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A 7-year-old boy attends the clinic accompanied by his mother, hasn’t been seen for over one year ago and presents with scaly dry patches on his skin, ear pain, cough with wheezing, and has been out of his rescue inhaler (Albuterol) for the last few days.

The three differential diagnoses for coughing

1. Acute bronchitis – this can present with coughing, both productive and non-productive. As a first symptom, the patient coughed for a week and wheezed for two days. In this case, acute bronchitis is the first differential diagnosis. During acute bronchitis, the bronchi in the lungs may swell and become inflamed (Hoerr, 2021). The edema causes narrowing of the airways, which makes breathing more difficult. The common signs of bronchitis are coughing and wheezing.

2. Asthma- The second differential diagnosis is acute asthma exacerbation because it also presents as wheezing, coughing, and shortness of breath. Exacerbations of respiratory symptoms can result from respiratory illnesses or allergies. Asthma exacerbations involve worsening symptoms and reduced lung function. Patients with asthma may experience an attack as a new onset, or they may experience one as a result of a “trigger” such as an upper respiratory infection due to a virus, an allergy, air pollution, or another irritant, or if they fail to take their control medication as a result. Additionally, the patient has previously used an inhaler to treat airway symptoms (Lizzo, 2023).

3. Allergies– The third differential diagnosis is upper respiratory symptoms such as wheezing, coughing, sneezing, and runny nose. Allergens can cause these symptoms as well. The patient has a history of inhaler use. Also, allergies may contribute to obstruction of the airway. In this manner, allergies can be a significant trigger for asthma exacerbations, especially when an inhaler is not available (Chabra & Gupta, 2023).

The final diagnosis is acute bronchitis, and the patient has lingering symptoms of a virus because his cough lasted for a week and was exacerbated by his asthma, acute bronchitis is the diagnosis for Timothy.

The differential diagnosis of the second problem (right ear pain)

1. Acute otitis media. An infection of the middle ear is called otitis media, which results in swelling and redness behind the eardrum and an accumulation of fluid (Paul & Moreno, 2020). Acute otitis media causes ear pain.

2. Otitis externa (OE) is an inflammation of the external auditory canal that can be infectious or non-infectious. Occasionally, inflammation may spread to the tragus or pinna of the outer ear, causing ear pain (Medina-Blasini & Sharman, 2020). Since it is more common in tropical and summertime regions, it is referred to as swimmer’s ear. A non-infectious or infectious otitis externa (EO) is an inflammation of the external auditory canal. The condition usually starts with ear pain and may spread to the tragus or pinna of the outer ear (Medina-Blasini & Sharman, 2020).

3. Cerumen impaction – ear impaction due to a foreign body in the ear. An ear infection caused by a foreign body may accompanied by otalgia. Timothy’s primary diagnosis is acute otitis media. Despite ear impaction and otitis externa being common conditions, ear exposure to water or the presence of a foreign object may indicate acute otitis media. It is possible to have otitis media if you have acute bronchitis along with a respiratory infection.

The final diagnosis of the patient was acute otitis media

Differential diagnoses for a dry, scaly skin patches

1. Psoriasis. As a result of overactive immune systems, skin cells may grow rapidly, which causes psoriasis. It causes patches of scaly, irritated skin, usually on the knees, elbows, or scalp, but it can also appear elsewhere (Raharja et al., 2021).

2. Eczema or Atopic dermatitis: Eczema is a relatively common but non-contagious disorder characterized by dry, itchy skin patches (NIAMS, 2022). Symptoms of eczema may worsen if you are exposed to allergens or irritants.

3. Contact dermatitis. An allergic reaction or direct contact with a substance can cause an itchy, dry, and scaly rash known as contact dermatitis (Bains et al., 2019). According to this case, the patient has psoriasis because the scaly patches on the elbow and behind the knees are characteristic of psoriasis.

The final diagnosis is psoriasis

Care plans and treatments for all diagnoses

Since acute bronchitis is self-limiting, supportive care and symptom management are the cornerstones of care. Several cough suppressants and bronchodilators can be used as treatments in this case. Robitussin Pediatric 7.5 Mg/5 Ml Oral Syrup. Take this medication orally, usually every four to twelve hours as needed. Inhale Ventolin HFA 90 mcg two puffs every four hours PRN to relieve coughing, shortness of breath, or wheezing (Hoerr, 2021).

