Medical Records: Extreme High and Low Findings In the Hospital.

Over my many years of hospitalist medicine, I've had the opportunity to witness extreme levels of human physiology.  I often go home at night wondering how God has made the human body so tolerable of such large variations in pathological conditions.  I shall use this post as an attempt to chronicle some of my more shocking variables I have laid eyes on.  I'm sure there are many I have forgotten, but for those I remember, please marvel in the endurance of the human body.  For some other experiences that deserve an entire post of their own, make sure to check out y other record hospital results over the years.

Highest Pulmonary Pressure:

This is my highest pulmonary pressure ever for a patient.  Known as Pulmonary Hypertension, they had a pulmonary pressure of  133 mm Hg on cardiac echo (estimated with a right ventricular pressure).  Holy Pulmonary Pressures Batman.

Crazy INR/Hgb Ratio:

A normal INR/Hgb ratio runs about 0.07. A normal PT/INR is 1.   It is the test we use for measuring "coumadin levels". For most conditions, doctors want an INR between 2 and 3 as stable coumadin or warfarin dosing.   A person not on coumadin and with normal body clotting activity has an INR of 1. A normal hemoglobin, or the oxygen carrying capacity of your red cells of your body, is about 13-15.

Therefore, a normal ratio of INR/Hgb is 1/14, or 0.07. So when I see a patient with a INR/Hgb ratio of 3.2 my hospitalist wheels started turning. A personal record for me.  And in an octogenarian none the less.

Anorexia Lowest Weight:

She was a 50 year old female and only weighed 24 kilograms. That's 53 pounds folks. That's my lowest weight ever for an anorexic patient.  My first plan of action was to get a clergy to come talk to her. I am way out of my league on this one. I have no idea how to help her. When she won't let me, as is usually the case in patients with anorexia.  They need fare more than just a hospitalists to care for them.

Highest HDL:  

What's the highest HDL ever?  For me it's this cirrhotic alcoholic who presented with an HDL of greater than 135.  This gentleman's HDL level is "desirable".  The way I see things, there's no need to worry about his end stage cirrhosis with all the life threatening sequela that comes with it.  With an HDL that high, his heart will live forever.  For most folks, the benefits of alcohol reach a dose dependent level rather quickly, usually at a maximum of one or two drinks a day.   For this guy, perhaps, I should tell him to keep drinking and drinking and drinking.    It may be the only thing keeping him alive. 

HIGHEST BLOOD SUGAR:

You may have just seen the highest blood sugar ever.  You are an internal medicine intern. It's your first month of residency. You're covering the VA medicine service tonight. You just finished your sixth admission of the night when in roles a 32 year old carny complaining of a three week history of progressive weakness. He is brought in by his beautiful wife at 2 am when she realize he can't get it up because he's too weak.

Here are your pertinent laboratories intern:
ABG 7.28/40/90
Na 132
K 2.5
Cl 100
T-CO2(bicarb) 17
Glu 1675
BUN 50
CR 2.8

1. What's going on?
2. What do you do about it?
3. What are your main risks of treatment?
4. What's your free water deficit and how should you replace it? (assume 70kg)
5. What is your true sodium level?
6. What's his delta anion gap?
   

Your supervisor went home with the swine flue and your attending missed his flight from Chicago after his wife caught him with another woman. It's just you intern. What are you going to do?

BLOOD ALCOHOL CONCENTRATION OF 0.708 AND NOT EVEN A NATIONAL RECORD

The highest blood alcohol concentration I've ever seen is around 0.550.  In my experience, it's usually a Native American that presents to the hospital with such an incredible level of intoxication.    The legal blood alcohol concentration in most states is 0.08.  That means blowing a blood alcohol concentration of 0.550 and 0.708 is about seven and nine times the legal limit respectively.  Most people would be dead on arrival with a blood alcohol concentration of 0.708.  But not this lady.  From the Smoking Gun:

Meet Marguerite Engle. 

That 0.708 is not even the national blood alcohol concentration record.  That record belongs to an Oregon woman, Terri Comer, 43, who blew a 0.720 last year after being discovered unconscious in her car.  Talk about extreme sports. It's clear to me that these blood alcohol concentrations indicate the body's remarkable ability to build tolerance in alcoholics.  And it's one reason alcoholics often believe they don't have a problem, when clearly, they do.

MOST ER VISITS.

 I don't know what the record number of hospital visits are out there are. But I saw a guy in the ED the other day that had 240 ER visits in the last six years. That's 40 visits a year, every year for six years. That's an average of one visit every 9 days for six years. That's six long and painful years. That doesn't even include all the numerous admissions to the hospital. Imagine spending over 10% of your life in the emergency room for six long years.

FASTEST PATIENT EXAM

This patient represents my fastest patient exam ever.  She'd been hospitalized for over two months awaiting placement in a nursing home. Nobody wanted her because she represented too great a risk to other nursing home patients.  It's interesting that a hospital with an emergency department can be forced to see every patient that comes through their doors, but every nursing home in this universe can refuse to accept any patient at any time.

