1st peer: Week 3 Discussion Part I Table 1Red EyePlease complete the differential diagnosis table for cc: red-eye.Clinical FindingsDiagnosisTreatment/ManagementOphthalmia neonatorumRedness, discharge, and swelling in a newborn’s eye within the first month of lifeN. gonorrhea, Chlamydia, HSVAntibiotic eye drops or ointments, systemic antibiotics if severe, referral to an ophthalmologist for further evaluation.Bacterial conjunctivitisRedness, purulent discharge, eye irritationStaphylococcus, StreptococcusTopical antibiotic eye drops or ointments maintain eye hygiene, avoid touching eyes, and wash hands frequently.Viral conjunctivitisRedness, watery discharge, and irritation often associated with upper respiratory infectionAdenovirus, enterovirusSymptomatic treatment, artificial tears, cold compresses, avoiding close contact with others, maintaining good hygiene Allergic conjunctivitisRedness, itching, tearing, no purulent dischargePollen, dust, pet danderAvoid allergens, antihistamine or mast cell stabilizer eye drops, and oral antihistamines if needed. Corneal abrasion, foreign bodySudden onset of eye pain, tearing, redness, sensation of foreign body in the eyeTraumaRemoval of foreign body if present, antibiotic eye drops or ointments, avoid rubbing eyes, use protective eyewear Periorbital CellulitisRedness, swelling, pain around the eye, and fever, often in childrenHaemophilus influenza, StrepOral or intravenous antibiotics depending on severity, possible hospitalization for severe cases, referral to an ophthalmologistBlepharitisRedness, scaling, crusting of eyelids, irritation, burning sensationStaphylococcal, seborrheicLid hygiene (warm compresses, eyelid scrubs), topical antibiotics or steroids if severe, manage underlying conditions.Hordeolum (Stye)Red, painful lump near the edge of the eyelid, localized swellingStaphylococcalWarm compresses, topical antibiotics if the infection spreads, incision and drainage if persistent, and maintain eyelid hygiene.ChalazionA painless, firm lump in the eyelid may cause localized swelling.Chronic lipogranulomaWarm compresses gentle massage, if persistent, may require incision and curettage by an ophthalmologist. Table 2Abnormal Ophthalmologic FiningsComplete the tableStrabismusAmblyopiaEsotropiaDescriptionMisalignment of the eyesDecreased visionEye turns inwardManagement/TreatmentGlasses, patching, surgeryPatching, atropine penalizationGlasses, patching, surgeryRed ReflexLight Reflex Test/Corneal Light Reflex/Hirschberg Test)Describe how to perform the procedure.An ophthalmoscope is used to shine light into the patient’s eyes from about 30 cm away. Observe the red reflex in both eyes simultaneously.Have the patient look straight ahead at a light source while you shine a penlight or ophthalmoscope light at the bridge of their nose. Observe the reflection of the light on the corneas of both eyes.What is an expected finding?Both eyes should display a symmetrical red reflex.The light reflex should be centered on the pupils and symmetrical in both eyes.Screening for?Cataracts, retinoblastoma, and other ocular abnormalities.Strabismus, which can indicate misalignment of the eyes.Table 3Dental Health1. When should a child’s first dental appointment occur? By first birthday.2. When do the first primary teeth erupt? 6 months3. A child usually has 6-8 primary teeth by _8-10months_ (what age?)4. A child has a complete set of 20 primary teeth, including second molars, by ______(what age?) Between ages 2 and 3.Table 4Ear PainComplete the table.Common DifferentialsDescriptionCausative AgentsClinical FindingsTreatment/ManagementPrevention/EducationOtitis ExternaInfection of the outer earPseudomonas, Staph aureusEar pain, dischargeTopical antibiotics Dry ears after bathingAcute Otitis Media (AOM)Infection of the middle earStreptococcus pneu, H. fluEar pain, feverOral antibiotics Vaccinate for pneumococcus and fluOtitis Media w/ EffusionFluid in the middle earEustachian tube dysfunctionHearing loss, speech delayWatchful waiting, tympanostomy tubes Breastfeeding, avoid secondhand smokeList 5 other Differentials for ER painDescriptionClinical FindingsManagement1.TMJ DisorderGrinding teeth, jaw clenchingManagement: Mouth guard, stress reduction2.Dental CariesTooth decayFillings, fluoride treatments3.Foreign