You can't keep a good newFNP down

Since newFNP last exposed herself to a patient's aromatic purulent discharge in a not-altogether successful attempt, newFNP has incised and drained not one, but two further patient lesions.

Lesion one: lady business abscess. OK, not exactly lady business but suprapubic in locale and wholly a result of picking at one's ingrown hair. Hands. Off. Ingrowns. I restate my case initially argued in "Picky Evolution."

Lesion two: epidermoid cyst. NewFNP has been waiting for this since she first became acquainted with one during her independent study in derm.

NewFNP is floating in her derm dreamworld. Oh, how newFNP loves derm. Bring on the Retin-A, kiss that acne and those wrinkles good-bye. NewFNP would love to scrapy-scrape your big fat plantar's wart, just as she would love to inject your inflamed acne lesion with kenalog. NewFNP loves to draw pics of derm lesions. NewFNP simply loves derm. It's a pure, unadulterated love.

OK, back from dreamworld. So, an epidermoid cyst. Not pretty. It forces one to utilize culinary analogies when describing cyst contents: cheesy. Soft cheese. Soft white cheese. Rondele, anyone? The I&D is exactly the same, except that you want to get the sac which contains the contents out in order to prevent recurrence and numbing the patient is so much more difficult. The contents of the cyst are firmer and therefore require a larger bored syringe in order to introduce the lidocaine. Ouch, big fat needle.

What can ruin a perfect I&D is another provider's student attempting to horn in on the I&D action. And by horning in, newFNP means asking not once, not twice, but five times to either perform or observe the I&D. At each query, newFNP replied 'no,' each response becoming progressively more firm and annoyed, the last of which being, "You can stare at me all you want; the answer is no." Is the student six years old? No, no she isn't. Yet newFNP found herself speaking to her as though she were. There is a reason that newFNP does not have a student: because newFNP needs the experience herself. NewFNP still is gaining comfort in her role as pus-expressor.

Note to all students: when your preceptor says 'no,' there is a reason. Don't push it. Should newFNP even have to tell anyone that? NewFNP is certain that her readership is already savvy enough to realize the non-kosher maneuver by our student.

In the end, not even pushy student could spoil the supremely successful I&D. NewFNP was even able to disrupt and express the sac. You can imagine my happiness - bordering on beatitude.

Out of the mouths of babes

NewFNP has fallen in love with the well child visit. Yes, it's true that sometimes the 13-year old well child weighs more than newFNP. Thankfully, those visits are rare enough. But for the most part, well child visits afford newFNP a break from diabetes and BMIs of 45. NewFNP likes all kinds of well child visits now, but has always held a soft spot for teenagers. Especially ones that ask funny questions.

So, all in all, an average 14-year old male well exam. Thin, plays field hockey (quite unusual in my inner city area), respectful, has all parts intact and has no inguinal hernia. Testicular torsion education - done. Safer sex/abstinence education - done. Repeated denials of current or prior sexual activity - accepted by newFNP.

As always, when about to exit the room, newFNP asked, "Do you have any questions?"

"Yeah, I have a question," he replied. "Is it bad to masturbate?"

The way he asked was so sincere. I set the chart on the counter, faced him squarely and said, "No, it's not bad. Everybody does it. Just don't get caught."

He was visibly relieved. Whacky kids!

You never forget your first

It's true for any number of experiences. First kiss, first love, first bad grade (not that newFNP would know anything about that), first abscess I & D. Now, let me go on the record as having stated that newFNP likes gross stuff. But what newFNP does not like are gross smells. Seriously. NewFNP has never eaten ketchup because she is repulsed by its aroma.

Here is the sequence of events:

12:30 patient: mucopurulent cervicitis
12:45: lunch
1:15 patient: abscess

The smell. Holy shit, the smell. First of all, it was an ass abscess. Top of the rump, right gluteal fold. Second of all, there were 5 of us in the small MF-ing exam room. Me, the patient, her sister, the super-MD I work with, and my favorite MA who lives for nasty procedures. Again, the room is small. The room was also hot. And did I mention the stench of the abscess? Can you see where this combination of forces leads?

So, prep, anesthetize, cut, express, express, express, express, express (you get the idea), whiff, feel faint, get hot and clammy, realize you are about to hit the deck, call for back-up, sit, regain composure, express, pack, cover. Try to get the smell out of your memory. Try harder. Keep trying. Visualize the relative beauty of the cervicitis. Thank the heavens for bullshit URI appointments.