This is an example of one of those patients that can take days, weeks, sometimes months to place.  They aren't safe to go home because they lack even the capacity to make poor medical decisions.  Their family abandons them with the mentality that it isn't their problem to fix.  The nursing homes don't care.  They have every right to pick and choose, just like doctors do as an outpatient.  No insurance?  That's a problem.   Bad insurance?  Bad disease?  Sorry, that's the hospital's problem.

A while back a patient was sued by a hospital because they refused to go to the only nursing home that would accept them.  The patient instead wished to stay in the hospital, I suspect forever.    Fortunately, the hospital isn't an appropriate place for long term management of stable disease. 

In this case, every morning this patient would pull her sheets over her head and sleep in peaceful seclusion.  Every morning she'd have nothing to say.  Every morning I would wake her up and interrupt her peaceful dreams.  Why?  Every morning I am required to write a note on her because hospital bylaws require a daily evaluation by  the attending physician. That' me, the hospitalist.  So every day I am required to do an evaluation, the depth of which is determined by me.  I can choose how much or how little I wish to do.  I let the circumstances guide my decision making process. 

After two months in the hospital, it becomes painfully  silly for me to wake her up every morning, pull the sheets off her head and ask her if she slept well last night.  So this time I didn't.  I asked the nurse if the patient had any issues or concerns.  I looked at the patient sleeping under her blanket from the bedside and I wrote my low level 99231 hospital follow up note

126/78  *  72  *  20  *  98.6

 Dementia, awaiting placement

That's my evaluation and it meets every lawful requirement necessary to be paid for by the Medicare National Bank for a CPT® 99231 evaluation.

OLDEST ALCOHOLIC

So I think I happened across the oldest case of alcoholic hepatitis ever.  He was 99 years old and loved his vodka.  He even admitted to a "little vodka every night".  He came in with a classic 2:1 AST:ALT ratio on his liver enzymes in a non obstructive pattern.   But it didn't click with me at the time.  He's  99 years old.  What kind of 99 year old gets alcoholic hepatitis?  It's unheard of.

In the course of his ER evaluation, he was found to have a markedly dilated common bile duct of 25 mm, despite his previous cholecystectomy.  With a little conservative management By doing nothing but observing him for a few days all his liver enzymes returned to normal.  That's how you diagnose alcoholic hepatitis in a 99 year old.   Patients lie to their doctor,  even the 99 year olds.  So what.  You're my hero old man.   Don't let anyone tell you differently.  Just make sure the social worker sends you to a vodka friendly nursing home where you might even meet my patient who was drunk at the nursing home with an alcohol level of 0.210.  That's the drunkest nursing home patient I've ever met! You guys can be roommates.

WORST SOCIAL HISTORY

This has to be the worst social history ever.  Everyone knows that in order to get paid under the evaluation and management (E/M) rules of the Medicare National Bank, the more nonsense information you obtain, the more you get paid.  Does it meet Medicare medical necessity?  Of course it does.  It always does.  For your documentation to support CPT®  99223  instead of  99221, the social history component is mandatory. 

So what do physicians do for their documentation?  They write something, anything, just to meet the compononent requirements for E/M, even if you think it has no bearing on the care plan going forward.  There is nothing anywhere that clarifies when a social history is not indicated.  It will always be indicated.  And to get paid, physicians must  include it.  That's why doctors document it.  I would much rather just move on to more important things when social history doesn't matter.  But the Medicare National Bank makes it matter, every time.  That's the way E/M works.  So what did the worst social history ever look like?   Here is an APRN social history I saw once!

Patient presents with her daughter.

I don't know what they're teaching in nursing school these days or if taking a social history is even  a nursing education requirement.  It's obviously not an APRN requirement, at least not for this one.    That's not even a history.  That's an observation.  It describes the present.  If you want to make it appear like you at least applied some effort, say that the patient was drinking or smoking with her daughter.  Now that's a social history worth documenting.  What's the worst thing you've ever seen documented for social history?

SMALLEST X-RAY 

A 76 year old woman presented as a direct admission from a dentists office with an acutely painful and swollen left  cheek. That's a once in a lifetime hospital admission. The dentist even called the hospitalist and arranged for an inpatient surgical evaluation. 

Happy: Hi Ma'am.  I noticed you've got a painful and swollen face and the dentist said you needed to come into the hospital for intravenous antibiotics.

Ma'am:  Yes.  It hurts a lot.  The dentist took an X-ray and gave it to me.  He thought you might want to see it.

Happy:  That's great.  Do you have it with you?  (Looking around the room for a big manila envelope)

Ma'am:  Yes.  (Reaches into coat pocket and pulls out a tooth X-ray)

Happy: Interesting.  That's got to be the world's smallest X-ray that a hospitalist has ever seen.  I think a stat outside film radiologist over read is in order.

Impression: CHF vs PNA vs COPD