|
   
September
2003 Telemedicine Clinic in Robib
Report and photos submitted by
David Robertson
On Tuesday,
September 2, 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:
From: dmr@media.mit.edu <dmr@media.mit.edu>
To: Kvedar, Joseph Charles,M.D. <JKVEDAR@PARTNERS.ORG>;
Paul
Heinzelmann (E-mail) <ph2065@yahoo.com>;
Kelleher-Fiamma, Kathleen M., Telemedicine <KKELLEHERFIAMMA@PARTNERS.ORG>;
Lugn, Nancy E. <NLUGN@PARTNERS.ORG>; Gary Jacques <gjacques@bigpond.com.kh>;
Jennifer Hines <sihosp@bigpond.com.kh>; Rithy Chau <tmed_rithy@bigpond.com.kh>;
Bunse Leng <tmed1shch@bigpond.com.kh>; dmr@media.mit.edu
<dmr@media.mit.edu>
CC: Brandling-Bennett, Heather A. <HBRANDLINGBENNETT@PARTNERS.ORG>;
Dr. Srey Sin <012905278@mobitel.com.kh>; aafc@forum.org.kh
<aafc@forum.org.kh>; Bernie Krisher <bernie@media.mit.edu>
Sent: Mon Sep 01 06:06:22 2003
Subject: Reminder, Cambodia Telemedicine,
September 2nd, 2003
Please reply to David Robertson <dmr@media.mit.edu>
Dear All:
A quick reminder that the September
Telemedicine clinic in Robib, Cambodia is still scheduled for Tuesday, 2
Septmeber 2003.
We'll have the follow up clinic at 8:00am,
Wednesday, 3 September (9:00pm, Tuesday, 2 September in Boston.)
Best if we could receive your e-mail advice before this time.
Thanks again for your kind assistance.
Sincerely,
David
Date: Tue, 2 Sep 2003 05:46:22 -0400
From: dmr@media.mit.edu
To: JKVEDAR@PARTNERS.ORG, "Paul
Heinzelmann, MD" <pheinzelmann@PARTNERS.ORG>,
"Kelleher-Fiamma, Kathleen M. - Telemedicine" <KKELLEHERFIAMMA@PARTNERS.ORG>,
"Lugn, Nancy E." <NLUGN@PARTNERS.ORG>, "Gary
Jacques" <gjacques@bigpond.com.kh>, "Jennifer
Hines" <sihosp@bigpond.com.kh>, "Rithy Chau"
<tmed_rithy@online.com.kh>, "Bunse Leng"
<tmed1shch@bigpond.com.kh>, dmr@media.mit.edu
CC: "Brandling-Bennett, Heather A."
<HBRANDLINGBENNETT@PARTNERS.ORG>, tmed_montha@online.com.kh,
aafc@forum.org.kh, "Bernie Krisher" <bernie@media.mit.edu>
Subject:
September 2003 Telemedicine Patient #1: THORNG KHUN,
female, 38 years old
Please reply to David Robertson <dmr@media.mit.edu>
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, ½ 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.
From:
"Kelleher-Fiamma, Kathleen M., Telemedicine" <KKELLEHERFIAMMA@PARTNERS.ORG>
To: "'dmr@media.mit.edu'"
<dmr@media.mit.edu>
Subject: RE:
September 2003 Telemedicine Patient #1: THORNG KHUN, female, 38
years old
Date: Tue, 2 Sep
2003 20:04:25 -0400
-----Original
Message-----
From: Kvedar,
Joseph Charles,M.D.
Sent: Tuesday,
September 02, 2003 8:00 PM
To:
Kelleher-Fiamma, Kathleen M., Telemedicine
Subject: RE:
September 2003 Telemedicine Patient #1: THORNG KHUN,
female, 38 years old
_______________________________________
Patient #1: THORNG KHUN, female, 38 years old, follow up
patient
approximately 7
months pregnant with apparent toxic goiter /
hyperthyroidism.
Thank you for this
interesting case. Mr.
