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Showing posts from October, 2012

Getting Used to Electronic Health Record

I will start with full disclosure.  I still use paper charts.  While I think my practice of medicine is "uber"-up-to-date...the truth is it could be 1950 when you look at my patient records.  Charts are huge and some  patients I've seen for decades are on volume 3, just to make them manageable.  So this very week I am coming on board with a full blown, state-of-the-art Electronic Health Record.

The government is pushing EHRs and, in fact CMS (Center for Medicare and Medicaid Services) has already imposed a 1% penalty on  doctors  that are  not doing e-prescribing of prescriptions.   The penalty goes up to 1.5% in 2013.  There are also some large incentive dollars connected with "Meaningful Use".  It is a complicated set of criteria put out by CMS that pushes physicians toward investing in the EHR.

With all of these incentives why haven't more physicians converted?  For one it is darn expensive and the best systems require large groups or hospital funding …


The answer to yesterday's medical challenge was #1 angioedema.  The patient had progressive swelling on the face and had previously had swelling of the larynx, trunk and extremities.  A diagnosis of hereditary angioedema was made from a blood test.

Angioedema just means swelling under the skin.  Spots of angioedema are called "hives" and they are usually from an allergic reaction.  Histamines and other chemicals are released by certain types of white blood cells when an allergen is detected.  This can occur because of insect bites, animal dander, pollen, food allergies, and certain medications.  People with hereditary angioedema, a rare condition,  lack a certain protein (C-1 esterase)  that is part of the body's immune system.  The swelling can come on quickly and be dangerous if it limits breathing through the larynx.

For more common hives (urticaria) or angioedema, antihistamines are the best treatment and avoidance of the allergen.

Thanks for your diagnoses.  

EverythingHealth Diagnostic Challenge

Hello Readers,
This weeks Image Challenge from The New England Journal of Medicine is a good one.  Also it is pretty common.  The patients symptoms developed over a few hours and she came to the Emergency Room.  Is it:

1.  Angioedema
2.  Facial palsy
3.  Frey's syndrome
4.  Parotid adenoma
5.  Parotitis

 Make your best diagnosis in the comments section and the answer will be posted tomorrow.

Fallen Hero-Lance Armstrong

Reading the daily updates about the Lance Armstrong bicycle team doping scandal is like watching a train crash.  It gets worse and worse and there is no turning back for America's sport hero, Lance.  I read his book "It's All About the Bike" and even wrote a book review on it, praising his true grit story and come-back from being on death's door from testicular cancer.  Lance Armstrong, the boy next store with his good looks, amazing athleticism and cancer charity (Livestrong) has fallen off his pedestal.

The reports that are now being disclosed by his bike team aide, Emma O'Reilly  show that Lance and his team ingested and injected a boatload of illegal substances to improve performance over their entire successful careers.   The one that caught my eye was injectible testosterone, a performance enhancing drug when used in high quantity.  I thought back to his diagnosis of testicular cancer and the rapid spread of the disease before he was even diagnosed.


Different Roles in Health Care

I was working late this week; making patient call backs, filling prescriptions, reviewing labs and finishing charts from the day.  It was dark out and the medical office was quiet and empty.  The janitorial crew started their work of emptying trash, picking up the scattered debris from the busy patient flow and sanitizing surfaces.  I looked up and a beautiful Latin woman, age about 30,  wearing latex gloves, was emptying the overflowing trash can.

"You are working overtime", she said with a heavy Hispanic accent.  I laughed, realizing how late it was and how tired I was and still had more work to do.  Then I stopped and really looked at her.  She was busy putting liners in cans and dusting surfaces.  She was working fast because there were many other offices ahead of her that also needed cleaning.

"You are working overtime too", I said.  "Yes", she replied, "I will work until 12:30"  (that's AM)

"I bet this is a second job for you"…

Knee Replacements on the Rise

According to a new study in JAMA, knee replacement surgery could reach 3.5 million a year by 2030 in the United States.  Wonder why health costs are rising?  We have new expensive technology that improves quality of life but may also break the Medicare bank!

The study showed that the number of knee surgeries performed more than doubled from 1991 to 2010.  Fortunately, length of stay in the hospital (a major driver of cost) decreased from 7.9 days to 3.5 days.  In the 90's more patients were discharged to institutions for  rehab and now patients are discharged to home with home health services.

The researchers attribute the potential increase in demand to aging baby boomers and a rise in conditions that contribute to arthritis - namely obesity.  Also there are more trained orthopedic surgeons that perform the surgery and it is becoming more mainstream.

Total knee replacement (TKR) will be a key driver of health care costs in the future.  Many studies have demonstrated that TKR is …