And a tip: for those who are also new to abscesses, my MD told me that the pH of the pus weakens the effect of the lido so numb 'em up somethin' good! Happy draining!

And the hits just keep on comin'

NewFNP has been on hiatus, largely although not entirely due to a lack of fun/interesting stories to share. Nonetheless, as newFNP indugles in a some moments of reflection here and there, she finds that there are some stories worth sharing.

In the on-going series of firsts, allow newFNP to share some of the new experiences she has had in the past two weeks:

-first patient passing out, becoming diaphoretic and having a BP of 68/42 and a HR of 40 during venipuncture.

-first patient with 8+ hours of uncontrolled epistaxis coupled with first experience of being unable to find 1:1000 epi and served with a side of being the only provider in the clinic.

-first realization that my 19-year old patient is engaged to and not the daughter of my 58-year old patient. Permit me an aside, s'il vous plait. Upon further questioning, this young woman disclosed that she and her partner had begun "dating" when she was an assumingly worldly 13-years old. Their son is three. What was her life like that a then 52-year old man was attractive to her? Where were her parents? Why did the man troll down that path of pedophilia? And why is the gentleman I know today, the same man who was screwing a child, so incredibly likeable?

-first suspected child abuse reporting call, only it wasn't suspected. Note: don't forget to ask what the child is hit with, ie. a belt, a hand, a shitty start to life.

-first time of blinking back tears due to feeling utterly overwhelmed, suprisingly not on the same day as the child abuse report.

-first time looking in an ear and seeing something resembling the aftermath of a roadside bomb. Shades of red and gray, jagged edges to a clearly blown TM. Tumor v. traumatic rupture of TM? Let's have the ED decide.

Oh, life. Is it too soon to ask for a raise?

Home sick

No, not 'homesick' as in newFNP is at work and missing her 1-bedroom apartment, but home sick as in see 'formula for success.' More time to devote to old NYT crosswords and The New Yorker.

But anyway, the time spent at home sick can't be all fun and games and cursing one's stabbing abdominal pains. As such, let newFNP tell you three little words that will make any newFNP truly embrace her 'sit-near-the-door' policy.

"I hear voices."

Super. I'm 30 minutes behind schedule and you hear voices. Are you sure you don't just have a cough?

Allow me to set the stage. My mid-40's patient was sitting on the exam table, paper gown and drape in place, and had an affect that quite frankly screamed medicated mental illness. She lacked emotion. She was treated with 2 anti-psychotics and 1 SSRI. Perhaps newFNP should let her psychiatrist know that something in her med cocktail wasn't fitting the bill.

So here newFNP is with the voice-hearing lady. After enquiring as to what the voices said to her and thinking, "please don't let it be 'kill the nice blue-eyed NP,'" I was relieved to hear the relatively benign, "Well, they are babies and they are telling me that I am their mother." OK, doesn't sound emergent.

Then she proceeded, as earnest as could be, "Is that normal?"

Hmmm... normal. Possible responses include:

a) "Normal, shnormal."
b) "I think the attraction to motherhood speaks to a lot of women very strongly."
c) "Who am I to say what normal is?"
d) "No. Shit no, that is not normal. Fuck!"

Now, if community-health-newFNP was an infertility-newFNP, she would lean more towards 'b'. But my community health clinic's scope of practice does not include infertility issues and this lady wasn't speaking about her deep-seeded inner desires for pregnancy. I chose a softer version of 'd' with a splash of 'b' thrown in for flavor.

This patient was not a sexually active lady, but believed wholeheartedly that there was a possibility that she was hearing these voices because she was, in fact, pregnant. Now that is getting into a whole area of religion and mental illness with which newFNP is not comfortable. Urine hcg negative. Let's get you in to your psychiatrist.

All in a day's work.

By the way, the swamp nurse article in this week's issue of The New Yorker made newFNP's job look like no work at all. NewFNP is all manicures and pilates compared to Miss Luwana. Here is a quote from the article:

"The mom I'm working with now is a sixteen-year-old unmedicated, bipolar rape victim and crack-addicted prostitute with a pattern of threatening to kill her social worker, who recently abandoned her baby at her ex-boyfriend's sister's, and who has an attempted murder charge in another situation..."

