Sunday, July 31, 2011

Therapist needed

While taking a recent social history...

Me: How much alcohol do you drink?

Patient: Barely none.

Me: Oh, OK (I was pretty sure he meant "hardly any").

After he left, however, I was still thinking about his statement a little more...

Barely:(adverb) only just, no more than, almost not, scarcely

None:(pronoun) not one, not any

Lets see...

Putting the two definitions together-only just not one, only just not any, no more than not one, no more than not any, almost not not one, almost not not any, scarcely not one, scarcely not any

You think I have too much free time on my hands?

Actually I don't.

I probably need to get some therapy to keep me from over analyzing things that are said.

Can anyone out there help?

Saturday, July 30, 2011

Not so simple

I was returning a phone call to a 57 y/o patient I had known for years.

Me: How can I help you?

Patient: It's real simple. I'm applying for disability. I just need for you to write a brief statement in my record that it's your opinion I contracted hepatitis C from exposure to blood while I was working.

In the midst of saying "Oh" and asking "what do you need again," I quickly located a consult note from an infectious disease specialist from about 7 years ago. The very first sentence of the note stated "he reports that he did intravenous drugs in the 1970's and feels that's how he was infected."

Me: I'm looking at a note from about seven years ago in your record. Let me read it to you...

Patient: Oh, I didn't know that was in there. Um, thanks. I'll get back to you later if I have any questions.

Me: You bet. Best to you always.

I then said a silent, "thank you computerized patient record!"

Friday, July 29, 2011

An inexpensive nose job

A 56 y/o male:

Patient: I broke my nose when I was younger and it had a bad curve, but since I've gotten older and started to wear glasses, it straightened out.

Me: You had your nose straightened with surgery?

Patient: No, wearing glasses with the nose pads just seemed to straighten it out.

Me: OK, that's great (it actually looked quite straight).

I couldn't think of anything else to say. For the rest of the day, however, I kept taking off my glasses to look at and feel my relatively flimsy nose pads.

I had no idea they were capable of such great feats!

I'm sure the plastic surgeons and ENT doctors will try to keep this from becoming widespread knowledge.

Thursday, July 28, 2011

The day after a 91

Cool story...

Last week had a first visit with a 60 y/o male. He relocated to this area after separating from his wife (this is not the cool part of the story).

He's a golf pro and he's already employed by a local Country Club.

He became a pro at about age 40, after an almost 20 year career as a circulation manager for a major metropolitan newspaper.

I asked if he was ever on the tour (you know, the guys you see playing on TV).

Patient: I became a pro because I loved to play, but mainly because I loved to teach. I struggled with wondering if I should try to play on the tour or just continue to be a teaching pro. Finally, I qualified for an event. On the first day, I shot a 51 on the front nine and a 40 on the back nine. A 91 (for all non golfers that's 20 over par-a TERRIBLE round).  That night I wanted to quit because I was embarrassed. I then realized it was GODS way of letting me know playing on the tour wasn't for me. I felt this huge sense of relief. The next day I shot a 68 (a very GOOD score; three under par). Obviously, I didn't make the cut for the final two rounds, but felt great. I knew what I was supposed to do for the rest of my life; teach golf.

That's the cool part of the story!

Wednesday, July 27, 2011

My watch test

Most elderly folks still wear watches (unlike the younger generation).

Although there are no studies, I often use the "watch test" as a quick office check for cognitive impairment (even in folks who I had not previously suspected of being impaired).

When I check a pulse, as I do on all patients, I always look to see if the watch is right side up and if the time is correct.

The day and date are not as important. My eyes are younger than many of my patients and I even have a hard time reading those on most watches.

If either the orientation or the time is wrong, cognitive impairment is probable.

Putting a watch on everyday is part of a long term routine for most elderly folks.

Having it on correctly and with the correct time involves a higher level of function.

Check it out.

Tuesday, July 26, 2011

Know the number

Unfortunately, I see patients everyday with horrible teeth.

I keep supplies in my office for an emergency brush and floss, on myself, whenever I finish looking in to one such mouth of a patient.

I've received dental consults back over the years with notes concerning work done on tooth #11,#12, #20 and #22, for example.

Finally, after MANY years, I decided to investigate how teeth are numbered.

The Universal tooth numbering system always starts on the right upper back-the third molar is tooth #1. It proceeds to the left upper back (third molar #16), then down to the bottom back left (tooth #17) and on around to the right lower back (tooth #32).

