Normally, newFNP enjoys being correct. NewFNP likes good grades and completed NY Times crossword puzzles (only the Sunday magazine crossword, not the NYT crossword). At this relatively early stage of her career, newFNP also enjoys correct diagnoses. When she presumptively treats a strep throat while awaiting culture results, she feels selfishly relieved when the cultures are positive.
NewFNP, however, is not so pleased with her correct presumptive diagnosis in her sweet 68-year old patient. This woman's chief complaint was urinary incontinence, but she also noted a very foul vaginal discharge. Oh, and some vaginal bleeding. Not all the time, but vaginal bleeding nonetheless. The words "post-menopausal vaginal bleeding is cancer until proven otherwise" rang in newFNP's head as she was taking the history.
Other pertinent info:
- no sexual activity for many years
- last pap 2004 - patient assumes it was normal
- vaginal discharge progressively worsening over 6 months
- vaginal bleeding times 4 months - intermittent
Although it feels insensitive to say it, newFNP had to choke down her gag reflex during the exam. The odor was reminiscent of abscess contents. The discharge was green and, man alive, was it ever copious! It was literally running out of the speculum as fast as newFNP could swab it.
Now, newFNP frequently wonders if cervical lesions will be visible to the naked eye. Ectropion, sure. But what about those purple lesions? Are they moles? Should I know this? Whenever newFNP sees something she is unclear on, she makes sure to get a nice sample of it for the pap. Well, what this lady had going on was so visible that newFNP had to look at it many times over to actually believe what she was seeing.
If memory serves correctly, the chart note read something like: Gray round lesion, approx 1.5 cm, rough surface, adjacent to cervix at 3:00. Friable.
The referral note states: Rule out gyn cancer. Pap pending.
The pap isn't pending. It was faxed to newFNP today. Squamous cell carcinoma. No BV, no trich, no gardnerella. No GC/CT. All of that discharge must have been necrotic tissue sloughing off.
In the next few days, newFNP will be, for the first time, telling a patient that she has cancer. In Spanish. In fucking Spanish.
It is horrible to be right sometimes. Yet, it does reinforce the adage that seeing enough normals will help you to recognize the abnormals. That, however, isn't enough consolation for newFNP right now.