Now that makes me feel like I am working in a private practice.

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!

Pet Peeves

There are a few things that turns newFNP off during the clinical encounter. And I'm not talking about all the patients who ask me about my marital status.

Nope, I mean the ones who open the door and stare at me when I'm reading another patient's chart in the hallway. Estimada paciente, do not go back into your room and leave the door open while waiting for me. Read the thoughtful en espanol educational materials that I have photocopied on cheerfully-colored paper on my own time and that will offer helpful suggestions to help you lose 30 [read: 50] pounds. I hate that you continue to stare at me while I read your chart in the hallway so as to garner a shred of an idea as to why you might be visiting me. I understand that you are waiting a long time for me. I promise that I'll be in ASAP. Now shut the damned door.

But even more than the patient-imposed open door policy, newFNP gets all bunched up when, after opening the door, she sees the patient perched on the rolling stool. I'm telling all y'all motherfuckers that I have two graduate degrees, a stethoscope and a white coat. I have earned the rolly stool. Who doesn't know that the rolly stool is for the one who writes the prescriptions? Move it, buster. If it's a kid, I let it slide because - hey- the rolly stool is fun. But adults get no love from newFNP is they steal the stool.

Why is newFNP so lame as to even give a fuck if the patient wants the rolly stool? A) It's a safety thing. I am positioning myself closest to the door in case you are a weird-o or mentally disturbed like the guy who stabbed Carter on 'ER'. B) I don't want to sit in the regular chair. Period. C) The rolly stool is mine. D) Respect. It's silly, but it seems disrespectful somehow. I'm sure it's not intentional but nonetheless, you go to your seat and I'll go to mine.

End of story.

The apple doesn't fall....

When newFNP was a student, she wrote a (fascinating and insightful) paper about parental loss in childhood, but specifically adolescence. It doesn't take a frigging genius to know that this is one of the most painful losses a child faces, that its consequences are potentially devastating and can be life-long. The legacy of that loss can profoundly shape the child.

Given that newFNP has such keen acumen, she should be incredibly prepared with all of the right words when a patient tells her that he or she has, in fact, experienced parental loss.

My 11-year old patient's mom died when she was 8 - complication of diabetes. My 11-year old patient is 243 pounds. Her acanthosis is pronounced. Can you see the trajectory?

She knows. I know.

She is scared. She is terrified to have her sugar checked because what will happen to her if she has diabetes? Will the same end meet her as met her mother? And she is only 11.

It is so complex. Her dad tends to give her whatever she wants because he cannot give her what she has lost. So she gets honey buns and Hot Cheetos. She is too young to know how to really do anything different. She is too scared to honestly talk to me (in 15 minutes) about her weight because of what it signifies.

This is the poignancy of family practice. This family is in crisis. They both need to make changes and they both need support following their loss. I want to give them the tools to mend their family as best they can. But 15 minute appointments. Damn.

I don't know if what I did was right, but I told her that I was there to help her and that I wanted her to know that there are people in this world who care for her, who love her. I told her that I would be there for her even when she wasn't sick, that she could come in just to talk if she needed to. I told her that my mom died when I was young because I remember thinking that I was the only person in the world who could ever experience such heart-wrenching loneliness. Shit, I hope that still falls within the confines of holistic care. Patients feel free to ask me about my marital status and parity, so I can tell other patients personal stories if they are relevant, right? I just wanted her to know that she had somewhere to turn and I didn't know how else to make her see that.

And now I need to find a childhood grief specialist. Who takes public insurance. Motherfuck.

Don't send me back

There are days when newFNP is simply unable to dodge all the shit being thrown her way. Today, of course, was one of those days. From 10 AM on, I had nothing but problems. Here they are.

One. Depression followed by PTSD. The depression was just sad. The PTSD, on the other hand, wasn't entirely convinced that he wanted to live. Clearly not an easy appointment. At least now I know how to write a 'safety contract' in Spanish. Oh, and when you are telling me that you think you'd be better off dead in one sentence, the next sentence sure as shit had better not be 'why do you think my throat hurts?'!!

