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Quick
Case Study #4
PEDIATRIC CASE STUDY
Use the following template to complete your answers to this case study and
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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, Unilateral. Itching, red eye, crusted dry
yellowish drainage
Corneal abrasion/eye trauma
No bilateral involvement. Pain, red eye
Herpes simplex blepharitis
No bilateral involvement. Itching, red eye, crusted
dry yellowish drainage, eye pain
Iritis
Unilateral. Pain, red eye
Glaucoma
Unilateral. Pain, red eye
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
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
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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
when he looks at bright lights. Mary states warm
wet washcloths have helped relieve burning
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
FINDINGS
Skin is pink and supple, no
lesion noted.
Heart sound
S1 and S2 normal, without
murmur
Clear to auscultation
Breath sounds
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
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
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Eyes (cont.)
eyelids present. Crusted
yellow drainage on lashes.
Conjunctiva markedly
inflamed. Cornea and eyelid
margins without ulceration.
PERL with positive red reflex
bilaterally. Visual acuity
reveals OD 20/20, OS 20/20.
Fundoscopic
Discs well marginated. No
AV nicking
Lymphatics
No palpable lymph nodes in
the head of neck.
diagnoses. Visual
acuity should be
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
Itching, redness, edema of
eyelids.
Vision normal.
Bacterial conjunctivitis
Unilateral. Itching, redness
and edema of eyelids.
Purulent drainage, eyelids
sticking together. on
lashes. Normal visual
REFUTING DATA
No bilateral involvement.
No history of seasonal
allergies. Pain is usually
associated with allergic
conjunctivitis, clear
drainage is associated with
allergic conjunctivitis.
OS sclera white, without
injection, erythema, or
edema. OD edema of
eyelids present. Nares
patent and free of
drainage. No pharyngeal
erythema or edema. No
oral lesions. Denies history
of throat pain, ear pain,
rhinorrhea.
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acuity and pupillary
reactivity. Photophobia;
discomfort, “pain not that
bad”. No palpable
preauricular nodes.
Younger brother was
started on Keflex 3 days
ago for impetigo on his
face- could be same
bacteria
Chemical conjunctivitis
Viral conjunctivitis
Corneal abrasion/eye
trauma
Herpes simplex blepharitis
Itching and redness. OD
edema of eyelids present.
Normal vision
No bilateral involvement.
Has not been in a
chlorinated pool. Eyes are
not dry. No history of
exposure to chemicals
Burning, redness, and
No bilateral involvement.
itching in. Has swam two
No palpable preauricular
times in the past week in
nodes. Crusted yellow
non-chlorinated pool.
drainage on lashes in OD,
Conjunctiva markedly
discharge from eye should
inflamed. OD edema of
be watery in viral. No
eyelids present. Normal
history of recent or
vision.
concurrent respiratory
infection. Pain is bad when
he looks at bright lights.
Joe has two younger
siblings who do not have
any eye symptoms
Unilateral. OD edema of
Visual acuity is not
eyelids present.
deceased, increased
Conjunctiva markedly
lacrimation should not be
inflamed. Pain is bad when purulent. No history of
he looks at bright lights.
trauma to eye or contact
lens use. Cornea and
eyelid margins without
ulceration.
Burning, itching, inflamed
No bilateral involvement
eye lid margins. OD
No recent cold sores or
edema of eyelids present.
exposure to herpes
Pain is bad when he looks lesions. No redness or no
at bright lights. Cornea and palpable preauricular
eyelid margins without
nodes.
ulceration. Crusted yellow
drainage on lashes in OD.
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Iritis
Glaucoma
PERL with positive red
reflex bilaterally. Visual
acuity normal. More
common in children than
adults.
Unilateral. OD edema of
eyelids present.
Conjunctiva markedly
inflamed. Pain is bad when
he looks at bright lights.
Unilateral. Conjunctiva
markedly inflamed.
Redness and photophobia
No decreased visual acuity
in PE, pupils are equal
(would expect small
pupillary size of affected
eye); no blurred vision
reported. Itching not a shin
with iritis
Cornea without cloudiness.
Visual acuity reveals,
increased lacrimation
should not be purulent.
Fundus exam was normal
(would expect optic nerve
atophy, congestion or
cupping) OD 20/20, OS
20/20. PERL with positive
red reflex bilaterally. Pupils
not fixed of oval.
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
Eye culture and gram stain
RESULTS
Test not done.
RATIONALE
Would not perform for mild
case of conjunctivitis with a
suspected viral, bacterial,
or allergic origin. Visual
acuity performed revels
reveals OD 20/20, OS
20/20. If N. gonorrhoeae
is suspected or
conjunctivitis has failed to
respond to treatment or in
cases of ophthalmia
neonatorum, membranous
conjunctivitis, and
prolonged, severe
conjunctivitis should gram
stain and cultures be done
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(Dunphy, Winland-Brown,
Porter, and Thomas,
2015).
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
Unilateral. Itching, redness and edema of
eyelids. Purulent drainage, eyelids
sticking together. on lashes. Normal
visual acuity and pupillary reactivity.
Photophobia; discomfort, “pain not that
bad”. No palpable preauricular nodes.
Younger brother was started on Keflex 3
days ago for impetigo on his face- could
be same bacteria
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?
 Gentamycin solution 0.3% apply 1-2 drops in right eye q 4 hours during the day
for 7-10 days so vision is not impaired, this will help with medication compliance
 Gentamycin solution 0.3% apply 0.5 inch ribbon in right eye at bedtime for 7-10
days and warm compress for pain for prolonged contact with ocular surface and
added soothing effect (Dunphy et al., 2015).
(2) What is your rationale for choosing this particular agent?
 Gentamycin eye drops are a water soluble antibiotic which has shown activity
against gram positive and gram negative bacteria (Dunphy et al., 2015).
 This treatment recommendation is used for bacterial conjunctivitis the most
common bacterial causes are S. aureus, S. pneumoniae and H. influenza.
(3) What education does Mary need to provide relief for Joe and decrease the risk of
reinfection?
 Medication needs to be placed in outer aspect of lower lid.
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Secretions are infectious for 48 hours after beginning medication.
Patient should remain out of school until eye no longer has exudate or has been
on medication for 24 hours.
Good handwashing, not touching the infected eye, and not sharing washcloths
and towels can decrease the spread of conjunctivitis to other family members.
The medication applicator should not be touched to the eye.
Remove any discharge from eye by cleanse eye with diluted no-tear shampoo or
by eye lavage.
Use separate eyecups with each lavage of the eye or use artificial tears, wait five
minutes after instilling antibiotic drops to prevent washing out medication.
Return demonstration of eye drops to ensure proper technique and prevent
contamination (Dunphy et al., 2015).
Dunphy, L., Winland-Brown, J., Porter, B. & Thomas, D. (2015). Primary care: The art
and science of advance practice nursing. Philadelphia: F. A. Davis Company.
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