Full Answer Section

1. Atypical Pneumonia (e.g., Mycoplasma pneumoniae, Chlamydophila pneumoniae):

   • Reasoning: Atypical pneumonias can present with a persistent cough, sometimes accompanied by wheezing, and may not always involve a high fever, especially in older children and adolescents (though Timothy is 7). Given the duration of the cough and the wheezing, this should be considered, although it’s less likely than an asthma exacerbation in a known asthmatic with these specific symptoms.

Differential Diagnoses for the Right Ear Pain:

1. Acute Otitis Media (AOM):

   • Reasoning: Ear pain (otalgia) in a child is a primary symptom of AOM, a common bacterial or viral infection of the middle ear. The report of new onset ear pain alongside respiratory symptoms (cough) increases the likelihood of AOM, as URIs often precede middle ear infections.

2. Otitis Media with Effusion (OME):

   • Reasoning: OME involves fluid buildup in the middle ear without acute inflammation. While typically not as painful as AOM, it can cause ear discomfort or a feeling of fullness. It can sometimes follow a viral URI or AOM. The lack of fever doesn’t exclude OME, but the reported “pain” makes AOM more probable.

3. Referred Pain (e.g., from temporomandibular joint (TMJ) issues, dental problems, or pharyngitis):

   • Reasoning: Pain originating from other areas of the head and neck can sometimes be referred to the ear. While less common in a 7-year-old presenting with a cough, it’s important to consider, especially if the ear examination is normal. However, the association with respiratory symptoms makes a primary ear issue more likely.

Differential Diagnoses for Dry Scaly Patches:

1. Atopic Dermatitis (Eczema):

   • Reasoning: The description of dry, scaly patches on the elbows and behind the knees is highly characteristic of atopic dermatitis, a chronic inflammatory skin condition common in children. The location of the patches is also typical for eczema.

2. Psoriasis:

   • Reasoning: Psoriasis is another chronic skin condition that can cause scaly patches. However, psoriasis lesions are typically thicker, more silvery, and often found on extensor surfaces (like the front of the elbows and knees) more than flexural areas (behind the knees). While it can occur in children, the distribution described is more classic for eczema.

3. Tinea Corporis (Ringworm):

   • Reasoning: Tinea corporis is a fungal infection that presents as circular, scaly patches with a raised border. While it can be dry and scaly, the description of patches on the elbows and behind the knees without the characteristic ring shape makes this less likely. However, a fungal infection should be considered in the differential for any new scaly skin lesion.

Primary (Final) Diagnoses:

1. Asthma Exacerbation: The history of known asthma, current respiratory symptoms consistent with asthma, increased albuterol use, and lack of recent controller medication strongly suggest an asthma exacerbation.

2. Acute Otitis Media (AOM): The report of right ear pain in conjunction with a recent cough makes AOM the most likely diagnosis. An otoscopic examination (which would be performed in a real clinic setting) would be crucial to confirm this.

3. Atopic Dermatitis: The description and location of the dry, scaly patches on the elbows and behind the knees are highly suggestive of atopic dermatitis.

Plan of Care:

1. Asthma Exacerbation:

• Medications:
  • Albuterol Inhaler (ProAir HFA or Ventolin HFA): 90 mcg/actuation, 1 inhalation every 4 hours as needed for wheezing or shortness of breath.
    • Dispense: 1 inhaler
    • Refills: 0
  • Prednisolone Oral Solution: 10 mg/5 mL, Dispense 30 mL. Take 20 mg (10 mL) by mouth once daily for 5 days.
    • Dispense: 30 mL
    • Refills: 0
• Patient Teaching:
  • Albuterol Inhaler Technique: Demonstrate proper inhaler technique, including using a spacer if available. Emphasize the importance of shaking the inhaler before each use and holding the breath for 10 seconds after inhalation. Explain that albuterol is a rescue medication for quick relief of symptoms.
  • Prednisolone: Explain that prednisolone is an oral steroid that helps reduce inflammation in the airways. Instruct the mother to administer the full course as prescribed, even if Timothy’s symptoms improve. Discuss potential side effects such as increased appetite, hyperactivity, and mood changes.
  • Asthma Action Plan: Provide or review an age-appropriate asthma action plan that outlines how to recognize worsening symptoms, when to use rescue medication, and when to seek medical attention.
  • Trigger Avoidance: Discuss potential asthma triggers (e.g., allergens, irritants, cold air, exercise) and strategies to minimize exposure.
  • Importance of Follow-Up: Emphasize the need for a follow-up appointment to assess asthma control and discuss long-term management.

