Tech Talk

As we all know, the DSM is getting a do-over. As the NYT pointed out today, narcissistic personality disorder is on the chopping block.

Well, newFNP can help pad those empty pages. She is here to offer a new criterion for "psychotic disorder NOS" that should make it into the new psychiatry bible.

NewFNP is a fan of technology helping her out throughout the course of her workday. Where would she be without her iPhone and its BMI calculator, its OB wheel, its ICD-9 coder and its access to her gmail account so as to enable newFNP to track her online package shipments while at work? (Damn you, Madewell, and your cute new sweaters for 25% off!!) NewFNP's clinic is en route to electronic health records and newFNP is very much looking forward to forgoing the search for a decent black pen every day.

But these technologies are not those of interest to newFNP in regards to her hypothesis of how technological advances are shaping the scientific and clinical milieu.

NewFNP has noted time and again that people who are somehow psychotic attribute profound significance to the shitty photos snapped on their cell phone cameras.

NewFNP has seen many, many a flip-phone and Blackberry image and has been told that the image in the blurry photo of a sex partner was the aura of a snake, that there was a hand coming out of someone's head, that there were angels reflected in the mirror. In each and every photo, newFNP saw essentially the same thing -- a crappy, blurry cell phone picture utterly lacking in reptiles, odd appendages or the supernatural. And she can say definitively that the more expensive phone did not take a better crappy ass picture.

In one patient, newFNP gently asked if anyone had ever told him in the past that he may have a mental illness? No, he told newFNP, he was a Christian and he had burned the curtains in the living room after having sex with the snake-aura partner in order to purify himself. His response did not diminish newFNP's concern.

Perhaps the criterion can be "On at least three of the past seven days, the patient has engaged in excessive cell-phone photography (excluding those on iPhone 4 with flash and photography apps) and has inappropriately placed religious or spiritual significance on the incomprehensible images attained."

You're welcome, APA. You get that one for free.

Family Tradition

The first time newFNP saw positive cerebellar findings in a chronic alcoholic, she thought that the patient had misunderstood her instructions. Not that rapid alternating movements (RAM) are so hard to describe, especially as newFNP always demonstrates said movements, but -- you know -- maybe the patient just missed the boat.

In retrospect, she shouldn't have been surprised. This patient was a middle-aged man who walked as though he was an epileptic zombie. Yeah, that gait ataxia is a good first clue. (This video of a professional man in pleated Dockers-style pants demonstrated a pretty great example of ataxic gait and, frankly, is kind of hilarious.)

Yet, newFNP was astonished to see the floppy-fish movements of the RAM. When she moved on to finger-nose-finger (at a arm's length away of course -- any yayhoo with half a cerebellum can make reasonable contact as less than full extension), she felt lucky to have left the room unblinded. She didn't even conduct a Romberg as she felt concern for the patient's safety.

That was about a year ago when newFNP was in the research clinic. That patient did not matriculate into the study.

Today, however, she had a patient in his mid-40's who began drinking at the age of 12 when his drinking buddy was his father. Having just been released from jail, he came to see newFNP to refill his diabetes meds. The last time she saw him, newFNP noted that he smelled of alcohol. This time, he lacked the aroma but exhibited the slurred speech one might note with acute intoxication. The dysarthria reminded her of her patient with cerebellar ataxia some time ago. His neuro exam confirmed newFNP's suspicion of cerebellar injury.

Now, newFNP loves her wine. And her mojitos. And her Maker's Mark with ginger ale. Wait -- where was newFNP going with this??

Ah yes, alcoholism is truly devastating. This man cannot work, he is in and out of jail and his father died from the disease that is killing him as well. The last two times newFNP assessed his readiness to change his drinking behavior, he was very clear and straightforward -- not ready, not yet. Since leaving jail this time, he has been drinking very little. He states it's time to get straight.

It's just too frigging bad that his cerebellum has been pickled before he came to that decision. Perhaps he will see some improvement if he can achieve some sustained abstinence. Until then, newFNP gives him his multi-vitamins. Today he got prenatal vitamins -- they were all newFNP had to give.

For other clinicians and students out there who need help getting substance abusing patients into care, the SAMHSA Treatment Locator is super helpful.

Grammar

Once upon a time, when newFNP was a younger lady and a new MPH student, the most influential professor of her life taught her a valuable lesson: data are plural.

This is certainly one of the least important lessons she learned from this professor from a public health perspective, but is one newFNP very commonly reflects upon given the frequency with which it is ignored. It has served newFNP well over the years in her academic writing and conversation, but it has also served to drive newFNP to drink when she all too frequently hears public health and medical professionals say "The data is..." It's like nails on a mother-effing chalkboard to newFNP.

