Responded more to the title of the post.
Don't fret over it. There's no hidden agenda in my post. Just a comment.
Don't fret over it. There's no hidden agenda in my post. Just a comment.
-
CycleTrack and SDN are teaming up to make medical school admissions more transparent and accessible! Read the announcement to learn how we’re supporting the future of CycleTrack’s free application-tracking tools .
Physical by an NP
Started by lawguil
Get help with your application
Use all the free resources available to you from SDN: articles, guides, expert advising, forums discussions, and school research.
...double post
Right before I left Hawaii almost two years ago, a cardiac surgeon rushed a patient up for an emergency cath. Guess he didn't remember much about hot gallbladders 😀 It didn't make the news though.
I trust my gut...We (as health care workers) usually know what's up (diagnostically), but want to remain objective; And if we are male, we appease our wives 😍 and go to the clinic
We have a walk in/primary care clinic in our small (12,000) town...We go there for most everything (Having ran both an ER and an UC, I know what should go where, though, seemingly this should be common sense, but...........)
Anyway, we have encountered both an NP and a PA...IN THIS CASE (not generalizing), the PA gets it, hands down...The NP was clueless (in one particular case...5 year ER nurse turned NP)
I don't know...Having worked alongside both (I'm a long time RN), I'll take a PA...
BUT, for well woman visits and midwifery, an NP is superior...
Did he actually push the gurney?
Naw, he wouldn't do such a task that was beneath him...
The history of NPs (as I was taught it) is that when MediCaid became a reality, some physicians and nurses in Colorado (I think) started discussing how low-income children would be able to have access to a provider when there were not enough physicians to see all the children who would now have coverage. Discussions for an NP program stalled when the nursing faculty felt that nursing needed its own identity and the suggested NP role was too much like medicine. Thus, interested parties started the first PA program. NPs came soon after when another group in another state wasnt so put off by the nursing/medicine dilemma and started the first NP program. [Disclaimer: this is what I was taught; any historical inaccuracies are not intended.]
I think that FNPs serve a valuable role in American health care. Most FNPs practice within their scope of practice and training, as do most PAs and most MD/DOs. I personally feel that FNPs should always have a requirement for MD collaboration (although note that this is not the same as supervision) and I vigorously oppose efforts of FNPs to re-cast themselves as MD equivalents, because they do not have the training and experience of MDs. I think that the DNP is a really bad idea (this of course is another topic discussed in other threads), and the idea of distance learning FNP programs makes me really sad because I think that they could ruin it for all the FNPs who are doing good things and went to good programs. I myself am applying to medical school this year because I want to manage the kind of complex, multi-system illnesses that FNPs should not be diagnosing and managing independently.
I also think that healthcare is really complicated. For my own anonymity Im going to be vague, but I work in a setting thats not primary care. I work in a team and feel that Im able to contribute to the teams work and efficiency without endangering any patients safety. Our team takes over patient care from other teams, and this is all happening in a setting where there are residents and medical students. I have caught many cases of inappropriate care, missed diagnoses, mismanaged established diagnoses, and gross malpractice; these errors have resulted in bad outcomes for the patients. The residents are in a top-ranked program and their supervising physicians are faculty at a top-10 medical school. There are many systems issues contributing to these errors including resident work hours, too many patients per team for the attendings to safely supervise, medical students writing orders that are co-signed but not carefully reviewed, physicians who dont consult on cases that are clearly beyond their expertise, and everybody being really busy and crisis oriented. Not to mention that patients often have no idea what is going on and are frustrated that they cant just talk to someone.
I know that this is a discussion about NP training, but Im bringing this up because the tone of the thread is that NPs are practicing beyond their scope and maybe shouldnt even have a scope. I think that there are many problems in healthcare, and NPs practicing in situations beyond their scope is one, but there are others as well that include physicians overconfident about their own areas of expertise who arent doing patients any favors. Some of the issues that have been brought up on this thread are systems issues, including that NPs are put into positions where the are being asked to do more than they should by organizations motivated by money (urgent care clinics, private practices looking to increase numbers, new providers not receiving sufficient training or performance reviews, etc).
I have read back through the comments to my earlier posts and I think that it is fair to say that NPs are not trained the same way as PAs. Given that mid-level providers are in direct competition for many jobs, I can understand how PAs might think that this is unfair. NPs also cite the general rule that they can manage 80% of what is seen in a primary care practice and refer the other 20%.
The tone of the comments asking if NPs have even a basic knowledge of disease seemed a little patronizing. My attempt to breakdown the algorithm for consulting an MD perhaps confused the issue that NPs do not consult on every patient and know how to diagnose and manage common disorders. The point about the red flag symptoms was directly to address concerns that NPs are incompetent and dangerous (see the reflux/MI example cited in an earlier post); NPs are trained to follow the red flag algorithm in order to ensure patient safety. Most patients dont need it. Many patients who seem to have hypertension really do have hypertension. Many patients who seem to have asthma have asthma. NPs are trained to work with common disorders in primary care and refer when necessary.