Two. Hi, my new diabetic patient. I see you are 39 and have already had a below-the-knee/above-the-ankle amputation. I see that your burn wounds, affecting both hands, are not healing after 1 month, are slightly smelly although not infected and that your sugar is 'HHH.' Oh, you say you're peeing all of the time and that your vision is blurry? I can't say that I'm shocked.

Diabetes. Damn! Did everyone read the special in the NY Times about Spanish Harlem and the 20% prevalence of Type 2 amongst the residents there? Read it. It actually gives some good insight into how people cope (or don't) with the illness.

Three. It's 4:35. You're my 55-year old 3:30 complete physical and pap. It's not your fault that you're in my room late. I'm sorry you had to wait for me. Blame it on the diabetic guy.

Four. Prescription nightmare. Not my fault, but my mess to deal with nonetheless.

Five. My two incorrectly scheduled pediatric physicals, both scheduled at the same time, both 30 minutes late. Yes, your mom was pissed. I'll tell you what: next time be on time or call and let us know that you're late. Don't tell the receptionist that you didn't know you had to be on time. Have common sense and don't be mean to the front desk staff. This happened while I was with the patient who wanted to die, trying to get the social worker on the phone. So, no, I won't leave my patient to explain to you why I'm not seeing you today.

Is it any surprise that I cannot remember the other 18 patients I saw today? None of them were really 'easy,' many of them were new.

As I looked at charts in the hall before entering the patients' rooms, I was very conscious that I had to keep my frustration with my day to myself. I had to tell myself that Sra. X deserved the best of newFNP, not the frazzled and borderline tearful newFNP. That is a tactic I haven't had to employ frequently, but it was indispensible today.

And, thankfully, it worked. Yes, I was miserable with stress. Yes, I thought of requesting a phenobarbital-induced coma. Yes, I was thinking of ways to avoid ever going back to work again as long as I live. But I treated my patients well at the end of the day.

Even the one whom I saw at 5:15.

A Cure for the Obesity Epidemic

I've got it. It's a plan that will never come to fruition, but one I think has the potential to be quite effective. No, it's not the removal of sodas and Taco Bell, Golden Arches,Burger King and vending machines from schools. It's not more exercise or daily P.E. in schools. It's not 'you'll get Type 2 diabetes and have hypertension and dyslipidemia, all predisposing you to a big old MI.' Those are good ideas, by the way, great ideas even, but my proposed campaign is meant to have a visceral response, striking at the very core of insecurities all over the world.

(I love hyperbole.)

It's fair to say that all people have some degree of interest in their genitals, right? I mean, we have penis pumps, Brazilian waxes thanks to those evil J Sisters, circumcision, female circumcision as well as various nether-region accoutrement. Men can't stop touching their goods from infanthood until, well, until they die I guess. This obsession is the basis for my campaign.

My idea is this: let's raise the awareness of the 'hidden penis' and the 'fat vagina.'

I mean, does any guy want to exchange his average penis for a huge pannus? It's not even a fair trade!

And ladies have labiaplasty in order to have a perfect genital portrait. Not my patients, but I've seen the advertisements and if plastic surgeons can play off vag insecurity, then so can public health. So don't get a huge vag!

And after this awareness raising campaign, we can transition back to the more traditional interventions. It's worth a shot. The other methods sure as hell aren't working very well.

Take that, 911!

Yesterday, in the midst of uncontrolled hypertension and diabetes (see 'Rant'), the 7-year old patient in the next room was having dyspnea.

I swear, the kid looked fine when he walked into the clinic, but by the time I saw him in the room, his fever had shot up to 104.0, his 02 had dropped to 90-93% and he was sweating like a west coast native during a New England summer. The only thing missing was frizzy hair. In addition to these alarming findings, his eyes both got red and puffy. Not the way newFNP looks around grass and cats, but peri-orbitally he just looked wrong.

In addition to the fever, he also had rhonchi & wheezing so newFNP treated him to grape flavored Motrin, strapped him onto the nebulizer and put a cold pack behind his neck. In the back of my mind, I was wondering if I should treat him for the likely pneumonia or send his ass to the ED. And this is where the struggle of community health comes in.

The kid perked up, but still didn't seem A-OK to me. I was content to send him to the ED with his mom and three siblings, but they had no car. I asked her to call someone but no one was available to help her out. At this point, newFNP wasn't convinced that the kid needed an ambulance, but newFNP was also distinctly uncomfortable with sending him home.