As newFNP was sitting in her providers' meeting today (number of productive minutes = 7; number of minutes = 120) and hearing the noun-verb mismatch over and again, she was thinking to herself, "Thank you, SBS, for preventing newFNP from committing this academic faux pas... and thanks a lot!"

Do that voodoo that you do

One of newFNP's struggles is to work within a culture that is so utterly different from that of her own. Generally that manifests in requests for disability paperwork or in the dramatic vocalization of pain.

However, this struggle became uniquely salient today as newFNP was completing a physical on a 41-year old man. While he has a partner and family in his home country, he has been in the U.S. for twelve years and has a partner here as well. Apparently, his original partner was none too pleased because, as he told newFNP, she put a curse on him in order to make him impotent.

And dammit, it worked.

Now, newFNP might have taken an educational trip to a forbidden island in which voodoo is practiced and she might have entered an apartment which was protected from the evil eye by a special red fabric and was receiving some kind of power from a chicken with its legs bound by a red cloth, but that is as much as newFNP knows about witchcraft and black magic and voodoo -- which is to say she knows nothing. At her fancy nursing school, they wanted to teach the students frigging Reiki, but not even an elective on traditional/cultural medical practices/voodoo? Way to be culturally competent.

NewFNP could find no physical health concern that would explain this young, fit man's ED. From his perspective, his health was non-contributory.

NewFNP probed for a psychological explanation. Was he perhaps feeling guilty for having another partner here? He stated without equivocation that he was not.

(Hell, who can blame a dude for finding another lady after twelve long years? NewFNP is having a dry spell that nowhere near approximates that - thank god - and she's considering some recidivism.)

She asked him if he would like to try Viagra. He did not, because as he explained, the problem rested in the curse.

Not sure where to take this encounter, newFNP asked him if he believed that her curse was the only cause of his erectile dysfunction. He was certain that it was. In that case, newFNP told him, it seems as though you need to find someone to reverse that spell.

And for that, newFNP is hard pressed to recommend a single practitioner.

Thanks, but no thanks

It was placenta. The patient is fine albeit somewhat peeved.

In her follow up visit, she told newFNP that when she first felt something falling out of her lady business, she called her husband into the bathroom to survey the scene as she was unable to see beneath her newly post-partum abdomen. He confirmed that there was, indeed, something gone quite awry and that there was most certainly something alien in her nether regions.

"Pull it out!" she instructed him.

He declined and, instead, brought her into the clinic.

For those who are interested, the AAFP has a decent article about how to evaluate whether one has actually accounted for the whole thing. The article is a bit old, but newFNP doesn't think that the placenta has changed much in the past twelve years.

Contingency management

NewFNP deals with a lot of vaginal complaints. They generally run along the lines of itch, olfactory woes or a forgotten objet causing distress and/or one of the aforementioned concerns.

What is exceedingly uncommon (n=1 in five years) is for a woman, three days post-partum, to present to clinic with a chief complaint of "something is coming out of my vagina." NewFNP had two differentials: retained products or prolapsed uterus.

As newFNP and her patient assumed their respective positions, newFNP briefly thought, "Holy mother, is that an umbilical cord??" before coming to her senses. What she saw was a shiny, slimy, veiny mess with a decent sized clot in the middle of it, discovered only by digital exploration of said mess. NewFNP admits that she was surprised at the absolute lack of vaginal bleeding given the situation.

"Placenta," she thought. "Now what?"

NewFNP gave the protruding mass a gentle tug. Nothing moving and no pain on the patient's end. A slightly more forceful tug elicited movement but nothing spectacular. At this point, newFNP brought in Dr. Dual-Ivy-League-Degrees for assistance. While newFNP maneuvered the speculum around the protruding mass, Dr. Dual-Ivy-League-Degrees tugged with the ring forceps. Again, nothing. Not wanting to cause a hemorrhage and noting increased vaginal bleeding and that the patient's pulse was 120, newFNP and Dr. Dual-Ivy-League-Degrees stopped their efforts and called for an ambulance.

NewFNP probably could have handled the entire situation alone, but was just too uncertain. If the patient had been hemorrhaging and had something protruding from her vagina, that is an entirely different call: get whatever is causing the problem OUT. But this was different and newFNP just hasn't managed post-partum complications such as this in the past.

What a great learning experience for newFNP, both in learning about the actual care of this patient and of trusting her knowledge and feeling confident in her care.

Hasta la vista, toenail!

For five long years, there has been nothing that brings the quease to newFNP's stomach more than the very thought of removing a patient's ingrown toenail. NewFNP has used evasive maneuvers to avoid having to learn the procedure thus far, but now that she's signed on for another two years in the trenches (two months down --holla!!), she figured that she might as well jump in completely.