BodyObject stuck in the earRemoval with instrumentation4.Impacted CerumenBlockage of the ear canalIrrigation, cerumenolytics5.MastoiditisInfection of the mastoid boneIV antibiotics, surgical drainage Part II Case Scenario 3:Alex is a 4-year-old male brought into the clinic by his mom because he ran into another classmate playing on the playground. His mouth is bleeding, and his front two teeth appear to be loose. On oral exam, he has several dental caries. His vital signs are within normal limits, and his weight today is 40 pounds. What additional information does the APRN need to treat Alex?What type of treatment does Alex need for his loose teeth?What should the APRN make sure to include in his physical examination?What can he have for pain? Please include the dosage and instructions you will provide.What education should the APRN provide to Alex’s parents about his dental caries?When assessing Alex, the APRN needs to gather additional information to treat his dental injuries and caries properly. A thorough dental history is essential, including previous dental work, trauma, or infections. The APRN should ask about Alex’s oral hygiene habits, diet (frequency of sugary snacks/drinks), and fluoride exposure (toothpaste, mouthwash, community water supply). It’s also important to know if Alex has a dental home (established care with a pediatric dentist).Alex’s loose front teeth require gentle evaluation. The APRN should assess the degree of mobility and potential for aspiration. Treatment may involve monitoring for tooth loss or referral to a pediatric dentist for extraction if necessary.The APRN must ensure a comprehensive physical examination is performed, not just focusing on the oral trauma. This includes inspection of the head/neck for additional injuries and assessment of respiratory status due to potential aspiration risk.For pain management, acetaminophen is appropriate. The dose for a 4-year-old (40 pounds) would be 15mg/kg/dose every 4-6 hours as needed, at most 75mg/kg/day. The APRN should educate the parents about administering the recommended dose, using the provided measuring device, and staying within the maximum daily dose.The presence of dental caries in a 4-year-old indicates a high risk for further decay. The APRN must educate Alex’s parents about prevention strategies. This includes brushing with a smear of fluoride toothpaste until age 3, then a pea-sized amount. They should limit sugary snacks/drinks, encourage healthy snacks (fruits and vegetables), and schedule a follow-up with a pediatric dentist. If their community water supply is not fluoridated, a supplement may be necessary. In addition to these measures, it is imperative that the ARNP relays to the parents the importance of creating healthy dental care routines. Many parents need to care for their teeth and, by poor example, inadvertently teach their children not to prioritize dental care. I am in my forties and have just spent more money than I care to admit to creating a healthy dental routine.2nd peer: Case scenario 4 Week 3 Discussion Part I Table 1Red EyePlease complete the differential diagnosis table for cc: red eyeClinical FindingsDiagnosisTreatment/ManagementOphthalmia neonatorumErythema, chemosis, purulent exudate with N. gonorrhoeae; clear to mucoid exudate with ChlamydiaCulture (ELISA, PCR), Gram stain, R/O N. gonorrhoeae, ChlamydiaSaline irrigation to eyes until exudate gone; follow with erythromycin ointment For N. gonorrhoeae: ceftriaxone or IM or IVFor chlamydia: erythromycin or possibly azithromycin POFor HSV: antivirals IV or POBacterial conjunctivitisErythema, chemosis, itching, burning, mucopurulent exudate, matter in eyelashes; worse in winterCultures (required in neonate); Gram stain (optional); chocolate agar (for N. gonorrhoeae) R/O pharyngitis, N. gonorrhoeae, AOM, URI, seborrheaNeonates: Erythromycin 0.5% ophthalmic ointment?1 year of age: Fourth-generation fluoroquinoloneFor concurrent AOM: Treat accordingly for AOM Warm soaks to eyes 3-4x/ day until clear No sharing of towels or pillows No school until treatment beginsViral conjunctivitisErythema, chemosis, tearing (bilateral); HSV and herpes zoster: unilateral with photophobia, fever; zoster: nose lesionCultures, r/o corneal infiltration Refer to ophthalmologist if HSV or