Rithy's recommendation of
a multivitamin is a
good one and should continue through pregnancy and into breastfeeding.
I also agree with drawing her T4 again.
(Note: drawing the FREE T4 is
preferred over the total T4 if available, as pregnant euthyroid patients
may have falsely high total T4).
I am glad we got the TSH and T4 results as hyperthyroidism
in pregnancy may be
difficult to diagnose on clinical grounds alone since
many of the signs of
hyperthyroidism are also seen with normal pregnancy,
such as: (Heat
intolerance diaphoresis,warm skin, fatigue, anxiety, emotional lability, tremulousness,
tachycardia, wide pulse pressure)
The
low TSH of 0.02 mcgU/ml and elevated T4 is diagnostic of
hyperthyroidism and
supports your diagnosis of toxic goiter.
Note that Low TSH in pregnancy can also be seen in : Graves
disease ? Toxic
adenoma ? Hyperemesis
gravidarum ?
Gestational
trophoblastic
neoplasia ?
Metastatic follicular cell carcinoma
? De
Quervain's
thyroiditis ? Silent lymphocytic thyroiditis
? Struma ovarii
?
Hydatidiform mole
Toxic multinodular goiter, or solitary toxic nodule
?Antithyroid drugs should be used (radioactive iodine and
thyroidectomy are
contraindicated in pregnancy)
?Fine needle aspiration is often done on solitary nodules
to
rule out cancer, but
it is relatively rare in pregnant patients and
likely
not available in
Phnom Penh.
?Regardless of the cause of hyperthyroidism, untreated
pregnant patients
have a higher incidence of preterm delivery,
perinatal
mortality, and
maternal heart failure. So we should treat her with
medication.
Propylthiouracil (PTU)
?A reasonable starting dose could be 100 to 150 mg q 8
hours,
but may need up to
900 mg per day.
?Free T4 and/or T3 should be rechecked in 2-3 weeks to make
sure that she hasn't
become hypothyroid from the medicine - which puts
the
baby at risk. Free
T4 should ideally be maintained just high of normal
(ie.Free T4= 2.5;
Total T4(RIA)= 13; TSH= .3)
?Once serum thyroid hormone levels return to normal, it is
necessary to
decrease the dosage to 50-300 mg daily for PTU in divided
doses. When doses of
PTU are > 300 mg/day fetal goiter and
hypothyroidism
may result. TSH
levels should be checked every 3-4 weeks to assess
thyroid
function. The free
T3 and T4 levels should ideally be just above the
normal
range.
?
?Side effects of PTU are not common but include: rash
(10%),
fever, metallic
taste, bronchospasm, oral ulcerations, hepatitis,
lupus-like
syndrome.
Agranulocytosis occurs in about 0.1 per cent of patients.
Beta Blockers
?Control of adrenergic symptoms such as tachycardia only if
necessary.
Probably best to avoid if possible.
?Propanolol 20 to 40 mg BID or TID
?Atenolol 50 to 100 mg qd. To keep maternal heart rate at
80-90 BPM.
?Prolonged use puts fetus at risk for IUGR, fetal
bradycardia,
hypoglycemia, and subnormal response to hypoxemic stress.
What about the baby?
?Neonatal hyperthyroidism occurs in < 2% of infants born
to
hyperthyroid
mothers.
?Since infants are protected during gestation by the
antithyroid
medication received by the mother, symptoms occur only
after
delivery when the
beneficial effect of the antithyroid medication is
gone.
?These infants should be followed closely for the first 2
weeks after
delivery.
Assessment:
1.
Probable toxic goiter / hyperthyroidism
2.
Third trimester Pregnancy
Plan:
1.
Begin low dose of PTU (i.e. 100mg or 150mg q 8 hours).
Takes
at least a week to
work.
2.
Recheck T4 after 2 weeks on the medication and adjust PTU
dose as necessary
attempting to keep the level just above normal range.
Check the normal
ranges of your lab but would likely be as follows: free T4
about 2.5, Total T4
in range of 13.
3.
