There are often times when the chief complaint truly misses the nuance of what the real concern holds in store.
Wednesday, July 29, 2009
For instance, a chief complaint of diarrhea in a child is not so common, not so nuanced, not so big of a deal.
(As an aside, newFNP had a pediatrics professor who invariably pronounced the word diarrhear, which so brought glee to newFNP and BostonFNP during a long day of dry lectures-- and it still does to this day!)
But what if diarrhea is not just diarrhea? What if it is encopresis? Well then, you're in for a hell of a different appointment.
The history went something like this: the six year old boy was toilet trained, but then he started soiling. When he's with mom, she has him wear diapers, even to school. When he's with dad, he is instructed to go commando so that he is forced to "learn to control himself." Both interventions wholly unacceptable and antithetical to appropriate treatment.
To be fair, this is in part the clinic's fault. He had been seen twice before for the same problem, had received minimal guidance and had no improvement in symptoms. No big surprise there. It's a confusing diagnosis for parents. It's tough for primary care providers to give diagnoses such as this the appropriate care given that it involves greater than 10-15 minutes, education from the provider and counseling from an actual counselor.
What makes this even more difficult is when the kid's father is intoxicated in the exam room and when the kid's mom is absent - both from the appointment and largely from his home life as she works and spends an extraordinary amount of time volunteering at church. It was clear to newFNP that the kid was used to his dad being drunk when she watched him call his name and gently slap his face in order to rouse him when she called them in from the waiting room.
All throughout the encounter, newFNP was concerned about neglect. But the kid was clean, he was growing appropriately, and he related well with newFNP and with his father. His future might not be the brightest given the family history of alcoholism and the poverty, but poor alcoholics raise healthy thriving kids so we'll have to institute a prospective study to see where this kid goes. NewFNP decided that it wasn't neglect - that it was ignorance regarding the problem and lack of support.
NewFNP gave the appropriate education, both verbally and in written form, instructed the father that both the diapers and the sans undies must stop A.S.A.F.P., ordered an x-ray, prescribed Miralax and toilet times, and hooked the family up with free counseling. This took about 40 minutes.
Worth it. They showed up to their counseling appointment the next day and have follow-up scheduled.