routine evaluation?  

Patient #15: ROS Nheb, male, 74 years old

Chief complaint: Dizziness, headache, blurred vision, neck tender on and off for eight years.  Just got worse five days ago.

Assessment: Hypertension.  COPD?  DMII?

Recommend: EKG, some blood test, chest x-ray. 

SHCH: Requires assessment at KTRH

Patient #16: SENG Sovann, male, 14 month old child

Chief complaint: Mass on the nose since he was born.  Size 4 x 3 cm and painful.

Assessment: Tumor?  Menigosele?

 Recommend: Nose x-ray, CT scan, refer to Kantha Bhopa Children’s Hospital. 

SHCH: The excellent advice for the child with similar problem last month applies here. Requires referral to KB in Phnom Penh.  

Did the similar, but older child return? He did not arrive for transport last time.

Patient #17: ROS Chhiv, female, 51 years old

Chief complaint: Elephant foot for the last ten years.

Assessment: Bilariossis?

Recommend: Refer to hospital for evaluation, check stool microscopic, some blood tests.

SHCH: MGH advice will be valuable. Could be referred to KTRH if room available in vehicle.  

Patient #18: SREY Somaly, female, 44 years old

Chief complaint: Mass on the right upper abdomen, cough with sputum for five days.

Assessment: Abdominal tumor?  Pulmonary TB?

Recommend: Abdominal ultrasound, some blood test, chest x-ray, examine sputum. 

SHCH: Refer to KTRH for surgical evaluation, sputum testing, x-rays.  

Following replies are from Boston:  

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

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

Subject: FW: Patient #1: ENG Nga

Date: Mon, 18 Jun 2001 10:01:15 -0400  

>From Dr. Paul Cusick of MGH.  

>  -----Original Message-----

> From:             Cusick, Paul S.,M.D. 

> Sent:            Friday, June 15, 2001 6:44 AM

> To:            Kelleher, Kathleen M., PHS - Telemedicine

> Subject:            RE: Patient #1: ENG Nga  

>

> Based on symptoms and likely diabetes, evaluation for ischemic heart and

> treatment/evaluation of diabetes mellitus is appropriate. Hemoglobin A1C and

> EKG and/or functional stress would be appropriate.  PSC  

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

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

Subject: FW: Cambodia Project Patient #7

Date: Fri, 18 May 2001 16:25:10 -0400  

Patient #7  

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

From: MacCollin, Mia,M.D.

Sent: Friday, May 18, 2001 4:27 PM

To: Kelleher, Kathleen M., PHS - Telemedicine

Subject: Re: Cambodia Project Patient #7  

Hi Kathy.  

I agree that a formal neurological consultation with a complete exam would

be helpful, along with physical therapy and speech therapy.  I also think

it might be worthwhile to consider an EEG and a cranial MRI scan.  

Hope this is helpful.  

Let me know if there is anything else I can do . . . . .

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

From: "Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@partners.org>

To: <wbutler@bohr.mgh.harvard.edu>

Cc: "Marino, Barbara J." <BMARINO@partners.org>

Sent: Thursday, June 14, 2001 2:53 PM

Subject: Patient # 8: HONG Kim Hak  

> Thank you Dr. Butler and Barbara:

>

> Please let me know if you feel that this child should travel to a pediatric

> hospital for care and briefly what you would do if the child presented in your

> office.

>

> Kathy  

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

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

Subject: FW: Patient # 8: HONG Kim Hak

Date: Thu, 14 Jun 2001 16:50:08 -0400  

Here's a response from Dr. William Butler of MGH Neurosurgery.  

Kathy  

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

From: William E. Butler [mailto:wbutler@bohr.mgh.harvard.edu]

Sent: Thursday, June 14, 2001 4:40 PM

To: Kelleher, Kathleen M., PHS - Telemedicine

Subject: Re: Patient # 8: HONG Kim Hak

Kathy,  

This child has hydrocephalus. The head is big and the anterior fontanel is

bulging way out. When detected early these kids may a decent outlook for

normal development. With this kid the condition is relatively advanced even

as it is, so the outlook for future good neurologic function is not so hot.