Numbers are assigned and remain the same even when a tooth has been pulled from the location it should lie.

Knowing this numbering system hasn't done a darn thing in improving the dental hygiene of my patients.

It just makes me feel good about using the dentists "lingo" when placing a consult or calling a dental colleague over the phone.

Even had one dentist remark that it was rare to have the referring medical provider use the numbering system, but that it was greatly appreciated.

I didn't let him know I was smiling on the other end of the phone.

Ah, it's the simple things in life that often bring joy!

Monday, July 25, 2011

Three useful (equestrian) terms

I spent a good part of this past weekend (and many other parts of weekends) at a horse show.

My 15 y/o daughter has been riding for about 4 years and has become quite an accomplished equestrian.

She rides her horse (Blues) almost everyday and they compete in shows at least once a month.

I've picked up (aren't I smart!) a few horse terms over the years that sure encompass a lot:

1. Colic: used when something is wrong with the horses digestive tract-can represent any thing from gas to intestinal torsion (life threatening). Luckily, whenever our horse has had colic, a massive passage of gas (a horse fart) has always been curative, so far.

2. Lame: means that something is wrong from a musculoskeletal standpoint. It also means that the horse can't be ridden (a real bummer for my daughter as well as the folks (my wife and I) who are writing the checks for her to follow her passion).

3. Sound: all good. A-OK. Ready for action. Now we're talking!

Three useful terms.

Sure would make documenting a lot easier if I could use them in my office notes!

Friday, July 22, 2011

Moving to Florida

I've practiced in central Florida since 1993.

I can't begin to count the number of times I've heard (usually from an elderly person with many functional impairments and health concerns), "My doctor up north told me I needed to move to Florida (pronounced flor-e-da by many north easterners) to improve my health."

I love Florida and I'm not a fan of the cold and snow, but for some elderly folks I can't help but think:

1. Your doctor (up north) felt this heat and humidity would be good for your health?

2. Your doctor felt that our air quality (high pollen counts, wild fires, etc.) would be good for your health?

3. Your doctor felt that moving away from ALL your family members would be beneficial for your care?

Occasionally I think...

What would I use as a reason to "move back up north to improve your health?"

1. You could actually use the warm clothes you still own.

2. The cold weather might reduce swelling in certain parts of your body (could be true).

3. Being close to ALL your family members, that still live up north, might be beneficial to assist in your personal and health care needs (hopefully would be true for many).

and finally...

4. You could count on your long term memory to navigate routes and remember the names of people and places (from years ago), even when you have short term memory impairments!

Thursday, July 21, 2011

Get back on your toes, now!

I'm asked to fill out disability forms for patients frequently, but some functional assessment forms ask for answers I can't give to such thought provoking questions as:

In the midst of an 8 hour work day, what percentage of time can the individual walk on heels, walk on toes, squat, or crawl?

In the midst of an 8 hour work day, what percentage of time can the individual lift 0-4 lbs, 5-9 lbs, 10-14 lbs, 15-19 lbs, etc.?

I guess I have a pretty easy job when it comes to physicality.

None of my patients, however,  has ever admitted to having to spend part of his/her work day toe walking while carrying some weights.

I guess someone must. The same questions keep appearing.

Sure would love to be a fly on the wall at their workplace.

Wonder what kind of job they have?

Wednesday, July 20, 2011

The Hallelujah dance

Everyone who takes care of patients has an occasional "difficult" patient.

My definition of a difficult patient is simple: It's someone who, for whatever reason, invokes a feeling of dread or doom in you and/or your staff.

It usually has nothing to do with a patients age or their underlying medical diagnoses or co-morbidities.

Some are part of your life only briefly; others you get to know for many, many years.

I used to enjoy watching the television show "Becker."

The actor, Ted Danson, played the part of an internist (Dr. Becker) working in a New York City medical office.

In one of the episodes, one of his difficult patients announced she was moving to North Carolina to live with a son.

Dr. Becker then went on to say how much he had enjoyed taking care of her over the years and how much he would miss being her doctor.

He then let the patient know he would be right back and excused himself for a minute. He closed the exam room door.

Once in the hallway and alone, he broke into a huge grin and started to do a "hallelujah" dance.

After a brief moment of joy, he went back into the exam room and finished his solemn good-byes.

Most, seasoned, primary care providers can understand the joy he temporarily expressed.

Just always remember to dance in private.

