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October
2001 Cambodia Telemedicine Clinic
Report
submitted by David Robertson
Date:
Thu, 11 Oct 2001 10:44:37 -0700 (PDT)
From:
David Robertson <davidrobertson1@yahoo.com>
Subject:
Cambodia Telemedicine Clinic text - 11 October 2001
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
In-Reply-To: <NEBBLOHAEIHDALAOKLDEGECLCEAA.ggumley@bigpond.com.kh>
MIME-Version: 1.0
Content-Type:
multipart/mixed; boundary="0-1246034273-1002822277=:71162"
Status: RO
please
reply to <dmr@media.mit.edu>
Dear
Dr. Kvedar and Kathleen/Telepartners,
Dear
Dr. Gumley & Dr. Hines,
Following
and/or attached is the text of Nurse Montha's
examinations at today's Robib Telemedicine Clinic in Cambodia.
JPG
attachments will follow tomorrow, time permitting.
Thanks
for your help.
Best
regards,
David
Telemedicine
Clinic in Robib, Cambodia 11
Oct. 2001
Please
reply to David Robertson <dmr@media.mit.edu>
We
are looking for advice regarding the following patients.
Most helpful if e-mail advice could be
received
in Cambodia between 7:00 and 8:00AM, October
12 (8:00-9:00pm, October 11, in Boston.)
I’ll download
e-mail at that time (and will try to check again at 9:00am.)
Nurse Montha will discuss your recommendations
with the patients during the follow-up clinic that starts at 8:00am
on the morning of October 12.
I
am sorry this is arriving late but am still having the
same computer problems we have every month in this remote
location… If you get
this message, it is after
trying to send this one e-mail to you for over three hours…
We
also had a difficult drive from Phnom Penh yesterday,
over 12 hours, partly bad road conditions, partly two vehicle
breakdowns, so we plan to depart Robib hopefully no later than
11:30am on October 13.
We
will be squeezing people that arrived in two vehicles
into one returning vehicle, but could still transport some patients
to Kampong Thom Hospital or hospitals in Phnom Penh if a physician
recommends by e-mail that we do so.
Patient # 1: YOU LOR,
female, 64 years old
|
Chief
complaint: Big and painful mass on the right side
of the face, pain radiating to the whole face, for two years.
Difficult to breath.
BP:
140/70
Pulse: 100
Resp.: 22
Temp. : 36.5
Past
history: Unremarkable. Patient
has been to the
hospital in Phnom Penh (not sure which one) and others
in the provinces. Doctors
there said they were unable to help her because “it is too
late.”
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, not pale
Face: has big mass, right side, size 25 x 25 cm, not mobile
and hard.
Limbs: Normal
Assessment:
Malignant facial tumor?
Recommend:
Should we refer her to hospital for blood
tests, x-ray, refer to surgeon?
Or should we treat her in the village with painkillers?
If treated in the
village, please provide the name of the medication. |
Patient # 2: SAO CHHOEUN,
male, 55 years old
 |
Chief
complaint: Headache, neck tender, blurred vision, on and off
for three years.
BP:
100/60
Pulse: 80
Resp.: 20
Temp. : 36.5
Past
history (notes from August clinic): Unremarkable.
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not tender.
Bowel sound: positive
Skin: not pale,
warm to touch, no rash
Limbs: normal
Ear, nose, throat: normal
Urinalysis: normal
Assessment: Tension headache, muscle pain.
Recommend:
Should we treat him in the village with medication
like Paracetemol or Aspirin? |
Patient # 3:
MEAK NATH, male, 37 years old
|
Chief
complaint: Headache, weakness, mouth contractions
sometimes for more than one year.
BP:
100/70
Pulse: 120
Resp.: 20
Temp. : 36.5
Past
history: Six weeks ago he had malaria (plasmodium falciparum.)
During that time he was confused for about 20 days.
After malaria medication and treatment by medical staff
at the Robib Health Clinic, he got much better.
