Pediatric Medicine

Likely due to language disparities, my less-than-five-year-old patient sat quietly on the examination table patiently waiting for me to start. She was smart and well-versed in the way of the doctor's office. As I approached, she knew when to open her mouth, brush her hair back for access to her ears and when to take deep breaths for adequate pulmonary auscultation. Finally finished with my exam, I returned to my documentation and in her best thespian performance let out a wee little, "a-choo," followed by a finger to the nose for good measure. [Picture: Before The Shot, by Norman Rockwell]

Child's Play

This month on pediatrics I am observing all kinds of lost treasures from childhood. From true emotions that come out in smiles, laughter and screams which somehow get tucked away when we grow older to naive playing with other people never met, ringing bells just because they are there and making sounds for no other reason than to entertain the thoughts floating inside one's head. It brings thoughts of Patch Adams gallivanting through a pediatric unit striving to see just a glimpse of a smile.

I had to laugh a little when another patient in the middle of their numerous vaccinations screamed in horror, their mother encouraging manners and to say thank you. What child wants to show appreciation for a shot and multiple at that?! Nevertheless, it brought a smile to my face when the little voice, through tears, cried out a profound, "thank you!"

Children are trying to be good even though their world revolves around them sometimes. It bothers me when their parents get cloudy vision and choose to refuse care that would easily remedy problems because they lack time or money. Taking your child to the emergency department is not just a suggestion by your doctor, it is sound medical advice that merits following. It makes me wonder why they brought the child in the first place if all they are going to do is ignore our recommendations. So who is the egocentric one now? Clearly, parents are responsible for their child's well-being. Maybe it's time for parents to have their own time out and come to their senses.

While I observe their behavior and character, I wonder what has happened to the child in me. Have I suppressed it so much that it can no longer come out to play or do I encourage its development in the hopes of a happier, healthier me?

Question of the Week

While doing a routine well-child exam you notice your 7 year-old male patient has freckles in his axilla and multiple café-au-lait spots on his torso; 3 anteriorly and 4 posteriorly. There is mild genu varus, no scoliosis and no vision abnormalities. What is the most likely condition this patient has?

A. Lesch–Nyhan syndrome
B. Henoch–Schönlein
C. von Recklinghausen disease
D. Chediak Higashi syndrome
E. Tuberous sclerosis

Answer & Explanation

Behind the Mask

Unless you work in an operating room, the routine of what to expect may be rather frightening and foreign. The anesthesiologist makes sure patients fall asleep and somewhere between the induction agents and analgesics there is very little remembered. It's no wonder so many are mystified by the effects of a surgeon's cold steel before, during and after an operation.

The Mystique of Surgery

Surgeon David Gelber recognized he was captivated by the operative challenge that is surgery early in his career, yet so many of his patients were unawares of what to expect. In an effort to shed light on how a surgeon is capable of cutting open human flesh, repairing pathologic organs and un-opening a patient for maximized healing, Dr. Gelber has written Behind the Mask: The Mystique of Surgery and the Surgeons Who Perform Them. While doubling as his memoir, Dr. Gelber pens a thought process from start to finish of how operative cases are approached to promote a successful outcome.

Sometimes funny, at other points emotional, the reader journeys through surgical cases and how they molded Dr. Gelber's career. Life saving operations and split-second decisions are among the many stories which depict a professionally educated approach to patient anomalies and diseases. Despite an eager attempt at simplifying the language to be read by all, I felt there existed a writing style that would be better understood by medical personnel or those familiar with basic medical terminology. Commonly, definitions were given and ideas explained, but occasionally the reader may be left confused about anatomical or medical associations. Nonetheless, the text proved to be a quick read that entertained with sophistication and matter-of-fact generalizations. I enjoyed seeing through a surgeon's eyes how he performs his duties. With this piece, the surgical unknown may no longer be cloaked in mystery as it once was, rather, it brings knowledge to the lost time and memories experienced while laying on the surgeon's operating table.

Question of the Week

An 8 year old girl comes to your office complaining of a sore throat for 3 days. Her mother reports the patient had a maximum temperature of 101.5F yesterday that resolved with Acetaminophen, no wheezing, no cough, no ill contacts and no recent travel. On exam, the patient's temperature is 100.8F, tonsils are erythematous with gray-white exudate, and anterior cervical lymphadenopathy on the left. The treatment of choice is which of the following:

A. Observation with "watchful waiting"
B. Amoxicillin with Clavulinic Acid
C. Penicillin V
D. Amoxicillin
E. Ibuprofen

Answer & Explanation

Doctoring Through Humor

Every once in a while, funny things happen. This time, brilliantly dressed man, tall in stature with half a head of blue hair paced on the stage recanting memories from his career as a medical doctor and health activist. There was no shortage of clowning, which was only exaggerated when he literally disappeared inside his over-sized pants...yes really. 

Smile, It Scares the Blues Away

Recently, I had the opportunity to listen to and chat with Hunter Adams, better known as "Patch" Adams. Most people recognize the Hollywood title, and in person, he was simply fantastic. Patch is a one of a kind personality who has established the Gesundheit Institute, a free medical clinic where health is paramount for the individual, family and community. While in his final years of medical school, Patch had a vision on how to change the world and healthcare itself by eliminating the "red tape" that is found in bureaucratic medicine. His cheery disposition, desire to spread happiness and creative outlook stoke a positive reaction in most people who have the pleasure of his company.

