Report and photos compiled by Rithy Chau, Telemedicine Physician Assistant at SHCH On Thursday, February 26, 2004, Rattanakiri Provincial Hospital (RPH) staff began their TM clinic. The patients were examined and their data were transcribed along with digital pictures of the patients, then transmitted and received replies from their TM partners in Boston and Phnom Penh. There were three new cases presented at this month clinic. All their data and photos were transmitted. The following day, Friday, February 27, 2004, the TM clinic opened again to receive the same patients for further evaluations, treatments and management. Finally, the data of the follow-up for patient treatment and management would then be transcribed and transmitted to the PA Rithy Chau at SHCH who compiled and sent for website publishing. [One follow-up case was added to this month clinic. Her data was included in this report. Since there was no staff for radiology service available during this TM clinic, no studies were ordered and done.] The followings detail e-mails and replies to the medical inquiries communicated between TM clinic at RPH and their TM partners in Phnom Penh and Boston : -----Original
Message----- Dear All, Please be informed that the next TM clinic at the Rattanakiri Provincial Hospital will be held On Thursday, 26 February at 8:00 AM local time for one full day. The data of the patients are expected to enter and transmitte to those of you in SHCH and partner (Boston) that evening. Please try to make your replies by noontime the following day, Friday 27 February. The patients will be asked to return that afternoon on Friday to receive treatments and plan of follow-up or refer. Thank you for your cooperation and service. Best regards, Channarith Ly Do you Yahoo!?
-----Original Message----- Deal All, This is the first patient of this month ,Patient KP#00058 and the rest photo will be sent later. Best regards, Channarith Rattanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners Patient: T#00053, 22F, TALAY Village
Name/Signature of Clinician: ...Dr san......... Date:26/02/2004 Please send all replies to kirihospital@yahoo.com and cc: to tmed_rithy@online.com.kh and tmed1shch@online.com.kh.
-----Original Message----- In summary, the patient is a 40 year-old female who one year ago had similar symptoms and who now experiences intermittent palpitations on exertion, burning retrosternal chest, belching, decreased appetite, asthenia, weakness, "trembling muscles," headache, and blurred vision. The palpitations on exertion, retrosternal chest pain, decreased appetite, and asthenia may reflect cardiac disease. Ischemic cardiac disease is unlikely in a 40 year-old female without comorbidities, but not impossible. Other causes of cardiac dysfunction such as valvular heart disease or various forms of cardiomyopathy may explain the symptoms. An EKG and chest X-ray are valuable first steps diagnostically to evaluate for disturbances of rhythm, evidence of ischemia or heart strain, abnormal heart size, and evidence of pulmonary congestion. The recurrence of several vague symptoms such as headache, decreased appetite, weakness, and asthenia raise the possibility of a waxing and waning autoimmune disorder such as systemic lupus erythematosis. An erythrocyte sedimentation rate and antinuclear antibodies would be a place to start ruling out these diagnoses. With blurred vision as part of the spectrum of recurrent symptoms, multiple sclerosis with optic neuritis must also be considered. A thorough eye examination with attention to visual acuity, visual fields, and appearance of the optic disc would be helpful, as would a thorough neurologic examination. These symptoms may also represent anemia, which may be secondary to GI disease, nutritional deficiency, or other causes. A complete blood count would be recommended. Diabetes or renal failure could cause some or all of this constellation of symptoms, and a basic chemistry panel of electrolytes, renal function (BUN and creatinine), and glucose level would be recommended. Finally, hyperthyroidism can cause palpitations, tremors, and most of the rest of the constellation of symptoms, and would be a disease that could have been treated in the past with an oral medicine. A TSH can be checked to rule this out. The symptoms of belching, burning retrosternal chest pain, and decreased vision sound like gastroesophageal reflux disease. A trial of acid lowering therapy is not unreasonable, such as omeprazole. Hypercalcemia, as is mentioned in the case as a possible diagnosis, can cause fatigue, malaise, and nausea. It also tends to cause thirst and polyuria (not mentioned for this patient). It seems unlikely in this patient, but a calcium level can be checked. Hypocalcemia, as is suggested in treating the patient with calcium, causes paresthesias (numbness, tingling) in the extremities and around the mouth, and, when severe, causes spasm in the hands and feet (carpal-pedal spasm), which does not sound like the case in the patient. Again, a calcium level can be checked. Recommendations: Consider also: James F. List, M.D., Ph.D.
