Chronic Illness

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A 7-year-old boy named Timothy, who has asthma, comes to your clinic with his mother. His mother tells you that Timothy has been coughing for a week and has been making a wheezing sound for the last two days. She mentions that they haven’t visited the clinic in over a year, and they have run out of Timothy’s albuterol inhaler, which he was using three times a day for the past week his only medication. There is no fever present. Additionally, Timothy’s mother reports that he has been complaining of pain in his right ear. Furthermore, you observe dry, scaly patches on Timothy’s elbows and behind his knees.

For Timothy’s cough, right ear pain and the dry, scaly patches, please provide three potential differential diagnoses (DDx) for each condition, along with your brief reasoning for selecting each DDx. Subsequently, identify the most likely final diagnoses.

Finally, outline a comprehensive plan of care for Timothy’s final diagnoses. Include prescription details as if you were sending them to the pharmacy for fulfillment. Explain the patient teaching that should be provided and specify when Timothy should return to the clinic for follow-up. Ensure that your responses are supported by clinical practice guidelines or two high-level scholarly articles. Avoid using point-of-care references.

Sample Solution

Assessing Timothy’s Conditions

Cough

Potential Differential Diagnoses:

  1. Exacerbation of asthma: Given Timothy’s history of asthma and recent increase in wheezing, an exacerbation of his asthma is a likely possibility.
  2. Upper respiratory infection (URI): A cough is a common symptom of URIs, especially in children.
  3. Foreign body aspiration: While less likely, foreign body aspiration could be considered, especially if Timothy has a history of putting objects in his mouth.

Right Ear Pain

Potential Differential Diagnoses:

  1. Acute otitis media (AOM): Ear pain is a common symptom of AOM, especially in children.
  2. Otitis externa (OE): OE, also known as swimmer’s ear, can cause ear pain, especially if there is a history of water exposure.
  3. Temporomandibular joint (TMJ) dysfunction: TMJ pain can sometimes be referred to the ear.

Dry, Scaly Patches

Potential Differential Diagnoses:

  1. Eczema: Eczema is a common skin condition characterized by dry, itchy patches.
  2. Psoriasis: Psoriasis is another skin condition that can cause dry, scaly patches.
  3. Fungal infection: A fungal infection, such as tinea corporis (ringworm), can also cause dry, scaly patches.

Most Likely Final Diagnoses

Based on the information provided, the most likely final diagnoses are:

  • Exacerbation of asthma
  • Acute otitis media
  • Eczema

Plan of Care

Asthma Exacerbation

  • Prescription: Albuterol inhaler, 4 puffs every 4-6 hours as needed. Ipratropium bromide inhaler, 2 puffs every 6 hours as needed.
  • Patient Teaching: Explain how to use the inhalers correctly, the importance of taking medication as prescribed, and the need to avoid triggers. Advise the mother to contact the clinic if Timothy’s symptoms worsen or do not improve after a few days.
  • Follow-up: Schedule a follow-up appointment in 1-2 weeks to assess Timothy’s response to treatment and adjust medication as needed.

Acute Otitis Media

  • Prescription: Amoxicillin, 50 mg/kg/day divided in two doses for 10 days.
  • Patient Teaching: Explain the importance of completing the entire course of antibiotics, even if symptoms improve. Advise the mother to contact the clinic if Timothy’s symptoms worsen or if he develops a fever.
  • Follow-up: Schedule a follow-up appointment in 2-3 weeks to assess the resolution of the ear infection.

Eczema

  • Over-the-counter (OTC) treatment: Recommend a topical corticosteroid cream or ointment, such as hydrocortisone 1%, to be applied twice daily to the affected areas.
  • Patient Teaching: Explain how to apply the topical medication correctly and the importance of avoiding irritants and allergens. Advise the mother to keep Timothy’s nails short to prevent scratching.
  • Follow-up: Schedule a follow-up appointment in 2 weeks to assess the response to treatment and adjust it as needed.

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