Report and photos compiled by Rithy Chau, Telemedicine Physician Assistant at SHCH On Tuesday, January 11, 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 those follow-up patients who came for medication refills and/or bloodwork) and received replies from their TM partners in Boston and Phnom Penh. The following day, Wednesday, January 12, 2005, the TM clinic opened again to receive the same patients for further evaluations, treatments and management. There was another patient that one of the TM doctors decided to send as additional case during this month TM clinic and reply was received from SHCH the next day (13 Jan 05). 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. 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 :
-----Original Message----- Dear All,
I am writing to inform you
that the TM clinic of this month is scheduled for Tuesday, January
11,2005 beginning at 7:30 local time for one full day. We expect to enter
and transmit the patient data to those of you at SHCH and at Partner in
Boston that evening.
Best regards,
-----Original Message----- Dear All, There are two new cases for this month TM Clinic at Rattanakiri Referral Hospital. Four other new cases did not appear during this morning clinic hours. The first case is KO#00100 and photos. Please try to reply all before noontime tomorrow January 12, 2005, Cambodian time. Regards, Rithy/Channarith
Rattanakiri
Provincial Hospital Telemedicine Clinic with Patient: KO#00100, 38F, Sre Ang Krorng Village
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----- From: Jack Middlebrooks [mailto:jmiddleb@camnet.com.kh] Sent: Tuesday, January 11, 2005 8:49 PM To: Kiri Hospital; Rithy Chau; jmiddleb@camnet.com.kh; Cornelia Haener; Ruth Tootill; Brian Hammond; Paul Heinzelmann; Kathleen M. Kelleher; Joseph Kvedar Cc: Ed & Laurie Bachrach; Bernie Krisher; Noun So Thero; Noun SoThero; Nancy Lugn Subject: Re: Rattanakiri TM Clinic January 2005 KO#00100 Dear Rithy and Dr. Baramey: I agree that it is reasonable to send blood to SHCH for thyroid function tests, however she does not seem to have signs or symptoms of hyperthroidism. It is certainly possible that this is a tumor that is not a goiter, and it is worrisome that she is having difficulty swallowing. For both of these reasons, I think a surgical evaluation would be helpful, and I will defer to the opinion of Dr. Cornelia about how she would proceed. Best regards, Jack
-----Original Message-----
-----Original Message----- This patient has a history of a neck mass that has been present for over a year. It is a very large mass that is no doubt encroaching on the structures in her neck, including her Esophagus and Trachea, which account for her symptoms of dysphagia and shortness of breath. The most likely diagnosis is a Multi Nodular thyroid goiter. Her symptoms could also be consistent with to Graves Disease, or to thyroid cancer, but the mass seems very smooth for that. Alternatively, she could have a mass that arises from structures other than the Thyroid. The first step to take is to check TSH, and if that is depressed, a T4 and T3. If these latter values are high, she needs a radioactive thyroid uptake scan to confirm thyroiditis caused by Graves' disease. The lesion needs to be aspirated with Fine needle aspiration: You have the Thyroid ultrasound images to help you guide the FNA and this can safely be done by an internist or an endocrinologist. You need a tissue diagnosis. You may also consider a Barium Swallow to see how much the Esophagus is being compressed posteriorly due to the tumor. With a tumor this size, she most likely will need a surgical solution to relieve her current symptoms Olga Smulders-Meyer, MD -----Original Message----- From: Cornelia Haener [mailto:cornelia_haener@online.com.kh] Sent: Wednesday, January 12, 2005 8:47 AM To: jmiddleb@camnet.com.kh; 'Kiri Hospital'; 'Rithy Chau'; 'Ruth Tootill'; 'Brian Hammond'; 'Paul Heinzelmann'; 'Kathleen M. Kelleher'; 'Joseph Kvedar' Cc: 'Ed & Laurie Bachrach'; 'Bernie Krisher'; 'Noun So Thero'; 'Noun SoThero'; 'Nancy Lugn' Subject: RE: Rattanakiri TM Clinic January 2005 KO#00100 Dear Rithy and Dr. Baramey, I agree with Dr. Jack Middlebrooks, that thyroid function tests are of value. I have seen many cases with low TSH and normal T4/T3 (subclinical hyperthyroidism). This would help us to make a decision towards surgery. Concerning the diagnosis, I think it is rather benign than malignant due to the slow progression in the last 3 years. Bigger benign goiters tend to cause dysphagia as well. Compression of esophagus or trachea might be another indication for surgery. I agree that she should have a surgical evaluation. However, I would wait sending her to P.P. till we know if T4 is normal or not. If T4 is elevated, then rather treat her with Carbimazole/propranolol first for 3 months before sending her down for a surgical evaluation. We would not do a thyroid operation on a hyperthyroid patient till she is euthyroid under treatment. Thanks Cornelia
-----Original Message----- Hello Rithy and Channarith: Thank you for sending the two cases today.