I have put so much time into this thread and Ive been open about my opinions regarding NP practice because I think that some of the generalizations about NPs have been too harsh. The postings are overwhelmingly negative and people seem to have deep feelings about NP practice that wont change no matter how productive a discussion this could be. Im not naive that this site is called student doctor and that there is a very pro-medicine, pro-medical model attitude here. I have put these posts up because I think that if everyone agrees over and over that NPs are incompetent and dumb, the message readers take away could affect patient care. This thread has almost 1,300 views. When pre-meds and PA students and others read this thread and leave with the opinion that seeing an NP may be worthless at best and dangerous at worst, thats not fair to the reality of NP practice. It also creates the kind of inter-disciplinary strife and power struggles that quickly devolve into being about the providers and having nothing to do with the patients best interests. The reality of 21st century medicine in America is that it will involve teams and it will involve mid-level providers including NPs.
I think that FNPs serve a valuable role in American health care. Most FNPs practice within their scope of practice and training, as do most PAs and most MD/DOs. I personally feel that FNPs should always have a requirement for MD collaboration (although note that this is not the same as supervision) and I vigorously oppose efforts of FNPs to re-cast themselves as MD equivalents, because they do not have the training and experience of MDs. I think that the DNP is a really bad idea (this of course is another topic discussed in other threads), and the idea of distance learning FNP programs makes me really sad because I think that they could ruin it for all the FNPs who are doing good things and went to good programs. I myself am applying to medical school this year because I want to manage the kind of complex, multi-system illnesses that FNPs should not be diagnosing and managing independently.
I also think that healthcare is really complicated. For my own anonymity Im going to be vague, but I work in a setting thats not primary care. I work in a team and feel that Im able to contribute to the teams work and efficiency without endangering any patients safety. Our team takes over patient care from other teams, and this is all happening in a setting where there are residents and medical students. I have caught many cases of inappropriate care, missed diagnoses, mismanaged established diagnoses, and gross malpractice; these errors have resulted in bad outcomes for the patients. The residents are in a top-ranked program and their supervising physicians are faculty at a top-10 medical school. There are many systems issues contributing to these errors including resident work hours, too many patients per team for the attendings to safely supervise, medical students writing orders that are co-signed but not carefully reviewed, physicians who dont consult on cases that are clearly beyond their expertise, and everybody being really busy and crisis oriented. Not to mention that patients often have no idea what is going on and are frustrated that they cant just talk to someone.
I know that this is a discussion about NP training, but Im bringing this up because the tone of the thread is that NPs are practicing beyond their scope and maybe shouldnt even have a scope. I think that there are many problems in healthcare, and NPs practicing in situations beyond their scope is one, but there are others as well that include physicians overconfident about their own areas of expertise who arent doing patients any favors. Some of the issues that have been brought up on this thread are systems issues, including that NPs are put into positions where the are being asked to do more than they should by organizations motivated by money (urgent care clinics, private practices looking to increase numbers, new providers not receiving sufficient training or performance reviews, etc).
I have read back through the comments to my earlier posts and I think that it is fair to say that NPs are not trained the same way as PAs. Given that mid-level providers are in direct competition for many jobs, I can understand how PAs might think that this is unfair. NPs also cite the general rule that they can manage 80% of what is seen in a primary care practice and refer the other 20%.
The tone of the comments asking if NPs have even a basic knowledge of disease seemed a little patronizing. My attempt to breakdown the algorithm for consulting an MD perhaps confused the issue that NPs do not consult on every patient and know how to diagnose and manage common disorders. The point about the red flag symptoms was directly to address concerns that NPs are incompetent and dangerous (see the reflux/MI example cited in an earlier post); NPs are trained to follow the red flag algorithm in order to ensure patient safety. Most patients dont need it. Many patients who seem to have hypertension really do have hypertension. Many patients who seem to have asthma have asthma. NPs are trained to work with common disorders in primary care and refer when necessary.
I have put so much time into this thread and Ive been open about my opinions regarding NP practice because I think that some of the generalizations about NPs have been too harsh. The postings are overwhelmingly negative and people seem to have deep feelings about NP practice that wont change no matter how productive a discussion this could be. Im not naive that this site is called student doctor and that there is a very pro-medicine, pro-medical model attitude here. I have put these posts up because I think that if everyone agrees over and over that NPs are incompetent and dumb, the message readers take away could affect patient care. This thread has almost 1,300 views. When pre-meds and PA students and others read this thread and leave with the opinion that seeing an NP may be worthless at best and dangerous at worst, thats not fair to the reality of NP practice. It also creates the kind of inter-disciplinary strife and power struggles that quickly devolve into being about the providers and having nothing to do with the patients best interests. The reality of 21st century medicine in America is that it will involve teams and it will involve mid-level providers including NPs.
