Differential and working diagnosis, treatment plan
Discuss what questions you would ask the patient, what physical exam elements you
would include, what further testing you would want to have performed, differential and
working diagnosis, treatment plan, including inclusion of complementary and OTC
therapy, referrals, and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to
national guidelines and evidence-based research in support of your ideas.
1. A 16-year-old mother has brought in her 5-day-old infant to the clinic with
bilateral purulent eye discharge. The infant is breastfeeding well and has had 6
yellow seedy stools within the past 24 hours.
• What more should you know about this infant and mother?
• How should you manage this infant’s condition?
Sample Solution
Questions for the patient:
- How long has the eye discharge been present?
- Is it worse in one eye than the other?
- Is it painful?
- Is it accompanied by any other symptoms, such as fever, rash, or cough?
- Is the infant breastfeeding well?
- How many wet diapers and yellow seedy stools has the infant had in the past 24 hours?
Full Answer Section
- Is this the first time the infant has had eye discharge?
- Has the infant been exposed to anyone else with eye discharge?
- Has the infant been using any eye drops or ointments?
- Is the infant taking any medications?
- Is the infant breastfed or formula-fed?
- How often does the infant breastfeed?
- Does the infant have any other health problems?
Physical exam elements:
- Visual acuity
- Conjunctival injection
- Corneal edema
- Discharge
- Lid edema
- Systemic examination, including temperature, heart rate, respiratory rate, and oxygen saturation
Further testing:
- Gram stain and culture of the eye discharge
- Complete blood count (CBC) with differential
- C-reactive protein (CRP)
- Blood culture
- Viral cultures (if indicated)
Differential diagnosis:
- Bacterial conjunctivitis
- Viral conjunctivitis
- Allergic conjunctivitis
- Impetigo
- Contact dermatitis
- Dacryocystitis
Working diagnosis:
Bacterial conjunctivitis is the most likely diagnosis in this case. The infant has bilateral purulent eye discharge, which is a classic presentation of bacterial conjunctivitis. The infant is also breastfeeding well and has had 6 yellow seedy stools within the past 24 hours, which are not typical symptoms of viral conjunctivitis.
Treatment plan:
- Topical antibiotic eye drops or ointment
- Warm compresses to the eyes
- Frequent cleaning of the eyes with saline solution
- Pain medication, if needed
- Referral to an ophthalmologist, if the infection does not improve with treatment
Complementary and OTC therapy:
- Some parents may choose to use complementary or over-the-counter (OTC) therapies for their infant's conjunctivitis. There is some evidence to support the use of these therapies, but they should not be used in place of medical treatment. Some examples of complementary and OTC therapies that may be helpful for conjunctivitis include:
- Eyebright tea compresses
- Goldenseal eye drops
- Colloidal silver eye drops
- Eyelid scrubs with diluted tea tree oil
Referrals and other team members needed to complete patient care:
- If the infant's conjunctivitis does not improve with treatment, the patient may need to be referred to an ophthalmologist.
- A lactation consultant may be helpful if the mother is having difficulty breastfeeding.
- A social worker may be helpful if the mother is struggling with financial or emotional challenges.
National guidelines and evidence-based research:
- The American Academy of Pediatrics (AAP) recommends that all infants with conjunctivitis be seen by a healthcare provider. The AAP also recommends that infants with bacterial conjunctivitis be treated with topical antibiotic eye drops or ointment.
- The Centers for Disease Control and Prevention (CDC) provides information on the diagnosis and treatment of conjunctivitis.
- The National Institutes of Health (NIH) provides information on the causes, symptoms, and treatments for conjunctivitis.