This case study will focus on the primary diagnosis of Conjunctivitis. Further more, it will include differential diagnosis, pathophysiology, symptoms, treatment, and anticipatory guidance for each primary diagnosis. On the basis of the relevant history of KS’s Right eye redness with greenish-yellow discharge X 2 days, now left eye is red, + itching in both eyes, both eyes crusty and hard to open in the morning, and KS’s older sibling seen last week for pink eye, Conjunctivitis would be the primary diagnosis to explore.
PRIMARY DIAGNOSIS & DIAGNOSTIC FINDINGS:
Conjunctivitis (inflammation of the conjunctiva) is the most common ocular disease worldwide (Smeltzer & Bare, 2000). It is characterized by a pink appearance because of subconjuctival blood vessel hemorrhages (Smeltzer & Bare, 2000). Conjunctivitis is classified according to its cause, The major causes are microbial infection, allergy, and irritating toxic stimuli (Smeltzer & Bare, 2000). Conjunctivitis can also be a secondary infection of an existing ocular infection or can be a manifestation of a systemic disease (Smeltzer & Bare, 2000).
Acute bacterial conjunctivitis is commonly called pink-eye (Burns, Barber, Brady, & Dunn, 1996). It is frequently caused by non-typeable Haemophilus influenzae or Streptococcus pneumoniae (Burns et. al., 1996). Preschoolers are the most commonly affected age group (Burns et. al., 1996). In the US, Conjunctivitis is responsible for approximately 30% of all eye complaints in ED visits (Silverman, 2004).
Bacterial conjunctivitis is characterized by acute onset, minimal pain, occasional pruritis, and, sometimes, exposure history (Silverman, 2004). The following clinical findings may also be seen; erythema of one or both eyes, burning, stinging, or itching of eyes, photophobia, petechiae on bulbar conjunctiva, sticky purulent or mucopurulent discharge, encrusted and matted eyelashes on awakening, symptoms of upper respiratory infection, otitis media, or acute pharyngitis (Burns et. al., 1996). Bacterial conjunctivitis usually is diagnosed by history and physical examination (Whaley & Wong, 1999). Conjunctival smear and culture are helpful in differentiating specific types of conjunctivitis (Behrman, Kliegman, & Arvin, 2004).
DIFFERENTIAL DIAGNOSIS/ DIAGNOSTIC FINDINGS:
Differential diagnosis may include but are not limited to; Seasonal allergic rhinitis, iritis, and corneal abrasion. Seasonal allergic rhinitis is often associated with bilaterally injected, irritated eyes, and a thick white, ropy discharge (Lamb, 2002). Itching is significant and almost invariable symptom (Lamb, 2002). Initial treatment consists of topical vasoconstrictors and cold compresses for relief of symptoms (Lamb, 2002). Topical corticosteroids may be necessary for a few days if symptoms are severe (Lamb, 2002).
Acute iritis represents inflammation of the anterior uveal tract (Lamb, 2002). Patients complain of pain, periocular headache, reduced visual acuity, and photophobia (Lamb, 2002). Examination reveals more marked redness around the edge of the cornea, reduced vision, and photophobia (Lamb, 2002). Biomicroscopy will reveal protein and exudates and iris debris in the anterior chamber (Lamb, 2002). Topical steroids are used to control the inflammation (Lamb, 2002). Cyclopegic drops dilate the pupil and help prevent formation of adhesions between the inflamed iris and the lens, refer to ophthalmology (Lamb, 2002).
Corneal abrasion, among the most frequent ocular injuries, these epithelial defects cause intense pain, tearing, and decreased visual acuity associated with redness and blepharospasm (Lamb, 2002). After topical anesthesia, fluorescein stain observed with ultraviolet light will glow bright yellow-green in areas denuded of epithelium (Lamb, 2002). After ascertaining that ocular penetration has not occurred and that the cornea and conjunctiva are free of foreign materials, apply a topical antibiotic ointment and pressure-patch the lids tightly closed to minimize movement against the cornea (Lamb, 2002). The abrasion should be improved after 24 hours and completely healed within 48 hours or refer to an ophthalmologist (Lamb, 2002).
Treatment of conjunctivitis depends on the cause (Whaley & Wong, 1999). Viral conjunctivitis is self-limiting, and treatment is removal of the accumulated secretions (Whaley & Wong, 1999). Bacterial conjunctivitis is usually treated with topical antibacterial agents such as polymyxin and bacitracin (Polysporin), or trimethoprim and polymyxin (Polytrim) (Whaley & Wong, 1999). Drops may be used during the day, with an ointment at bedtime because the ointment preparation remains in the eye longer (Whaley & Wong, 1999). Corticosteroids are avoided because they reduce ocular resistance to bacteria (Whaley & Wong, 1999). Supportive treatment includes removal of the accumulated secretions.
Conjunctivitis can progress to increasingly severe and sight-threatening infections (Silverman, 2004). DISPOSITION: Discharge Instructions 1. Ilotycin ointment, apply thin strip to lower affected eyelids, 3 times a day for 10 days. 2. Warn compresses to reduce discomfort. 3. Handout given on conjunctivitis. 4. Encourage frequent hand washing and do not share towels. 5. Return to preschool after using antibiotic ointment for 24 hours. 6. Return to ER for any concerns or if eye is still pink in 3 days, pain increases, or vision becomes blurred.
Barber, N., Brady, M. A., Burns, C. E., Dunn, A. M. (1996). Pediatric Primary
Care A Handbook for Nurse Practitioners. Philadelphia: Saunders.
Behrman, R. E., Kliegman, R. M., & Arvin, A. M. (1996). Nelson
Textbook of Pediatrics (15th ed.). Philadelphia: Saunders.