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Telemedicine
Report 2
Second monthly
Telemedicine examinations
in Robib on March 16 and 17
The
second monthly telemedicine consultations were held on March 16 and 17
at Robib’s local health
clinic.
| On
the afternoon of March 15, Mr. Yim Deth, the Robib clinic's medical
assistant; Mr. Koy Somontha, the visiting nurse from the Sihanouk Hospital
Center of Hope in Phnom Penh, and David Robertson, the director of the
American Assistance for Cambodia telemedicine project in Cambodia, drove
throughout Robib village to inform residents to attend the following
morning's clinic. Koy
Somontha ("Montha") made follow up examinations of some of last
month's patients as well as potential new telemedicine patients in their
homes and front yards. Two
patients from the February clinic, an 11-year-old boy and an 11-month-old
baby girl, had recently chosen to return from Kanta Bhopa children’s
hospital in Phnom Penh where |
 |
| they
had received tests and provided medicine.
Montha counseled their families on the importance of returning to
the hospital in Phnom Penh for scheduled monthly checkups and refills of
medication. What follows are the e-mail exchanges between telemedicine
participants in Robib, and doctors at the Sihanouk Hospital Center of Hope
in Phnom Penh and Massachusetts General Hospital in Boston.
Nurse Koy Somontha examined the patients, and David Robertson took
digital photos, transcribed examination data into a laptop computer, and
sent and received e-mail via the village school's Internet link.
Several
other villagers were examined by Montha during the three days in the
village but their medical conditions were assessed as less urgent and
their data was not sent over the Internet.
These patients were counseled on how to take care of their medical
needs within the village and encouraged to return to the April 22
telemedicine clinic if they feel their medical condition has not improved
and warrants another exam.
For
the telemedicine patients, both hospitals replied within a few hours with
recommendations for follow up care and a second clinic was held on March
17 to discuss the e-mail recommendations with all the patients.
What follows are the e-mail exchanges and some of the photos that
were transmitted:
Date:
Thu, 15 Mar 2001 23:38:16 -0800 (PST)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: 16 March, morning Telemedicine clinic
To: JKVEDAR@PARTNERS.ORG, ggumley@bigpond.com.kh
Cc: bernie@media.mit.edu
Dear Dr. Kvedar and Dr. Gumley:
Attached
is the text from nurse Koy Somontha from this morning's
Telemedicine clinic in Robib.
Attached digital photos follow.
We
will see all these patients again at 8:00am on Saturday.
Advice in time for Saturday AM follow up appreciated.
We
will see more patients this afternoon, send another e-mail
this evening regarding those patients, and check
incoming e-mail.
Best
regards,
David
|
Telemedicine
Clinic in Robib, Cambodia
AM, 16 March 2001
 |
Patient
#1: Chhim Neang,
female, 40 years old
Chief
complaint: edema
all over the body, SOB on and off for ten years, passing little urine
BP:
100/60
Pulse: 80
Resp.: 28
Temp. : 36.5
Past history: unremarkable
Lungs:
Clear
on both sides, no crackle or wheezing
Heart: irregular
rhythm, positive murmur, loud
Abdomen: soft,
flat, not tender
Bowel sound: positive
Skin: pale,
warm to touch, pitting edema
Assessment: valvular
heart disease? Chronic renal
failure? Anemia?
Recommend:
Refer
patient to hospital for some blood test, chest x-ray, abdominal and heart
ultrasound |
|
 |
Patient
#2: Ngourn Sokheang,
female, 15 years old
Chief
complaint: lymph
node on the right side of the neck for 2 years and the right armpit for 1
month and sweats at night
BP:
80/40
Pulse: 84
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: warm
to touch but has one scar behind right ear.
Neck has a few masses, size 4cm x 2cm
Assessment: TB
lymph node? Cancer?
Recommend:
Chest
x-ray, neck ultrasound, blood tests, do biopsy |
|
 |
Patient
#3: Noung Kim Chhang,
male, 48 years old
*
Follow up patient from February Telemedicine clinic (teacher in
village)
Chief
complaint: palpitation,
SOB, dry cough lessening
pneumonia
cleared up after antibiotics from last clinic
BP:
100/50
Pulse: 120
irregular
Resp.: 26
Temp. : 36.5
Past
history: has
been to Sihanouk Hospital twice, last on 12 Sept 2000, diagnosis
mitral stances. EKG
showed irregular rhythm.
