chouxpastry

If CBC is normal, I would generally not pursue additional testing to prove iron deficiency or GI blood loss. However, if a correlating BMP/Chem-7 demonstrates acute on chronic renal insufficiency along with hemoconcentration, then I would attempt re-hydration versus further testing. Serum iron is very fluctuant and thus unreliable. In general, an iron panel is a more comprehensive diagnostic indicator of iron deficiency. Occult fecal testing may be positive if patient has mildly symptomatic hemorrhoidal/local bleeding. Do you have other lab values on this patient? I would consider r/o cardiac, pulmonary, malignancy etx in light of patient's goals of care at 87 years.

Potassium does not have an opposing electrolyte to my understanding unlike Ca and P (and not necessary a definite inverse relationship either as acute kidney injury or superimposed acute imbalances can create exceptions)...kidney people please correct me if I'm wrong…I'm in GI . It's found in abundance within intracellular fluids versus Na+ which is found in much higher concentrations in extracellular fluids. Na-K pumps located on cellular membrane actively maintain this homeostatic electrical neutrality. IMO, posting medical questions on ANY forum should be taken with a grain of salt! I would hate to be caught quoting CoolDoc123 as my rationale for doing something...

While I am still a newbie, my greatest struggle so far has surprisingly been establishing my "place" within a hospital that's unfamiliar to the practice of PAs and NPs. Dare I even say the culture is somewhat hostile? In it remains an unfortunate hierarchical structure of physicians versus underlings (sadly not even an exaggeration as I am constantly mistaken for a doctor, and the palpable look of fear from those who address me as such is truly devastating). This is a marked departure from the comparatively NP-friendly institutions I trained in as a student, where despite being a student, I was still considered an able "colleague" who was expected to pull my weight in intellectual contribution. And while I could not give a hoot about what people think of my career and qualifications, it DOES hinder my work and development as a NP to be left out of 98% of the physician to physician conversations about patient cases. Believe it or not, these patients are mine, and I absolutely do need to know what's going on! Furthermore, I seem to be practicing in the last standing hospital within a tech-saturated metropolitan area that's stuck in the stone age of paper documentation, effectively leaving me perpetually cross-eyed in order to barely interpret medical hieroglyphics. To top it all off, being a shorter than short female who looks like a child does not help my cause. END RANT:mad: Nonetheless, despite the shortcomings and frustrations of being a NP, I absolutely love my job. While I would have loved to have the full and extensive 10+ year training of a physician, I simply could not afford the time or the money! Moreover, I am able to have a good work/life balance. I am not tied to my job, but still have the tremendous honor of assisting a sick person to health, or conversely, a dignified passing. And so to that I will push on, and continue to (un)pleasantly surprise physicians with questions about their (and MY) patients:)

I greatly appreciate those who have defended direct entry NPs on this thread as I am one myself. It saddens me a bit to read sweeping generalizations about direct entries and I want to offer my own POV:)...not everyone has the luxury of working as a nurse prior to becoming a NP. I absolutely loved my med-surg capstone rotation in nursing school, but graduated during a time when finding new grad RN work in the hospital was exceptionally difficult. Rather than let my school mode momentum fizzle, I decided to continue onto my master's. Once I began NP clinicals however, something clicked and I realized being a NP was my nursing niche (having the stature of a chihuahua but the mentality of a great dane generally does not work in my favor when I love being hands on for all of my patients). I currently work in an inpatient setting, and am doing well. I say this with much respect of those NPs with years of invaluable RN experience under their belts:)Hospitals tend to cast a more stringent eye towards their NPs than in the outpatient setting. Although I practice in a state with "collaborating relationships", the hospital where I am credentialed interchangeably treats PAs and NPs alike and places numerous limitations, including co-signatures for every admission, follow up, and discharge. Moreover, I am absolutely positive that if I ever exhibit continuous clinical incompetence, my supervising physicians will give me the boot! With regards to the OP, I do believe that hospital experience for outpatient cardiology NP is incredibly beneficial but not a be all end all to being successful. Telemetry, CVICU, or interventional cardiology experience will be extremely helpful I imagine. If you see the "worst", it will help you to anticipate outcomes for stable patients in the outpatient setting. Of course there are certain cardiovascular diseases in which symptoms would generally not manifest into high acuity situations, e.g. infrequent exercise-induced PVCs, but those can certainly be learned! I have seen many listings for strictly outpatient cardiology NPs so yes, I think it's definitely possible to do outpatient only. I would familiarize myself with 12-lead EKG interpretation and to know it like the back of my hand!

