Real World NP – Details, episodes & analysis

In this conversation, Liz Rohr interviews Jennifer Carlquist, a physician assistant with extensive experience in cardiology, who discusses the assessment and management of chest pain.

They covered: 

- Assessing cardiac versus noncardiac chest pain

- Assessing risk for MI and when to send patients to the ED or not

- What EKG findings to watch out for, and how to learn more to build your ekg reading confidence (and what’s new!)

- What we can do for patients to assess and manage heart disease risk, including labs and tests to check in primary care (including the coronary calcium score, LPa, and homocysteine)

- How to communicate and collaborate effectively with ER providers

- Further resources to learn if you’re in cardiology or interested in making the switch from primary care

Takeaways

- Consider both cardiac and non-cardiac causes of chest pain, especially in female patients with atypical symptoms.

- Take a detailed history, including risk factors and family history, and be aware of red flags that may indicate a more serious condition.

- Recognize the limitations of certain diagnostic tests, such as EKGs and troponin levels, and consider a CTA with FFR for outpatient testing.

- Collaboration between primary care providers and the ER is crucial, and concise reporting of findings is key to effective communication.

- Differentiating between hyperkalemia T-waves and hyperacute T-waves can be challenging, but hyperkalemia T-waves are pointy and hyperacute T-waves are more blunted and broad-based.

- Inverted T-waves in leads other than AVR and V1, especially if they are symmetric, can indicate the need for urgent evaluation.

- Q-waves can form within an hour of an infarction, and a small Q-wave in lead III without other abnormalities may be a normal finding.

- When learning EKG interpretation, it is important to start with understanding what a normal EKG should look like and then focus on high-risk findings.

- Inflammation is a significant risk factor for heart disease, and non-traditional risk factors such as psoriasis and early menses should be considered.

- Lab tests such as the coronary calcium score, LPa, and homocysteine can provide valuable information in assessing heart disease risk.

- Magnesium supplementation can be beneficial for patients with palpitations and hypertension, but the specific type and dose should be tailored to the individual.

- Primary care providers play a crucial role in assessing heart disease risk and can collaborate with cardiologists to order appropriate tests and make informed decisions.

- The three-day EKG challenge and the Cardiology Fundamentals Mentorship program are valuable resources for learning and advancing in cardiology.

- The importance of fostering a supportive and collaborative environment in healthcare to provide the best care for patients.

For a full transcript and conversation chapters, visit the blog https://www.realworldnp.com/blog/assessing-chest-pain

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© 2024 Real World NP. For educational and informational purposes only, see https://www.realworldnp.com/disclaimer for full details.

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In this conversation, Liz Rohr and Shelby Pope discuss the importance of taking a comprehensive history of substance use, and how to assess and treat stimulant use disorder. They cover the challenges healthcare providers face in asking the right questions, and emphasize the need for open conversations and non-judgmental approaches.

They cover screening for addiction, how to elicit a substance use history, including types and routes of substance use. Shelby covers the mechanism of action of cocaine and methamphetamine in the brain, the withdrawal symptoms associated with stimulant use disorder, and the next steps for primary care providers in managing patients with stimulant use disorder. They also explore the use of psychosocial interventions and off-label pharmacologic treatments for stimulant use disorder.

Takeaways

• Open and non-judgmental conversations are essential when discussing substance use with patients.
• Screening practices, such as using screeners like PHQ-2, SBIRT, and DAST, can help identify substance misuse or struggles.
• Taking a comprehensive history of substance use, including the type, amount, frequency, and motivation, is crucial for providing appropriate care.
• Healthcare providers should be aware of the different routes of administration and the potential risks associated with each.
• Stimulant use disorder, particularly cocaine and methamphetamine use, can have significant adverse effects and poor outcomes. Cocaine and methamphetamine are both monoamine neurotransmitter reuptake inhibitors, increasing serotonin, norepinephrine, and dopamine levels in the brain.
• There is a withdrawal syndrome associated with stimulant use disorder, characterized by depression, fatigue, and sleep disturbances.
• In managing patients with stimulant use disorder, primary care providers should consider triage based on severity and acuity, and refer patients to appropriate resources such as rehab or the ER.
• Psychosocial interventions, such as cognitive behavioral therapy and contingency management, are the mainstay of treatment for stimulant use disorder.
• Off-label pharmacologic treatments for stimulant use disorder include mirtazapine, bupropion, injectable naltrexone, topiramate, and psychostimulants.
• It is important for healthcare providers to be aware of state regulations and their own comfort level in prescribing off-label medications for stimulant use disorder.

