Today started with a hike to some stupas located about an hour north of our guest house. We had an incredible view of the Nako village and its terraced landscape. I was only a few kilometers from the contested border with China/Tibet, according to Google maps. China is just beyond the mountains you'll see in the photo gallery below.

After breakfast, we headed to our next clinic site in a slightly larger village 17 kilometers away known as Chango. We set up clinic in a nunnery in town. My first patient required the use of the portable ultrasound. On the history and physical, we found that he likely had a pleural effusion and possible tuberculosis. The ultrasound confirmed the presence of an effusion.

Our next patient had multiple murmurs and turned out to have mild aortic insufficiency and tricuspid regurgitation. I’ve now taught the students some of the basic echo views. The students who complete the echo workshop at night get to perform the echos during the day. You'll see one of the British medical students scanning a patient in the gallery.

We had another busy day that included a 33-year-old man with a likely undiagnosed coarctation of the aorta, as well as a 63-year-old woman with what sounded like previously undiagnosed angina with very atypical symptoms.

Due to the difficulty of obtaining a history (many of the patients here speak a mix of Nepalese and Hindi, so oftentimes we need two translators for each patient visit – one to translate English to Hindi and another to translate Hindi to Nepalese), we had to do our best with a physical exam in order to make diagnoses.

One of our other students found a posterior wall motion abnormality on her echo, which confirmed our clinical suspicion. As a result, we asked the patient to make the 20-hour trip to Shimla in order to be evaluated by a cardiologist.

Unfortunately, many of the patients here do not have access to specialty care and must travel long distances. Because of this barrier, many never make the trip.

Finally, we made the hour-long drive back to Nago, where I held my third echo workshop with the students. After dark, we went stargazing with headlamps up near the top of the hill close to our guest house. Then we called it a night.

Tomorrow, we’ll drive to Kaza and get ready for our next set of clinics.

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