photophobia is present Cool compresses 3-4x/ dayAllergic conjunctivitisStringy, mucoid exudate, swollen eyelids and conjunctivae, itching (key finding), tearing, palpebral follicles, headache, rhinitisEosinophils in conjunctival scrapings) Naphazoline/pheniramine, naphazoline/antazoline ophthalmic solution, mast cell stabilizer, refer to allergist if needed Corneal abrasion, foreign bodySensation of a foreign body, erythema, severe pain, photophobia, decreased vision, tearingFluorescein staining, slit lamp examination Refer to ophthalmologist if severe Oral analgesics or ophthalmologic NSAIDs If no symptoms of corneal infection, topical antibiotics QID for 3- 5 days may be prescribedPeriorbital CellulitisAfebrile,swelling, erythema, upper lid is affected more often than the lower lid, orbital discomfort, pain, proptosis, or paralysis of the extraocular musclesVisual acuity, extraocular movement, and pupillary reaction testing, CBC, blood cultures, CT scan 7-14 day Amoxicillin Warm soaks to the periorbital area every 2 -4 hours for 15 min Failure to improve in 24 hours indicates a need for hospitalization and parenteral antibiotics, usually ceftriaxone. Monitored daily until blood cultures are negative for 48 hours or clinical improvement is seen.BlepharitisSwelling, erythema, flaky, scaly debris over eyelid, burning feeling in eyes, mild bulbar conjunctival injection Meibomian gland expression, fluorescein staining, microbial testing Use warm compresses for 5 -10 min at a time 2-4x/ day and wipe away lid debris. Massage the lids 2-4x/ day to express meibomian secretions. Remove contact lenses and wear eyeglasses for the duration of the treatment period. Purchase new eye makeup; minimize use of mascara and eyeliner. Use artificial tears for patients with inadequate tear poolsHordeolum (Stye)Tender, swollen red furuncle, foreign body sensationMicrobial testing, inspection, palpation and evaluation of eyelid Rupture occurs spontaneously when the furuncle becomes large Warm, moist compresses 3-4x daily, 10 -15 minutes each help the process of rupturing. Hygiene of the eye with (50%) solution of no-tears shampoo 1-2x/ day. Antistaphylococcal ointment (ex. 0.5% erythromycin) can be effective If no rupture refer to ophthalmologist for I&DChalazionMild erythema, eyelid swelling, after inflammation resolves, a slow-growing, round, nonpigmented, painless mass remains.Medical history, physical exam, meibomian gland expression, OCT Acute lesions are treated with hot compresses. Refer to an ophthalmologist for surgical incision or topical injections if the condition is unresolved or the lesion causes cosmetic concerns. A chalazion can distort vision by causing astigmatism as a result of pressure on the orbit.Table 2Abnormal Ophthalmologic FiningsComplete the tableStrabismusAmblyopiaEsotropiaDescriptionA defect in ocular alignment, aka lazy eyeA unilateral deficit in which there is defective development of the visual pathways needed to attain central vision.Inward deviation of one or both eyes.Management/TreatmentPatching the unaffected eye for 2 hours a day. Surgical alignment of the eyes may be necessary.Refer to an ophthalmologist or optometrist for prescription corrective lenses. Moderate amblyopia usually responds to 2 hours of daily patching or weekend atropine. (Maaks, Starr & Gaylord)Surgery, botox, prism glasses, eye patch. (Maaks, Starr & Gaylord)Red ReflexLight Reflex Test/Corneal Light Reflex/Hirschberg Test)Describe how to perform the procedureDarken the room, stand an arm’s length away from the child with the ophthalmoscope’s light set at 0 or +1 to illuminate the face. Look at both pupils simultaneously and separately.Performed with the child looking straight ahead, first on a near-point object and then on a far-point object about 20 feet away. The process is sometimes aided by asking the child questions about the object.What is an expected finding?In children with fair skin pigmentation, the red reflex is bright red-orange; in those with darker pigmentation, the red reflex is dark red-brown or pale yellow.A normal test reveals the reflected light as a small white dot symmetrically located in the same position of each eye.Screening for?Detect the presence of asymmetric refractive errors, strabismic deviations, and abnormalities