Wednesday, May 18, 2016

Boy Scout Camporee with BlackHawk Council
Illinois Railway Museum
May 13-15, 2016

Disclaimer:  This is all in fun/tongue in cheek. We actually had a great time and no one suffered from hypothermia.

     The windswept prairie grass was wet and the mud sucked at our boots. The rain had slowed to a soaking, cold drizzle. The “gulag lights” at either end of the field lit up rows of tents, Boy Scout trailers and kitchen flys. Some sites had tents lined up in military precision, Patrol boxes all set up, and others were rag-tag and thrown together slap dash, like ours.

     One thing was for sure, though. I was not going to be able to sleep in my tent. The wind was so fierce it blew in the sidewall of my tent and I would be unable to sleep for fear of collapse.  The thought, “Why didn’t I bring my 2 man tent? It’s small and low to the ground!” kept buzzing around my head. 

     To add to the excitement, the air conditioning was out in my car and the windows were fogging up without it. Three teenaged boys and me, driving rain, cold air, and an hour and a half drive could have been a disaster, but I had coated the windshield with shaving cream, which stopped it from fogging up. McGyver-ing is a way of life with a 12 year old van.

     Sleeping on the bench seat of the second row of seats in the van was extraordinarily uncomfortable. I put on long johns, sweat pants, dry socks, and several upper layers, and used the extra sleeping bag in the van. I woke up with cramps in my calves, numb hands, and a headache. Benadryl helped a little, but not enough.

     Saturday morning broke with cloudy skies and temps in the upper 30’s, low 40’s. I walked to the campsite from the van, after using the Port-a-Potties, and attempted to locate propane for the stove, the coffee, and a lighter. This was a difficult task with brain fog from benadryl, sleep deprivation, and no coffee. Fortunately, I had brought a lighter, as they seem to disappear with each camping trip, never to be seen again.
Be Prepared.

     After I got the coffee going, the other parents started to wake up. Breakfast was “eggs in a bag.”  This gourmet concoction consists of eggs in a freezer bag, mushed up with  add ins, like ham or cheese, salsa, onions, peppers. You push out the extra air, and boil the eggs in the bag. Then you use the hot water for your dishes, which consist of your coffee cup, pot, and fork because you eat out of the bag.  The problem with this breakfast is the fact that you now have 10 plastic bags to throw away, and no one remembered to bring garbage bags. Hmmm.

     This is when we noticed that several of our boys were NOT prepared. One had on a short sleeved shirt and shorts and no coat, several didn't have enough layers or hats, or gloves. Argh. Clothes were traded, shared, and layered, and a clothesline was set up to dry out wet clothes at the campsite.

     By 8:30 a.m., the boys were up and had managed to feed themselves a cold breakfast, and the adults were more or less functional. We meandered over to the Illinois Railway Museum entrance to attend the opening ceremony. We were assigned groups for the boys to get the Railroading Merit Badge, and informed of the activities for the afternoon. (archery, dodgeball, air riflery, archery, and black smith-ing) as well as checking out the museum at our own pace.

     “Look, Listen, Live”  was the theme of the Operation Lifesaver. The engineer leading it told us some frightening statistics about how often someone is hit by a train in the US and how to avoid this fate.

     We learned how to identify 10 different types of railroad cars, and we saw steam , electric, and diesel locomotives.

     We saw an empty wine bottle of Beaujolais sitting on the steps of an old passenger car that had clearly been broken into and was being used by local oenophiles to do their wine tasting events in the middle of the night.

     Later the boys tried their hands at the Tomahawk throwing contest. The boys were much better at Tomahawk throwing than their parents, which changed the dynamic of the camporee completely. The parents threw the Tomahawks into the woods while the boys actually hit the targets. Granted, the parents probably hit a few chipmunks in the process, but the boys definitely had the upper hand after that.

Next was the Black smithing.
The blacksmiths were awesome.
Their rule was:  

Don’t be stupid.

