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Quick Case Study #4 PEDIATRIC CASE STUDY Use the following template to complete your answers to this case study and upload in Canvas 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 1 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 2 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. 3 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. 4 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 5 (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. 6 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. 7