Monday, October 29, 2007


NewFNP is no Dr. Ruth, but she does pretty much accept that the most important body part in many a man's life is his penis. No big surprise there.

So when a 50-something year old guy presents to clinic with the chief complaint of the old johnson not working, newFNP is generally willing to help a dude out. She does, however, want to know why said johnson might be flying at half mast.

Thus, the history. Onset? Two weeks ago. Taking any meds? No. Any known health problems? No. Hmm, not much there. Glucose is normal. Chest pain? Maybe a little this morning, but none now. Next up, EKG.

This is where it gets interesting. It's not so often that one catches a guy in the middle of an M.I. but one might think to delve further into this possibility when one's EKG shows both ST elevation and T-wave inversion. When newFNP brought up this likely scenario, her patient noted that he had, in fact, been diagnosed with an M.I. a mere three days ago in the emergency department. He received some medications, but wasn't taking them because he didn't trust the doctors there.

Didn't think to bring that up, did you pal?

Well, buddy, newFNP won't be bringing your penis up with a Viagra prescription since you are actively infarcting. Now, take an aspirin and high-tail it back to the ED, would ya?

Maybe we should all take a lesson from Harlequin romance novels and embrace the notion that if you take care of the heart, my friend, generally the penis will follow.

Unless, that is, you've decroded its blood supply with Gatorade, tortillas and Sugar Babies.

Tuesday, October 23, 2007

Trichtillomaniac, maniac on the floor!

NewFNP has few compulsions. Yes, she likes to keep her eyebrows groomed. True, she flosses regularly. OK sure, she wishes that she was more of a compulsive exerciser, but who amongst us could resist the lure of Harold & Kumar Go To White Castle arriving via Netflix? NewFNP is not made of steel!

What newFNP does not do is pull her own hair out. Figuratively speaking, sure, during a tough clinic day. But literally? Friends, newFNP quite frankly spends too much on highlights to just toss these tresses aside!

NewFNP would have never suspected her first trichotillomaniac this week. Please bear in mind that it is Tuesday and that newFNP works in family practice, not psych. Anyway, this woman only pulls out her eyelashes. Holy crap, that has got to hurt! NewFNP's patient was less concerned with the pain, however, than she was with the mounting costs of false eyelashes. She felt despair because, as she said, her natural lashes were much more lush than the falsies. She felt embarrassed that she could not stop pulling them out. She never even mentioned pain, although newFNP is wincing at the thought of pulling out her own eyelashes. Fuck. No. NewFNP grimaces when one lash gets a little cattywompus and has to be realigned.

The second trichotillomaniac has been a patient in newFNP's practice for as long as newFNP has been there. Today, she told newFNP that she has been pulling out the hair on her scalp for years and has now begun to yank out her armpit hair. Now, newFNP has waxed her own axillae and knows that experience to be somewhat unpleasant. But to take each hair out individually? No, no sir. No can do.

This patient has beautiful braids and has them styled in a fashion which successfully hides her compulsion. But move them aside and hello patchy alopecia!

Now, newFNP's family practice curriculum did not really cover trichotillomania. NewFNP only really knows about it because there was a random treatment center in the town where she completed her undergrad education and she felt compelled to learn what in the hell the place treated! What newFNP didn't know then is that some trichotillomaniacs eat their pulled hair. These folks can develop trichobezoars, or hair casts, in their stomachs and intestines.

Go ahead and put that on your differential for abdominal pain.

Monday, October 22, 2007

Natural mood enhancement

NewFNP did not go to nursing school to have days like this. There are some days when one just wants to be a researcher. Or a bank teller. Today was one such day.

For starters, how do all of the depressed patients know to come on the same day? When they go to the ED for headache and back pain, does the attending tell them to head to newFNP's clinic at 8:30 on a frigging Monday morning? If depression is contagious, that may explain why newFNP was in a pissy mood after her first three patients. It wasn't just newFNP who got bum-rushed with neurovegetative complaints today. Nope, two of us had multiple patients in need of what newFNP charts as 'supportive encouragement' with a side order of SSRI.

Then, one of newFNP's few patients who are circling the drain came in after having been discharged from the hospital yet again. In health age, this gent is at least three times his chronological age, putting him at about 163 health-years-old. The most fucked up things is, despite test after test and hospitalization and after hospitalization, newFNP isn't entirely certain why. This is partly because he is so unaware of what his doctors and nurses in the hospital are doing and is, thus, unable to share any info with newFNP. It is, however, in large part due to the fact that newFNP has never received any documentation regarding his inpatient care.