Lungs:
clear both sides
Heart: regular rhythm, no murmur, but tachycardia.
Abdomen: soft,
flat, not tender, positive Epigastric pain
Bowel sound: positive
Skin: mild pale,
warm to touch, no rash
Limbs: no edema,
no deformity
Mouth: contractions to the right side when he speaks or smiles
Urinalysis: Urobilinogen +, Protein +
Assessment: Anemia secondary to malaria?
Malaria?
Dyspepsia. Peripheral
neuropathy? Tension
headache.
Recommend:
Refer him to Kampong Thom Hospital for blood tests like CBC,
malaria smear and complete neuro exam. |
Patient # 4: THORNG
BUNTHOEUNN, female, 14 years old
|
|
Chief
complaint: Severe itching on the left side for one
month.
BP:
110/60
Pulse: 114
Resp.: 20
Temp. : 36.5
Past
history: Five years ago she had malaria.
After malaria
medication and treatment by medical staff at the Robib Health
Clinic, she got better.
Lungs:
clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender
Bowel sound: positive
Skin: rash on the
abdomen, both thighs, but greater on left thigh.
Very itchy.
Ear, nose, throat: normal
Limbs: no edema, not stiff
Assessment:
Scabies.
Recommend:
Should we refer her to Kampong Thom
Hospital to meet the dermatologist or should we try to treat
her in the village by skin medication?
If so, please
give the name of the medication. |
Patient # 5: SOR KIM SOEUN,
male, 27 years old
|
Chief
complaint: Epigastric pain radiating to upper back
for three weeks. Stool
with black color for three
days.
BP:
120/60
Pulse: 80
Resp.: 20
Temp. : 36.5
Past
history: In 1998, he had vomiting with blood. He met
the doctor in Preah Vihear province and was treated well by
modern medicine during his admission in the hospital.
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft,
flat, not tender, positive epigastric pain
Bowel sound: positive
Skin: not pale,
warm to touch, no rash
Ear, nose, throat: normal
Limbs: normal
Assessment: Dyspepsia. Gastritis?
G.I. bleeding?
Recommend:
Should we refer him to the hospital for some blood tests,
abdominal ultrasound, and colo check?
Or treat him in the village?
Please give the name
of the medication if you agree. |
Patient # 6: PROM NAN,
female, 28 years old
|
Chief
complaint: Epigastric pain, vomiting after every meal,
on and off for three months.
BP:
100/60
Pulse: 80
Resp.: 20
Temp. : 36.5
Past history: Unremarkable.
Lungs: clear both sides
Heart: regular rhythm, no murmur Abdomen:
positive Epigastric pain, soft, flat, and not
tender
Bowel sound: positive
Skin: not pale,
warm to touch
Ear, nose, throat: normal
Limbs: normal
Assessment:
Dyspepsia.
Recommend:
Should we treat her in the village?
Please give me the name of the medication if you agree. |
Patient # 7: CHAN HAT,
male, 43 years old
|
Chief
complaint: Right elbow, shoulder, joint pain, on and
off for one year. Epigastric
pain on and off for one
year.
BP:
110/60
Pulse: 100
Resp.: 20
Temp. : 36.5
Past
history: Two years ago he was admitted to Praketomealia
Hospital for three months.
He had migraine
but he got better after hosital treatment.
Lungs:
clear both sides
Heart: regular rhythm, no murmur
Abdomen: Soft, flat and not tender. Positive Epigastric pain.
Bowel sound: positive
Skin: not pale,
warm to touch, no rash
Joints: right hand has a little pain but not stiff or swollen
Ear, nose, throat: normal
Limbs: normal
Assessment:
Dyspepsia? Right
hand joint pain.
Anxiety?
Recommend:
Should we treat in the village?
Please give
me the name of the medication if you agree. |
Patient # 8: SAIN SOK,
male, 18 years old
|
Chief
complaint: Headache and vertigo for three months.
