And a-one and a-two

Everyone has euphemisms for the act of defecation as well as the product, do they not? BM. Dropping the kids at the pool. Poop. Number two. Around newFNP's house, the act is called going to London and the product is London. Don't ask, as the terms were not invented by newFNP herself. She is certain, however, that their origins are not Anglophobic in nature.

NewFNP thought that she had heard all of the shit-slang until a nine-year old boy enlightened her. He was in for diarrhea so newFNP was asking all the usual questions. Vomiting as well or not so much? Watery or some formed stool? How many times a day? Fever/chills? Foreign travel? Food-borne illness, perchance?

And finally, newFNP asked the kid whether he had gone to the bathroom that day? He replied in the affirmative. "Number one or number two," newFNP asked.

"Number three," he replied.

NewFNP is thirty-three years old, has nine years of higher education, and she never, ever knew that a term existed for diarrhea. They just don't teach that kind of shit in the Ivies. Ivory Tower indeed!

Number three. Awesome.

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Click here to find out how your own number two rates!

A shout out

How do people work and have a family? NewFNP cannot imagine how she could manage both.

NewFNP left her house at 7:30 this morning. She worked, worked, worked, worked, worked - you get the picture. Then it took her thirty full minutes to drive five miles to her gym. She worked out for one hour while listening to iTunes and reading her prestigious alumni mag and then spent the next twenty-five minutes driving home.

Fucking major league baseball - can't those dickholes make a shuttle to the stadium so a sister can get home after a long day at work and not sit in a line of traffic with people sporting face paint and foam #1 hands?

Anyway, newFNP rolled into her house around 7:45, hit the showers *and then* began to prepare dinner. Thank God for leftover daal in the fridge. Then dishes, lunch for tomorrow, a little reading of "The Tipping Point" and now her newFNP sits, wondering how in the world parents do this?! And single parents - holy smokes! They must be perpetually exhausted.

So hats off, baby. Props to those parents who work like dogs and come home and work some more. How in the world do you do it?

Yellow fellow

Some of newFNP's more diligent readers might be wondering what, in fact, happened with Mr. Alcoholic Hepatitis. Perhaps some are even wondering what in the world they might do if they found themselves with a similar patient.

Well, wait no longer because newFNP's boyfriend is out of town, the David Sedaris article in this week's NYer is read and newFNP is therefore here with all of the answers. OK, maybe two or three of the answers.

The single most important intervention is complete and total abstinence from alcohol. Bo-ring! NewFNP recommended this several times to her young patient and, as previously noted, referred him to AA. She gave him a multi-vitamin because who can get their 5-9 servings of fruits & veggies if they are chug-a-lugging beer after beer?! And she checked his liver enzymes and acute hep panel, just to be on the safe side. What else could newFNP do? If newFNP worked in a fancy clinic, she would have ordered an ultrasound and perhaps even a liver biopsy. But newFNP works in a not-so-fancy clinic so her patient's visit was much more low tech.

No acute hepatitis - nope, this sad state of affairs was brought on by good old fashioned boozing. His liver enzymes showed - no surprise here - elevated AST and ALT. They weren't off the hizzie, however, just 193 and 110 respectively. But his bilirubin - holy toledo! Normal values max out at 1.4 mg/dL and jaundice is typically diagnosed at 2.5-3 mg/dL. Homeboy was rocking a bili of 24.3. Good day sunshine!

He is scheduled to come in on Saturday. NewFNP hopes that his eyes are no longer the color of a highlighter pen when she next sees him.

For those clinical die-hards out there, click here for an article about jaundice in the adult. God, it's a fascinating read. It's as good as Judy Blume's Wifey.

Axial load - of crap!

NewFNP is fortunate to work in a practice site where there are exceedingly few patients who are drug seeking, unlike her good pal BostonFNP who has, a number of times, had to revive people who have overdosed in her clinic's bathroom. The only things that newFNP's patients are overdosing on are carbohydrates!

After a while in practice, one just gets a feeling as to who is bullshitting and who is in real distress. However, newFNP doesn't want to make the mistake of letting her gut override her intellect and thus attempts to approach each patient as though their complaint is valid. Sure, it can be a real challenge at times, but newFNP tries, people, she really does.

