-----Original Message----- Dear Rithy and Montha, I would try to answer case # 0001 first and the rest will follow. 1. Both legs weakness with DTR's normal, ataxia, foot drop (steppage), Romberg's test positive in an alcoholic make me think of more of polyneuropathy and Wernicke's encephalopathy than Pott's (anal sphincter tone also normal). I agree with you on multivitamin, though I would check how many mg of B1 in a tablet. He would need at least 50 mg B1 a day for at least 1 week or more until improvement. Also, advise him to stop drinking, drink enough fluid. If he quits drink, please watch for his withdrawal. 2. Chronic cough 3-4 months, family members also cough, and with CXR like that (also elevation of righ hemi-diaphragm) make me think of something chronic like TB. I agree with you on AFB sputum. Since there is an outbreak of ?pneumonia in his community, a RUL hyperlucency infiltrate with air-bronchogram, fever, chest pain and high WBC, I would think also of bacterial pneumonia. In this case I would follow CENAT protocol: start cotrimoxazole 960 mg BID for 2 weeks while waiting his sputum AFB. Since he is alcoholic, he has high chance of aspiration pneumonia, so I would add Pen VK 500 mg qid for 10 days to cover anaerobic. After 2 weeks of ABx, if he is still symptomatic and sputum AFB 3x are negative, and CXR more or less the same, according to CENAT the patient should be put on TB medicines. Please check other family members as well. 3. Anemia: I agree with you on mebendazole, FeSO4. I would add folic acid also if available because alcoholic often time has nutruition problem. I don't know if this is from his chronic infection # 2 above, his Etoh, his worms or his internal hemorrhoid. 4. Internal hemorrhoid and perianal open lesion with milky discharge: I agree with you on cephalexin. In addition I would discuss with local surgeon. Hope it helps you some. Have a nice days at Ratanakiri. Sincerely, Bunse Leang, M.D.
Sihanouk
Hospital Center of HOPE,
-----Original Message----- The history and physical exam were ambiguous. Sounds like he had been coughing for 4 months, treated for pneumonia 2 months ago, and partially improved but had continued fever and coughing productive of mucoid sputum. On physical exam, I couldn't understand the motor examination. Were the arms completely normal? Were both legs affected with bilateral foot drop? What was the muscle tone in the legs? Was there clonus? As for the sensory examination, was it really normal? How was the vibration and position sense to assess posterior columns? Normal sensory exam would rule out any peripheral neuropathy. Romberg was positive yet there was no dysmetria or truncal ataxia, though history stated he was weak and ataxic. Positive Romberg test could point towards cerebellar lesion or peripheral neuropathy or posterior column disease, but there were no other cerebellar signs, nor was there any signs of neuropathy on exam. If he just had foot drop, was it one [suggestive of peroneal neuropathy], or both [suggestive of spinal cord lesion]. Given the clinical information as it is, I am most impressed by his chest xray. Given his age, and endemicity of tuberculosis, I would be most concerned about underlying pulmonary tuberculosis with extensive pulmonary scarring, bronchiectasis and emphysematous changes in the RUL. Differential would include fungal infections [actinomycetes] or Pseudomonas pseudomallei concurrent or superimposed infections. Unlikely to be lung malignancy, although in an older person, lung cancer with paraneoplastic syndrome could present with peripheral neuropathy. As for leg weakness, I would like to have better history and physical exam to be able to decide whether this is a nerve palsy [like peroneal palsy], peripheral neuropathy [metabolic], posterior column disease [B12 deficiency], transverse myelitis [due to tuberculosis], transverse myelopathy due to vertebral osteomyelitis [TB Pott's disease]. Unlikely to be lesions in brainstem or cerebrum. Heng Soon Tan, M.D.
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Ratanakiri
Provincial Hospital Telemedicine Clinic Patient: CC#0002, 39F, One Village
-----Original Message----- Dear Rithy and Montha, Case # 0002 I agree with you about referral for further work-up, probably to us first because of cc of RUQ abdominal pain and mass in abdomen. I also worry about her intrauterine mass, vaginal bleeding post-coital, and weight loss. Hope it helps you some. I need to go to ER now. See you again soon for the next cases. Bunse Leang, M.D.
