Home / Patient Encounters (page 7)

Patient Encounters

What Visit Billing Code to Use?

There are certain things that patients say that make even those of us who think they have heard it all stop and shake their collective heads. A young lady comes in and wants to be evaluated for sexually transmitted diseases. That’s what she says in triage, at least. She gets back to the room and she’s swearing like a truck driver. Her boyfriend left his cell phone at home before he went to work and she started looking through his texts. “He’s texting nastiness to at least 8 other women and they all sound like skanks.” Then she starts going through the content of the texts … including where some women reportedly asked to have bodily fluids deposited and other women who want cocaine sprinkled on other areas and then licked off. Oh, and then there are the women who boast about how large … oh nevermind. You get the idea. The patient was being overly loud and descriptive when discussing the texts and repeatedly had to be told that the content of the texts really didn’t make a difference in her medical care. Then she got angry. She wanted her description of the text messages written verbatim into the medical records. Nope, not happening. She demanded to speak to the administrator. The administrator shows up and finally asks “Why is it so important that the text messages are included in your medical records?” Wrong question. The patient yells out “Because I drove all the way across town to come to this hospital because my boyfriend works here as a surgical and I want anyone who looks at my chart to know that JIM SMITH IS A F**KING SCUZZBAG! THAT’S why!” Somehow I don’t think that “outing a scuzzbag” is a codeable diagnosis, but I’m sure the ladies in the cafeteria now know your problems after your little outburst, though. And if Jim is anywhere in the building, he’s likely now sneaking out the back door. ————————————————— This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on DrWhitecoat.com, please e-mail me.

Read More »

Why the Lady With Knee Pain Got a Pelvic Exam

It was a busy night in the emergency department, so the patient had to wait for  to be seen. By the time the doctor got in the room, she was in obvious pain. Her knee was killing her. It bothered her a little two days prior. The pain got worse a day later. By the time she woke up that morning, she wasn’t able to walk on her knee. She hadn’t injured it as far as she could remember, but it looked like the kneecap was missing whenever she straightened it out. And did she mention that it was killing her? In all fairness, the patient’s knee was definitely warm and swollen. It wasn’t that her kneecap was missing, but rather that the effusion in her knee was making her kneecap disappear. Really couldn’t do much of an exam on her knee because the pain was just too bad. Whenever she moved it, she yelled in pain. She got some pain medications and an x-ray. A couple of “unnecessary” lab tests were added just in case. Of course, the xrays were normal and the labs were all abnormal. White count 20,000. Sed rate 65. CRP 19. The patient was getting a knee tap. The orthopedist didn’t want to hear about the case. “It’s gout. Don’t you know how to treat gout in the emergency department?” Sorry. The emergency department staff forgot to bow and pay homage before asking the secretary to dial your cell phone number. Forgive them. In answer to your question, “Yes, we do know how to treat gout in the emergency department. Would you prefer that we use Ancef 1 gram or 2 grams?” So after paying further homage and sacrificing a psychiatry intern to please the Bone Gods, the knee tap proceeds against the orthopedic recommendations. Even without orthopedic guidance and an intraoperative CT scan to prove proper placement, 130 ccs of yellow cloudy fluid is able to be retrieved. Lab analysis shows no crystals. Obviously that will be considered a lab error when the orthopedist reviews the slide in the morning, but for now, the white count of 28,000 with 98% segs must be addressed. The patient gets a dose of vancomycin and Levaquin. Knowing one of the more common etiologies of acute monoarticular infections in young adults, then the doctor breaks the news to the patient. “Unfortunately, we have to do a pelvic exam.” “Whaaat? Are you high or something?” “Well, one of the more common causes of arthritis in situations like this is … well … a sexually transmitted disease. So we need to check to see whether or not you have an asymptomatic infection.” Sure enough, there was yellow discharge and cervical motion tenderness. The staff engages in a moment of silence, bows toward the orthopedic wing of the hospital, and the secretary re-dials the orthopedist’s pager to relay the findings. “What do you want me to do about it? Obviously, it’s a gyne problem. Call a gynecologist.” Ahhhh, yes. Again, how dumb could the emergency medical staff be? It is common knowledge that women have babies in their knees. Heck, by the size of this patient’s knee, she’s probably six months pregnant. Another collective bow before hanging up the phone, then the gynecologist is called. He makes some comment about having a urologist look up the orthopedist’s nose, but agrees to accept the admit. The patient’s boyfriend came to visit her at about the six hour mark. As they talked, eventually he complained enough about his sore throat that the patient convinced him to register to be seen in the emergency ...