in the ocular media (e.g., cataracts, corneal abnormalities, retinoblastoma).Evaluates extraocular muscle function by projecting a small light source onto the cornea of the eye with the child looking straight aheadTable 3Dental Health Fill in the Blank1. When should a child’s first dental appointment occur?Within 12 months or within 6 months of first tooth eruption.2. When do the first primary teeth erupt?6 months3. A child usually has 6-8 primary teeth by _____ (what age?)1 year4.A child has a complete set of 20 primary teeth, including second molars by ______(what age?) 2-3 years old Table 4Ear PainComplete the table.Common DifferentialsDescriptionCausative AgentsClinical FindingsTreatment/ManagementPrevention/EducationOtitis ExternaSwimmers ear; Inflammation of the EAC and can involve the pinna or TMBacteria, fungi, virusesPain, pressure, fullness, swollen EAC, red, pruritusEardrops containing acetic acid or antibiotic with and without corticosteroid drops are the treatment of choice.Avoid water, scratching, use alcohol vinegar otic mix 3-5x/dayAcute Otitis Media (AOM)Acute infection of the middle earS. pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis, and S. pyogenes (group A streptococci)Ear pain, fever, irritability, ear pulling, otorrheaAmoxicillin is the first-line antibiotic for AOMOtolaryngology referral. Placement of tympanostomy or PE tubes can help relieve discomfortOtitis Media w/ EffusionFluid accumulation in the middle ear spaceAir pollution, allergies, eustachian tube dysfunctionTM amber color, mild hearing loss, fullness/pressureNasal decongestant, antihistamines, surgical interventionPromote hand hygiene, avoid allergens, avoid cotton swabsList 5 other Differentials for ear painDescriptionClinical FindingsManagement1.SinusitisNasal congestestion, HA, cough, fever, ear pressure/fullnessAmoxicillin, Augmentin, NSAIDs, nasal irrigation2.MastoiditisEar pain, foul smelling ear discharge, fever, hearing lossEmpiric antibiotics, NSAIDs, mastoidectomy3.Tympanostomy Tube Otorrhea (TTO)Ear discharge, foul odor, ear pain, muffled hearingAntibiotics, ear drops, ear canal cleaning4.LymphadenitisFever, pain, redness, warmthAntibiotics, warm compress5.ParotitisPain, tenderness, dry mouth, swellingWarm compress, Tylenol, NSAIDs, antiboticsCase Scenario 4This patient came in with a specific issue and will require focused assessment. The APRN should start assessing Tony’s general appearance to observe any additional symptoms such as distress, rash or swelling of any body parts that parents may forget to mention. Next, examining the ears is necessary to assess the right ear via an otoscope and compare it to the left one. APRN should pay close attention to tympanic membranes and note any signs of infection and damage. In addition to ears, APRN should examine lymph nodes, throat, nose and assess cardiovascular and respiratory systems. Since Tony also has a cough and runny nose, it is important to rule out any pulmonary infections that may require additional treatments. APRN should look for redness or swelling in the throat and examine color and consistency of nasal discharge. It is important to rule out other possible roots of fever, nasal congestion and cough to avoid recurrence of the same problem.Tony’s symptoms can be managed by prescribing antibiotics and acetaminophen or Motrin to treat fever and pain. Since Toney is allergic to penicillins, APRN should prescribe Azithromycin. Ton’s parents should be educated on the importance of finishing antibiotics even if symptoms go away. Next, they need to be educated on a maximum dose of 4000 mg of acetaminophen within 24 hours and they should alternate between acetaminophen and Motrin to control fever. They should go to the emergency department if the fever becomes uncontrollable or Tony becomes lethargic. Finally, they should try to keep Toney well hydrated and rested to promote faster recovery.APRN should explain to Tony’s parents the concept of acute otitis media and what can cause it. Parents need to be aware of possible complications and understand the importance of adhering to medication regime. They need to know the side effects of medications too and report them to APRN. Finally, they should be educated on the preventative measures to avoid ear infection in the future.