Repeat T4 every 3 weeks until delivery and adjust PTU
accordingly.
4.
Once serum thyroid hormone levels return to normal, it is
necessary to
decrease the PTU dosage to 50-300 mg daily in divided doses.
When doses of PTU
are > 300 mg/day and are taken long term, fetal goiter and
hypothyroidism may
result.
5.
TSH levels could also be checked every 3-4 weeks to assess
thyroid function.
6.
Draw baseline CBC if not already done.(PTU can cause
changes
in CBC)
7.
Follow infant closely after delivery for 2 weeks for signs
of hypothyroidism.
8.
Please provide us an update on her condition for continued
follow-up.
Joseph C. Kvedar,
M.D.
Date: Tue, 2 Sep 2003 05:50:41 -0400
From: dmr@media.mit.edu
To: JKVEDAR@PARTNERS.ORG, "Paul
Heinzelmann, MD" <pheinzelmann@PARTNERS.ORG>,
"Kelleher-Fiamma, Kathleen M. - Telemedicine" <KKELLEHERFIAMMA@PARTNERS.ORG>,
"Lugn, Nancy E." <NLUGN@PARTNERS.ORG>, "Gary
Jacques" <gjacques@bigpond.com.kh>, "Jennifer
Hines" <sihosp@bigpond.com.kh>, "Rithy Chau"
<tmed_rithy@online.com.kh>, "Bunse Leng"
<tmed1shch@bigpond.com.kh>, dmr@media.mit.edu
CC: "Brandling-Bennett, Heather A."
<HBRANDLINGBENNETT@PARTNERS.ORG>, tmed_montha@online.com.kh,
aafc@forum.org.kh, "Bernie Krisher" <bernie@media.mit.edu>
Subject:
September 2003 Telemedicine Patient #2: NGET SOEUN, male,
56 years old
Please reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 2 September 2003
Patient #2: NGET SOEUN, male, 56 years ol
|
|
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. |
From: "Goldszer,
Robert Charles,M.D." <RGOLDSZER@PARTNERS.ORG>
To: "Kelleher-Fiamma,
Kathleen M., Telemedicine" <KKELLEHERFIAMMA@PARTNERS.ORG>,
"'dmr@media.mit.edu'" <dmr@media.mit.edu>
Subject: RE:
September 2003 Telemedicine Patient #2: NGET SOEUN, male, 56 years
old
Date: Tue, 2 Sep
2003 17:05:25 -0400
Sounds to me like I
would continue his current medications.
His condition is
much better and he was discharged with prescription for:
-Aldactone,
50mg, one tablet every three days
-Multivitamin, one
tablet daily
I would add Weight
of patient once a week for 2-3 weeks, to be sure he is not
reacumulating too much fluid.
No alcohol or liver
toxic medications or foods
Repeat ultrasound of
abdomen and liver in 6-8 weeks if he remains stable.
RCGoldszer
Telemedicine
Clinic in Robib, Cambodia – 2 September 2003
Patient #3: CHHOUK THOM,
male, 34 years old
 |
Chief
complaint: Convulsions two times last month.
Subject:
HPI.
Last July, patient got malaria.
He was treated with modern medicine at the local
health center. In
the last month he got malaria again.
He also went to see the medical assistant at the
Phnom Dek health center.
He was treated again by malaria medication.
Ten days later after he had the last malaria, he had
convulsion, first with contractions on the right hand and
right leg, then radiating to whole body, especially to the
head. After
that he became unconscious for about 30 minutes and then he
awoke. His
family helped him with massage during unconsciousness. He
gets this convulsion accompanied by headache and dizziness,
blurred vision, and neck tenderness.
Past
medical history: He’s had good health in previous
times, no operations.
Social
history: Does not smoke, does not drink alcohol.
Family
history: Unremarkable.
Allergy:
No known allergies.
Current medication:
None
Review
of system: No sore throat, has lost weight about 4 kg
during last 6 weeks, no fever, no shortness of breath, no
cough, no chest tightness or pain, has upper abdominal pain,
no stool with blood and no diarrhea.
