I’m working on a nursing discussion question and need an explanation and answer to help me learn.

               Clinical has been exciting and much anticipated for myself and I imagine many of you all. I am a part time student so it has taken me a bit to get to this point (and will take me longer to get to graduation!). I anticipated working with my preceptor to be stressful and I was worried about becoming that novice learner again from my higher level of comfort as a nurse. But it has been such a wonderful experience!

               My first clinical is in a Rural Health/Critical access organization’s walk-in clinic. This does defer from a larger organization’s urgent care. The walk-in clinic is more a family practice area for acute visits only. However, this clinic has been this organizations’ respiratory clinic. The nurse practitioner providers in this clinic routinely see 25 to 40 patients daily. Some are very easy acute visits and others need to have some diagnostic testing to help diagnose their condition.

               My preceptor and fellow providers still see many respiratory illnesses and that is the majority of the cases they have seen with the pandemic of COVID-19. All visits seen by my preceptor and myself are acute visits. Other diagnoses that are common include injuries needing sutures or repair, injuries that require an x-ray to diagnose and possible splinting (rarely do they cast a patient), UTIs, abdominal pain, ear infections, skin rashes, and other acute illnesses.

               Some of the resources available to the walk-in providers include ER physicians, the primary care physician network that has the panels of the patients we see. These 2 resources help in complicated or unstable situations that need clarification or a higher level of care. Other resources available during daytime hours are a clinic social worker, pharmacy, and a pharmacist to assist with complicated medication questions. Community resources include a shelter for women and a network of behavioral health networks.

               One of the most interesting patient presentations up to this point would be a 39-year-old male presenting with a textbook example of acute gout in second big toe. He started a couple days prior to presenting to the walk-in clinic after he ate a large celebratory meal of steak and seafood. He also drinks 2-3 beers each night. He presents with a swollen red and tender first joint of the second toe on the right foot.  The classic nature of this patient’s presentation is what makes it interesting!

               History taking, physical exam, and patient education I am comfortable in pulling on my 27 years of nursing experience. I am becoming very astute at encouraging a patient to focus on history in the walk-in clinic environment. It is an art to listen but encourage movement forward in the information phase of the visit and help guide the agenda towards a timely conclusion.  In areas where there are resources available it is easy to reference material needed for the role as a nurse practitioner. Pharmacology and prescribing are a moderate comfort zone. Although textbook or reference material and real life sometimes vary widely so having that preceptor and mentor is so helpful in learning certain treasured tidbits. Diagnosis is still a work in progress for my comfort zone. Again, when it is cut and dry or you have a diagnostic tool to indicate a clear diagnosis, it isn’t difficult. However, skin issues still challenge me. For instance, we had a 71-year-old woman in with sores around her nose. Differential diagnoses immediately include impetigo, herpes, shingles, and skin infection. We were looking for the presenting characteristics of each lesion. This patient was a poor historian. Yes, she had exposure to impetigo to her 3-year-old granddaughter. (Her granddaughter is 6 now, no exposure for 3 years! This history came after a great deal of getting the patient to focus.) She has had shingles in the past. Presented on her left flank. These sores were bilaterally on both nares and only inside her nares. She had placed cosmetics on it this morning because it was so red and ugly. In addition, she had “popped” the area in the morning and was presenting to us in the evening. This was not a clear diagnosis to me the novice FNP learner.

               Using my resources and asking questions has been one of the biggest lessons at this point I have learned. Not being afraid to look up something I am unfamiliar with and clarifying what I see during the visits with patients helps my relationship with my preceptor grow as well. I look forward to building on the knowledge base of my first clinical. My challenge is the area that I am in is all acute visits and I have not heavily experienced the physical or History and Physical format. Also, the urgent care settings and walk-in clinics do not do a complete review of symptoms since they are seeing only the focused chief complaint. This too will be an area I look forward to expanding in future clinical rotations.