I don't think she was inept at all. She did EXACTLY what she was supposed to do, get the MD. Kudos to her. I mean I don't expect my PA or NP to know the minutia of Adamantinoma (I know bad example), but if they are seeing a new patient for me that has had it in the past I would hope they would bring it up to me. Now you can argue all day about she should have known what hodgkin's lymphoma is. That is different.
The point to my post was that the profession itself isn't weak, that particular NP was weak.
Since reading this post, I've had contact with several NPs and PAs, and a heck of a lot of RNs, and every one of them knows what Hodgkin's lymphoma is. I find it rather inept that a practicing NP doesn't know this rather common diagnosis (when it comes to lymph nodes).
Your example of adamantinoma is comparing apples and oranges. Only 200 cases have ever been reported, yet hodgkin's affects how many each year? Medline says about 7800. I still believe it's something the NP should have had knowledge of, making her inept.
I'm sure she knows more about it now, though.
Wouldn't it be great if we could get her understanding of the examination discussion? I in no way doubt the OP understanding of the conversation. Yet, there is always seems to be two sides to a story, maybe I have been watching too much CSI.
Unfotunately this is a written board with one-sided posts. I guess you just had to be there to take in the full account. I'm going by what the OP posted.
D
deleted6669
I currently have an np student. I'm sure she doesn't know what hodgkins is. yesterday she didn't know what diverticulitis was or how to treat it. and this is her last rotation, although it is only 45 hrs long.....
emedpa said:
Yikes. Diverticulitis is fairly common.
Yep, the ER was busy that night. He had one end and I had the other.
4am and I can't sleep. 3 weeks of night shift has screwed up my clock for when I actually COULD sleep at night. 🙁
So for some idiot reason this thread was on my mind and I felt compelled to look up my old objectives from fall 1998 Clinical Medicine class. Found the Heme/Onc folder and my notes from the anemias/leukemias/lymphomas lecture (can't believe I didn't get some kind of repetitive motion disorder from all that handwriting) but didn't find the objectives which I wanted...must be another folder.
So instead I decided to post the brief notes from the powerpoint presentation on Leukocyte Disorders which I gave last fall to the PA students at Pacific U. in Forest Grove, OR (my alma mater). Of course medicine evolves and we know more than we knew 8 years ago, but the conceptual knowledge expected of us was the same.
FWIW, this type of lecture is typical of the PA didactic year.
Trail Pass made some compelling arguments that NPs shouldn't be expected to know the ins & outs of cancer, just to recognize that some cancers have telltale signs and these "Red flags" should tip off the NP that there may be a problem and s/he should refer. I disagree: especially as primary care providers I think the NP is at a distinct disadvantage not to know as much pathology as s/he can. Yes, "common things are common", but some uncommon things are not so uncommon that they shouldn't be taught. I myself knew the basics of Hodgkin's as a student, and certainly would consider it as a possibility in a patient with painless lymphadenopathy. To be fair, I didn't REALLY know and understand Hodgkin's well until I had a 17 yo softball player who came in with an unresolving cervical node for 3 weeks. She flunked the trial of antibiotics so she went to ENT. Even the ENT thought it was benign but sure enough, the FNA proved Hodgkin's. She (the patient) got the full workup and sure enough, she had Stage 3 disease with nodes in the pelvis. BUT because Hodgkin's is so responsive to treatment in most young'uns she did well and is about 3yr out from treatment and in college.
I interviewed 2 years ago for a teaching job in a PA program here in SC (um, the only PA program in SC). I didn't get the job but I did have a delightful interview with the medical director who taught me something valuable: his mantra to his students who continually asked "What should we know for the test?" He would just smile and say, "Know all you can." I loved that and have incorporated it into my own educational philosophy.
Being a PA is an exercise in lifelong learning. I expect it is the same for an NP. My educational bent is of course toward PAs because that's what I know best and that's how I was trained, and I think we as PAs benefit from a thorough exposure to pathophys. I agree we don't learn it to the cellular and biochemical level of the physician, a fact which has frustrated me as a practitioner and has spurred my own desire to go back to med school, but I do believe there is still a lot of good in what we do and how we train PAs to step in to the provider role in conjunction with other providers and our supervising physicians.