As such, 911 was called to save the day. Of course, the kid looked super by the time the four paramedics arrived. As I recounted his tale, sounding like an idiot as always ("Um, I can't remember his BP - sorry"), the strapping, capable and tough paramedics looked upon newFNP as a nuisance, a burden, an embarassment to medical/nursing professionals everywhere.

Well, fuck them because the kid's mom called and told me that her son stopped breathing in the hospital. Now, I don't know if he de-satted or if he really stopped breathing, but he remains in the hospital as of now. All through the night I was wondering if I had over-reacted, but I am so thankful that I made the decision to send him.

Take that, hot paramedics! You think you know everything with your pecs and your biceps and your six-foot-three! Blow me.

Rant

NewFNP is tired today. When newFNP is tired, newFNP is pissy and easily frustrated. It's a familiar rant - the one I am about to share - but a rant I continue to feel the need to express nontheless.

If you are nearly 300 pounds, with a BP of 191/106 and a glucose of 425, don't fucking tell me that you are on motherfucking Jenny Craig or Weight Watchers or that you are Sweating to the Oldies. Just tell me that you had a Double Western Bacon Cheeseburger for breakfast and that you might just have a repeat for lunch, extra mayo and a large fries. Do not blow sunshine up newFNP's ass, especially sleepy newFNP. Because newFNP will hate you.

Part of the problem with being newFNP is that, as newFNP, you like to get straight A's & maybe one B in some bullshit class. Well, when you are my uncontrolled diabetic and hypertensive patient, I get an F. And it's your fault. Like a group project gone woefully awry.

I'm willing to work with you and even carry the burden of our group endeavor. But don't piss on my head and tell me it's raining. Oh, My Lady of Uncontrolled Chronic Disease, why must you torture me? You are too young for nephropathy and LVH, and you understand me because we speak in English. Yet you do not heed my sage advice.

And newFNP stayed up too late last night to be empathic newFNP to all patients today. That is a burden of the role. One must be on one's game, even when one is a crabapple. Therefore, newFNP must now toddle off to bed so as to be stellar tomorrow.

Because that patient is coming back. Balls!

She don't lie, she don't lie, she don't lie.....

I'm sure that if there is one question on the minds of newFNP's readers, it is this:

What the hell is up with the coke nail?

You all know what I mean, right? It's the nasty-ass long pinkie nail that men sport. I have yet to see a lady rocking the coke nail. Aside from the male gender prevalence, these are the other demographic details I have amassed.

1) Men of all ages feel it is appropriate to advertise their love of the cocaine via a long manicured pinkie nail.
2) Men of varying cultural backgrounds find common ground in the coke nail. Does newFNP sense an opportunity for coalition building amongst cokeheads? The Million Pinkie Coke Nail March? Better wear protective eyewear!

NewFNP will take this opportunity to judge the pinkie nail. Judgement: foul. People need to head to the cokehead nail salon and chop off that disgusting talon. Ugh. Just seeing it grosses me out.

If anyone has insight into the coke nail phenomenon, please e-mail me at newfnp@gmail.com. I must gain understanding into this disturbing and widespread occurrence. Is there an alternative explanation? Is it just to clean one's ears?

Help me understand this frightening trend. I beg of you, help.

Follow-up visit

So, my yeast ear lady came back today. Sure enough, the culture showed budding yeasts. And for those who are keeping track, Diflucan does in fact work on extra-vaginal candida infections.

But here is the crazy part. My patient was not only rocking otic yeast.

As I skillfully manipulated the otoscope to visualize the canal, I perceived an eerie green glow. Did she have Kryptonite in her ear? Did she melt some Play-Doh in there?

In fact, no. She had a pseudomonas aeruginosa. And Cipro Otic costs approximately $80. How it sucks to be uninsured with an uncommon gram-negative otitis externa.

A Tale of Two Fat Ladies

The tale has almost nothing to do with fat, although both of the ladies around whom the tales revolve were in the mid-300 pound range. No, these tales are far more interesting to newFNP than fat.

Tale One:

How many times can one person consume antibiotics for an ulceration caused by moist flesh rubbing on its neighboring moist flesh? The answer: a shitload.

