Saturday, August 29, 2009

A very happy 4th anniversary

Today is the 4th anniversay of newFNP. She is hardly new anymore, is she?

NewFNP's anniversary week has been graced by a long-time patient welcoming a new baby girl, another long-term patient hospitalized and dying, and by the always exciting return of one Ms. Cocoa Brown. A story for another day.

Because today, on her 4th anniversary, newFNP is dolling herself up for a celebration. She is so appreciative that her cousin and his fiancee scheduled their wedding on such a special day.

To her favorite ice climbing, engineering, post-doctoral molecular geneticizing couple - mazel tov.

Thursday, August 20, 2009

Milk it does...

Several weeks ago, newFNP stepped in to do a well child exam on an 18-month old well known to her.  NewFNP takes care of her grandma (scleroderma), her grandpa (missing frontal skull bone after 2 infected craniostomies following a truck tire exploding and striking him in the head) and her mother (21-year old with uncontrolled hypertension on 5 daily medications including clonidine with a history of methamphetamine use, now abstinent).  

When newFNP saw this child's hemoglobin, her heart sank.  It was 4.9.  The child's skin had an unhealthy grayish hue.

Repeat it, newFNP instructed her MA.  Her blood was pinkish.  The repeat hemoglobin was 4.5.

Shit, newFNP muttered.

Is it leukemia?, newFNP asked her colleague.  It's leukemia, he responded.  4.9 is fucking low.

NewFNP went with the grandparents into the exam room as the young girl's mom was at work, where she is six days per week.

NewFNP told them that she needed to send the little girl to the hospital and that she was concerned about leukemia.  

Never before has newFNP been on the verge of tears in an exam room.  But she knows this family and she knows that they have been to hell and back and that they all still suffer and she loves taking care of all of them -- that is one of the joys of family practice.  

She called the patient's mom and told her to come immediately to take her daughter to the emergency room.  The patient was crying, her mom was crying, her grandma was crying.  NewFNP was barely holding it together.

Hours later, newFNP spoke with the patient's mom to see what had transpired.

What had transpired was the this little girl was drinking upwards of 50 ounces of milk daily.  She didn't have leukemia -- she was a lactoholic.  She was discharged from the ER with iron.  No transfusion, no nothing.  Follow up and repeat the CBC in 2 weeks.  NewFNP couldn't believe it.  

4.9.  From milk!??!!**

Her repeat CBCs have been greatly improving, her pallor has disappeared and she appears to be not at all suffering withdrawal from her milk dependence.

Pass it on.

**When kids drink too much milk, they don't eat iron-rich foods -- or much of any foods for that matter -- and they may have intestinal irritation that causes asymptomatic blood loss in the stool thus causing anemia.   

Wednesday, August 05, 2009

Broken heart

NewFNP was awaiting the EKG results for her 20-year old methamphetamine treatment seeking patient when her awesome lab supervisor came out and handed her this:

NewFNP was a little stunned.  Q-wave in III.  rR' in V1-V3.  A 20-year old guy.  "What the fuck," newFNP thought to herself.  Her lab supervisor helpfully offered that the young man had a large vertical scar to his chest.

Ah, cardiac surgery.  If newFNP were a cardiologist, she might have been able to identify the EKG changes immediately.  Alas, she is not so she was left to question the young man as to his cardiac history.

She asked him to tell her about his heart surgery.  He replied that he had never had heart surgery.  Hmmm.  NewFNP then inquired as to the etiology of the large suprasternal scar.  

"Oh yeah," he replied.  "I had a heart transplant."

"A heart transplant??!" newFNP responded and then inquired if he was taking any medications.  He replied that he was not, leading newFNP to deduce that he was likely mistaken as to the nature of his surgical procedure.  

She asked him why he may have had heart surgery as a child.  He was unable to tell newFNP.  

NewFNP conducted his cardiac exam which was -- not surprisingly -- abnormal.  His pansystolic murmur over the aortic region obliterated S2.  His murmur over the pulmonic region was palpable.  The other murmurs were less extraordinary.

At this point, newFNP was stumped.  In retrospect, she should have put it together.  Pulmonic stenosis.  Childhood cardiac surgery.  But newFNP has never seen anything like this and she just couldn't put the pieces together.  

Thankfully, the young man's dad showed up to the clinic and explained that the patient had Tetralogy of Fallot repaired when he was 18-months old.  Prior to the repair, he had multiple Tet episodes leading to numerous hospitalizations.  The surgical repair was delayed due to a lack of health insurance.  As a result, he spent his first 18 months lacking oxygen.

It is fair to say that this young man is not bright.  In her interactions with him, newFNP often sensed that his IQ was quite low.  Now she had a reasonable explanation as to why.  The bummer is that because his IQ is so low, he cannot appreciate the consequences of his actions like others might.  

For instance, methamphetamine is cardiotoxic.  His heart is repaired, but not normal.  This combination might give someone else pause.  It was clear that this young man did not understand the potential impact.  His parents understand though.  It was difficult to see the sadness and desperation in their faces as their son averted his eyes and spaced out during the visit.

He is set up with a cardiology referral, an addiction treatment referral and a list of clinics where he can have neurocognitive testing completed and get referred to vocational education.  He still doesn't understand why these appointments are important.  He has other things to worry about.  His girlfriend wants to have a baby.  His friends want to go out and party.  He has no concept of consequences.