[NP-Clinical] Re: Trigeminy, PVCs
Carla Anderson
carla_rayne at yahoo.com
Sun Jan 7 13:13:27 PST 2007
Excellent info about including bulimia in the differential dx for this arrhythmia! I appreciate that Tracy. Carla Anderson, FNP/Portland, OR
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Today's Topics:
1. Re:trigeminy, PVC's (Tracy Klein)
2. RE: Re:trigeminy, PVC's (Priscilla Merrill)
3. Re: [ACC-Circle] More on ear problems (Christine Smith)
4. Methacholine challenge test? (Christine Smith)
5. ENT expertise on Eustachian Tube Dysfunction (Christine Smith)
6. RE: Methacholine challenge test? (shuyer at mindspring.com)
----------------------------------------------------------------------
Message: 1
Date: Sun, 7 Jan 2007 10:58:26 -0800 (PST)
From: Tracy Klein
Subject: [NP-Clinical] Re:trigeminy, PVC's
To: np-clinical at nurse.net
Message-ID: <111591.34822.qm at web54208.mail.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1
Did you mention heart rate? Orthostatics? Lytes? Even
though this woman was described as "normal weight"
this was a not infrequent presentation of my eating
disorder patients. And, of course, bulimics can be of
normal weight and usually are. If the patient was
orthostatic, if heartrate was below 50 (hard to tell,
I know, with trigeminy), if I saw anything in my oral
exam to make me concerned, I would strongly consider
it in my differential. It was self correcting with
nutritional rebalancing and hydration.
Tracy Klein, WHCNP, FNP
Portland, Oregon
------------------------------
Message: 2
Date: Sun, 7 Jan 2007 14:33:01 -0500
From: "Priscilla Merrill"
Subject: RE: [NP-Clinical] Re:trigeminy, PVC's
To: "'NP Clinical'"
Message-ID: <001a01c73292$a4be56e0$6600a8c0 at Priscilla>
Content-Type: text/plain; charset="windows-1250"
Good points. She was normal weight, if anything a bit over. Again, she was
a quick sick so am seeing her back next week to review everything. I
ordered lytes (included with cmp_) and will have them back Tuesday (we have
weekend clinic so if anything was way off, it'd be addressed by another
provider). HR was 58 as I recall but hard to count since it was all over
the place. I think ecg was rate of 62.
-----Original Message-----
From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net]
On Behalf Of Tracy Klein
Sent: Sunday, January 07, 2007 1:58 PM
To: np-clinical at nurse.net
Subject: [NP-Clinical] Re:trigeminy, PVC's
Did you mention heart rate? Orthostatics? Lytes? Even
though this woman was described as "normal weight"
this was a not infrequent presentation of my eating
disorder patients. And, of course, bulimics can be of
normal weight and usually are. If the patient was
orthostatic, if heartrate was below 50 (hard to tell,
I know, with trigeminy), if I saw anything in my oral
exam to make me concerned, I would strongly consider
it in my differential. It was self correcting with
nutritional rebalancing and hydration.
Tracy Klein, WHCNP, FNP
Portland, Oregon
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------------------------------
Message: 3
Date: Sun, 7 Jan 2007 12:11:16 -0800
From: "Christine Smith"
Subject: [NP-Clinical] Re: [ACC-Circle] More on ear problems
To: "Jonathan Miller"
,
Cc: ACC-Circle at listserve.com
Message-ID: <010d01c73297$fd5735b0$6401a8c0 at ChristineNB>
Content-Type: text/plain; format=flowed; charset="iso-8859-1";
reply-type=response
THANKS for the wisdom! I knew there was an ENT guy on this list somewhere.
Dave - I will add the Val Salva to the regimen too.
Jonathan -
Why an antihistamine? I have never done that? And do you think Astelin has
any benefit?
I am seeing allot of this in my free clinic and I have Astelin samples but
no nasal steroids.
The cheapest nasal steroid is Generic Flonase and it is $48 at Costco.
Also, I saw a 8 yo girl a few nights ago with an ear ache for one week
following a URI.
Suddenly, she had a "painful pop" and thick white/green drainage coming out.
So much
crud in her ear I could not see the TM. Plus, she was not too cooperative
though she said
the ear did not hurt really anymore. I do not have an ear suction available
except a bulb
syringe. Still could not see the TM. Finally, I opted to put her on
Cortisporin Otic Suspension
and Amox and bring her back in two days.
Last night I rechecked the ear - TM looks intact but sort of white, thick
looking. No pain.
She cannot hear much out of the ear. My hearing test was having her listen
to dial tone from
the phone on both ears which she could hear, but not nearly as well on bad
ear and she also
could not hear me rubbing her hair together at all on the bad ear. I will
see her again in one
week.
She will not be able to get in with an ENT for weeks. She is a Latina
immigrant, no insurance
and it takes weeks to get them in with Primary Care.
Thanks in advance for your expertise!
