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Telemedicine
Clinic in Robib, Cambodia – May 2001
Report
submitted by David Robertson
Date:
Fri, 18 May 2001 09:16:49 -0700 (PDT)
From:
David Robertson <davidrobertson1@yahoo.com>
Subject:
Cambodia Telemedicine Clinic - 18 May
To:
"Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>,
KKELLEHER@PARTNERS.ORG,
sihosp@bigpond.com.kh
Cc:
bernie@media.mit.edu, aafc@forum.org.kh,
Graham Gumley <ggumley@bigpond.com.kh
Dear
Kathy / Telepartners:
The
following patients were seen today in Robib, Cambodia by Sihanouk
Hospital Center of Hope nurse Koy Somontha.
SHCH Director Dr. Graham Gumley was also in Robib observing
and advising the project today.
Ideal
for us would be to receive any recommendations from Boston by the
end of Friday, May 18, 6pm Boston time.
That will be May 19, 7am in Robib, and we will be having
another clinic from 8am-noon where we could follow up with these
patients and arrange hospital transport if recommended by the
doctors in Boston.
Any
recommendations that come in later will still be quite helpful and
appreciated and will be discussed with the patients during our next
Robib Telemedicine clinic on June 14 & 15.
Attached
is text. Next several
messages I will try to attach photos as long as our generator
continues to run (getting late and generator is low on gas.)
Sincerely,
David
Telemedicine
Clinic in Robib,
Cambodia – 18 May 2001
Morning:
Patient
#1: Som Tol, male, 48 years old
 |
Chief
complaint: Feel burning on both
soles and palms, palpitation, frequency of urination, blurred
vision. Last
6 months chest pain.
BP:
100/60
Pulse: 104
Resp.: 20
Temp. : 37.0
Past
history: not significant
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender
Bowel sound: positive
Skin: warm to
touch, no edema
Limbs: numbness and feel burning in all limbs
Urinalysis: Glucose: ++++, Ketone: +, Protein: +
Assessment:
DMII (Diabetic Militus Type II) and Peripheral Neuropathy,
Ruled out Ischamic Heart Disease
Recommend: Blood tests,
EKG, and chest x-ray. Sihanouk
Hospital Center of Hope’s Dr. Gumley was present for
examination and recommends referral to Kompong Thom Provincial
Hospital. |
Patient
#2: Meas Phary, female, 36 years old
 |
Chief
complaint: Mass on the anterior neck
for over ten years. Weakness,
chest palpitations on and off for five years.
BP:
90/40
Pulse: 84
Resp.: 20
Temp. : 37.0
Past
history: One month ago was admitted
to Preah Vihear Provincial Hospital for 15 days for goiter.
Lungs:
clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender
Bowel sound: positive
Skin: warm to
touch, no edema
Neck: Mass size 4 x 6 cm, positive mobile
Assessment:
Simple goiter? Ruled out parasitis.
Recommend: Blood tests (TSH,
T3, T4,) neck ultrasound, stool microscopic.
Dr. Gumley suggests patient go to Phnom Penh by herself
for blood tests. |
Patient
#4: Ngoun Kim, female, 44 years old
 |
Chief
complaint: Difficult to swallow and
has mass on anterior neck for seven years.
Palpitations and dizziness on and off for one year.
Edema all over both feet on and off for one year.
BP:
120/80
Pulse: 88
Resp.: 20
Temp. : 36.5
Past
history: not significant
Lungs:
clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender
Bowel sound: positive
Skin: warm to
touch, no rash, no dehydration
Limb: no edema
Neck: Mass
size 3 x 3 cm, postive mobile
Urinalysis: urobilinogen: ++, blood: +
Assessment: Simple goiter?
Recommend: Blood tests
like TSH, T3, T4 and neck ultrasound.
Dr. Gumley suggested patient go by herself to Phnom
Penh for these tests. |
Patient
#5: Say Heang, female, 54 years old
 |
Chief
complaint: Mass
on anterior neck size 6 x 5 cm for approx. ten years.
Headache and sometimes chest tightness for one year.