BP:
90/50
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: not pale,
warm to touch, no rash
Ear, nose, throat: normal
Limbs: normal
Assessment:
Tension headache. Vertigo
Etio?
Recommend:
Should we treat in the village?
Please give
me the name of the medication if you agree. |
DR.
GUMLEY SAID OKAY AND REFERRED FOLLOWING PATIENT TO SHCH
LAST MONTH, APPOINTMENT DATE WAS TBA.
May
she travel to Phnom Penh with another Telemedicine patient on
Sunday, then be seen at SHCH this Monday morning, 15 October?
She has never traveled to Phnom Penh
on her own and if SHCH could see her on Monday, she could share a
guesthouse and transport with another Telemedicine patient that
already has a SHCH appointment on Monday morning.
 |
A
further note on this patient, TEAM SOKUNG, she lost her husband
recently. Her
husband, Telemedicine patient KHORN SOKHOM,
died last month after treatment at Kampong Thom Hospital.
TEAM SOKUNG is depressed and hoping to visit
your hospital to see a doctor soon. |
September
2001 Patient # 9: TEAM SOKONG, female, 33 years
old
 |
Chief
complaint: Mass on the anterior neck for three years. Tremor,
neck tender, headache on and off for three years.
BP:
100/60
Pulse: 100
Resp.: 20
Temp. : 36.5
Past
history: Unremarkable.
Lungs: clear both sides
Heart: regular rhythm, no murmur, and no trill
Abdomen: soft,
flat, no mass, and not tender
Bowel sound: positive
Skin: not pale,
warm to touch, no rash
Neck: has a mass, size 3 x 4 cm.
Legs: normal
Tremor: on head and arm.
Assessment:
Toxic goiter?
Recommend:
Do some blood work like TSH and T4 in SHCH.
Should
we refer her to our hospital or not? |
From:
"Gere, Katherine F." <KGERE@PARTNERS.ORG
To:
"'davidrobertson1@yahoo.com'"
<davidrobertson1@yahoo.com>
Cc:
"Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject:
FW: Cambodia Case #2
Date:
Fri, 12 Oct 2001 14:22:10 -0400
-----Original
Message-----
From:
Schwamm, Lee H.
Sent: Friday, October 12, 2001
9:25 AM
To: Gere, Katherine F.
Subject: RE: Cambodia Case #2
There
is no neurologic exam given. without this information, no meaningful
advice can be given.
Lee
H. Schwamm, MD Assistant
Professor of Neurology, Harvard Medical School Associate
Program Director, MIT- Clinical Research Center Associate Director,
Acute Stroke Service, MGH and Director, CIMIT National Stroke
Program http://www.stopstroke.org
Mailing
Address:
Department of Neurology
Massachusetts General Hospital VBK915
55 Fruit Street, Boston MA 02114
voice:
617-724-1597
Fax: 617-724-6834
Pager: 617-726-2241 #21306
-----Original
Message-----
Patient
# 2: SAO CHHOEUN, male, 55 years old
>
Chief complaint: Headache, neck tender, blurred
>
Vision, on and off for three years.
From:
"Gere, Katherine F." <KGERE@PARTNERS.ORG>
To:
"'davidrobertson1@yahoo.com'"
<davidrobertson1@yahoo.com>
Cc:
"Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject:
FW: Cambodia Patient #3
Date:
Fri, 12 Oct 2001 15:42:39 -0400
>
-----Original Message-----
>
From:
Ryan, Edward T.,M.D.
>
Sent:
Friday, October 12, 2001 3:39 PM
>
To: Gere,
Katherine F.
>
Cc: Ryan, Edward
T.,M.D.
>
Subject:
RE: Cambodia Patient #3
>
>
The problem at hand seems to be headaches and "right sided
facial
>
contractures when speaks or smile". I'm going to assume that
these facial
>
contractures are new, and that they represent a facial paralysis. If
the
>
facial paralysis is old, it's probably just a Bell's palsy (no
treatment).