My patient has had an ulceration on her left breast for years. It comes and goes, it's purulent then not, it has been the target of antibiotic treatment time and time again, none of which at the hands of newFNP. As newFNP has stated time and time again, she is a tight-ass with antibiotics. Rather than empirically treat and given her ongoing love/hate affair with Amox and Keflex, newFNP cultured said ulceration and sent it off to the lab. Bye bye culture!

Imagine my surprise today when, in the midst of 17 patients seen in the morning session, I see a lab result screaming 'MRSA' sitting on my desk. No wonder the 2-year course of antibiotics didn't knock that sucker out.

Aside: newFNP had never actually recommended a bra as a component of treatment for a patient until I saw that those pendulous breasts, each bigger than my head, were resting unsupported on the patient's ample abdomen. Rx: BRA!!!

Tale Two:

Religion is important to many of my patients. NewFNP tends to keep any spirituality, or lack thereof, to herself but listens respectfully when patients share their faith. NewFNP has even been known to encourage spiritual counsel in times of distress.

My kind and compassionate patient today has relied upon her faith to support her during a difficult transition from married to separated. Her faith is so important to her that she brought a photocopied reading to drink in during her lengthy wait at the clinic. All in all, a smart move.

As I was examining her, she placed the readings on the exam table behind her. During her lung exam, I glanced down and noticed the word 'Jews' in the selection. During a seemingly thorough, entirely benign and incredibly distracted exam, I came to learn that her religion teaches its followers that the Jews are indeed responsible for killing Jesus Christ. I was frustrated and saddened, yet said nothing. What is there to say?

When TV is the cure

Cold & flu season has struck my clinic and, as newFNP has up to date information on the latest and greatest treatment guidelines, I would like to offer these words of advice to all of the patients streaming in and out of my clinic with body aches, fever and malaise: stay the fuck home. Watch some Daily Shows that you have TiVo'd. Check out reruns of CHiPs or Dos Mujeres, Un Camino. For the love of god, sleep - but do not expose me, my staff and my patients with pneumonia, diabetes and asthma to whatever you have brewing! And quit asking me for antibiotics. You're not getting any.

It's not that newFNP doesn't sympathize with how crappy one feels when one has the flu. It's just that a guiding principle of public health is to reduce one's exposure to potentially hazardous conditions. Your partner's herpes are acting up? I can't think of a better time to abstain. Granny has a touch of the TB? Don't share a non-ventilated close space with her.

But, you see, this goes both ways. If you know that your penis is leaking green discharge and you need to take a percocet in order to pee, don't hit up your special lady or fella for sweet lovin'. And if you are fluish, please have the courtesy of limiting your exposure to others. Sure, your family will suffer, but does that mean the entire community must as well?

Oh, and if your penis is leaky, that is a perfect time to hit up the clinic for antibiotics. We'd gladly give you a Rocephin injection! With Lidocaine and everything.

But does it itch?

Ear pain. We've all had it, but I'd hazard a guess that we haven't all had the symptoms one patient was experiencing today. Last month, she was treated for otitis externa and has been using cortisporin otic drops. Steroid-containing drops. Her pain was intensifying over the past three days so she returned for follow-up care. In addition to her otalgia, she also had tender pre-auricular lymphadenopathy. Her past medical history is negative for diabetes, FYI.

Good ear looks good. Textbook, one might say. Affected ear on the other hand... I carefully looked in her ear and thought, "Now, if I were looking in a vagina, I would be quite certain that I was seeing yeast." Now, I do not come home to peruse Gray's Anatomy every evening, but I am confident that I know an ear from a vagina. But yeast? In the ear? Another first for newFNP. It was all I could do not to laugh as I used a vaginal wet mount swab to grab a culture of the ear funk. Ah, improv.

I treated her with Diflucan under the philosophy of what's good for the south is good for the north. I can't wait to get that ear wet mount back.

Oh, the learning curve

Did we learn about labs in school? I don't think so. I think that there should be an elective about lab result interpretation. Mind you, newFNP attended a well-respected institution, but has somehow made her way through without having a good understanding of lab results. Don't think for a minute that I can't interpret a CBC, because I can, but when you start throwing a jacked kidney my way, I am flat out lost. When there are too many numbers in the 'abnormal' column, my eyes glaze over as though I am back in C.O.C.

