October 2003 Telemedicine Clinic in Robib
Report and photos
submitted by David Robertson
On Thursday,
October 9, 2003, Sihanouk Hospital Center of Hope nurse Koy Somontha
gave the monthly Telemedicine examinations at the Robib Health
Clinic. David Robertson transcribed examination data and took
digital photos, then transmitted and received replies from several
Telepartners physicians in Boston and from the Sihanouk Hospital
Center of Hope (SHCH) in Phnom Penh.
The following day, all patients returned to
the Robib Health Clinic. Nurse "Montha" discussed advice received
from the physicians in Boston and Phnom Penh with the patients.
Following are the e-mail, digital photos and
medical advice replies exchanged between the Telemedicine team in
Robib, Telepartners in Boston, and the Sihanouk Hospital Center of
Hope in Phnom Penh:
Please reply to David Robertson <dmr@media.mit.edu>
Dear All:
Sorry the October Telemedicine clinic in Robib,
Cambodia had to be delayed a few days (due to my travel schedule,)
but now we are here in the village and the clinic will take place on
Thursday, October 9th.
We'll have the follow up clinic at 8:00am,
Friday, October 10th (9:00pm Thursday in Boston.) Best if we could
receive your e-mail advice before this time.
We will try to depart the village by 9:00am on
Friday as the wet road conditions have made for slower travel (the
travel time between Kampong Thom and Robib was double today, four
hours instead of the usual two hours.)
Thanks again for your kind assistance.
Sincerely,
David
Please reply to David Robertson <dmr@media.mit.edu>
Dear All,
Sorry we were not able to e-mail the cases
yesterday. We could connect from the dish in Robib to the satellite
above, but there was no connection onward from the satellite to the
internet (maybe bad weather on the Thai side of the link.) But we
are on-line now.
Because of the longer travel time, we are
hoping to depart the village in a few hours. Short replies from
SHCH may be best for all in the interest of time. We will also add
the Boston replies to our report and follow up with the patients.
Sincerely,
David
-----
Telemedicine
Clinic in Robib, Cambodia – 9 October 2003
Patient #1: NGET SOEUN, male, 56 years
old, follow up patient
 |
Subject: Patient still has
headache, weakness, no cough, has blurred vision, increased
appetite, no abdominal distension, no stool with blood, no chest
pain, and he has good urination.
Object: Looks stable.
BP: 100/40
Pulse: 80
Resp.: 20
Temp. : 36.5
Weight: 39 kg
Hair, ears, nose, and throat: Okay.
Eyes: Mild pale, no jaundice.
Lungs: Lower bilateral crackle.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, has positive bowel sound
all quadrants.
Limbs: No edema..
Assessment: Cirrhosis. Hepatitis?
C.O.P.D.?
Plan: Keep the same treatment.
- Spironolatone, 50mg, 1/2 tablet
twice daily for 30 days
- Furosemide, 40 mg, 1/2 tablet
daily for 30 days
- Propranolol, 40 mg, 1/4
tablet twice daily for 30 days
- Multivitamin, one
tablet daily for 30 days
Please give me any other ideas.
Please note past history from last month attached below: |
Telemedicine Clinic in Robib, Cambodia – 2 September 2003
Patient #2: NGET
SOEUN, male, 56 years old
Note:
We have seen this patient three
times, last trip we took him to Kampong Thom Hospital for
evaluation. We diagnosed him with Ascitis with cirrhosis and
hepatitis. He was admitted to Kampong Thom Hospital for 19 days,
just discharged yesterday (after we visited him at the hospital.)
The following tests were done:
- CBC (RWC = 6300/mm3,
PN = 61%, PE = 03%, PB = 00%,
Lymphocyte = 36%, MO = 00%
- BS = 70mg/dl
- Malaria = negative
- Transaminase (SGOT =
72ui/l, SGPT = 103 u/l)
- ESR (1h = 90 mm/l, 2h
= 105 mm/l)
- UA (Negative)
- Urine microscope
(present a few white blood cells and a few epithelial cells.)
- Abdominal ultrasound
presented with +3 of Ascitis with cirrhosis
- Chest x-ray
(conclusion = normal)
- Ascitis fluid (WBC =
113/mm3, PN = 42%, L = 58%)
- Rivaltat Test
(Negative)
- They also did Ascitis
drainage of about one litre.)
