When you're sliding into first...

There are often times when the chief complaint truly misses the nuance of what the real concern holds in store.

For instance, a chief complaint of diarrhea in a child is not so common, not so nuanced, not so big of a deal.  

(As an aside, newFNP had a pediatrics professor who invariably pronounced the word diarrhear, which so brought glee to newFNP and BostonFNP during a long day of dry lectures-- and it still does to this day!)

But what if diarrhea is not just diarrhea?  What if it is encopresis?  Well then, you're in for a hell of a different appointment.  

The history went something like this: the six year old boy was toilet trained, but then he started soiling.  When he's with mom, she has him wear diapers, even to school.  When he's with dad, he is instructed to go commando so that he is forced to "learn to control himself."  Both interventions wholly unacceptable and antithetical to appropriate treatment.  

To be fair, this is in part the clinic's fault.  He had been seen twice before for the same problem, had received minimal guidance and had no improvement in symptoms.  No big surprise there.  It's a confusing diagnosis for parents.  It's tough for primary care providers to give diagnoses such as this the appropriate care given that it involves greater than 10-15 minutes, education from the provider and counseling from an actual counselor.  

What makes this even more difficult is when the kid's father is intoxicated in the exam room and when the kid's mom is absent - both from the appointment and largely from his home life as she works and spends an extraordinary amount of time volunteering at church.  It was clear to newFNP that the kid was used to his dad being drunk when she watched him call his name and gently slap his face in order to rouse him when she called them in from the waiting room.

All throughout the encounter, newFNP was concerned about neglect.  But the kid was clean, he was growing appropriately, and he related well with newFNP and with his father.    His future might not be the brightest given the family history of alcoholism and the poverty, but poor alcoholics raise healthy thriving kids so we'll have to institute a prospective study to see where this kid goes.  NewFNP decided that it wasn't neglect - that it was ignorance regarding the problem and lack of support.

NewFNP gave the appropriate education, both verbally and in written form, instructed the father that both the diapers and the sans undies must stop A.S.A.F.P., ordered an x-ray, prescribed Miralax and toilet times, and hooked the family up with free counseling.  This took about 40 minutes.  

Worth it.  They showed up to their counseling appointment the next day and have follow-up scheduled.  

And a-one and a-two

Everyone has euphemisms for the act of defecation as well as the product, do they not? BM. Dropping the kids at the pool. Poop. Number two. Around newFNP's house, the act is called going to London and the product is London. Don't ask, as the terms were not invented by newFNP herself. She is certain, however, that their origins are not Anglophobic in nature.

NewFNP thought that she had heard all of the shit-slang until a nine-year old boy enlightened her. He was in for diarrhea so newFNP was asking all the usual questions. Vomiting as well or not so much? Watery or some formed stool? How many times a day? Fever/chills? Foreign travel? Food-borne illness, perchance?

And finally, newFNP asked the kid whether he had gone to the bathroom that day? He replied in the affirmative. "Number one or number two," newFNP asked.

"Number three," he replied.

NewFNP is thirty-three years old, has nine years of higher education, and she never, ever knew that a term existed for diarrhea. They just don't teach that kind of shit in the Ivies. Ivory Tower indeed!

Number three. Awesome.

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Click here to find out how your own number two rates!

The three D's

NewFNP apologizes for the recent silence, but she has moved (homes, not clinics) and is just settling in to her new place. Ahhhh.... home sweet apartment home.

Anyway.

NewFNP must have previously noted how patients' chief complaints come in waves. One day it's nothing but pap smears - one vag after another. The only difference is the amount of hair. You might be surprised to know that a 250-pound woman has the flexibility to get a Brazilian but they do! The next day, one might be swimming in abscesses and chalazions. Frankly, it's uncanny - do newFNP's patients all know each other and coordinate their visits? Perhaps they figure that newFNP will really be on her game if they all come for the same thing on the same day. Suckers!

So newFNP just had the diabetes and depression day. Some patients even had both. Now, newFNP is no expert on either, but can manage each effectively in the primary care setting. NewFNP admits that she is a little dodgy when it comes to changing for oral hypoglycemics to insulin, but she has no fear regarding starting an adult patient with depression on an SSRI. But one after the frigging other for eight hours? Fucking hell. NewFNP thinks of her mental health colleagues and is so thankful that there are people in this world who can address these sometimes debilitating depression cases. Because newFNP sure as hell cannot during her 15 minutes. The diabetes/depression day is not a rewarding one for newFNP. It just doesn't make for a fun clinic day.

That is until newFNP was rewarded for her diabetes/depression diligence with The Third D: Dookie. Now, newFNP is no stranger to euphemisms for the act of moving one's bowels. She generally, however, reserves 'dookie' for elementary school students and not for 38-year old men. NewFNP truly attempts to be professional during her visits with patients, but then someone says something like this, "Yeah, I used to dookie like 3 or 4 times a day, but now I maybe dook once. Maybe twice, but I used to dookie a lot." All that newFNP heard was "dookie, dook, dook, dookie, dook." Oh, it was awesome. NewFNP was biting the inside of her lip in order not to start laughing.

The Dook. NewFNP will never forget him.

I had this pain....

When newFNP has a pain that self-resolves, she is thankful and happily moves on with her life. That is not the case, however, for many of newFNP's patients. I cannot begin to tell you the frequency with which I hear of bygone aches and pains, now entirely resolved.

So you say that your back hurt 3 months ago? Interesting.

