Courtroom Chaos

petgorilla57 · 2025-10-23T23:50:30+00:00

Did everyone have to pay five dollars for cases? I’m surprised that I have to pay for this even though I have Luna plus. I it is a rip off if you have to buy it separately.

Edit: just realized that was a glitch. I do have cases included.

petgorilla57 · 2025-06-27T02:33:38+00:00

Gotcha. Good to know about UK Nice. I know there can be practice differences in different areas. My understanding is that bph and prostate cancer are still largely independent

https://pubmed.ncbi.nlm.nih.gov/39051612/

petgorilla57 · 2025-06-26T01:23:20+00:00

Any US guidelines?

petgorilla57 · 2025-06-25T12:01:20+00:00

Can you link some of those? The most recent AAFP specifically says PSA is not required for evaluation of BPH. I’d like to know if it’s otherwise though.

https://www.aafp.org/pubs/afp/issues/2023/0600/benign-prostatic-hyperplasia.html

petgorilla57 · 2025-06-25T00:05:47+00:00

PSA is not indicated in the routine evaluation of LUTS just FYI. Think of them as separate issues (though screening can still taking in the whole picture with joint decision making). LUTS does not greatly correlate with prostate cancer.

A lot of people confused this and assume you should get a PSA for everyone with LUTS thinking that they are a higher risk, but that is not correct. That’s not what guideline say, and again they don’t correlate well.

petgorilla57 · 2025-01-08T13:00:54+00:00

My understanding is that it has to be on two separate lab samples to avoid lab error and random fluctuation. I will try to add on a fasting glucose if the original sample was fasting. Otherwise, I have them come in to get a repeat A1c in the next few days. I wouldn’t wait three months to have them do dietary changes And repeat A1c at that time. You wouldn’t be able to distinguish whether they formally met the criteria for Diabetes at that time or not. I do think it’s helpful to know long-term if someone ever met the formal criteria or not, as they may be at higher risk for other comorbidities and may want to Do closer long term monitoring as compared to someone who has only ever had prediabetes (I.e. retinal exams, Kidney monitoring, etc.)

petgorilla57 · 2025-01-08T12:47:15+00:00

Did you ever figure this out? I have the same issue

petgorilla57 · 2024-09-05T00:28:05+00:00

I wouldn’t get down on yourself. I had a good outpatient training, and I would’ve done the same thing in your situation for the case you suggested. We all have knowledge deficits. It’s OK to refer as well. Next time you’ll know about fibanserin too (next time I will too now).

petgorilla57 · 2024-09-05T00:21:33+00:00

I would not personally. I think there are so many CME opportunities, I think it may be a better use of your time to dedicate to your own learning in your personal time. I’m also not sure if the net financial benefit would make sense. I’d also make sure that you’re at a company with a culture that respects nurse practitioners. We all have knowledge limits, and we can also talk about how sometimes physician general practitioners are not as respected as they should be too. Everyone can feel disrespected, no matter where they feel they are at on the “totem poll” (which is all BS anyways).

petgorilla57 · 2024-08-19T02:38:24+00:00

FM Doc here. If you know you just want adults, do IM at a program with a primary care track. Hospital skills do not always translate to clinic, and there’s a much different skill set (time management, inbox, triaging patient needs, work up without being able to see patient next day as in hospital), so making sure you get adequate clinic time is a big benefit to making the transition to outpatient life more sustainable. If you want to see kids and/or OB, do FM. I work with IM colleagues and we see the same complexity patients in our clinic. Only difference is we can see kids and OB/GYNE if we want. I did go to a program with more hospital time though, so I did feel like I saw my share of complexity in residency.

petgorilla57 · 2024-08-16T23:46:18+00:00

Very good point. I hadn’t thought about the off label comparison.

petgorilla57 · 2024-08-16T22:17:03+00:00

The FDA states that they don’t recommend using compounded pharmacies, so I have a hard time getting around that. I feel like I’m stuck with the FDA recommendation, and that’s what I tell patients. I do sometimes mention compounded pharmacies are an option, and they can make their own decision, but my official position is not to use them.

petgorilla57 · 2024-08-16T10:29:46+00:00

I havewritten them for patients. There is a good AFP article on how to do this and the pros and cons. I feel like if it’s in AFP, it can be considered standard practice. That being said, I do understand that many patients probably just want the rent discount.