-----Original Message----- Dear Dr. San and Dr. Channarith, Palpitation on exertion, burning chest pain, muscle weakness, blurred vision, muscle trembling. What did her doctor tell her? Does she have weight loss? Does she have tremor? Any polyuria, thirsty? We would wait for her ECG, CXR, Calcemia, Blood sugar, Ionogram, TSH. In the time only omeprazole for the possible GERD. We would not use calcium or ASA yet. Regards, Bunse/Rithy
-----Original Message----- Deal All, This is the Patient SR#00059 and there will be more photos to be sent later. Best regards, Channarith Rattanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners Patient: [SR#00059], 40 yol , V village , labaseak commune.
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.
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-----Original Message----- Reading the history and physical I think the differential diagnosis is very broad. We need some more information from the history that would help narrow the differential: which joints are involved? are they symetric? worse in the morning or worse with activity? is she still having fevers? any weight loss? any history of depression/psych problems? what does she do for work? As for tests to help us narrow the differential: does she have hearing loss on exam (even a gross evaluation)? I would dip her urine to check for blood; I would send her blood for a sedimintation rate (ESR) which would be very helpful. Putting it all together, I think a vasculitis is possible and an ESR and urine dip would be very suggestive if they are positive and change the managment. Other joint conditions, like fibromyalgia are also possible and a depression or psych history would also help; osteoarthritis is also possible. I would start treating her with arthritic doses of ibuprofen, 800 mg three times a day for 2-3 weeks and re evaluate after we get some of the above information. I think the ECG looks ok and I would not give atenalol for now. I would also hold on calcium or PCN. Anti acids or omeprazole are ok for possible reflux. Please write back with follow up. Jonathan Sadeh, M.D.
-----Original Message----- Dear Dr. San and Dr. Channarith, Chronic Polyarthritis in a 40 F. We have several questionsIs it symmetric, any morning stiffness, swelling, redness, do the hands affect as well? ESR? any rashes? urinay discharge? how about her eyes and visions? In the the mean time we would use only paracetamol for pain and cimetidine for her dyspepsia. Her knees X-Ray is too bright. One solution is to set your camera EV feature to minus part to get the picture darker. Please see tips on taking pictures. Regards, Bunse/Rithy
-----Original Message----- Dear All, This is the patient NH#00060 .There are more photos to be sent later. Thank you, Channarith Rattanakiri Provincial Hospital Telemedicine Clinic with Sihanouk Hospital Center of HOPE and TelePartners Patient: NH#00060, 40M, Village II
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.
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-----Original Message----- 40yo man has recurrent left chest wall pain. The previous injury could have ruptured a thoracic disc and cause an impingement on a thoracic nerve root. Is there evidence of loss of pin, touch and temperature sensation or pain along a dermatome supplied by a thoracic root? Thoracic spine xray could be helpful if there was a previous thoracic vertebral fracture or facet joint arthritis. However a normal thoracic spine xray does not preclude a disc. The definite diagnosis requires CT or MRI scan of the thoracic spine. If it is not a ruptured disc, even posttraumatic facet joint arthritis could cause the referred pain. Degenerative facet joint arthritis is usually a problem of the lumbar spine, but posttraumatic injury could result in arthritis anywhere else in the spine. The past history of treated tuberculosis makes you wonder about Pott's disease or tuberculous infection of the vertebra. However the pain is not constant, there is no gibbus deformity of the spine from a collapse vertebra and there is no sign of active infection on CXR and white count. Sometimes herpes zoster [shingles] infection can cause recurrent neuralgia in the dermatome of previous outbreak. He should be asked about that. Lastly he has mild diastolic hypertension that needs to be rechecked on followup. Heng Soon Tan, M.D.