What's that? You had a headache last year, just once and then it went away? Well, aren't you a medical miracle.

Pardon me? What caused that pain you experienced last July? NewFNP must confess, she'd be hard pressed to say.

Lest anyone think that newFNP is an asshole, she does in fact inquire as to whether there are any other health concerns that might have brought the patient to the clinic. Most frequently, the answer is no. Sometimes, however, there is another chief complaint.

One such example is my mid-30's male patient who segued from resolved pain to constipation. Ah, poop. Now there is something you can really assess and sink your teeth into during the history-taking!

For instance, when was your last BM? Today.

I see. And how often do you have a BM? Every day. Twice a day.

This is the point during which newFNP questions her Spanish skills. Twice a day? Constipation? Something is not adding up!

OK, well, twice a day falls well into the range of normal...

At this point, newFNP's patient won the Brown Star Award when he disclosed his normal bowel pattern of three movements per day. Maybe the day after Thanksgiving, but every single day?!?

As newFNP sees it, Mr. Poopie has just saved himself an estimated roll or two of TP per month, not to mention an estimated 30-45 minutes per week away from the throne.

Perhaps he could devote that saved time into an extra workout!

The formula for success

Gentle reader, it is vomiting and diarrhea a-go-go here in newFNP land. We have seen countless children over the past few days with all manners of fluid evacuation. Patients have it. Staff members have it. Children of staff have it. Will anyone escape? My facialist is always telling me that I need a colonic in order to have perfect skin. Maybe she's got it all wrong. Maybe I just need some acute gastroenteritis to flush out the toxins!

Alas, the toxin-flushing argument is likely not going to be a winner with a worried parent. So what do you tell the patient's worried mom? Sure, fluids, fluids, fluids, but how much exactly? No worries, newFNP is here to provide the answer to that pressing question. As newFNP always says, there is no time like the present to review the exciting world of pediatric maintenance fluids.

Here's the formula:

First 10 kg: 100/ml/kg/day (aka 1000 ml if the kid is a full 10 kg - see how easy this is!)
Second 10 kg: 50/ml/kg/day
Each added kg: 20/ml/kg/day

For example, a 28-pound (13 kg) kid requires 1000ml + 150ml = 1150ml/day. Let's divide by 30 and tell the patient something they understand: No less than 38 ounces in 24 hours, buddy.

See, easy peasy! That is, if you have a calculator or are John Nash.

Oh, and newFNP is certain that everyone already knows to get a urine on these kids. A nice little quantitative measure of current hydration status. The whole "sunken orbits" is a little too subjective for newFNP. Maybe the kid was just not blessed with a doe-eyed countenance! Does that indictment really need to be a part of the permanent medical record?

Happy calculating!

Achy Breaky Heart

A crazy thing happened today. I saw the most patients I have ever seen in a single day (n = 28) and I left the clinic at 5:00 PM on the nose. It was divine. I am in a state of joy bordering on beatitude.

I did, however, send a patient to the emergency room. I like to have both the calm and the storm, I guess. Here is why this man had a ride with the paramedics. He had chest pain, dyspnea (worse when supine, so I guess technically it was orthopnea) and had diagnosed left-sided heart failure last year that resulted in him receiving a pacemaker. His father died from heart failure at age 54. And did I mention that, despite treatment with 80mg TID of Lasix, he had urinated exactly once (4 ounces – he actually measured) in 48 hours?

Now, I must confess that I partially sent him because I was scared, the only provider in the office this afternoon, and I knew that his history and symptoms were both serious and beyond my ability to care for. I think that it was the right decision. He was overweight and his exam was unremarkable, but as I’ve previously mentioned, ausculatory exams on obese persons are exceedingly difficult. Did I hear crackles? I did not. Nor did I hear normal breath sounds; I heard faint breath sounds and faint heart sounds. His abdomen was huge. Was he holding fluid in there? I don’t know, but the doctors at the emergency room will.

For those students/new practitioners who are familiar with the lower extremity edema/DOE/chest pain presentation of heart failure, please allow me to point out that this picture often points to right-sided failure. Left-sided HF is sneakier. I was too freaked out to think about that until the paramedic mentioned it, leaving me to feel like a huge jackass. Whatever – my ego will survive and I am the wiser for it.

Here are some tidbits to refresh and/or inform:

Signs of HF include:
DOE/PND/orthopnea
Cough with or without frothy sputum (yeah – gross)
Abdominal pain +/- nausea
Constipation (who knew??)
Exercise intolerance (I’d hazard a guess that 90% of my patients have this as they never exercise)

Symptoms of HF include:
Fine crackles, generally bibasilar
S3
Edema
JVD
Tachycardia
Hepatomegaly
Pallor or cyanosis

However, Uphold & Graham point out that “[in] left-ventricular systolic dysfunction, signs and symptoms are not reliable indicators or cardiac functioning; patients with severely impaired ventricular performance may be completely asymptomatic until they overexert themselves…” Thus, the ED visit today.

Which reminds me… the paramedic asked me, as I was standing there feeling like a buffoon, if any of the patient’s medications were constipating. A) I don’t fucking know for certain but probably not and B) constipated or not, homeboy has essentially not taken a leak in 2 days and has both a personal and family history of cardiac disease. Can we deal with the poop later, please? When I’m thinking of priorities, it goes something like this:
1) heart failure
2) poop

Twenty-eight patients. I think my days on easy street will be coming to an end. I exceeded my goal – set by the clinic manager - of 22-25 patients/day. Crap.