List of common medical issues in primary care probably varies with age group and population but it sounds like you have a lot of older adult pts...HTN, dyslipidemia, CAD, HF, COPD, URI, UTI, CKD, DM and its sequelae, dysphagia, GERD, chronic constipation, HBV, HCV, DJD, osteopenia/osteoporosis, gout, memory loss, dementia, Parkinson, TIA, CVA, DVT, cancer screening, anemia, weight loss/failure to thrive, hypothyroid, BPH, fatigue, insomnia, depression, anxiety, falls...this list goes on but this is what immediately comes to mind from what i can recall from my internal medicine preceptorship that was gerontology heavy. List of common tests to order in association with the medical condition common lab tests: cbc w/ diff; cmp or chem-14 for kidney and liver function, fasting glucose; u/a +/- culture for infection, glucosuria and proteinuria; lipid panel to crack down on that LDL; TSH bc thyroid disorder (esp hypo) covers a wealth of different symptoms. for primary care, i would def keep in mind preventative care stuff like what populations to screen for breast ca, colon ca, T2DM, osteoporosis, etc. also, when to refer to specialists or hospital admission. List of commonly prescribed medications, dosages, length of treatment too long to expound on...but i use the free version of epocrates for dosing unfamiliar rx and renal dosing. length of tx depends on the outcome you anticipate, e.g. longer and stronger course of abx for a pt with multiple co-morbidities Medications to avoid for the elderly with chronic medical conditions and co-morbidities again too long to expound on but in general, i always avoid rx w/ CNS and anticholinergic effects bc elderly are more sensitive Medications to avoid in elderly with chronic kidney disease risk and benefit analysis is more important imo. but def chronic NSAIDs (tylenol, tramadol are better for DJD pain. can consider more potent drugs via pain specialist or topical/PO narcotics depending on situation). in general, most elderly have some degree of renal insufficiency bc GFR is partially based on age. most CKD pts stay within stage III and never advance to ESRD. that being said, make sure any long term rx you prescribe are not known to be nephrotoxic and if so to frequently check kidney function and discontinue offending agent that appears to be causing acute on chronic kidney injury! Medication to avoid in patients with diabetes again risk and benefit analysis is more important imo. there are many rx that cause hyper- or hypoglycemia...prednisone/steroids (esp long term), beta blockers, and nephrotoxic agents (e.g. chronic NSAIDs, abx, etc). Other pearls i've learned along the way: -anemia: is not a normal consequence of aging! it always irks me when a pcp defaults to supplemental iron w/o a proper w/u! -GERD that is only partially responsive to high dose PPI therapy needs a referral, i.e. for an EGD (esp to r/o Barrett's/malignancy). -CHADS2 or CHA2DS2-VASc score your elderly with afib for proper CVA prophylaxis. strokes are awful and you should minimize one's risk. on the other hand, consider conservative therapy for a fall risk pt. hemorrhagic vs embolic CVA...sometimes you are stuck between a rock and a hard place with the elderly :/ -involuntary weight loss is not normal. CA should be on the top of your suspicion list. -simplify med regimes for the elderly as much as possible. personally i hate uptodate (though i do use it from time to time). when it comes to 15 min per complicated pt, i don't have the luxury to scroll down a ten pg document. but to each their own and whatever works:D! i would pick a reliable source and stick to it to avoid being overwhelmed. lastly, i do somewhat agree with bostonfnp's comment. if you are in an unsupportive environment as a novice practitioner, i would be very wary...for your own safety as well as your patient's! just my opinion as a novice myself:)

