Tuesday, May 25, 2010

Ninety-nine

If newFNP could stress one thing -- aside from the importance of clear skin and a cute wardrobe -- to students, it would be that one must learn to elicit and write down a decent medical history. It is very clinically challenging to have too little information and may go as far as to cause newFNP to call chronically poor documenters 'douchebags.'


Say for instance one orders a CEA on a patient for apparently no reason whatsoever, as the subjective area of the progress note is left blank, and then say for instance that CEA comes back mildly elevated (4.2 ng/mL in a non-smoker) with all fecal occult blood tests negative. This may cause newFNP to think to herself, "What the fuck, douchebag."

It's not because newFNP doesn't appreciate that this abnormal test result necessitates follow up. It is that newFNP does not have one iota of medical history from whence to begin.

NewFNP walked into the exam room and immediately made the very subjective assessment that this 70-year old gentleman looked bad. He complained of chronic cough and dyspnea on exertion. NewFNP inquired as to whether he had ever noted hemoptysis with cough. He had. NewFNP was thankful that his daughter attended the visit with him as she mentioned in an off-the-cuff fashion that he had had multiple positive PPDs, but not even one chest x-ray.

Balls.

NewFNP listened to his lungs. The left lung was peachy. The right, not so much. NewFNP started at the bottom: diminished. She moved to the middle: unimpressive. She progressed upward: rales. She moved her stethoscope back down and asked the man to say "ninety-nine." Again the sound was diminished at the bottom of the lower lobe. She moved it to the middle of his back and almost had her tympanic membranes ruptured by the volume with which the words "ninety-nine" resonated through her stethoscope.

Positive whispered pectoriloquy, hemoptysis, positive PPDs sans CXR evaluation and an elevated CEA equals a trip on into the county emergency department. Truth be told, the first three would have prompted newFNP to refer for an ED evaluation, but newFNP is certain that this man received his chest CT much more easily having shown documentation of the elevated CEA.

NewFNP called the patient today. He was hospitalized overnight and had a negative chest CT. The AFB is pending.

And newFNP's documentation is clear, written in neat penmanship and thorough for the next provider.


2 comments:

Anonymous said...

Amen! Now I don't feel so lonely bitching about good documentation...

kim said...

I'm still trying to figure out why the CEA? Wonder why you heard those sounds/differences with a normal CT? And what part prompted the ER visit verses continued out patient workup?

I never use whisper perctor-whatever, I find that patients tend to get louder when I ask them to say it again, not very specific I guess. but thanks for the review, I may just try it again one day soon. :)