Medication
during hospitalization: The
doctors at Kampong Thom covered him with some medications:
- Ampicilline, 500mg,
two tablets three times daily for 10 days
- Aldactone, 50mg, one
tablet twice daily for seven days
-
Atenol, 50mg, 1/2 tablet
daily for
seven days
- Kel, one tablet twice
daily for seven days
-
Furosemide, 40 mg, 1/2 tablet
daily for
seven days
-
Multivitamin, one
tablet daily for seven days
- IV fluids such as
D5%, 500ml, four bags
His condition is
much better and he was discharged with prescription for:
- Aldactone, 50mg, one
tablet every three days
-
Multivitamin, one
tablet daily
My assessment today:
Subject:
Patient has decreased shortness of
breath, sometimes cough, no palpitations, has blurred vision, no
fever, has headache, no chest pain, has dizziness, decreasing
abdominal distension, no stool with blood, and good appetite.
Object:
Looks stable. Alert and oriented x
3.
BP: 100/60
Pulse: 68
Resp.: 20
Temp. : 36.5
Hair, ears,
nose, and throat: Okay.
Eyes: Mild pale, mild
conjunctiva jaundice
Lungs: Right lower crackle.
Heart: Regular rhythm, no
murmur
Abdomen: Soft, flat, not
tender, has positive bowel sound all four quadrants,
Limbs: No edema and no
deformity.
Assessment:
Cirrhosis, Ascitis, Hepatitis, Right lung congestion?
Plan: I want to
cover him with:
- Spironolatone,
50mg, 1/2 tablet twice daily for 30
days
- Furosemide,
40 mg, 1/2 tablet daily for 30 days
- Propranolol,
40 mg, 1/4 tablet twice daily for
30 days
Please
give me any other ideas.
Dear David and
Montha,
I am sorry, I did
not see the questions and I thought it is just for our information.
The patient is
documented liver cirrhosis. If the patient does not have edema on
Aldactone 50 mg every three day, I would just continue the same dose
of Aldactone and multivitamine, though it seems strenght that liver
cirrhosis with aldoctone every 3 days.
Regards,
Jennifer/Bunse
Dear
David,
Please see below another opinion from Dr. Ed Ryan regarding pt # 1.
Kimberly A. Lacey
Partners HealthCare System, Inc. - Telemedicine
Office: 617-724-9938; Cell: 617-816-5941
Fax: 617-228-4635
http://www.telemedicine.partners.org
-----Original
Message-----
From:
Ryan, Edward T.,
M.D.
Sent:
Friday, October 10, 2003
9:46 AM
To:
Lacey, Kimberly
Subject:
RE: October 2003
Telemedicine, RESEND, Patient #6: YIM SOKIN, male, 23 years old
very
nonspecific. would consider mild congestive heart failure with
bilateral lower lung crackles (vs primary lung process/fibrosis).
could try 10 mg furosemide a day for a few days and see if any
symptomatic improvement. if no improvement and pulmonary findings
persist, would consider CXR.
Edward T. Ryan,
M.D., DTM&H
Tropical &
Geographic Medicine Center
Division of
Infectious Diseases
Massachusetts
General Hospital
Jackson 504
55 Fruit Street
Boston,
Massachusetts 02114 USA
Administrative
Office Tel: 617 726 6175
Administrative
Office Fax: 617 726 7416
Patient Care Office
Tel: 617 724 1934
Patient Care Office
Fax: 617 726 7653
Email: etryan@partners.org
or ryane@helix.mgh.harvard.edu
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 9 October 2003
Patient #2: THORN KHUN, female, 38 years
old, follow up patient
 |
Subject: Patient still has
palpitations, decreased dizziness, decreased shortness of
breath, and has neck tenderness, no chest pain, no fever,
decreased blurred vision, no abdominal pain, and no diarrhea.
Object: Looks stable. Alert and
oriented x 3 (time, place, person.)
BP: 100/60
Pulse: 100
Resp.: 20
Temp. : 36.5
Wt.: 62 kg
Hair, ears, nose, and throat: Okay.
Eyes: Decreased bilateral exothalsis, decreased pain.
Neck: Goiter the same size as last month, 3 x 6 cm.
Lungs: Clear on both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, positive bowel sound all
four quadrants, fetus (good, moving.)
Limbs: No edema and no stiffness.
Assessment: Toxic goiter. Pregnancy of
eight months.
Recommend: Should we continue
multivitamin tab once daily for another 30 days and add Feso4,
folic acid 200, 25mg, one tab per day? Draw blood for T4 and
TSH test.
Please give me any other ideas.
