Boops! I did it again...

50 year old lady came in with a history of RA, rheumatoid arthritis. She also had many joint deformities. Her symptoms were nasal congestion, yellow phlegm, hoarseness, shortness of breath, and severe coughing. Her condition was not improving before she came to Doc. An x-ray order showed a hazy density in her lungs. She was then referred to her pulmonologist (or pulmonary disease specialist, one who specializes in treatment of pulmonary conditions or diseases).

The pulmonologist determined that she had boop. (Yes, this is an actual term. It is an acronym for Bronchiolitis obliterans with organizing pneumonia.) Basically the tiny sacs or alveoli and small bronchi become very inflamed and infected causing severe pain, coughing, and other symptoms.

She underwent a very high dose of steroids.

However, from the huge influx of steroids the patient developed Cushing syndrome.

Cushing syndrome is developed in two ways, either intrinsically or extrinsically. This was an extrinsic case as she was consuming prednisone.

Cushing Syndrome Symptoms: moon-face, weight gain, increased blood pressure, hump neck, increase in blood suger, edema, and reddish, unusual stretch marks.

Her steroids were gradually tapered off over time and she was eventually cured.

I see people...

A young woman came in complaining of a severe headache in the front part of her head.

According to the patient, the headaches would usually happen before the start of her periods. This time however the headache started after her period. The patient was experiencing nausea and vomiting. She was very sensitive to loud sounds and light. It was a recurring headache every menstrual cycle. But there were no other neurological symptoms. Patient denied any family history of migraine headaches.

Doc concluded that menstruation related to migraine headaches was the likely cause. This diagnosis makes sense because of hormonal changes during a period.

Treatment options were simply anti-migraine medicine (sumatriptan). The medicine does not prevent headaches, only relieves the symptoms before it starts.

Doc noted that some some patients experience a visual "aura". Some people see some light changes in their vision. So it is almost like a clue that a migraine headache was the likely cause.  In extreme cases, some people can get a stroke from their migraine headaches.

Allergy

In the office, we decided to bring in allergy prick testing. It is very simple. All you have to do is grab the prick device dip it in the wells and apply it to the patient's skin. Then after 30 minutes compare it to the positive control (histamine) and compare.

The common treatments for allergies are usually OTC medications like allegra or claritin. However, for some patients these medications are not enough. So they turn to treatment options such as SCIT(subcutaneous immunotherapy). This involves the patient coming into the office and receiving shots of the specified allergens according to their allergy test. They then receive shots of increasing concentration until they can reach "maintenance" or to the point where they only need to take a shot once a month to maintain their allergy relief.

I personally did SCIT at one point. However, continually going into the office and continually paying a copay adds up very quickly. In Europe, there is a very similar treatment called SLIT(sublingual immunotherapy). You simply apply the treatment under your tongue and increase the concentrations over time. It is not as accepted in the states but it very well could be.

Kidney Stones

A middle aged asian man came in today complaining of pain in his right flank.

The patient experienced sudden onset of pain on his right flank in the morning. The pain never subsided. He woke up in the middle of the night at 2 AM with same quality of pain. When he urinated, he felt a burning pain in his lower abdomen. He experienced frequent urination and nausea. There was no vomiting, blood in urine, or chills. 

Upon examination, he had a clear case of right flank tenderness. Urine showed a tiny blood spec, and a clearly positive microscopic hematuria. 

Dr. concluded that he may have had some sort of kidney stone. Dr. ordered a CT along with extra hydration and some exercise. Patient needed to ensure that he filtered his urine to make sure he could find the stone. The patient was also prescribed percocet for th epain. Dr. explained to the patient that it would be extremely painful for the stone to pass. If it was larger than 4mm large it would most likely not pass and would need to be referred to a specialist.

The patient did not look comfortable.

And I hope I never get a kidney stone.

The Troubles of Billing in a Medical Office Part I

It is very difficult to collect claims in a medical office.

The basic premise consists of the following:

Step 1

The patient comes to see the Dr. who examines the patient and fills out a superbill that looks very similar to this:

Step 2

After Dr. completes the superbill, she hands the bill to the billing staff. We input the claim according by adding in each CPT code(or procedural code) along with the appropriate ICD codes(diagnosis codes, whatever the patient was diagnosed with.)

Step 3

That claim is then sent to the clearing house. The clearing house will run a set of checks on the claim and send it back to us if there is anything wrong.

Step 4

Once I fix the claim, the claim is sent back to the clearing house who then sends it to the insurance company. The insurance company will then go through the claim and send us the remittance.

Then you pray you get paid.  Next post:  a million ways your claim can get denied.

Heartburn

A male patient middle aged came in today complaining of left upper chest pain. He woke up with an uneasy chest pain that lasted for about a minute. He had shortness of breath. It went away and he went back to sleep. And when he woke up around 10 AM he experienced another similar pain. So After the second instance of pain, he came in to see Dr. He kept insisting that he had lung disease and he kept asking Dr. what was wrong with his lungs.

I could see how challenging it is to deal with patients who keep insisting or arguing that there is something else wrong or different than the doctors real diagnosis. Once Dr. was certain that it had to be a heart attack, she quickly did an EKG. Even the daughter kept continually asking why she was doing an EKG when it was a problem with his lungs.

Once she saw the EKG results and saw that the patient had an unstable angina from the clear acute EKG changes(An unstable angina is a condition when your heart doesn't get enough blood flow and oxygen.) he was immediately given aspirin and cholesterol lowering medication (Lipitor).

Sent to ER.

Don't let the bed bugs bite

Dr. brought in a young boy and a girl aged 7 and 5 years old respectively for rashes. The rashes had been going on for several months, but the family did not have insurance, thus, they took their time to see a physician.

The girl had rashes all over the body and scratch marks all over the body except her face. The boy has the same symptoms.

When I was looking at this, I was thinking to myself, "what the hell kind of disease is this?"

Upon further discussion and examination, it was determined that the kids had to have had bed bugs. Dr., asked very specific questions:

Where do the kids sleep? Do they have their own beds? Has she ever gotten better?

So whenever, the little girl slept by herself, she consistently got better. However, when she played with little brother and fell asleep in his bed, she would get the rashes again.

Therefore, it was determined that there were bed bugs in the boy's bed. After prescribing some anti-itch medication and instructions of how to clean the mattress the kids were discharged.

I hate bugs.