Report and photos compiled by Rithy Chau, SHCH Telemedicine On Tuesday, April 27, 2005, Rattanakiri Referral Hospital (RRH) staff began their TM clinic. PA Rithy Chau was present during this month clinic. The patients were examined and the data were transcribed along with digital pictures of the patient, then transmitted (except for a few follow-up patients who came for medication refills and/or further instruction on referring to PP) and received replies from their TM partners in Boston and Phnom Penh. The following day, Wednesday, April 28, 2005, the TM clinic opened again to receive the same patients for further evaluation, treatment and management. Finally, the data for treatment and management would then be transcribed and transmitted to the PA Rithy Chau at SHCH who compiled and sent for website publishing. Note: X-ray machine was broken during this month TM clinic. The followings detail e-mails and replies to the medical inquiries communicated between TM clinic at RRH and their TM partners in Phnom Penh and Boston : From:
Kiri Hospital [mailto:kirihospital@yahoo.com] Dear All, There are 5 new cases in this month.This the first case of this month patient PC#00113 .There will more photos to be sent later. Best regards, Channarith/Rithy
Rattanakiri
Provincial Hospital Telemedicine Clinic with
Please send all replies to kirihospital@yahoo.com and cc: to tmed_rithy@online.com.kh . The information transmitted in this e-mail is intended only for the person or entity to which it is addredded and may contain confidential and/or priviledged material. Any review, retransmission, dissemination or other use of or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this e-mail in error, please contact the sender and delete material from any computer. -----Original
Message----- Dear Dr.Kok San, dear Rithy Chau, Regarding the 40 yo female with slowly growing cervical mass: We also think that this is probably an hypothyroid goiter, nevertheless an ultrasound should be performed to make sur this is homogenic. If the thyroid study turns out to be negative, aCat scan and maybe a biopsy should be considered. Other unlikely causes could be: PTB, Lymphoma other soft tissue tumors. Thank you Olga Smulders-Meyer MD -- No virus found in this incoming message. Checked by AVG Anti-Virus. Version: 7.0.308 / Virus Database: 266.10.4 - Release Date: 4/27/2005
From:
Jack Middlebrooks [mailto:jmiddleb@camnet.com.kh] Dear Rithy and Channarith: As a general principle for evaluating any patient with a chief complaint of dysphagia, it is helpful to ask if the problem is swallowing solids, liquids, or both. Often with a mass, the problem begins as difficulty swallowing solids, and over time, progresses to difficulty swallowing liquids. Does the patient ever have the sensation of food "getting stuck?" If so, asking the patient to indicate where the sticking sensation occurs can help localize the problem. I agree with your assessment and plan. If the TSH is low, the patient should be treated until she is euthyroid; because she is having difficulty swallowing, I suspect our surgical department would be willing to consider resection of the mass once her TSH is normal. If her TSH is normal, I would suggest an ultrasound, and possibly a biopsy, for further evaluation. I will defer to Dr. Cornelia to comment on this possible surgical referral. Best regards, Jack Sent:
Thursday, April 28, 2005 8:14 AM Dear all, I agree with Jack’s plan. I would add a chest X-ray to determine, if the trachea is deviated by the goiter. Thanks Cornelia Haener
From:
Kiri Hospital [mailto:kirihospital@yahoo.com] Dear All, This is the patient KR#00114 and the photos will be sent later. Best regards, Channarith/Rithy
Rattanakiri
Referral Hospital Telemedicine Clinic with
Please send all replies to kirihospital@yahoo.com and cc: to tmed_rithy@online.com.kh . The information transmitted in this e-mail is intended only for the person or entity to which it is addredded and may contain confidential and/or priviledged material. Any review, retransmission, dissemination or other use of or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this e-mail in error, please contact the sender and delete material from any computer. From:
Fiamma, Kathleen M. [mailto:KFIAMMA@PARTNERS.ORG]