-----Original Message----- Surgical opinion: A: RUQ pain DDX Perihepatitis/Adhesions/Appendix- or Colontumor Suspicion of uterus fibroid Tumor right mid abdomen DDx Ovarian tumor/Appendix- or Colontumor P: I would strongly suggest to perform at least rectal exam and vaginal exam. It might help you to localize these processes. Afterwards refer to the closest hospital with surgeon experienced in at least bowel resections, may be referral to Phnom Penh not needed. If referral to Phnom Penh, then better SHCH than MCH because of all the DDx. Dr. Cornelia Haener, SHCH
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Ratanakiri
Provincial Hospital Telemedicine Clinic Patient: SM#0003, 35F, Bey Village
-----Original Message----- Dear Rithy and Montha, Case # 0003 1. Palpitation, headache, nausea, epigastric pain, belching, dizziness, blurred vision: these could be due to chlopropamide. Chlorpropamide is well known to cause side effects: GI symptoms, headache, skin hypersensitivity, SIADH (especially in elders). Since her UA is negative I would stop chlorpropamide and watch the symptoms. I would check her glycemia weekly. If high more than 2 times, I would use metformin instead because she is obese. She also needs to reduce her weight, change her lifestyle, do regular exercices. I agree with you, however, on paracetamol for HA, cimetidine for epigastric pain. I would add metoclopramide 5-10 mg qid for her nausea and hope it helps her hiccups. 2. HA, blurred of vision and stocking-glove sensation: since there is no focal deficits, I would just follow her closely. Bunse Leang, M.D.
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Ratanakiri
Provincial Hospital Telemedicine Clinic Patient: CN#0004, 40M, Tahourn Village
-----Original Message----- SHCH reply: Patient with chronic nephrolithiasis and anemia. 1) 1) Chronic nephrolithiasis: Odds are that this is ca oxalate. Although multiple stones shown in renal pelvis it doesn’t look like a staghorn calculus. Would do as much of a work up as resources there allow including serum chemistry (Na, K, BUN Cr, uric acid, calcium, phosphate, bicarbonate and if possible a timed urine collection for Cr, Na, uric acid, ca, (oxalate uric acid others probably not available) Treatment: liberal fluid intake, decrease Na intake; consider thiazides later if hypercalcuric 2) 2) Anemia: can we get a peripheral smear or at least mean RBC volume. Because there is approximately a 1.7% incidence of HIV in the blood supply, I would transfuse only if his family provided the donor. Otherwise, empirically give iron and recheck Hct in one month. 3) 3) It is interesting that a number of conditions could manifest with recurrent stones and anemia. 4) 4) Have pt return when test results available. Gary Jacques
-----Original Message----- Hello Rithy: Here is the response for CN#0004 Kathy
-----Original Message----- Anemia: Anemia is more severe than what you would expect in hemoglobinopathy like thalassemia. Iron deficiency or hemolysis should be considered, though B12 and folate deficiency are possible. The history suggests a subacute onset rather then recent acute hemorrhage. Absence of malaria parasite, jaundice, enlarged liver and spleen do not suggest chronic malaria. More information would be useful: History: any previous anemia, bleeding like melena or hemorrhoidal bleeding, or malaria infection? how is the diet? family history of anemia? Exam: rectal exam for hemorrhoids, stool guaiac test. Lab: red cell indices: MCV and morphology of red cells: microcytic or macrocytic? retic count. Fe/TIBC, ferritin, [folate and B12 if indicated]. Followup: recheck CBC and ferritin in 3-6 months after transfusion and iron therapy. If ferritin is normal, and anemia persists, consider hemoglobin electrophoresis. Renal stones: Multiple renal stones raise possibility of chronic UTI causing stones. Does he have gout or hypercalcemia? Or is this more hypercalciuria? Homocysteinemia could be considered. Further treatment depends on whether a metabolic problem exists. Do you have access to urologist to remove stones or provide lithotripsy treatment? History: any previous UTI? or gout? Exam: urinalysis to look for crystals. Urine culture. 24h urine for calcium and uric acid. Serum calcium and uric acid. Heng Soon
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Ratanakiri
Provincial Hospital Telemedicine Clinic Patient: PN#0005, 37F, One Village
-----Original Message----- SHCH reply: pt with a number of problems as follows: 1) 1) chronic rhinitis by history. Allergic vs. vasomotor. Agree with trial of antihistamine. Do you really have Zyrtec? If so 10mg q day is good. No need for mucomyst or humidifier at this point 2) 2) Chronic cough with clear lungs and nl CXR. May be secondary to #1 3) 3) ? H/O of heart disease w/o murmur. Irreg rhythm needs EKG. Will await results. Does she have any physical limitation such as dyspnea on exertion? 4) 4) Dyspepsia agree with antacid such as cimetidine 400mg bid Gary Jacques
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-----Original Message----- 1. It does sound like allergic rhinitis is a problem here and it may be causing cough by way of post-nasal drip--I would use zyrtec and add a nasal steroid which is the best therapy for allergic rhinitis. Other possible causes--asthma would be a more likely cause for cough and shortness of breath in a young woman who also has allergies. I would prescribe albuterol 2 puffs as needed and see if there is symptomatic relief. I would not use mucomyst which can irritate the airways and make things worse. 2. Cimetidine and anti acids like tums are good for the dyspepsic symptoms. 3. Heart issues--I would confirm the irregularity of the heart rate; is it irregularly irregular (suggesting atrial fibrilation) or just an occasional missed beat? if the former then I would suggest getting an ECG sooner rather than later. An echo at some point may be needed as well, but if her heart rate is in sinus now it can wait. Jonathan Sadeh, M.D.
