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.

News Flash

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

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

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

Psych!

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

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

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

"No," she responded.

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

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

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

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

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

"No."

"Some #4s??" she tried.

"No."

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

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

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

Booze Clues

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

She hasn't seen much improvement.

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

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

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

And he still doesn't have insurance.

Bad Mojo

NewFNP has had one hell of a week and, if she is not mistaken, it is merely Wednesday.

Not that newFNP is overly superstitious, but she finds that the first patient of the day can sometimes set the tone for the rest of the day. And are stars aligned - or misaligned or crossed or something - because newFNP's first patients have been outliers, each and every one of them.

Monday's first patient was a run of the mill IUD insertion and things were sailing along as smoothly as ever. The tenaculum was at 10-&-2 and the Mirena's arms were released when the speculum went AWOL. It settled on the still intact tenaculum while newFNP's MA nearly infarcted. NewFNP should damned well know better but this tends to happen with overweight ladies and this patient was only slightly overweight. NewFNP removed the IUD and blindly attempted to remove the engaged tenaculum. If you have never tried this before, it's a task not as easily completed as one might like. Fortunately, the repeat placement went much more smoothly than the initial in no small part thanks to newFNP's MA keeping the speculum in its desired location.

At least Monday's patient was in the clinic when the situation went down. It is important to have a little background on newFNP prior to hearing about Tuesday. NewFNP is chronically early and is therefore in clinic thirty minutes prior to any other provider. So when a patient who had been standing outside waiting to be seen began seizing in line, newFNP was the only provider on the scene. The ambulance and firetruck had come and gone before the clinic was actually even open for business. And thirty-one patients later, newFNP went home.

And finally, this morning our clinic nurse brought a slurring patient to newFNP's attention. According to the patient, her methadone dose was increased yesterday. It took longer than necessary to elicit this information as the patient was nodding off during the subjective component of the interaction. She denied all drug use which may be the case but people may overdose on methadone and a good place to OD is in the hospital where there are doses of Narcan and ER physicians and IVs. Furthermore, her asthma was uncontrolled. Further-furthermore, she was six months pregnant. NewFNP put her on oxygen and a nebulizer and again invited the paramedics to the clinic.

Please. Please. Tomorrow. Let tomorrow be easy. Super frigging easy.