>
If new, the differential is quite long. Cerebral malaria (he had
malaria
>
and altered mental status) can leave permanent neurological damage.
If
>
that is the case, there is nothing to do (but I doubt this explains
it).
>
It is also possible his malaria was a red-herring, and that he had
>
encephalitis (fever, altered mental status for 3 weeks, which would
be
>
long for malaria [with cerebral malaria, he should have died or
gotten
>
better long before 20 days]). If he had encephalitis, there is a
long list
>
of possibilities, including herpes simplex encephalitis (but strange
that
>
he recovered without treatment), and Japanese encephalitis (JE).
Sept is
>
the peak season in SE Asia for JE, if he has rural pig contact, I
would
>
assume this is JE. 1/3 of effected individuals recover from their
>
encephalitis with permanent neurological damage. And probably fewer
than
>
1% of individuals with JE have classic full blown encephalitis.
Obviously,
>
there is a long list of other CNS infections that could cause this
>
picture. The most worrisome/treatable, would be a space occupying
lesion
>
(pyogenic brain abcess, tuberculoma, focal meliodosis, etc). Also,
if he
>
is HIV positive, CNS toxoplasmosis and CNS lymphoma would be on the
list.
>
A CNS tumor is also on the list (even if HIV negative) with
headaches and
>
a focal neuro exam. CNS syphilis and TB can also give chronic
headaches
>
and cranial nerve abnormalities. Focal neuropathies rarely affect
only the
>
facial nerve.
>
>
I would look for treatable causes, are his discs sharp on
fundoscopic exam
>
(if papilledema, would strongly suggest CNS space occupying lesion).
If LP
>
possible, could consider (if no papilledema), to see if any
pleocytosis.
>
>
What he really needs (unfortunately) is a CT and LP (limitations
>
understood). His anemia may very well be from his previous malaria.
>
>
Good luck,
>
>
Edward T. Ryan, M.D., DTM&H
>
Massachusetts General Hospital
>
Harvard Medical School
>
>
Contact information:
>
Division of Infectious Diseases
>
Jackson 504
>
55 Fruit Street
>
Boston, MA 02114 USA
>
Administrative Tel: 617-726-3815/6175
>
Administrative Fax: 617-726-7416
>
Laboratory Tel: 617-724-3743
>
Outpatient Appointments/Clinical Issues Tel: 617-724-1934
>
Outpatient Appointments/Clinical Issues Fax: 617-726-7653
>
Email: etryan@partners.org (best)
>
Email 2: etryan@helix.mgh.harvard.edu
>
>
-----Original Message-----
>
From:
Gere, Katherine F.
>
Sent:
Friday, October 12, 2001 3:17 PM
>
To: Ryan,
Edward T.,M.D.
>
Subject:
Cambodia Patient #3
>
>
Thanks!!
>
>
Patient # 3: MEAK NATH,
male, 37 years old
>
> Chief complaint: Headache, weakness, mouth
>
> contractions sometimes for more than one year.
From:
"Gere, Katherine F." <KGERE@PARTNERS.ORG>
To:
"'davidrobertson1@yahoo.com'"
<davidrobertson1@yahoo.com>
Cc:
"Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject:
FW: Cambodia Case #4
Date:
Fri, 12 Oct 2001 15:19:13 -0400
-----Original
Message-----
From:
Kvedar, Joseph Charles,M.D.
Sent:
Friday, October 12, 2001 3:15 PM
To:
Gere, Katherine F.
Subject:
RE: Cambodia Case #4
It
is challenging to diagnose skin disease without an image or
morphologic description. For
itch, if 1% hydrocortisone cream is available, that would be a nice
start. Also if a tub is available, tepid baths in salt water (0.9%
NaCl is a rough guide) can help as well.