Please see last month’s assessment that follows below: |
Telemedicine Clinic in Robib, Cambodia – 2 September 2003
Patient #1:
THORNG KHUN, female, 38 years old, follow up patient
Note:
We saw this patient previously and
followed up with her last month. We diagnosed her with toxic goiter
and pregnancy of about 6 months. Rithy Chau of SHCH ordered to draw
blood for T4, TSH and the result showed T4=28 pml/l and TSH = 0.02
microIU/ml. Rithy also ordered us to cover her with a multivitamin,
1 tab daily for 30 days, and to draw her blood again this trip for
T4. Please see her detailed history from July 2003 & August 2003
attached below.
Subject:
Patient still has a little bit of
dizziness, decreased palpitations, decreased blurred vision,
decreased shortness of breath, decreased neck tenderness, no fever,
no cough, no sore throat and no vaginal bleeding.
Object:
Looks stable. Alert and oriented x
3 (time, place, person.)
Wt.: 62 kg
BP: 105/80
Pulse: 94
Resp.: 20
Temp. : 36.5
Hair, ears,
nose, and throat: Okay.
Eyes: Pink conjunctiva, not pale, and no jaundice.
Neck: Goiter the same size
as last month, 3 x 6 cm (not developing.)
Lungs: Clear on both sides,
no crackle and no wheezing.
Heart: Regular rhythm, no
murmur
Abdomen: Soft, no pain,
positive bowel sound all four quadrants, fetus (good, moving.)
Limbs: No edema and no
stiffness.
Assessment:
Toxic goiter. Pregnancy of seven months.
Recommend:
Should we continue multivitamin tab once daily for another 30 days
and draw her blood for T4 as Mr. Rithy suggested, then see her again
next visit? Please give me any other ideas.
History from
July 2003:
Please reply to
David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib, Cambodia – 10 July 2003
Patient #5:
THORNG KHUN, female, 38 years old
Chief complaint:
Patient complains of chest
pain and palpitations on and off for three months.
History of
present illness: Three
months ago she got symptoms of chest pain and palpitations, chest
pain like stabbing. It lasts about 4-5 minutes at a time, and it
happens 3-5 times per two days. Chest pain goes away with massage
or when she leans forward on a chair. Sometime she feels worse at
nighttime. She gets these symptoms accompanied by sweating,
dizziness, headache and sometimes almost fainting. She had never
met a doctor, just came to see us.
Current
medicine: None
Past medical
history: Malaria in 1983.
Family history:
Her mother has hypertension.
Patient has seven children.
Social history:
Unremarkable
Allergies:
None.
Review of
system: Has no fever, no
cough, has chest pain, no diarrhea, has dizziness, and has
palpitations.
Physical exam
General
Appearance: Looks stable.
BP:
130/60
Pulse: 116
Resp.: 22
Temp. : 36.5
Hair, ears,
nose, and throat: Okay.
Eyes: Mild exothalsis.
Neck: Small mass at anterior
neck, mobile, size about 3 x 4 cm.
Skin: Not pale and no
jaundice.
Lungs: Clear both sides,
symmetrical sides.
Heart: Regular rhythm, no
murmur
Abdomen: Soft, flat, not
tender, and has positive bowel sound.
Limbs: Okay
Assessment:
Ischaemic heart disease? Toxic goiter?
Recommend:
Should we draw her blood for Thyroid test like TSH, T4, T3 and give?
- Propranolol, 40mg,
˝ tablet daily
Please
give me any other ideas.
To summarize, the
patient is a 38 year-old female with 3 months of positional chest
pain and palpitations. On examination, she has tachycardia,
exophthalmos, and an anterior neck mass.
The most likely
explanation is thyrotoxicosis, the chest pain and palpitations
representing episodes of atrial fibrillation. I recommend drawing
thyroid function tests and starting a beta blocker. Because of its
short half-life, propranolol should be started at 10 to 20 mg three
times daily.
The positional
nature of the chest pain and its duration also raise the possibility
of chronic pericarditis. If the patient is found to be euthyroid,
this must be further investigated. While there are many potential
etiologies of chronic pericarditis, one must place tuberculosis high
on the list. I would recommend getting an EKG (which may show
diffuse P-R depressions)and a chest X-ray as well as placing a PPD/Mantoux
test.
Cardiac ischemia
secondary to coronary artery disease is unlikely in the described
scenario.
James F. List,
M.D., Ph.D.
Endocrinology,
Massachusetts General Hospital
Dear Montha and
David,
Good morning!
This patient may
have hyperthyroidism from her symptoms, but to me she does not look
like she is having exophthalmos and her thyroid does not look
obvious for an enlargement. Can she go to K. Thom for an EKG and
CXR and some blood work like CBC, cem with BUN, creat and glucose.
Propranolol 10mg bid may help to relieve her symptoms, but I would
check the heart first before the thyroid.
