What is Chronic Kidney Disease?

Chronic Kidney Disease (CKD) is an alteration in the normal function of the kidneys caused by a chronic process and it is usually not reversible. Functionally, the kidney tissue is less capable of performing its functions which include: the filtration of blood, the control of the acid base status, electrolyte concentration control, fluid and blood pressure management, generation of erythropoietin for red blood cell production and  activation of vitamin D.

The processes that most commonly result in CKD are persistent uncontrolled hyperglycemia from diabetes mellitus, persistently elevated blood pressures, acute or subacute inflammatory conditions of the kidneys and genetically mediated anatomic abnormalities such as polycystic kidney disease (PKD). These processes result in scarring and fibrosis of the kidney tissue, with loss of renal cells in the cortex and medullary portions of the kidneys. 

Chronic kidney disease is usually classified in stages, going from I to V. The function that has been chosen to  assign the stages is the filtration function, measured as a variable called glomerular filtration rate (GFR). Although the kidney has many different functions, they are related to each other. The relationship is not perfect, but is is safe to say that if there is a reduction on the filtration function function of the kidneys, the other functions will be affected, in variable degrees. It is also possible that certain functions of the kidney may be affected with little change in other functions, for example, there are conditions that involve abnormalities in the handling of potassium or acidity without a change in the filtration function or generation of erythropoietin, however, these conditions are not too common.

The final stage of CKD is called end-stage renal disease (ESRD). At this stage, renal replacement therapy (RRT) becomes necessary. RRT includes dialysis (in its different modalities) and renal transplantation.

Marco A. Ramos MD

The Importance of Properly Documenting Malnutrition States

Malnutrition is a very common condition in the hospitalized patient. Up to 40% of the hospitalized patients can have some degree of malnutrition (1), and, severe malnutrition can rage between 8.4 and 21.4% (2,3). Surprisingly, in spite of being so common, this condition is one of the most under-documented conditions. 

This condition, if present, is associated with worse outcomes than if not present. A poorly nourished body will respond poorly to infection and other insults through a weakened immune system. The extracellular and intracellular compartments become depleted of electrolytes and other substances essential for the proper functioning of tissues. All this translates into a state associated with higher severity of illness and risk of mortality.

Making sure that malnutrition is properly documented and  stratified, i.e, specifying mild moderate or severe, is key for the following reasons:

- It helps seeking proper reimbursement for resources consumed in the care of this condition.

- It would accurately reflect severity of Illness (SOI) and risk of mortality (ROM).

- Quality measures such as observed/expected mortality rates and risk adjusted mortality rates are influenced by the presence or absence of malnutrition.

The ASPEN Criteria are an accepted way of identifying malnutrition and staging it. They rely on history to obtain information regarding weight and loss of food intake, they use the physical exam to describe the loss of muscle and adipose tissue, the presence of edema and the reduction of handgrip strength. Variables such as albumin and pre albumin and measurements such as weight are not considered diagnostic criteria. 

The fact that malnutrition is an under-documented condition may be a driver for increasing the queries for that diagnosis. in order to avoid fraud and abuse, it is critical to keep a high quality of the query, consistent with policies and regulations. The queries always need to be supported by the right clinical indicators and have to be non-leading. The dietitian’s evaluation is a valuable document that will help with queries and communication with providers.

In conclusion, malnutrition is very common, it is under-documented and it is related to poor medical outcomes. Documenting malnutrition impacts quality reporting and improves reimbursement. The ASPEN criteria are used to diagnose it and, in order to avoid fraud and abuse, queries have to be thoroughly supported.

Marco A. Ramos MD, CCDS

References

1. Barker LA, Gout BS, Crowe TC. Hospital Malnutrition: Prevalence, Identification and Impact on Patients and the Healthcare System. International Journal of Environmental Research and Public Health. 2011;8(2):514-527. 

2. Rocandio AM, Arroyo M, Ansotegui L. Assessment of nutritional status on hospital admission: nutritional score. European Journal of Clinical Nutrition 2003; 57: 824–831. 

3. Constans T, Bacq Y, Brechot JF, Guilmot JL, Choutet P, Lamisse F. Protein-energy malnutrition in elderly medical patients. Journal of the American Geriatric Society.1992;40:263–8.