Object: Looks okay.
Alert and oriented x 3.
Weight: 45 kg
BP: 110/60
Pulse: 68
Resp.:
20
Temp.
: 36.5
Hair,
eyes, ears, nose, and throat: Okay.
Skin:
Not pale, no
jaundice, warm to touch
Neck:
No goiter and no
lymph node.
Lungs:
Clear both
sides.
Heart:
Regular rhythm,
no murmur
Abdomen:
Soft, flat, not tender, has upper abdominal pain,
positive bowel sound all four quadrants.
Limbs:
No edema, no stiffness, and no deformity.
Neuro Exam:
- Mental
good orientation (person, place and date)
- Cerebella
function, good intact
- Reflex,
hyper reflexive on both elbows and on the right knee
3/2, others are normal
- Motor,
normal 5/5
- Sensory,
normal
Assessment: Epilepsy secondary to
malaria complication? Hypocalcaemia?
Dyspepsia.
Plan: Can we cover him with Tums, 1
gr twice daily for one month and observe his convulsion next
trip? Ask him to do some exercise.
Please give me any other ideas.
|
Date:
Tue, 2 Sep 2003 10:56:06 -0400
From:
dmr@media.mit.edu
To:
JKVEDAR@PARTNERS.ORG, "Paul Heinzelmann, MD" <pheinzelmann@PARTNERS.ORG>,
"Kelleher-Fiamma, Kathleen M. - Telemedicine" <KKELLEHERFIAMMA@PARTNERS.ORG>,
"Lugn, Nancy E." <NLUGN@PARTNERS.ORG>, "Gary
Jacques" <gjacques@bigpond.com.kh>, "Jennifer
Hines" <sihosp@bigpond.com.kh>, "Rithy Chau"
<tmed_rithy@online.com.kh>, "Bunse Leng"
<tmed1shch@bigpond.com.kh>, dmr@media.mit.edu
CC:
"Brandling-Bennett, Heather A." <HBRANDLINGBENNETT@PARTNERS.ORG>,
tmed_montha@online.com.kh, aafc@forum.org.kh, "Bernie Krisher"
<bernie@media.mit.edu>
Subject:
September 2003 Telemedicine Patient #4: SUM SENG, male, 25
years old
Please
reply to David Robertson <dmr@media.mit.edu>
Telemedicine
Clinic in Robib, Cambodia – 2 September 2003
Patient #4: SUM SENG,
male, 25 years old
 |
Chief
complaint: Upper abdominal pain on and off for two
months.
Note:
We saw this patient last in March 2002.
He was diagnosed with dyspepsia.
We covered him with TUMS; 500mg three times daily for
two months and then dismissed him.
Subject:
HPI.
Patient got upper abdominal pain on and off for two
years, pain radiating to the back, pain like stabbing
sometimes, especially after a meal.
He gets these symptoms accompanied by excessive
saliva and nausea in the morning.
Past
medical history: Dyspepsia in March 2002.
Social
history: Unremarkable.
Family
history: Unremarkable.
Allergy:
None.
Current medicine:
None.
Review
of system: No fever, no sore throat, no weight loss, no
shortness of breath, no cough, no chest pain, has upper
abdominal pain, no stool with blood and has diarrhea
sometimes.
Physical exam: Looks stable.
Weight:
49 kg
BP: 90/50
Pulse: 70
Resp.:
20
Temp.
: 36.5
Hair,
eyes, ears, nose, and throat: Okay.
Skin:
Not pale, warm
to touch, 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.
Assessment:
Dyspepsia, Parasitis.
Plan: Should we cover him with Tums,
1 gram twice daily for one month and also try Albendazole,
100mg twice daily for three days?
Give advice about food and exercise.