What newFNP knew today was that his BP was a troublesome 56/36. That is on the low side for him, but - astoundingly - is not out of his range of normal. The highest newFNP has even seen him is around 80/50. He's got a touch of the old renal failure and truly variable glucose. Addison's? Perhaps, but newFNP has never been able to get an ACTH on him, nor has she been able to get his hospital records.

Now, newFNP has sent him to the ED once to rule out Addisonian crisis and a second time when he was hypotensive and having syncopal episodes at the vital signs station. Today, he was rather perky aside from complaints of dizziness. NewFNP had him drink about 32 ounces of water in 30 minutes and then rechecked his BP. It was 70/50. He felt better. NewFNP's big treatment for this guy today was none other than water.

Take that, big pharm! Water saved the day.

NewFNP left work today feeling as though she had really helped no one. It was a horrible feeling. Thankfully, newFNP's city is enjoying unseasonably warm weather - the kind of weather that makes an evening walk while listening to one's iPod cure a rotten day in the clinic, proving newFNP's rule that a little physical activity really improves one's mood.

Let's hope this weather holds on a bit longer.

Thursday, October 18, 2007

Exam room 6, ready for seating

NewFNP hasn't commented on obesity lately, but she cared for a patient who got her thinking. This patient has a BMI over 60. Although newFNP is no Mavis Beacon, BMI >60 is no typo. This patient came in for various complaints, including abdominal pain. Let's just call newFNP's exam "limited by habitus."

This patient also noted lesions in her skin folds. NewFNP has treated fungal intertrigo in this patient before, but has not seen her in well over a year. Perhaps if she would have, newFNP might have stopped the awful maceration to this patient's thighs, pannus and buttocks. NewFNP hasn't been doing weights lately and it showed as her arm was shaking in an effort to hold back the pannus in order to examine the extent of the damage.

And can newFNP say it once again, ladies? If your BMI is over 60, your lady parts are also going to be fat. And when those lady parts get fat, the picture is oh-so not pretty. And when you have macerated abdominal, thigh and groin-adjacent skin, it is, quite frankly, time to hang up the bikini underpants and find peace with the big cotton grandma bloomers.


But what really struck newFNP is how demoralizing it must be for this patient to come to the clinic, to have newFNP struggle to hold back her obese belly and to have newFNP counsel her on the merits of the grandma panty. How she must feel some amount of shame every day regarding her weight. How every activity must be a struggle for her. As horrifying as the physical effects of obesity are, the emotional effects must be comparably devastating. NewFNP felt a combination of honor and horror when this patient asked her if she would do her pap. On the one hand, she must have felt respected and cared for by newFNP. On the other hand, that is going to be one hell of a pelvic exam.


When newFNP was in public health school, she had this frigging awful narcissistic professor who informed the students about her success as a physician, model, poet and basketball player, ad nauseam. She also took away our break, probably because she knew that we would talk vicious shit about her, not only to read us her crappy poetry, but also to make us exercise. We hated her for it. This was, after all, public health school. The majority of us had already had our morning workouts before we came to her piece of shit class. NewFNP isn't saying that she is going to adopt this as a practice, but that she must admit that she has considered finding a far less offensive way to encourage physical activity in the waiting room. After all, the patients may be sitting there for hours.

Perhaps newFNP's clinic should buy buzzers a la Cheesecake Factory. The patients can then go exercise and we can buzz them when their exam room is available!

Wednesday, October 10, 2007

Yuck Mouth

Two thousand and seven has been, quite frankly, a real drag for newFNP.

To recap, a truly beloved family member died, newFNP and her formerly live-in Punjabi now ex-boyfriend broke up, and a mere one week later newFNP was in a serious car accident from which she walked away without a scratch - so, a bad and a good there. Then, one of newFNP's BFF's moved to South frigging Africa to do public health. Ugh. In sum, a shithole of a year to date.

And now newFNP has to have a fucking root canal tomorrow morning.

Son. Of. A. Bitch. Seriously, there are not enough swear words in the universe to express newFNP's distaste for her current situation. And if there is one thing that newFNP knows, it is motherfucking swear words.

NewFNP's insurance covers a portion of this horrific and utterly undesired procedure, but leaves newFNP to cover upwards of $600 of the cost herself. Really, Dental HMO? That is coverage? No wonder tons of poor people are walking around with mouths that look like jack-o-lanterns from just yanking those decayed fuckers out.

NewFNP has known for quite some time that community dental health is utterly lacking, but it seems as though dental care for the insured leaves a lot to be desired as well. Even The New York Times took this on today in this article noting how dentists are faring well, although many teeth in the heads of Americans are not. NewFNP's clinics is one of the rare free clinics around that offers dental care - free dental care. One shudders upon seeing the lines and is astounded by the number of emergencies who are seen on a daily basis.

