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Case Study #4 PEDIATRIC CASE STUDY

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SCENARIO Mary Jennings has brought her son Joe to your office. Joe is a 6-year old Jordanian male. He presents with the complaint of an itchy red eye. Mary states that it was crusted with dry yellowish drainage several times this morning. Joe has complained to Mary frequently about pain in his eye."

TENTATIVE DIAGNOSES Based on the information provided so far, what are the potential diagnoses?

Potential Diagnoses Conjunctivitis

Provide rationale to support each potential diagnosis based on information provided above. Acute condition, itchy red eye, crusted with dry yellowish drainage, eye pain

Corneal abrasion/eye trauma Acute condition, red eye, itchy, eye pain

Herpes simplex blepharitis

Eye pain, red eye, itchy, yellowish drainage

Iritis

Red eye, eye pain

Glaucoma

Red eye, eye pain/ discomfort

HISTORY Below is the history obtained from the mother/child. What are the significant findings that will help you narrow down to a specific diagnosis? Significant findings are highlighted

Requested Data Allergies Medications Recent changes in health

Chief complaint: onset, location, quality, aggravating/alleviating factors

Data Answer None known. None. No problems until present complaint. Last checkup 3 months ago. Joe describes burning, itching, and pain in OD. States that pain is not "too bad." Mary describes a thick yellow drainage. States it looks like pus. Joe's eyelids got stuck together by drainage. Joe denies a change in vision and blurred vision. Pain is bad when he looks at bright lights. Mary states warm wet washcloths have helped relieve burning

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Associated manifestations

Associated symptoms History of exposure to conjunctivitis History of swimming in chlorinated or contaminated water History of trauma to eye History of exposure to chemical Recent cold sores or exposure to herpes lesions Recent history of impetigo

Family members with eye problems Past medical history

No history of recent or concurrent respiratory infection. Denies history of throat pain, ear pain, rhinorrhea. None.

Has swam two times in the past week in nonchlorinated pool.

None. None. None.

None, but his younger brother was started on Keflex 3 days ago for impetigo on his face. Joe has two younger siblings who do not have any eye symptoms. Normally healthy. No hospitalizations or surgeries.

PHYSICAL EXAM Significant portions of PE based on the chief complaints

SYSTEM Skin

Heart sound Breath sounds

Vital signs Ear, nose, throat

Eyes

FINDINGS Skin is pink and supple, no lesion noted.

S1 and S2 normal, without murmur Clear to auscultation

T (oral) 98. HR 84, RR 22, BP 88/56 TMs pearl gray bilaterally. Nares patent and free of drainage. No pharyngeal erythema or edema. No oral lesions. OS sclera white, without injection, erythema, or edema. OD edema of eyelids present. Crusted yellow drainage on lashes.

RATIONALE Overall quick assessment of visible skin should be performed. Particular attention should be given to the face. Provides baseline information. Allows the NP to determine if there has been respiratory involvement. Gives an indication of possible infection. Gives an indication of possible infection.

Needs to evaluate eyes thoroughly to identify possible diagnoses. Visual acuity should be

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Eyes (cont.) Fundoscopic Lymphatics

Conjunctiva markedly inflamed. Cornea and eyelid margins without ulceration. PERL with positive red reflex bilaterally. Visual acuity reveals OD 20/20, OS 20/20.

Discs well marginated. No AV nicking

No palpable lymph nodes in the head of neck.

completed for all patients with eye problems. It is vital for patients with decreased vision. This test may be painful if the child has photophobia. Provides a quick indication of eye health. This test may be difficult owing to photophobia and constriction of pupils. Palpation of lymph nodes can provide an indication of infection.

DIFFERENTIAL DIAGNOSES Provide the significant positive and negative data that support or refute your diagnoses.

DIAGNOSIS Allergic conjunctivitis

SUPPORTIVE DATA Normal visual acuity- OD 20/20, OS 20/20; burning, itchy, eye pain; red eye; pain describes as "not too bad"; denies changes in vision and blurred vision; PERL; no palpable lymph nodes in the head and neck.