5 Reasons to Join A Weight Loss Challenge

I have been in several weightless challenges in the past, and here are 5 things that I have “gained” from “losing”. 

ACCOUNTABILITY: 

Having to be accountable to a coach, and do weekly weigh ins, makes us focus on the numbers on the scale. That weekly number on the scale tells us if we are doing things right, or if we need to modify some things. Our coach can have a conversation with us of what we might need to do to switch things up, and get onto the right path. Plus, we are accountable to the group. The majority of people do not like to quit things.  This forces us keep dredging forward, even when our brain might be telling us to stop.  

STRONGER FRIENDSHIPS:  

Struggling together with other people, is known to help form bonds, and strengthen relationship.  Sometimes these bonds can be so strong that the result is finding life-long friends.  Workouts are funner as a group! Learn from other group members about their difficulties, and how they overcame them. Friends can help solve weightloss or health questions, and can help us become stronger and more healthy individuals.

HELPS US THINK OUTSIDE THE BOX: 

A challenge is exactly that….a “CHALLENGE”!  We are challenged to think and act differently; think outside of the box, and perhaps do things that we would never had tried outside of The Challenge.  It challenges us to take a hard look at our lifestyle and eating habits, and challenges us to clean up our daily routines and stop dieting mistakes (i.e. eating too many processed foods, consuming foods that aren’t nutrient dense, drinking too much diet soda, eating too much salt, eating too large of portions, etc.).  We might even read a health magazine, book or documentary to help us learn new information about food and it’s relation to our body.  It challenges us to give our bodies a break from these cycles of ‘eating abuse’ that can lead to disease and pain.  When we feel healthier, we tend to make better decisions and have a better outlook on life.

FOCUSED/SHORT TERM GOAL:  

It gives us a calendar day to count down to….the goal is in sight!  We can push ourselves harder knowing that it is not an infinite diet, and the struggle will not always be like it is during the challenge.  For example, I wouldn’t normally say to myself “hey, I only worked out one time today…it’s a Friday night...lets hop on the treadmill!”. The challenge is a short time (56 days, but who’s counting!?!?!) to become stronger, and healthier.  Often, this leads people to make permanent changes in their every day life, because they feel so vibrant and healthy.

REGAIN OUR OWN PERSONAL POWER:

It feels amazing to see the number on the scale go backwards instead of forward!!!  We feel like we are in control of our lifestyle.  We choose to focus on the foods we put into our mouth.  We choose to join a gym; get outside and move around; try something new.  This is a wonderful feeling of empowerment.  Sometimes we dig so deep that we find our own power, and end up breaking cycles of addiction. Our clothes begin to fit better.  It’s a win-win situation!!!

By Alana Garcia-Ramos

The Opioid Epidemic. The Role of Healthcare Workers in Resolving it

It is no secret that there is an opioid epidemic and that is causing numerous deaths related to overdoses of heroin and other opioid “painkillers”. Also, there is the added problem of infections caused by the use of intravenous street drugs, which include HIV and hepatitis B and C. Many people get addicted to opioid “painkillers” in the healthcare setting. Opioid use usually starts as treatment for painful conditions, however, due to the potent addictive effects of these drugs, dependance can follow. Once a person is dependent on opioids it is only a matter of time for illegal consumption to begin. 

For many years, there has been a very liberal approach to the prescription and ordering of opiate analgesics. This has served as one of the starting points for this epidemic and all the social issues derived from it. It is also no secret that there is a black market for the opioid pills, where they have a high price. It is also no secret that a large percentage of filled opioid prescriptions end up on the black market

Physicians and other healthcare workers have become aware of this issue and there are many initiatives, starting from personal practice preferences, to healthcare institution based approaches. There are a variety of non-opioid analgesics than can be used in combination, together with surgical techniques such as nerve blocks that can be useful in certain cases. Opioids can be left as last resort medication and they can still be used liberally (in a controlled fashion) in end of life situations, such as hospice care 

Marco A. Ramos MD

Documenting Malnutrition. Part 5

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

The criteria for the physical findings in malnutrition in the setting of chronic illness are stricter than the ones of malnutrition in the setting of chronic illness. This means that the findings have to be more obvious to be considered positive. However, the signs and regions that are evaluated are essentially the same.

