CASE PRESENTATION 1Casey Coon RN, BS, FNP-S

PEDIATRICIAN’S OFFICE

Krista- 5 year old female Presents to the Pediatrician’s office

with her mother Chief Complaint: bilateral eye

discharge for 2 days

HISTORY OF PRESENT ILLNESS

Mother states K has had bilateral eye discharge for 2 days now. She has been waking up with her eyes crusted shut for the past 2 mornings and she has had to use a warm, wet washcloth to get them open. She also has had a stuffy nose and a cough for the last few days.

PAST MEDICAL HISTORYPAST MEDICAL HISTORY:

Medical Illness: Denies any history of asthma, cancer, diabetes, heart disease, bleeding disorders.

Accidents/Injuries: None

Surgeries/Hospitalizations/ Transfusions: None

Immunizations: reviewed immunization record, all shots are up to date at this time.

Medications: Multivitamin

Allergies: denies any food, drug, environmental or latex allergies.

Social: Attends school in kindergarten. Does well in school.

Family: rest of family is well at this time.

REVIEW OF SYSTEMS

General: Denies fever, denies chills, fatigue, night sweats no weight loss or change in appetite.

Skin: Denies any rashes or itching, no lesions, no changes in hair or nails.

Head: Denies any headaches or dizziness, no lumps or lesions, no pain.

Ears: denies ringing, denies any hearing loss or pain, no discharge.

Eyes: has yellow drainage in both eyes, both eyes have been crusted shut for 2 mornings now, no change in vision, no tearing, denies pain.

Nose: has a stuffy nose, no bleeding or sinus infections.

Mouth and Throat: Denies any hoarseness, brushes teeth twice a day, no bleeding or lesions. Sees a dentist every 6 months. Denies sore throat.

Neck: Denies any lumps or lesions, no trauma, no pain or stiffness.

Cardiovascular: Denies any history of murmurs or heart troubles.

Respiratory: has an occasional dry cough, denies SOB, no history of asthma.

HEALTH STATUS/RISKS, DISABILITY AND FAMILY PROBLEMS

Health status: Appears to be a healthy 5 year old female, no acute distress

Health risks: PT is at risk for multiple contagious diseases due to her age and school status

Disability: Does not appear to have any disabilities

Family Problems: Does not appear to have family problems at this time

EXAMVS: temp- 98.7 degrees oral, pulse- 100, respirations- 18, Blood pressure- 90/60, O2 sat 99% on RA weight-37 lbs. height-38 inches

General: appears well, well nourished, is in no acute distress.

Head: Norm cephalic, no lumps, lesions, or pain.

Nose/throat: bilateral nostrils patent, no bleeding or lesions, tonsils + 1, uvula midline, no redness noted.

Ears: symmetrical, placement even with the eyebrows, external canal patent, no redness noted. Tympanic membranes pearly gray, bony landmarks present, cannot visualize cone of light in either ear, small amount of cerumen present, no discharge noted.

Eyes: pupils are 3mm, equal, round and reactive to light and accommodation, conjunctiva are red and irritated, there is a purulent yellow discharge from both eyes, sclera are white, no fundal papilledema present, no hemorrhage, lids are symmetrical, no swelling or redness, extra ocular movements positive, visual fields and acuity good.

Skin: Warm, pink and dry, no lesions, redness or rash noted.

Lungs: Lung sounds clear anteriorly and posteriorly. Percussion was not attempted.

Heart: S1 and S2, no murmurs, gallops or clicks noted.

DIFFERENTIAL DIAGNOSIS?

Blepharitis Episcleritis Iritis Acute Angle Closure Glaucoma Acute Bacterial Conjunctivitis Acute Viral Conjunctivitis

DIAGNOSIS

Acute Bacterial Conjunctivitis Common causes of bacterial conjunctivitis, an inflammation of the bulbar

and/or palpebral conjunctivas, include staphylococci, streptococci, gonococci, and Chlamydia.

Signs and symptoms of bacterial conjunctivitis include the following:

Follicles or papillae on the inflamed conjunctiva Discharge: More purulent than in viral conjunctivitis, with more mattering of

the eyelid margins and greater associated difficulty prying the eyelids open following sleep

Enlarged preauricular lymph node: Unusual in bacterial conjunctivitis but found in severe conjunctivitis caused by N gonorrhoeae

Eyelid edema: Often present in bacterial conjunctivitis, but mild in most cases; severe eyelid edema in the presence of copious purulent discharge raises the suspicion of N gonorrhoeae infection

(Yeung, 2013).

TREATMENT

Polytrim 1 drop into both eyes TID for 7 days Polytrim (polymyxin B sulfate and trimethoprim

ophthalmic solution) is a sterile antimicrobial solution for topical ophthalmic use.

Polytrim Ophthalmic Solution is indicated in the treatment of surface ocular bacterial infections, including acute bacterial conjunctivitis

Safe for use in pediatrics

(Drugs.com, 2004).

EDUCATION

Education was given to mother to ensure that K washes her hands often and uses hand sanitizer K needs to stay home from school for the rest of today and tomorrow Instructions on giving your child eye drops Wash your hands. Get your child into any of these positions to give the eye drops: 

tilt your child’s head back lay your child flat on his or her back ask someone to hold your child in a safe position wrap your baby or young child in a light blanket or sheet to keep his or her arms and legs still

Shake the bottle Remove the top from the bottle and throw away the plastic seal. Gently pull down your child’s lower eyelid. Avoid touching the dropper against your child’s eye, eyelashes or any other surface. Hold the dropper above your child’s eye and squeeze one drop into the lower eyelid. Release the lower eyelid and let your child blink a few times to make sure the drop is spread around the

eye. Wipe away any excess with a clean tissue. If you are using another type of eye drop, wait a few minutes before giving it. This will stop the first drop

being washed out by the second before it has had time to work.

(Great Ormand Street Hospital for Chilldren, 2013).

QUESTIONS/ COMMENTS?

REFERENCES

Drugs.com. (2004). Polytrim. Drugs.com. Retrieved from http://www.drugs.com/pro/polytrim.html

Great Ormand Street Hospital for Children. (2013). How to give your child eye drops. Our Hospital Site. Retrieved from http://www.gosh.nhs.uk/medical-conditions/medicines-information/how-to-give-your-child-eye-drops/

Yeung, K. K. (2013, March). Bacterial Conjunctivitis. Medscape. Retrieved from http://emedicine.medscape.com/article/1191730-overview