If an antihistamine such as diphenhydramine or hydroxyzine is
available, it can be used in dose of 25-50 mg tid-qid.
Perhaps
is the rash is still present on your next visit, we could get some
images
Joseph
C. Kvedar, M.D.
Director,
Partners Telemedicine
Vice Chair, Department of Dermatology
Harvard Medical School
One
Longfellow Place, Suite 216
P.O. Box 8941
Boston, MA 02114
617-726-4447 (voice)
617-228-4609 (fax)
617-921-3662 (pager/cell)
jkvedar@partners.org
http://telemedicine.partners.org
-----Original
Message-----
From:
Gere, Katherine F.
Sent: Thursday, October 11,
2001 3:48 PM
To: Kvedar, Joseph Charles,M.D.
Cc: Kelleher, Kathleen M. -
Telemedicine
Subject: Cambodia Case #4
Joe:
Can
you do this one?
Patient
# 4: THORNG BUNTHOEUNN, female, 14 years old
>
Chief complaint: Severe itching on the left side for
> one month.
From:
"Gere, Katherine F." <KGERE@PARTNERS.ORG>
To:
"'davidrobertson1@yahoo.com'"
<davidrobertson1@yahoo.com>
Cc:
"Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject:
FW: Cambodia Case #5
Date:
Mon, 15 Oct 2001 10:04:36 -0400
>
-----Original Message-----
>
From:
Wright, Cameron D.,M.D.
>
Sent:
Monday, October 15, 2001 8:25 AM
>
To: Gere,
Katherine F.
>
Subject:
RE: Cambodia Case #5
>
>
he needs an egd in the hospital. would put him on a h2 blocker in
the
>
meantime. cam
>
>
-----Original Message-----
>
From:
Gere, Katherine F.
>
Sent:
Thursday, October 11, 2001 4:48 PM
>
To: Wright,
Cameron D.,M.D.
>
Cc:
Kelleher, Kathleen M. - Telemedicine
>
Subject:
Cambodia Case #5
>
>
Thanks for your assistance.
>
Kathy Gere
>
>
Patient # 5: SOR KIM SOEUN, male, 27 years old
>
>
>
> Chief complaint: Epigastric pain radiating to upper
>
> back for three weeks. Stool
with black color for
>
> three days.
From:
"Gere, Katherine F." <KGERE@PARTNERS.ORG>
To:
"'davidrobertson1@yahoo.com'"
<davidrobertson1@yahoo.com>
Cc:
"Kelleher, Kathleen M. - Telemedicine" <KKELLEHER@PARTNERS.ORG>
Subject:
FW: Cambodia case #8
Date:
Fri, 12 Oct 2001 14:25:09 -0400
-----Original
Message-----
From:
Schwamm, Lee H.
Sent:
Friday, October 12, 2001 9:25 AM
To:
Gere, Katherine F.
Subject:
RE: Cambodia case #8
same
as before
Lee
H. Schwamm, MD
Assistant
Professor of Neurology, Harvard Medical School Associate Program
Director, MIT- Clinical Research Center Associate
Director, Acute Stroke Service, MGH and Director, CIMIT National
Stroke Program
http://www.stopstroke.org
Mailing Address:
Department of Neurology
Massachusetts General Hospital VBK915
55 Fruit Street, Boston MA 02114
voice: 617-724-1597
Fax: 617-724-6834
Pager: 617-726-2241 #21306
----Original
Message-----
From:
Gere, Katherine F.
Sent: Thursday, October 11, 2001 5:52 PM
To: Schwamm, Lee H.
Cc: Kelleher, Kathleen M. - Telemedicine
Subject: Cambodia case #8
Lee:
Any chance
you could take a look at this one as well? If not do the other
first.
Thanks
Kathy Gere
Patient
# 8: SAIN SOK, male, 18 years old
> Chief
complaint: Headache and vertigo for three months.
[English Version][Khmer
Version]
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