BP:
160/80
Pulse: 80
Resp.: 20
Temp. : 36.5
Past
history: not significant
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
Neck: Has mass on the left anterior, size 6 x 5 cm.
Assessment:
Simple goiter, mild hypertension.
Ischaemic heart disease?
Recommend: Blood tests,
EKG and x-ray. Dr.
Gumley suggests referral to Kompong Thom Provincial Hospital. |
Patient
#7, Bun Sarak Mony, female, 5 years old
|
Chief
complaint: Can’t speak, very
panicky for five years
BP:
-
Pulse: 100
Resp.: 25
Temp. : 36.5
Past
history: When she was five months
old, she had a high fever (temp. over 40,) had small
convulsions.
Lungs:
clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender
Bowel sound: positive
Skin: warm to
touch, no edema
Other observations: Eye contact normal, muscle tone
normal, normal crying, little walking (weak but not sticky,)
is able to stand, can listen to someone, can hear.
Assessment:
Neurological dysfunction.
Recommend: Neurological
assessment and physical therapy.
|
Patient
# 8: Chhay Channa, female, 31 years old
|
Chief
complaint: vaginal discharge, yellow
color and bad smell, on and off for seven years.
Painful all on the body, especially right arm and upper
back on and off for eight years.
BP:
90/60
Pulse: 112
Resp.: 20
Temp. : 37.7
Past
history: not significant
Lungs:
clear both sides
Heart: regular rhythm, no murmur
Abdomen: pain
on both lower quadrants
Bowel sound: positive
Skin: warm to
touch, no edema
Assessment:
vaginitis? Salphangitis? Muscle pain.
Recommend:
Need culture for vaginal discharge.
Go to meet gynecologist. |
Patient
#9, Ny Hom, male, 62 years old
 |
Chief
complaint: Dry cough and ear
ringing, blurred vision for one year.
BP:
130/70
Pulse: 74
Resp.: 20
Temp. : 36.5
Past
history: smokes cigarettes a lot
Lungs:
clear both sides, breath sound
decreases on both base.
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender
Bowel sound: positive
Skin: warm to
touch, no edema
Ears: close to deaf in both ears.
Eyes: Opacity both eyes.
Assessment:
Cataract, rule out chronic obstruction pulmonary disease (COPD.)
Recommend: Meet
opthamologist. Dr. Gumley suggests he go to next “eye camp.” |
Patient
#10: Tann Hoeum, male, 9 years old
 |
Chief
complaint: Soft mass on the nose
since birth.
BP:
-
Pulse: 100
Resp.: 22
Temp. : 36.5
Past
history: not significant
Lungs:
clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender
Bowel sound: positive|
Skin:
warm to touch, no edema
Nose: soft mass, size 3 x 3 cm
Assessment:
Tumor? Mengiosele?
Recommend: Refer patient
to Kantha Bhopa Children’s Hospital. |
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 . . . . .
******************
Dear.
Dr. MacCollin:
Thank
you very much for your interest in this program. Feel free to call with any questions.
Kathy
*********************
Patient
#7, Bun Sarak Mony, female, 5 years old
1196,
1197, 1198 jpg
Chief
complaint: Can't speak, very panicky for five years
Assessment:
Neurological dysfunction.
Recommend:
Neurological assessment and physical therapy.
Mia
MacCollin, M.D.
Neuroscience
Center, MGH--East
Bldg
149, 13th St.
Charlestown,
MA 02129
phone:
(617) 726-5725
FAX:
(617) 724-9620
Apathy
is a dominant gene. Mutate.
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: Cambodia Project Patient #2 - Meas Phary, female, 36 years old
Date:
Fri, 18 May 2001 14:56:56 -0400
Hi
David:
Here
is the response for patient #2.
It was completed by Dr. Gilbert Daniels,
Co-Director
of Thyroid Associates at Massachusetts General Hospital.
Kathy
-----Original Message-----
From:
Daniels, Gilbert H.,M.D.