-----Original Message----- Dear Dr. San and Dr. Channarith, Thanks for the case. Left scapular pain radiates to left clavicular for 7 years without any muscke atrophy noted, ECG only incomplte RBBB, CXR normal, Echocardio normal. We would like to know: Range of motion of his left shoulder Costochondral joints by palpation - any tenderness? Does he has pain when you bend his back forward or backward? Can we have Ribs X-ray, Spines X-Ray, ESR For the moment we would only give paracetamol for the pain. You have sent us a fair amount of pictures. We would like to give you some tips on how to take pictures. Please find in attachement tips on taking pictures. Essential parts are not too near, steady hands, know when to use flash and EV setting for X-rays pictures. Regards, Bunse/Rithy ATTACHMENT Telemedicine: how to get a good quality picture 1. Visit telemedicine sites: Sothnikum on 9 Feb 2004 and Siem Reap on 10 Feb 2004. 2. Objectives – increase quality pictures for telemedicine. 3. In our experience, this would be easier if: - knowing tips on shooting technique - Have FotoStation - Have Photoshop 4. Tips on shooting technique a. Both sites have Sony camera 4 Mega pixels b. To get good picture - Set the camera to: · Image size: set to the highest value 2272 x 1704 · Image quality: set to Fine · This will result in big picture file of 11 MB, but FotoStation will bring it down to approximately 50 KB. - Not too near · it will blur image o solution is to use move away from the target and use zoom o then shoot picture · too near and use flush – it will result in white and no image o solution is to move far from the target o use zoom o then shoot - Keep your hand steady - EV – use this feature especially for CXR, darker or lighter images setting 5. FotoStation a. Utility - Help to reduce size of the picture file so that it can be sent through e-mail - Search your file using name of the file or keyword b. Steps - Create folders Master and Web - From a big picture file of 11 MB, called Master picture, which is usually of good quality, FotoStation can bring it to 50 KB picture file, called Web pictures, without damaging the quality of the picture. These small files are good enough for website and power point shows. The master pictures are for print out as in journal publication. · Master pictures: set up the camera to: o Image size: set to the highest value 2272 x 1704 o Image quality: set to Fine o This will result in approximately 11 MB picture file o After shooting pictures, copy all master pictures to Master folder. When Master folder is around 650 MB, back it up to CD-R, and you may delete master pictures in your computer. · Web pictures: using FotoStation to edit image o First naming the Master picture, e.g. M-KH-SK-234-A1 (M=Master). Right click on the picture and choose Rename picture fro the menu. This picture stays in Master folder. o Then right click and edit image. Use width 22 and resolution 72 o Then save as W-KH-SK-234-A1 (W=Web) in Web folder. - Search picture · When you want to retrieve your file that is in your more or less 1000 files · You can search by the name of the file or by using keyword
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Inserting keyword to your file: o Point to Text o Type your keyword and enter o You can type as many keyword as you want, e.g. PCP, Takeo, KH... · Search file: type name or keyword at “Search” prompt - One remark. When delete picture the program will ask you second time. Make sure you delete the file you want to delete and not others. 6.
Photoshop a. Utility – blocking eyes for confidentiality b. Steps: - Open the file - Then choose rectangle - Click to where you want to block - Then choose Save as
-----Original Message----- Dear Rithy, The patient NS#0006 was recommended to continue the carbimazole 5mg po qd at least 1 year and recheck her TSH and free T4 in three months.Yesterday she came and told me that she left the medication only for one week.Could you please sent her the medication for her continue treatment with Mr Ty ? I heard he will come to Rattanakiri on Monday 1 March. Thank you, Channarith
-----Original Message----- Dear Channarith, Thank you for the reminder. I have sent with Ty 100 tablets of Carbimazole 5mg (from SHCH) for this patient's supply of maitanance dose fro the hyperthyroid problem for the next three months. Please keep us to date with her condition. Thank you, Rithy Friday, February 27, 2004Follow-up Report for Rattanakiri TM Clinic There were 3 new (and 1 f/u) patients seen during this month TM clinic at Rattanakiri Provincial Hospital (RPH). Their data 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 RPH for all patients is 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.] Patient NS#0006, 17F, Village IFinal assessment: 1) Euthyroidism This patient was prescribed with medication supplies at no cost from SHCH: 1. Carbimazole 5mg 1 tab po qd x 3 months Patient KT#00058, 40FFinal assessment: 1) GERD This patient was prescribed and treated with medications from RPH (or otherwise indicated) as follows: 1. Omeprazole 20mg 1 po qd x 2 mo (bought at market) Patient SR#00059, 40F, Village VFinal assessment: 1) OA 2) GERD 3) Hypocalcemia This patient was prescribed with medications from RPH (or otherwise indicated) as follows: 1. Ibuprofen 400mg 1 po bid x 14d 2. Omeprazole 20mg 1 po qd x 2 mo 3. Calcium 1 amp po qd x 1 wk 4. PNC V 250mg 2 po tid x 14d Patient NH#00060, 40M, Village IIFinal assessment: 1) Arthralgia This patient was prescribed with medications from RPH (or otherwise indicated) as follows: 1. Paracetamol 500mg 1 po qid x 7d 2. Vit B-complex 1 po tid x 7d The next Rattanakiri TM Clinic will be held on March 2004
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