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Ratanakiri
Provincial Hospital Telemedicine Clinic Patient: NS#0006, 16F, One Village
-----Original Message----- SHCH reply: Pt with goiter and exophthalmoses and amenorrhea presented initially with hyperthyroidism but now after carbimazole therapy she is hypothyroid. Most likely this is Grave’s disease. Please comment whether this is a diffuse goiter or nodular. Recommend: may await TFTs if you like, although February 03 is fairly recent and you could choose to decrease carbimazole now to 2 tabs q day and follow up TFTs in a few months. High dose steroids can help with opthalmopathy but since side effects are high and monitoring is problematic I would not initiate them now. No need for surgery at this point. Gary Jacques
-----Original Message----- Surgical opinion A: Graves' disease goiter Grade II (WHO classification), hypothyroidism under treatment P: I would suggest to decrease the carbimazol, unless the new thyroid tests are back to normal. The patient should be euthyroid over one year treatment. Afterwards, I would try to stop the carbimazole. She has around 20 - 30 % chance of recurrent hyperthyroidism because Grade II goiter. In case of recurrence, I would suggest subtotal thyroidectomy in Phnom Penh, either Norodom Sihanouk hospital(experienced thyroid surgeon available) or Sihanouk hospital Center of HOPE. Because of possible surgical complications, especially permanent hypocalcemia and recurrent nerve damage, I would complete the conservative treatment. Calcium is not easily available in the provinces, very expensive in the pharmacies outside our hospital. The patient has to know as well, that the ophthalmopathy will not improve a lot, even after surgery, you might like to try a short course of steroids high dose though. I hope this suggestion helps. Thanks Dr. Cornelia Haener, Sihanouk hospital Center of HOPE -----Original Message-----
From: Kelleher-Fiamma,
Kathleen M. - Telemedicine Sent: Friday, May 23, 2003 12:54 AM To: 'tmed_rithy@bigpond.com.kh' Cc: Kedar, Iris,M.D. Subject: FW: NS#0006 - The patient has thyrotoxicosis, likely secondary to Graves' disease given her exophthalmos. She has been treated with antithyroid medication with resulting iatrogenic hypothyroidism. Her dose will need to be decreased and her thyroid function tests followed. She will probably need 5 to 10 mg once daily to keep her thyroid function tests in the normal range. The goal is to normalize the TSH. Given the size of the patient's goiter, her disease is unlikely to go into spontaneous remission. She will likely need definitive therapy with either radioactive iodine or surgery. There is no rush to do this, though treatment with carbimazole does carry risks, including the risk of agranulocytosis.
James F. List, M.D., Ph.D.
Thursday, May 22, 2003 Follow-up Report for Ratanakiri TM ClinicNone of the previous patients (in April) returned for this month TM clinic. All six patients seen were new to the TM clinic at Ratanakiri Provincial Hospital (RPH). Per advice sent by Boston TelePartners and Phnom Penh Sihanouk Hospital Center of HOPE, the following patients were managed and treated per local medical staff: [Please note that 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 PP#0001, 24M, Gnok VillageThis patient received all medications from RPH pharmacy as follows:
Health Unlimited (an international NGO) in Ratanakiri brought this patient to the TM clinic and their staff will take the responsibility to get additional supplies of medications to the patient who lives in a very distant village. TM clinician also suggests for the patient to get a spine x-ray (e.g. T10- to sacral) to rule out any spinal lesion relating to Pott’s Dz even if his AFB sputum smear x3 were negative. Also, if the patient’s symptoms do not improve or abate after 14d of treatment, consider starting him on TB medications with referral to RPH DOTS clinic. Patient CC#0002, 39F, One VillageThis patient received all medications from RPH pharmacy as follows:
This patient is being referred to SHCH in Phnom Penh as a surgical case. She will travel on her own and make her own arrangement to stay in Phnom Penh.