Now, happy reading:
Objectives: Disorders of Leukocytes
 Review normal WBC values and morphology:
 Neutrophil
 Lymphocyte
 Monocyte
 Eosinophil
 Basophil
Objectives
 2. Recognize the clinical presentation and laboratory findings of the following leukocyte disorders:
 Chronic Myelogenous Leukemia (CML)
 Acute Lymphocytic (Lymphoblastic) Leukemia (ALL)
 Chronic Lymphocytic Leukemia (CLL)
Objectives
 3. Recognize the clinical presentation and laboratory findings of the following lymphomas:
 Non-Hodgkins Lymphoma
 Hodgkins Disease
 Multiple Myeloma
Lymphomas: Non-Hodgkins
 Non-Hodgkins Lymphomas
 B-cell Lymphomas
 Precursor B cell lymphoblastic lymphoma
 Small lymphocytic lymphoma/ CLL
 Marginal zone lymphomas
 Nodal marginal zone lymphoma
 Extranodal MALT
 Splenic
 Hairy cell leukemia
 Follicular lymphoma
 Mantle cell lymphoma
 Diffuse large B cell lymphoma
 Burkitts lymphoma
 T-cell Lymphomas
 Anaplastic large cell lymphoma
 Peripheral T cell lymphoma
 Mycosis fungoides
Other Lymphomas
 Hodgkins Disease
 Multiple Myeloma
 Waldenstroms Macroglobulinemia
Hodgkins Disease: Overview
 Painless lymphadenopathy and lymphoid enlargement of liver and spleen
 Presence of Reed-Sternberg cells
 Related to EBV
 Bimodal age distribution
 Most common between 15-45 yo and after age 60
 More common in men between 15-45 yo
 4 major subtypes:
 Nodular lymphocyte predominant
 Nodular Sclerosis
 Mixed Cellularity
 Lymphocyte Depleted
Distinguish from other malignant lymphomas by pathology
Also consider: infectious mononucleosis, cat-scratch disease, drug reactions
Hodgkins Disease: Presentation
 Begins in a lymph node area, and progresses along the chain to contiguous areas of lymph nodes
 Cervical, supraclavicular, and mediastinal lymphadenopathy
 Stage A lack of constitutional symptoms
 Stage B 1/3 of patients present with constitutional symptoms
Hodgkins Disease:
Laboratory Findings
 Ann Arbor staging system
 Includes CT scans of neck, chest, abdomen, and pelvis
 Biopsy of bone marrow
 Presence of Reed-Sternberg cells confirm diagnosis
Reed-Sternberg Cell
Hodgkins Disease: Treatment
 Chemotherapy cures > 50%, even with advanced stage disease
 Radiation therapy cures 90% of stage IA and IIA disease
Non-Hodgkins Lymphoma
 Group of malignancies arising from cells in the lymphoid tissue
 90% of cases are from B-lymphocytes
 Higher incidence in patients with HIV and other immunodeficiencies
 Incidence has been rising 1-2% since the 1950s
 Peak incidence 20-40 y/o
Non-Hodgkins Lymphoma
 Lymphomas divided into two categories
 Indolent
 Aggressive
 Clinical Features
 Diffuse, painless, persistent lymphadenopathy is most common
 Common extralymphatic sites
 Constitutional symptoms less common than in Hodgkins
 Laboratory
 Persistent, unexplained nodes should be biopsied
Non-Hodgkins Lymphoma
 Treatment
 Radiation therapy may cure indolent lymphomas, but usually limited role
 Aggressive lymphomas require aggressive combination chemotherapy
 Prognosis
 6-8 years in indolent lymphomas
Multiple Myeloma
 Bone marrow is replaced by malignant plasma cells
 Monoclonal protein in serum
 Proteinuria
 Lytic lesions in bones
 May be caused by a new herpes virus
 Older adults median age is 65 (rare under age 40)
 Equal incidence in men and women
Multiple Myeloma
 Signs and symptoms
 Normochromic normocytic anemia
 Normoblasts may be present in blood
 Leukocyte count slightly decreased, normal, or slightly increased
 Elevated ESR
 Striking feature: Rouleaux formation
 Bone pain, back and ribs, sternum
 Infection (esp. encapsulated organisms e.g. S. pneumoniae; H. influenzae)
 Rouleaux
Multiple Myeloma
 Physical Exam
 Pallor
 Bone tenderness
 Soft tissue masses
 May have neuro symptoms if spinal cord is compressed
Multiple Myeloma
 Labs
 Anemia (normochromic normocytic)
 Neutrophils and platelets are normal at onset
 HALLMARK: paraprotein on serum protein electrophoresis (SPEP) (M spot)
 Bone marrow with plasma cell infiltration
 Bone x-ray
 Hypercalcemia
 Renal failure
 Amyloidosis in 10-15% of MM contributes to RF
MM: Bone Marrow Aspiration
Multiple Myeloma
 Treatment
 Palliative for bone pain
 Autologous stem cell transplantation for patients < 60 y/o
 Prognosis is poor
 Median survival 3 years
And finally
 A few more that were not listed on your objectives, but are mentioned in Current, so I suppose theyre fair game
 (Bonus questions anyone??)
