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Considering all the symptoms exhibited by this 5-year-old patient, including a cough and wheezing over the past two days, along with additional complaints of ear pain and dry scaly patches behind her knees and elbows, I can arrive at several potential differential diagnosis for this pediatric case.
Atopic Dermatitis (Eczema): As per the information from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIH), Atopic dermatitis, commonly known as eczema, is a persistent (long-lasting) condition that leads to skin inflammation, redness, and irritation.
The management of eczema focuses on keeping the skin moisturized and avoiding triggers. Non-pharmacological approaches, such as lukewarm soaking baths lasting 10–20 minutes, using mild and unscented soaps with a neutral pH, and considering the inclusion of oils or emulsification agents like CeraVe, Cetaphil Restoraderm and Aquaphor for example in the daily skincare routine, are recommended.
Based on the findings by Schwartz in 2023, incorporating 2 teaspoons of household bleach (e.g., Clorox) per gallon of bath water can be beneficial in reducing the occurrence of recurrent cutaneous infections in children.
Pharmacological treatments consist of topical corticosteroids. As per the American Academy of Pediatrics (n.d.), for young children (excluding the face), it is recommended to employ a low-potency preparation like hydrocortisone 1% or 2.5%. If needed, a mid-potency preparation such as triamcinolone 0.025% or 0.1%, or fluocinolone 0.025%, can be considered.
As stated by the National Heart, Lung, and Blood Institute (NIH) in 2022, asthma is a chronic (long-term) ailment that impacts the lung airways - the tubes responsible for transporting air in and out of the lungs. The Centers for Disease Control and Prevention report that approximately 1 in 13 individuals in the United States suffer from asthma.
The treatment for asthma typically involves long-term management with inhaled corticosteroids or other controller medications to reduce inflammation and prevent asthma attacks.
For this patient in particular, I will initiate treatment by administering a nebulizer treatment in the office. The dose will be Albuterol 1.25 mg in the nebulizer, and I will instruct the mother to continue giving the treatment 3 or 4 times per day as needed.
During the office visit, a peak flow meter will be used to measure the lung function and assess how well the lungs are functioning.
In the event that there is no improvement with the nebulizer treatment, the patient will be requested to return to the office for further evaluation. At that point, if necessary, I will prescribe inhaled corticosteroids such as fluticasone (Flovent HFA) 88 mcg (2 puff) twice daily by oral inhalation, as part of the ongoing management plan for managing asthma.
Based on the presented symptoms and considering the association between the two conditions, I have selected these two diagnoses: contact dermatitis and asthma. According to a study by Yaneva and Darlenski in 2021, there is a significant connection between asthma and atopic dermatitis (AD). Various factors contribute to the increased risk of atopic comorbidities, including systemic factors like genetics and impaired Th2 immunity, as well as tissue-specific factors such as local immune response, barrier dysfunction, abnormal microbiome, and environmental triggers.
1. J45.9: Asthma, unspecified. Two classic symptoms of asthma are cough and wheezing which can be triggered by numerous factors including an upper respiratory tract infection or exposure to allergens. The classic triad of asthma, eczema, and allergies underscores their interrelation also known as the “Atopic March or Atopic Triad” (Lizzo & Cortes, 2023). The exact cause is unknown, but it is believed to be influenced by both genetic and environmental factors (Lizzo & Cortes, 2023). Prior to a formal asthma diagnosis, children may be preliminarily labeled with reactive airway disease or wheezing associated with respiratory infections (Lizzo & Cortes, 2023).
2. J06.9: Acute upper respiratory infection, unspecified. Cough and wheezing could be due to a viral or bacterial respiratory infection. Allergies (part of the classic triad) do not directly cause upper respiratory tract infections, but they can contribute to an increased risk of development due to inflammation and congestion of the respiratory system (Lizzo & Cortes, 2023).
3. H65.01: Acute serous otitis media, right ear. Typically, AOM follows a viral upper respiratory tract infection in children. It is the second most common pediatric diagnosis in the emergency department following upper respiratory infections (Danishyar & Ashurt, 2023).
4. L20.9: Atopic dermatitis, unspecified. The presence of dry, scaly patches in the flexural regions such as the elbows and popliteal fossa raises suspicion for atopic dermatitis, a prevalent form of eczema seen in the pediatric population (Kolb & Ferrer-Bruker, 2022). This condition is frequently linked to other IgE-mediated disorders, including allergic rhinitis, asthma, and food allergies (Kolb & Ferrer-Bruker, 2022).
Treatment & Management
1. Asthma: pediatric patients who present with an acute exacerbation should be assessed immediately to determine if they need a higher level of care. The following recommendations are provided by Lizzo and Cortes (2023):
· Diagnostic:
· Chest X-ray: may reveal hyperinflated lungs and interstitial prominence.
· Allergy Testing
· Spirometry
· Non-Pharmacologic:
· Trigger Avoidance
· Pharmacologic:
· Metered-dose Inhalers
· Nebulizers (Albuterol, Ipratropium)
· Corticosteroids
2. Upper Respiratory Tract Infection: the etiology is presumed to be primarily viral, however; to confirm or rule out a bacterial origin, a swab and culture should be obtained for definitive identification.
· Viral: supportive care including rest, fluids, and fever management.
· Bacterial: targeted antibiotic therapy.
3. Acute Serious Otitis Media: the primary treatment objective is effective pain management and administration of antibiotics. “Watchful waiting” has not gained wide acceptance in the United States (Danishyar & Ashurst, 2023).
· Pain Control: NSAIDs or acetaminophen.
· Antibiotics: high-dose amoxicillin or a second-generation cephalosporin are the first-line agents (Danishyar & Ashurst, 2023).
· TM Perforation: ototopical antibiotics such as ofloxacin deliver higher concentrations without any systemic side effects (Danishyar & Ashurst, 2023).
4. Atopic Dermatitis: Kolb and Ferrer-Bruker (2022) identify four major components of treatment which include:
· Trigger Avoidance
· Daily Skin Care: keep the skin moisturized with hypoallergenic emollients twice daily, applying within 3 minutes of exiting a lukewarm bath or shower to prevent skin drying.
· Anti-inflammatory Therapy: topical corticosteroids, topical calcineurin inhibitors, systemic corticosteroids, antihistamines, and immunosuppressants. These agents reduce inflammation, control symptoms, and reduce the potential for flare-ups. Use is dependent on severity.
· Complementary Modalities:
· Probiotics may benefit some patients as it is believed that the bacterial products may enhance the immune system and prevent the development of allergic IgE antibody response.
· Bleach baths may relieve symptoms by lowering the risk of superinfection with bacteria.
· Phototherapy with UVA/UVB light