Lungs:
clear
Heart: positive
murmur with irregular rhythm, positive thrill
Abdomen: same
Bowel
sound: positive
Skin: warm
to touch, no edema, mild pale
Assessment: valvular
heart disease
Recommend:
EGK,
chest x-ray, blood work, abdominal ultrasound
Note
from patient:
Patient said he hasn’t gone back to Sihanouk Hospital as
recommended last time because he has no money.
Would gladly go to the hospital if expenses could be
covered. He would like a relative to accompany him to Phnom Penh, and
have transport, housing and food expenses. |
|
 |
Patient
#4: Noong Heab, male,
65 years old
Chief
complaint: left
side body weakness for two years, cannot walk.
Upper abdominal pain, nausea on and off for two years.
Sometimes has tightness in chest.
BP:
120/60
Pulse: 60
Resp.: 20
Temp. : 36.5
Past
history: Smoking
and drinking alcohol heavily for many years, stopped alcohol one year ago
but still smoking, 2-3 cigarettes per day.
Knew he had hypertension of 190/? as reported by medical staff at
Robib health center.
Lungs:
bronchitis
on left lower base lobe
Heart: irregular
rhythm, no murmur
Abdomen: soft
flat, positive epigastric pain
Bowel sound: Positive
Skin: warm
to touch and no edema.
Limb:
left arm and left leg very weak.
Assessment: Stroke
secondary to hypertension. Chronic
obstruction Pulmonary disease?
Dyspepsia. Rule out ischaemic
heart disease.
Recommend:
blood
tests, EKG, chest x-ray, abdominal ultrasound, physiotherapy |
|
 |
Patient
#5: Kim Chin Da,
female, 20 years old
*
Follow up patient from February Telemedicine clinic
Chief
complaint: same as last visit: lymph
nodes on both sides of neck and both armpits are
growing off and on for two years. Back deformity started 8 years
ago
BP:
80/40
Pulse: 100
Resp.: 24
Temp. : 27
Past
history:
Fell from tree 10 years ago
Lungs:
clear
both sides
Heart: normal
sound
Abdomen: soft
and not tender
Bowel sound: positive
Skin:
not pale, no edema, sweats at night, lesions around ears, neck,
groin
Assessment: TB
lymph node and Pott’s disease?
Recommend:
chest X-ray, spinal x-ray, blood tests, take pus of lymph node
for gram stain and culture (TB.)
Additional:
Refer patient to Hospital to evaluate diagnosis, and prescribe
correct medicine.
|
 |
Patient
#6: Sam Lay,
male, 40 years old
Chief
complaint: Productive
cough on and off for one year.
Weakness and painful on all joints for one year.
Itchy all over body for one month. Blurring vision. Passing
urine too much for four month.
Patient feels he eats a lot food but lacks energy and is
skinny.
Patient
mentioned when he passes urine outdoors, he tasted it and it was
sweet. Ants always
gather around the urine. We
don’t have urine stick in clinic.
BP:
78/100
Pulse: 100
Resp.: 26
Temp. : 36.5
Past
history: Went
to Preah Vihear Prov. Hospital, doctor did chest x-ray and
collected sputum. Sputum
negative but film showed lesions.
Was given medicine for TB treatment, patient took for
more than one month but discontinued treatment and no follow up
visit because of lack of money.
Patient
looks sick.
Lungs:
both
upper lobes crackle
Heart: normal
rhythm and no murmur
Abdomen: soft,
flat, not tender
Bowel sound: positive
Skin: rash
all over body, mild pale, very skinny, warm to touch
Assessment: Pulmonary
TB, diabetes, scabies, and malnutrition
Recommend:
chest x-ray, blood tests, urine stick |
Date:
Fri, 16 Mar 2001 03:51:08 -0800 (PST)
From: David Robertson <davidrobertson1@yahoo.com>
Subject: 6 more patients - 16 March afternoon Telemedicine clinic
To: JKVEDAR@PARTNERS.ORG, ggumley@bigpond.com.kh
Cc: bernie@media.mit.edu
Dear Dr. Kvedar and Dr. Gumley,
Attached
on this message and following messages are text and photos of 6 more
patients seen this afternoon.