Please give me any other ideas.
|
Date: Tue, 2 Sep 2003 11:00:20 -0400
From: dmr@media.mit.edu
To: JKVEDAR@PARTNERS.ORG, "Paul
Heinzelmann, MD" <pheinzelmann@PARTNERS.ORG>,
"Kelleher-Fiamma, Kathleen M. - Telemedicine" <KKELLEHERFIAMMA@PARTNERS.ORG>,
"Lugn, Nancy E." <NLUGN@PARTNERS.ORG>, "Gary
Jacques" <gjacques@bigpond.com.kh>, "Jennifer
Hines" <sihosp@bigpond.com.kh>, "Rithy Chau"
<tmed_rithy@online.com.kh>, "Bunse Leng"
<tmed1shch@bigpond.com.kh>, dmr@media.mit.edu
CC: "Brandling-Bennett, Heather A."
<HBRANDLINGBENNETT@PARTNERS.ORG>, tmed_montha@online.com.kh,
aafc@forum.org.kh, "Bernie Krisher" <bernie@media.mit.edu>
Subject:
September 2003 Telemedicine Patient #5: THO CHANTHY,
female, 36 years old
Please reply to David Robertson <dmr@media.mit.edu>
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.
|
| |
|
 |
From: "List,
James Frank,M.D.,Ph.D." <JLIST@PARTNERS.ORG>
To: "'dmr@media.mit.edu'"
<dmr@media.mit.edu>
CC: "Kelleher-Fiamma,
Kathleen M., Telemedicine" <KKELLEHERFIAMMA@PARTNERS.ORG>
Subject: RE:
September 2003 Telemedicine Patient #5: THO CHANTHY, female, 36
years old
Date: Tue, 2 Sep
2003 16:57:53 -0400
In summary, the
patient is a 36 year-old female recently admitted to the hospital
with thyrotoxicosis from Graves' disease, now with atrial
fibrillation and possibly heart failure (cardiomegaly on CXR).
I suspect that she
still has thyrotoxicosis given atrial fibrillation at
her young age. Treatment for her thyrotoxicosis should be with
carbimazole at a dose high enough to bring her thyroid function
tests to normal, and then at a maintenance dose sufficient to keep
her thyroid function tests normal. T4 and TSH need to be checked
to follow the effect of treatment. If she is symptomatically
thyrotoxic on 5 mg per day of carbimazole, then her dose will need
to be increased to the range of 5 to 10 mg three times daily until
her T4 comes down into the normal range. One can anticipate a
maintenance dose at that point that is somewhat higher (perhaps 10
mg per day). Following T4 and TSH every two to four weeks as
therapy is adjusted will be needed, remembering that her TSH may
lag behind her T4 as her thyrotoxicosis improves. When T4
and TSH
are stably in the
normal range, TSH can be checked every 3 to 6 months
to make
sure therapy is on
target.
Of note, in the
United States, definitive therapy with radioactive iodine is the preferred
treatment modality for Graves' disease if a remission is not
achieved on anti-thyroid drugs within 9 to 12 months. Definitive
therapy can also be achieved with surgery. The patient should
avoid iodine, as this can make her hyperthyroidism worse (except
when used as an adjunt in preparation for surgery). Also of note,
carbimazole can lead to side effects including agranulocytosis,
rash, arthralgias, vasculitis, and cholestatic jaundice.
While she is
thyrotoxic, treatment with beta-blockers is also indicated. She should
take 10 to 20 mg of propranolol 2 to 3 times daily, starting at
the lower dose and titrated upward to normalize her heart rate as
blood pressure and heart failure symptoms permit.
For the atrial
fibrillation, in the setting of thyrotoxicosis and possible heart failure
there is controversy regarding how aggressive to be with
anticoagulation. At a minimum, the patient should aspirin daily to
decrease the risk of thromboembolic stroke.
Finally, the case
history reports blurred vision (improving) and proptosis. The patient
has Graves' ophthalmopathy. If this worsens (i.e. if she develops
worsening visual symptoms or increased proptosis), she may need
orbital decompression surgery or orbital radiotherapy to
prevent permanent visual loss.
James F. List, M.D.,
Ph.D.
Molecular
Endocrinology
Endocrine Associates
Massachusetts
General Hospital
|