Case #101 did not
contain any clinical history. We only received 4 images...two of which
seem to be be the same. Many thanks, Kathy Fiamma
-----Original Message----- As follow up to my previous message, I am providing the reconciliation for today. Case #100 was completed by Dr. Olga Smulders-Meyer. Since we did not receive clinical notes for patient #101, we were unable to provide an opinion, so therefore, you will only receive one opinion at this time. We will be happy to complete the consultation at some point tomorrow 1/12/05 if you send the clinical history. Best regards,
Kathy Fiamma
-----Original Message----- Dear All, Sorry for the delay. The internet was not working properly last night and I could not send you the last case. All of the photos were already sent. Please let us know if you did not get all the photos--CXR, EKG, face for KV#00101. Regards, Rithy/Channarith
Rattanakiri
Provincial Hospital Telemedicine Clinic with Patient: KV#00101,46F ,village I
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 Rithy: I agree with your plan. Jack
-----Original Message----- Was the patient able to walk without any difficulty prior to this episode? How sudden was her presentation? I'd like to know if her presentation was acute onset with sudden, maximal deficit in the beginning--which would argue for an embolic source. Strokes secondary to hypertension tend to be stuttering, with waxing and waning symptoms. Her clinical history as is suggests CVA related to her hypertension. The etiology of this acute event is likely related to the discontinuation of her antihypertensive medications. Since the CVA occurred at least two weeks ago, there would be little role for invasive intervention for the current CVA. However, I would aggressively optimize her antihypertensive regimen. As you have done, atenolol is a good initial choice for her hypertension. If her heart rate does not tolerate (if she becomes bradycardic), I would consider adding hydrochlorothiazide and reducing the dose of atenolol. She needs aggressive control of her hypertension to prevent further CVA. In addition, she needs to be on full-dose aspirin--325mg (or no less than 300mg). She should also be on a statin, with a goal LDL < 100, for secondary prevention of stroke. Additionally, please listen to her neck for any bruits when she returns to detect if she has stenosis of her ICA. She needs close followup of her hypertension. Thank you for this interesting case, April Armstrong, MD
Department of
Medicine
-----Original Message----- Additional recommendations: With regards to pt KV#00101, 46F, in addition to the recommendations that I had just sent you, I would like to add that, ideally, an ACE inhibitor should probably be added on as the next agent for BP control because it's proven to reduce secondary risk of stroke (it's probably a better agent than hydrochlorothiazide in this patient). I don't know how available ACE inhibitors are in your area. In someone so young with stroke, please consider a hypercoagulable workup. Sincerely, April Armstrong April W. Armstrong, MD
Department of
Medicine email: awarmstrong@partners.org
-----Original Message----- Dear All, Here is the additional case Patient CK#00102 .There will be more photos to be sent later. Best Regards Channarith/Rithy
Rattanakiri
Provincial Hospital Telemedicine Clinic with Patient: CK#00102, 18F, Kachagn Village
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 Rithy and Dr. Baramey: I think your first assessment is the most likely-- I suspect his woman has a cardiac problem resulting in significant hepatic congestion. I think the single most useful diagnostic study would be an echocardiogram to determine if she has an ASD or valvular heart disease. It would also be reasonable to draw blood (and send to SHCH) for HBV and HCV to know if there is another underlying problem with her liver, as well as serum protein and albumin to understand if her edema is a result of her cardiac disease, low oncotic pressure, or both. The fever and leukocytosis is also concerning, and it is difficult to know the source of infection. (I cannot see the CXR clearly-- if you are able to see a pulmonary infiltrate, you have your source.) Given her history of recurrent pneumonia, I agree with your idea to treat empirically for pneumonia. As she has no evidence of cirrhosis, I think SBP is unlikely. I assume there is no evidence of hepatic abcess on any of the other ultrasound images. As we are considering an ASD or valvular heart disease, it is also important to consider endocarditis-- I would suggest evaluating her hands and feet for evidence of septic emboli, and performing a UA to look for hematuria (also a sign of septic emboli.) If possible, I would draw blood for culture. You have done a nice evaluation of this difficult case! Jack Wednesday & Thursday, January 12-13, 2005Follow-up Report for Rattanakiri TM Clinic There were 3 new patients seen during this month TM clinic at Rattanakiri Referral Hospital (RRH). The data of all new 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 Telemedicne January 2005
1. NS#0006, 17F, Village I
2. TC#00018, 70F, Thouy Village
3. EB#00078, 40F, Konmom Village
4. NS#00089, 14F, Village I
5. UP#00093, 51F, Village I
6. KO#00100, 38F, Sre Angkrorng Village Diagnosis: 1. Nodular Goiter? 2. Thyroid tumor? Treatment Plan: 1. Check free T4 and TSH at SHCH on 16/01/05 2. TSH = 0.99, Free T4 = 13.71 3. Perform FNA (fine needle aspiration) for cytology at SHCH at next visit 7. KV#00101, 46F, Village I Diagnosis: 1. CVA with left side weakness 2. HTN Treatment Plan: 1. Atenolol 50mg ½ tab po bid x 14 days 2. ASA 500mg ¼ tab po qd 3. Vit B COMPLEX 1 tab po qd 8. CK#00102, 18F, Kachagn Village Diagnosis: 1. ASD/VSD? 2. VHD? 3. RVH 4. Pneumonia 5. Anemia Treatment Plan: 1. Digoxin 0.25mg 1 tab po bid 2. Ampicilline 1g IV tid 3. Gentamycine 80mg IV bid 4. KCL 600mg 1 tab po bid 5. Blood drawn to be evaluated at SHCH: Creatinine, BUN, SGOT/SGPT, Albumin, Tot Protein, Tot Bilirubin on 16/01/05; did U/A and urine albumin at RRH 6. Creat = 75, BUN = 3.1, SGOT = 80, SGPT = 39, Alb = 46, Tot Prot = 79, Tot Bili = not enough sample; U/A = 2+ Bili, Urine Alb = Trace + 7. Send patient to Phnom Penh for 2D cardiac echo at Calmette Heart Center
The next Rattanakiri TM Clinic
will be held on
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