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| Topic: Mesothelioma |
| Benefits of Electronic Patient Record produced with EMR System |
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Electronic patient charts increase patient safety and accuracy of documentation. The healthcare provider does not have to decode illegible handwriting and scribbling of handwritten charts. The EMR allows secure access to patient charts from any location by the medical practitioners so that pertinent patient information can be viewed 24/7.
The EMR supports effective exchange of patient data such as: lab results, reports, discharge notes, referral notes, and visit summaries. This enables the healthcare provider to effectively share patient care information across clinical programs, geographic locations, care providers and disciplines.
Most importantly the EMR helps eliminate duplication of efforts and increase efficiency in gathering knowledge for effective decision making, thus allowing the health care provider to focus on care for patients.
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| Dear Dr. Smith,
I had the pleasure of evaluating your patient, Mr. B.T., for a possible diagnosis of pleural mesothelioma. As you know, the patient is a 78 year old male who started to experience some weakness and fatigue, associated with shortness of breath on exertion, about 6 months ago. Over the last few months he has become progressively weaker, he has lost 9 pounds, and his shortness of breath has become worse. Last week he developed anterior chest pain, which prompted him to seek medical attention. He was seen in your office, and acute myocardial disease was ruled out. With his history of asbestos exposure the diagnosis of mesothelioma was entertained. A chest x-ray was done in your office, which showed a right sided pleural effusion, which was considered compatible with the diagnosis of malignant pleural mesothelioma.
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| Past History |
| View the ease in which this section was created using an EMR |
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The patient used a computer kiosk in the waiting room to fill out most of the historical data, including the patient’s past history, the family history, the occupational history and the current medications. Additional details were added by the physician after the patient was seen in consultation.
In other examples the patient completed past medical history, family history, current medications and allergies via a secure internet based form the night before the patient was seen by the physician. In this manner some EMR’s allow patients to enter regular diabetes results, weight, blood pressure, and more from home. Abnormal results can be directly sent to the provider and a reminder call sent to the patient to make an immediate appointment.
When a new chart is created for a previously seen patient, the data for past medical history, family history, current medications, and allergies can be brought forth and inserted into the current chart. The physician can modify and/or add new information to the current patient record.
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The patient has generally been well, other than the problems mentioned above.
The patient smoked 1 pack per day for 21 years, but quit 14 years ago.
The patient drinks about 4 beers per day, on the weekend only. |
| Allergies: |
Penicillin
Intravenous dye for IVP |
| Family History: |
Father died of malignant pleural mesothelioma: age 67
Mother died: lung cancer: age 71 (since lung cancer may mimic mesothelioma, the diagnosis of mesothelioma in the patient’s mother should be considered as a possible cause of death)
2 brothers and a sister are alive and well. |
| Occupational history: |
The patient, and the patient’s family, has an interesting occupational history. The patient’s father worked in asbestos mines for 30 years prior to developing asbestosis, and mesothelioma. Prior to 1972 asbestos miners routinely returned home wearing their work clothing. At that time the risk of asbestos was not clearly recognized. It was thought that massive exposure to asbestos was required to initiate the inflammatory changes which result in mesothelioma. Subsequently, it has been shown that even a few of the highly carcinogenic needle shaped amphibole fibers can cause pleural mesothelioma. The patient’s mother was probably exposed to asbestos in her home, perhaps by washing her husband’s clothes.
During WWII the patient worked in the ship building industry. He his not sure if he was exposed to asbestos at this time, but it is likely. Asbestos was widely used in ship building during WWII due to its insulating and fire retardant properties. The patient did work with ship boilers, and was an assistant plumber. Both occupations have been associated with a high risk of asbestos exposure and subsequent malignant mesothelioma. After WWII the patient decided to work in the construction industry. He installed floors and ceiling tiles. At that time most ceiling tiles contained asbestos to reduce the risk of fire. Some flooring materials also contained asbestos fibers. He retired at age 65 in 1990. Thus, for over 40 years your patient was exposed to asbestos, most of which was undoubtedly the more carcinogenic amphibole variety. |
| Medications: |
| View the ease in which this section was created using an EMR |
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The EMR automatically checks the medical record for any possible medication allergies or cross-reactivity.
Patient prescriptions are automatically faxed or e-prescribed to the patient’s pharmacy,
reducing errors due to illegible writing, and transcription errors.
In this arena, EMR’s can significantly increase patient safety by detecting potential medication errors.
The Electronic system checks for drug interactions, patient allergy interactions, and patient conditioned interactions.
