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Telemedicine
Clinic in Robib, Cambodia
September 12, 2001
Report submitted by David Robertson
Date:
Wed, 12 Sep 2001 06:51:00 -0700 (PDT)
From:
David Robertson <davidrobertson1@yahoo.com>
Subject:
Cambodia Telemedicine Clinic - 12 September - text #1
To: JKVEDAR@PARTNERS.ORG,
KKELLEHER@PARTNERS.ORG, ggumley@bigpond.com.kh
Cc: dmr@media.mit.edu,
bernie@media.mit.edu, sihosp@bigpond.com.kh,
aafc@forum.org.kh
In-Reply-To: <NEBBLOHAEIHDALAOKLDEGECLCEAA.ggumley@bigpond.com.kh>
MIME-Version: 1.0
Content-Type: multipart/mixed;
boundary="0-288838466-1000302660=:29337"
Status: RO
please
reply to <dmr@media.mit.edu>
Dear
Dr. Kvedar and Kathleen/Telepartners,
Dear
Dr. Gumley,
Attached
is the text of Nurse Montha's examinations at today's Robib Telemedicine Clinic.
JPG
attachments will follow in several more e-mail messages.
Thanks
for your help.
Best
regards,
David
PS
Dr. Kvedar and Kathleen, I will try to log on to the Telepatners site with some
of the cases after I send everything first by e-mail, time and generator
permitting. If I do not get cases
entered via the website tonight, I could try inputting some of the data again
from Phnom Penh at the end of this week.
Telemedicine
Clinic in Robib, Cambodia – 12 Sept. 2001
Please
reply to David Robertson <dmr@media.mit.edu>
We are looking for advice on the following
patients. Most helpful if
e-mail advice could be received in Cambodia by 7:00AM, September 13 (8:00pm,
September 12, in Boston.) I
will download e-mail at that time. Nurse
Montha will discuss your recommendations with the patients in a follow-up clinic
during the morning of September 13.
We plan to depart Robib at 12:00pm on
September 13 and could transport patients to Kampong Thom Hospital or hospitals
in Phnom Penh if a physician recommends by e-mail that we do so.
With a long holiday weekend in Cambodia approaching, any transport out of
the village might be best done on the 13th and outpatient hospital
exams on the 14th.
Advice that arrives after we depart Robib
village is still welcome. The less
urgent cases will return to the next Robib Telemedicine Clinic for follow up
(dates are October 11 & 12.)
Patient # 1: PHENG ROEUNG, female, 56
years old
|
Note: Patient
at three previous Telemedicine clinics.
Chief
complaint: Still has shortness of breath (at
rest and on exertion,) palpitations and dizziness.
BP:
160/70
Pulse: 150
Resp.: 30
Temp. : 37
Past
history: Patient was seen at SHCH on 17 August
2001. The doctor at Sihanouk
Hospital thought that she had dyspepsia and vertigo and put her on Tums
and Promethazine. The doctor
said if she is not better, patient could return to the hospital.
Lungs:
clear both sides
Heart: regular rhythm, no murmur, and positive trill, tachycardia HR
150.
Abdomen: soft, flat, not
tender, and no mass.
Bowel sound: positive
Skin: warm to touch, no
dehydration signs, no rash.
Neck: has small mass, size 2 x 2 cm.
Assessment:
Toxic goiter? Mild
hypertension.
Recommend:
Should we refer her again to SHCH for blood work, EKG, and chest
x-ray?
NOTE from David: This patient has
been seen at 4 clinics now. Initially
she was hospitalized at Kampong Thom and most recently was seen at SHCH
last month. What is the next
step in her treatment? Patient
does not look like she is getting better.
I noticed that her throat area was palpitating strongly during her
exam.
If she is being referred back to
SHCH, may she have an appointment this Friday morning, 14 September?
Asking for that date because of the upcoming long holiday period and this
patient could have free transport to Phnom Penh when we return tomorrow
evening. |
Patient # 2: PHIM SICCHIN, female, 35
years old
 |
Note: Previous Telemedicine patient
Chief
complaint: Still pale, shortness of breath all
the time, weakness, palpitations.
BP:
100/60
Pulse: 100
Resp.: 40
Temp. : 37.5
Past
history (notes from August clinic): We have seen
this previous Telemedicine patient at two other clinics.
The assessment then was valvular heart disease, anemia, and
hepatitis. Two months ago she
was admitted to Kampong Thom Hospital for 10 days.
They gave her a blood transfusion of two units for her anemia and
gave her some medication like ASA and vitamin.
Past
history (notes from today’s clinic): In July,
I did a reassessment and suggested to Dr. Jennifer that we refer the
patient to our hospital but Dr. Hines did not agree to my idea.
