C.J. is a 27-year-old male who started to present crusty and yellowish discharge on his eyes 24 hours ago. In the beginning, he thought that by washing his eyes vigorously the discharge would go away but on the contrary, it increased causing blurry vision, especially in the morning. Once he clears his eyes of the sticky discharge his visual acuity is normal again. Also, he has been feeling a throbbing pain in his left ear. His eyes became red today, so he decided to consult to get evaluated. On his physical assessment, you found a yellowish discharge and bilateral conjunctival erythema. His throat and lungs are normal, and his left ear canal is within normal limits, but the tympanic membrane is opaque, bulging, and red.

Case Study 2 Questions:

Based on the clinical manifestations presented in the case above, what would be your diagnosis for C.J. Please name why you got to this diagnosis and document your rationale.

Any additional diagnosis or complication noted? Explain.

With no further information would you be able to name the probable etiology of the eye affection presented? Viral, bacterial, allergic, gonococcal, trachoma. Why and why not?

Based on your answer to the previous question regarding the etiology of eye affection, which would be the best therapeutic approach to C.J.’s problem? Include any additional treatment or approach to any other diagnosis or complication present in this case.

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ANSWER

1. C.J.’s symptoms, including crusty and yellowish discharge from the eyes, bilateral conjunctival erythema, blurry vision, and throbbing pain in the left ear, suggest a diagnosis of bacterial conjunctivitis and acute otitis media (AOM). Rationale: The presence of crusty and yellowish discharge, along with conjunctival erythema and ocular discomfort, are typical signs of bacterial conjunctivitis. Additionally, the opaque, bulging, and red tympanic membrane indicates acute otitis media, which commonly occurs concurrently with upper respiratory infections.

Additional Diagnosis or Complication: 2. Considering the presence of ocular and ear symptoms, a complication of otitis media such as mastoiditis or eustachian tube dysfunction may be suspected. Further evaluation, including imaging studies and tympanometry, may be required to confirm.

Probable Etiology of Eye Affection: 3. The most likely etiology of the eye affection is bacterial conjunctivitis. This is supported by the presence of purulent discharge, conjunctival inflammation, and ocular discomfort. Allergic conjunctivitis is less likely due to the absence of itching and the acute onset of symptoms. Gonococcal and trachoma infections are less common and typically present with different clinical features.

Best Therapeutic Approach: 4. The best therapeutic approach for C.J.’s bacterial conjunctivitis would involve topical antibiotics such as broad-spectrum fluoroquinolones or polymyxin B/trimethoprim. Additionally, supportive measures such as warm compresses and eye hygiene should be recommended. For acute otitis media, oral antibiotics targeting common pathogens such as amoxicillin or amoxicillin/clavulanate are indicated. Analgesics may be prescribed for pain relief. Close follow-up and monitoring for resolution of symptoms are essential.

Overall, prompt diagnosis and appropriate management of bacterial conjunctivitis and acute otitis media are crucial to prevent complications and ensure optimal patient outcomes.

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