Archive for October, 2010

One of the first things a new clinical rotation does to you is create a sense of anxiety. It seems like you don’t know anything (this is only me, after all, what do I know?). Reading stuff in a text book is WAY diferent than confronting a patient face-to-face. Each knock at the exam room door before you enter has a particular uncertainty to it. What will you see on the other side? Will the parents be nice, or look at you with that look that says “Not only are you not a doctor, but a student nurse practitioner”? Will the problem be obvious, or will it be one of those times where the diagnosis could be one of a dozen options, for example: rash or a fever? Can I maintain the professional persona, or will I melt into a blithering idiot?

I have to do what I told my LPN students when I first took them into a clinical: “You have done all of this in lab, just go in there and pretend you have done it a million times already, just act professional and you will feel professional.” Ha!, Those words are haunting me now!

A few weeks ago (my excuse for this story is that it happened early in the clinical rotation, I never panic now…….really, never) I got a patient with a presenting complaint of high fever for several days, recorded around 103+ by Mom.  I knocked on the exam room door with my stethoscope draped around my neck and Miss Brightlight clutched in my hand, and entered. The mom was sitting in the chair with her three-year-old across her lap. He looked very pale, his eyes were closed, and there was no reaction to me entering the room and introducing myself. Mom and Dad looked at me expectantly. The child was limp, his arms and legs just dangled, his head hung over his mom’s arm. “He has been so sick! He hasn’t eaten or had anything to drink all day. We are so worried.” The child didn’t move. I panicked.

“I’ll be right back,” I told them and got my preceptor. “This kid is really sick! He just lays there, he is pale and looks terrible.” My preceptor asked me “Did you try to wake him up?”……….Oh………..Duh.

Needless to say, I went back in and asked mom to put the child on the table. He woke right up and was actually fine. Had a simple strep throat. I felt pretty stupid. My preceptor is an angel, she did not say a word, didn’t even smirk. I love her.

I poke them a bit before panicking now.

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Recently, one of my dogs kept getting a rash on his belly, in his armpits and under his chin. He kept rubbing his face on the carpet until he wore patches of hair off his ears and around his eyes. I was really puzzled by this, he never had any allergies before.

So, I put on my diagnostic hat and started thinking about it. The rash on his belly was red and especially bad under his armpits, the skin around his eyes looked atopic (like eczema) and it was all obviously itchy as he kept chewing at his feet and belly and rubbing on the carpet and shaking his head a lot. The rash was obvious as this dog always sleeps on his back…

Lookit my rash, mom!

I tried to think of what was new in his life recently…..food not changed, no new toys or treats…oh, yes, new treats. But, it seemed so local, this rash, only on his belly and face. Food allergies erupt all over. Flea allergies (not that he has any) show near the base of the tail. Then I noticed an area in the yard with a ground cover called Oyster plant, we had put it in recently and it was doing nicely. Hmmm….A little research on the internet, and I had the answer.

The culprit

Oyster plant, otherwise known as Moses in a Basket and Boatlily, or taxonomically as Tradescantia bermudensis, turns out to be poison ivy for dogs. I saw that the bed had been enthusiastically plowed in the hunt for lizards and other interesting little animals that Elwood loves to find. Too bad, the plant was so pretty and made such a good ground cover for the area. Oh well, the plants were dug out and tossed into the yard waste bin to be hauled away.

Maybe ferns would look nice in that particular spot, but, I wonder if little ferns are toxic to dogs. I will definitely look into it before planting them. Perhaps I should look up the other plants we have in the yard, too. You never know.

Elwood is doing fine after a short course of Benadryl.

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After a rough week of seeing multiple toddlers with nasal congestion (RSV, flu, common cold, allergies, sinusitis, ear infection, teething, strep?) or diarrhea/vomiting (viral gastroenetritis, flu, GERD, diet changes, constipation/impaction, rotavirus, food poisoning, etc, etc, etc) and trying to figure out the correct diagnosis with the variably accurate information we were getting from the parents, it seems a good time to give some hints.

