When it's good to be newFNP

NewFNP has had a wonderfully and oddly rewarding work week.

First, she received the most heartfelt thank you letter from a patient on Monday. She has truly never received anything like it in her life and she knows that such notes will be few and far between in her career.

Then, Dr. Dual-Ivy-League-Degrees told newFNP that "a friend" had stopped by to say hello. Not having many friends in her area of clinical practice, her face must have betrayed her puzzlement. As it turns out, an adolescent patient for whom newFNP cared a couple of years ago (see Healing) just stopped by to say hi and tell newFNP how he was doing. He gave newFNP an awkward fourteen-year old boy hug and updated her on his life. He looked happy and it made newFNP immensely happy to see him feeling good.

And finally, newFNP completed a well-child visit on a 9-month old for whom she has cared since birth. NewFNP also did her mom's prenatal care and cared for her for three years prior to her pregnancy. It is truly one of the joys of family practice to share patients' lives with them and as newFNP held this beautiful baby girl in her arms, she was reminded her of that.

And it's a holiday weekend. Time for a weekend getaway, SATC2 and maybe even a new tattoo!

Ninety-nine

If newFNP could stress one thing -- aside from the importance of clear skin and a cute wardrobe -- to students, it would be that one must learn to elicit and write down a decent medical history. It is very clinically challenging to have too little information and may go as far as to cause newFNP to call chronically poor documenters 'douchebags.'

Say for instance one orders a CEA on a patient for apparently no reason whatsoever, as the subjective area of the progress note is left blank, and then say for instance that CEA comes back mildly elevated (4.2 ng/mL in a non-smoker) with all fecal occult blood tests negative. This may cause newFNP to think to herself, "What the fuck, douchebag."

It's not because newFNP doesn't appreciate that this abnormal test result necessitates follow up. It is that newFNP does not have one iota of medical history from whence to begin.

NewFNP walked into the exam room and immediately made the very subjective assessment that this 70-year old gentleman looked bad. He complained of chronic cough and dyspnea on exertion. NewFNP inquired as to whether he had ever noted hemoptysis with cough. He had. NewFNP was thankful that his daughter attended the visit with him as she mentioned in an off-the-cuff fashion that he had had multiple positive PPDs, but not even one chest x-ray.

Balls.

NewFNP listened to his lungs. The left lung was peachy. The right, not so much. NewFNP started at the bottom: diminished. She moved to the middle: unimpressive. She progressed upward: rales. She moved her stethoscope back down and asked the man to say "ninety-nine." Again the sound was diminished at the bottom of the lower lobe. She moved it to the middle of his back and almost had her tympanic membranes ruptured by the volume with which the words "ninety-nine" resonated through her stethoscope.

Positive whispered pectoriloquy, hemoptysis, positive PPDs sans CXR evaluation and an elevated CEA equals a trip on into the county emergency department. Truth be told, the first three would have prompted newFNP to refer for an ED evaluation, but newFNP is certain that this man received his chest CT much more easily having shown documentation of the elevated CEA.

NewFNP called the patient today. He was hospitalized overnight and had a negative chest CT. The AFB is pending.

And newFNP's documentation is clear, written in neat penmanship and thorough for the next provider.

News Flash

NewFNP hasn't read the study herself, but as she was driving home today she heard a news story on NPR stating that use of Viagra may be associated with long-term hearing loss, as opposed to the sudden hearing loss that was previously known.

This news is revolutionary -- Pfizer can seek a whole new indication for Viagra's use. Gents can continue to bone up on their partners without having to listen to requests to take out the recycling or trim the bushes.

It's the perfect lifestyle medication for the AARP set.

Psych!

NewFNP sees a lot of mental illness in her practice, but it is mostly dysthymia and depression. There have been a couple of wildly positive Mood Disorder Questionnaires, of course, which are generally accompanied by such wild extremes of dress that conducting the MDQ seems almost superfluous.

But it is really rare for newFNP to see schizophrenia in her clinic and it is really, really rare for her to have two schizophrenic patients on the same day.

NewFNP's first schizophrenic patient of the day was a G15P9 three-hundred pound crack-smoking schizophrenic with no teeth who lived in a board and care. She needed a pap and an HIV test which, you gotta hand it to her, is pretty decent self care for someone who is really deeply troubled. She had been off of her Seroquel for a few months and her flat affect was remarkable. NewFNP has never had so many monosyllabic responses to questions, even on her worst of dates. But it wasn't her negative symptoms that had newFNP concerned. NewFNP asked her of she had been hearing things that others could not hear.

"No," she responded.

NewFNP then asked if she had been seeing things that others could not see.

In the flattest of voices, with no change in tone whatsoever, she replied, "Last week the shadows came back."

The way in which she replied was so freaky and the response itself so fucking creepy that newFNP just resumed her Seroquel rather than having her wait for her psychiatric appointment.

Later in the same day, everyone's favorite schizophrenic patient, Cocoa Brown, came back to clinic for a follow up appointment. She, too, was smoking crack, had horrible dentition and approaching three-hundred pounds. Her weight had increased 24 pounds over the past month. She felt uncomfortable and wanted pain medication.

"Can't you give me some Tylenol #3s?" she asked newFNP.

"No."

"Some #4s??" she tried.

"No."

Her lower extremities were edematous. She was experiencing orthopnea. NewFNP's heart sank as she told Cocoa Brown that she was concerned about heart failure. She wrote some prescriptions and, not wanting her to go AWOL as she is wont to do, exited the exam room with her to accompany her to the lab.

As she walked out the room, newFNP's colleague - a good-looking Cuban doctor - told her hello. She smiled, giggled and said in an unreasonably loud voice, "He's handsome!"

NewFNP dropped her off at the lab where she, of course, bolted without having her BNP drawn. Oh, Cocoa. Seroquel or no, newFNP just can't give you the help you need to make you well.

Booze Clues

About a month ago, newFNP was lamenting the effects of hitting the bottle a bit too much. She had sent a gentleman to the emergency room, only to have him return - angry - with absolutely nothing done about his ascites. NewFNP has won him back over, has increased his Lasix and has serially monitored his bilirubin, albumin and weight. She gave him prenatal vitamins as that is the only type of vitamin available in her clinic. She gave him protein and salt guidelines.

She hasn't seen much improvement.

The good news is that the bilirubin is approaching normal and he is abstaining from alcohol.

The bad news is that one might mistake the rotund abdomen under his t-shirt as a basketball but it is, in fact, ascites. It is no exaggeration to say that his panza is 40-week-gestation-sized large, taut and in need of a paracentesis. Now, in addition, the cirrhosis, portal hypertension and ascites are leading to hepatic hydrothorax -- his lungs are wet and he has orthopnea. He has decreased one lousy pound since starting high dose Lasix. He smells like an ammonia factory.

NewFNP is far from being a liver specialist, but she thinks that the situation is not good. He needs a new liver and, even more so than the perfect flattering trouser, they are not so easy to come by.

And he still doesn't have insurance.