So she took off a toenail today and it was just as gross a procedure as she had expected. It is very tactile in that the remover can feel the nail tearing from the bed via the kelly clamp. And that tactile sensation did nothing to quell the quease. To top it off, newFNP can only imagine how awful it must be to have the procedure done and that made her feel even worse.

But she didn't pass out or barf on the patient's foot, so newFNP is content to call the procedure a success.

Consumption

The New Yorker is tailor-freaking-made for newFNP this week. A Talk of the Town piece about Pavement (you can bet newFNP has her tickets!!), an article about FB, another about Tavi and an article about J. Crew!! When in the world will she find the time to watch Sons of Anarchy??

But newFNP's life hasn't been all fashion and literature and hot, swaggering, conflicted motorcycle club VPs.

She has blissfully received one day of pediatrics and women's health in the midst of her grueling internal medicine and outpatient OB schedule. Except that life is not to blissful when one sees a 22-month old kid -- in the U.S. for four days -- with hemoptysis, such that his little jeans are covered with blood, and right apical rales that are gurgling to beat the band.

He had been in clinic two days prior and had been treated for a severe stomatitis. While the mom did note that he had the hemoptysis, the other provider treated the stomatitis and placed a PPD. The PPD was, as one might expect, stunningly positive.

It was no great stretch for newFNP to mask that sweet boy and send him to the emergency room after explaining her concern for active TB to the mom. And, of course, there this little boy remains, on oxygen with fulminant TB. It's hard for newFNP to imagine that those apical rales weren't present two days prior, but it's always easier to see things clearly in retrospect, is it not?

Mondays with Grandma

NewFNP's grandma is ninety-five. She has been demented for quite some time and this makes visits with her really difficult.

But lately, her health has been worse and, conversely, her cognition has been clearer. It's a gift to newFNP, but makes newFNP wonder how much longer she has. Last Monday, newFNP was snuggling with her and crying when her grandma pointedly and caringly said, "Honey, I don't want you to cry for me."

Today, newFNP was holding her hand when her grandma looked into her eyes, tears rolling down her smooth cheeks and said, "It's too hard to... it's too hard to..."

NewFNP said asked her what was too hard, even though she knew.

"It's too hard to say goodbye," her grandma whispered and then closed her eyes.

And it is. It is a fucking nightmare to say goodbye to someone you love so dearly, ninety-five years old or not. As her grandma slept, newFNP spent hours quietly sharing memories, offering words of peace and watching the gentle rise and fall of her chest. She held her hand and kissed her forehead before she left for the evening.

Bon anniversaire!

NewFNP celebrated five years of being newFNP today by hitting an 8AM spin class -- her first spin class in a year. Yowza.

A lot has changed in these five years. All of her friends from nursing school are married and most have kids or are pregnant (hooray nycPNP!!), whereas newFNP is bordering on cougardom. She has lost some of her closest loved ones and has gained others. She has visited three new countries, had three major hair-do changes and is on her third car.

But newFNP's most significant change is that she is confident in who she is as an NP. She is continually challenged by her patients, by working in community health and by keeping herself well while working in a dysfunctional environment.

But she is learning and she is capable. Just this week, newFNP diagnosed erythema nodosum and nephrotic syndrome -- both just known of but never seen differential diagnoses until now. That feels quite good. She saw what she thought might just be chancroid, which to hear newFNP's patient tell it feels not at all good, but might feel better after a change from acyclovir to azithromycin.

Now all newFNP is left to contemplate is where is this little endeavor -- the one you are reading -- going to go next?

Thank you sir, may I have another?

Remember the joy newFNP felt when she received her letter of completion from NHSC? Lord have mercy, she signed on for two more years. By the time newFNP finishes her loan repayment contract, she will have had seven crazy years at her community health clinic and $50,000 less debt.

NewFNP imagines that the phrase "seven-year itch" will take on a whole new meaning.

NewFNP has a few more pearls she brought home that she thought she would share with her NP colleagues and students. They pertain to neurology.

NewFNP was recently visiting BostonFNP who noted that if a patient can climb up onto the exam table, half of her neuro exam was done. An exaggeration, sure, but it makes a point: a busy clinician needs a high yield and fast exam. So, here you go.

Regarding Mental Status -- The MMSE tests the hippocampus only. In a screening test, if the patient can give a 100% coherent history, the mental status exam is likely normal. One must test fluency, comprehension and repetition to determine if language is intact.