Christine Smith, NP
Antioch, CA
----- Original Message -----
From: "Jonathan Miller"
To: "Christine Smith" ;
Cc:
Sent: Saturday, January 06, 2007 11:26 PM
Subject: Re: [ACC-Circle] More on ear problems
> Entex-PSE is a good choice but not always a healthy choice in those with
> hypertension (which is a large part of the population). ETD is a very
> common disorder that I prefer to treat as aggressively as the patient will
> allow. It is almost never an overnight fix and I inform the patient up
> front that this may or may not take several weeks.
>
> Initially I will presribe and antihistmine (I like zyrtec and or
> allegra...decongestant combo if able to do it), singulair, and nasal
> steroid (two sprays each nostril BID...pointed away from septum).
> Sometimes I will increase the allegra or zyrtec to BID and also the
> singulair to BID. The three work toward the same goal through different
> avenues and work VERY well together. I don't have the patient return for
> at least 4-6 weeks. If there is no improvement, then I will add prednisone
> 40-60+mg QD for a week then taper...all the while taking the three
> previously mentioned meds. Sometimes a high dose of oral steroids seems to
> "jump start" the process. Middle ear insufflation (or an "Ear Popper") is
> an option if you have the instrument in the office...but I don't think it
> works all that well (at least permanently).
>
> Afrin is an okay choice but usually not my first line due to the side
> effects of prolonged use. However, if I have the patient use it, I have
> them use heavy doses at a time. For example; one spraying session would
> include: Spray in each nostril, wait 5 minutes, then blow your nose; spray
> a second time in each nostril, wait 5 more minutes, blow nose; spray a
> third time, wait 5 minutes, blow nose. I have the patient do this 2-3
> times daily for 3 days. Again, all the while taking the other meds.
>
> If after much time and many medications later they still are not better,
> they should see an ENT for further work-up (sinus disease, myringotomy
> and/or tubes, etc). As for the zebra, often a sudden hearing loss can feel
> like ETD to the patient. A rule of thumb that I've learned never to forget
> is that whenever I have a patient with a new ear problem that presents in
> some sort of decrease in hearing (including plugged sensation), ALWAYS,
> ALWAYS, ALWAYS get an audiogram!! To many times practioners fail to order
> a simple hearing test. I have seen many times pathologic hearing losses
> from a seemingly small chief complaint.
>
> Hope this helps,
> -Jonathan Miller, PA-C, MHS
> Otolaryngology
>
>
>
> Hope this helps. Don't be afraid to be aggressive.
> ----- Original Message -----
> From: "Christine Smith"
> To:
> Cc:
> Sent: Friday, January 05, 2007 6:23 PM
> Subject: [ACC-Circle] More on ear problems
>
>
> WELCOME TO THE ACC-CIRCLE DISCUSSION LIST!
> See bottom of this post for help with setting user options or
> unsubscribing.
>
> *********************************************************
> Any miracle treatment for these pts with chronic plugged ear - Eustachian
> tube dysfunction, after a URI? I see several of these a week and always
> just advise Guafenison 400- 600 BID and Sudafed. Any other ideas? I have
> one lady that is driving me nuts and the TM looks perfect - just this
> clogged feeling with some popping.
>
> Christine Smith, NP
> Antioch, CA
> *********************************************************
> TO UNSUBSCRIBE OR CHANGE YOUR OPTIONS GO TO:
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>
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> great PR campaign. WE NOW ALSO HAVE PINS.@$5.00 EACH
> http://amcollege.org/Patches.html
>
>
------------------------------
Message: 4
Date: Sun, 7 Jan 2007 12:21:54 -0800
From: "Christine Smith"
Subject: [NP-Clinical] Methacholine challenge test?
To: ,
Message-ID: <011d01c73299$79f394a0$6401a8c0 at ChristineNB>
Content-Type: text/plain; charset="iso-8859-1"
I have no idea what these are or where they get them. Anyone have any ideas where someone would go for this and cost? Pulmo specialist? Below is the excerpt from an NP friend
My son (no job and no insurance right now) is trying to join the Army to "find himself". He had asthma as a child, but hasn't had to use an inhaler for several years. They want him to have a methacholine challenge test in order to clear him. Any ideas how/ where he can get that done and how much it might cost him? I guess the miltary is not desperate enough for recruits to pay for the test.
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Message: 5
Date: Sun, 7 Jan 2007 12:24:13 -0800
From: "Christine Smith"
Subject: [NP-Clinical] ENT expertise on Eustachian Tube Dysfunction
To:
Message-ID: <012301c73299$ccc0f010$6401a8c0 at ChristineNB>
Content-Type: text/plain; format=flowed; charset="iso-8859-1";
reply-type=response
I am forwarding this on from the ACC list serve from Jonathan, PA - who
works in ENT.
