Kallendorf-Case Study #4 PEDIATRIC CASE STUDY 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 Corneal abrasion/eye trauma Herpes simplex blepharitis Iritis Glaucoma Provide rationale to support each potential diagnosis based on information provided above. Itchy red eye Yellowish drainage Crusted several times in the morning Pain in his eye Eye pain, redness No complaint of foreign body present, no blurred vision, no history of trauma Itchy eye, crusting of the eyelids, eye pain No complaint of foreign body sensation, no lid erythema, no vesicles Reddened eye, pain, No complaint of headache, no blurred vision Eye pain, No complaints of halos around lights, reduced visual acuity or vision changes, no blurred vision, no headache or nausea 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? Requested Data Data Answer Allergies None known. Medications None. Recent changes in health No problems until present complaint. Last checkup 3 months ago. Chief complaint: onset, location, Joe describes burning, itching, and pain in OD. States quality, aggravating/alleviating that pain is not "too bad." Mary describes a thick yellow factors 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 Associated manifestations No history of recent or concurrent respiratory infection. Associated symptoms Denies history of throat pain, ear pain, rhinorrhea. History of exposure to None. conjunctivitis History of swimming in Has swam two times in the past week in non-chlorinated chlorinated or contaminated water pool. History of trauma to eye None. History of exposure to chemical None. Recent cold sores or exposure to None. herpes lesions Recent history of impetigo None, but his younger brother was started on Keflex 3 days ago for impetigo on his face. Family members with eye Joe has two younger siblings who do not have any eye problems symptoms. Past medical history Normally healthy. No hospitalizations or surgeries. PHYSICAL EXAM Significant portions of PE based on the chief complaints SYSTEM FINDINGS RATIONALE Skin Skin is pink and supple, no lesion noted. Overall quick assessment of visible skin should be performed. Particular attention should be given to the face. Provides baseline information. Heart sound S1 and S2 normal, without murmur Breath sounds Clear to auscultation Allows the NP to determine if there has been respiratory involvement. Vital signs Ear, nose, throat Eyes 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. Conjunctiva markedly 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 completed for all
Eyes (cont.) Fundoscopic Lymphatics 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. 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 SUPPORTIVE DATA REFUTING DATA Allergic conjunctivitis Itchy eye, Yellowish drainage, Crusted in the Discharge has pus like feature morning, Pain in his eye Negative for rhinitis, allergic pharyngitis Bacterial conjunctivitis Itchy eye, Yellow purulent drainage, Crusted in the morning, Pain in his eye Edematous eyelid with matting Absent lymphadenopathy Chemical conjunctivitis Itchy eye, Yellowish drainage, Crusted in the morning, Pain in his eye May be associated with concurrent otitis media. No history of trauma No known contact with chemicals Viral conjunctivitis Itchy eye, Yellowish drainage, Crusted in the morning, Pain in his eye Swam in nonchlorinated pool No preauricular involvement Photophobia present No symptoms of upper respiratory tract infection Inflamed conjunctiva Corneal abrasion/eye trauma Eye pain, photophobia No complaint of foreign body present, or blurred
Herpes simplex blepharitis Itchy eye, Crusting of the eyelids Burning sensation vision, no history no trauma chronic condition primarily in the 3 rd or 4 th generation of life negative for minimal discharge or eyelash matting Negative for lymphadenopathy or presence of meibomian gland dysfunction Iritis Tearing, photophobia, pain, redness Discharge is not usually associated in iritis Decreased vision Glaucoma Aching eye pain No complaints of halos around lights, reduced visual acuity or vision changes, no blurred vision Adult typically older than 40 years; nausea and vomiting may be present as well as a deep, dull, periocular headache; unilateral; pain associated with decreased vision; mid-dilated, unreactive pupil; presence of an afferent pupillary defect
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 RATIONALE Eye culture and gram stain Test not done. Culture of discharge is not usually recommended for mild conjunctivitis with a suspected viral, bacterial, or allergic origin. Exceptions include: neonatal conjunctivitis, or if unresponsive to treatment. (Uphold & Graham, 2014) 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 Bacterial Conjunctivitis Burning sensation Discharge is purulent, and the patient complains of crusted lids in the morning and throughout the morning. Parent reports child swam in nonchlorinated pool. Patient or parent denies contact with chemical irritants. Patient or parent denies a history of allergic rhinitis. No preauricular nodes present Photophobia present 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 Ophthalmic (AzaSite) 1% Apply to affected eye twice per day (12 hours apart) x 2 days, then daily for 5 days (Uphold & Graham, 2014)
(2) What is your rationale for choosing this particular agent? This dosing option is more convenient for a school age child allowing for twice daily dosing versus TID, QID, or more frequent interval medications. This will likely lead to more compliance with treatment and less stress for the 6 year old. (3) What education does Mary need to provide relief for Joe and decrease the risk of reinfection? Education: o Conjunctivitis is the inflammation of the lining of the eyelids and eyeball. It may be caused by bacteria, virus, allergy, mechanical irritation, chemical irritation or medications. o Ensure measures to avoid spread, such as hand washing, no sharing of towels, linens, bedding, and taking time away from school. Child may return to school 24 hours after antibiotic treatment. o Wash hands before and after applying medication. o Start medication as soon as possible and return to the office if problem persists after 5 days of treatment. o Encourage Joe to avoid rubbing his eyes and work on proper hand hygiene with him and his sibling. (Epocrates, 2013) Application: o Tilt your head back slightly and pull down your lower eyelid to create a small pocket. Hold the dropper above the eye with the tip down. Look up and away from the dropper and squeeze out a drop. o Close your eyes for 2 or 3 minutes with your head tipped back, without blinking or squinting. Gently press your finger to the inside corner of the eye for about 1 minute, to keep the liquid from draining into your tear duct. o Use only the number of drops your doctor has prescribed. If you use more than one drop, wait about 5 minutes between drops. o Wait at least 10 minutes before using any other eye drops your doctor has prescribed. o Do not touch the tip of the eye dropper or place it directly on your eye. A contaminated dropper can infect your eye, which could lead to serious vision problems. o Do not use the eye drops if the liquid has changed colors or has particles in it. Call your pharmacist for new medicine. o Use this medication for the full prescribed length of time. Your symptoms may improve before the infection is completely cleared.
o Store an unopened bottle of azithromycin ophthalmic in the refrigerator. Do not freeze. o After opening the bottle, you may keep the medication at room temperature for up to 14 days. Keep the bottle tightly closed when not in use. Protect from moisture and heat. (Epocrates, 2013) References Epocrates. (2013). Epocrates Rx Pro (Version 14.5) [Mobile Application Software]. Retrieved from https://online.epocrates.com Uphold, C.R., & Graham, M.V. (2014). Clinical guidelines in family practice. (5th ed.). Gainsville, FL: Barmarrae Books, Inc.