Sent:
Friday, May 18, 2001 2:52 PM
To:
Kelleher, Kathleen M., PHS - Telemedicine
Subject:
RE: Cambodia Project Patient #2
This
is not typical for patients whom we see. The skin over the thyroid
nodule is red and apparently warm. If we saw a patient such as this
we would also draw thyroid blood tests as noted, do an ultrasound as
noted, but would immediately do a thyroid aspiration (FNA) to see if
there is an infection in the nodule Best Gil.
From:
"Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To:
"David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject:
FW: Cambodia Project Patient #4
Date:
Fri, 18 May 2001 14:58:18 -0400
>
-----Original Message-----
>
From:
Smulders-Meyer, Olga,M.D.
>
Sent:
Friday, May 18, 2001 2:56 PM
>
To:
Kelleher, Kathleen M., PHS - Telemedicine
>
Subject:
RE: Cambodia Project Patient #4
>
>
Ngou Kim, a 44 yr old woman, with a neck mass. The fact that she has
had it
>
for 7 years, makes a malignancy less likely. Still given the size of
the
>
growth, she really needs to be seen by an endocrinoloigist and have
a fine
>
needle aspiration to look at the pathology. She needs to have a TSH
as well a
>
test for thyroid antibodies, to confirm or rule out Hashimoto's
thyroiditis
>
and hypothyroidism. If her TSh is depressed she may need a
thyroidscan to rule
>
out a hot nodule, and Graves disease.
>
of all these tests the FNA is the most important.
>
She was noted to have Hematuria, and I would repeat a urinalysis in
the
>
hospital. The patient is 44 and could still be menstruating.
From:
"Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To:
"David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject:
FW: Cambodia Project Patient #5
Date:
Fri, 18 May 2001 15:17:50 -0400
Recommendations
for patient #5 are listed below.
>
-----Original Message-----
>
From:
Smulders-Meyer, Olga,M.D.
>
Sent:
Friday, May 18, 2001 3:11 PM
>
To:
Kelleher, Kathleen M., PHS - Telemedicine
>
Subject:
RE: Cambodia Project Patient #5
>
>
Say Heang, 54 year old woman has mild systolic hypertension that
should
>
just be treated medically with a Betablocker, Ace inhibitor or a
Diuretic.
>
The patient should be counselled on weight and excercise. Once she
is
>
normotensive, and still has symptoms of chest discomfort with
exertion,
>
one might consider a sterss test. This woman is still young, and CAD
is
>
less likely. Also check her fasting cholesterol.
>
>
In terms of her thyroid mass, she needs a TSH, a thyroid ultrasound
and a
>
fine needle aspiration. Differential diagnosis of a solitary nodule
>
include: benign adenoma, thyroidcarcinomas, and lymphoma.
>
If in fact, there might be multiple nodules present, then Hashimoto'
>
thyroiditis, multinodular goiter.are most likely.
>
The consensus is, that of all nodules ,only about 10-20 % are
>
malignancies, all others are benign lesions mentioned above.
From:
"Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To:
"'David Robertson (E-mail)'" <davidrobertson1@yahoo.com>
Subject:
FW: Cambodia Project Patient #88 - Chhay Channa, female, 31 years
old
Date:
Fri, 18 May 2001 15:31:21 -0400
Hi
David:
Response
for patient #8 is below.
By
the way, I did not receive a clinical history or photos for patients
#3 & #7.
Kathy
>
-----Original Message-----
>
From:
Goodman, Annekathryn,Md
>
Sent:
Friday, May 18, 2001 3:21 PM
>
To:
Kelleher, Kathleen M., PHS - Telemedicine
>
Subject:
RE: Cambodia Project Patient #8
>
>
Thank you very much for your consultation.
This 31 year old woman complains
>
of a malodorous vaginal discharge for seven years. I would be
interested in
>
obtaining some more history from her.
>
>
Questions:
>
-does she have any
children?
>
-if she has children, how did she deliver her children? When was the
last
>
child born? Did she experience any trauma from the delivery such as
a perineal
>
tear?
>
-is she sexually active? What does she use for birth control?
>
-has she been sexually or physically assaulted?
>
-has she ever had any sexually transmitted infections?
>
-has she had any abortions?
>
-what medicines or home remedies has she used? Has she put anything
in her
>
vagina (medicines, douches, etc)
>
-does she have any urinary problems?