Tuesday, July 19, 2011

Pain greater than 10/10 does not compute!

Pain is the 5th vital sign.

The currently accepted pain scale is based on a scoring system of zero to ten.

0/10 equals no pain.

10/10 equals worst ever, unbearable, agonizing distress.

13/10 is not allowed.

Even 10+/10 pain is not allowed.

Folks would never report 0-/10 pain for "less than no pain."

I like to keep things as simple as possible.

Therefore, there is no pain greater than WORST EVER, UNBEARABLE, AGONIZING DISTRESS or 10/10.

Got it?

Monday, July 18, 2011

Concerned about theft?

A 51 y/o male was seen for the first time, for a complete physical exam.

While examining his genitals I noticed he had his first name tattooed, length wise, on the shaft of his penis.

He didn't mention anything so I decided to ask a simple question.

Me: Were you afraid that someone might try to take your penis and not return it?

He smiled.

Patient: No, I was just really drunk one night. Good thing I didn't have a long name.

We both laughed.

Sunday, July 17, 2011

Pondering elective orthopedic sugery?

A quick recommendation:

If you are thinking about undergoing an elective orthopedic surgery (knee, hip, back, etc.), do not talk with anyone who is sitting in a doctors waiting room.

Often, if you do, you will find that it is someone who had the same procedure you are considering and who unfortunately, did not do well.

I always remind folks I see that this is why they are in the waiting room...they did not do well.

It's much better to talk with folks you meet shopping, socializing, fishing, golfing, traveling, etc.. They usually represent the subset of patients that underwent the procedure and were a success.

The vast majority of folks do well. Meeting them will allow you to be in a much better frame of mind while weighing the pros and cons of having an elective procedure performed.

Saturday, July 16, 2011

Feeling out of balance?

A few years ago, folks with all kinds of musculoskeletal complaints would come in wearing magnetic bracelets.

Often, if I was feeling particularly devious, I would ask, "aren't those bracelets supposed to correct your musculoskeletal issues?"

The newest craze are the balance bracelets (a rubber bracelet with a little piece of, what looks like, tin-foil).

I'm at a medical conference this weekend and I've even spotted a few health care providers wearing them.

Here's the "scientific" information I could find: "the Power bracelets contain two hologram's which are embedded with frequencies that react with your body's electromagnetic field. When the power hologram comes in contact with your body's energy field it begins to resonate in accordance with each individuals energy system, creating a harmonic loop that optimizes your energy field. It maintains energy flow while it clears the pathways so electrochemical exchange functions like the well tuned generator it was designed to be."

Oh, and don't forget the usual disclaimer: "the above statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure or prevent any disease process."

Wow. Can't think of anything else to say.

It just brings up one question, however: why do so many patients have a hard time understanding and accepting why disease entities such as uncontrolled diabetes, hypertension, hypothyroidism, hypogonadism, sleep apnea, etc. can effect multiple body systems when they seem so capable of understanding and accepting the "science" behind their $29.95 balance bracelets?

Any thoughts?

Friday, July 15, 2011

My bad

While seeing a 47 y/o patient:

Me: Still smoking 2 packs a day?

Patient: No (said with an annoyed, somewhat angry tone)!

Me: How much are you smoking now?

Patient: I almost always come in under 2 packs a day.

Me: So, a pack and a half a day?

Patient: Yeah, on a lot of days.

Me: Sorry I insulted you by questioning if you smoked 40 cigarettes a day. It's great to know you're only smoking 30 to 40 a day.

Surprisingly, I then caught the slightest hint of a smile on his face

Thursday, July 14, 2011

An office yogi-ism (for all Yogi Berra fans)

A 79 y/o male with multiple medical diagnoses:

Patient: Don't get me wrong Doc. I'm grateful to be alive. A lot of my friends living, who are my same age, aren't alive anymore.

Me: (After my usual "what did he just say" pause) You bet, I'm glad you're thankful for your health. It's always great to see you.

Wednesday, July 13, 2011

Open mouth, don't insert foot

I saw a 39 y/o male recently.

Unfortunately, he had been out of work for two years and didn't seem overly motivated to find a new job.

He asked if I would check his knee due to some recent pain.

I asked if he had done anything recently in which he could have strained it.

He said he was on "vacation" last week and did more walking than usual.

Usually (but not always), I'm able to remind myself of a quote from Calvin Coolidge: "You don't have to explain something you never said."