Case in point. I had a patient last week who was an interesting looking little guy. 65 years old. First name: Latino. Last name: Asian. Not a common combination in my 'hood, but stranger unions have certainly happened. Skin was a little yellow looking, belly was really round. Maybe I should have picked up on that, but if I stopped to really consider every weird-looking, rotund patient who crosses my path, I would have no time to peruse the internet for Sigersons and flattering Theory trousers.

My patient also had a very chatty wife who accompanied him to his physical and freqently interjected her own tales of health woes throughout his exam. NewFNP can only handle so many distractions and annoying chatty wife was throwing me off my game.

Long story short, Mr. Latino Asian likes to drink. Hell, newFNP likes to drink, but not like this guy! I drew his labs and got this, amongst many other abnormal values, back:

Albumin 2.6 (3.8-5.0) So - low, right?
Bilirubin 6.5 (0.1 - 1.5) Let's call that one 'elevated.'
AST 113 (1-45) Remember - Alcohol, Statins, Tylenol
ALT 56 (1-55) Ding ding! Most normal lab value goes to ALT!!

Another provider took a nano-second glance at the labs and said "Oh, AST 2 times the ALT is pathognomonic for alcoholism." She then glanced at him and said, "He is clearly cirrhotic." He is??? Well, shit. If I would have known it was so obvious...

The problem is that many things need to be so flagrantly obvious. Your blood pressure 210/105? Buddy, you are one hypertensive motherfucker. Blood sugar in the 600's? I'll lay my money on diabetes.

But other seemingly obvious diagnoses escape me, to say nothing of the not-so obvious diagnoses.

On the bright side, I really feel like I have my charting/prescription signature nailed.

"I" statements

We are all taught to speak to patients in "I" statements, especially when confronting something that is potentially uncomfortable. This may include, "I notice that you have bruises in the shape of fingers" or "I see that you weigh 498 pounds" or "I can see that you are upset by your gonorrhea infection and need for a painful Rocephin injection."

However, sometimes newFNP's "I" statements escape her. This week, it was because I wasn't sure what I was (not) seeing and feeling. When I was in school, I had a similar experience in which a patient, upon whom I was gearing up to perform a DRE, assumed the position, thereby exposing her tail. "I see you have a shaggy tail. Has that always been there?" No, no - I didn't say that, but any sensitive statement I may have been able to come up with was vanquished by the magnitude of my shock. Why didn't they tell me in Advanced Health Assessment that I may happen upon a tail? I was ill-prepared.

I was also ill-prepared for my 36-year old father of three with tiny, hard testicles as well. Now, although newFNP does not possess said equipment, she has once or twice been familiar with those who do *and* has seen enough in the clinical context to know that they should be more like matzo balls than walnuts. So, what was I to say?

"I notice that your testicles are like raisins. Were they ever prune-like?"

"I feel that your testicles are firm like marbles... and not much bigger. Were they ever more like Everlasting Gobstoppers - the big ones?"

"I see that your testicles are essentially non-existant. Do you really have three children?"

See? It's hard to have good "I" statements on the fly. Part of the reason it was difficult is because I was uncomfortable telling this gent that his balls were weird. Is there a guy out there who wants to hear that? In Spanish. In my crappy-assed Spanish.

"Sus testiculos son demasiado locos." Bad, bad newFNP. Must learn sensitive Spanish!

May-December

In the spirit of "Shopgirl," in which a fresh, vibrant Claire Danes dates a geriatric Steve Martin, I offer this thought. It's not only the aging Hollywood set who enjoy a youthful romp with a partner half their age. Not at all. This week, a 76-year old patient told me that he had 10 children, the youngest of whom was an astonishing 5 years old. A quick mathematical calculation told me that his wife must not be his age. Yes, my patient's first wife died when she was 70. I don't think that the mourning period was a long one before he nabbed his currently 38-year old wife.

When I think of dating someone nearly 40 years my senior, I think of one thing and one thing only: money. Now, I could be wrong, but my sense is that this 38-year old woman is not rolling in an A8, nor is she sporting a Harry Winston, nor is she head to toe in D&G. But even if the hottest rich 70-year old in the world wanted to date me, he would still be 70. Whatever works for my patients is cool with me, but I am, quite frankly, grossed out by the thought of shagging a grandpa. Do you think she has to inject his hips with cortisone so that he can lay the sweet moves on her?

Guh-ross.