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Message----- Dear Dr. Channarith, Concerning patient CC#0002, the surgeon at HOPE examined her and found that the mobile mass is in fact her kidney being strangely mobile for unknown reason. Thus they did not have any plan to surgically treated her. They sent her home with tx of her other medical Gyn problem (yeast infection). Please reassure her again that this is just a variation of normal anatomy. If there is new symptom of severe abdominal pain, she can come to see you even when there is no TM clinic. Please feel free to comment. Rithy Patient SM#0003, 35F, Bey VillageThis patient received all medications from RPH pharmacy as follows:
Discontinue chlorpropramide since negativeU/A dipstick, regular exercise and diet to reduce some weight, information on factors that aggravate GERD symptoms. Patient CN#0004, 40M, Tahourn VillageThis patient received all medications from RPH pharmacy as follows:
Due to high risk of HIV transmission via blood transfusion, it was not recommended that this patient is to receive blood transfusion at this time. Drink copious fluid and return to RPH if new symptoms develop or condition worsen. Patient PN#0005, 37F, One VillageThis patient received all medications from RPH pharmacy as follows:
Prescription was written for patient to buy cetirizine 10mg 1 tab po qd at a local pharmacy.
-----Original Message----- Dear Dr Rithy I am sorry for replying to you late because since we finished the TM clinic on May20,23 ,I had to join the workshop for one week. This morning I try to send the ECG result of the patient PN#0005 to you ,did you receive it yet?.For this patient we gave the citirizine and cimetidine to her on treatment May,23 but she didn't feel better. If you receive,please send me the suggestion. Otherwise the patient CN#0004 received only Folic acid 1tab bid.I can not provide multivitamine and ferrous sulfate to him because since he got folic acid he didn't come back. Best regard Channarith
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From: Rithy Chau [mailto:tmed_rithy@bigpond.com.kh]
Dear Dr. Channarith, I have received your e-mail with the EKG readings of PN#0005 and thank you for the note on Pt. CN#0004. I have discussed the EKG readings with Dr. Bunse at SHCH and agreed that the patient has a unifocal PVC (premature ventricular contraction)seemed like on every sixth beat. Her heart rate is within normal limit and her rythm is regualr except for the occasional PVC. No ischemic changes or any other abnormalities seen. To help with her present symptoms of palpitation and occasional SOB, you can start her on Atenolol 25mg qd and have her coming back on our next TM clinic. (Can she get the medicine there in Ratanakiri? If not, let us know.) Concerning the date for the next clinic in June (24-25), will this be alright with you and your staff? I am cc: this message for our other TM partners as well; if there are any other suggestion from them you and I can discuss more about PN#0005 management. Please tell the patient to continue the other medications even if they don't seem to help her at the moment and tell her that the atenolol may help to relieve her heart symptoms. Again thanks for interacting and if you have a case to work as a TM clinic simulation, please let me know, preferrably during this week or the next week to give us some time to learn the TM process together. Sincerely, Rithy
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Message----- Dear Dr Rithy Thank you for your suggestion quickly. Now I start her on Atenolol 25mg qd from our RPH pharmacy. Concerning the date for the next TM clinic in June(24-25) will be Ok with me and our doctor. Sincerely Channarith
-----Original Message----- Dear Dr. Channarith, Can we get additional lab on PN#0005, we want to know what her potassium level is. You can do chemistry test with creatinine to assess her renal function as well. Let us know if she has any new cardiac symptoms. Also, you can keep this in mind that once her dyspepsia symptoms resolved we can start her on aspirine low dose. Schedule her to come and see us at next TM clinic. Please feel free to comment. Rithy
-----Original Message----- Dear Dr. Channarith, I saw patient NS#0006 today. She came back from seeing an ophthalmologist in Takeo and was given a low dose of prednisolone 15mg QD x 10d for her ptosis/exophthalmos. She said it her mildly after 8 days treatment. We check her lab result from her last visit with us. She is HIV negative, HBs-Ag negative, HCV (Hep C) negative, free T4 of 6 and chemistries with BUN and creatinine and CBC within normal limit. We have already given her Albenazole 400mg bid x 5d to eradicate parasitic infection since she last visited us last week 26 May. Now we start her on a higher dose of prednisolone 40mg po bid x 14d. She will return to see the ophthalmologist in Takeo again scheduled for 7 June and return to see us in 2 weeks. She will continue with the carmimazole 5mg 1 po bid and recheck her thyroid fn. in 1.5 months. Please feel free to comment. Rithy
The next Ratanakiri TM Clinic will held on Tuesday and Wednesday, June 24-25, 2003
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