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. 

In order to diagnose severe malnutrition in the setting of chronic illness, the adipose tissue loss has to be “severe”, compared to severe malnutrition in the setting of acute illness in which the loss only has to be “moderate”.

When we evaluate the muscle tissue loss we have to look to the same regions of the body as described for severe malnutrition in the setting of acute illness.

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 severe malnutrition in the setting of chronic illness, the muscle tissue loss has to be “severe”.

So, a PE may read like this:

“Mr X is a 62 year old gentleman who presented to the primary care provider’s (PCP) office with a history of diarrhea for 3 months.”

HENT: Eyes look severely sunken in orbital cavity

Musculoskeletal: Severely hollow temporal areas, severe reduction of muscle mass of interosseous muscles of the hands. Severely reduced skin fold at the level of the triceps. Ribcage shows severely marked ribs. 

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

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.

References

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

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

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

Documenting Malnutrition Part 3

The History of Present Illness (HPI) in Severe Malnutrition in the Setting of  Chronic Illness

Chronic disease is frequently associated with malnutrition Examples of this are cancer, liver disease, malabsorption syndromes, heart failure, etc. In these cases, the process that ends in a patient being hospitalized is an acute problem such as an infection or an acute dysfunction of an organ system. The malnutrition is in the background, predisposing the patient to a worse outcome.  When these situations occur, the weight loss, the decline in appetite and the physical changes in the patient’s body are not taken into account by the patient or the family when they refer the history. Questioning properly becomes very important. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines¹  states that in order to consider a patient having severe malnutrition in the setting of chronic illness, he or she has to consume less than 75% of the estimated energy requirement for at least 1 month. Since 2 criteria are needed, the requirement may be fulfilled by documenting weight loss or an aspect of the physical exam. Regarding the loss of weight criteria, ASPEN guidelines say that in order to consider a patient for having severe malnutrition in the setting of chronic illness, the loss of weight in 1 month has to be 5% or more. If the loss of weight happens in 3 month, it has to be 7.5% or more, if it happens in the preceding 6 months it has to be 10% or more and if it occurs in 1 year it has to be at least 20%

So, an HPI may read like this:

“Mrs Y is a 53 year old  lady who presented to the emergency department (ED) with a history of nausea, vomiting and diarrhea for 1 day. She was diagnosed with Crohn’s disease 5 years ago and in the past year she has had several flares. As an average, for the past month she has eaten only 50-70 % of her normal meals due to bloating and lack of appetite. In the past 6 months she has lost 15 pounds. She used to weigh 125 pounds. She presented to the ED because she was unable to keep any oral intake and she started to note a darker urine and a decrease in its volume”

Please note that the last piece of information can also be placed in the Review of Systems (ROS). The information in the HPI anticipates what is going to show in the Assessment and Plan (A/P)

References

1 http://www.baxternutritionacademy.com/ie/disease_related/identifying_malnutrition.html Retrieved December 13, 2016

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

Crohn’s Disease and its Complications

Crohn’s disease is an inflammatory disease of the bowel that can affect any part of the intestinal tract, from the mouth to the anus. It symptoms, may include abdominal pain, diarrhea, bloody stools, abdominal distention, and intestinal malabsorption.  It can also cause extra intestinal symptoms, such as fever, joint pain, skin rashes, eye problems and generalized fatigue.  Currently, it affects 0.32 percent of people in Europe and North America and its prevalence has been increasing over the past decades.

This condition is caused by a combination of genetic and environmental factors. There are several genes known to be strongly associated with the presence of Crohn’s disease¹. In addition, an environmental risk factors such as tobacco exposure, seems to be equally important. It is known that tobacco smokers are twice as likely to be affected by this entity than non smokers².

There are various degrees of severity for Crohn’s disease and it can be complicated by intestinal obstruction, fistula formation, gastrointestinal bleeding, intestinal perforation and abscesses. There is a higher risk of cancer in the areas of inflammation caused by Crohn’s disease. Due to the inflammatory nature of the condition, food malabsorption can develop leading to weight loss and malnutrition.