>
-does she have any problems having a bowel movement?
>
-is she having monthly menstrual cycles? Has there been any change
is her
>
menstrual cycles?
>
-Does she have any abnormal vaginal bleeding? Does she have any
bleeding after
>
sexual activity?
>
-does she have any fevers, chills, night sweats?
>
>
Work-up:
>
>
-I would recommend obtaining a careful medical history with the
questions
>
outlined above.
>
-In addition to a general physical examination, she needs a pelvic
>
examination. This
examination involves the following:
>
-careful inspection of the vulva and perianal region. Look
for signs of
>
trauma, healing injuries, healing childbirth injuries.
>
-look for ulcers or growths that may be secondary to
infectious diseases
>
such as herpes, chancroid, condyloma, or
tumors
>
-evaluate the vagina using a speculum. Look at the walls of
the vagina.
>
Look for discharge, ulcers, growths. Look at the exocervix. Evaluate
the
>
cervix for ulcers, bleeding, growths.
>
-Acetic acid can be applied to the vagina and cervix.
Premalignant
>
lesions will look white after application of acetic acid.
>
-take cultures of the cervix for gonorrhea and chlamydia.
>
-do a wet prep of the vaginal discharge to look for yeast,
"clue cells"
>
(diagnostic for gardenerella vaginalis)
>
-take a pap smear.
>
-evaluate the vagina and cervix by bimanual examination. Feel
for
>
nodules, masses. Assess the size and shape of the cervix.
>
-evaluate the uterus and ovaries by bimanual examination.
>
-do a rectal examination. A rectovaginal examination is the
best method
>
of picking up ovarian masses in the cul de sac, evaluating the
parametria for
>
abnormalities that might suggest an advanced cervical cancer, and
for
>
evaluating the utero-sacral liga ments.
>
-Her total body pain, right arm pain, and back pain may or may not
be related
>
to her gynecologic complaints. If she has an infectious disease,
this may
>
cause systemic symptoms. If she has an advanced infection with
gonorrhea, she
>
could develop gonococcal arthritis. Perhaps tuberculosis could cause
these
>
symptoms. We have seen several women from South East Asia who have
had
>
advanced TB with ascites and peritonitis.
>
>
Please let me know if you have other questions.
>
>
Sincerely yours,
>
>
Annekathryn Goodman
From:
"Kelleher, Kathleen M., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To:
"David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Cc:
"Kvedar, Joseph Charles,M.D." <JKVEDAR@PARTNERS.ORG>
Subject:
Telemedicine Clinic in Robib, Cambodia - 18 May 2001
Date:
Fri, 18 May 2001 17:03:32 -0400
Dear
David:
Here
is a summary of today's activity:
Case
#2 completed by Dr. Gilbert Daniels from MGH Department of
Endocrinology
Case
#4 completed by Dr. Olga Smulders-Meyer from MGH Department of
Medicine
Case
#5 completed by Dr. Olga Smulders-Meyer from MGH Department of
Medicine
Case
#7 completed by Dr. Mia MacCollin from MGH Department of Neurology
Case
#8 completed by Dr. Anne Kathryn Goodman from MGH Department of
Gynecologic Oncology
Case
#1 will be completed by Dr. Lee Schwamm from MGH Department of
Neurology
Case
#9 will be completed by Dr. Neil Bhattacharyya from BWH Department
of Otolaryngology
Case
#10 will be completed by Dr. Jorge Arroyo from BWH Department of
Ophthalmology
Photographs
and clinical histories for case #3 and case #6 were missing from the
document that you sent to me this afternoon so I am assuming that
you decided not to send those two patients.
-----------------------------------------------------------
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., PHS - Telemedicine" <KKELLEHER@PARTNERS.ORG>
To:
"David Robertson (E-mail)" <davidrobertson1@yahoo.com>
Subject:
FW: Cambodia Project Patient #10
Date:
Mon, 21 May 2001 12:27:55 -0400
Two
more cases will follow shortly.
Best
regards,
Kathy
>
-----Original Message-----
>
From:
Bhattacharyya, Neil,M.D.
