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.
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.