Waldenstroms Macroglobulinemia
 Nonspecific symptoms
 Splenomegaly common
 Monoclonal IgM paraprotein
 Plasmacytic lymphocytes infiltrate bone marrow
 Absence of lytic bone disease
 Malignant B cell disease; hybrid of lymphocytes and plasma cells
 Insidious onset in 60s & 70s
 Fatigue related to anemia
 Mucosal & GI bleeding secondary to engorged blood vessels, platelet dysfunction
 +/- HSM, LAD; retinal veins engorged; purpura may be present; no bone tenderness
 Anemia universal; Rouleaux formation common
 Monoclonal IgM spike on SPEP in beta or gamma globulin region
 Serum viscosity sometimes significantly increased (4-6x H2O)
 Treatment and survival rates variable; median survival 3-5 years
Myelofibrosis
 Bone marrow becomes fibrotic
 Platelet-derived growth factor (PDGF)
 Extramedullary hematopoiesis in liver, spleen, lymph nodes
 Dry tap
 Teardrop poikilocytosis on peripheral smear
 Myeloproliferative, toxin, infection
 Adults over age 50; insidious onset
 Fatigue due to anemia; abdominal tenderness due to splenomegaly (often massive)
 Uncommon: bleeding, bone pain
 WBC count is variable
Myelofibrosis
 No specific treatment
 Transfusion for anemia
 Androgens may boost blood counts (poorly tolerated in women)
 Allogeneic bone marrow transplantation
 Median survival from time of diagnosis: 5 years
 End-stage: generalized debility, liver failure, bleeding from thrombocytopenia
 Some cases terminate in AML
Myelodysplastic Syndromes
 Cytopenias with hypercellular bone marrow
 2 or more hematopoietic cell lines have morphologic abnormalities
 Acquired clonal disorders of hematopoeitic stem cell
 Usually idiopathic
 May be seen after cytotoxic chemotherapy
 Ineffective hematopoeisis occurs
 Ultimately may evolve into AML; preleukemia
 Usually over age 60; may be asymptomatic
 Ultimately fatal disease (infections, bleeding)
Hairy Cell Leukemia
 Pancytopenia
 Splenomegaly, often massive
 Hairy cells on blood smear and esp. in bone marrow biopsy
 Uncommon indolent B-cell lymphocytic cancer
 Middle-aged men (median age 55)
 Striking 5:1 male predominance
 Anemia universal; 75% thrombocytopenia and neutropenia
 Dry tap on bone marrow
Hairy Cell Leukemia
 Distinguish from other lymphoproliferative diseases (Waldenstroms macroglobulinemia, non-Hodgkins lymphomas)
 Treatment: cladribine (2-chlorodeoxyadenosine; CdA); relatively nontoxic with benefit in 95%; complete remission > 80%
 Long-lasting response with most patients surviving > 10 years with current treatment modalities
Review and Questions
So for some idiot reason this thread was on my mind and I felt compelled to look up my old objectives from fall 1998 Clinical Medicine class. Found the Heme/Onc folder and my notes from the anemias/leukemias/lymphomas lecture (can't believe I didn't get some kind of repetitive motion disorder from all that handwriting) but didn't find the objectives which I wanted...must be another folder.
So instead I decided to post the brief notes from the powerpoint presentation on Leukocyte Disorders which I gave last fall to the PA students at Pacific U. in Forest Grove, OR (my alma mater). Of course medicine evolves and we know more than we knew 8 years ago, but the conceptual knowledge expected of us was the same.
FWIW, this type of lecture is typical of the PA didactic year.
Trail Pass made some compelling arguments that NPs shouldn't be expected to know the ins & outs of cancer, just to recognize that some cancers have telltale signs and these "Red flags" should tip off the NP that there may be a problem and s/he should refer. I disagree: especially as primary care providers I think the NP is at a distinct disadvantage not to know as much pathology as s/he can. Yes, "common things are common", but some uncommon things are not so uncommon that they shouldn't be taught. I myself knew the basics of Hodgkin's as a student, and certainly would consider it as a possibility in a patient with painless lymphadenopathy. To be fair, I didn't REALLY know and understand Hodgkin's well until I had a 17 yo softball player who came in with an unresolving cervical node for 3 weeks. She flunked the trial of antibiotics so she went to ENT. Even the ENT thought it was benign but sure enough, the FNA proved Hodgkin's. She (the patient) got the full workup and sure enough, she had Stage 3 disease with nodes in the pelvis. BUT because Hodgkin's is so responsive to treatment in most young'uns she did well and is about 3yr out from treatment and in college.
I interviewed 2 years ago for a teaching job in a PA program here in SC (um, the only PA program in SC). I didn't get the job but I did have a delightful interview with the medical director who taught me something valuable: his mantra to his students who continually asked "What should we know for the test?" He would just smile and say, "Know all you can." I loved that and have incorporated it into my own educational philosophy.
Being a PA is an exercise in lifelong learning. I expect it is the same for an NP. My educational bent is of course toward PAs because that's what I know best and that's how I was trained, and I think we as PAs benefit from a thorough exposure to pathophys. I agree we don't learn it to the cellular and biochemical level of the physician, a fact which has frustrated me as a practitioner and has spurred my own desire to go back to med school, but I do believe there is still a lot of good in what we do and how we train PAs to step in to the provider role in conjunction with other providers and our supervising physicians.