On the verge of practicing medicine myself as a rookie doctor, I spent a couple minutes consulting with Dr. Adams. After expressing my enthusiasm for my fast approaching residency and my simultaneous anxiety of the same, he could not fathom why as this is the best time to grow as a young doctor. His words of advice were to "never lose the humor." There are so many positive experiences to be had that it would be a shame to miss out on account of fearing the experience itself. Through his discourse, personality and example, I am reminded that we can be whoever we want and that it is acceptable to be the one who doesn't follow the norm. Compassion is a characteristic that is given to benefit the lives of others, and in my eyes, Patch exemplifies this quality with great finesse. Thank you for your words and example.

Question of the Week

What can I do to contribute to a happier me and society?

Answer & Explanation

Medical Coding

Guest post from Deanne Hicks, Medical Billing and Coding Instructor

Greetings! My name is Deanne Hicks and I have worked in the Health Information Technology field as a certified coder for the past ten years. So, what is coding? The greatest analogy I can use to describe coding is to compare it to learning a new language. Essentially, it is the art of storytelling. A coder abstracts information from the patient's medical chart and translates that medical information into alpha or numeric codes that are up to five characters in length. There are several uses for codes, with the most common usage to drive reimbursement for providers. The other uses are for statistic collection, vital records for cause of death, public safety for communicable disease reporting, epidemic/pandemic reporting from hospital records in certain geographic areas and a host of other topics.

You may wonder how someone becomes a coder. For me, I needed a life change and decided to go back to school. Having just gone through a fairly difficult pregnancy, undergoing several encounters with a myriad of different providers over a course of almost two years, medical terminology and anatomy became fascinating to me. I wanted to learn more! I signed up for a diploma program as a medical office assistant and away I went, on a journey from which I have never turned back. I learned more about the human anatomy than I ever thought possible. When I took my medical terminology course, I was completely hooked! Once I got to the medical billing and coding portion of my program, I was on cloud nine. Although medical billing an insurance didn't interest me, I still persevered onward, patiently awaiting this thing called medical coding. Once I learned how to code, it was as if I had found my passion. For the first time in my life I knew what I wanted to be when I grew up...a Coder.

Earlier, I mentioned that coding is first and foremost, utilized in order to get the provider paid. As young medical students who dream of becoming a physician someday, wouldn't you eventually like to get paid for your time? I realize you will most likely have a hefty student loan to repay, so I suspect you will appreciate getting maximum reimbursement for services rendered. Yes, your practice will have a coder to assist you in this effort, but what you need to keep in mind is this; coders code from the medical record so the more complete and specific the documentation is, the more specific the code choice will be. In turn, the higher the reimbursement might be!

Here is a great example, hypertension. In the coding manual, hypertension is divided into three types, those being malignant hypertension, benign hypertension and unspecified hypertension. Malignant hypertension (ICD-9 code 401.0) is defined as very high blood pressure that comes on suddenly and quickly, with the diastolic reading above 130mmHg. With malignant hypertension, complications could arise with kidneys, blindness or an increased risk of stroke or myocardial infarction. If a patient exhibits symptoms such as blurred vision, confusion, anxiety, chest pain, nausea, vomiting, shortness of breath, or weakness in the limbs with a high diastolic reading, malignant hypertension needs to be considered. However, more often than not, the treating physician will simply enter the abbreviation of "HTN" on the encounter form. Because coders code from the medical documentation given, the only code choice would be unspecified hypertension (ICD-9 code 401.9). Also, benign hypertension's (ICD-9 code 401.1) definition describes this type of hypertension as slightly elevated blood pressure which, if left untreated, could cause cardiovascular and central nervous system complications.

If a physician were to document and diagnose the specific type of hypertension, this would open up the opportunity to allow a deeper evaluation of the patient with blood work, ECG if warranted, additional body systems to examine and evaluate as well. In order to code the encounter in the outpatient setting, the more body systems examined and the more test results to review on subsequent visits, the higher the level of coding for the physician's cognitive skills. All things considered, the reimbursement level for the provider will increase over a period of time, which will certainly help to make the practice thrive and in turn give the patient a higher level of care.

Everyone is a winner! Here is the successful chain of events:

1. Medical students learn to give greater detail in medical documentation in preparation for future billing
2. Coders and billers can code more specifically from detailed documentation
3. Greater reimbursement can be obtained
4. Patient's, doctors and coders are happy

So, physicians-in-training, add one more thing to your to-do list. Take a coding course offered at your local community college. Arm yourself with coding knowledge. I realize your brains are constantly being stuffed like a turkey with all that medical info, but as you know, we only use a small portion of brain power anyways. Cramming a little more knowledge into that head of yours will pay off for you big time!

Good luck!

Deanne works with Lincoln Group of Schools, a group of career training schools. She is a medical billing and coding training instructor, which is one of the various Lincoln programs available.

Question of the Week

While attending the cardiology clinic, the staff nurse measures the blood pressure of a 61 year-old man and finds that it is 182/100 mmHg sitting and 190/104 standing. He has a heart rate of 82/minute, with an irregularly irregular rhythm. On auscultation of the heart, there are no murmurs, but he has bibasilar crackles on chest examination. Which of the following pathological findings is most likely to be present?

A. Left ventricular hypertrophy
B. Left atrial myxoma
C. Occlusive coronary atherosclerosis
D. Cor pulmonale
E. Mitral regurgitation

Answer & Explanation