Read More »

The Doctor That Took Care Of The Lawyer That Sued Him

By BirdStrike M.D.   I walk in for a shift and sign up for my first patient.  To my surprise the patient sitting on the bed is my friend and co-worker Dr. Jerry.  Before walking into the room, I notice from afar, his hand is grotesquely swollen, black and blue.  I walk in to the room and say with a chuckle, “Jerry, what the heck are you doing here?  You are supposed to be on vacation.  Wow, you must really love this place?” Jerry happens to be what we ER doctors refer to as a “machine.”  He can walk into an emergency department in chaos and seemingly singlehandedly bring it under control, with what at times seems like superhuman brute force.  Of all the ER doctors I’ve worked with, if anyone was truly born to be an ER doctor, he is.  “Close the door,” says my patient, Dr. Jerry. “What happened?  Did you fall?  Your hand looks horrible,” I ask.  “Good thing you’re on vacation starting today, because with that mangled paw you’re not going to be doing any suturing or any other procedures that require more than a stump for a hand for quite a while,” I add. “You can’t tell anyone.  It’s embarrassing.  You promise?” Jerry asks. “Sure man, no problem.  It’s between you and me and the HIPAA Gods.  What happened?” I plead. “You know my luck, and the black cloud that follows me, right?  Well, I walk in for an overnight shift a few days ago and the department’s dead.  For once in 10 years, there’s practically no one in the whole department.  In fact, there was no one in the whole department.  I sit down and I’m thinking: this is weird.  Maybe for once I’ll have a great shift and just sit on my butt all night and not get crushed with a constant onslaught of chaos.  Just then I look up, and into room 11 walks in,” says Jerry changing to a tone of doom, “Gary the Medical Malpractice Lawyer.” “Gary the Guillotine?  No way!  I thought we were the ‘most negligent group of physicians he’s ever seen in his career’?  Funny how he has sued, or attempted to sue just about every single doctor in this group and when he’s sick he comes here?!  You’ve got to be kidding me?  I’m sick to my stomach even thinking about it,” I say, trying not to gag on my words. “Yeah, it was unbelievable.  You should have seen this guy.  Yucking it up with Jane, you know, Jane the new nurse?” he says. “No.  I haven’t worked with her, yet,” I say. “You know, Jane, the one that just finished nursing school?”  Jerry explains, raising his eyebrows. “Oh…..Yes.  How could I forget?  Jane…,” I answer. “He was all over her like a dog on a rib-eye.  What’s he, 50 years old, and she’s what, barely of consenting age?  Anyways, I signal to her to get out of the room and come talk to me before I go in, because in NO WAY is it even remotely possible for me to go in the room and treat this guy objectively.  Do you remember what this guy did to me?”  Jerry asks. “He tried to sue you, like most everyone else at this hospital,” I answer. “Yes, and during a deposition, he asked me about the fact that I disclosed having been treated by a psychiatrist briefly, on my medical license application,” Jerry began to explain. “So what?  I think you mentioned that before.  You took Prozac for 2 weeks or something.  Big deal,” I say. “You’re ...

Read More »

The Case of the Bleeding Ear Takes a Bizarre Twist

By Birdstrike M.D. My shift is over and I’m ready to head out the Emergency Department door.  When I walked in 12 hours ago, the department had 20 waiting patients.  I look up at the monitor and after 12 hours of trying to wrestle the department under control, not only is it not under control, now we’re 25 patients deep in the weeds.  My partner Dr. Jim looks at me and says, “Get out of here.  Don’t even think about staying late.  You can’t save the world.”  With me leaving, the department will drop to single coverage with Jim taking the reins alone the rest of the night.  Despite his words, the dejected look on his face reads, Help! It’s going to be a long and grueling overnight shift for Dr. Jim. I look up at the monitor and it says, “Ruptured eardrum.”  That’s easy, I think to myself.  I’ll stay late and see at least one more patient to help out.  I walk in the room and it’s a 16-year-old girl, in a green and white basketball uniform, with her mom and dad, who looks like he could be a retired football linebacker.  “I got hit in the ear with the ball.  I can’t hear at all, and my ear’s bleeding.  This is the second time, it’s happened.  Last time I couldn’t play basketball for a week,” she says. “Okay, let’s take a look,” I say.  I put a couple of drops of peroxide in the ear to soften up the dried blood.  Hmm?  There are no bubbles.  I clean out the ear and…what is that smell?  Do I smell raspberry jelly?  I clean out the ear more and look at the ear drum.  It’s perfect.  There’s no rupture and no laceration in the canal.  Her ear is completely normal. “I won’t be able to play this weekend, will I?” she asks.  “Just put me on the injured list this weekend, and we’re good to go,” she says with a bubbly smile.  Being that she’s 16, and still a minor I ask her parents if she and I can talk in private for a minute.  They say okay, I have a female nurse come with me, and we close the door.  “Did you put something in your ear?” I ask.  “Like raspberry jelly or something, to make it look like blood?” “Yes,” she says, looking deflated.  She then confesses that she doesn’t want to go to the tournament and concocted the whole story to have a reason to be injured, so she could go to her boyfriend’s party, instead.  I thank her for her honesty.  “Can I go now?” she asks. I discharge her and on the way out the dad comes back in, “Doc, she faked it didn’t she?  I know she doesn’t want to play in the tournament.”  Without speaking, I gave a half nod.  He smiled and walked out.  Even though I was dog-tired after working 12 1/2 hours and staying late, I finished the shift a little lighter, with a simple case where no one died, no one bled out, or inappropriately demanded narcotics. A week later prior to a shift, our ED director Dr. Bob comes to me and says, “Hey Bird, how’ve you been?  I’ve got some good news, bad news and ugly news.  Which do you want first?” “None of it,” I answer. “Okay, the good news.”  Then, with the phrase no ER physician ever wants to hear, “Remember that kid you saw last week?  The one with the bleeding ear?” “No.  Wait, do you mean the one with raspberry jelly coming out ...