Now, happy reading:
Objectives: Disorders of Leukocytes
 Review normal WBC values and morphology:
 Neutrophil
 Lymphocyte
 Monocyte
 Eosinophil
 Basophil
Objectives
 2. Recognize the clinical presentation and laboratory findings of the following leukocyte disorders:
 Chronic Myelogenous Leukemia (CML)
 Acute Lymphocytic (Lymphoblastic) Leukemia (ALL)
 Chronic Lymphocytic Leukemia (CLL)
Objectives
 3. Recognize the clinical presentation and laboratory findings of the following lymphomas:
 Non-Hodgkins Lymphoma
 Hodgkins Disease
 Multiple Myeloma
Lymphomas: Non-Hodgkins
 Non-Hodgkins Lymphomas
 B-cell Lymphomas
 Precursor B cell lymphoblastic lymphoma
 Small lymphocytic lymphoma/ CLL
 Marginal zone lymphomas
 Nodal marginal zone lymphoma
 Extranodal MALT
 Splenic
 Hairy cell leukemia
 Follicular lymphoma
 Mantle cell lymphoma
 Diffuse large B cell lymphoma
 Burkitts lymphoma
 T-cell Lymphomas
 Anaplastic large cell lymphoma
 Peripheral T cell lymphoma
 Mycosis fungoides
Other Lymphomas
 Hodgkins Disease
 Multiple Myeloma
 Waldenstroms Macroglobulinemia
Hodgkins Disease: Overview
 Painless lymphadenopathy and lymphoid enlargement of liver and spleen
 Presence of Reed-Sternberg cells
 Related to EBV
 Bimodal age distribution
 Most common between 15-45 yo and after age 60
 More common in men between 15-45 yo
 4 major subtypes:
 Nodular lymphocyte predominant
 Nodular Sclerosis
 Mixed Cellularity
 Lymphocyte Depleted
Distinguish from other malignant lymphomas by pathology
Also consider: infectious mononucleosis, cat-scratch disease, drug reactions
Hodgkins Disease: Presentation
 Begins in a lymph node area, and progresses along the chain to contiguous areas of lymph nodes
 Cervical, supraclavicular, and mediastinal lymphadenopathy
 Stage A lack of constitutional symptoms
 Stage B 1/3 of patients present with constitutional symptoms
Hodgkins Disease:
Laboratory Findings
 Ann Arbor staging system
 Includes CT scans of neck, chest, abdomen, and pelvis
 Biopsy of bone marrow
 Presence of Reed-Sternberg cells confirm diagnosis
Reed-Sternberg Cell
Hodgkins Disease: Treatment
 Chemotherapy cures > 50%, even with advanced stage disease
 Radiation therapy cures 90% of stage IA and IIA disease
Non-Hodgkins Lymphoma
 Group of malignancies arising from cells in the lymphoid tissue
 90% of cases are from B-lymphocytes
 Higher incidence in patients with HIV and other immunodeficiencies
 Incidence has been rising 1-2% since the 1950s
 Peak incidence 20-40 y/o
Non-Hodgkins Lymphoma
 Lymphomas divided into two categories
 Indolent
 Aggressive
 Clinical Features
 Diffuse, painless, persistent lymphadenopathy is most common
 Common extralymphatic sites
 Constitutional symptoms less common than in Hodgkins
 Laboratory
 Persistent, unexplained nodes should be biopsied
Non-Hodgkins Lymphoma
 Treatment
 Radiation therapy may cure indolent lymphomas, but usually limited role
 Aggressive lymphomas require aggressive combination chemotherapy
 Prognosis
 6-8 years in indolent lymphomas
Multiple Myeloma
 Bone marrow is replaced by malignant plasma cells
 Monoclonal protein in serum
 Proteinuria
 Lytic lesions in bones
 May be caused by a new herpes virus
 Older adults median age is 65 (rare under age 40)
 Equal incidence in men and women
Multiple Myeloma
 Signs and symptoms
 Normochromic normocytic anemia
 Normoblasts may be present in blood
 Leukocyte count slightly decreased, normal, or slightly increased
 Elevated ESR
 Striking feature: Rouleaux formation
 Bone pain, back and ribs, sternum
 Infection (esp. encapsulated organisms e.g. S. pneumoniae; H. influenzae)
 Rouleaux
Multiple Myeloma
 Physical Exam
 Pallor
 Bone tenderness
 Soft tissue masses
 May have neuro symptoms if spinal cord is compressed
Multiple Myeloma
 Labs
 Anemia (normochromic normocytic)
 Neutrophils and platelets are normal at onset
 HALLMARK: paraprotein on serum protein electrophoresis (SPEP) (M spot)
 Bone marrow with plasma cell infiltration
 Bone x-ray
 Hypercalcemia
 Renal failure
 Amyloidosis in 10-15% of MM contributes to RF
MM: Bone Marrow Aspiration
Multiple Myeloma
 Treatment
 Palliative for bone pain
 Autologous stem cell transplantation for patients < 60 y/o
 Prognosis is poor
 Median survival 3 years
And finally
 A few more that were not listed on your objectives, but are mentioned in Current, so I suppose theyre fair game
 (Bonus questions anyone??)