-----Original Message----- A very interesting case. Your did an excellent job communicating the facts to me. This is a 65 year old male with history of smoking, alcoholism, and gastritis (possibly H.pylori-related), now with 2 months of right chest pain and SOB. You told me that he was recently found to have a pleural effusion which was mostly acellular and had low protein. Do we know what the glucose was? On examination he is not febrile but is tachypneic. He apparently has a pleural effusion, which is confirmed by radiography. He has conjunctival pallor, suggestive of anemia. He also has an enlarged liver and superficial abdominal varicocities. Laboratory evaluation notable for leukocytosis, anemia, and mildly abnormal liver function tests. Chest x-ray with right pleural effusion and some shift to left. Abdominal ultrasound with enlarged liver. My concerns are that this gentleman is very ill with a massive pulmonary effusion, weight loss, anemia, hyponatremia. Most probably he has a pulmonary malignancy (weight loss, history of smoking) or he has atraumatic hemothorax, perhaps from variceal bleeding (which would explain his anemia. Other possibilities are pulmonary tuberculosis, other pneumonia (probably not bacterial, since it has been going on for 2 months and he is afebrile). His low sodium suggests pulmonary pathology, specifically cancer, pneumonia, or MTB. Rheumatoid lung is possible, but less likely. Another possibility is chronic pancreatitis with sympathetic effusion. I am not worried about his urine. He may have hyperglycemia and could progress to diabetes. I think he needs to be hospitalized for work up, but I’ll leave that up to you. At the very least he needs: 1. Large volume thoracentesis (for both diagnosis and therapy) 2. Send fluid for glucose, protein, cell counts, pH, amylase, LDH, and cytology 3. Chest CT after fluid removed 4. What was his MCV and RDW on the CBC? 5. Blood for CBC again in one week. Also check amylase, iron, TIBC, folate, B12, bilirubin. Repeat glucose in the future. 6. I strongly agree with sputum for AFB x 3. 7. I agree with MTV, stopping smoking and drinking, inhalers. I would not give him iron or folate until you know what you’re treating. 8. I would *not* recommend wasting time and money on antibiotics because the probability of a bacterial pneumonia is very small. - Daniel Z. Sands, MD, MPH
dsands@caregroup.harvard.edu From:
Jack Middlebrooks [mailto:jmiddleb@camnet.com.kh] Dear Rithy and Dr. San: Thank you for the excellent preparation of this case presentation. I agree with your plan to take three sputum AFB's-- ruling out active pulmonary TB would be my highest priority. Second, it would be very helpful to get a clear view of his right lung on a CXR (is there a tumor? a cavity? an infiltrate?)-- removing the effusion might make this possible. I would attempt another thoracentesis; if only a small amount of fluid can be removed, I agree with your plan to place a chest tube. Once the chest tube is in place and the fluid has drained (if it's not loculated), I would repeat CXR's-- including upright and lateral views. Given his high WBC and considering the difficulty of making a rapid diagnosis, I agree with your plan to treat empirically for bacterial pneumonia. Of course, liver failure can also cause pleural effusion due to low plasma oncotic pressure. This patient has an enlarged liver however, suggesting that he does not have chronic liver disease/cirrhosis. From the information you've presented, he does not seem to have acute liver failure, as his AST and ALT are normal. I would suggest drawing blood for total serum protein and albumin, if possible, to better evaluate this possibility. I would be pleased to get follow-up reports about this patient, and would consider referring him to SHCH if the above strategies are not helpful. Best regards, Jack From:
Cornelia Haener [mailto:cornelia_haener@online.com.kh] Dear all, This patient has markedly dilated neck veins and dilatation of the superior epigastric vein as well. My suspicion is that he has a compression or thrombosis of the superior vena cava due to a malignancy. Please do AFB anyway to rule out TB. Thanks Cornelia
From: Kiri
Hospital [mailto:kirihospital@yahoo.com] Dear All, This is the patient RN#00115. Best regards, Channarith/Rithy
Rattanakiri
Referral Hospital Telemedicine Clinic with