Any domestic
problems at home? Can you also work up to rule out any GI problem
of dyspepsia or GERD? How is her menses? Any GYN complaints?
Thanks,
Rithy (Dr.
Jennifer agreed)
History from
August 2003:
Please reply to
David Robertson <dmr@media.mit.edu>
Telemedicine Clinic in Robib, Cambodia – 12 August 2003
Patient #1:
THORNG KHUN, female, 38 years old
Chief complaint:
Patient still complains of
chest pain sometimes, neck tenderness, and palpitations.
Note:
We sent this patient to Kampong Thom
Hospital last month for consultation and management of her health
problem. Kampong Thom was only able to do something for the stomach
problem, for the goiter they could not do anything as they cannot do
the thyroid function test. They did an unknown blood test and an
EKG. The patient was admitted there for five days and covered with
medication and discharged with chronic gastritis diagnosis.
Subject:
Patient still has palpitations, shortness of breath, sometimes chest
tightness, has a headache, neck tenderness, has no abdominal pain,
no fever, has neck tightness, no hair loss, has sweating, and no
coughing.
Object:
Looks stable.
BP: 110/60
Pulse: 104
Resp.: 20
Temp. : 36.5
Hair, eyes,
ears, nose, and throat:
Okay.
Neck: Small mass at anterior
neck, moveable, size 3 x 6 cm (not developing.)
Lungs: Clear both sides and
symmetry on bilateral size.
Heart: Regular rhythm, no
murmur
Abdomen: Soft, flat, not
tender, and has positive bowel sound
on all four quadrants. She has been pregnant for six months. She
said there is good fetal movement.
Limbs:
No stiffness and no edema.
Assessment:
Toxic goiter? Pregnancy for six months.
Plan: I think we
should draw this patient’s blood and do a Thyroid function test at
Sihanouk Hospital Center of Hope in Phnom Penh, then follow up with
her next month. Please give me any other ideas.
Patient #1 Thorng
Khun, 38F
We think the
patient is clinically euthyroid but we need to rule out this
problem. You can draw her blood to do a TSH and free T4 at SHCH.
If her symptoms are tolerable without medications, this is better
since she is pregnant. Wait for her TSH and free T4 before
considering any medication. Her sx could have come from pregnancy
itself. What you can give her is multivitamins with iron and folate
(prenatal vitamins) taken qd with meal. Find out also what exactly
happended at K Thom Hosp. and her lab results, etc.
> -----Original
Message-----
> From: Kvedar,
Joseph Charles,M.D.
> Sent: Tuesday,
August 12, 2003 9:17 PM
> To: Kelleher-Fiamma,
Kathleen M., Telemedicine
> Subject: RE:
Patient #1: THORNG KHUN, female, 38 years old
>
> Thank you for
this interesting case.
>
> Patient #1 38 yo
female with chest pain, palpitations
> and neck
mass/tenderness.
>
> General
recommendations regarding the report:
>
> Review of
symptoms and physical exam ; any other
> symptoms
consistent with thyroid disease? (ie
> diarrhea,
nervousness, trembling, moist skin)
> (hyperrelexia?)
> Was EKG normal?
>
> The constellation
of symptoms presented does suggest
> hyperthyroidism
of some kind.
>
> 1. Acute
thyroiditis (also called DeQuervain's
> throiditis) often
presents with pain and often follows
> a viral illness.
is therefore quite possible in her.
> 2. Toxic goiter
or toxic adenoma are also possible in
> that a nodule was
apparently identified on exam.
> 3. Graves disease
is usually a diffuse painless goiter
> and is therefore
less likely.
>
> If at all
possible have thyroid studies completed
> somewhere (TSH,
free T4, T3 re-uptake) would be a
> good start. A
thyroid scan (radioactive iodine
> uptake)- if
available- would be next if she is indeed
> hyperthyroid to
differentiate the possible causes -
> BUT SHOULD NOT BE
USED IN PREGNANT PATIENTS.
>
> Recommendations:;
> 1. Patients
with thyroiditis usually improve on
> their own.
Management of non-pregnant patients
> includes treating
the symptoms if they are severe
> (tachycardia,
nervousness) with beta blockers such as
> propanolol.
Also, prednisone 20mg to 40mg for a short
> course often
gives rapid relief of pain associated
> with painful
thyroiditis but often not recommended
> during pregnancy.
> Propylthiouracil
is the drug of choice in pregnant
> patients with
hyperthyroidism. Typical initial dose
> is 100mg per day
and may increase to three times per
> day. Symptoms
usually improve in 2-3 weeks.
> 2. If not done
already, rule out anemia as a
> contributing
cause with a CBC
>
Joseph C. Kvedar,
M.D.