Waldenstroms Macroglobulinemia
 Nonspecific symptoms
 Splenomegaly common
 Monoclonal IgM paraprotein
 Plasmacytic lymphocytes infiltrate bone marrow
 Absence of lytic bone disease
 Malignant B cell disease; hybrid of lymphocytes and plasma cells
 Insidious onset in 60s & 70s
 Fatigue related to anemia
 Mucosal & GI bleeding secondary to engorged blood vessels, platelet dysfunction
 +/- HSM, LAD; retinal veins engorged; purpura may be present; no bone tenderness
 Anemia universal; Rouleaux formation common
 Monoclonal IgM spike on SPEP in beta or gamma globulin region
 Serum viscosity sometimes significantly increased (4-6x H2O)
 Treatment and survival rates variable; median survival 3-5 years
Myelofibrosis
 Bone marrow becomes fibrotic
 Platelet-derived growth factor (PDGF)
 Extramedullary hematopoiesis in liver, spleen, lymph nodes
 Dry tap
 Teardrop poikilocytosis on peripheral smear
 Myeloproliferative, toxin, infection
 Adults over age 50; insidious onset
 Fatigue due to anemia; abdominal tenderness due to splenomegaly (often massive)
 Uncommon: bleeding, bone pain
 WBC count is variable
Myelofibrosis
 No specific treatment
 Transfusion for anemia
 Androgens may boost blood counts (poorly tolerated in women)
 Allogeneic bone marrow transplantation
 Median survival from time of diagnosis: 5 years
 End-stage: generalized debility, liver failure, bleeding from thrombocytopenia
 Some cases terminate in AML
Myelodysplastic Syndromes
 Cytopenias with hypercellular bone marrow
 2 or more hematopoietic cell lines have morphologic abnormalities
 Acquired clonal disorders of hematopoeitic stem cell
 Usually idiopathic
 May be seen after cytotoxic chemotherapy
 Ineffective hematopoeisis occurs
 Ultimately may evolve into AML; preleukemia
 Usually over age 60; may be asymptomatic
 Ultimately fatal disease (infections, bleeding)
Hairy Cell Leukemia
 Pancytopenia
 Splenomegaly, often massive
 Hairy cells on blood smear and esp. in bone marrow biopsy
 Uncommon indolent B-cell lymphocytic cancer
 Middle-aged men (median age 55)
 Striking 5:1 male predominance
 Anemia universal; 75% thrombocytopenia and neutropenia
 Dry tap on bone marrow
Hairy Cell Leukemia
 Distinguish from other lymphoproliferative diseases (Waldenstroms macroglobulinemia, non-Hodgkins lymphomas)
 Treatment: cladribine (2-chlorodeoxyadenosine; CdA); relatively nontoxic with benefit in 95%; complete remission > 80%
 Long-lasting response with most patients surviving > 10 years with current treatment modalities
Review and Questions
Where the hell are these sorry a** nurses coming from??
You know what I am tired of everybody bashing everyone else. Grow up people and get a life. There are good and bad of every profession and I am sorry if you got a bad NP. Don't let one experience forever skew your opinion of a whole profession.
I have heard of plenty of bad PA's and MD's yet I don't see any forums bashing these guys. In fact in honor of bashing each other why don't we start a forum about the horrible physicans we have had. I bet we could even discover what schools they went to. Please people grow up and move on, this stuff is really old and boring!
I have heard of plenty of bad PA's and MD's yet I don't see any forums bashing these guys. In fact in honor of bashing each other why don't we start a forum about the horrible physicans we have had. I bet we could even discover what schools they went to. Please people grow up and move on, this stuff is really old and boring!
Ive actually found this post to be educational. I've learned a lot about entry level standards for NP's and PA's. I've even taken the opportunity to compare the contents of the curriculums of each and realized the stark differences. Several NP's and PA's have spoken up including one NP who felt that her well regarded FNP program covered very little oncology. We've learned that NP's learn to recognize red flags and refer to somebody that can diagnose the problem and PA's are trained to diagnose the problem, order the appropriate workup, and treat and/or refer the problem.
Sorry if you don't like what you are hearing....I don't like what i've learned either, but it is valuable information and information like this should be available to patients so they can make educated decisions about who they see! For now, knowbody is required to read this post if they don't want to.
There might be educational information, but it's disguised by some anti-NP vs. anti-PA sentiments. Someone saying their program has very little oncology is different than saying "where are these sorry-@ss nurses".
Sure, it would seem that this sort of thing would be identifiable, but I agree with what Carolina Girl said.
