Pediatric Primary Care Case Studies (86 page)

   Explain the use of the topical antibiotic drops and the benefit of treating bacterial conjunctivitis.

   Reassure them that his symptoms should decrease 1 to 2 days after treatment with complete resolution in about 7–10 days.

   Advise him to:

   Either wash his hands with antibacterial soap or use hand sanitizer after touching his eyes, nose, or mouth to reduce the spread of the bacteria (Aronson & Shope, 2005).

   Avoid sharing towels with other family members.

   Stay out of school or daycare until antibiotics are initiated (Aronson & Shope, 2005). If his school is in the midst of an epidemic, he may be required to stay home until his conjunctivitis has resolved (Centers for Disease Control and Prevention, 2003).

When do you want to see this patient back again?

Usually patients are not seen in follow-up for bacterial or viral conjunctivitis unless symptoms do not resolve as expected. Patients should return if pain, vision changes, fever, or increased swelling of eyelids develop. If symptoms do not decrease as expected within 2 days of treatment, further evaluation is needed with possible referral to an ophthalmologist. In cases of allergic conjunctivitis and allergic rhinitis, patients should be instructed to return if the prescribed medications do not alleviate the symptoms or the symptoms worsen. These patients may need referral to an ophthalmologist for additional evaluation and treatment.

Key Points from the Case Study

1. Bacterial conjunctivitis is a diagnosis made based on clinical suspicion and exclusion of other causes of conjunctivitis.

2. Treatment of conjunctivitis varies based on the type of conjunctivitis the patient has.

3. The majority of cases of conjunctivitis can be managed by the primary care practitioner, but referral to an ophthalmologist may be required in certain cases.

REFERENCES

Aronson, S. S., & Shope, T. R. (2005). Pinkeye (conjunctivitis). In
Managing infectious diseases in childcare and schools
(pp. 97–98). Elk Grove Village, IL: American Academy of Pediatrics.

Boguniewicz, M., & Leung, D. Y. M. (2007). Ocular allergies. In R. M. Kliegman, K. J. Marcdante, H. B. Jensen, & R. E. Behrman (Eds.),
Nelson essentials of pediatrics
(pp. 978–979). Philadelphia: Elsevier Saunders.

Buznach, N., Dagan, R., & Greenberg, D. (2005). Clinical and bacterial characteristics of acute bacterial conjunctivitis in children in the antibiotic resistance era.
Pediatric Infectious Disease Journal
, 24, 823–828.

Centers for Disease Control and Prevention. (2003). Pneumococcal conjunctivitis at an elementary school—Maine, September 20–December 6, 2002.
Morbidity and Mortality Weekly Report, 52
, 64–66.

Giglotti, F. (1995). Acute conjunctivitis.
Pediatrics in Review, 16
, 203–207.

Hwang, D. G., Schanzlin, D. J., Rotberg, M. H., Foulks, G., & Raizman, M. (2003). A phase III, placebo controlled clinical trial of 0.5% levofloxacin ophthalmic solution for the treatment of bacterial conjunctivitis.
British Journal of Ophthalmology, 87
(8), 1004–1009.

Langley, J. M. (2005). Adenoviruses.
Pediatrics in Review, 26
, 244–249.

Olitsky, S. E, Hug, D., & Smith, L. P. (2007). Disorders of the conjunctiva. In R. M. Kliegman, K. J. Marcdante, H. B. Jensen, & R. E. Behrman (Eds.),
Nelson essentials of pediatrics
(pp. 978–979). Philadelphia: Elsevier Saunders.

Ono, S. J., & Abelson, M. B. (2005). Allergic conjunctivitis: update on the pathophysiology and prospects for future treatment.
Journal of Allergy and Clinical Immunology, 115
, 118–122.

Patel, P. B., Diaz, M. C., Bennett, J. E., & Attia, M. (2007). Clinical features of bacterial conjunctivitis in children.
Academic Emergency Medicine, 14(1)
, 1–5.

Pickering, L. K., Baker, C. J., Long, S. S., & McMillan, J. A. (Eds.). (2006).
Red book: 2006 report of the Committee on Infectious Diseases
(27th ed., pp. 149, 202–203, 284, 401, 412–415). Elk Grove Village, IL: American Academy of Pediatrics.

Rietveld, R. P., ter Riet, G., Bindels, P. J., Sloos, J. H., & van Weert, H. C. (2004). Predicting bacterial cause in infectious conjunctivitis: cohort study on informativeness of combinations of signs and symptoms.
British Medical Journal, 329
(7459), 206–210.

Rose, P. W., Harden, A., Brueggemann, A. B., Perrera, R., Sheikh, A., Crook, D., et al. (2005). Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomized double-blind placebo-controlled trial.
Lancet, 366
(9479), 37–43.

Wald, E. R. (2004). Periorbital and orbital infections.
Pediatrics in Review, 25
, 312–320.

Chapter 22

The Toddler with Recurrent Ear Infections

Kathleen M. Boyd

In modern medicine, the primary care provider often relies heavily on advanced imaging technology and supportive laboratory evidence to clinch a diagnosis. On occasion, we are privileged to elucidate a clinical diagnosis based on just a thorough history and physical examination and provide treatment options based on that decision.

Educational Objectives

1.   Identify the distinguishing signs and symptoms of acute otitis media (AOM) and otitis media with effusion (OME).

2.   Apply the guidelines for management of acute otitis media and otitis media with effusion.

3.   Recognize the risk factors associated with development of acute otitis media.

4.   Identify when patients need to be referred to an otolaryngologist for treatment of otitis media.

   Case Presentation and Discussion

Sam Burgess is a 16-month-old African American boy who presents to your office with a history of fever, rhinorrhea, and tugging at his ear. He is accompanied by his mother, who is 12 weeks pregnant, and his 3-year-old brother, who also seems to have cold symptoms.

You talk with Sam’s mother about his presenting symptoms and past history and complete a detailed physical exam.

What questions will you ask Sam’s mother related to his fever and ear pain?