2. Acute Otitis Media (AOM):

• Medications:
  • Amoxicillin Oral Suspension: 400 mg/5 mL, Dispense 15 mL. Take 5 mL (400 mg) by mouth twice daily for 10 days.
    • Dispense: 15 mL
    • Refills: 0
• Patient Teaching:
  • Amoxicillin Administration: Instruct the mother on the correct dosage and frequency of amoxicillin administration. Emphasize the importance of completing the entire course of antibiotics, even if Timothy feels better, to prevent antibiotic resistance and treatment failure.
  • Pain Management: Recommend over-the-counter pain relievers such as acetaminophen (Tylenol) or ibuprofen (Motrin) for ear pain, dosed according to Timothy’s weight.
  • Observation for Improvement: Advise the mother to monitor Timothy’s symptoms and expect improvement in ear pain and other signs of infection within 48-72 hours.
  • When to Seek Further Care: Instruct the mother to contact the clinic if Timothy’s ear pain worsens, if he develops a fever, if there is drainage from the ear, or if his symptoms do not improve within 72 hours.

3. Atopic Dermatitis:

• Medications:
  • Hydrocortisone Cream 1%: Apply a thin layer to the affected areas twice daily.
    • Dispense: 30 gram tube
    • Refills: 1
• Non-Pharmacological Management:
  • Emollients: Recommend frequent use of fragrance-free, hypoallergenic moisturizers (e.g., petroleum jelly, Eucerin, Cetaphil) several times a day, especially after bathing, to hydrate the skin and improve the skin barrier.
  • Gentle Skin Care: Advise using mild, fragrance-free soaps or cleansers. Avoid hot water and harsh scrubbing during baths or showers. Pat the skin dry gently.
  • Trigger Identification: Discuss potential eczema triggers (e.g., certain soaps, detergents, fabrics, temperature extremes, stress) and strategies to avoid them.
• Patient Teaching:
  • Hydrocortisone Cream: Explain that hydrocortisone cream is a mild topical steroid that helps reduce inflammation and itching. Instruct the mother on how to apply a thin layer to the affected areas only, as directed. Advise against using it on broken skin or for prolonged periods without medical advice.
  • Importance of Emollients: Emphasize that regular and liberal use of moisturizers is the cornerstone of managing atopic dermatitis.
  • Avoiding Scratching: Advise strategies to minimize scratching, such as keeping fingernails short, using cool compresses, and distracting Timothy when he is itchy.

Follow-Up:

• Asthma: Timothy should return to the clinic for a follow-up appointment within 1 week to reassess his asthma control and discuss long-term management, including the potential need for a daily controller medication.
• Acute Otitis Media: Timothy should have a follow-up appointment in 10-14 days to ensure the ear infection has resolved. Earlier follow-up is warranted if symptoms worsen or do not improve as expected.
• Atopic Dermatitis: Follow-up for the atopic dermatitis can be scheduled in 2-4 weeks to assess the response to treatment and discuss long-term management strategies. However, the mother should be advised to contact the clinic sooner if the eczema worsens significantly or does not improve with the initial treatment.

Supporting Clinical Practice Guidelines and Scholarly Articles:

1. National Heart, Lung, and Blood Institute (NHLBI). (2020). 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Expert Panel Working Group. (This guideline provides comprehensive recommendations for asthma diagnosis and management, including exacerbation treatment.)  

2. American Academy of Pediatrics (AAP). (2013, reaffirmed 2019). Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media. Pediatrics, 131(3), e964-e999. (This guideline outlines the diagnostic criteria and treatment recommendations for acute otitis media in children.)

3. Eichenfield, L. F., Tom, W. L., Berger, T. G., Krol, A., Paller, A. S., Schwarzenberger, K., … & Boguniewicz, M. (2014). Guidelines of care for the management of atopic dermatitis: Section 1. Diagnosis and assessment of atopic dermatitis. Journal of the American Academy of Dermatology, 70(2), 338-350.