     That was it.

     Don’t pick up hot iron if you drop it. Use the gloved hand to handle the hot iron. Wear your eye protection-- in other words:  Don’t be Stupid.

     Even the smallest kids were allowed to participate, and all of them made “S-hooks,” despite the parents yelling that they wanted a harpoon tip, or a candelabra. The kids seemed pretty happy with the S-hooks though, and the parents were glad to have their children back without third degree burns. It made us realize that our kids actually CAN follow directions. I offered to hire the Smithy to come live with us and to get my kid to do his chores, but he declined, albeit politely.  After all, he is a Scout. 

     Later, the sun broke through and the sky cleared… for 5 minutes. 
     The parents, or "Bigfoot Patrol," had a gourmet meal of beef stew made by our Scoutmaster, and the boys had walking tacos. I think we won that competition, hands down. The boys were ogling our dinners with desire. “Next time you guys can do this,” we told them.

     Of course, at bed time, the sky completely cleared causing the temperature to drop precipitously. We had frost on our tents in the morning. I was so tired, that I slept like a dead person for 8-9 hours, only awakened occasionally by my nose tip being cold, or my hands being completely numb from the positioning in my mummy bag, or my hips screaming in pain from side sleeping in a ball in one position for 4 hours in a row. But besides that, it was a great night sleep.


     There was supposed to be a 5 K run in the morning at 6:30 a.m. I don’t know if that actually took place because, let’s face it-what teenager actually gets up at 6:30 a.m. voluntarily? So that didn’t happen. But we got up, broke camp, and were home by 10:30 a.m. which was great, except I had to set up the tent in the backyard to dry out and do 700 loads of laundry, and dry out my son’s bag on the clothesline, and…

May 13-15, 2016

Tuesday, May 10, 2016

How To Read Your Electronic Medical Record Chart Notes


I am Not an SOB! How DARE YOU!

Many Patient Portals are now allowing patients to see the progress notes that physicians write.  This can be a confusing and frustrating experience for patients. 

     One of the problems I have seen is patients taking offense at the medical terminology, thinking physicians are making a personal judgement, instead of writing objective terminology.  

     Let me explain.

     Physician's notes are generally written in the SOAP method:  

                         Subjective, Objective, Assessment and Plan.

     Subjective:  This section describes the patient's complaints. "Complaints" does not mean what it does in normal language. "Complaints" are what the patient is "complaining of" or suffering with, or what brought the patient in to begin with. Why is the patient here? 

     Part of the HPI or History of Present Illness, is the Chief Complaint.  This is the reason for the visit that the patient tells the medical assistant.  It may not be the "real" reason the patient is there, as often, patients feel uncomfortable telling a medical assistant why they are really there. 

     In the HPI, doctors use a lot of standardized abbreviations which may be misconstrued by patients, or just plain not understood at all. 

     For example, "The patient is SOB" does not mean, "the patient IS an SOB", but that the patient is "short of breath."  

     Often we use quotation marks to state exactly what a patient has told us, and then we elaborate with the Review of Systems(ROS).  

     The ROS is a litany of questions we ask to try to ascertain any other associated symptoms going along with the chief or main complaint. We generally start with weight loss or gain, rashes, sleep problems, and work our way down from the head to the toes. This litany can change based on the chief complaint. 

If it is clear the patient is suffering from a cold, we aren't going to ask about toe fungus in the ROS. 

     We also have to use very standardized, objective language. Some of this can be misconstrued as insults as read by patients, but is medically objective language. The biggest one is "obesity."  Obesity is a BMI of 30 or higher.  A BMI of ≥ 35 or 40–44.9 or 49.9 is morbid obesity. A BMI of ≥ 45 or 50 is also known as super obese.

     When doctors use these terms, they are not making a personal slur, or insult. It is a medical term. 

