I’ve now seen two really excellent physicians really stumble when it comes to using an electronic medical record, and it puts them at a severe disadvantage. While they could easily perform a better and faster physical than me, take a better history, and come up with a better list of possible diagnoses, I’ve got them beat hands-down when it comes to entering orders, medications, consults, or clinic notes. They hunt and peck with two fingers, staring at the keyboard, and click everywhere very cautiously. They’ve learned one way to get the system to do what they want it to do, and while it works, it makes a lot of wasted time. One of the physicians even told me he has to come in on weekends to get all his notes written, because it takes him so long.

We’re moving toward a medical record; if you’re not comfortable with computers, and don’t know how to use them effectively, hire the neighborhood whiz to come give you a few lessons. You’ll save immense amounts of time in the future.

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Part of the difficulty of medicine is turning the qualitative into the quantitative, so various physicians have come up with rating or scoring scales to try to make one able to compare one patient’s state to another. I’ve been reviewing a number of these recently, so I thought I’d start a collection. Feel free to add your favorites.

Pulse Scoring

Pulses are rated on a scale ranging from 0 (not palpable) to 2+ (normal). In the event that the pulse is not palpable, the doppler signal generated is also rated, ranging again from 0 to 2+.

Edema Scoring

1+ Mild pitting, slight indentation, no perceptable swelling of the leg
2+ Moderate pitting, indentation subsides rapidly
3+ Deep pitting, indentation remains for a short time, leg looks swollen
4+ Very deep pitting, indentation lasts a long time, leg is very swollen

Strength Scoring

5/5 Normal strength: movement against gravity with full resistance
4/5 Movement against gravity and some resistance
3/5 Movement against gravity only
2/5 Movement with gravity eliminated
1/5 Visible/palpable muscle contraction, but no movement
0/5 No contraction

Glasgow Coma Scale

I. Motor Response
6 – Obeys commands fully
5 – Localizes to noxious stimuli
4 – Withdraws from noxious stimuli
3 – Abnormal flexion, i.e. decorticate posturing
2 – Extensor response, i.e. decerebrate posturing
1 – No response
II. Verbal Response
5 – Alert and Oriented
4 – Confused, yet coherent, speech
3 – Inappropriate words, and jarbled phrases consisting of words
2 – Incomprehensible sounds
1 – No sounds
III. Eye Opening
4 – Spontaneous eye opening
3 – Eyes open to speech
2 – Eyes open to pain
1 – No eye opening
Glascow Coma Scale = I + II + III.
A lower score indicates a deeper coma and a poorer prognosis.

Deep Tendon Reflexes

0: absent reflex
1+: trace, or seen only with reinforcement
2+: normal
3+: brisk
4+: nonsustained clonus (i.e., repetitive vibratory movements)
5+: sustained clonus

Heart Murmur Grading

Grade 1 = very faint
Grade 2 = quiet but heard immediately
Grade 3 = moderately loud
Grade 4 = loud
Grade 5 = heard with stethoscope partly off the chest
Grade 6 = no stethoscope needed

Apgar Score for Newborns

Color
All pink (2 points)
Blue extremities/pink body (1 points)
Blue/pale (0 points)
Heart rate
over 100 (2 points)
less than 100 (1 points)
Absent (0 points)
Respirations
Good/crying (2 points)
Irregular/slow (1 points)
Absent (0 points)
Response to nose catheter
Sneeze/cough (2 points)
Grimace (1 points)
None (0 points)
Muscle tone
Active (2 points)
Some extremity flexion (1 points)
Limp (0 points)

Mallampati Airway Score

Class 1: Can see PUSH Pillars Uvula Soft Palate Hard Palate
Class 2: Can see USH Uvula Soft Palate Hard Palate
Class 3: Can see SH Soft Palate Hard Palate
Class 4: Can see H Hard Palate

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Quote of the Day, to an 84 year-old Asian woman with Hepatitis C from an attending:

Doc: So we’d like to figure out what the subtype of your viral genotype is…
Patient nods.

This woman had no, I mean no idea what a genotype is, let alone a subtype of it. Please don’t forget, when you’re talking to a patient, speak to his or her level, not MEDICAL. I would look just as dumbfounded as my patient today, and probably nod as well if a lawyer spoke law to me, or if a mechanic spoke car to me. I’m sure I’m at fault myself sometimes, but I think I’m pretty good at catching myself, and pretty good at detecting the dumbfounded “what the hell are you talking about” look, too.

There’s evidence to suggest that patients will be more adherent if you speak their language, too. Everyone wins.

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Being the goodie two-shoes student that I am, I’m reading ahead in the 2006 edition of Goroll’s Primary Care Medicine , learning about screening tests, and I see these two listings (my emphasis):

Condition : Susceptibility to hepatitis B virus. Risk factors : Male homosexual , exposure, occupation (health care worker), pregnany.
Condition : Syphilis. Risk factors : Male homosexual , other sexually transmitted disease, pregnany.

I looked at some of the other entries to see if I was being overly sensitive. They list a risk factor for sickle cell disease as “African American.” And that’s true, to some extent–it’s more likely that people of African descent will have the sickle cell mutations in their genes.

But this “male homosexual” bullshit is entirely different. It’s not like the “male homosexual” has some sort of genetic makeup or inherent compromised state that makes him more likely to contract hepatitis or syphilis. So what is it? Is it the HIV+ male homosexual? If so, why not just say HIV+? Is it the male homosexual who has unprotected sex? Why not say all people who have unprotected sex? Isn’t “exposure” to Hepatitis B a requirement for infection, as well as a risk factor? It’s not like us male homosexuals somehow grow Hepatitis B inherently, like some people of African descent make sickled red blood cells.

I’ll admit medicine (and society) is getting better with acceptance of all people that are different, but it’s these little remnants of inherent pathology or deviance that just piss me off to no end.

Maybe I’ll email Dr. Goroll and see what he says.

Update: Dr. Goroll emailed back in a day with a very kind response, and forwarded my question (stated a little more gracefully in the email) to the author of the chapter. He also noted the book is constantly being updated and corrected in OVID.com and eScholar.

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The powers that be (or, if you prefer, the Power that be’s) have a funny sense of humor. Take medical student who thinks feet are totally disgusting, and sign him right up for Podiatry clinic. Ambulatory Medicine clerkship, we are not getting off … on the right foot. (Pun intended.)

Last month, on Geriatrics, I had a diabetic patient in clinic, so I took off his socks, only to have little flakes of foot skin (eczema? xerosis?) fly up into the air and be inhaled by yours truly. From now on, I’m just asking the patients to take their own damn foot apparel off.

If it’s anything, medicine is damn humbling.

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