Dear David and
Montha,
Rithy is busy with
employee health clinic today, so I help him for this month Robib
telemed.
The patient has
hyperthyroidism and pregnancy (8 months now). T4 = 28 around July
2003. She is on multivitamin, FeSO4/Folic acid.
It is good that she
is now better. Usually in pregnant hyperthyroidism, we keep T4
between 20-30 (NL lab in SHCH is < 20), that is a little bit high.
This is to avoid
fetal hypothyroid, which is bad. I agree with you to continue only
multivitamin and FeSO4/Folic acid, check T4 now and follow-up T4
month 9 and month 10 (after delivery). Where is she going to give
birth? I hope at health clinic or hopsital.
Regards,
Jennifer/Bunse
-----Original Message-----
From:
List, James
Frank,M.D.,Ph.D.
Sent:
Friday, October 10,
2003 10:18 AM
To:
'mailto:dmr@media.mit.edu';
Kelleher-Fiamma, Kathleen M., Telemedicine
Subject:
RE: October 2003
Telemedicine Patient #2: THORN KHUN, female, 38 years old
The patient has improving symptoms but still has
palpitations and neck tenderness. She is now 6 months pregnant. Her
thyroid function
tests when checked were indicative of thyrotoxicosis,
with an elevated T4 and a suppressed TSH.
It is important to get as close to euthyroid in
this patient as possible because of the increased rate of
obstetrical complications in hyperthyroid patients, including
abortion, stillbirth, and premature labor. Again, the neck
tenderness suggests thyroiditis, though Graves' and toxic nodular
goiter are possible. If the patient continues to be thyrotoxic at
this point, the duration of the thyrotoxicosis would suggest Graves'
or toxic nodular goiter.
Recommend: Recheck thyroid function
tests.
If continued thyrotoxicosis, begin therapy with antithyroid drugs.
In the United States, we use propylthioruracil in pregnant patients,
but carbimazole and methimazole are commonly used in other countries
and are acceptable. The dose depends on the level of thyrotoxicosis,
and it is important to recheck thyroid function tests every 1 to 2
weeks until she is stably euthyroid. Optimally, T4, Free T4, T3, and
TSH will be checked. At a minimum, T4 and TSH will be checked. Of
note, the patient may be found to be euthyroid or hypothyroid on
repeat labs (this is possible if the etiology of the thyrotoxicosis
was thyroiditis). The former should be followed with laboratory
testing
over time as a hypothyroid phase may ensue; the latter would need to
be treated with L-thyroxine.
In addition, would continue MVI, iron, and folic
acid. The case also mentions 25 mg one tab per day, but does not
state what the medication is - therefore no recommendation can be
made for this. If it is atenolol, it is fine to continue if the
patient is thyrotoxic, and should be tapered off if the patient is
euthyroid or hypothyroid.
James List, M.D., Ph.D.
Endocrinology
Massachusetts General Hospital
> -----Original Message-----
> From: Kelleher-Fiamma, Kathleen M.,
Telemedicine
> Sent: Friday, October 10, 2003 6:48 AM
> To: List, James Frank,M.D.,Ph.D.
> Cc: Lacey, Kimberly; Lugn, Nancy E.
> Subject: FW: October 2003 Telemedicine
Patient #2: THORN KHUN,
> female, 38 years old
>
> Hi Dr. List:
>
> This case is a follow-up case that you did
previously.
>
> If you will be unable to complete, please
inform Kim Lacey who is cc'd on
> this message as I will be out of the office.
>
> Best,
>
> Kathy
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 9 October 2003
Patient #3: MEAS PHARY, female, 38 years
old
 |
Chief complaint: Small wound on the
left side of the neck for the last two months.
Subject: Patient has small mass on
the left side of the neck, mass has become itchy with redness.
Patient scratched the area and then bleeding and oozing came
out. From that time, it has been bleeding on and off
accompanied by pain and hardness around it. She has never
consulted with anyone about this problem until now.
Past medical history: In May 2001
she came to see us and Dr. Gumley of Sihanouk Hospital suggested
that she go on her own to the hospital to do a Thyroid test
(patient did not follow up.)
Social history: No smoking and no
drinking alcohol.
Family history: Unremarkable.
Allergy: None known.
Current medicine: Took ampicilline
one gram twice daily for 12 days and just stopped one week ago.
Review of system: No sore throat, no
weight loss, no cough, no fever, no chest pain, has shortness of
breath sometimes, no abdominal pain, and has regular periods.
Object: Looks stable.