Read More »

How to Get Tazed Out of Spite

One of the “regulars” comes into the ED. He has a long rap sheet of pain medication prescriptions on the state database from multiple different providers and is complaining of back pain for which he is requesting a prescription for more pain medications. The 30 Percocet that he filled three days ago have mysteriously vanished. The emergency physician tells him he’s on “The List” and tells him that he’s going to get Naprosyn and like it. The patient tells the nurse that he doesn’t want Naprosyn. The nurse responds that she can only administer the medications that the doctor orders — and the doctor ordered Naprosyn. The patient then spit on the nurse. The nurse screamed. A “code white” is called and half the hospital comes running to the ED. The patient then realizes that he kicked the proverbial hornet’s next, so he pulls a Little Jack Horner, sits in the corner, and won’t leave. He tries to kick anyone who comes near him. Police are then called. Four burly cops come busting through ambulance bay doors like it’s a bank robbery. They go in the room and tell the patient to leave. He still won’t move. When they try to pull him out of the corner, he kicks one of the officers. OK, now he’s going to jail. One of the officers runs back outside and brings in a German Shepherd on a leash with drool dripping from its fangs. “If you don’t come out of the corner, I’m going to turn the dog loose on you.” The patient sits there with his arms folded. Police have everyone leave the room. “OK, ATTACK”. Then the patient leans forward and starts talking baby talk to the dog. “Oh, there’s my wittle doggie. How’s my good doggie? Commere, boy.” The dog walks up to him and sniffs his hands. “ATTACK!” yells the police officer. The patient reaches out, scratches the dog’s cheeks, and says “That’s a good doggie. Sit, boy.” The dog sits down. “ATTACK!” Yells the police officer even louder. The dog wags its tail and stays seated. Dog gets taken from the room. Police pull the curtain. A bit of scuffling and all you hear next is the patient’s muffled yell and the rapid “pop pop pop pop pop pop pop” of a Taser being deployed. Then the curtains fly back open and the patient is dragged out of the emergency department backwards with one officer on each arm saying “Where did my widdle doggie go?” “But wait!” the nurse yells behind him, “you forgot your prescription for Naprosyn!” While Elmer Fudd speak happens to be one of my pet peeves, this incident was pretty damn amusing. ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr. Whitecoat.com, please e-mail me.

Read More »

Alert and Oriented x 3

A blast from the past … A nursing home patient was brought by ambulance for a complaint that they woke her from sleep, er, um she was having mental status changes. Her chart listed a slew of medical problems including dementia and the fact that she was “non-verbal.” It was busy that day, so the nurses ordered the basic “dementia” workup while the patient was waiting in the room. When it was finally her turn to be seen, I went into her room and began asking her questions. She didn’t say anything. It was a little frustrating – how exactly was her mental status different if she wasn’t talking? At least it made my job a little easier in documenting the history. As I examined her, she just laid there. Heart and lungs sounded fine. She would slowly pull her hands away if I pinched her fingernails, but I couldn’t get a great neurologic exam on her because she wouldn’t do anything I asked. She just laid in the bed with a blank stare. I could tell there was some higher brain function left, though, because I walked out of the room for a few minutes and when I returned, she had rolled on her side and pulled the covers over her face. I usually make small talk with the patients – even if they are demented. Actually, it’s probably a sign of my own impending dementia. So, kind of rhetorically, I stood in front of her and said “Mrs. Peel, you don’t seem happy today. What’s wrong?” From beneath the covers a raspy voice blurted out “I’ve been waiting in this motherf@#king ER for three hours. That’s what’s wrong.” With that statement, she proved to me that she was alert and that she was oriented times three – to person (herself), place (she knew she was in the ED) and time (she knew how long she had been waiting). Once I rearticulated my jaw, I asked her what would make her happy. She didn’t answer me. I had a lollipop in my pocket from a previous kid who “didn’t like butterscotch.” So I said “how about a lollipop?” Still she didn’t say anything. I lifted up the blanket covering her face and put the lollipop in front of her face. Her eyes were shut and she didn’t open them. Like a little clam, she pulled the covers back down over her face. As the ambulance crew was wheeling her back to the rig for her all expense paid trip back to the nursing home, I looked up to say good bye and the covers were still pulled over her head. Just like the Madagascar penguins, I “smiled and waved.” I actually laughed out loud when the tech found the lollipop wrapper on the floor by the side of the patient’s bed. She was playing possum at the ol’ nursing home. And I busted her. But it was our little secret. And to see why I recently felt this way, you’ll have to read this post on my other blog. ————————————————— This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on DrWhitecoat.com, please e-mail me.

Read More »