As a treatment for Otitis media, the American Academy of Pediatrics (AAP) recommends azithromycin 10 mg/kg once daily for three days (Wolf et al., 2022). If the patient consistently loses hearing, follow the antibiotic therapy accordingly and contact the provider. Another option is Amoxicillin (20–50 mg/kg/day, divided into 8 hours) may be prescribed for ten days for otitis media (Vanneste & Page, 2019).

Psoriasis in children and adolescents may treated with topical medications. Psoriasis has been widely treated with topical steroids because they suppress the immune system, reduce inflammation, and reduce proliferation. A thin layer of Clobetasol Propionate (0.05%) should applied twice a day to the affected area of the skin (Katakam, et al., 2021). Alternatively, Eucerin cream could be applied BID as a topical application. Cream may applied to the affected area for a 30-day refill (Frazier & Bhardwaj, 2020).

Patient Education and follow up

• Education focuses on medication instruction and prevention.
• Instruct the child to cover his mouth and nose whenever he sneezes or coughs.
• Hand washing should be a priority for your child.
• Verify that your child has had all recommended vaccinations, including the annual flu shot.
• Bring the patient to the ER if he experiences difficulty breathing.
• Ensure that Timothy and his mother are trained on the proper use of inhalers.
• Explain that the amoxicillin should completed as prescribed, even if symptoms improve.
• Discuss the use of hydrocortisone cream and moisturizer.
• Patients should be encouraged to spend time outside since it has many positive health effects.
• Patients with psoriasis should follow a healthy, balanced diet.

Follow-up: Timothy needs to return to the clinic in two weeks to evaluate his response to treatment. A return to the clinic is mandated if his symptoms worsen or he develops a fever.

References

Bains, S. N., Nash, P., & Fonacier, L. (2019). Irritant contact dermatitis. Clinical Reviews in Allergy & Immunology, 56(1), 99–109. https://doi.org/10.1007/s12016-018-8713-0

Chabra, R., & Gupta, M. (2023, August 7). Allergic and environmentally induced asthma – StatPearls NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK526018/

Frazier, W., & Bhardwaj, N. (May 15, 2020). Atopic dermatitis: Diagnosis and treatment. American Family Physician. https://www.aafp.org/pubs/afp/issues/2020/0515/p59…

Hoerr, F. J. (2021). The pathology of infectious bronchitis. https://doi.org/10.1637/aviandiseases-d-21-00096

Katakam, B. K., Munisamy, M., & Rao, R. (2021). Recommendations for management of childhood psoriasis. Indian Dermatology Online Journal. https://doi.org/10.4103/idoj.idoj_965_20

Lizzo, Jenna M Pediatric Asthma {updated 2023, Aug 7} In: StatPearls Treasure Island (FL); STATPEARLS publishing https://www.ncbi.nlm.nih.gov/books/NBK551631/

Medina-Blasini, Y., & Sharman, T. (2020). Otitis externa. PubMed: StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556055/

NIAMS. (2022, November). Atopic Dermatitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/health-topics/atopic-der…

Paul, C. R., & Moreno, M. A. (2020). Acute otitis media. JAMA Pediatrics, 174(3). https://doi.org/10.1001/jamapediatrics.2019.5664

Raharja, A., Mahil, S. K., & Barker, J. N. (2021). Psoriasis: a brief overview. Clinical Medicine (London, England), 21(3), 170–173. https://doi.org/10.7861/clinmed.2021-0257

Vanneste, P., & Page, C. (2019). Otitis media with effusion in children: Pathophysiology, diagnosis, and treatment. A review. Journal of Otology, 14(2), 33–39. https://doi.org/10.1016/j.joto.2019.01.005

Wolf, R. M., Langford, K. T., & Patterson, B. L. (2022). Improving adherence to AAP acute otitis media guidelines in an academic pediatrics practice through a quality improvement project. Pediatric Quality & Safety, 7(3), e553. https://doi.org/10.1097/pq9.0000000000000553