NewFNP's first walk-in patient of the day started with a call to the on-call phone last night. NewFNP's colleague fielded the call and let newFNP know that this patient would be coming into the clinic. The patient started out her visit by giving the front desk clerk shit when she had to fill out paperwork as she was here "with an emergency" - low back pain. Yes, a little lumbago is right up there with crushing chest pain and profuse intractable bleeding! She then proceeded to evade newFNP's questions about how she hurt her back until her shifty-eyed husband prompted her to relay her history. It didn't involve any trauma, it didn't include any radiculopathy, it was free from any form on incontinence - thank goodness!

NewFNP proceeded to the exam. Straight leg raise - negative. Deep tendon reflexes - 2+ bilaterally. Palpable spasm - absent. Axial load - positive.

For those of you unfamiliar with the axial load test, wary (astute?) clinicians use it to detect malingering. One simply applies downward pressure to the top of the head and asks if it results in pain. It shouldn't.

NewFNP always feels a tad guilty about employing it. She feels as though she is conducting a sting operation. Is the patient lying to get the good drugs? Is the patient who is experiencing true pain thinking that by replying in the affirmative, she is more likely to get the care she needs? Who knows. In newFNP's practice, patients are very prone to expressing their pain in no uncertain terms (see Ayyyyy me duele!). It's tough for newFNP to see through that manner of expression sometimes.

Honesty and trust are so crucial in the history and exam. This patient didn't seem honest with newFNP and it is likely that neither of us trusted the other. NewFNP wrote her a prescription for Ibuprofen and Cyclobenzaprine and advised gentle stretches, ice & heat and to continue modified physical activity. Return to clinic 4 weeks prn.

Mellow yellow

NewFNP has an M.A. who is unflappable. Nothing fazes her. In fact, in thinking about her, newFNP has just realized how much respect she has for this M.A., a powerful and seemingly fearless woman.

Well, today she was a-tremblin' with the site of dark, dark brown urine sitting in her lab. She walked into newFNP's office and said, "NewFNP, that man's urine is black." As newFNP walked in to take a peek, she informed newFNP that, in addition to having urine the color of Dr. Pepper, his eyes were yellow.

It is so nice to have a diagnosis before one even walks in the room. Of course, that would only be dealing with the medicine aspect of Mr. Big Liver. NewFNP wanted to get to the bottom of this mystery; she wanted the back story as to why this 30-something year old man's body was poisoning him and how he poisoned it.

When newFNP walked in the room, she was startled by the yellow eyes. They were really yellow, some might say goldenrod! They were Michael Jackson 'Thriller' yellow. Even his skin had an eerie golden hue and newFNP doubts that her patient had spent much time applying faux tan. It has been the exceedingly rare case in which newFNP was able to palpate a liver, but this guy's liver was the size of a small child.

Turns out that he had broken his foot last October, subsequently lost his job and began drowning his sorrows in 6-12 beers per day, by his own account. Likely a little more given that we all under-report our vices, do we not? He did stop drinking for six days when his eyes started to turn the color of French's mustard and did not experience the DT's, so newFNP felt confident that she could advise him to go cold turkey without bringing on a potentially fatal consequence.

AA referral in place. Multivitamins dispensed. LFTs pending. NewFNP can't wait.

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Not to turn this into a gossip column, but Padma Lakshmi is fucking crazy. Beautiful, yes, but crazy for divorcing newFNP's other Indian man, Salman Rushdie. Some people just don't know how good they've got it!

Bienvenidos

A while back, newFNP was feeling like she needed to grow and to have some different experiences in her role at the clinic. She has attempted to engage her clinic manager and some collaborative partners about creating classes and educational materials, but the reality is that newFNP is stuck in the clinic all day, every day seeing patients. No one wants her anywhere else.

Well, newFNP needed something new! Something invigorating! Something that made her want to wake up and spark some change.

So newFNP contacted her alma mater and let them know that she would be willing to precept a master's entry student. And voila! NewFNP's first preceptee is starting this week.

Is it too much to hope that this student is jaded, bilingual and in possession of a potty mouth? Or at the very least that she in accepting of these very things in a preceptor?

July 2007 baby. NewFNP rocking the preceptorship.