Thursday, March 30, 2017

Stroke: People at Risk and its Consequences

"Stroke" is a the common term for an "acute cerebral infarction", which means injury with loss of neurons of the brain tissue. There are 2 main causes for stroke: the obstruction of one of the arteries that feeds blood to the brain and bleeding from blood vessels in the brain. Both situations are very serious and can lead to loss of brain cells, loss of physical or intellectual function and death.

The people who are at risk for stroke are diabetics, people with high blood pressure, smokers, obese and patients with high cholesterol. If someone already has had a stroke he or she has a higher risk to have another one. In addition, for an individual who has coronary artery disease or peripheral artery disease, there is an increased risk of stroke. Atrial fibrillation (AF; an irregular heart beat) increases the chances of stroke, that is the reason why many persons with AF have to take an anticoagulant (blood thinner). Finally, there are genetic conditions that can increase the risk of stroke. Examples of this are sickle cell disease and increased coagulation disorders such as Factor V Leyden.

Stroke can be a devastating condition for the individual and it is definitely a major public health problem1 due to the immense cost it represents. It accounts for approximately 320 billion dollars every year in healthcare direct and indirect expenditures2. The patient has to deal with loss of function, which could be physical  (paralysis of arms, legs and/or face), and intellectual deficits like the loss memory and inability to speak. The recovery from stroke is usually slow and involves the use different levels of rehabilitation services.


1. Hankey GJ. StrokeHow Large a Public Health Problem, and How Can the Neurologist Help?. Arch Neurol. 1999;56(6):748-754. 

2. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation. 2016;133:e38-e360.

Marco A. Ramos MD

Thursday, March 16, 2017

Documenting Malnutrition. Part 4

The Physical Exam (PE) in Severe Malnutrition in the Setting of  Acute Illness

The presence of physical findings of malnutrition in the setting of acute illness is more difficult to find than in the typically malnourished chronically ill patient. Because of this, the criteria are less strict. In addition, there is the complication that most likely we do not know the premorbid condition of a patient so it would be difficult to assess the loss of muscle mass or the loss of adipose tissue. 

In order to assess the adipose tissue loss, we have to look for the following regions of the body:

- The periorbital region
- The triceps region for the triceps skin fold
- The ribcage region

When we assess the periorbital region we look for how sunken the eyes look in the orbital cavity. When we assess the tricipital fold, we see how much tissue can our fingers grab when we separate the triceps muscle from the skin and subcutaneous  tissue and when we examine the ribcage, we assess how prominent the rib bones look. 

The ASPEN criteria to determine severity of the malnutrition are very subjective. For example, in order to diagnose non-severe malnutrition in the setting of acute illness the adipose tissue loss in the mentioned regions has to be “mild”. In order to diagnose severe malnutrition in the setting of acute illness, the adipose tissue loss has to be at least “moderate”.

When we evaluate the muscle tissue loss we have to look to the following regions of the body:

- The temporal region (temples)
- The supraclavicular region (clavicles)
- The interosseous region in the hands
- The shoulder region
- The scapula region
- The thigh region.
- The calf region

Again, the ASPEN criteria are very subjective and in this case, what we are looking for is how depressed the hollow in the temporal region may be and how prominent the bony structures may look in all the other regions. The muscle size of the thighs and calves can also be assessed subjectively. In order to diagnose non-severe malnutrition in the setting of acute illness the muscle tissue loss in the mentioned regions has to be “mild”. In order to diagnose severe malnutrition in the setting of acute illness, the muscle tissue loss has to be at least “moderate”.

So, a PE may read like this:

“Mr A is a 58 year old gentleman who presented to the emergency department (ED) with a history of nausea, vomiting and abdominal pain for 5 days.

HENT: Eyes look moderately sunken in orbital cavity
Musculoskeletal: Moderately hollow temporal areas, moderately reduced muscle mass of interosseous muscles of the hands. Moderately reduced skin fold at the level of the triceps. Ribcage shows moderately marked ribs. 

Marco A. Ramos MD
Second Medical Opinions PLC
Physician Advisor in Clinical Documentation Improvement

Wednesday, March 1, 2017

What is COPD? Who has it?

COPD stands for Chronic Obstructive Pulmonary Disease. There are 2 main conditions that are associated with COPD. The first condition is emphysema (the most common) and the second condition is chronic bronchitis. Smoking tobacco is the most common cause for COPD, although there are relatively rare genetic conditions that lead to similar changes without the influence of smoking cigarettes.

The term “chronic” represents that the anatomical changes in the lungs become fixed and may not reverse, although stopping smoking will certainly slow down the progression towards oxygen dependency. The term “obstructive” refers to the loss in elastic recoil of the lung tissue that will prevent the airways to be sufficiently opened at the time of exhaling air. This causes functional obstruction and air to be trapped in the lungs.

COPD can be a seriously debilitating condition. In its more severe form, it leads to the need of oxygen supplementation for the patient. In addition, a person with COPD is more prone to lung infections and even minor viral illnesses can cause acute respiratory failure. This can cause the need for intensive care and mechanical ventilation.

As it was mentioned before, smoking tobacco is the main culprit for this condition. It is never too late to stop smoking. COPD progression may not be stopped but it may be slowed down significantly. There are several medications that can be used in order to treat symptoms and reduce the functional obstruction in the airways. A physician will help any patient regarding smoking cessation and the treatment of COPD.

Marco A. Ramos MD