Please send all replies to kirihospital@yahoo.com and cc: to tmed_rithy@online.com.kh . The information transmitted in this e-mail is intended only for the person or entity to which it is addredded and may contain confidential and/or priviledged material. Any review, retransmission, dissemination or other use of or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this e-mail in error, please contact the sender and delete material from any computer. -----Original
Message----- Subject: Case PC RN #00115 Dear Dr.Kok San, dear Rithy Chau, I.regarding the 72 female with weakness, tremor (for 4years) loss of appetite and weight, fatigue ang dry cough: We agree with your approach to the case, although there might be some other differential diagnoses you could consider. 1. Weakness rigidity and tremor: Pakinsons? (is probably the most likely diagnosis although unusual weakness) Do further evaluation! frequency of the tremor in rest?, rigor?, akinesis?, onset unilateral? how does she write?, mimics? A trial with Levodopa and Carbidopa should be easy to perform and does not do any harm Vitamine Deficiency We do agree with supplementation, also check Vit B12 level Guirran Barre onset in both legs with weakness and sensibility changes? Find out more detailed why she cannot walk on her own when her strength seems to be fine. 2. Fatigue, weightloss, cough Cancer? Consider especially ovarian cancer after unknown PSH, she needs a good pelvic examination, as her abdomen looks distended and you want to make sure that she does not have any ascites (consider ultrasound) Another possibility could be lungcancer Endocrinologic causes check thyroid PTB We agree on that, rule out because of cough. The performed X-ray does give the impression of a right mediastinal mass, perform a CT if possible! Thank you Olga Smulders-Meyer MD From:
Jack Middlebrooks [mailto:jmiddleb@camnet.com.kh] Dear Rithy and Channarith: Thank you for this interesting case. The first picture shows the patient squatting on the bed-- a position that requires considerable balance and lower body strength and suggests that her difficulty with mobility is more than just a problem with muscle strength. While I have been unable to view the video you sent, our discussion by phone this morning was very helpful. To review it briefly: My first thought for this patient is that she should be well-evaluated for Parkinson's disease. A clear description of her tremor would be very helpful. As you know, the classic Parkinsosn's tremor is "pill-rolling"-- at rest, the patient's thumbs move quickly back and forth over the second and third fingers. "Cogwheeling" is the term used to describe impaired muscle relaxation and is detected as follows: After instructing the patient to relax all muscles, the examiner grasps the patient's wrist and moves the arm from a fully flexed position (patient's palm touching their shoulder) to a fully extended position (arm straight.) While straigthening the arm, the examiner pays attention to feel any resistence to smooth extension-- "cogwheeling" refers to the feeling of short bursts of resistence to relaxed arm straightening. The same phenomenon can be detected by grapsing the patient's hand as though in a handshake and slowly moving the forearm from a supinated to pronated prosition. Finally, patients with Parkinson's are classically described as having "mask-like facies," meaning that their faces have little expression. From your description by phone, it sounds as though the patient does have significant cogwheeling and fask-like facies and I feel comfortable making a diagnosis of Parkinson's disease. FYI: Parkinson's disease can also affect the autonomic nervous system and cause gastric hypomotility and orthostatic hypotension-- this could explain her poor appetite and dizziness. In summary, I agree with your plan and congratulate you on a fine job with this case. Jack
From: Kiri
Hospital [mailto:kirihospital@yahoo.com] Dear All, This is the patient LH#00116. Best regards, Channarith/Rithy
Rattanakiri
Provincial Hospital Telemedicine Clinic with
Please send all replies to kirihospital@yahoo.com and cc: to tmed_rithy@online.com.kh . The information transmitted in this e-mail is intended only for the person or entity to which it is addredded and may contain confidential and/or priviledged material. Any review, retransmission, dissemination or other use of or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this e-mail in error, please contact the sender and delete material from any computer.