For a full transcript and conversation chapters, visit the blog: https://www.realworldnp.com/blog/treating-substance-use-disorder 

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© 2024 Real World NP. For educational and informational purposes only, see realworldnp.com/disclaimer for full details.

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Are you a nurse practitioner feeling lost, uncertain, or unfulfilled in your career? This raw, honest, and needed conversation with Amanda Guarniere, the founder of Resume RX, explores:

• The career challenges NPs are facing
• Alternative career paths many NPs are considering
• Changing power dynamics between employers and employees
• How to think about career changes and honor YOURSELF in the process

We dive into the growing concerns among NPs regarding stagnant wages, shifting power dynamics between employers and employees, and the desire for personal fulfillment beyond traditional clinical settings.

We chat about the rise of entrepreneurship, side hustles, and non-clinical roles that allow NPs to leverage their expertise and pursue their passions.

We encourage NPs to challenge societal expectations and professional scripts that may stop them from doing what they love.

If you liked this post, also check out:

• New Nurse Practitioner Survival Guide 
• New NP: Q&A - Is This Normal?
• Primary Care Nurse Practitioner Roundtable: How Are We Doing After Covid?

Timestamps:

00:00 - Introduction

02:45 - Practical Strategies on Navigating NP Clinical and Job Search

03:55 - Are Nurse Practitioners Okay?

05:25 - Dissatisfaction and Desperation Among NPs

07:55 - How Can ResumeRX and Real World NP Support NPs

12:39 - Personal Reflection on the Impact of COVID

13:29 - Challenges Faced By Nurse Practitioners

17:04 - Evolving Career Landscape for NPs

25:29 - NP Burnout

28:36 - Self-Judgment and Criticism 

34:35 - What’s The Next Best Thing

Read the blog post here.

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© 2023 Real World NP. For educational and informational purposes only, see realworldnp.com/disclaimer for full details.

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Dizziness alone accounts for about 5% of all primary care office visits in the US. 

5%! That's a huge number. 

But as a chief complaint, dizziness is somewhat nebulous. The causes of dizziness can run the gamut from annoying-but-benign to yikes-let's-get-you-to-the-ER. So how do you sift through all the possibilities and uncover what’s really going on with your patient? 

In Diagnostic Approach to Dizziness, we walk NPs through the basics of assessing patients who are experiencing dizziness. We talk about:

✅ The four buckets of ideologies that your patient’s dizziness might fall into 

✅ The critical patient history questions. (And why it's important to drill down on what patients mean when they say they're CONSTANTLY dizzy.) 

✅ The diagnostic steps and key physical tests to run (and how to do them in a not-scary way for your patients!)

🚩And the red flags you absolutely need to watch out for 

Read the blog post here.

Stressed about labs? Watch our free Top Three Mistakes New NPs Make Interpreting Labs training at realworldnp.com/training

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Back pain — it’s truly one of the most common issues you come across in primary care. That’s why you need to have your diagnostic approach to it down pat as a nurse practitioner. 

And the sooner you get comfortable diagnosing back pain in primary care, the sooner you’ll feel confident helping your patients on their road to recovery. 

In this week’s episode, we talk about why you should really take a triage-based approach to back pain — among other chief complaints — plus other hot takes on assessing back pain such as:

✅ Red flags that are critical — if sometimes tricky — to uncover when taking a patient history 

✅ Key tests to consider when you're doing a physical exam 

✅ Should you order imaging or further testing?  