Regarding Cranial Nerves -- The cute and funny neurologist at the CME extravaganza notes that visual field testing is extremely informative and underutilized by generalists. In patients who are unable to cooperate, the examiner may point one finger towards the eye of the patient. This should elicit a blink in both eyes and can be recorded as blinking or not blinking to threat.

Regarding Upper Motor Neuron/Pyramidal Weakness -- Assess for pronator drift as the supinator muscle is an extensor muscle which are weaker than flexor muscles. Assess fine finger movements and toe tapping. Is one side faster than the other? If so, problem. Assess one muscle in each of the four extremities. Position the patient in the desired position and tell them, "Don't let me push you down." Test the fingers and big toes bilaterally and you're set.

Regarding Sensory Testing -- Pick either vibration or position sense and temperature or pinprick and test each big toe. Done. Because if your patient is losing sensation, it's starting distally. If the exam is positive, you can move it on up. You can trace a pin up a patient's abdomen and ask him if there is a spot where the sensation changes. If so, map it out with your dermatomes and you'll know where the spinal lesion is.

Ankle clonus indicates a severe upper motor neuron lesion.

To distinguish between true and psychogenic weakness, have the patient bend their arm and you move it down. If a patient is truly weak, the examiner should be able to overcome the patient smoothly. If it's psychogenic or weakness from fatigue, you will note breakaway weakness -- the patient resists at first and the movement is jerky and then the patient no longer resists and the movement is smooth.

The Romberg is a hell of a good test. All you have to do is ask a patient to stand, put their feet together and close their eyes. If they can't stand, you know that their vestibular and/or motor system is jacked. If they can't put their feet together, their cerebellum is effed up. If they fall when they close their eyes, their proprioception is on the fritz and you have a positive Romberg.

And finally, BostonFNP was right -- the single most useful neuro exam is ambulation. Have the patient walk, turn and walk again. Have them walk on their tippy-toes and have them tandem walk.

NewFNP cannot believe that she is back in her urban abode and having to work a real day tomorrow. Thank goodness Gap of all places had some new flattering trousers and a cute stripy boatneck top to ease newFNP back into her work week.

Continuing edu-vacation v.2010 part 2

NewFNP would be absolutely fine to stay on CME, take hikes through beautiful mountain trails, reconnect with good pals from grad school, drink White Russians and play Quiddler.

For those who are interested, newFNP posted her notes from a very helpful EKG interpretation lecture on the newFNP Facebook page. The response has been quick and somewhat shocking. How is it that so many new nurse practitioners feel like their EKG education was utter shit? NewFNP certainly did. One reason might be that the lecture newFNP attended was one that is normally given to medical residents. What the fuck, expensive brand-name nurse practitioner school from which newFNP is a proud alum? Your students don't deserve as good an education? Lame. Apparently, there is a nationwhide epidemic of poorly taught EKG interpretation in NP schools. Super lame.

NewFNP maintains that NP education needs a bit of a re-vamp. A little more specialty exposure that is highly relevant to primary care -- like dermatology, neurology, endocrinology and cardiology -- is in order. Seriously, when so many NPs are planning to work in community health where access to specialty care is nearly non-existent, throw your students (and their future patients) a bone. And then give NPs a residency. It doesn't have to be three years, but even a year or eighteen months would go a long way in helping newly minted NPs be more ready to care for patients.

Sadly, it's unlikely that newFNP will ever be in a position to transform nursing education. Yet with all the NPs in this country and in school currently, she wonders just how in the hell is it that it hasn't been done yet?

Continuing edu-vacation v.2010 part 1

NewFNP is so excited to be away from clinic for a week. Why is taking care of people so exhausting? (And rewarding, of course, but still exhausting!)

In the last week, the clinic was absolutely overloaded with patients, both in volume and acuity. A chief complaint of lab results twice revealed patients with GFRs in the teens. A chief complaint of staple removal revealed a young woman needing the staples removed from the incision in her wrist where she had tried to kill herself. Three likely cancers. One repeat teen pregnancy.

NewFNP is now lounging poolside, beverage at hand, chic new Pixie hairdo getting lots of compliments. She is at CME and she is recharging her batteries. She is somewhat concerned that her batteries need recharging after a mere four months back in full-time community health practice. She does, however, know that one thing that will always recharge newFNP's batteries, aside from J. Crew cashmere and coddington platform suede heels, is a (possibly) inadvertently hilarious comment at CME.

In discussing the newest ACOG pap screening guidelines, an OB/GYN and head of newFNP's state family planning program mentioned that one need never perform pap screening in a woman with a vaginal cuff after complete hysterectomy for non-malignant concerns. He then noted, "This one has been slow to penetrate into clinical practice."

