Where did you get your license, KMart

llg, PhD, RN · Dec 7, 2009

. based on what i have read, the np should have seen you to evaluate your condition. the pa was wrong, the np was wrong and the md may have been wrong.

yep. the np should have seen you before making a judgment. the pa should not have told you needed antibiotics without examining you, etc. etc. etc.

elkpark · Dec 7, 2009

The long-standing, widespread practice of overuse and misuse of antibiotics is precisely why we have all the resistant bugs creating problems now. I'm always glad to see practitioners be cautious and hesitant about Rxing antibiotics until they know it's a bacterial condition and they've got the right antibiotic.

kanzi monkey · Dec 8, 2009

Sorry, but I don't agree. I think it is a shame that you are belittling this person's education and credentials because you don't agree with her clinical judgement. It sounds like she is trying to avoid unnecessary prescribing of antibiotics in favor of inexpensive and safe home measures such as nasal washes and OTC meds for comfort. What's wrong with that?
If the PA you work with is so certain that antibiotics are indicated, why did he not prescribe them?

Can you form a reliable clinical judgement without assessing your patient? Sure it may have to happen sometimes, but if at all possible a patient with prolonged, worsening URI symptoms should at least be seen. Also, she has asthma and may be more likely to acquire a superimposed bacterial infection or suffer worsening asthma symptoms.

I'm not saying the NP was wrong in her diagnosis, or that the MD who DID prescribe meds was right to do so. But assuming the MD wasn't just prescribing at the request of the patient, s/he has a bit more credibility in the diagnosis arena for, you know, taking a peek.

litebrightgirl · Dec 8, 2009

Ok. I did not go to my PCP because I couldn't get in for another 3 weeks. That is why I went to urgent care. Second, I have a hx of asthma and was only on a preventil inhaler and my asthma has been getting increasingly worse so the MD put me on Advair. The urgent care clinic is downstairs from my PCP, so he had access to my records and was able to prescribe it. Third, I went to work today and the MD in the office sent me home after 4 hours because my symptoms were getting worse. I was never given a neb tx in the urgent care. Don't know why b/c he listened to my lungs and said they were tight. Today, the MD in the office gave me a neb tx and agreed with the MD in urgent care's dx, not the NP who wouldn't see me. I didn't want to start a war with all of this. BTW, I agree that MD, PA, and NP prescribe meds too much but for her not to even look at me and say I'm not sick was unacceptable. Oh and prarienp, I didn't feel like my chest was tightening so I didn't know that I had a problem with my lungs. I was coughing too much to pay attention to that. And I didn't tell the MD in urgent care I needed abx b/c he at least took the time to examine me. Not trying to be smartmouthed, just answering your question

Bonosgrrl · Dec 8, 2009

What I find odd about this story, is that the NP would dx without physical exam. Not saying it didn't happen the way you reported, but it is strange to me in this day of lawsuits galore that any practitioner would offer up diagnosis and treatment without a physical exam.

HeartsOpenWide, RN · Dec 8, 2009

I work in a doctor's office and the PA said I need to get a script for a z-pack.

Ok. I did not go to my PCP because I couldn't get in for another 3 weeks. That is why I went to urgent care.

I tend to side with the FNP. ABX need to be given out with digressions. Unless it is blatantly obvious that a person needs ABX, other forms or treatment should be given. If it is blatantly, then a broad spectrum should be given while waiting for a culture to indicate a more specific ABX treatment. Everyone assumes that when they are getting sick they should have ABX, and many doctors want to keep their patients happy regardless of the fact that their patients are requesting ABX when they should be given Tamaflu or even a prescription for a day off of work and some chicken-noodle soap and OTC meds. From your description it sound more like a cold than a bacterial infection; but of course I have not seen you. Don't forget that some of the assessment includes subjective information, and a good physician can physically assess a lot just by observing a person without touching them, but not all; I do agree that the FNP should have at least listened to your lungs.

Just a question, if the PA in your office told you you needed a z-pack why did he/she not write you a prescription? You said the PA could not see you for three weeks? I use to work in a physicians office and I do not buy that; they could have spent 10 mins seeing you after hours. Also, if the PA said you needed a z-pack I am guess this was without a physical examination and just by observation or else he would have written you the z-pack...so to get angered because the FNP would not give you ABX by observation just as the PA did is being hypocritical and you are choosing to side with the person you want something from. Its this very demanding attitude that is one of the reasons that there are so many bacteria out there resistant to ABX.

core0 · Dec 8, 2009

What I find odd about this story, is that the NP would dx without physical exam. Not saying it didn't happen the way you reported, but it is strange to me in this day of lawsuits galore that any practitioner would offer up diagnosis and treatment without a physical exam.