She suggested putting her on Furosemie 20mg q 12 and Albendazole.
We gave the meds but her situation is still not better, paleness has
increased.
Urinalysis:
negative
Lungs: clear both sides
Heart: regular rhythm, positive mild murmur
Abdomen: positive splenomegalie about 4 cm and pain on left upper
quadrant. Not tender.
Bowel sound: positive
Skin: pale, warm to
touch, no rash, no edema
Assessment: Anemia secondary from Malaria. Valvular Heart Disease?
Parasitis? Aplastic Anemia?
Recommend:
May we refer her to our hospital in Phnom Penh for tests?
|
Patient # 3: PANG
LY, male, 37 years old
|
|
Chief
complaint: Edema all over the body on and off
for one year, persistent edema for the last seven days.
Upper epigastric pain on and off for four years.
Sometimes cough up with sputum.
BP:
120/80
Pulse: 88
Resp.: 20
Temp. : 36.5
Past
history: Unremarkable. (+ smoking, + alcohol,
but stopped two years ago)
Lungs: left lower quadrant has Rhoncit, right
side clear
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not
tender, no mass
Bowel sound: positive
Skin: warm to touch, no
rash, no edema, no dehydration signs, not pale
Legs and arms: + pitting
edema
Face: mild edema
Urinalysis: negative
Assessment:
Nephrotic Syndrome? Chronic
Renal Failure? Left side
bronchitis. Dyspepsia.
Recommend:
Chest x-ray, EKG, some blood work, urine microscopic.
Should we
refer him to Kampong Thom Hospital?
|
Patient #
4: CHOURB CHOK, male, 31 years old
|
|
Chief
complaint: Weakness, can’t walk.
All fingers, toes, and joints painful for one year.
BP:
130/70
Pulse: 120
Resp.: 20
Temp. : 36.5
Past
history: Unremarkable.
Previously smoked for six years but stopped two years ago.
Lungs:
clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, no
mass, and no pain
Bowel sound: positive
Skin: not pale, warm to
touch, no rash
Joints: toes, fingers, ankles, wrists + pain, not swollen, +
contraction
Urinalysis: negative
Assessment:
Polyarthritis? Muscle
deficiency?
Recommend:
Do some blood work, some x-rays of fingers and toes.
Should we refer him to Kampong Thom Hospital?
|
Patient # 5: TOT SOK, female, 45 years
old
 |
Chief
complaint: Epigastric pain radiating to chest
and throat for seven months. Sometimes burps.
BP:
110/70
Pulse: 88
Resp.: 20
Temp. : 36.5
Past history:
Unremarkable.
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not
tender, mild epigastric pain after meal
Bowel sound: positive
Skin: not pale, warm to
touch, no rash
Legs and arms: no edema
Joints: no pain, not swollen, not stiff
Assessment:
Dyspepsia.
Recommend: Should we treat her in the village? Please give me the name of the medication if you agree.
|
Patient # 6: KHORN SOKHOM, male, 41
years old
|
|
Chief
complaint: Abdominal distension and pain for 20
days. Dry cough on and off
for four years. Both legs
edema for seven days.
BP:
110/60
Pulse: 120
Resp.: 26
Temp. : 36.5
Past
history: Unremarkable but drinks alcohol and
smokes.
Lungs:
Decreasing breath sound on both lower sides.
Top both sides clear.
Heart: regular rhythm, murmur (mild) at apex
Abdomen: positive tender,
has a few burn wounds, soft, positive hepathosplenomegalie, mild pain
Bowel sound: positive
Skin: not pale, warm to
touch, a few small burn wounds on abdomen
Legs:
both sides positive pitting edema.
Genitals: Right scrotum swollen but no pain
Urinalysis: Bilirubine +, urobilinogen large
Assessment:
Ascitis? Cirrhosis?
Hepatitis? Both pleural effusion secondary to pulmonary TB.
Valvular Heart Disease? Right
hernia.
Recommend:
Suggest heart and abdominal ultrasound, some blood tests, chest
x-ray, exam for AFB, urine microscope.
Should we refer him to Kampong Thom Hospital?
|
Patient # 7: CHHIM HOY, female, 31
years old
|
Chief
complaint: Palpitations, poor appetite,
epigastric pain for one month.
BP:
110/70
Pulse: 100
Resp.: 20
Temp. : 36.5
Past
history: Unremarkable.
Lungs: clear
both sides
Heart: regular rhythm, no murmur
Abdomen: Soft, flat and not tender. Epigastric pain after meal.
Bowel sound: positive
Skin: skinny, not pale,
warm to touch, no rash
Urinalysis: negative
Assessment:
Malnutrition. Dyspepsia.