BP: 100/60
Pulse: 84
Resp.: 20
Temp. : 36.5
Weight: 51 kg
Hair, eyes, ears, nose, and throat: Okay.
Neck: Mass on the anterior neck, 5 x
6 cm and mobile, no pain. Another small mass on the left side
about 1 x 1 cm, has pain and mild redness, but not lymph node.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, has
positive bowel sound all four quadrants.
Limbs: Okay
Assessment: Simple goiter? Small left
side neck wound.
Plan: May we refer her to Kampong Thom
Hospital for consultation with surgeon? Please give me
any other ideas. |
Dear David and
Montha,
1. Goiter: It sounds
and looks like euthyroid goiter. It looks small and no compression
symptoms, probably no need to do anything now.
2. Wound:
Interesting. I agree with you to refer to K.Thom. I think they would
do biopsy, if this is the case we can provide formaldehyde liquide
to store the biopsy tissue and bring to SHCH, and we can ask advice
from pathologist through telepathology service (University of
Basel).
Regards,
Jennifer/Bunse
Hello David... please see below one more
consult for you...
Kimberly A. Lacey
IS Financial Coordinator
Partners Healthcare System - Telemedicine
Phone: 617-724-9938; Mobile: 617-816-5941
Pager: 617-724-5700, ID# 32799; Fax:
617-228-4635
http://www.telemedicine.partners.org
-----Original Message-----
From: Tan, Heng Soon,M.D.
Sent: Friday, October 10, 2003 3:31 PM
To: Kelleher-Fiamma, Kathleen M., Telemedicine
Subject: RE: October 2003 Telemedicine Patient
#3: MEAS PHARY, female,
38 years old
She has 2 separate problems. She has most
likely a simple goiter if the mass is homogenous [not nodular] and
midline. If it is only one enlarged lobe, then it could be a nodule.
I would screen for hyperthyroid symptoms [weight loss, smooth skin,
glossy hair, increased sweating, insomnia, irritable mood, increased
appetite and energy, irregular menstrual pattern, increased bowel
frequency, tremors] or hypothyroid symptoms [weight gain, dry skin,
dry hair with alopecia, increased sleep, depressed mood, lethargy,
heavier menses, constipated bowel habits, muscle aches]. If she has
none of these, she is likely euthyroid. Blood testing with TSH will
confirm the diagnosis. Suppression of euthyroid simple goiter with
l-thyroixine may be useful cosmetically. Iodinated salt should be
used.
As for the discharge, I would be concerned
about scrofula or tuberculosis with infected underlying lymph node
and discharging sinus. The sinus tract could also be draining an
apical tooth abscess if she has a toothache. The posterior position
of the sinus tract would be against infected branchial cyst sinus.
Besides tuberculosis, actinomycetes and
nocardia bacterial infection should be considered. Diagnosis is made
by AFB stain, gramstain and culture for TB and bacteria using a swab
from the sinus tract. PPD or Mantoux skin test could be useful.
Appropriate antibiotics are available once diagnosis is established.
HS
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 9 October 2003
Patient #4: THO CHANTHY, female, 36
years old, follow up patient
 |
Chief complaint: This patient
complains of still having palpitations sometimes and headache.
Subject: Patient sometimes has
palpitations and shortness of breath, has a headache, increased
weight (5 kg gain in one month,) increased appetite, good sleep,
no fever, no chest pain, decreased neck tightness, decreased
tremors, no abdominal pain, no diarrhea, increased thirst,
decreased tremor in extremities.
Object: Looks stable.
Weight: 49kg
BP: 120/60
Pulse: 84
Resp.: 20
Temp. : 36.5
Hair, ears, nose, and throat: Okay.
Eyes: Less pain, decreased bilateral exothalsis.
Neck: Goiter size, 10 x 8 cm, no JVD.
Lungs: Clear both sides, no crackle or wheezing.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, has
positive bowel sound all four quadrants.
Limbs: No edema and less tingling.
Assessment: Toxic Goiter. Afib
resolved? Muscle pain.
Plan: Should we cover her with the same
meds the next 30 days?
- Carbimazole, 5mg, one tablet three
times daily
- Propranolol, 40mg, 1/4 tablet twice
daily
- Aspirin, 300mg, 1/4 tablet
daily
- Multivitamin, one tablet daily
Also draw her blood for T4 and TSH to be
done at SHCH. Please give me any other ideas and see past
history from last month: |
Telemedicine
Clinic in Robib, Cambodia – 2 September 2003
Patient #5: THO
CHANTHY, female, 36 years old
Chief complaint:
This patient still complains of palpitations and headache.