The nurse seemed most concerned about afternoon
patient #1. Montha
said this patient might benefit from
getting to a hospital in Phnom Penh soonest, possibly
when we depart Robib on Saturday morning. Your advice on this and the
other patients appreciated.
We’ll
see the 6 patients from this morning again on Saturday
at 8:00am, then 6 patients from this afternoon
at 9:30am on Saturday. Will
check e-mail at 7:00am Saturday (Cambodia time,)
which is 7:00pm Friday in Boston.
Best
regards,
David
Telemedicine
Clinic in Robib, Cambodia
PM, 16 March 2001
 |
Patient
#1: Sok Seng,
female, 55 years old
Chief
complaint: palpitations,
SOB, chest tightness for two years. Mass
on the anterior neck for ten years.
BP:
170/66
Pulse: 160
Resp.: 24
Temp. : 36.5
Past
history: In
1977, she had malaria, treated by local medicine (roots, herbs,) got better.
Lungs:
Clear
on both sides
Heart: regular
rhythm, positive little systolic murmur, tachycardia (rate 160 and loud)
Abdomen: soft,
flat, and not tender
Bowel sound: positive
Skin: not
pale, warm to touch, rash. Neck has
mass on anterior, size 3 x 3 cm.
Assessment: Toxic
goiter. Valvular heart disease?
Recommend:
Refer
patient to hospital for blood test, chest x-ray, EKG. |
 |
Patient
#2: Norg Chhun,
female, 53 years old
Chief
complaint: headache
and dizziness, sometimes chest pains, blurry vision, neck tender on and off for
five years
BP:
168/90
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: warm to
touch. Positive mild edema both
legs.
Assessment:
mild
hypertension and rule out ischaemic heart disease
Recommend:
Chest
x-ray, EKG, blood tests |
 |
Patient
#3: Chhoum Chandy,
female, 42 years old
Chief
complaint:
headache and chest pains projecting to back, mild edema all over the body for
one year
Pass little urine for last year.
BP:
80/50
Pulse: 80
Resp.: 20
Temp. : 36.6
Past
history: Hematuria
in 1976
Lungs:
clear
Heart: regular
rhythm, no murmur
Abdomen:
soft
and flat
Bowel sound: positive
Skin: positive
pitting edema on both legs, warm to touch, no rash and not pale
Assessment: chronic
renal failure? Ischaemic heart
disease?
Recommend:
EGK,
blood work, urinalysis + microscopic |
 |
Patient
#4: Heng Saok, female,
55 years old
Chief
complaint: feels
burning in chest, sometime chest pain, dry cough for one year.
Epigastric pain for three months.
BP:
100/60
Pulse: 88
Resp.: 20
Temp. : 36.5
Past
history: Malaria
two years ago. Went to the hospital and was treated with malaria drugs, got
better.
Lungs:
both
upper lobes have crackles.
Heart: regular
rhythm, no murmur
Abdomen: positive
epigastric pain
Bowel sound: Positive
Skin: not pale,
warm to touch and no edema.
Assessment:
Pulmonary TB?
Chronic Pneumonia? Dyspepsia.
Recommend:
blood tests,
chest x-ray, collect sputum for TB test (AFB) |
 |
Patient
#5: Chan Sem,
male, 53 years old
Chief
complaint: both
legs weakness and numbness, joint pain all over the fingers, toes, both knees
and both ankles for nine months.
BP:
100/60
Pulse: 80
Resp.: 20
Temp. : 26.5
Past
history:
unremarkable
Lungs:
clear
both sides
Heart: Regular
rhythm
Abdomen: soft and
not tender
Bowel sound: positive
Skin: not pale,
no edema, warm to touch
Joints: positive
pain in both ankles, knees, and all finger joints, but not swollen
Assessment:
arthritis
and Beri Beri
Recommend:
X-ray and blood tests
|
 |
Patient
#6: Ros Oeun,
female, 60 years old
Chief
complaint: Dry
cough on and off for five years. Sore
throat, weakness, epigastric pain for five months.
BP:
120/60
Pulse: 84
Resp.: 20
Temp. : 36.5
Past
history: Went
Preah Vihear Provincial Hospital three times, admitted for fifteen days each
time. She says doctor did not
provide a diagnosis.
