Brandi Malsy Pediatric Case Study
Case Study #4
PEDIATRIC CASE STUDY
Use the following template to complete your answers to this case study and
resubmit via tigermail to Dr. Wilder (wildebf@auburn.edu) on or before the due
date.
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.
Red eye, itching, dry yellowish drainage, and eye
discomfort
Corneal abrasion/eye trauma
Red eye, itchy eye, eye discomfort/pain
Herpes simplex blepharitis
Iritis
Eye discomfort/pain, itchy eye, red eye, yellowish
drainage
Red eye, eye discomfort/pain
Glaucoma
Red eye, eye discomfort/pain
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 highlighted
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,
Joe describes burning, itching, and pain in OD.
location, quality,
States that pain is not "too bad." Mary describes a
aggravating/alleviating factors
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
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Brandi Malsy Pediatric Case Study
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
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 eyelids
present. Crusted yellow
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
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Brandi Malsy Pediatric Case Study
Eyes (cont.)
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.
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
POSITIVE DATA
Visual acuity normal- OD
20/20, OS 20/20; burning,
itching, and eye pain;
denies change in vision or
blurred vision; PERLA; no
palpable lymph nodes in
head or neck; Red eye
NEGATIVE DATA
Pain is bad when he looks
at bright lights; denies
throat pain or rhinorrhea;
only one eye is affected; no
complains of scratchy
sensation in eye
Bacterial conjunctivitis
Itching in OD; thick, yellow
drainage that is described
as looking like pus; eyelids
stuck together by drainage;
visual acuity is normal and
Joe denies blurry vision or
change in vision; swam two
weeks ago in
nonchlorinated pool;
younger brother started on
Keflex 3 days ago for
impetigo on his face;
markedly inflamed eye;
PERL; no palpable lymph
nodes in the head or neck;
No history of respiratory
infections; does not
complain of throat pain, ear
pain, or rhinorrhea;
complains of pain when he
looks at bright lights.
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Brandi Malsy Pediatric Case Study
Chemical conjunctivitis
burning and itching
sensation
Red eye, burning
No history of exposure to
sensation, pain is described chemicals; states he swam
as “not too bad”
in nonchlorinated pool.
Viral conjunctivitis
Visual acuity is normal;
itching, burning, and pain in
eye; denies change in
vision or blurry vision;
conjunctiva markedly
inflamed.
Thick yellow drainage that
looks like pus; no history of
recent or concurrent
respiratory infection- TMs
are pearl gray bilaterally
and nares are patent and
free of drainage, no
pharyngeal erythema; pain
is bad when he looks at
lights; no palpable lymph
nodes in head or neck;
No history of eye trauma
Corneal abrasion/eye
trauma
Pain is bad when he looks
at lights; eye redness; eye
pain/discomfort; eye
burning
Herpes simplex blepharitis
Younger brother was
started on Keflex 3 days
ago for impetigo on his
face; itching and burning in
OD; pain is bad when he
looks at lights; thick yellow
drainage that looks like pus;
eyelashes crusted together;
eye lid edema; eye redness
Cornea and eyelid margins
without ulceration, normal
visual acuity; no recent cold
sores or exposure to
herpes lesions; no recent
upper respiratory infection;
no palpable lymph nodes
in head or neck
Iritis
Pain is bad when he looks
at light; eye redness;
complains of burning and
itching to eye
Normal visual acuity;
cornea and eyelid margins
are normal and without
ulceration; no blurred vision
Glaucoma
Eye redness and eye
pain/discomfort
Normal visual acuity; no
history of eye trauma; no
family history of glaucoma;
yellow drainage that is
described as pus; Discs
well marginated; drainage
that is causing crusting of
the eyelashes.
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Brandi Malsy Pediatric Case Study
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
This test is not indicated at
this time. Culture of eye
discharge is only
recommended for
suspected conjunctivitis if
unresponsive to initial
treatment or if N. gonorrhea
is expected, which it is not.
The visual acuity test was
normal.
DIAGNOSES
Based on the data provided, what are the appropriate diagnoses for Joe?
List all appropriate diagnoses for Joe in priority order.
Diagnoses
Rationale
1. Bacterial conjunctivitis
1. Joe has thick yellow eye drainage that
looks like pus; discharge has caused
eyelids to crust together; conjunctiva
markedly inflamed, OD edema of eyelids
are present; visual acuity is normal; eye
redness and eye pain that is “not too bad”.
2. Allergic conjunctivitis
2. Itching and burning to eye, 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?
First choice: Polymyxin-B and Trimethoprim (Polytrim) ophthalmic drops- 1 drop in
affected eye(s) every 3 hours, up to 6 doses per day for 7 days.
Second choice: Azithromycin 1% solution (AzaSite)- One drop in affected eye(s) BID
(12 hours apart) for 2 days, then once daily for the next 5 days.
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Brandi Malsy Pediatric Case Study
(2) What is your rationale for choosing this particular agent?
Polymyxin –B component component has only a Gram-negative spectrum making it
relatively ineffective. Trimethoprim has a broad spectrum, including methicillin-resistant
staphylococci. The combination of these two drugs, in Polytrim, makes it a good choice
for empiric treatment of bacterial conjunctivitis. It can be used in children ≥ 2 months of
age.
Azithromycin 1% solution is a macrolide antibiotic solution that is active against Grampositive microbes and also against H. influenza. Azithromycin 1% solution can be used
in children ≥ 1 year of age. Azithromycin would be the second choice for treatment as it
is more expensive than Polytrim; therefore, it would be beneficial to know if Joe has
insurance.
(3) What education does Mary need to provide relief for Joe and decrease the risk of
reinfection?
Education should be given to include:
1. Ocular solutions should be instilled into the inner aspect of the lower eyelid.
2. Do not touch the medication applicator to the eye.
3. Conjunctivitis is highly contagious. Therefore, do not share towels or wash cloths with
other family members.
4. Continue with warm compresses, as they can be effective for providing pain relief.
5. All family members should use good hand washing techniques.
6. The medication should be used for the entire 7 days, even if symptoms subside.
7. Ophthalmic solution may be refrigerated to reduce stinging and burning when instilled
into the eye.
References
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Brandi Malsy Pediatric Case Study
Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advanced Health Assessment and Clinical
Diagnosis in Primary Care (4th ed.). St. Louis, MO: Mosby.
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary Care: the
Art and Science of Advanced Practice Nursing (3rd ed.). Philadelphia, PA: F.A. Davis.
Goolsby, M. J., & Grubbs, L. (2011). Advanced Assessment: Interpreting Findings and
Formulating Differential Diagnoses (2nd ed.). Philadelphia, PA: F.A. Davis Company.
Seller, R. H., & Symons, A. B. (2012). Differential Diagnosis of Common Complaints (6th ed.).
Philadelphia, PA: Saunders.
Uphold, C. R., & Graham, M. V. (2012). Clinical Guidelines in Family Practice (5th ed.).
Gainesville, FL: Barmarrae Books, Inc.
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