I'm sorry to hear about your sitch! I totally agree with the above about sticking it out for a few more months before job searching again. First, working 50-60 hours/week is not okay...unless your salary accounts for these "unpaid" hours. Others may disagree, but my work is quality and it's not up for charity unless I say it is. However, I do believe that the hours issue is loosely linked to your current "training wheels" situation...being that the more independent you are, the more leverage you simultaneously acquire. A seasoned PA I'm working with suggested that I periodically seek performance evals with my attending physician(s) and specify goals I have reached as well as current areas of weakness. This way my supervising physician(s) can "tangibly" assess my progress. I'm not sure if your institution allows for adjustments in your role, but I truly believe that regardless, routine communication with my supervisors is important. It doesn't have to be long and drawn out or pestering and incessant, just brisk, confident, and routine conversation. I also love the suggestions made by traumasrus. The financial ineffectiveness of not allowing you to see your own patients is real!

the cardiology position sounds so awesome! it looks like you are going to learn A LOT. if i were in your shoes, i think i would express interest in joining but meanwhile continue to interview just in case an offer does not pan out. i'm sorry to hear about your new grad interviewing experiences...i'm a new grad and share your pain!

BCgradnurse: yes, that is exactly my dilemma. i always tell loved ones "at the end of the day, work is just work" but have a hard time applying this to real life! i also understand and agree with your assessment - my FNP program did not dip at all into acute care (which i find unfortunate given diseases do not compartmentalize themselves into in- and outpatient). and while i was fortunate to briefly precept in an inpatient setting + select subspecialties, i will certainly admit that i am not trained for acute care. however...i took an immediate liking to acute care as a NP student, and am convinced this is what i want to do. but we'll see in several months time whether this remains my opinion...

i too am a new FNP grad in CA, and my personal experiences differ from the above posts. there are abundant family practice jobs in both metropolitan areas and non. employers are also more than willing to train new grads. RN experience is of tremendous value, but having little to no experience is by no means a deal breaker. the major caveat is that you have to commit your due diligence to applying and following up with job applications. a CV that portrays a healthy array of NP skills and knowledge demonstrates your future potential as a productive employee (e.g. laceration repair, 12-lead EKG interpretation, etc.). living in TX may further be another barrier, but i have no experience with applying out of state. i would definitely first apply for CA licensure and then consider relocating to CA even prior to finding a job...but again this is just what i imagine. just wanted to jump in and offer my two cents! please don't give up if your daydream is actually your life dream :) also, us californians are, contrary to hollywood portrayal, not as mean as we look

i do not work in ortho but was recently about to go into spinal...I unfortunately only have suggestions for *free* resources as this quest was short-lived. Here is what I found... youtube: sounds questionable but there are a lot of really good videos on musculoskeletal anatomy, surgical procedures, suturing, etc. podcast: learningradiology - general radiograph interpretation. app: night at the ED - CT imaging. case study format. coursera: medical neuroscience by duke, clinical neurology by ucsf, anatomy of the upper limb by upenn. im sure there are waaaay more you can find with further research. at the very least the above suggestions are free😛 what area of ortho are you looking into?

thank you for your concerns everyone! while the salary is a great bonus, it is not my main reason for going with one job or the other. i will be doing only hospitalist coverage until I am ready to take on more. in any case I am still weighing my choices but for now more i am more inclined to sacrifice a little quality of life for a cool(er) job. the process of composing these posts is incredibly helpful to my decision making.

carachel2 and atomicwoman: family... good question about a training program. no formal program from either sides altho spinal and gi have both worked with new grads PAs/NPs and the intensivist currently works with physician residents. both sides expect about six months of training before I even begin being somewhat productive. juan de la cruz: thanks for the info. I will likely do a post cert if this case. thank you all for your input. I had serious career fear of missing out after writing this post and will likely go with the icu offer. hip brunches and latte art can certainly wait. should probably hit the books now...