The treatment of Crohn’s disease has to include lifestyle changes such as stopping smoking and following dietary recommendations such as low dietary fiber, low casein and gluten free diet. In addition to this, there are certain medications that may be used for the exacerbations of the disease, such as steroids and some long term medications like methotrexate and biological therapies. At this point, the advise of a gastroenterologist is the most valuable tool.

Marco A. Ramos MD

References

1. Genome-wide association defines more than thirty distinct susceptibility loci for Crohn's disease. Barrett JC, Hansoul S, Dan L. Nicolae DL, et al. Nat Genet. 2008; 40(8): 955–962

2. Tobacco and IBD: Relevance in the understanding of disease mechanisms and clinical practice. Cosnes J. Best Pract Res Clin Gastroenterol. 2004; 8(3):481-96

Documenting Malnutrition. Part 2

The History of Present Illness (HPI) in Severe Malnutrition in the Setting of Acute Illness

Documenting malnutrition, specially in the acute setting is one of the most disregarded aspects in clinical documentation. Many acute disease processes that lead to hospitalization, are preceded by a reduction in the intake of food and/or loss of weight. For example, a patient who is diagnosed with pneumonia with septic shock, could have started the process one week prior to the admission with an upper respiratory tract infection and with loss of appetite. Due to the decline in oral intake, the patient could have lost some weight and some patients may track their own weight or there might be outpatient records showing previous weights when the patient was not having the acute illness. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines¹  state that to consider a patient having severe malnutrition in the setting of acute illness, a reduction of more than 50% of the estimated energy requirement has to be present for 5 days or more. Since 2 criteria are needed, the requirement may be fulfilled by documenting weight loss or an aspect of the physical exam. Regarding the loss of weight criteria, ASPEN guidelines say that in order to consider a patient for having severe malnutrition in the setting of acute illness, the loss of weight in 1 week has to be 2% or more. If the loss of weight happens in a month, it has to be 5% or more and if it happens in the preceding 3 months it has to be 7.5% or more.

So, an HPI may read like this:

“Mr X is a 74 year old gentleman who presented to the emergency department (ED) with a history of 7 days of progressive productive cough, dyspnea, anorexia and fever. The patient referred that 7 days prior to presentation he developed “cold”. He said that his oral intake was reduced to about 25% of a normal meal. 3 days prior to admission, he developed productive cough with a green sputum and 2 days prior, high fever quantified at 102 F. Due to the symptoms getting progressively worse and the addition of dyspnea on mild efforts, he decided to show up in the ED. He stated that his usual weight is 150 pounds and now he is weight 145 pounds.”

Please note that the last piece of information can also be placed in the Review of Systems (ROS). The information in the HPI anticipates what is going to show in the Assessment and Plan (A/P)

References

1 http://www.baxternutritionacademy.com/ie/disease_related/identifying_malnutrition.html Retrieved January 12, 2017

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

Vitamin D and Cancer

In a previous post from January 27, 2016  (http://blog1.smopinions.com/2016/01/7-interesting-facts-about-vitamin-d.html), it was mentioned that there are associations between vitamin D deficiency and certain types of cancer. This post will explain a little bit more about them.

Regarding colorectal cancer, it was noticed about 2 decades ago, that there is more mortality from colorectal cancer in the northern and northeastern parts of the United States, the ones which receive less sunlight. This in itself is not enough to establish a meaningful association, however, it gave a starting point for research. Then, 2 studies showed that having levels above 30 ng/dL in the blood may reduce the incidence of colorectal cancer by half^1,2.

With respect to breast cancer, a recent study found that postmenopausal women may get a benefit from having adequate vitamin D levels in the blood. The risk of developing breast cancer in this particular group of women was lower than in the same group of women with lower vitamin D in their blood³.

Finally, in regards to prostate cancer, it has been found that this cancer is also more common in regions with less sun exposure. In addition, lower vitamin D levels in the blood are related to more aggressive forms of prostate cancer. Last but not least, adequate levels of vitamin D may aid in the slowing of the progression of this type of cancer⁴.

