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!

Taking it (the Big) Easy

The last time newFNP was in New Orleans, she was 22, on a meandering cross country road trip which had such highlights as the Carlsbad Caverns, Graceland and a variety of Shoney's restaurants, and was bunking in a bright pink hotel called The Frenchmen.  

This time she is at a conference - an addiction medicine conference - at the Hilton.  

Note to the addiction medicine conference organizers: there is a W just a block away.  Think about it.

Anyway, the highlight of the conference so far may be the following patient quote shared with the audience of listeners at a lecture about stimulant use and hypersexual behavior.  The patient, noting his inextricable link between buckwild sex and cocaine use lamented, "I guess I'll just have to get used to sex without the hookers and the drugs." 

The quote is funny, but newFNP acknowledges that is problem is, of course, not.

NewFNP did make a quick afternoon escape from addiction to see a super great/creepy exhibit at the Audubon Insectarium and to sample some local cuisine: she had fried alligator (and a salad) for lunch.  

Yum.

Welcome back, my ass!

The rough thing about attending a posh CME in a serene location is that one tends to forget the reality of everyday work life in the ghetto. In case you had forgotten, allow newFNP to refresh your memory: it sucks.

NewFNP is right back in the thick of it: leaving an hour late, attempting to correct the fact that she had seven patients scheduled in the three o'clock hour today and dodging bullets fired by the ever-critical and sorely lacking in introspection OB-GYN. Hey sister, when you point one finger at newFNP, there are four pointing at yourself, you ho-bag.

NewFNP returned from her conference ready to take on the world. Well, the world has dealt newFNP a real shit-storm. So much so that newFNP has begun to question whether she really is doing well for her patients.

The OB/GYN is quick to point out the cazillions of flaws she sees in the care that newFNP and the other prenatal providers have delivered, yet this provider sees an average of 10 patients per clinical day. She is not at all hesitant to allow other providers to see the remaining patients on her schedule as she delves into every detail of her patients' care. NewFNP truly makes every effort to address all pertinent aspects of medical care as well as engaging the patient about social issues, but newFNP has a 30-patient schedule and, therefore, misses things sometimes. Does this make newFNP a bad, incompetent or inadequate provider? Is the OB/GYN right in just giving a big "F-you" to the rest of us while she assesses for every fucking hangnail that may trigger preterm labor, birth anomalies and the omnipresent threat of legal action?

Another new physician pointed out that newFNP's clinic is "killing" our patients because we cannot start diabetic patients on insulin if their A1C's are over 8.5 or 9. The reason newFNP is unable to do so is that a very small number of patients can afford blood glucose monitoring supplies. The new provider didn't mean it as a judgment, but rather as a statement of fact. However, newFNP feels acutely aware that she is between the proverbial rock and hard place. NewFNP can either slowly kill them with the ravages of hyperglycemia or quickly kill them with the rapid action of hypoglycemia. Talk about choosing between the bat and the belt! What a fucked up world we live in. Perhaps there is a program that would supply all of newFNP's DM patients with testing supplies and syringes, but newFNP doesn't have even five minutes in her day to research this.

NewFNP is uncertain what to do. She is at her two-year anniversary at her clinic. NewFNP is community health and had planned on staying at this clinic indefinitely. But how in the fuck can newFNP put up with all of this?

On the positive side, everyone loves newFNP's new hair-do - even the fashionable gay guy so newFNP knows that she is looking hot! Watch out!

And she's back...

New FNP learned quite a bit while she was at her CME. However, the most striking thing that newFNP learned is that her patients will likely not benefit from a fucking shred of what they should be receiving.

For instance, the lovely and brilliant physician who lead the Obesity 2007 chat couldn't stress enough the importance of a nutritionist. Yes, indeed. However, let's just say that hiring a nutritionist is not on newFNP's clinic's short-list. Very low calorie diet? In newFNP's clinic, we call that 'food insecurity' as no one ever self-restricts to 800 kcal/day. NewFNP was thrilled to have it made public that a BMI of 26 has a positive effect on mortality. Ah, NHANES, God bless ya! NewFNP already knows that a little extra cushion is her natural set point, but she is stoked to know that science is getting on board with the voluptuous lady. Interestingly, this speaker did spend a fair amount of time on discussion of how fitness truly helps in preventing mortality. If your BMI is 31 but you are a walking-fool (45 minutes/day while talking), you're actually not in that bad of shape. However, if the only exercise you go is extending your left arm though your auto-roll-down car window to reach for your double bacon piece of shit burger, then - yes - you are on the train track to an MI.

And the fertility lecture. Fascinating, especially when newFNP has had two thirty-something friends struggle with it. Practical in newFNP's urban free health clinic? Uh, no. Interesting to learn that laying supine with the knees up for twenty post-coital minutes is advised if attempting pregnancy. NewFNP suspects that adopting such a position might lead to a 'round two' which goes against the tenet of QOD action for best baby-making.

NewFNP learned a lot about bisphosphonates. However, newFNP has succeeded in getting a single patient a bone mineral density scan. NewFNP would love to help the ladies spare the hip fracture - hell, who wouldn't! But newFNP is reluctant to just start adding Actonel to the water supply.