If you read the original post, the OP told the NP the symptoms but never registered for the clinic. The NP essentially told her with those symptoms you aren't going to get antibiotics. In all probability the algorithm that the clinic uses doesn't give antibiotics for those symptoms regardless of physical findings. The NP chose not to bother with the patient knowing what the outcome would be (presumably).

This is essentially a more complex version of what we did as medics in the Army. We had an algorithm which started with the CC and directed the exam. For example if you had a sore throat you opened the book to page 9 (ENT complaints) and followed the instructions. At each line there were decision points. For example if the patient was unable to touch their chin to their chest then that mandated immediate evaluation by the PA or physician. These tend to work fine when applied to healthy 20 year olds without other medical conditions. On the other had when dealing with the general public and the multiple comorbidities that we see it does not work as well. Especially when it substitutes for the providers judgment.

Caveat my N here is small and related to one clinic system and one diagnostic algorithm. I've reviewed two cases in the last year both involving retail clinics and NPs where algorithms led to patient misadventures (and in one case patient demise). Both cases involved a URI type presentation that ended up being pneumonia. The way the algorithm was designed there was no input for physical exam findings. In one case the NP clearly documented that there were no right base breath sounds, however the algorithm directed the provider to give supportive care.

I'm not suggesting that all retail care is like this, however, the use of an algorithmic approach to medicine contains many pitfalls. From a corporate point of view algorithms have many advantages. They largely prevent inappropriate prescribing and mandate that the provider adhere to evidence based practice. However, no algorithm can cover all eventualities. In addition the algorithm is only as good as the providers ability to use it.

Just like the NP we have a hard time judging whether any of the care was appropriate without seeing or examining the patient.

David Carpenter, PA-C

CraigB-RN, MSN, RN · Dec 9, 2009

Ahh the old Dr Amoset. I had forgotten about those. I remember running those sick calls with the notebook in front of me. :) I also rememberd the first time I had a female patient and there were no pages for female problems. The drawback of "cookbook" medicine.

Dixiecup · Dec 12, 2009

since none of us were there to actually eval the pt, from what she has told us, I believe the guidelines state that an immunocomprimised pt such as one with hx of asthma, presents with a cough that she has had for a while now, should be prescribed a zpack, along with some albuterol neb tx every six hours to get all that gunk opened up. In addition I would have probably prescribed a medrol dose pack to help alleviate the cough also and get rid of some of that inflammation but this is just my opinion. hard to eval someone on paper!

NocturneNrse · Dec 12, 2009

Sounds "Flu-Like".. and that's viral.. perhaps she was thinking along those lines. Abx's aren't going to help a virus. BUT.. she could have been more professional and compassionate about her interaction with you. = (

paacollins · Dec 12, 2009

You have some healthcare providers that will NOT prescribe abx no matter what and sometimes they ARE needed. If you've had a cold for a month I tend to think it is a sinus infection or upper respiratory infection that would warrant abx. I think the NP was wrong by not checking out the patient before she stated "you are not getting anything". I wouldn't have liked the attitude either. You can't tell what someone needs until you access them and you can't do that by simply asking the symptoms.

Dr. Tammy, FNP/GNP-C · Dec 13, 2009

since none of us were there to actually eval the pt, from what she has told us, I believe the guidelines state that an immunocomprimised pt such as one with hx of asthma, presents with a cough that she has had for a while now, should be prescribed a zpack, along with some albuterol neb tx every six hours to get all that gunk opened up. In addition I would have probably prescribed a medrol dose pack to help alleviate the cough also and get rid of some of that inflammation but this is just my opinion. hard to eval someone on paper!

This is incorrect and inconsistent with standards. First, someone with asthma is not presumed to have an immune system compromise--this is a respiratory condition. Second, prescribing antibiotics for someone without bacterial rhinosinusitis is not consistent with current literature nor medical standards. The standards from the American Academy of Otolaryngology indicate supportive care to alleviate symptoms and show that those with positive relief after 14 days (the vast majority with rhinosinusitis) would not benefit from antibiotics. Third, Amoxicillin--not azithromycin is the proper empiric antibiotic selection for those with ABRS. Lastly, there is no evidence to support that systemic glucocorticosteroids are either safe or effective for rhinosinusitis. There is stong evidence, however, that supports the association between systemic steroids administration and weakening an individuals immune system, especially in the context of an individual batteling a URI.

http://www.guideline.gov/summary/summary.aspx?doc_id=12385&nbr=006414&string=Sinusitis

Inappropriately prescribing and use of the wrong antibiotics is a leading cause of bug resistance and figures largely why azithromycin carries a 30% resistance to previous isolates in my particular geographic area.