Lungs:
clear
both sides
Heart: regular
rhythm and no murmur
Abdomen: soft,
flat, not tender, but pain on epigastric area
Bowel sound: positive
Skin: not pale,
no edema
Throat: Redness
and hypertrophic tonsillitis
Assessment: Chronic
pharyngitis and tonsillitis? Dyspepsia.
Recommend:
throat culture, blood tests, and urine stick
|
From:
"Graham Gumley" <ggumley@bigpond.com.kh>
To: "David Robertson" <davidrobertson1@yahoo.com>
Subject: Re: 16 March, morning Telemedicine clinic
Date: Fri, 16 Mar 2001 22:07:32 +0700
Thanks for the great work!
See
attached file.
Regards.
Graham
Dear David and
Montha
Thanks for the
excellent information and
organization.
I will put our
replies in CAPITALS after the
information on each patient.
Patient #3 has
been seen at the SHCH previously and if transportation can be set up
at some point reassessment at the SHCH would be wise.
The other cases
are predominantly TB. I am not certain yet of the Kampong Thom
facilities, however I think they could be managed through this
Provincial Hospital network.
Thanks.
Dr. Graham
Gumley
Telemedicine
Clinic in Robib, Cambodia
AM, 16 March 2001
Patient
#1: Chhim Neang, female, 40 years old
Chief complaint: edema all over the body, SOB on and off for ten
years, passing little urine
Assessment: valvular heart disease?
Chronic renal failure? Anemia?
Recommend: Refer
patient to hospital for some blood test, chest x-ray, abdominal and
heart ultrasound
Comment: Agree with above plan and assessment
Patient
#2: Ngourn Sokheang, female, 15 years old
Chief complaint: lymph node on the right side of the neck for 2
years and the right armpit for 1 month and sweats at night
Assessment: TB lymph
node? Cancer?
Recommend: Chest
x-ray, neck ultrasound, blood tests, do biopsy
Comment: Agree with above plan and assessment
Patient
#3: Noung Kim Chhang, male, 48 years old
* Follow
up patient from February Telemedicine clinic (teacher in village)
Assessment: valvular heart disease
Recommend: EGK, chest x-ray, blood work, abdominal ultrasound
Note from patient: Patient said he hasn’t gone back to Sihanouk
Hospital as recommended last time because he has no money.
Would gladly go to the hospital if expenses could be covered. He would like a relative to accompany him to Phnom Penh, and
have transport, housing and food expenses.
Comment: Agree with above assessment. Is there
some local way this can be facilitated?….
(This is an excellent justification for the combined Silk/Pig
program that would support such transportation and medical follow-up)
Patient
#4: Noong Heab, male,
65 years old
Chief complaint: left side body weakness for two years, cannot
walk. Upper abdominal
pain, nausea on and off for two years.
Sometimes has tightness in chest.
Assessment: Stroke secondary to hypertension.
Chronic obstruction Pulmonary disease?
Dyspepsia. Rule out
ischaemic heart disease.
Recommend: blood tests, EKG, chest x-ray, abdominal ultrasound,
physiotherapy
Comment: Good assessment. The weakness most
likely to be related to the hypertension and possible Cerebral
ischaemia or the Cardiac Arrhythmia with secondary embolus from the
heart. Will need more detailed assessment and the tests you recommend.
Important but not urgent. Should stop smoking.
Patient
#5: Kim Chin Da, female, 20 years old
* Follow up patient from February Telemedicine clinic
Assessment: TB lymph node and Pott’s disease?
Recommend: chest X-ray, spinal x-ray, blood tests, take pus of
lymph node for gram stain and culture (TB.)
Additional: Refer patient to Hospital and to evaluate diagnosis, and
prescribe correct medicine.
Comment: Agree with above plan and assessment
Patient
#6: Sam Lay, male, 40 years old
Chief complaint: Productive cough on and off for one year.
Weakness and painful on all joints for one year.
Itchy all over body for one month.
Blurring vision. Passing
urine too much for four month. Patient
feels he eats a lot food but lacks energy and is skinny.
Assessment: Pulmonary
TB, diabetes, scabies, and malnutrition
Recommend: chest x-ray, blood tests, urine stick
Comment: Agree with above plan and assessment.