-----Original Message----- An adult with hypertension and proteinuria presenting with facial edema suggests renal disease with nephrotic syndrome and very likely renal insufficiency. Hypertension could explain headaches, renal insufficiency could explain weakness and anorexia, and proteinuria explains facial edema. To separate out other primary [IgA nephropathy] from secondary causes of glomerulonephritis [abuse of NSAIDs, diabetes, chronic hepatitis, multiple myeloma, lupus, amyloidosis] requires initial workup to check renal status: history of NSAID use, CBC, ESR, chem 7 [BUN, creatinine, electrolytes, blood sugar], blood lipids, albumin and globulin, urinalysis with microscopic examination of urine sediment for cells and casts and 24 hour urine measurement of creatinine clearance and protein excretion. Further testing to screen for secondary causes include ASOT for strep infection, ANA, complements, cryoglobulins, RPR for syphilis, HBsAg, HCV, HIV. Renal ultrasound will define size of kidneys to confirm chronic renal disease if kidneys are small, check for reflux disease with pyelonephritis if multiple scars are present, or amyloidosis and polycystic kidneys if kidneys are large, and exclude renal vein thrombosis [requires CT]. Nephrotic from nephritic urine suggests different differential diagnosis. If only proteinuria is present [nephrotic]: "A United States study of 233 renal biopsies performed in adults with the full-blown nephrotic syndrome (in the absence of an obvious underlying disease such as diabetes mellitus or systemic lupus erythematosus) between 1995 and 1997 found the major causes to be membranous nephropathy and focal glomerulosclerosis (33 percent each), minimal change disease (15 percent), and amyloidosis (4 percent, but 10 percent in patients over age 44)". [UpToDate medical reference] If urine showed cells as well as proteinuria [nephritic]: "although the nephrotic syndrome can develop in patients with postinfectious glomerulonephritis, membranoproliferative glomerulonephritis, and IgA nephropathy, these individuals most commonly have a "nephritic" type of urinalysis with hematuria and cellular (including red cell) casts as a prominent feature". [UpToDate medical reference] Ultimately a renal biopsy may be the only way of classifying her renal disease. If urine is nephrotic and no other secondary causes are apparent, a course of 1mg/kg steroids may be worthwhile if minimal change disease is likely. Heng Soon Tan, M.D. From:
Jack Middlebrooks [mailto:jmiddleb@camnet.com.kh] Dear Rithy and Dr. Baramey: In addition to your assessment, I would include hypothyroidism, Cushing's syndrome, and diabetes with renal failure on a differential diagnosis for this patient. Depression may be a separate or related diagnosis. I would suggest drawing blood for Na, K, Cr, glucose, TSH, T3 and T4. It would also be very helpful to perform urine microsccopy to look for active sediment to evalaute the possibility of glomerulonephritis. I will be interested to learn the results of these studies. With best regards, Jack
From: Kiri
Hospital [mailto:kirihospital@yahoo.com] Dear All, This is the patient LP#00117 and the photos will be sent later. Best regards, Channarith/Rithy
Rattanakiri
Provincial Hospital Telemedicine Clinic with
Please send all replies to kirihospital@yahoo.com and cc: to tmed_rithy@online.com.kh . The information transmitted in this e-mail is intended only for the person or entity to which it is addredded and may contain confidential and/or priviledged material. Any review, retransmission, dissemination or other use of or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this e-mail in error, please contact the sender and delete material from any computer.