As much as newFNP enjoys a day off, she would rather be opening huge abscesses and taking cockroaches out of ears than sitting in a fancy endodontist's office trying to figure out how she, a relatively well paid person, is going to pay for this.

No wonder newFNP's patients are so sick by the time they get to newFNP's clinic.

Thursday, October 04, 2007

Say what???

NewFNP must be a monkey's uncle, hell must have frozen over and pigs must be flying because the brain-trust at newFNP's clinic did not can the mooning LVN.

Nope, the flashing was just a "joke that went too far."

Yeah, too far over her bare ass. And, please, let's all just overlook the fact that she denied it all, just flat out lied. Strong character. Good choice to keep this one.

Seriously, what do people have to do to get fired? NewFNP could hypothesize that flashing one's va-jay-jay might do it? On the other hand, maybe not - there is another provider who pretty frequently rocks the camel-toe and shows a significant amount of cleavage and she's been there longer than has newFNP.

Maybe the administration figures that patients will continue to frequent the clinic of they know that there is a chance for a free peep show.

Seriously people, what the hell?

Tuesday, October 02, 2007

Now boarding

There are several ways in which patients can endear themselves to newFNP.

For instance, they might express heartfelt thanks for the care they've received. They might tell newFNP how young she looks when, in fact, she is not.

Most endearing of all, they might be funny as shit in the exam room.

NewFNP's first patient of the day hit the ball out of the park when she did all three and started newFNP's first post-move work day off right!

Now, newFNP knows that it is through the magic of Nars that she looked so youthful this morning. Who the fuck wouldn't look youthful with a fresh sweeping of Sin blush across the apples of one's cheeks? However, beyond her welcome flattery, this patient was truly grateful for the care she received and expressed her gratitude freely.

It was not, however, the flattery or the gratitude which endeared this patient so profoundly to newFNP. No, it was the fact that she was the funniest historian newFNP has encountered, hands down.

This patient, a woman in her fifties, came in with a chief complaint of vaginal discharge - already one can appreciate the potential for humor in the face of a not-so-humorous condition if you are the patient. This discharge, according to newFNP's patient, had "set her back." NewFNP had never heard that turn of phrase in this context before. She is more familiar with its use in the context of something along the lines of "That new Miu Miu purse set newFNP back a car payment!" So, when evaluated in that context, newFNP understood that the discharge was significant.

NewFNP's patient went on to give newFNP details of the discharge, such as the fact that it was malodorous enough to warrant "a hell of a scrub" before coming to the clinic. In addition, it was copious enough to require the use of feminine protection.

Now, newFNP's patient had a hysterectomy some years ago and, as a result, was unfamiliar with the decades-old advances in pantyliner technology. She stated that she had purchased some pantyliners but, upon running out, could not afford another box and borrowed some pantyliners from her daughter.

"Those damn things look like an airplane! I ain't never seen a pantyliner like that - it had wings!"

Superfluous information? Sure. Welcome? Fuck yeah.


Monday, October 01, 2007

Full moon

NewFNP's clinic has rapid staff turnover. Now, there are some staff members who have been there for years and years, but it is not uncommon for people to not last through the 30-day probation period.

The most speedy exit came from an MA who just didn't show up to work her third day. No phone call, no 'nice to have known ya!' - she just didn't come back.

Then we had an LVN who single-handedly emotionally dismantled our MA staff by starting rumors and spreading gossip. He was let go after several wildly inappropriate comments in the presence of the interim COO after about two months of employment.

And finally, the current employee termination. Our most recently former LVN began working ten days ago. She was lazy, said 'shit' in front of a patient on one occasion and engaged in useless banter with the MA's. That kind of behavior, while bothersome to newFNP, does not get you fired from newFNP's clinic.

But do you know what will get you fired? Mooning three other staff members in the hallway during a busy clinic day.

A few years ago, newFNP and her girl gang were returning to our grad school's home town after having attending one of the most well-attended political marches in recent history. We were driving alongside a van caravan, each van filled with eight undergraduate-aged guys who appeared to be jocks. Four of the front man-van riders mooned the gents in the rear van. NewFNP's car honked and the guys were clearly embarrassed to have flashed five lovely ladies. But these are just the people who should be mooning - 19-year old guys.

Not a 30-something LVN. At work. When work is not a strip club. Sure, pink undies are nice but newFNP and her staff do not need to see them.

Don't let the door hit you on your currently covered ass on your way out!