More research is needed in order to confirm and strengthen these associations. In the mean time, it does not hurt to have adequate levels of vitamin D in the blood, particularly for people living north of the 30th parallel.

References

1. Serum 25-hydroxyvitamin D and colon cancer: eight-year prospective study. Garland CF, Comstock GW, Garland FC, Helsing KJ, Shaw EK, Gorham ED. Lancet. 1989;2(8673):1176-8.

2. Meta-analysis: longitudinal studies of serum vitamin D and colorectal cancer risk. Yin L, Grandi N, Raum E, Haug U, Arndt V, Brenner H. Alim Pharm Therap. 2009 30(2):113-25

3. Plasma vitamin D levels, menopause, and risk of breast cancer: dose-response meta-analysis of prospective studies. Bauer SR, Hankinson SE, Bertone-Johnson ER, Ding EL. Medicine (Baltimore). 2013;92(3):123-31

4. Association between serum 25(OH)D and death from prostate cancer. Tretli S, Hernes E, Berg JP, Hestvik UE, Robsahm TE. Br. J. Cancer 2009;100(3):450-4.

Marco A. Ramos MD

Documenting Malnutrition. Part 1

There are several types of malnutrition. There is protein malnutrition (kwashiorkor), calorie malnutrition (marasmus) and the combined protein calorie malnutrition. In our society, the most common form of malnutrition is the latter and it will be the one most used in the medical records. There are also several degrees of malnutrition, mild, moderate and severe) and they can be associated to an acute or a chronic process. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommends that the diagnosis of malnutrition in the adult patient be supported by the presence of two or more of the following: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized edema, and decreased handgrip strength¹. The degrees of malnutrition can be seen in tables, available online² 

Properly documenting malnutrition requires to have the discipline of always including in the history of present illness (HPI) and review of systems (ROS) a nutritional history. A significant percentage of the disease processes that lead to an admission of a patient to the hospital include a problem with food intake or weight loss. In addition to this, the physical exam can enable us to describe the loss of muscle mass, the loss of subcutaneous fat, the presence of edema and the decreased handgrip strength. The assessment and plan (A/P) should include a nutritional diagnosis (if pertinent) and its chronicity, degree of severity and type.

Lastly, once the diagnosis is established, a plan to deal with it has to be formulated. This plan could be a dietitian consult, a gastroenterology consult for a feeding tube, an interventional radiology consult for TPN vascular access, to cite some examples.

References

1. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.

2. http://www.baxternutritionacademy.com/ie/disease_related/identifying_malnutrition.html Retrieved December 13, 2016

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

Altitude Sickness. How to Avoid it.

Some of the most beautiful places in the world are situated in mountainous regions of the world. Many of these places are very popular places for tourism. The majority of travelers are not used to high altitudes. The atmospheric pressure at 10000 feet above sea level (3050 meters above sea level) is two thirds that of the one at sea level. This means that when traveling to such altitudes it is like one third of the atmosphere (and oxygen) has been removed.

Altitude sickness is characterized by headache, nausea, shortness of breath on exertion, tachycardia and fatigue. In very rare circumstances, it can cause pulmonary edema or cerebral edema. 

In order to avoid or minimize the symptoms of altitude sickness, the traveler from sea level has to take it easy. Upon arrival to the high altitude location, rest, walk slowly, and take deep breaths. The tourist must eat lightly and allow one or two days for proper acclimatization (getting used to the new environment). True acclimatization does not complete until 2 or 3 weeks, however, there is never so much time during vacation. A strategy that some travelers employ is to travel to the desired destination in a stepwise fashion, stopping in intermediate altitude towns prior to the arrival to the high altitude place.

Finally, there are medications that physicians are familiar with and that may help. Travelers should contact their respective doctor for this purpose.

Marco A. Ramos MD

Documenting Obesity

Obesity is defined by having a body mass index (BMI) of 30 or more. For clinical purposes, the BMI is a screening tool, however, for the purposes of documenting in a patient’s chart it is very important  to make the difference between people who have obesity and people who do not. Continuing with definitions, morbid obesity is when someone has a BMI of 40 or more. 