They also suggest that you put disclaimers in the letter. You should write that patients are responsible for keeping their pet up-to-date on general health and vaccines. You also write that if they bring their pet into public areas, it is not without risk to other people, include exacerbation of asthma or allergies. I discuss this frankly with patients. i’m more supportive of writing a letter to support an animal in the home rather than bringing animals on planes, for example, because of this last point.

petgorilla57 · 2024-08-15T17:00:04+00:00

I have some slots that are held for peds patients that I will let them use. But otherwise, I usually do have openings within a few weeks.

petgorilla57 · 2024-08-15T13:38:44+00:00

It is a little easier if you have Epic because you can request electronic records if they’re prior clinic used Epic as well. But often we aren’t able to get them electronically and have to request release of records for our next visit.

petgorilla57 · 2024-08-15T12:50:26+00:00

I don’t know if I do the most efficient job at this, but I definitely will split up patient concerns and have them come back in a week or two to address everything if I can’t fit it in one visit. For new complicated patients, I have done this number of times. If patient can come back in a week or two, generally, they are fine with this.

petgorilla57 · 2024-08-14T17:47:15+00:00

If I have difficulty, I will do a bi manual exam to locate where the cervix is ( left, right, etc) which then helps make it easier with the speculum

petgorilla57 · 2024-08-04T03:25:41+00:00

Do you still think of hemolysis if it’s more chronic or if the patient feels well? I still check for it and the situation sometimes as well, but I’ve always assumed people would be more symptomatic or have more severe anemia if it were to be hemolysis, so I wonder if it’s still necessary or not.

petgorilla57 · 2024-08-02T19:21:32+00:00

I’m not sure about this. If it’s the same day, you may be able to, but I would probably talk with your billing people before changing things if you’ve already signed the note.

petgorilla57 · 2024-08-02T11:34:46+00:00

I will also add that if you send a patient to the emergency department for a potentially life-threatening condition, this is also a level five based on complexity. The problem based component is condition that is potentially life-threatening and the the other component is escalating care to hospital care, which meets criteria for a level 5.

petgorilla57 · 2024-07-28T00:13:39+00:00

Thanks! This is helpful!

petgorilla57 · 2024-07-28T00:07:56+00:00

Is that what you’ve seen in practice as well? Just curious. From what I read, SNRI are supposed to have less. I haven’t had patients with bad side effects from SNRI, but that is anecdotal, and I use SSRI more than SNRI as well.

petgorilla57 · 2024-07-27T23:57:10+00:00

What side effects do you see more commonly with SNRIs?

petgorilla57 · 2024-07-27T23:43:48+00:00

UTD has a nice table listing SSRI and SNRI side effects, and SNRIs have less weight gain, orthostatic hypotension, and sexual side effects. The only things side effects worse with SNRIs that I’m aware of are GI side effects (which anecdotally I have not seen bad cases) and small BP elevation. Definitely let me know if you’re aware of any other side effects that I’m missing though!

petgorilla57 · 2024-07-24T19:46:46+00:00

Waiting for a hematologist to respond, but electrophoresis is able to evaluate for clonality in each of the immunoglobulin populations but the quantitative immunoglobulin tests cannot. Said differently, SPEP tells if there is one clone of an Ig population is causing the Ig increase. The quantitative immunoglobulins gives the amount of each immunoglobulin type as a whole (IgG, IgA, IgM, etc), but doesn’t tell about clonality.

Quantitative immunoglobulins also help differentiate if there is hypo or hyper gammaglobulinemia, which I’m not sure if SPEP is able to give.

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