Fortunately, I avoided the temptation and said nothing along the lines of, "but you've been on a vacation for the last two years."

His knee exam was fine. I suspected he had chrondomalacia of the patella.

I reviewed some OTC meds he could take, reviewed quadriceps strengthening exercises he should do and advised the use of a knee sleeve.

I said nothing more...phew!

Tuesday, July 12, 2011

A great start to a day in the office

An 82 y/o male was born on September 5th.

He just so happened to have the first appointment of the day with me on a September 5th.

I noticed his date of birth just prior to going in to the exam room to see him.

I grabbed a small candy bar from our secret stash and gave it to him.

Me: Happy birthday! I'm sorry I wasn't able to put a candle in the candy bar.

Patient: Thanks. You know some years my birthday falls on Labor Day...of course it was labor day regardless for my mother in the year I was born!

He then laughed almost uncontrollably for a few seconds and I smiled with him.

It was a great way to start the day.

Later, I couldn't help but think how wonderful it was for him to have this life long joke that still gave him a bout of laughter every time he got the opportunity to tell it to someone new.

Monday, July 11, 2011

Definition #1, I think

In the midst of taking a social history on an elderly male:

Patient: ...and my son Boo-Boo lives just around the corner and comes to see how we are doing at least every other day.

Me: Your son is named Boo-Boo?

(Quick definition: #1. A stupid or embarrassing mistake; a blunder or #2. A slight physical injury, such as a scratch)

Patient: My wife and I planned to have two children, but we had three and he's the youngest, so it's always been his nick name.

Me: Wow, that's a little harsh but funny! How old is he now?

Patient: He just turned 60.

Sunday, July 10, 2011

Is there a hidden camera in our house?

Staying on the subject of my son...

My wife and I are certain that there's a hidden camera in our house.

We should probably get legal representation in a law suit against the folks involved in the daily "Zits" cartoon.

We need to get some royalties-just a small cut of the money-that's all!

The only change made is the name of the lead character (Jeremy instead of our son Tom).

I suspect the parents of other 16 y/o young men feel the same.

To the cartoonists...great job!!

Saturday, July 9, 2011

Wanted: one undercover photographer

My son just got back from a week long youth trip.

It was the longest amount of time he had ever been away.

All of the kids were asked to leave their cell phones at home.

The leaders had phones and e-mail access, if needed, for emergencies.

Pictures, however, were posted everyday on facebook.

It appeared to be an action filled week.

Looking at the pictures, obviously, was a highlight of the day for my wife and me.

Seeing him smiling, laughing and enjoying himself was all we needed.

Just a picture a day kept our worry at bay.

He heads off to college in a couple of years.

Sure would be nice to have an undercover photographer send us a picture everyday...just kidding!


Thursday, July 7, 2011

Quietly retreat

Our local newspaper had a brief article today about an unfortunate man that was mauled to death by a Grizzly bear at Yellowstone National Park.

He was hiking with his wife along the Wapiti Lake trail when he surprised a female bear with her cubs.

The bear attacked and fatally wounded the man.

She was defending her cubs.

Two years ago we (my wife, son, daughter and I) were on the same trail.

I vividly remember the notices posted everywhere:

"If you see a bear and it's not aware, quietly retreat from the area. If you see a bear and it's aware, flap your arms (to make yourself look bigger), talk in a loud voice and retreat from the area. If the bear is aware and charges you stand completely still-it might be a false charge. If the bear continues to charge you, immediately drop to the ground and curl up in a ball."

At the time I remember that I had no problem with the first two sentences of instructions. The 3rd and 4th were a different story.

We saw a Grizzly while on the trip (an incredibly cool thing).

He was only about 30 yards from us.

Luckily, it was not aware.

We quietly retreated!

Wednesday, July 6, 2011

Computer generated templates

Want to have a long impressive note that may or may not have anything to do with the reason for an office visit?

Use some of the various computer templates on the market.

It now not unusual to receive a 5 page note from a specialist from a follow-up visit.

I've seen 10-12 page primary care notes, for one visit.

Don't get me wrong. The computerized patient record has clear advantages.

The fact that it is interpretable is an advantage.

The fact that it's readable is also a disadvantage.

Many times wrong information is copied and pasted from note to note.

Patients often bring outside records in which they have made corrections to such items as their social history.

Its' also generated some lively discussions when a complete physical is recorded and the patient is sure the surgeon only did a brief exam of their umbilical hernia.