Obesity is very common in our society. For this reason, it tends to be overlooked and not included in the patient’s chart when documenting. In addition, many physicians feel uncomfortable including  diagnosis that may make the patient not feel good about him or herself. Obesity and specially morbid obesity, are associated with increased morbidity and mortality by worsened outcomes and delayed recovery times. Hospitals use more resources when treating patients who are obese or morbidly obese.

In order to make sure obesity and morbid obesity are properly documented, providers have to develop the habit of including a BMI, close to the patient’s vitals. Moreover, providers should always allow in their templates a space for a nutritional diagnosis.

Finally, its is extremely important to include the diagnosis of obesity hypoventilation syndrome if the patient has a BMI greater than 30 and also has a diagnosis of obstructive sleep apnea (OSA) or a documented wake up arterial partial pressure of carbon dioxide greater than 45 mmHg with no other cause such as chronic obstructive pulmonary disease  (COPD), asthma, or hypoventilation from other causes.

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

What is Obstructive Sleep Apnea? Who is at Risk?

Obstructive Sleep Apnea (OSA) is a very common condition in which the upper airway gets obstructed by relaxed soft structures during sleep. This obstruction leads to inadequate air exchange in the lungs, increased diaphragm and chest wall muscle contractions as efforts to relieve the obstruction occur. In addition, OSA is characterized by poor sleep quality due to multiple brief periods of waking up during the night as the body moves and loud gasps happen. Finally, due the the poor sleep quality, daytime sleepiness is a feature of this condition, with all the problems this entrails.

There are certain groups of people who are at risk of having OSA. Obese or overweight individuals, patients with enlarged tonsils or large tongues, people with a thick or large neck or individuals who have upper airways with small diameters. The formal diagnosis of OSA is made with an overnight sleep study, however it can be strongly suspected if a person has daytime sleepiness, snores loudly and if there are visible episodes of “not breathing” (apnea) during sleep.

OSA can lead to elevated blood pressure, problems with attention and concentration, daytime sleepiness, irritability, and headaches. Treatment includes the avoidance of alcohol, sleeping on a side, use of a continuous positive air pressure (CPAP) device, surgery to remove extra tissue, and the use of an implantable upper airway stimulator. A primary physician will be able to refer someone who may have this condition to a local sleep specialist.

Marco A. Ramos MD

Tips For Great Clinical Documentation Part 4

In the previous post of the series, I highlighted the importance of being consistent when documenting, as the days pass and as the patient’s situation changes. In this post, I am going to mention how creating templates can help and how and why to avoid medical record cloning

Create templates, but avoid medical record cloning.

When providers see patients and document, a sequence of actions occurs that does not vary patient to patient. First the provider sees the record, the new laboratory workup, the past history, then, he or she sees the patient and finally the creation of a new note takes place. This last step also has its own sequence because all different types of notes have defined sections that have to be present for all cases. Creating templates for documentation helps with not forgetting to include the necessary elements of the history and physical, progress note, consultation, discharge summary, postoperative note, etc. In addition to that, a template can make the provider remember to include always certain aspects that may be missed, like a nutritional assessment, for example.

One of the abilities of  electronic health record systems is the ability of being able to import parts of a previous record into a new note. Some information may change little on a day to day basis. The ability of “cut and paste” can lead to medical record cloning if appropriate measures are not taken. Medical record cloning can lead to fraud, in the sense that a chart may contain information that may not represent exactly what happens to the patient in a particular day and and the same time lead to inaccurate billing. In order to avoid medical record cloning physicians using the “cut and paste” technique must make sure that the note is unique for the day, that it reflects what happened in that particular day and that billing is consistent with the content of the note.

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation Improvement

Who is Obese? 5 Dangers of Obesity

The healthcare community has defined obesity as a body mass index (BMI) of 30 or more. The BMI is the ratio between the weight of a person (in kilograms) and the square of the height (in meters). There are many calculators online that can calculate the BMI using pounds and feet/inches. This is a very inexact way of classifying overweight people because there could be very muscular people that could be obese according to this definition. In addition, it may cause shorter people to be overrepresented in the obese population.  In spite of this, the BMI provides an easy way of classifying people according to weight that can lead to meaningful research and can serve as an effective screening tool.

