Telemedicine – An Illustration

Telemedicine using email communication to give diagnosis and advices.

ROJoson – February 2018

On February 25, 2018, I received this note from a classmate who wanted to help a patient in Guimaras.

February 25, 2018

Hi Brods & Sisses!
Attached are photos of a 17yo charity patient seen by a doctor during Med Mission in Guimaras. Do we have any Brods/Sisses (From Iloilo preferred; from PGH , OK too) who are willing to help with her diagnosis & treatment?
Valdez Foundation will assist with logistics.

Dr. Bernard




February 26, 2018

Hi Rey
Do we have Brods/Sis in GSI PGH? Are you still an active consultant at PGH?
Who do I refer to ?
This patient is 17 yo female who had ultrasound of the neck 6 months ago showing  3.5×2.3 solid mass on the right and 2 masses on the left measuring 4.1×2.9 and 4.9×3.9 cm. Thyroid was normal. Pictures now show massive enlargement and fluctuation associated with 30 lbs weight in 6 months
Brods and Sisses have suggested CBC with differential and biopsy for a definitive diagnosis.
Dr. Bernard

February 26, 2018

Dear Bernard,

If the thyroid is normal, considering there are masses on both sides of the neck,  we may be dealing with lymphoma. Nasopharyngeal ca is a consideration too pending more data.

Are there masses in the axilla and inguinal areas?  If there are, then most likely lymphoma.
Yes, we have brods in GSI.  Rodney Dofitas is presently the division chief.  Tito Espiritu is another brod there.  I am still connected with GSI but not active already.
Where is the patient? in Guimaras?  Who can furnish us more data to get to a more definite diagnosis.  I don’t think CBC is critical in diagnosis.  If lymphoma is suspected, section biopsy and not needle biopsy is recommended.  
However, I need more data if I cannot examine her personally.

March 3, 2018
Question- for Dr. Rey Joson: How do we get in touch with Dr. Rodney Dofitas?
How do we go about scheduling a charity patient to be seen in PGH?
Details of doing the biopsy- outpatient?
         local anesthesia?
        approximate cost?
Question for Dr. Amy: Any more workup reports?
Pls see Dr. Joson’s email below.
Also, would the Valdez Foundation assist this patient’s logistics (transport/lodging/ hosp bills, etc) ?
Dr. Bernard

March 3, 2018
If I may suggest,
1. through such email communication which is equivalent to telemedicine, let me take a crack at a more specific clinical diagnosis first (with the patient at home base – Guimaras).  We need to have a more specific clinical diagnosis to be able to recommend a more cost-efficient move (what to do next in terms of medical management and where to send patient to – Iloilo or Manila.)   I need a clearer photograph of the patient’s head and neck and more data (a physician seeing the patient right now in Guimaras should be able to supply me with the needed info.)  The photos can be sent to me through this email.  I can also communicate with the physician to seek more data.  THIS IN EFFECT IS TELEMEDICINE and can facilitate the cost-efficient management of the patient.
2. After the clinical diagnosis, I can then recommend the best option to take in consideration of the working diagnosis – such as what further exams to make (needle biopsy, section-biopsy, x-ray, CT-scan, nasopharyngolaryngoscopy, etc).; where to have these exams done (Guimaras, Iloilo, or PGH); and which specialists are needed to treat her (eg, if lymphoma, medical oncologist with a biopsy done by a surgeon; if nasopharyngeal ca, ENT and radiotherapist and medical oncologist; if TB, pediatrician; etc.)  This illustrates the importance of a more specific clinical diagnosis which can be gotten through email / telemedicine and which can facilitate the cost-efficient management of the patient.
3. We can also look for specialists we know in Guimaras or Iloilo who we think can treat her properly and for free.  Last resort will be PGH.  Even in PGH, we have to know which department to refer to (based on our specific clinical diagnosis).
So, do you want me to take a crack for a more specific clinical diagnosis as outlined in No. 1?  If yes, give me clearer pictures and have a physician seeing her at present to communicate with me.
Or would you just outrightly refer her to PGH Department of Surgery c/o Dr. Rodney Dofitas and let Dr. Dofitas handle her (whether in his Division or refer to other Departments)?
My 2-cent worth.  My recommendations.
Dr Rey

March 3, 2018
Thank you, Rey.
I think your suggested “Telemedicine” practice is commendable.
To this end, we need contact information of the physician (one who examined the patient recently) in Guimaras or Iloilo-
Address, cp#, best time to call, email address
To further assist Rey with a clinical diagnosis
Amy, pls email althogether
Patient’s Detailed History & Personal Information
Physical exam
More photos
Thank you Rey for all the good work you do for the advancement of medical practice in the Philippines.

