Resources for primary care NP

Dranger · May 6, 2015

Common meds to avoid with CKD:

http://www.unckidneycenter.org/patiented/Chronic%20Kidney%20Disease%20and%20Medicines.pdf

Obviously with antibiotics make renal dosing changes. This should be in most pharm books or clarify with pharmacy

Fnpatlast · May 6, 2015

Awesome Dranger! This is the type of resources I need. Thank you. I'm looking for more. It's hard to think when I have a waiting room full of patients and mind is blank.

Dranger · May 6, 2015

Pocket medicine primary care is a great resource for common dx and treatments, read the reviews.

Pocket Primary Care (Pocket Notebook Series): 9781451128260: Medicine & Health Science Books @ Amazon.com

I would invest in Epocrates or Uptodate if your employer has it

allnurses Guide · May 7, 2015

I just started a full time job as a primary care NP in an outpatient clinic a week ago. As soon as I was shown my office and logged on the computer. I was told my first was ready to see me. There's little to know guidance from anyone. I feel so lost.
I need several resources:
List of common medical issues in primary care
List of common tests to order in association with the medical condition
List of commonly prescribed medications, dosages, length of treatment
Medications to avoid for the elderly with chronic medical conditions and co-morbidities
Medications to avoid in elderly with chronic kidney disease
Medication to avoid in patients with diabetes
Best medication for the cold, muscle pain, skin rash, dry skin,
and the list goes on....
I am using my school notes and resources but having a list at the tip of my fingers will help a great deal.
In addition to navigating through a complex electronic medical record, not knowing what tests to order or prescribe just make me want to pack my bag and quit.
I just ordered 5 minute clinical consult for rush delivery.
I appreciate your help, advice, tips.

I am shocked you were able to graduate without at least knowing what resources to use to find the answers to most of these questions. This is very basic pre-entry to practice information.

If you truly have no support in your current practice you should find a new job as you are in a dangerous place.

A few suggestions:

1. Buy the Buttaro text for Primary Care A Collaborative Practice. It covers all the common diagnoses and includes workups, differentials, and treatment as well as when to refer.

2. Invest in UpToDate, or at least LexiComp for a good pharmaceutical reference.

3. Print out a copy of Beers Criteria drugs for the elderly.

In all honesty if you don't know diagnostics and treatments for very common diagnoses then you are at an unsafe level for practice and getting out of that situation will protect your license and your career as well as your patients.

Sent from my iPhone.

Fnpatlast · May 7, 2015

Please let's be mindful of our choice of words as we encourage one another on this forum. I couldn't have passed AACC without knowing the basics of disease management. I'm requesting for a list of resources with readily available information for a novice practitioner. I do have uptodate and micromedex attached to my EHR. If I can't open up and disclose some of my fears on this forum, where can I turn? If you have no positive comments, then don't respond to my request. The last thing I need is a forum with no support!

Fnpatlast · May 7, 2015

Thanks Dranger, I look this up as well. Thanks for your help.

chouxpastry · May 7, 2015

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:)

Fnpatlast · May 7, 2015

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:)

Thanks for taking the time to provide these tips. It all ties in well with what I learned in school and quite applicable to my current patient population. My collaborating is currently on vacation. I hope she'll be more supportive when she returns. In the meantime I'll do my home work and gather as much resources on my fingertips.

I agree browsing through uptodate is very time consuming when you have other patients waiting. But I do use it as a reference. Currently I see about 6 patients/day. They allotted 1 hour for each patient until I get used to the computer system. This is the time for me to do my own research. I'm determined to stay at this clinic and excel in primary care.

Barnstormin' PMHNP · May 7, 2015

I am still a grad student, but I have useddifferent apps and Up to Date and Epocrates and they are both cumbersome. Look at Unbound Medicine | Medical & Nursing Apps for iPad, iPhone, Android they have many excellent apps, the drug guide is one of the most clearly organized I have seen. They also have Bates assessment and numerous others that may help you. I recommend a book, "Symptom to diagnosis", by Lange. It has the most common scenarios, differentials, tests, and meds in a very concise format, this is a great reference. Also invaluable, "Advanced health assessment and clinical diagnosis in primary care" by Dains, Baumann, and Schleibel. They pretty much walk you through everything

Best wishes.

allnurses Guide · May 7, 2015

Please let's be mindful of our choice of words as we encourage one another on this forum. I couldn't have passed AACC without knowing the basics of disease management. I'm requesting for a list of resources with readily available information for a novice practitioner. I do have uptodate and micromedex attached to my EHR. If I can't open up and disclose some of my fears on this forum, where can I turn? If you have no positive comments, then don't respond to my request. The last thing I need is a forum with no support!

First off, I provided you with some good resources that you requested.

It is not out job to be blindly encouraging or blindly supportive, as blunt as I may have been, it just might be the best advice you get as a novice provider. Being in a dangerous practice environment puts your license and future career in jeopardy.

It is absolutely a good thing that you posted with your concerns and are taking steps to improve your practice. I have suggested some good resources that cover epidemiology, clinical presentation, differential diagnosis, appropriate diagnostics, and appropriate treatment.

Remember that in practice nothing is black-and-white and that general lists and treatments don't work for every patient, plus you need to be sure your diagnosis is accurate in the first place.

Fnpatlast · May 8, 2015

Thanks brainstorming RN, I will look up the resources you provided. I do have another Lange book for primary care which I'm using for reference. The more resources I have the better.