There are many dangers that originate from being obese. I will list here the five most relevant ones

1. Diabetes mellitus. Having excessive adipose tissue causes insulin resistance and some obese people may become diabetic because of this.

2. Hypertension. Obesity is associated with hormonal variations that may lead to salt and water retention and constriction of small arteries. These changes can elevate the blood pressure.

3. Sleep apnea.  This condition is related to obesity. It causes the breathing to stop many times during the night causing problems with oxygenation and getting rid of carbon dioxide.

4. Osteoarthrosis. The extra weight that the obese person has to carry has an impact on the hip and knee joints. This may lead to incapacitating pain and joint replacement surgeries.

5. Cancer. Breast, colon, gallbladder and endometrial malignancies are more common in overweight individuals than in people with normal weight

Diabetes and hypertension are  significant risk factors for coronary artery disease and stroke. Sleep apnea is directly related to hypertension. This means that obesity may impair a person’s health in multiple ways.

Marco A. Ramos MD

Tips for Great Clinical Documentation Part 3

In the previous post of the series, I outlined the importance of using the terms “probable”, “possible”, “likely” and “not ruled out” when documenting in a medical chart. In this post I am going to highlight the importance of being consistent with the diagnoses throughout the duration of the record.

Be consistent with diagnoses throughout the record.

In clinical practice, a provider, as seen in the previous post, can make decisions and place orders based on a probable diagnosis. As the days pass and more clinical data is available, most of those diagnoses will be clarified and the decision-making might change or remain the same. For this reason, it is important to document what happened with the initial “probable” diagnosis. The use of the term “ruled out” is very useful because it tells the coder that what we initially thought was probable, it is not a possibility anymore. In a case of “probable pneumonia” in the first day, the record may read on the second day: “Pneumonia was ruled out”. This implies that antibiotics are not being used anymore, so the chart would reflect proper allocation of resources.

The other situation that needs to be taken into account is the one that results from the resolution of a problem. This is particularly important in prolonged hospitalizations, when problems that were there originally, end up being resolved. It is good practice to carry the diagnosis in the assessment section and document “resolved”. This has the added benefit of letting providers that  arrive later in the picture, that a patient had a problem and it is not present anymore. With respect to the allocation of resources, it is different to document “resolved” that to document “ruled out”. “Resolved” means that the problem was there and was corrected using the treatments ordered by the provided. “Ruled out” means that the problem was never there and any continued use of resources is not justified. A document may read like this: “Hyponatremia. Present on admission, resolved.”

Marco A. Ramos MD

Second Medical Opinions PLC

Physician Advisor in Clinical Documentation

5 Facts Everyone Needs to Know About Factor V Leiden

Here are 5 facts that everyone needs to know regarding a common condition that predisposes to potentially deadly clot formation, either deep vein thrombosis (leg clots) or pulmonary embolism (lung clots).

1. Factor V Leiden (FVL) is a mutated Factor V, one of the factors essential to form a clot. The mutated factor, once activated, is more difficult to clear by the body, being this the reason why people with this mutation may form clots easier than people who do not have it.

2. About 5% of Caucasians have at least one copy of FVL (of 2 possible from mother and father). It is rare in other ethnicities. 0.02% of Caucasians have the two mutated copies.

3. A person with one copy of FVL has a 4 to 8 times increased chanced of developing a clot. A person with 2 copies has up to 80 times increased risk of developing a clot. Someone with a normal Factor V has a chance of developing a clot of 1 in 1000 in 1 year. This means that an individual with one copy of FVL can have a 4-8 in 1000 (0.4-0.8%) chances to develop a clot in a year and an individual with the 2 copies can have a risk of 8% per year to develop a clot.

4. Smoking, estrogen therapy, pregnancy and recent surgery are situations known to increase the chance of blood clots in any person, however the effects can be more pronounced in people with FVL

5. If a person with FVL develops a second clot, he or she is a candidate for lifelong anticoagulation (blood thinning) therapy.

References

1. Learning About Factor V Leiden Thrombophilia. Retrieved on August 28, 2016 from https://www.genome.gov/15015167/

Marco A. Ramos MD