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Archive for September, 2010


I just entered the last patient’s HIPPA approved information into my school’s logging system for the week. This was the first full week of clinical time at the pediatrician’s office, and I look back amazed at what I have learned in a few short days. Well, the days themselves weren’t short, a standard eight hours, but in the grand scheme of things a week is nothing.

But what a difference! When my preceptor first said “Okay, go see this patient”, I felt that sinking feeling you get when a police cruiser lights up behind your car. “By myself?” I asked. Keep in mind I have been a nurse for a long time and have done assessments on paranoid schizophrenics, dying hospice patients, prison inmates, etc. for YEARS.  In this situation, I am suddenly an almost clueless rank beginner, and the thought of a simple assessment seems like a world-shaking task. Silly me.

It is always worse in anticipation than reality. Now, after a week, that moment when you knock on the exam room door isn’t scary anymore. I can go into a room with that previously dreaded anxious parent and little tot needing attention and actually know that I can be useful. I can actually see a tympanic membrane at least half the time, and know that magic wand, the tympanogram, is available to corroborate. It is actually becoming fun to play with the kids to warm them up so as to get more or less cooperation for the inspection of ears for potatoes. It seems that sore throats and earaches are all the rage this week, with an ocassional tummy ache thrown in for variety.

Kids are a blast. Sitting in the little office corner that is my spot during an off moment, I sipped at my coffee and heard childish giggles, and questions, and running feet all over the office. The periodic crying was usually due to vaccinations or the dreaded strep throat swab. It was actually a pretty happy sounding place in general. The exam rooms are named for the paintings on the wall in each one. The nurses will say: Ready in Beach, or the strep in Dinosaur is negative. I never got to go to work in my brightly colored lizard shirt before.

One little guy came in with a worried dad who told me the child had been sick for two days. The patient was energetic and very squirmy when I tried to examine him. I asked “Did you eat worms for breakfast? You are so wiggly!” The delighted child replied “Yes, I had lots of worms for breakfast!”

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When you read about diseases and conditions of tympanic membranes and external auditory canals (eardrums and ear canals), the books show you nice little pictures of otitis externa, fungal infections, foreign objects in the ear canal, clean tympanic membranes and ones with perforations, cholesteatomas, infections and fluid levels, etc. The pictures show beautiful ear drums with the little bones clearly visible, and the cone of light (known as the umbo, love that word) which all indicate a nice healthy ear, or ones with a nice clear line of fluid visible and a bulging membrane.

Normal TM

It looks so simple…”Of course I can see the difference between and healthy and a diseased ear, it is so obvious!”.

Ha! Not so fast. Obviously the ears in the pictures are attached to unconscious people who have just had their ears thoroughly cleaned for ease of viewing. The picture is nicely magnified and crystal clear.

I practice, it is a little different. The patient looks at you with a dubious frown as you approach them with the otoscope. You reassure them it is nothing but a light and proceed…you pull on the pinna, brace your hand against their head to hold them still, insert the little funnel hoping it is far enough but not too far, and… all heck breaks loose. The child cries, squirms, bats at your hands and generally lets you know this is NOT what they had in mind. The mom holds the hands and you peer at the little lens and see…not much. The ear canal isn’t straight enough. You pull out and repull the pinna. Okay now you see…ear wax. Is that a little tiny bit of tympanic membrane behind the wax? Oooh, I think  I see the cone of light, but is the tympanic membrane a little grey? Child squirms some more, picture lost. Crap. Okay, the other side, this one doesn’t have as much wax, you can see a little better, now you see the tympanic membrane is a little red, but is it because of the crying? Or is it really inflamed?

Yes, this is exactly how it works...not.

I watch the NP who is my preceptor do an exam. She smoothly puts the otoscope in, 1 second and she’s done. “Yep”, she says, “I see that the TM is opaque and there is a fluid level.”

Sigh… It is going to take a lot of practice to get this particular skill right.

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After spending my first day in clinicals, I feel a little more confident. I followed my preceptor, assisting her where I could. 

We decided early on that it was sore throat day (better than nausea/vomiting day!). Only two of the kids we saw did not have a chief complaint of sore throat and runny nose. A three month-old had RSV, respiratory syncytial virus. We had to twirl a little brush in her tiny snorky nose to get that sample. She was not amused. Several kids had strep throat. The swab in the back of the throat far enough to make you gag, twice, to collect the specimen was also not a favorite part of the exam. I got excited when I heard one streppy kid had a rash, I wanted to see a scarlet fever rash. Darn kid was already pretty much over it and I didn’t really get to see the classic sandpaper rash. 

Open wide!

Several kids had ear infections. They can also complain of sore throat and runny nose, and may not necessarily have ear pain. We peer into their ears with the otoscope (otherwise known as Mrs. Lightbright, who is married to Mr. Longears, the stethoscope), assessing the tympanic membrane (eardrum). Normal eardrums are translucent and you can actually see the little bones of the inner ear through it. Pretty cool. Infected ears tend have foggier eardrums, and it is difficult to see the bones, they can also be inflamed, or have a visible fluid level behind. It is a judgement call as to whether the ear looks infected. It isn’t always obvious, so we did several tympanograms to give more data. The tympanogram is a little gadget that looks like a big ear thermometer, you seal the opening of the ear canal and push a button. The machine measures the pressure in the ear, if abnormal, it can indicate an ear infection. 

There is a lot of resistant bacteria around these days, so we don’t always jump on the pink stuff bandwagon in an effort not to create more. If you bring your child in with an ear infection that is new (not a recent repeat or unresolved one that was already treated) say less than three days duration, the NP or physician may not order antibiotics right away. Watchful waiting may be the best option, as many ear infections resolve spontaneously. According to all of my books, resistant bacteria are a result of too short antibiotic treatment, too low dose of an antibiotic, or quitting the antibiotics before the prescribed course is finished. These all allow the most resistant bacteria to live and multiply. Some bacteria are able to mess with the antibiotics and keep them from working (I am not going into detail about beta lactamase), so if the initial amoxicillin doesn’t work, we will bump it up to a drug that has an extra ingredient to prevent that. 

A very interesting first day. Now the fun part…logging all these cases into my school case log program. Sigh.

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