Subject: Re: [ACC-Circle] More on ear problems
> Entex-PSE is a good choice but not always a healthy choice in those with
> hypertension (which is a large part of the population). ETD is a very
> common disorder that I prefer to treat as aggressively as the patient will
> allow. It is almost never an overnight fix and I inform the patient up
> front that this may or may not take several weeks.
>
> Initially I will presribe and antihistmine (I like zyrtec and or
> allegra...decongestant combo if able to do it), singulair, and nasal
> steroid (two sprays each nostril BID...pointed away from septum).
> Sometimes I will increase the allegra or zyrtec to BID and also the
> singulair to BID. The three work toward the same goal through different
> avenues and work VERY well together. I don't have the patient return for
> at least 4-6 weeks. If there is no improvement, then I will add prednisone
> 40-60+mg QD for a week then taper...all the while taking the three
> previously mentioned meds. Sometimes a high dose of oral steroids seems to
> "jump start" the process. Middle ear insufflation (or an "Ear Popper") is
> an option if you have the instrument in the office...but I don't think it
> works all that well (at least permanently).
>
> Afrin is an okay choice but usually not my first line due to the side
> effects of prolonged use. However, if I have the patient use it, I have
> them use heavy doses at a time. For example; one spraying session would
> include: Spray in each nostril, wait 5 minutes, then blow your nose; spray
> a second time in each nostril, wait 5 more minutes, blow nose; spray a
> third time, wait 5 minutes, blow nose. I have the patient do this 2-3
> times daily for 3 days. Again, all the while taking the other meds.
>
> If after much time and many medications later they still are not better,
> they should see an ENT for further work-up (sinus disease, myringotomy
> and/or tubes, etc). As for the zebra, often a sudden hearing loss can feel
> like ETD to the patient. A rule of thumb that I've learned never to forget
> is that whenever I have a patient with a new ear problem that presents in
> some sort of decrease in hearing (including plugged sensation), ALWAYS,
> ALWAYS, ALWAYS get an audiogram!! To many times practioners fail to order
> a simple hearing test. I have seen many times pathologic hearing losses
> from a seemingly small chief complaint.
>
> Hope this helps,
> -Jonathan Miller, PA-C, MHS
> Otolaryngology
>
>
>
> Hope this helps. Don't be afraid to be aggressive.
> ----- Original Message -----
> From: "Christine Smith"
> To:
> Cc:
> Sent: Friday, January 05, 2007 6:23 PM
> Subject: [ACC-Circle] More on ear problems
>
>
> WELCOME TO THE ACC-CIRCLE DISCUSSION LIST!
> See bottom of this post for help with setting user options or
> unsubscribing.
>
> *********************************************************
> Any miracle treatment for these pts with chronic plugged ear - Eustachian
> tube dysfunction, after a URI? I see several of these a week and always
> just advise Guafenison 400- 600 BID and Sudafed. Any other ideas? I have
> one lady that is driving me nuts and the TM looks perfect - just this
> clogged feeling with some popping.
>
> Christine Smith, NP
> Antioch, CA
> *********************************************************
> TO UNSUBSCRIBE OR CHANGE YOUR OPTIONS GO TO:
> ACC-Circle mailing list
> http://mailman.listserve.com/listmanager/listinfo/acc-circle
> NOTE: To post a reply to the entire list, use your email program's *Reply
> To All* button; To reply to the sender only, use your email program's
> *Reply* button.
> NEED TO UNSUBSCRIBE?? *Please unsubscribe me* messages posted to the list
> are IGNORED. Go the the list web page to set your options.
> PROBLEMS? Email the list administrator at acc-circle-owner at listserve.com
>
> Wear your professions patch proudly. If enough of us do, we will have a
> great PR campaign. WE NOW ALSO HAVE PINS.@$5.00 EACH
> http://amcollege.org/Patches.html
>
>
------------------------------
Message: 6
Date: Sun, 7 Jan 2007 15:28:41 -0500
From:
Subject: RE: [NP-Clinical] Methacholine challenge test?
To: "'NP Clinical'"
Message-ID: <005401c7329a$6be60ea0$0c00a8c0 at huyer>
Content-Type: text/plain; charset="us-ascii"
Allergy/asthma clinics and pulmonologists routinely perform these (or at
least they did in the years that I worked for them). I have no clue as
the the cost these days, as I haven't done one in 7 years.
Susie
_____
From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net]
On Behalf Of Christine Smith
Sent: Sunday, January 07, 2007 3:22 PM
To: np-clinical at nurse.net; ACC-Circle at listserve.com
Subject: [NP-Clinical] Methacholine challenge test?
I have no idea what these are or where they get them. Anyone have any ideas
where someone would go for this and cost? Pulmo specialist? Below is the
excerpt from an NP friend
My son (no job and no insurance right now) is trying to join the Army to
"find himself". He had asthma as a child, but hasn't had to use an inhaler
for several years. They want him to have a methacholine challenge test in
order to clear him. Any ideas how/ where he can get that done and how much
it might cost him? I guess the miltary is not desperate enough for recruits
to pay for the test.
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