-----Original Message----- Thyroid appears to be a simple goiter rather than a nodular goiter from the examination. Certainly one has to exclude thyrotoxicosis if she has tremors and tachycardia, but she has no other symptoms of weight loss or weakness. The thyroid profile will settle the issue. Thyroglobulin and thyroid peroxidase antibodies will also help decide whether she has Hashimoto's disease or the potential for Graves disease. If it is a simple goiter, she may be interested to suppress it with levothyroxine. Heng Soon Tan, M.D. From:
Jack Middlebrooks [mailto:jmiddleb@camnet.com.kh] Dear Rithy and Dr. Baramey: I agree with your assessment and plan to send blood to SHCH for thyroid function tests. Jack Wednesday, April 27, 2005Follow-up Report for Rattanakiri TM Clinic There were 5 new and 5 follow up patients seen during this month TM clinic at Rattanakiri Referral Hospital (RRH). The data of all new and some follow-up cases were transmitted and received replies from both Phnom Penh and Boston. Per advice sent by Partners in Boston and Phnom Penh Sihanouk Hospital Center of HOPE, the following patients were managed and treated per local staff: [Please note that in general the practice of dispensing medications at RRH for all patients is usually limited to a maximum of 7 days treatment with expectation of patients to return for another week of supplies if needed be. This practice allows clinicians to monitor patient compliance to taking medications and to follow up on drug side effects, changing of medications, new arising symptoms especially in patients who live away from the town of Banlung and/or illiterate.] Treatment Plan for Rattanakiri Telemedicine Clinic April 2005 1. PC#00113, 40F, Village I
Dx:
Treatment : 2. KR#00114, 65M, Kang Meas Village Dx: 1. Right pleural effusion 2. Lung tumor ? 3. Hyperglycemia? 4. Pneumonia 5. COPD? Treatment: 1. Clarythromycine500mg 1 tab po bid x10 days 2. Para 500mg 1 tab po qid prn /pain 3. MTV 1 tab po bid 4. Feso4/folate200/0.25mg 1 tab po tid 5. Albuterol inhaler 2 puffs bid 6. Azthmacort inhaler 2 puffs bid 7. Stop smoking /EtoH 8. Chest PT
Dx: 1. Pakinson disease 2. Vit deficiency 3. Anemia? 4. Constipation Treatment: 1. .Levodopa 100mg /carbidopa25mg 1tab po bid x100days 2. Fleet 45ml ½ 22.5mL po bid prn constipation 3. B-complex 1tab po bid x30 d 4. MTV 1 tab po bid x100d 5. Feso4 /folate 200/0.25mg 1 tab po bid x100days 6. General PT instruction 4. LH#00116, 59F, Village I Dx: 1. Nephrotic Syndrome?? 2. UTI 3. Thyroid dysfunction 4. Cushing’s syndrome 5. PTB (per CXR)? 6. Cardiomegaly (per CXR)? Treatment: 1. Ciprofloxacin 500mg 1 tab po bid x7 d 2. Albendazol 200mg 2 tab po bid x5 d 3. Para 500 mg 1 tab po qid prn 4. free T4 and TSH, Albumin, tot cholesterol at SHCH 5. MVT 1 tab po qd x30 days 6. Feso4200mg /folate0.25 mg 1tab po bid x30 days 5. LP#00117, 34F, Village IV Patient left against her doctor’s advice. Follow-up Patients 1. CK#00102, 18F, Village IV Dx: 1. Cariac insufficiency (MR,AR) with good EF=80% 2. Anemia
a. Iron deficiency 3. Pulmonary HTN 4. Right & left atrial enlargement Treatment: 1. Enalopril 5mg ½ tab po qd x100days 2. Furosemide 40mg ½ tab po qd x100days 3. Albendazol 200mg 2 tab po bid x 5days 4. MTV 1 tab bid x 100 days 5. FeSO4/Folic acid 200/0.25mg 1 tab po tid x100days Patient supposed to return to Calmette Heart Center on 28/6/05, however, we will follow her up at RRH with advice from SHCH instead. 2. MS#00067, 44F, Oplong Village Dx: 1.Liver cirrhosis Treatment: 1. Spironolactone 25mg 1tab po tid x100days 2. Furosemide 40mg 1 tab po qd x100days 3. Propanolol 40mg ¼ tab po bid x100 days 4. MTV 1 tab po qd x100days 3. EB#00078, 41F, Village I Dx: 1. CHF 2. Incomplete RBB Treatment: 1. Enalopril 5mg ½ tab po qd x100days 2. Digoxin 0.25mg tab qd x100days 3 . Furosemide 40mg 1tab po bid x100days 4. Spironolatone 25mg 2 tab bid x100 days 5. MVT 1tab po bid x100days 4. ST#00108, 27F, Village I Dx: 1. GERD Treatment: 1. Omeprazole 20mg 1tab po qhs x 30 days 2. GERD prev education 5. UP#00093, 51F, Village I Dx: 1.Hyperthyroidism 2.osteochandritis Treatment: 1. Methimarzol 10mg ½ tab po qd x100 d 2. Para 500mg 1tab po qd prn pain 3. MTV 1tab qd po x 100 days 4. free T4 and TSH at SHCH
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Hx:
General:
Heart:
HRRR no murmur, no gallop . 