March 3, 2018

Encounter date : Feb 17; 2018
Guimaras Provincial Gym
Jordan, Guimaras

Mary Ann Joy xxxxxxxxx  (patient)
Barangay Lawi, Jordan, Guimaras
CP #0936 467 4387
Date of Birth: December 27, 2000

17 y/o female presented with bilateral neck mass weight loss of 30 lbs since September 2017 associated with difficulty swallowing
According to her mother , she underwent work up at local hospital with labs, CXR and Ultrasound.
Ultrasound report performed on 08/09/2017 showing normal thyroid , well marinated hypo echoic right mass measuring 3.5cmX 2.3 cm X 2.9 cm and 2 adjacent hypo echoic left solid mass measuring 4.1 cmX2.9cm and 4.9 cm X 3.9 cm

CXR report Negative ( per patient)
Labs : Results not available at time of exam

Social History ; Lives with parents . Youngest of 9 children , stopped going to school because of her medical condition

ROS : wt loss 30 lbs , no fever no chills ,
had epistaxis ; no hemoptysis
mild difficulty swallowing
Denies history or exposure to TB

Past Medical History :
Burn right hand from electrocution in 2015

Family History
Father :  xxxxxxx 50 y/old with poorly controlled Diabetes Disabled and stopped working as fisherman in 2000
Mother: xxxxxxx , 57 yrs old , healthy ,provider fir family works as charcoal maker; fuelwood gatherer; laundry woman – P 350.00 x 4 days / week income.
Contact # 09364674387

Physical exam – limited no neck mass
GS : Alert pleasant young female
HEENT : Pupils reactive , EOM intact
Diffuse bilateral neck mass , non movable ;
non tender. Skin intact , no redness, Fluctuant mass noted on left posterior  side




March 4, 2018

Dear Dr. Valdez,
Thanks for sending the history and physical examination findings, the pictures and the ultrasound findings.
17-year-old female with bilateral large neck masses extending from infraauricular to the almost the supraclavicular areas, nodular, thyroid gland apparently normal (based on ultrasound and on the picture – seems to have no midline pretracheal bulge).  There was mention of difficulty of swallowing (I don’t know how significant this is – may be caused by the heaviness of the neck masses) and also there was mention of epistaxis (again, I don’t know how significant this is – may be nonspecific).  
If we just focus on the picture of neck masses and no thyroid masses (putting on hold the difficulty of swallowing and epistaxis first), my primary clinical diagnosis is lymphoma [I will give a 80% degree of certainty]. (Bases: the hugeness of the neck masses which most likely are enlarged lymph nodes and the bilateral neck involvement and of course in the presence of normal thyroid gland.  If there is a mass in the thyroid gland, then we consider thyroid cancer with neck node metastasis.).   Pls. check if there are enlarged lymph nodes in the axilla and inguinal areas.  If there are, 99% we are dealing with lymphoma.
My secondary clinical diagnosis is a nasopharyngeal cancer (Bases: bilateral neck masses starting at the infraauricular areas which I assumed are lymph nodes and the epistaxis, if this is significant.)  The reason why I put nasopharyngeal cancer as secondary clinical diagnosis is because the NPCA does not usually present with huge and bilateral neck nodes.   Pls. check the oropharynx and nose for any bulge that could suggest the presence of a mass.
Can you ask the attending physician to give me answers to these questions:
1. Are there masses in the axillae and inguinal areas?
2. Are there bulging in the oropharynx?
3. How significant is the epistaxis?  how many episodes?  Is there unusual findings in the nose?
After I got the answers to my questions, I will make a decision on my clinical diagnosis, whether to stick to what I mentioned above or change it (depending on the additional info).
Then, I can recommend the next step.
Thank you.
Dr Rey

March 6, 2018

Thank you, Rey
I remember what our mentors in medical school taught us:  with a complete history and thorough physical examination one can arrive at a diagnosis 80% of the time and laboratory studies are done just to confirm the diagnosis. We believe in “clinical eye” based on extensive clinical exposure to diseases.
Hopefully we can clinch the diagnosis and will be able to help this girl soon.
Dr. Bernard

MRI Done:


Based on the MRI, primary diagnosis for me is lymphoma.

Just have to wait for the histopathological result of the biopsy.  Cannot move further in the management without the result.
If lymphoma, suggest refer to medical oncologist for further management – chemotherapy with or without radiation.
Dr. Rey

April 2, 2018

Attached are the histopathology report
As you stated Doc Joson – it’s Lymphoma (Non Hodgkins Lymphoma)
Few questions doc:
Would there be an advantage of sending her to Manila vs treatment locally ?  If she need radiation, would they have local faculty in Iloilo?
Estimated cost?
She is 17 yrs old,  adult status 18 or 21 yrs old in the Philippines?
I have requested a consent form from
Mary Ann’s parents  and indigent report . To date I have not received any.
Thank you Dr REY for your expert advice . Will plan strategy  with your advice to assist with her treatment  plan.

April 3, 2018

Dear Dr. Valdez,
I think the main treatment here is chemotherapy.  Look for a pediatric oncologist or medical oncologist in Iloilo.  The DOH hospitals there should have one.
Dr Rey

ROJoson’s Notes:
With the email communication, with the telemedicine through email, I was able to advise on the diagnosis and what needed to be done on the patient without the patient having to be transported to Manila.


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