Certainly Blood glucose will be helpful.
Next visit (April) will send Urine test strip for evaluation cases
like this. Perhaps blood samples can come back on some patients if we
have helicopter transport in April.
From:
"Graham Gumley" <ggumley@bigpond.com.kh>
To: "David Robertson" <davidrobertson1@yahoo.com>
Subject: Re: 16 March AM clinic
Date: Fri, 16 Mar 2001 22:34:11 +0700
Dear
David,
The
photographs are very helpful and clear.
They support the clinical diagnoses and do not change the
recommendations.
The young woman's spine deformity is most typical of TB.
The
older man's posture with the clenched fist and the toe down foot
position is typical of a post stroke situation (either from an
intracerebral bleed, occlusion or embolism ... no doubt somewhat
remote in time now and not themselves correctable, although PT would
be helpful). .... of course if the cardiac situation and hypertension
were assessed it may prevent a further stoke.
Thanks
Graham Gumley
From:
"Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "'davidrobertson1@yahoo.com'" <davidrobertson1@yahoo.com>
CC:
"Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>
Date: Fri, 16 Mar 2001 11:18:37 -0500
Dear
David:
Thank
you for the recent patient referrals.
I
am the Consultation Coordinator for Partners Telemedicine and am
working on the cases that you sent.
So far, the physicians with whom I have spoken arehappy to
opine on the cases and have committed to completing them by the end of
business
today (Friday 3/16).
I am available by phone or email to answer any questions
that you may have.
All of my contact information is listed below.
Best
regards,
Kathy
Kelleher Senior Remote Consultation Coordinator Partners
Telemedicine Two
Longfellow Place, Suite 216
Boston, MA 02114
Phone: 617-726-1051
Cell: 617-838-5083
Home: 617-241-0219
Fax: 617-228-4608
Page: 617-724-5700 x28976
http://telemedicine.partners.org
From:
"Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "'davidrobertson1@yahoo.com'" <davidrobertson1@yahoo.com>
Subject: FW: Cambodia project
Date: Fri, 16 Mar 2001 14:40:36 -0500
Dear
David:
Below
please find two of the twelve cases that you sent to Partners
Telemedicine. The
recommendations are attached in a "Word" document.
The remaining 10 cases are in process
and will be sent shortly.
Regards,
Kathy
Telemedicine
consultations
March
16, 2001
Patient
#1: Chhim Neang, female, 40 years old
Chief complaint:
edema all over the body, SOB on and off for ten years, passing
little urine
Assessment: valvular heart
disease? Chronic renal
failure? Anemia?
Recommend: Refer
patient to hospital for some blood test, chest x-ray, abdominal and
heart ultrasound
Patient
#1:
40 year old female with irregular heart beats and pitting
peripheral edema. Several possibilities arise, among which are:
1)
Post infectious heart and kidney disease, such as rheumatic
fever.
2)
Heart failure with secondary renal failure and edema.
3)
Liver failure (mild jaundice in the patient’s sclera), with
secondary right heart failure and
subsequent a) left heart failure and renal failure, or b) hepatorenal
syndrome with renal
failure secondary to liver failure.
4)
Idiopathic glomerulonephritis and secondary renal failure
5)
Renal failure secondary to diabetic nephropathy
6)
Chronic renal failure due to hypertension alone (unlikely since
BP provided is normal).
7)
Congenital renal malformation resulting in chronic renal
failure with time
8)
Interstitial nephritis due to some unknown environmental renal
insult, or medication.
Suggested
investigative plan:
1)
Monitor blood pressure closely. If possible with Ambulatory
Blood Pressure Monitoring
(ABPM)
2)
Blood chemistries including blood glucose, BUN/Creatinine,
Electrolytes, SGPT/OT,
Serum albumin and total protein, C3, CBC with differential and ESR.
3)
Cardiac ultrasound
4)
Renal ultrasound
5)
Urinalysis with microscopic exam of a fresh sample
6)
If indicated from the above tests, a renal biopsy
Patient
#2: Ngourn Sokheang, female, 15 years old
Chief complaint: lymph node on the right side of the neck for 2
years and the right armpit for 1 month and sweats at night
Assessment: TB lymph
node? Cancer?
