Pediatrics_Ramona_Frankel.docx

Ramona Frankel – Pediatrics CC – red eye Diagnosis –  Conjunctivitis, viral; Conjunctivitis, bacterial; Conjunctivitis, allergic; upper respiratory infection (URI) Problem Statement: ( Demographic description – chief complaint – Hx and PE key findings – risk factors ) Ramona Frankel is a 6 year old girl brought in by her mother with complaint of red eye. Her eye turned red about 3 days ago and is associated with purulent discharge that accumulates overnight. The patient has an injected conjunctiva with purulent exudate from the right eye without any surrounding edema redness tenderness surrounding. Her mother states that several other children at her school were also showing similar symptoms. CC: Ramona Frankel is a 6 year old girl brought in by her mother with complaint of red eye HPI: Her eye turned red about 3 days ago and is associated with purulent discharge that accumulates overnight Meds: None PMH: Noncontributory ROS: Noncontributory Physical Exam: VS: Pulse – 90; BP – 92/62 RR – 12; T – 98.6FF; SpO2 – 98% Eye: PE shows injected conjunctiva with purulent exudate from right eye without edema redness tenderness surrounding. ASSESSMENT/PLAN  Based on clinical assessment we suspect conjunctivitis of a bacterial or viral cause. This is a clinical diagnosis. Management Plan  Topical erythromycin or trimethoprim-polymyxinB  Supportive care: application of cold and moist compresses, artificial tears).  Counsel mother and child on prevention / hand-washing, touching eyes, sharing towels, etc..  F/U after antibiotics course. This study source was downloaded by from CourseH on :07:45 GMT -06:00 This study source was downloaded by from CourseH on :07:45 GMT -06:00 This study source was downloaded by from CourseH on :07:45 GMT -06:00 This study source was downloaded by from CourseH on :07:45 GMT -06:00 Powered by TCPDF ()