Yes I did an entry level masters! Incidentally I wanted to work as a RN in the hospital first but knowing myself I would likely lose the momentum to stop work and finish school. I did do a bit of home health as it was conducive to school but once I started clinicals I decided to stop working all together and just focus on school/clinicals. I have received concerned looks from potential employers but I do not regret my decision (I treated those student hours like I was getting paid!). About a third to half of my classmates are working at the places they precepted so that's a wonderful route to go. I have personally chosen to relocate and while it has taken patience and time to receive interviews not all has been lost! Good luck to you! And congrats on getting your RN!!

hi everyone, i have a career dilemma - I'm a new grad np who was offered the option of part time GI (primarily inpatient) and part time spinal ortho (both clinic and OR) in the city versus full time intensivist in a more rural area 1.5 hrs away from home. the personal benefit of the former is close proximity to family, friends, and the city (I am definitely a city girl). while the latter is a dream job that not to mention is offering >1.5x the income plus benefits so I don't have to finagle the minimum from the part time positions at this point I am leaning toward the former, but a part of me doesn't want to walk away from the job I eventually want. I like that specialties give me a more minute understanding of disease mgmt. but I also feel that the icu will give me an extensive crash course in most of inpatient work. there are other smaller nit picky issues I have with each side but it basically boils down to the dilemma of jobs I like but aren't crazy about in a geographically desirable area versus job I would love in geographically undesireable area. if theoretically I were to eventually go from gi+ortho to say icu would that be laughable? or would I be able to find someone (in the city) who is willing to train given I have at least some inpatient np experience? and fyi I am a new grad family np with no hospital RN experience... i am incredibly blessed to stumble upon both opportunities given my gross under qualifications in all aforementioned fields so this is like a "first world problem" in the nursing world (and literal actual world as well) but I would much appreciate any advice. thanks so much!!!

dude i'm looking to eventually work inpatient as well! except i have no RN experience... fyi, stanford is consolidating its brand and umbrellas both its university system as well as affiliated physicians/groups throughout the bay...the latter is spread throughout the east and south bay (SF and the greater peninsula are a separate unreachable territory). your local silicon valley and alameda/contra costa CANP chapters are another way to potentially bypass the HR wall via members who present job openings at meetings. to answer your question, i am doing both...although tbh much less applications to hospitals due to this irrational fear of rejection...

goodness would i love to start at 120K...and yes, these offers are from private practice (general and specialties both). i had the privilege of interviewing with a local university system and the benefits were unrivaled. it appears that private practices just cannot afford to pay NPs competitively. of course, ultimately, i can't generalize this observation for every NP position opening in the bay so best of luck, OP!

bayareaFNPstud: i too am a new grad FNP looking to relocate to the bay. in my recent experience, i have yet to come across a proposed salary exceeding six figures (w/e county positions). under no intention to start a gender debate, these are my experiences as a female new grad. in any case, i was told by a provider recruiter that the high desirability of the bay area keeps salaries low due to high competition. whether this is true or not, i do not know. i have also noticed that the health care market (i.e. dominant medical groups and their resulting local hold) in SF differs from the remaining bay area. to remedy the living expense dilemma (if that is the case for you) there are also opportunities east and north of the bay (e.g. stockton) - which i have certainly considered.