Recommend: Chest
x-ray, neck ultrasound, blood tests, do biopsy
Patient #2:
A 15 year old girl with cervical lymphadenopathy
Again, there is a wide differential for the case, as presented. The
assessment provided is helpful though in narrowing down the
possibilities to a few. A more specific exam of the lymph node and the
throat would have been helpful.
1)
Infectious lymphadenopathy due to bacterial, including
cat-scratch disease, or parasitic
infestation.
2)
Cancerous, including Hodgkin’s disease.
3)
Cervical lymphadenopathy secondary to a para-tonsillar abcess
(rarely this big though).
Suggested
plan:
The
most important measures are
1)
Chest X-Ray, and if indicated, Head, neck and abdominal CT scan
2)
Cervical node biopsy
3)
Tuberculin test
4)
EBV virus serology
5)
CBC with differential and ESR
Please
let me know if I can be of further help
Ghaleb Daouk, M.D., FAAP
Attending
Pediatric nephrologist
Director, Pediatric International Medicine
MGH
617-726-2908
617-724-0581 Fax
From:
"Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "'davidrobertson1@yahoo.com'" <davidrobertson1@yahoo.com>
Subject: 16 March afternoon Telemedicine clinic
Date: Fri, 16 Mar 2001 14:50:29 -0500
Dear
David:
Below
please find another response.
Patient
#1: Sok Seng, female, 55 years old
Chief complaint: palpitations, SOB, chest tightness for two years.
Mass on the anterior neck for ten years.
Assessment: Toxic goiter. Valvular
heart disease?
Recommend: Refer patient to hospital for blood test, chest x-ray,
EKG.
-----Original
Message-----
From:
Smulders-Meyer, Olga,M.D.
Sent: Friday,
March 16, 2001 1:47 PM
To:
Kelleher, Kathleen M., PHS - Telemedicine
Subject: RE: 6 more
patients - 16 March afternoon Telemedicine clinic
patient
#1, 55 y.o.woman with mass anterior neck, palpitations, SOB, who is
hypertensive, tachycardic. Most likely the patient is hyperthyroid,
related to the thyroid mass, a thyroid
adenoma. Given tachycardia, she might benefit from being started on a b-blocker,immediately,
such as Inderal to slow down her heartrate and thus decrease
her palpitations. and also will treat her hypertension while
her work
up is in progress. Her work up should include a TSH, thyroid scan to assess
the activity of the thyroid and a fine needle aspiration, as the
nodule is
so superficial and easily accesable. She also needs a CBC to rule out severe
anemia, but this is less likely. She should have an EKG, to assess for
LV
hypertrphy and a chest Xray. The most importat issue is to stabilize
her Heartrate
and Bloodpresure as soon as possible and to obtain the biopsy. Olga
Smulders-Meyer MD
From:
"Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To: "'davidrobertson1@yahoo.com'" <davidrobertson1@yahoo.com>
Subject: FW: Cambodia Project
Date: Fri, 16 Mar 2001 16:26:28 -0500
Dear
David:
Here
is the fourth response.
Patient
#5: Chan Sem, male, 53 years old
Chief complaint: both legs weakness and numbness, joint pain all
over the fingers, toes, both knees and both ankles for nine months.
Assessment: arthritis and Beri Beri
Recommend: X-ray and blood tests
-----Original
Message-----
From:
Patel, Dinesh G.
Sent: Friday,
March 16, 2001 4:17 PM
To:
Kelleher, Kathleen M., PHS - Telemedicine
Subject: FW: Cambodia Project
March
16 2001
Dear
Kathy,
Thank
you for asking me to review very interesting problem in 53 year old
patient. I have reviewed history and pictures of both hands, ankles
and feet. His Rt. Ankle is swollen and has some deformity with fingers
as well. Very hard
to pin point the diagnosis from this.
Weakness
and numbness in both legs can be from Spine related problem.
1
Disc herniation or spine problems. Maybe one should look into
the fact that it may be
possible to have Tuberculosis compressing
spine, discs and nerve roots
resulting in numbness and weakness.