✅ And how to advise patients and set expectations for recovery

Read the blog post here.

Stressed about labs? Watch our free training: 3 Mistakes New NPs Make Interpreting Labs for what to avoid and do instead at realworldnp.com/training

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It’s super common for new NPs — and experienced ones — to get anxious when encountering orthopedic complaints. 

It’s a conundrum — on one hand, it seems like it should be simple. After all, you can feel all the musculoskeletal body structures right there. 

But at the same time, there are so many (SO MANY!) nuances to each body part. And there’s a lot of ortho lingo to wrap your head around. 

That’s why it’s helpful to understand exactly what an orthopedic nurse practitioner does — and what that means for working in primary care.

So sit back and enjoy — this week, orthopedic nurse practitioner, Yessica Salazar, has stopped by to talk ortho with us...and left behind so many great clinical pearls that I just know will help you in your daily practice: 

✅ How to order knee X-rays the right way

✅ Her approach to medications for orthopedic complaints

✅ Non-invasive treatment options for patients 

Read the blog post here.

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Do you ever find yourself spending an ENTIRE 20-minute visit just getting a history?

And even with all that time, do you still leave the room feeling like you didn't even get the info you needed?

In this episode, I'm sharing my top tips for not only a FASTER history, but also a more accurate one — so you can take great care of your patients while saving time and, quite honestly, health care dollars.

You'll learn:

• My top tip to keep your patient visits moving
• Pitfalls of where you could be missing info (and how to ask questions to get the answers you're looking for)
• The most important question to ask to save you TONS of time in each visit

Read the blog post here.

Need more support? Check out the Lab Interpretation Crash Course for Nurse Practitioners

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Seeing "lower leg swelling" as the chief complaint for patients as a new nurse practitioner was incredibly stressful. What’s the best course of action? Should you give diuretics for symptom control? Is this something serious...or something totally ordinary?

I had a super interesting case the other week and knew immediately that I had to share it with you — and it was one that I actually got a double-check from my colleague on!

In this episode, you'll learn:

• The top DDXs - most common and red flags
• What important history questions to ask
• Two clinical pearls of patient histories
• Differential diagnoses
• How to manage patients in this common scenario - re: testing & treatment

Read the blog post here.

Need more support? Check out the Lab Interpretation Crash Course for Nurse Practitioners

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Urine microalbumin: you need to check it once a year for patients with diabetes. But interpreting the results — and knowing what to do with them! — can be tricky. 

In this episode, you’ll learn:

• When to order urine microalbumin labs
• How to interpret the results and what to do with them
• How to treat abnormal levels
• 4 steps to elevated microalbumin management

Read the blog post here.

Need more support? Check out the Lab Interpretation Crash Course for Nurse Practitioners

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I saw a meme recently that compared hyponatremia to folding a fitted sheet— you can watch a million videos on how to do it, but in the end you'll probably just crumple it up and hope you never have to deal with it again. 🤯

Luckily in primary care low sodium is easier to deal with outpatient, and doesn't have to be super complicated. In this episode, I talk about low sodium, which is one of the top abnormal labs in primary care.

Hyponatremia involves understanding kidney function, but I've broken it down into the simplest, clearest, most digestible way to give you the most helpful insight to take into your practice. I'll bring you through the step-by-step process to implement for the vast majority of patients you'll see, and if you need to go down the rabbit hole of workup further, you'll have the tools to do so!

You'll learn:

• How to know when your patient needs to go to the ER, and when you can work them up outpatient
• The simplest way to remember low sodium
• The #1 lab you should always think of when you see low sodium
• How to know if your patient needs IV fluid (or if that'd be the worst possible thing to do for them)

Read the blog post here.

Want more lab goodies? Check out the Lab Interpretation Crash Course for Nurse Practitioners

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