     Some other terms often used in the history/ROS are, 
     CP=Chest pain, 
     GERD=Gastroesophageal reflux (heartburn)
     melena=black, tarry, sticky stool indicative of an upper gastrointestinal bleed 
          (UGI bleed) as in a bleeding ulcer.
     hematochezia/BRBPR=bright red blood per rectum-which means what it says. 
          It is often from a bleeding source in the large intestine/colon
     GI=gastrointestinal (any section of the gut, from the esophagus to the rectum)
     GU=genitourinary (anything in the genital area or urinary tract)
     Neuro=neurologic symptoms/signs

The next section is OBJECTIVE: the PHYSICAL EXAM.

     Here again, there are many abbreviations.

     Generally the Physical Exam starts with the Vital Signs(VS):

  BP (blood pressure), HR (heart rate), T (Temperature), O2 sat(Oxygen saturations, expressed in percentages), Weight, Height, often in centimeters and kilograms. This is not to obsurate.  This is the international standard. We use metric often in medicine. 

     Then comes the BMI (Body Mass Index).

     BMI is a person's weight in kilograms (kg) divided by his or her height in meters squared. The National Institutes of Health (NIH) now defines normal weight, overweight, and obesity according to BMI rather than the traditional height/weight charts.

    The BMI is not always an accurate indication of the patient's fitness. For example, I have seen people with BMI's over 30, and not an ounce of fat on them because they were body builders. They were all muscle. 

     Next is the physical examination. 
     We start at the top and work our way down usually. Depending on the age of the patient, the physical exam may be different, but generally for teenagers and up, it is fairly standard. There may be some differences in the very elderly, where we look at things like their ability to get up out of a chair or walk. 

     Some standard abbreviations: 

PE=physical examination
HEENT=Head, Eyes, Ears, Nose, Throat
     PERRLA=Pupils Equal Round and Reactive to Light and Accommodation-
            When we shine the light in your eyes we are looking for pupillary reactions 
     EOMI=Extraocular Eye Movements Intact. This means your eye muscles are all 
            working normally
     Pharynx:  Your mouth and throat. We describe whether it is moist, red, whether 
           the tonsils are there and inflamed, whether you have post nasal drip. What 
           your teeth and gums are like. Are there sores in your mouth/gums. Bad breath?
     EAC and TM's=External Ear Canals and Tympanic membranes-your ear canal and eardrums. We describe what they look like, whether they are blocked with 
           ear wax (cerumen), and whether the "landmarks" or the normal things we see on
           eardrum look normal. 
     Nares=your nostrils. We describe the inside of your nose and whether it's swollen, 
           whether you have a deviated septum, ulcers, polyps or growths, etc. 

Neck=Here we describe the lymph nodes and whether they are enlarged. we describe 
     them based on location in the neck. We describe the thyroid (TMG) Thyromegaly-
     is the thyroid enlarged and are there nodules on it?

     Carotid arteries=not always discussed. Are there normal pulsations/sounds?

Pulm (Pulmonary)/Lungs:  
     CTA&P=Clear to auscultation (listening with the stethoscope-no abnormal noises) 
            and percussion-no abnormal sounds when we thump on your back.
     Rales/Crackles=sounds like hair being rubbed next to your ear, or like velcro being 
           pulled apart, heard when listening with the stethoscope. Can mean many 
           different things, from pneumonia, to scar tissue, to fluid in the lungs. 
     Rubs=a sound like grating or squeaking. It can mean there is a problem with the 
           pleura of the lungs, or outer coatings of the lungs. 