Granted, my experience is rather limited, but some glaring issues came to light this week, as I struggled with a head cold myself (probably a gift from one of the snorky tots I saw last week) to do a good job of diagnosing the kids’ problems. There are so many options for even the simplest symptom, and if the diagnosis isn’t right, the treatment won’t be effective.

Parents need to be aware of what it is like on the other side of the exam room door. There is a list of patients to be seen, usually one every 15 minutes. This limits the amount of time the physician or nurse practitioner has to get to the bottom of the problem, formulate a treatment plan, write up the scripts and instruct the parent in what they need to know to take care of their ill child, and chart everything in the wonderful computer program that is now the chart. This is not easy! The previous records need to be reviewed to know the background and medical history of the child, which may have a great bearing on the current situation; then we interview mom or dad and the child if old enough to get a history of the current complaint; then the physical exam which has to be focused but also general enough to catch other signs/symptoms which may be relevant. Then any last questions need to be resolved with further questioning of mom or a test such as the strep test, or a CBC.

So, what can Mom or Dad do to help the process and insure the best outcome for their child? Here are some good hints:

  • Come on time for the appointment, and leave other kids at home if at all possible. Having more than one child milling around in a small exam room can be very distracting to both mom and the NP. It makes it much more difficult to do a good concentrated interview and exam.
  • If you do have more than one child, maintain order. Allowing kids to run around the room, or out the door, or get into the drawers or the NPs tools, or talk constantly, also prevents the opportunity for good communication and physical exam.
  • Do not ask the NP “Oh, by the way, my other child is sick, too, can you check him out real quick?” Make a separate appointment. Remember, the NP has 15 minutes, and if you add a second child, it cuts it down to 7.5 minutes, or causes everyone else to have to wait longer. This is not fair to your kids or the other patients.
  • Have a log of your child’s symptoms. If you say that they have had a fever for 4 days, we have to ask how high the fever was for each day, how did you take the temperature, what did you do for the fever (such as give ibuprofen) and whether it worked. If you have a log of the temperatures, with times and remedies you tried with effect, this would be a great help. Same way for episodes of vomiting or diarrhea. How much, when, what did it look like, what do you think precipitated each episode, if you know: a coughing spell started a vomiting episode, or they have diarrhea right after everytime they eat something. For example, diarrhea should be listed like this: Wednesday, 10 AM, large amount of brown liquid.
  • Keep track of how many wet and poopy diapers your infant has, and how much and when he eats, listing the ounces of formula.
  • If you have a list of questions, that is good, but keep it reasonable and focused on the problem of today. If you add other stuff, things may get off track with a poorer outcome. Keep unrelated stuff for another visit, or the well visit.

All of this makes things easier for both you and your child, and also the practitioner.

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Going into a clinical practice as a student is something outside of most people’s comfort zone. Not only have you changed from expert RN to newbie NP student, which is a shock to the system anyway, but you are in someone’s actual, real live place of work. Not really a member of their team, but participating as such.  Of course, you feel a bit insecure, and you try to fit in. A lot of the success depends on your own attitude and behavior in that role, but the preceptor you have, as well as the rest of the staff at the place you are being precepted, can make the difference between a great learning experience, or total disaster.

I consider myself massively fortunate to have scored the preceptor I have. The practice has 3 physicians, and two nurse practitioners, one just graduated. The providers, nurses and all the staff are spectacularly supportive and nice. Wow. It could be so different.

The NP who is my preceptor is patient, never makes me feel stupid, answers all of my questions and gives me the benefit of her experience by teaching me lots of good stuff. Coming into this rotation, I was quite nervous since most of my experience has been with the older folks. Kids were not really on my radar, my own are in their 30’s, so it has been a while since I dealt with the little guys. She has made me feel welcome and doesn’t even act like I am slowing her down a bit, which I know I do sometimes. Even when I feel like I did not do a very good job with a diagnosis or something, she backs me up and points out what I did right.

Bottom line: be careful who you pick as your preceptor, if you have a choice. A bad fit makes for a decreased learning experience and stress, a good fit is wonderful! I hope all my preceptors are as good a choice as this first one is turning out to be.

Thanks to everyone in the practice, I haven’t had anything but positive experiences with all of you!

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