REFUTING DATA Pain is bad when he looks at bright lights; denies throat/ ear pain, rhinorrhea; no complaints of scratchy sensation in the eyes; only one eye affected; no history of seasonal allergies.

Bacterial conjunctivitis

Itching & pain in OD. Thick, yellow drainage- looks like pus. Eyelids stuck by drainage. Crusted yellow drainage. PERL. No palpable lymph nodes. Conjunctiva markedly inflamed. Normal visual acuity. Denies change in vision or blurred vision. Swam 2x in the past week in non-chlorinated pool. Younger brother was on Keflex 3 days ago.

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Chemical conjunctivitis Viral conjunctivitis

Corneal abrasion/eye trauma Herpes simplex blepharitis

Red eye, itchy, burning sensation, pain describes as "not too bad".

Normal visual acuity. Red eye, itchy, burning sensation, pain. PERL. Denies any changes in vision or blurred vision. Conjunctiva markedly inflamed.

Pain in OD, pain is bad when pt looks at the lights. Eye redness. Burning sensation. Itching and burning pain in OD. Pain is bad when pt looks at bright lights. Eye redness. Thick yellow drainage that looks like pus. Eyelashes crusted together. Eyelid edema. Younger brother was on abt 3 days ago for impetigo.

Swam 2x in the past week in non-chlorinated pool. Symptoms will be bilateral not unilateral Thick yellow drainage that looks like pus. No history of recent or concurrent respiratory infections. TMs are pearly gray bilaterally and nares are patent and free of drainage. NO pharyngeal erythema or edema. No history of eye trauma. Thick yellow drainage. Normal visual acuity.

Normal visual acuity. Corneal and eyelid margins without ulceration. No history of recent or concurrent respiratory infections. No palpable lymph nodes in head or neck. No exposure to herpetic lesions

Iritis Glaucoma

Eye pain. Eye redness. Burning and itching to eye.

Eye pain and eye redness.

Normal visual acuity. PERL. Denies any changes in vision and blurred vision. Cornea and eyelid margins are normal and without ulceration. Age. No family history of glaucoma. Normal visual acuity. PERL. Discs well marginated. Drainage.

DIAGNOSTIC TESTS Based on the history and PE, the following tests were ordered. The test and results are provided. You will need to provide a rationale to support the use of this test or provide documentation why you would not order this test in this case.

DIAGNOSTIC TEST

RESULTS

Eye culture and gram stain Test not done.

RATIONALE Test not indicated at this

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time. Culture of eye discharge is only recommended if unresponsive to treatment or if N gonorrhea is suspected. Normal visual acuity.

DIAGNOSES

Based on the data provided, what are the appropriate diagnoses for Joe?

List all appropriate DEFINITIVE diagnoses for Joe in priority order.

Diagnoses

Rationale

1. Bacterial conjunctivitis

Itchy, red eye, unilateral, thick yellow

drainage that looks like pus, crusting of the

eye, conjunctiva markedly inflamed, OD

edema of eyelids present, pain "not too

bad", normal visual acuity.

THERAPEUTIC PLAN Provide answers with scientific basis for the following questions about Joe's treatment plan. Provide APA references when indicated.

(1) What therapeutic agent would you use in planning care for Joe?

Azithromycin 1% solution- one drop in affected eye BID x 2 days then 1 drop daily x 5 days.

(2) What is your rationale for choosing this particular agent?

a. Azithromycin is active against gram + organism due to exposure to impetigo. b. Increase compliance with medication due to dosing being twice a day x 2 days

and once a day x 5 days.

(3) What education does Mary need to provide relief for Joe and decrease the risk of reinfection?

- Educate pt and mother that conjunctivitis is highly contagious - Secretions may remain infectious for at least 48 hours after the start of treatment. - Proper hand washing techniques - Patient should be educated not to touch his eyes and wash hands frequently - Do not share towels and wash cloths - Teach proper technique for medication administration of eye drops - Do not touch the medication applicator to the eye

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