Medical legally: if it wasn't recorded it wasn't done.

The opposite is also true: if it was recorded and wasn't done, it's FRAUD.

I'm certain that malpractice attorneys love the computerized patient record.

Given technology now available, it's not a stretch to envision patients secretly taping an encounter and then having their attorney compare it to the computerized patient record.

My recommendation: don't record things that weren't done. If using templates, delete parts that were not done and are not needed.

Don't have your integrity questioned due to ignorance on how to adapt a template to the actual visit that took place.

Also, if a visit can be well documented in just a couple of lines ( for a brief follow-up visit after an I and D of a cyst, for example), free text the note (type it!)-don't use a template.

Tuesday, July 5, 2011

Depression and insomnia

A number of years ago I was depressed.

For about 2 months, prior to seeking treatment, I had severe insomnia.

An hour and a half of sleep was a good night. I got to see how incredibly long, and miserable, a night is when you can't sleep.

I found out that Wal-Mart and Denny's are never crowded at 3 AM.

Every time I would try to sleep, and would close my eyes, I would visualize different images from my past.

The images followed no particular pattern, but would be of folks I had interacted with in the past including family, friends, classmates, co-workers, enemies, etc..

I couldn't shut my mind down.

At the time it reminded me of watching a slide show.

When patients are depressed, report insomnia and the inability to stop thinking at night, I always ask them if they are experiencing a "slide show of their life."

A lot acknowledge it's exactly like that.

"How did you know?" they ask.

"Been there, done that," I reply. "I had the same problem a number of years ago when I was depressed. Let's talk about what we can do to help you get some sleep."

Monday, July 4, 2011

Happy 4th!

Let every nation know, whether it wishes us well or ill, we shall pay any price, bear any burden, meet any hardship, support any friend, oppose any foe, to assure the survival and success of liberty-John Fitzgerald Kennedy

Where liberty dwells, there is my country-Benjamin Franklin

Liberty is the breath of life to nations-Goerge Bernard Shaw

There is nothing wrong with America that cannot be cured by what is right with America-William J. Clinton

Sunday, July 3, 2011

A simple request

(Since no-one reads this blog I can pretty much write about anything that's on my mind.)

We have a staff bathroom, like most medical facilities. It's not large and the sink is very close to the toilet.

Without fail, every time you wash your hands, water splashes on to the toilet seat. When the seat is wet and you've just arrived to make a deposit, you don't know if it's water, urine or some other body fluid.

It also has a trash can that's usually over flowing by the end of the day  (and unfortunately, often has used feminine products visible).


Before exiting the bathroom, push the trash down in the can, wipe any water off the toilet seat, pick up any pieces of paper towels from the floor, and use the air freshener if needed.

It doesn't take long to clean up and it sure enhances the "experience" for anyone that follows!

Saturday, July 2, 2011

Gotta laugh!

A 63 y/o male has advanced Parkinson's Plus Syndrome.

He has significant rigidity, immobility, falls frequently and has not responded to most medications.

His daughter (his caregiver) came with him to the appointment.

It was a fairly sad encounter as they were recalling the most recent visit to a well known neurologist, an expert in neurodegenerative diseases, including Parkinson's.

I hadn't received the consult note back yet.

The patient was teary eyed when he let me know the neurologist said there was "nutin more he could do."

After a brief pause, I responded (I couldn't stop myself), "he really said that?"


"He said nutin...n-u-t-i-n?"

Thankfully, all of us were then able to enjoy a good laugh.

Laughter is still the best medicine for patients, caregivers and the doctor!

Friday, July 1, 2011

The most expensive care anywhere

A 32 y/o male had been to the Emergency Room (ER) for lower abdominal discomfort.

Labs (blood and urine), as well as an abdominal and pelvic CT scan were normal.

I could not interpret the hand written medical record.

It didn't appear to include a physical exam.

The patient confirmed this observation.

No diagnosis or treatment was given.

He was told to see his primary care provider (me) the next day.

I did not know the ER doc.

On my exam, palpation of the epididymus of one testicle reproduced all his pain.

He was involved in a long term monogomous relationship.

He was told to use supporting underwear and given a prescription for an antibiotic (filled at a local grocery store for free).

A week later, on re-check, he was fine (cured!).

He had already received one bill from the ER for approximately $2200.00.

I decided not to let him know that additional bills (from the radiologist, etc.) would be arriving in the future.

Alrighty then...