Monday, November 28, 2005

But does it itch?

Ear pain. We've all had it, but I'd hazard a guess that we haven't all had the symptoms one patient was experiencing today. Last month, she was treated for otitis externa and has been using cortisporin otic drops. Steroid-containing drops. Her pain was intensifying over the past three days so she returned for follow-up care. In addition to her otalgia, she also had tender pre-auricular lymphadenopathy. Her past medical history is negative for diabetes, FYI.

Good ear looks good. Textbook, one might say. Affected ear on the other hand... I carefully looked in her ear and thought, "Now, if I were looking in a vagina, I would be quite certain that I was seeing yeast." Now, I do not come home to peruse Gray's Anatomy every evening, but I am confident that I know an ear from a vagina. But yeast? In the ear? Another first for newFNP. It was all I could do not to laugh as I used a vaginal wet mount swab to grab a culture of the ear funk. Ah, improv.

I treated her with Diflucan under the philosophy of what's good for the south is good for the north. I can't wait to get that ear wet mount back.

Wednesday, November 16, 2005

Oh, the learning curve

Did we learn about labs in school? I don't think so. I think that there should be an elective about lab result interpretation. Mind you, newFNP attended a well-respected institution, but has somehow made her way through without having a good understanding of lab results. Don't think for a minute that I can't interpret a CBC, because I can, but when you start throwing a jacked kidney my way, I am flat out lost. When there are too many numbers in the 'abnormal' column, my eyes glaze over as though I am back in C.O.C.

Case in point. I had a patient last week who was an interesting looking little guy. 65 years old. First name: Latino. Last name: Asian. Not a common combination in my 'hood, but stranger unions have certainly happened. Skin was a little yellow looking, belly was really round. Maybe I should have picked up on that, but if I stopped to really consider every weird-looking, rotund patient who crosses my path, I would have no time to peruse the internet for Sigersons and flattering Theory trousers.

My patient also had a very chatty wife who accompanied him to his physical and freqently interjected her own tales of health woes throughout his exam. NewFNP can only handle so many distractions and annoying chatty wife was throwing me off my game.

Long story short, Mr. Latino Asian likes to drink. Hell, newFNP likes to drink, but not like this guy! I drew his labs and got this, amongst many other abnormal values, back:

Albumin 2.6 (3.8-5.0) So - low, right?
Bilirubin 6.5 (0.1 - 1.5) Let's call that one 'elevated.'
AST 113 (1-45) Remember - Alcohol, Statins, Tylenol
ALT 56 (1-55) Ding ding! Most normal lab value goes to ALT!!

Another provider took a nano-second glance at the labs and said "Oh, AST 2 times the ALT is pathognomonic for alcoholism." She then glanced at him and said, "He is clearly cirrhotic." He is??? Well, shit. If I would have known it was so obvious...

The problem is that many things need to be so flagrantly obvious. Your blood pressure 210/105? Buddy, you are one hypertensive motherfucker. Blood sugar in the 600's? I'll lay my money on diabetes.

But other seemingly obvious diagnoses escape me, to say nothing of the not-so obvious diagnoses.

On the bright side, I really feel like I have my charting/prescription signature nailed.

Friday, November 11, 2005

"I" statements

We are all taught to speak to patients in "I" statements, especially when confronting something that is potentially uncomfortable. This may include, "I notice that you have bruises in the shape of fingers" or "I see that you weigh 498 pounds" or "I can see that you are upset by your gonorrhea infection and need for a painful Rocephin injection."

However, sometimes newFNP's "I" statements escape her. This week, it was because I wasn't sure what I was (not) seeing and feeling. When I was in school, I had a similar experience in which a patient, upon whom I was gearing up to perform a DRE, assumed the position, thereby exposing her tail. "I see you have a shaggy tail. Has that always been there?" No, no - I didn't say that, but any sensitive statement I may have been able to come up with was vanquished by the magnitude of my shock. Why didn't they tell me in Advanced Health Assessment that I may happen upon a tail? I was ill-prepared.

I was also ill-prepared for my 36-year old father of three with tiny, hard testicles as well. Now, although newFNP does not possess said equipment, she has once or twice been familiar with those who do *and* has seen enough in the clinical context to know that they should be more like matzo balls than walnuts. So, what was I to say?

"I notice that your testicles are like raisins. Were they ever prune-like?"

"I feel that your testicles are firm like marbles... and not much bigger. Were they ever more like Everlasting Gobstoppers - the big ones?"

"I see that your testicles are essentially non-existant. Do you really have three children?"

See? It's hard to have good "I" statements on the fly. Part of the reason it was difficult is because I was uncomfortable telling this gent that his balls were weird. Is there a guy out there who wants to hear that? In Spanish. In my crappy-assed Spanish.

"Sus testiculos son demasiado locos." Bad, bad newFNP. Must learn sensitive Spanish!

Saturday, November 05, 2005


In the spirit of "Shopgirl," in which a fresh, vibrant Claire Danes dates a geriatric Steve Martin, I offer this thought. It's not only the aging Hollywood set who enjoy a youthful romp with a partner half their age. Not at all. This week, a 76-year old patient told me that he had 10 children, the youngest of whom was an astonishing 5 years old. A quick mathematical calculation told me that his wife must not be his age. Yes, my patient's first wife died when she was 70. I don't think that the mourning period was a long one before he nabbed his currently 38-year old wife.

When I think of dating someone nearly 40 years my senior, I think of one thing and one thing only: money. Now, I could be wrong, but my sense is that this 38-year old woman is not rolling in an A8, nor is she sporting a Harry Winston, nor is she head to toe in D&G. But even if the hottest rich 70-year old in the world wanted to date me, he would still be 70. Whatever works for my patients is cool with me, but I am, quite frankly, grossed out by the thought of shagging a grandpa. Do you think she has to inject his hips with cortisone so that he can lay the sweet moves on her?