Automatic alerts and warnings are used to warn physician of potentially dangerous drug interactions.
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NSAIDs for chest pain
Hydrochorthiazide
Ventolin PRN |
| Review of systems: |
In addition to the shortness of breath mentioned above, the patient has had anorexia, and a sensation of tightness of the chest. He has had some nausea, but no vomiting or diarrhea. He has not had palpitations or peripheral edema.
The patient has had decreased libido for about 9 months. |
| Physical examination - |
| View the ease in which this section was created using an EMR |
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In this instance the physician utilized speech recognition to input unique data in conjunction with point-and-click method to insert normal studies. Utilizing both input options enabled the physician to rapidly create the patient chart.
The system enabled the physician to create personalized patterns with pre-populated templates for efficient/comprehensive documentation.
In addition, the EMR automatically captures monitoring data from our EKGs, pulse oximeters, and blood-pressure equipment. The data capture streamlines information gathering, and increases office efficiencies while positively impacting patient care.
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BP: 114/70 P: 92 R: 26 Temp: 98.4 Weight: 186 lbs.
Examination of the head, eyes, ears, nose and throat were unremarkable.
Respiratory exam revealed dullness to percussion in the right lung base. Breath sounds were absent in both lung bases, and decreased in all other lung fields.
Cardiac exam revealed 3 cm JVD. Heart sounds S1 and S2 were normal. A soft pericardial rub was heard. There was no peripheral edema.
Abdomen: soft and non-tender. Liver, kidneys and spleen were normal. There was no evidence of ascites.
Musculoskeletal and neurological exams were unremarkable |
| Laboratory studies: |
The chest x-ray is suggestive of mesothelioma.
Hgb: 14.1g%, WBC 9,200 Platelets 410,000
Glucose 118mg% Cr. 0.9 Bun 18 Na+ 143 K+ 4.3 Ca++ 9.4 Bili: 0.8 SGOT 26 SGPT 32
Alkaline Phosphatase 146 Chol 217 Trig 186 |
| Impression: |
| This patient likely has pleural mesothelioma secondary to long term exposure to asbestos. However, since chest x-rays cannot clearly differentiate the mesothelium from the lung parenchyma, the differential diagnosis includes a variety of inflammatory and malignant diseases. Tuberculosis is much less likely. |
| Suggestions: |
| A CT scan of the thorax, abdomen and pelvis has been ordered. Further diagnostic studies will be ordered after the CT scans are evaluated. If the patient does have mesothelioma a biopsy will be essential in order to establish the diagnosis. Staging studies will be needed to determine the extent of the disease. In view of the legal implications of a diagnosis of mesothelioma, and the difficulty in establishing a tissue diagnosis, the patient may need to be referred to the university for special histological studies.
Thank you for the referral of this patient.
M. R., M.D. |
| April 9, 2003
Dear Dr. Smith,
I saw Mr. B.T. for a follow-up evaluation of his probable pleural mesothelioma. Over the past week the patient’s symptoms have persisted unchanged. The CT scan did show a right pleural effusion. There was a suggestion of pleural thickening. The mediastinal window was clear.
I have ordered an MRI of the thorax to further evaluate the pleura, and a CT scan of the abdomen and pelvis, as well as a bone scan, to look for metastatic cancer. A serum testosterone level has been ordered since there are rare reports of metatstatic mesothelioma to the testes.
M.R., M.D. |
| April 16, 2003
Dear Dr. Smith,
The MRI did show a 3.7 cm thickening of the mesothelium of the right lung, highly suggestive of pleural mesothelioma. There was no evidence of metastatic disease on the CT scans of the abdomen and pelvis. The peritoneum appeared free of disease. The bone scan only showed arthritic changes. The testosterone level was normal.
At this time I think we need to set up a surgical consultation for a biopsy to confirm the diagnosis of mesothelioma. The histologic diagnosis of mesothelioma is often difficult to establish, and can be confused with other forms of lung cancer, or even benign inflammatory disease. Pleural fluid is often inadequate to confirm the diagnosis. Sufficient pleural tissue must be obtained, and special histologic studies are usually necessary. Electron microscopy is useful, and may be essential, in differentiating mesothelioma from benign inflammatory diseases, as well as primary or metastatic adenocarcinoma.
Mr. B. T. has informed me that he has consulted an attorney since he now thinks that he has mesothelioma. With this in mind, I think that Mr. B. T should be referred to Dr. Jones at the university. Dr. Jones has had a lot of experience with mesothelioma, and I think he has excellent judgment. The university has ready access to electron microscopy, should it be needed. The patient states that his father never consulted an attorney, and his family never received a settlement from the asbestos mining company.