thanks for the reply, coast2coast :) and sorry for my late reply, I completely missed your post. It appears that you have quite some insight into the SoCal np market. I would love to pm you about this topic if that's ok with you :)

i tried to maximize my NP clinical hours and took advantage as much opportunities as i could while in school. none of my interviewers have considered my lack of RN experience to be an insurmountable disadvantage. they have simply acknowledged it and later discussed the extra training i may require. these offers are not for new grad programs (i don't believe there are many "new grad NP programs" out there although i have seen some schools/hospitals offer NP residencies/fellowships in various sub-specialties). i clearly convey my new grad status prior and during every interview. i don't know how to explain it very well but the RN vs. NP job hunt/training process are each quite different. the opportunities for NPs are abundant, and the more related experiences you have, the more these doors will open for you. i hope that kind of answered your questions :)

hi Tina N. :) i would like to echo the sentiment that the new grad FNP job market is a lot more welcoming than the new grad RN market. in CA, the demand for FNPs is high (i see new job listings every week), and i do not believe this will dramatically change in the next few years. in my experience, it paid off to work as little as possible during NP school. i am encountering multiple job offers even prior to graduation, and i attribute 70% of this to extensive student clinical experiences. of course, if finances do not permit (as you have mentioned) and/or you can capably juggle NP school, a RN job, personal dealings, etc...the aforementioned advice need not apply! you can be extremely successful in this scenario as well - and not to mention stave off some debt! i shared the EXACT doubts you shared in your OP, but i've come to believe that in the medical field you reap what you sow. to augment marketability and probability of attaining a job, i highly recommend having extensive clinical experiences and acquiring a strong knowledge base during NP school. preceptors will sense your commitment and be more than willing to support you. don't worry! you will be fine :)

thank you for the recommendation. i will keep this in mind when the time comes :)

bostonFNP, with all due respect, unfortunately many NP programs do not have adequate resources to provide structured rotations or specific skills training to their students. the state i will certify in also does not bar primary-care trained NPs to work in an inpatient setting. that being said, it would be criminal for a NP to perform unsupervised care in an area he/she is inadequately prepared for.

thanks, alicia! i have seen a PA's resume describe each of her clinical rotations in the manner you described :) i think i'll have two different copies on hand with one providing more info on the exact procedures/skills i've acquired from my rotation. thank you again!!

ExpensiveBSN: there are one-year post-cert programs as well :) i just mentioned ucla b/c you mentioned being from southern california. and i will be taking the exact advice i provided in a previous post - make connections, get experience, study, and likely complete a post-certification program in the future :) IBSavn: thank you so much for your insight! i hail from california, and from the job listings i've seen...true inpatient jobs appear to come from within - the exception being more rurally-located institutions willing to train. it's good to know about MD as well. are there many states in the east coast that allow only acute-trained NPs to work inpatient? which ones are they (if you don't mind naming a few)? the two programs are definitely night and day like you stated. i am absolutely clueless as to what goes on when a patient is admitted (unfortunately no RN experience under my belt either), much less how to interpret x-rays, perform skilled procedures, etc. having only primary care training is imo even disadvantageous in the primary care/outpatient setting (e.g. ordering the appropriate follow-up testing in a post-hospital visit). however, self-study of acute care med is a daunting hill to climb with only a primary care background. i am definitely considering post-certification!

hi expensiveBSN :) i am also a FNP student with a strong preference for inpatient (or combined outpatient and inpatient) experience upon graduation. as bostonfnp has answered, a post-certification in acute cute medicine would be the most direct way to gain both academic and clinical experience in inpatient medicine (p.s., ucla offers exactly this - albeit a two-year program). and as bostonfnp has mentioned, these classes will not be redundant. your clinical focus will be on acute care disease management. if there is redundancy, it will be because the nature of medicine is continuous vs. repetitive curriculum. in the meantime, i might suggest getting hands-on experience with an appropriate acute care provider. acute care medicine is a big field and further exploration may help sort out your specific speciality of interest. with regards to supplemental learning material, i snooped a bit on med student/physician forums to find recommendations in the fields i was interested in. you will find an abundance of classic paperweights, board review books, podcasts, etc with just a quick search. for example, there are several well-crafted podcasts devoted entirely to the subject of emergency medicine (e.g., smart em, em basic). a good resource to have on hand is a copy of either cecil's or harrison's. an icu job may be difficult to get without a formal acute care certification - so minimally get some student experience before you graduate. these have just been my meager experiences as a student, but i hope they help. i'm in the same boat!