Recommendations
1
Lumbo sacral spine x-rays
2 MRI of Spine
3 Neurological consult
2 Joint pains
Most
of the knee pains are mechanical and if he is squatting for work etc.
he may have mechanical problems as well
Recommendations
1
Routine work ups like Sedimentation rate , Rh. Factor and have X -
rays as well
Exercises
to prevent weakness in muscles and stiffness in joint can be helpful together
with heat and Anti-inflammatory medicine such as Ibuprofen 400 mg.
twice day initially
for 7 days and reduce it if Patient has stomach acidity or ulcer then
may take
Celebrex 200 mg a day .Once all the data is collected we can review
the information
and discuss further thank you for asking me
Let us touch base again with more information
Dinesh
Dinesh
Patel M.D.
Mass.Gen.Hospital
Assistant Clinical Professor
Harvard Medical School
ACC
510
Boston Mass. 02114
617 726 3555
Fax 617 726-5349
e mail patel.dinesh@mgh.harvard.edu
From:
"Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>To:
"'davidrobertson1@yahoo.com'" <davidrobertson1@yahoo.com>
Subject: FW: CASES
Date: Fri, 16 Mar 2001 17:11:42 -0500
Dear
David:
Four more cases can be found below.
Kathy
-----Original
Message-----
From:
Smulders-Meyer, Olga,M.D.
Sent: Friday,
March 16, 2001 4:47 PM
To:
Kelleher, Kathleen M., PHS - Telemedicine
Subject: CASES
>Patient
#2: Norg Chhun, female,
53 years old
Patient
#2
53 y.o. woman with hypertension and headache.
The
patient is hypertensive and the headaches could be related to that.
Start her on a mild diuretic, and
follow her bi weekly, until normotensive, and see if headaches persist
then. The pedal edema should resolve with a diuretic. Bloodtests
should include renal function, albumen, and a urinalysis to rule out
proteinuria. An Ekg to determine long term detrimental effects of HTN and LV
function. Chest Xray is optional at this point; as she does not complain of SOB or decreased excercise
capacity, but it may give more information about cardiac size. Her neckpain has been present for 5 years, and might be
related to her persistent headaches. Review of use of neck, what kind
of ballast does she carry for work, for instance, as well as posture
issues might provide more clues. The fact it has been stable for 5
years makes it less worrisome, and more likely to be functional in
nature. Her blurry vision
warrants an eye exam by an ophthalmologist.
>
Patient #3: Chhoum Chandy, female, 42 years old
patient
#3
42
y.o. female with chest pains radiating to the back, and mild edema
"all over her body" for 1 year, and decreased urinary
output. This patient
needs renal function tests, including albumen, liver function tests,
urinalysis, and an active urine sediment, to determine if she has
developed chronic renal insufficiency and why. Ischaemic heart disease
is unlikely given her age. She is premenopausal women rarely have
ischaemia. Please check her Thyroid function as she may be
hypothyroid, causing generalized edema. She needs a chest Xray to
assess lungs and mediastinum for abnormalities.and an EKG might be
helpful to r/o pulmonary hypertension. Does she have chestpains on
exertion or at rest. ? This
should be further explored.
Ruling out renal failure, hepatic failure, hypothyroidism and
pulmonary HTN are the most important issues.
>
Patient #6: Ros Oeun, female, 60 years old
Patient
#6
60
y.o. woman presents with a 5 y.o. dry cough, sore throat and
epigastric pain.
Gastro
esophageal reflux is a common cause for a dry cough. It causes a sore
throat, and epigastric pain. I
would recommend an upper Gi, or if that is not available give her a
trial of Zantac or Tagamet for 6 weeks. See her back then.
Also check a CBC and sedrate, and if anemic, suspect a gastric
malignancy. In view of
cough, order a chest Xray, Rule out infectious processes as TB, assess
aorta for aneurysm (less likely) .
Urinalysis is not likely to yield much, nor is a throat culture
as it is a chronic pharyngitis, and not an acute bacterial pharyngitis.
From:
"Graham Gumley" <ggumley@bigpond.com.kh>
To: "David Robertson" <davidrobertson1@yahoo.com>
CC: "Joseph Kvedar" <jkvedar@telemedicine.partners.org>
Subject: PM Patients
Date: Sat, 17 Mar 2001 09:50:34 +0700
Dear
David and Montha.
You
have been busy and productive.
The real health situation there, among a relatively small population
is starting
to show up. Behind these more severe cases is a sea of poor health and
a fertile bed for Health care education and Public Health evaluation!
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