M.R., M.D. |
April 21, 2003
Dear Dr. Smith,
Mr. B.T has seen Dr. Jones. Dr. Jones is almost certain that the patient has mesothelioma. In view of the potential litigation he will do a diagnostic thoracotomy. If the pleura can be removed en bloc, he will do a total pleurectomy after frozen sections confirm the diagnosis. The patient understands that mesothelioma is virtually never curable. Pleurectomy may reduce shortness of breath and improve the patient’s quality of life.
Physical examination today revealed:
BP 120/70 P88 R24 Weight 185
The respiratory exam again reveals decreased breath sounds throughout, and dullness to percussion at the right lung base. The cardiac rub could not be appreciated today.
M.R., M.D. |
April 28, 2003
Dear Dr. Smith,
Mr. B. T. was seen in this office today, after a diagnostic thoracotomy on April 24. Biopsies have confirmed the diagnosis of mesothelioma. Dr. Jones decided not to remove the entire pleura, but did recommend the instillation of chemotherapy to reduce the pleural effusions. The patient understands that he has a terminal disease, but would like all available treatment to try to prolong his life. He states that his goal now is to stay alive long enough to help provide for his family. To this end, he has contacted the law firm of D, B, & R, who specialize in asbestos litigation.
I have referred the patient to Dr. Emerson for consideration of external beam radiation therapy to the pleura to try to shrink the mesothelioma and reduce the shortness of breath. Chemotherapy may be considered in the future.
In the usual circumstances screening for mesothelioma is not considered worthwhile, since virtually all patients die of the disease. However, in view of the strong family history and the likelihood that the patient’s father brought asbestos fibers into the home, I think the patient’s siblings should, at least, have chest x-rays. If there are any suggestions of pleural disease, then a full evaluation to rule out mesothelioma should be considered.
M.R., M.D. |
May 2, 2003
Dear Dr. Smith,
Dr. Emerson will proceed with radiation therapy to the right hemithorax to try to shrink the mesothelioma. It is understood that this is palliative only. He will start treatment after the patient heals from his recent surgery.
M.R., M.D. |
May 3, 2003
I was contacted by Mr. A.W., an attorney specializing in mesothelioma litigation, from the law firm of D, B, & R. With Mr. B. T.’s consent I have scheduled a deposition for May 11. With the patient’s consent, I have enabled Mr. A.W. to review the medical record online.
M.R., M.D.
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May 12, 2003
At the deposition yesterday it was established that Mr. B. T. does have malignant mesothelioma of the pleura. There was some discussion as to the source of the offending asbestos fibers. The patient worked in a navy shipyard, and he worked with asbestos manufactured by Johns Manville. The lawyer asked if it could be determined which asbestos fibers are responsible for the patient’s disease. I do not think that is possible. Mr. B. T. was told that he may not live long enough to see a settlement of any litigation that he may pursue. He was advised to consider a video deposition while he is still in reasonably good health.
M.R., M.D. |
June 4, 2003
Mr. B.T. came to the office today for a routine follow-up evaluation. Since starting radiation therapy he has experienced some increased fatigue. His appetite has decreased, and he continues to lose weight. He now spends at least 14 hours per day in bed.
BP: 118/76 P: 96 R: 28 Weight 178
Respiratory exam again reveals dullness to percussion in the lung bases. Breath sounds are absent at the bases, and decreased in all other lung fields.
The cardiac exam is normal.
There is no erythema of the chest wall. |
| Impression: |
The patient’s worsening fatigue and continued weight loss may be due to his disease, or to the ongoing radiation therapy.
Plan:
A repeat CT scan will be done about 1 month after the completion of radiation therapy.
M.R., M.D. |
July 2, 2004
Dear Dr. Smith,
Mr. B.T. recently completed a course of radiation therapy to the right hemithorax for palliative treatment of malignant mesothelioma. The patient received 50 Gy over 35 elapsed days. Towards the end of therapy he developed some erythema over the right anterior chest wall. He also developed a dry cough, and increased weakness and fatigue.
The acute adverse effects associated with the radiation therapy should subside over the next few weeks. At that time we will be better able to determine if his clinical deterioration is due to the treatment, or the underlying cancer.
Lab studies today:
CBC: Hgb: 11.9g% WBC 11,200 Platelets: 376,000
The chemistry profile remains normal.
M.R., M.D. |
| End of Case Study |
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