     RRR-Regular Rate and Rhythm
     Irreg RR-Irregular Rate and rhythm.
     Regularly irreg rhythm-just that. 
     S1, S2 normal-normal heart sounds of the opening and closing of the heart valves.
     S3 /S4- these are abnormal heart sounds which can be from heart failure, or a stiff
           heart or other causes
     No m/r/g-No murmurs, rubs or gallops. This means no heart murmurs, no heart rubs
           and no abnormal S3 or S4 sounds. 
     Murmurs are often graded from I-VI/VI in intensity and by location. 
           You many see: II/VI SEM ULSB nonradiating. This means, a 2 out of 6 murmur 
           heard in systole (part of the heart cycle) at the Upper Left Sternal Border. It is 
           not heard in other parts of the chest/neck/underarm (not radiating to those parts)

Breasts: We will describe any masses, discharge from the nipple, or lymph nodes. 
     We describe the breast in quadrants:  RUOQ, RUIQ, RLOQ, RLIQ are: 

          Right Upper Outer Quadrant, Right Upper Inner Quadrant, Right Lower Outer 
          Quadrant, and Right Lower Inner Quadrant. 

     NABS=Normal Active Bowel Sounds
     No HSM=No Hepatosplenomegaly-this means the liver and spleen are not enlarged
           Sometimes if the liver is enlarged, it is described in centimeters in the chart 
     No masses-means that the physician does not feel any masses. It doesn't mean 
            there aren't any masses, just that he/she cannot feel any.
     No rebound tenderness/no rebound- means when there is pain pressing down, it 
             is not worse when you let go of the pressure. This can be a sign of 
             inflammation of the lining of the abdominal cavity, if there is rebound. 

GU: Depending on the sex of the patient, the explanations vary, obviously. 
     Normal external (male/female) genitalia=self explanatory
     no adnexal masses (female)-on the internal pelvic exam done with the hands, the 
           examiner is unable to feel anything abnormal.  This can be "limited by body 
          habitus" which means the patient's adipose or fatty tissue, or strong abdominal
          muscles can make it difficult to actually feel anything.

This is not a complete list, obviously. There is the neurologic examination, musculoskeletal exam, etc. 

The NEXT section is DATA: 
     This is part of the OBJECTIVE section, and includes, labs, xrays, and other test results


     This is the section where the patient's "Problems" are delineated and discussed and the possibilities of diagnoses are discussed, and a plan for evaluation and management is put together. 

 PROBLEMS: These are now described through the ICD-10 coding system. 

     Within the healthcare industry, providers, coders, IT professionals, insurance carriers, government agencies and others use ICD codes to properly note diseases on health records, track epidemiological trends, and assist in medical reimbursement decisions.
     ICD-10 is frustrating because there are very specific ways to describe medical issues and there is not always a diagnosis code that perfectly pertains, so one needs to pick the BEST OPTION. 
     Also, a patient may come in with what sounds like panic disorder or anxiety. The doctor may be fairly certain this is what is going on. He/she puts in the diagnosis code of "Anxiety disorder." The patient sees this and is upset. They came in with heart racing and palpitations, and SOB (shortness of breath) and tingling in their fingers and around their mouths and are worried they will die. If the doctor doesn't explain that he/she is fairly certain this is anxiety, but is testing/evaluating for other causes also, the patient may be surprised to see this diagnosis code. 

     As a patient, one needs to understand that putting in 5 different diagnosis codes that can be summarized in a single fairly certain diagnosis code, makes the most sense and is what is required. The insurers and government want the MOST SPECIFIC DIAGNOSIS CODE.

     Also We can only put 4-6 diagnosis codes on a single "bill" to the insurance company, and if you came in with anxiety symptoms but also had something else, like a UTI, if we use: Dyspnea (shortness of breath), Palpitations, numbness, chest pain, and dizziness-all of which could be summarized under "Anxiety/Panic" attack, then we can't put the UTI diagnosis code. 

     We also order tests through the Electronic record, and these show up under the "PLAN" section of the note. You will see lab abbreviations, consult/referral recommendations, test orders like CT or ultrasounds there. 

I hope this helps a little. See my disclaimer though.

     ***This is a brief explanation. Please understand none of this is meant to be medical advice. If you have questions about your medical record, address them to your physician. I will not be answering any specific questions about your personal medical record. 

May 10, 2016