>
Sent:
Monday, May 21, 2001 7:19 AM
>
To:
Kelleher, Kathleen M., PHS - Telemedicine
>
Subject:
FW: Cambodia Project Patient #10
>
>
>
-----Original Message-----
>
From:
Neil Bhattacharyya [SMTP:neiloy@massmed.org]
>
Sent:
Sunday, May 20, 2001 8:06 PM
>
To:
Bhattacharyya, Neil,M.D.
>
Subject:
RE: Cambodia Project Patient #10 - Tann Hoeum, male, 9 years
old
>
>
Dear Kathy,
>
>
Attached is a Microsoft Word file with my evaluation of the
Cambodian case
>
listed above. Thank
you. Let me know if you
cannot read the file.
>
>
>
Best regards,
>
>
Neil
>
>
-----Original Message-----
>
From: Bhattacharyya, Neil,M.D. [mailto:NBHATTACHARYYA@PARTNERS.ORG]
>
Sent: Sunday, May 20, 2001 12:30 PM
>
To: @home -- Neil (E-mail)
> Subject: FW: Cambodia
Project Patient #10
RE:
Tann Hoeum
Cambodian Medical Project
The
patient is a nine-year-old young boy from Cambodia.
The history is quite limited, but he has had a soft mass
present in the nasal dorsum since birth (congenital).
A clinical photograph accompanies the limited clinical
information. He has a
lesion located along the nasal dorsum, somewhat to the right of
midline. It appears to
have produced some overlying skin change with increased redness. There is pseudo-hypertelorism due to the mass.
The left eye appears to be normal.
The mass has some impact on the right orbital volume in the
single frontal view that is available.
The forehead and brow region appear normal.
This
appears to be a congenital lesion, as it was present from birth.
I do not have any history as to whether or not it is
expanding. Several
important factors need to be considered in the evaluation of this
patient. First, he
should have an ophthalmology consultation to assess the status of
the right eye. Second,
the most important study, if available would be a magnetic resonance
imaging study with contrast of the facial skeleton and head.
If that is not available, then I would recommend a CT scan of
the facial skeleton and head to further delineate the origin and
boundaries of this mass. This will narrow the differential diagnosis considerably.
Clinically, the patient should be assessed for the presence
or absence of cerebrospinal fluid leak from the nose, the status of
the nasal air flow, and his sense of smell. Also, the presence or absence of epistaxis should be
determined.
The
differential diagnosis in this case is somewhat vast.
Given that the lesion is probably congenital, and is
involving the skin with increased redness and thickening of the skin
itself, I would consider arteriovenous malformation as a likely
possibility. A
cavernous hemangioma is less likely.
Importantly, one must consider meningocele or
meningoencephalocele. Each
of these entities can be well distinguished from one another with
MRI imaging. Also
included in the differential diagnosis would be congenital lesions
such as dermoid cyst and teratoma.
As the mass has been present since birth, I think infectious
etiologies are much less likely, but possible.
These would include syphilitic type infections or other very
slowly progressing infections. Finally, neoplastic etiologies should
be also considered. These
would include soft tissue tumors, angiofibroma, osseous tumors or
extracranial meningioma. Given
the duration of the lesion, these are also unlikely.
In
summary, the patient likely has a lesion since birth, which is
unlikely to be a neoplasm, but could likely be a malformation or a
very slow growing tumor. The
most important element of his evaluation will be the imaging
studies. Also, and
endoscopic examination of the nose should be performed, with
potential biopsy. However,
no biopsy should be undertaken until the possibility of a vascular
lesion or meningocele has been excluded.
Thank
you.
Sincerely,
Neil
Bhattacharyya, MD, FACS
Assistant
Professor of Otology and Laryngology
Harvard
Medical School
Brigham
and Women's Hospital
David
Robertson, coordinator for the Telemedicine project (left) and
Sihanouk Hospital Center of Hope nurse Koy Somontha (right) outside
the Robib Health Clinic with patients waiting for transport to the
hospital.
Nurse Montha helps the staff at
Kampong Thom Provincial Hospital perform an EKG on a Robib village
Telemedicine patient.
[English Version][Khmer
Version]
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