Note:
We sent this patient to Kampong Thom Hospital last month to begin
management of her Hyperthyroidism and Afib. Last month we also drew
her blood in the village to test at Sihanouk Hospital Center of Hope
for T4 and TSH. T4 = >88pml/l, TSH = < 0.02 micro IU/ml. She was
admitted to Kampong Thom Hospital for 19 days and they covered her
with following medications:
- Carbimazole, 5mg, one
tablet three times daily
-
Atenolol, 50mg, 1/2 tablet
daily
-
Aspirin, 500mg, 1/2 tablet
daily
- Almac, 500mg, one
tablet three times daily
-
Vitamin B, B6, B12,
one tablet twice daily
Kampong Thom
Hospital did some blood tests for her:
- CBC & cell count
- WBC = 5.200/mm3
- PN = 63%
- PE = 03%
- PB = 00%
- Lymphocyte = 34%
- Monocyte = 00%
- BS = 76mg/dl
Neck Ultrasound:
Showed Thyroid gland
enlarged, size 64 x 50 x 20 mm, conclusion was diffuse goiter.
EKG:
Done on 14 August 03 showed HR about
138/min. and Afib. EKG attached.
Chest x-ray:
Showed cardiomegalie.
She was discharged
from Kampong Thom Hospital yesterday and the doctors asked her to
continue meds as:
- Carbimazole, 5mg, one
tablet daily in the morning
-
Aspirin, 300mg, 1/2 tablet
daily
- Propranolol, 50mg,
1/2 tablet daily
My assessment today:
Subject:
Patient still has palpitations,
decreasing shortness of breath, increased sleepiness, increased
appetite, decreased blurred vision, decreased neck tightness,
abdominal pain sometimes, no stool with blood, no edema in legs,
increased weight.
Object:
Looks stable, alert and oriented x
3.
Weight: 44kg
BP: 120/60
Pulse: 90
Resp.: 22
Temp. : 36.5
Hair, ears,
nose, and throat: Okay.
Eyes: Still bilateral
exothalsis, decreased pain.
Neck: Goiter the same size,
not developing, no JVD.
Lungs: Clear both sides.
Heart: Irregular rhythm, no
murmur
Abdomen: Soft, flat, not
tender, has positive bowel sound all four quadrants.
Limbs: No edema and no
stiffness but still have both hands tingling.
Assessment:
Toxic Goiter. Afib.
Plan: Should we
cover her for the next 30 days with:
- Carbimazole, 5mg,
two tablets daily
- Propranolol, 40mg,
1/4 tablet twice daily
- Aspirin,
300mg, 1/4 tablet daily
- Multivitamin, one
tablet daily
Also draw her
blood for T4 as Dr. Bunse & Mr. Rithy of SHCH suggest? Follow the
prescription that Kampong Thom Hospital suggested. Please give me
any other ideas.
Dear David and
Montha,
Hi, I am back from
Belgium, after 1 month training course in September 2003 for HIV
care, ARV, and telemedicine. It was cold there but not really muddy
like Cambodia. How are you in Robib, very busy?
Hyperthyoid patient
with irregular heart rhythm. She patient is on carbimazole 5 mg TID
with propranolol and aspirin. she is better now with regular heart
rhythm, but T4 last month > 88. I would keep her the same
mediciation, but I think she does not need multivitamin. You may
check her T4 next month, not this month.
Good jobs,
Jennifer/Bunse
In summary, the patient had thyrotoxicosis and
atrial fibrillation with a diffuse goiter. She was started on
treatment with carbimazole and propranolol in August. She has had
normalization of her heart rhythm, though still has episodes of
palpitatons. She has had weight gain. She has muscle pain listed in
her assessment (not in her history). Her photos show a large goiter
and no stare.
The patient has been successfully treated for
Graves' disease with antithyroid medication and beta-blockade. She
will need to continue on antithyroid medication unless she has
definitive therapy with radioactive iodine or with surgery. She can
taper off the propranolol when she becomes biochemically euthyroid.
The thyroid status of the patient is hard to
tell. She has decreased (?but still present) tremor and occasional
palpitations. These would argue that she is still thyrotoxic. She
has weight gain and muscle pain. These would argue that she has been
overtreated and is now hypothyroid. And, of course, she may actually
be euthyroid.
TSH and T4 should be checked:
- If TSH low and T4 high, she should maintain
her current medication and have her laboratory studies rechecked in
2 to 4 weeks.
- If TSH low or normal and T4 normal, she
should taper down to carbimazole 5 mg twice daily, taper off
propranolol, and have her laboratory studies rechecked in 2 to 4
weeks
- If If TSH elevated and T4 normal or low, she
should taper down to carbimazole 5 mg once daily, taper off
propranolol, and have her laboratory studies rechecked in 2 to 4
weeks
Given that she still has palpitations, aspirin
should be continued in case this represents paroxysmal atrial
fibrillation.