Recommend:
Should we treat in the locale? Please
give me the name of the medication if you agree.
|
Patient # 8: ROS IM, female, 45 years old
|
|
Chief
complaint: Shortness of breath when lying down,
chest tightness and palpitations for three months.
Mass on anterior neck, size about 6 x 4 cm, for four years.
Epigastric pain for four months.
Coughing on and off for six months
BP:
130/70
Pulse: 120
Resp.: 26
Temp. : 36.5
Past
history: 1976 had malaria, lost weight and sweat
at night.
Lungs:
right upper crackle, left side clear
Heart: regular rhythm, no murmur
Abdomen: soft, flat, not
tender, no mass, epigastric pain after meal
Bowel sound: positive
Skin: not pale, warm to
touch, no rash
Legs and arms: no edema
Joints: normal
Neck: has a mass, size 6 x 4 cm, mobile.
Assessment:
Pulmonary TB? Toxic Goiter?
Dyspepsia.
Recommend:
Chest x-ray, some blood work (TSH, T4,) neck ultrasound. Should we refer her to SHCH? (Kampong Thom Hospital cannot
treat or perform surgery for goiters.)
|
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?
|
Patient # 10: CHAM OUT, male, 70 years
old
|
Chief
complaint: Mild fever, headache, and weakness
the last five days.
BP:
110/60
Pulse: 76
Resp.: 20
Temp. : 37
Past
history: Unremarkable.
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: Mild pain on
left upper abdomen. Soft,
flat, no mass.
Bowel sound: positive
Skin: Pale, warm to
touch, no rash, mild signs of dehydration
Assessment:
Malnutrition. Tension headache.
Recommend:
Encourage him to drink and eat. Can
I give any Paracetemol and multi-viamins to him here in the village for
releasing headache?
|
Patient # 11: IM DOEUN, female, 48 years old
 |
Chief
complaint: Big mass on the epigastric area for
three years. Mass became painful in the last four days.
Headache and neck tender on and off for two years.
BP:
190/130
Pulse: 72
Resp.: 22
Temp. : 37
Past
history: In
1979, she had malaria, but was cured very well with modern
medicine.
Lungs: clear both sides
Heart: regular rhythm, no murmur
Abdomen: has a mass on
epigastric area, size about 12 x 10 cm, mass is hard and not mobile.
Rest of abdomen is okay.
Bowel sound: positive
Skin: Positive pale, warm
to touch, no rash
Assessment:
Severe hypertension. Head
pancreatic tumor? Gastric
tumor?
Recommend:
Abdominal ultrasound, EKG, some blood tests, discuss with surgeon for
evaluation about mass. Should
we refer her to Kampong Thom Hospital ?
|
From:
"Graham Gumley " <ggumley@bigpond.com.kh>
To:
"David Robertson" <dmr@media.mit.edu>
Subject:
SHCH reply
Date:
Wed, 12 Sep 2001 23:28:43 +0700
Message-ID: <NEBBLOHAEIHDALAOKLDEAEDICFAA.ggumley@bigpond.com.kh>
MIME-Version: 1.0
Content-Type: multipart/mixed; boundary="----=_NextPart_000_0012_01C13BE2.AA1A9100"
X-Priority: 3 (Normal)
X-MSMail-Priority: Normal
Status: RO
Dear
David and Montha,
Reply
attached.
Good
work!
Graham
Telemedicine
Clinic in Robib Cambodia
12 Sept -- reply. 2001.doc
Patient # 1: PHENG ROEUNG, female, 56
years old
Note: Patient at
three previous Telemedicine clinics.
Chief
complaint: Still has shortness of breath (at rest and on exertion,) palpitations
and dizziness.
Assessment:
Toxic goiter? Mild hypertension.
Recommend:
Should we refer her again to SHCH for blood work, EKG, and chest x-ray?
SHCH Recommendation 12-9-01:
Review as above at SHCH Friday
Patient # 2: PHIM SICCHIN, female, 35
years old
Note: Previous Telemedicine patient
Chief
complaint: Still pale, shortness of breath all the time, weakness, palpitations.
Assessment:
Anemia secondary from Malaria. Valvular Heart Disease? Parasitis? Aplastic Anemia?
Recommend: May
we refer her to our hospital in Phnom Penh for tests?
SHCH
Recommendation 12-9-01:
Review as above at SHCH Friday
Patient # 3:
PANG LY, male, 37 years old
Chief
complaint: Edema all over the body on and off for one year, persistent edema for
the last seven days. Upper
epigastric pain on and off for four years.
Sometimes cough up with sputum.
Assessment: Nephrotic Syndrome? Chronic Renal Failure? Left
side bronchitis. Dyspepsia.