I'm not saying that you are smoking crack, but to say that you "...don't see any forums bashing these guys (ex. PA's)."
You really need to look around these forums a little. I'm not talking about the MD's, but PA's are bashed on a regular basis.
In fact, there are quite a few folks on these forums who think that PA's have littered the landscape with dead bodies, missed diagnoses and hold a pen and scrip pad ready to write a dangerous drug cocktail to every person that walks through the door. In addition, they seem to think that we are the root of all problems in the healthcare system.
All non MD healthcare providers are denigrated to one degree or another here and nurses, NP's and PA's all take their share of hits.
So please don't do the martyr thing as far as NP's are concerned.
Sorry, if I'm so harsh, but I'm really sick of all the PA bashing that goes on here.
-Mike
You really need to look around these forums a little. I'm not talking about the MD's, but PA's are bashed on a regular basis.
In fact, there are quite a few folks on these forums who think that PA's have littered the landscape with dead bodies, missed diagnoses and hold a pen and scrip pad ready to write a dangerous drug cocktail to every person that walks through the door. In addition, they seem to think that we are the root of all problems in the healthcare system.
All non MD healthcare providers are denigrated to one degree or another here and nurses, NP's and PA's all take their share of hits.
So please don't do the martyr thing as far as NP's are concerned.
Sorry, if I'm so harsh, but I'm really sick of all the PA bashing that goes on here.
-Mike
Please specify to whom you are talking to.......
And try not to use euphemisms like "I'm not saying you're smoking crack, BUT..." - you're highly unlikely to have a "friendly" debate and have others stop bashing PAs if you use that kind of rhetoric to argue with.
Sorry to sound so harsh, but I'm sick of everyong complaining that they are sick of everyone bashing them, and then they bash right back.
And try not to use euphemisms like "I'm not saying you're smoking crack, BUT..." - you're highly unlikely to have a "friendly" debate and have others stop bashing PAs if you use that kind of rhetoric to argue with.
Sorry to sound so harsh, but I'm sick of everyong complaining that they are sick of everyone bashing them, and then they bash right back.
Actually, since I quoted the person I thought it was obvious.
So that there is no further confusion, I was speaking to CarolinaGirl and I was actually using the smoking crack think as an attempt at humor.
To be quite honest with you the tone of her post was pretty harsh and that was why my response was the same.
BTW, I noticed that you were very quick to jump on me for how and what I posted but you said nothing at all to her about telling people to grow up and get a life and she did not quote or reference who she was talking to.
Nor did you.
If you are going to insert yourself into every argument, then at least be consistent about how you dish it out.
-Mike
I did not run a search to see if PA's were bashed and I am sure they are, that seems to be the nature of these things on SDN. I am just saying since I have been on I have not seen it.
CarolinaGirl,
Not a problem. Hang around a little while and you'll see it and NP, nurses and others will be bashed as well.
I tend to think that a lot of people do exactly what you say and blame a profession for what a few do and I pretty much agree with what you said.
I just had a knee-jerk reaction to what you said about bashing PAs, because in my experience it happens quite often around here.
-Mike
Not a problem. Hang around a little while and you'll see it and NP, nurses and others will be bashed as well.
I tend to think that a lot of people do exactly what you say and blame a profession for what a few do and I pretty much agree with what you said.
I just had a knee-jerk reaction to what you said about bashing PAs, because in my experience it happens quite often around here.
-Mike
D
deleted87716
Bashing = insecurity. Once you recognize that, it won't bother you as much. 😉
WOW - you've been on here........a month...........and yet your first post on this thread is one that lectures everyone else about their posts that YOU personally find inappropriate (not that we care), on a thread that had been dead for almost a month. Great contribution.
I'll take a wild guess that the bashing of NP's on this particular thread or even this board probably won't get better, and will probably get worse over time. Why? Because NP's and other advanced practice nurses seek total autonomy from physicians and physician oversight, but are woefully undereducated and underprepared to do so. You and Megboo want to call that bashing? I call it reality.
They jump on RNs, RTs, CRNAs, AA's,NPs, PA's .... Heck the DOs get treated like an ugly step child!!
It does make you wonder at times.
"grow up and get a life" was directed generally at posters who continually rip on the subject. To imply someone is smoking crack is a little more harsh and personal, and as a forum advisor, I'd rather stop personal attacks from the get-go rather than have threads spiral out of control.
Next time use the quote feature included in each post and people won't have trouble figuring out who you are "directly" responding to.
You admitted you had a knee-jerk reaction. Try to keep a thicker skin, especially in this forum.
Did you even read my post.
I already explained that it was an attempt at humor and you also did not respond to the fact that she did not quote and neither did you.
That is the definition of hypocritical.
-Mike
I didn't think it was funny, and I'm not getting into a pissing contest with you. The end.
Some of these kids think they know it all already and have NO sense of humor whatsoever.
