Case Study #4
PEDIATRIC CASE STUDY - Fall 2012
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
Provide rationale to support each potential
diagnosis based on information provided above.
Conjunctivitis
Corneal abrasion/eye trauma
Herpes simplex blepharitis
Iritis
Glaucoma
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
Associated manifestations
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
No history of recent or concurrent respiratory
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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
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
drainage on lashes.
Conjunctiva markedly
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
completed for all
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Eyes (cont.)
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.
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 pain - pain is
not “too bad’- denies
change in vision and
blurred vision-PERL-no
palpable lymph nodes in
the head of neck
NEGATIVE DATA
Pain is bad when he looks
at bright lights-
Bacterial conjunctivitis
Itching in OD, Thick yellow
drainage- states it looks like
pus- eyelids got stuck
together by drainage- visual
acuity is normal and denies
change in vision or blurred
vision- crusted yellow
drainage on lashes- PERLno palpable lymph nodes in
the head of neck- swam
two times in the past week
in nonchlorinated poolyounger brother was
started on Kelfex 3 days
ago for impetigo on his
face- conjunctiva markedly
Pain is bad when he looks
at bright lights- denies
history of throat pain, ear
pain
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inflamed
Chemical conjunctivitis
Viral conjunctivitis
Visual acuity is normalitching, burning and pain PERL- denies any change
in vision and blurred visionconjunctiva markedly
inflamed
Corneal abrasion/eye
trauma
Pain in OD- pain is bad
when he looks at bright
lights- no history of trauma
to eye
Herpes simplex blepharitis
Iritis
Glaucoma
Itching and burning in ODpain is bad when he looks
at bright lights- younger
brother was started on
Kelfex 3 days ago for
impetigo on his face
Pain in OD- pain is bad
when he looks at bright
lights
No history of exposure to
chemical- swam in
nonchlorinated pool
Pain is bad when he looks
at bright lights- no palpable
lymph nodes in the head of
neck – no history of recent
or concurrent respiratory
infection-TMs pearl gray
bilaterally, nares patent and
free of drainage- no
pharyngeal erythema or
edma- denies history of
throat pain, ear pain or
rhinorrhea
Itching- thick yellow
drainage-
Cornea and eyelid margins
without ulceration- normal
visual acuity – no recent
cold sores or exposure to
herpes lesions
Burning, itching and pain in
OD, thick yellow drainagePERL- no blurred vision
No palpable lymph nodes in Thick yellow drainagethe head of neck
normal visual acuity- PERL-
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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 would not be
ordered unless N.
gonorrhea is suspected
which it is not. The patient
has not been treated for
any type of conjunctivitis in
the past nor has he failed to
respond to any prior
treatment. 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. Patient has thick yellow drainage.
1. Bacterial conjunctivitis
Conjunctiva markedly inflamed. OD
edema of eyelids present. – Visual
acuity is normal.
2. Allergic Conjunctivitis
2. Itching and burning, 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- Azithromycin ophthalmic drops- 1 drop two time per day for 2 days then 1
drop daily for 5 days
Second choice – Trimethoprim and polymyxin B (Polytrim) – 1-2 drops four times daily
for 5-7 days
Third Choice – Erythromycin ophthalmic ointment – ½” four times daily for 5-7 days
References:
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Uptodate, 2012. Therapy of conjunctivitis. Bacterial Conjunctivitis. Retrieved from
http://www.uptodate.com/contents/conjunctivitis?source=search_result&search=b
acterial+conjunctivitis+children&selectedTitle=1%7E21
Gerzevitz, D., Porter, B. O. & Dunphy, L. M. (2011). Eyes, ears, nose, and throat
problems. In L. M. Dunphy, J. E. Winland-Brown, B. O. Porter, & D. J. Thomas
(Eds), Primary care: The art and science of advanced practice nursing (pp. 245330). Philadelphia, PA: F.A. Davis Company.
(2) What is your rationale for choosing this particular agent?
The reason this agent was chosen was because it is dosed less frequently. If the child
goes to school, it will be difficult to give the child ointment or drops four times a day.
Ointment can cause blurry vision for 20 minutes after use and if the child is in school
this could be a problem. Azithromycin drops are more expensive so it will be beneficial
to know if the child has insurance. If not then the second or third option should be
chosen because it is less expensive but will require dosing more frequently.
(3) What education does Mary need to provide relief for Joe and decrease the risk of
reinfection?
Education should be given to include:
1. The secretions may remain infectious for at least 48 hours after the start of
treatment
2. Conjunctivitis is highly contagious
3. Use good hand washing
4. Do not touch eyes
5. Do not share towels and washcloths
6. Do not touch the medication applicator to the eye
7. Should stay home from school or day care until there is no longer any secretions
but if that is not feasible then at least after receiving 24 hours of treatment
Reference:
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Gerzevitz, D., Porter, B. O. & Dunphy, L. M. (2011). Eyes, ears, nose, and throat
problems. In L. M. Dunphy, J. E. Winland-Brown, B. O. Porter, & D. J. Thomas
(Eds), Primary care: The art and science of advanced practice nursing (pp. 245330). Philadelphia, PA: F.A. Davis Company.
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