Really? Really? Slow to penetrate, huh? As BostonFNP's dad once said, learning without laughter is like a day without sunshine. NewFNP's day was full of sunshine with that one.

Bring on the double entendres, the dorky medical jokes, and the alcoholic beverages. Because newFNP is on edu-vacation!

NewFNP, that's who.

NewFNP has long been fascinated by two behaviors she often notes as regular occurrences in her clinic.

The first is that patients feel absolutely empowered to walk into the patient care area and ask the medical providers any number of questions while the provider is in between patients. These are patients who may have just happened to drop by, or who received a letter stating their labs were abnormal or who wanted to show a provider a rash or insect bite or what have you.

NewFNP finds this frustrating and fascinating. She would be hard pressed to stop her doctor in the hallway to ask her a question or show her a derm lesion. For being disempowered in many ways, it is remarkable - albeit somewhat misguided - that her patients have found a voice in this way.

The second behavior is fighting and swearing and name calling in clinic.

It was full-on baby daddy drama in clinic today as prenatal patient A and prenatal patient B realized in the reasonably tranquil waiting area that they were both carrying fetuses fathered by the same man. Although it did not come to fisticuffs, clinic security was on heightened alert.

As newFNP's medical assistant was vitaling prenatal patient B, newFNP heard the word "bitch" resonate down the hall four times. At this point, newFNP said, "Uh-uh. Not on my watch." She entered the vital sign area, closed the door and told the patient that while she understood that she was frustrated, that language was not tolerable in clinic.

To which prenatal patient B replied, "Who the fuck are you?!!?"

Indeed.

Fortunately, the remainder of the appointment went much more smoothly and newFNP noted that, in addition to sharing a baby daddy, newFNP's prenatal patients shared the exact same tattoo in front of their right ears on their cheek.

The remaining lot of tattoos - neck, chest and hands included - were all different.

The Freshmaker

To many of newFNP's patients, the human body is a big mystery. Perhaps because her patients have had limited access to medical care, they have fashioned DIY treatments for various ailments. Rubbing alcohol, of course, is the big savior, dematologically speaking. It's got a "cure for what ails ya" mystique amongst newFNP's patients. Tincture of violet is another go-to topical.

But mere derm problems are not the only health concerns for which patients fashion their own treatments.

Throw menopause into the body mystery equation and it's like one big clusterfuck of a mystery to many of newFNP's patients. The uncomfortably itchy atrophic vag, the non-existent sex drive, the beard, the emotional upheaval. Honestly, newFNP isn't looking so forward to it. But she will have options when she gets there. Maybe she'll hook up with Suzanne Somers a la Samantha from SATC, maybe she'll do acupuncture -- who knows!

But what she most certainly will not do it dutifully apply Vicks Vapo-Rub to her atrophic downstairs in other to refresh herself, which is precisely what her patient told her she was doing. Granted, new FNP is nowhere near her menopause (knock wood), but there are a few places in which newFNP would not apply Vicks no matter what and her Lady Gaga is one of them. Talk about a bad romance!

NewFNP Film Festival

Just last week, newFNP was lamenting her Groundhog Day-like hum-drum clinical existence. A pap here, a diabetic med refill there. Nothing but the same old, same old. In fact, she thought that should an abscess walk in the door, she would not have the slightest recollection as to how to treat it.

Well, the universe listened. She had one of those Field of Dreams type of scenarios. All she had to do was imagine an abscess and voila!! Not one, not two, not three but high five abscesses walked into the clinic. On the same woman.

Now, newFNP loves her some Hot Tub Time Machine, but she is remarkably less enamored with Hot Tub Folliculitis. It is not a sequel one would recommend. Apparently, this woman and her paramour took a romantic getaway to a local hotel and enjoyed a soak in the hotel jacuzzi. A fun time was had by all until newFNP's patient began experiencing some angry booty blemishes. By the time newFNP saw her, two of the five abscesses were ready to go.

It was the first time newFNP had ever incised and drained two abscesses on the same patient on the same day and the first time she had ever seen so much necrotic detritus exit the newly opened wound.

As is generally the case with incision and drainage, newFNP's patient felt immediately improved and newFNP felt a renewed enthusiasm for her role in clinic.

And just like in the movies, newFNP (and her patient) experienced a happy ending.

Punxsutawney newFNP

It has been just like Groundhog Day for newFNP. Stepping in the same puddle, getting annoyed by the same people and generally reliving the same thing day after day after day.

And then there was today, when newFNP literally hit her head against the wall while discussing yet another undesired change in her schedule.

Work. WTF. As newFNP's mom used to say, too bad we weren't born rich instead of so good looking.

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.