A multivitamin is always a good idea, but make
sure it does not also contain supplemental iodine.
James F. List, M.D., Ph.D.
Endocrinology, Massachusetts General Hospital
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 9 October 2003
Patient #5: SEANG VASNA, female, 31
years old
 |
Chief complaint: Mass on the left
breast for three months.
Subject: Patient has known mass on
the left breast for three months. She went to a traditional
doctor for advice and they told her to steam it with a warm
rock. After doing that it decreased in size on and off.
Sometimes she has strong pain on it. Mass is not developing and
it has a regular border and isn’t accompanied by any other
signs.
Past medical history: Unremarkable.
Family history: Her mother died of
hypertension.
Social history: Widow with two
children.
Allergy: None known.
Current medicine: None.
Review of system: No sore throat, no
weight loss, no cough, no chest pain, no shortness of breath, no
fever, no palpitations, no abdominal pain, and no diarrhea.
Object: Looks stable, oriented x 3
(place, person, and time.)
BP: 100/60
Pulse: 80
Resp.: 20
Temp. : 36.5
Hair, eyes, ears, nose, and throat:
Okay.
Skin: Not pale and no jaundice.
Neck: No goiter and no lymph node.
Lungs: Clear both sides.
Heart: Regular rhythm, no murmur
Abdomen: Soft, flat, not tender, has
positive bowel sound all four quadrants.
Limbs: Okay.
Breast: Left breast has mass, size
about 3 x 4 cm and mobile, has pain during palpitations, redness
on the left side caused by steaming.
Assessment: Left breast mass. Left
breast tumor?
Plan: May we refer her to Kampong Thom
Hospital for consultation with surgeon and do a breast
ultrasound? |
Dear David and
Montha,
I agree with you to
refer to K.Thom, I would request biopsy if possible for pathology
finding. It may be a cancer, but less likely due to the fact that it
decreases the size on and off after the steaming. She should stop
that.
It could be
mastitis, so meanwhile you may try indomethacine 25 mg P.O TID with
food and cloxacilline 500 mg QID for 7 days.
Regards,
Jennifer/Bunse
Patient #5 Seang Vasna 31 yo female
Thank you for this interesting patient.
Summary: 31 year old female with a palpable
breast mass for the past 3 months. It apparently is variable
in size but measures approximately 3X4 cm, intermittently tender,
and is mobile.
More complete history might include the
following:
* Description of nipple (inverted?
Drainage?)
* Secondary signs such as breast asymmetry or skin changes.
* Presence or absence of axillary lymph nodes
* Fever (as with an abcess)
* Relationship of symptoms to her period
* Whether a mammogram was ever done in the past
It appears there may be some breast skin
changes on the digital image similar to peau d'orange (orange
peel)and that makes it more suspicious for cancer.
Because the most serious consideration is of
course breast cancer. Risk factors for breast cancer should be
evaluated. These include:
* Age over 50
* Personal or family history of breast cancer or other cancers
* Early menarche (before age 12)
* Late menopause (after 50)
* Overweight
* Childless or first pregnancy after age 30
These could be explored. (I realize she has no
children, but I don't know if she was ever pregnant)
Because her mass isn't subtle it may be
considered a "dominant mass" - particularly if it persists
throughout the menstral cycle. The initial objective is to
determine if it is cystic or solid mass.
One approach is to consider initially
aspirating the mass with a needle by someone comfortable with
this procedure. A simple breast cyst has a low probability of being
malignant and may resolve from this procedure. If there is no
resolution of the mass within 7 days or if the mass is appears to be
solid, the breast should be evaluated by ultrasound or mammogram as
soon as possible. (In women less than 35, breasts may be more
difficult to image by mammogram so ultrasound is probably the best
way to go.) If aspirated fluid is bloody or if solid, early consult
with a surgeon is recommended.
The other approach is to go directly for the
ultrasound. If it is cystic, it can be considered low probability
for malignancy and may then be treated with either aspiration or by
serial breast exams to confirm that it is resolving.
She doesn't seem to have many risk factors for
cancer, but because of the size and what appears to be skin changes
on the image, the ultrasound to differentiate a cystic from a solid
mass sounds like a good first step, with a possible early surgical
consult if it appears to be solid seems like a good approach. If
needed, the surgeon will likely do either a needle biopsy, or
excisional or incisional biopsy.
Please feel free to contact me with any further
questions.
Paul Heinzelmann, MD