However, the head is going to continue to grow way out of proportion to the

rest of the body. With these kids the head can get so large that they can't

lift it. So even though the outlook for restoration of good neurologic

function is not so hot, treament is mandatory anyway.

This kid would have a head CT and/or brain MRI, then hydrocephalus treatment

(VP shunt or endoscopic third ventriculocisternostomy, depending). Some

cases of hydrocephalus result from brain tumor, encephalitis, meningitis or

other conditions that, if detected, would require treatment in their own

right.

As always, I'm happy to take care of the kid should he come here. There are

many centers in the world that can care for a kid with hydrocephalus.  

BB  

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

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

Subject: FW: Patient #9, PHENG Roeung

Date: Mon, 18 Jun 2001 10:02:19 -0400

>From Dr. Paul Cusick of MGH

>  -----Original Message-----

> From:             Cusick, Paul S.,M.D. 

> Sent:            Friday, June 15, 2001 6:48 AM

> To:            Kelleher, Kathleen M., PHS - Telemedicine

> Subject:            RE: Patient #9, PHENG Roeung

>

> Goiter needs evaluation w/ thyroid function testing and ultrasound/thyroid

> scan . Tachycardia requires EKG and rhythm strip.  HTN needs to be treated and

> controlled. If chest pain is due to Afib, then that would require treatment.

> However, given age and likely postmenopausal status,  ishemic workup needs to

> be considered. PSC  

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

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

Subject: FW: Patient #10: PHIM Sichhin

Date: Thu, 14 Jun 2001 15:50:41 -0400  

Response from Dr. Gilbert Mudge, BWH Cardiologist  

>  -----Original Message-----

> From:             Mudge, Gilbert Horton,Jr.,M.D. 

> Sent:            Thursday, June 14, 2001 3:33 PM

> To:            Kelleher, Kathleen M., PHS - Telemedicine

> Subject:            RE: Patient #10: PHIM Sichhin

>

> With this history and Physical Exam, she certainly needs an echocardiogram

> plus other W/U as suggested. Based upon her vital signs, physical findings and

> two photographs, she seems sufficiently stable to fly by helicopter.

> Unfortunately, I cannot glean much more from the information provided. 

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

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

Subject: FW: Patient #11: KONG Ky

Date: Thu, 14 Jun 2001 17:24:51 -0400  

>From Dr. Patel of MGH Department of Orthopaedics.  

Kathy

>  -----Original Message-----

> From:             Patel, Dinesh G. 

> Sent:            Thursday, June 14, 2001 5:19 PM

> To:            Kelleher, Kathleen M., PHS - Telemedicine

> Subject:            RE: Patient #11: KONG Ky

>

There is no information about knee or ankle

Do some basics like x rays etc.

Patient  needs  to consult internist for blurred vision etc.  

> 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: "Goldszer, Robert Charles,M.D." <RGOLDSZER@PARTNERS.ORG>

To: "Gere, Katherine F." <KGERE@PARTNERS.ORG>

Cc: "'davidrobertson1@yahoo.com'" <davidrobertson1@yahoo.com>

Subject: RE: Patient #12: SOR Sovanna

Date: Thu, 14 Jun 2001 19:25:31 -0400  

Sounds like GI bleeding is a possibility:

Recomend:

1) CBC, PT/PTT + follow cbc

2) treatement with antacids and/or histamine 2 blockers if possible

3) Endoscopy depending on changes in blood count or observed bleeding

4) Close monitoring of patient: Daily if possible until bleeding is

calrified

RCGoldszer  

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

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

Subject: FW: Patient #13: SOM Nheb

Date: Thu, 14 Jun 2001 16:53:39 -0400  

Here's a response from Dr. Yvedt Matory of BWH Dept of Surgery  

>  -----Original Message-----

> From:             Matory, Yvedt,M.D. 

> Sent:            Thursday, June 14, 2001 4:17 PM

> To:            Kelleher, Kathleen M., PHS - Telemedicine

> Subject:            RE: Patient #13: SOM Nheb >

> I cant really tell what is going on  from the pictures , but from the story,

> she needs ot be seen at  a local hospital. Dr. Yvedt Matory

From: "Gere, Katherine F." <KGERE@PARTNERS.ORG>

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

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