Recommend: Chest
x-ray, EKG, some blood work, urine microscopic.
Should we refer him to Kampong Thom Hospital?
SHCH
Recommendation 12-9-01:
Refer to Kampong Thom for evaluation
Patient
# 4: CHOURB CHOK, male, 31 years old
Chief
complaint: Weakness, can’t walk. All
fingers, toes, and joints painful for one year.
Assessment:
Polyarthritis? Muscle deficiency?
Recommend:
Do some blood work, some x-rays of fingers and toes.
Should we refer him to Kampong Thom Hospital?
SHCH
Recommendation 12-9-01:
Refer to Kampong Thom for initial workup. Will need CBC/ESR, alkaline
phosphatase, CXR and joint x-rays. Could blood be drawn for Rheumatoid Factor
and sent to Pasteur if not possible to do in K Thom? The x-rays and labs could
be reviewed in K Thom and sent to SHCH for evaluation prior to next Telemedicine
clinic.
Patient # 5: TOT SOK, female, 45 years old
Chief
complaint: Epigastric pain radiating to chest and throat for seven months. Sometimes burps.
Past
history: Unremarkable.
Assessment:
Dyspepsia.
Recommend: Should we treat her in the village? Please give me the name of the medication if you agree.
SHCH Recommendation 12-9-01:
Has she tried antacids at all? What was the response?
What antacid were we able to procure
locally last clinic? If she has not yet tried antacids we should try this first
and review next clinic…..Tums or equivalent would be suitable
Patient # 6: KHORN SOKHOM, male, 41 years
old
Chief
complaint: Abdominal distension and pain for 20 days.
Dry cough on and off for four years.
Both legs edema for seven days.
Assessment:
Ascitis? Cirrhosis?
Hepatitis? Both pleural
effusion secondary to pulmonary TB.
Valvular
Heart Disease? Right hernia.
Recommend: Suggest
heart and abdominal ultrasound, some blood tests, chest x-ray, exam for AFB,
urine microscope. Should we refer
him to Kampong Thom Hospital?
SHCH Recommendation 12-9-01:
Refer to Kampong Thom for evaluation including ultrasound, liver function
tests CXR and sputum for AFBs.
Patient # 7: CHHIM HOY, female, 31 years
old
Chief
complaint: Palpitations, poor appetite, epigastric pain for one month.
Assessment:
Malnutrition. Dyspepsia.
Recommend: Should we treat in the locale?
Please give me the name of the medication if you agree.
SHCH Recommendation 12-9-01:
Will discuss with Dr. Hines in am and reply further.(GG)
Patient # 8: ROS IM, female, 45 years old
Chief
complaint: Shortness of breath when lying down, chest tightness and palpitations
for three months. Mass on anterior
neck, size about 6 x 4 cm, for four years.
Epigastric pain for four months. Coughing
on and off for six months
Assessment: Pulmonary TB?
Toxic Goiter? Dyspepsia.
Recommend: Chest x-ray, some blood work (TSH, T4,) neck
ultrasound. Should we refer her to
SHCH? (Kampong Thom Hospital cannot treat or perform surgery for goiters.)
SHCH
Recommendation 12-9-01:
Refer to SHCH for evaluation
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.
Assessment:
Toxic goiter?
Recommend: Do some blood work like TSH and T4 in SHCH.
Should we refer her to our hospital or not?
SHCH Recommendation 12-9-01:
Refer to SHCH … however not as urgent so could come to hospital in two
weeks after (public holiday)
Patient # 10: CHAM OUT, male, 70 years old
Chief
complaint: Mild fever, headache, and weakness the last five days.
Assessment:
Malnutrition. Tension headache.
Recommend: Encourage him to drink and eat.
Can I give any Paracetemol and multi-viamins to him here in the village
for releasing headache?
SHCH
Recommendation 12-9-01:
What is his weight? Is he wasted? What
is his urinalysis?
Agree with
plan for meds and vitamins.
Patient
# 11: IM DOEUN, female, 48 years old
Chief
complaint: Big mass on the epigastric area for three years. Mass became painful
in the last four days. Headache and
neck tender on and off for two years.
Assessment:
Severe hypertension. Head
pancreatic tumor? Gastric tumor?
Recommend: Abdominal
ultrasound, EKG, some blood tests, discuss with surgeon for evaluation about
mass. Should we refer her to
Kampong Thom Hospital ?
SHCH
Recommendation 12-9-01:
Refer to Kampong Thom for evaluation with Abdominal x-ray and ultrasound
plus CBC and CXR.
They
may then consider referral to SHCH depending on the results of the tests.
[English Version][Khmer
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