One great overall experience that newFNP had was to see that her practice was already mirroring a lot of what these experts were recommending. Hallelujah! And she is doing procedures which many of the physicians in attendance don't do, such as IUC (new phrase - apparently IUD is out of vogue) insertions. Why would anyone want to do less? Sure, newFNP would want to do fewer prostate exams but newFNP wishes that she could, for example, be doing biopsies for her patients. Because frankly, if newFNP's clinic isn't providing the care, it's unlikely that newFNP's patients will receive specialist care.

There are, however, things that newFNP would like to do more of, such as starting patients on insulin. However, newFNP's patients don't have glucose monitors so one shan't prescribe a hypoglycemic without appropriate monitoring! This conference recommended starting patients on insulin when they have an A1C greater than 8.5. Holy fuck - newFNP rarely sees a patient with an A1C that low, at least when they initiate care with us. A1C of 15.4, sure. Of 17.2 - rarely but not unheard of. When newFNP gets an A1c into single digits on oral hypoglycemics, she is quite thankful.

Mostly what newFNP learned is that she loves to take bike-rides through one of her state's most beautiful areas, amongst trees and rivers and a huge, glorious lake. NewFNP learned that perhaps her huge urban area is not where she will be for the rest of her life, that perhaps she will need a mid-point between the luxuries of urban life and the natural beauty which is too few and far between in her city.

CME Update

When attending a CME, all of the answers seem so obvious.

Duh, the lesion in slide is melanoma. Ray Charles could see that!

Clinical practice, however, is not so tidy. Especially family practice. Being a generalist is tough. In the eyes of the patient, one is expected to know it all, be it funky dermatological lesion, West Nile Virus or lumbago. However, in clinical practice, patients give horrible histories and, in newFNP's practice, this issue is significantly exacerbated by the ole language issue. In clinical practice, newFNP doesn't have the luxury of having convenient multiple choice answers from which to choose her differential diagnoses.

NewFNP will, at some point, share some of the more illuminating information gleaned from the conference, but in the mean time, can she just say that she enjoyed so thoroughly her 12-mile scenic bike ride with BostonFNP and her younger sister RooSF? NewFNP is leading a life of leisure! Post-conference and gym yesterday, we all hit the pool where newFNP donned some very now Tom Ford sunglasses, slathered herself in SPF, and read The NewYorker. She topped her evening off with not one, but two margaritas and a crab tostada.

NewFNP loves her CME. It's not just all the leisure either. NewFNP feels inspired yet again to be an excellent clinician and is in touch with her inner nerd as she basks in the glow of the Power Point slides.

Ahhhh..... Continuing Medical Edu-vacation. Just what the nurse practitioner ordered!

Life imitating art

Does everyone remember when Aidan and Carrie broke up? At the end of the break-up episode, Carrie had her wild, curly mane and, at the opening of the next episode, it was transformed into a chic, short-ish curly-bob. New hair, new life.

NewFNP. New hair-do. Soon to be new apartment with new couch (thank the heavens for Crate & Barrel). Still with old job but without old boyfriend.

And, in the midst of it all, newFNP was actually thankful to have her crazy job, her NP student and her intellectual stimulation. How do people go through break-ups if they have some mindless job in which they can ruminate and sift through the remains of the relationship? It's not often that newFNP is thankful that she has nary a minute to re-apply lip gloss or take a sip of filtered water, but she has been very thankful for her hectic schedule this past month.

Even more so than that, newFNP has been thankful that her career actually means something to her patients.

This past week, newFNP had the pleasure of working with Dr. G. Dr. G. is newFNP's age and went to med school a mere block away from newFNP's nursing school. Yes, newFNP and Dr. G. have probably walked the same hospital floors but never knew each other until practicing community health on the other side of the country. Dr. G. mentioned to newFNP that one of the things -in a very long list, of course - that makes her a good provider is that she truly cares for her patients, that she listens, that she asks them questions about their lives. During this time of major personal change, it was nice to get that validation from a co-worker.

It was just as nice when a patient's fasting glucose dropped from the mid-300's to the low-mid 100's after newFNP stopped his oral hypoglycemics and started him on an all-insulin regimen. Most of newFNP's patient cannot afford glucometers and supplies, so newFNP hasn't had the opportunity to do this transition very often. Nonetheless, even though he is technically a Type 2 diabetic, newFNP believed that his pancreas had thrown in the towel. There isn't enough metformin in the world to help this guy out. Furthermore, this patient was an exception in that he had glucose monitoring supplies, so newFNP wrote out a detailed baseline NPH insulin regimen with instructions for regular insulin sliding-scale coverage. She was so proud of herself and her patient when his glucose started to stabilize.

Now, newFNP knows that this one day of control may be an anomaly. However, to get props from a co-worker and to achieve something akin to medical success constitutes one hell of a week for newFNP.

Just wait until those fuckers see newFNP's fierce new hair-do. They'll have to wait a week, though, because newFNP and BostonFNP are hitting up the vacation CME in a fun-filled resort town.

As BostonFNP's dad once told us, learning without laughter is like a day without sunshine. NewFNP cannot wait to have both at her Continuing Medical Edu-vacation.