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16-year-old female presents with tooth pain for 3 days and red, watery eyes for 1 week. History of seasonal allergies, but eyes are more irritated than usual. Tooth pain causing decreased appetite and increased sleep. Swelling in the left lower jaw and reported fever. No dental visit yet, brushing teeth twice a day. Parents both work full-time, no smoking or drinking in the home. Child in full-day kindergarten for 2 months. No significant family medical history.

Objective Information:

Temperature: 100 F, BP: 97/71, HR: 100, RR: 20, Weight: 97 lbs, BMI: 22.54

General: Well-developed, well-nourished, hydrated

Skin: No rash or lesions

Head: Normocephalic

Eyes: Itchy, red, teary; normal pupils and irises

ENT: Normal ears, nose, hearing; normal oropharynx

Neck: Supple, non-mobile adenopathy.

CV: Normal rate, rhythm, heart sounds

Lungs: Normal respiratory rate and breath sounds

Abdomen: Normal bowel sounds, no masses or tenderness

GU: Normal female genitalia, Tanner stage 1

MSK: Normal tone and muscle strength

Differential Diagnosis:

1. Dental abscess with cellulitis

2. Allergic conjunctivitis

3. Seasonal allergies exacerbation

Plan for Priority Diagnosis (Dental Abscess with Cellulitis):

Refer to a dentist promptly for evaluation and treatment of the tooth pain and swelling. Prescribe appropriate antibiotics to address the infection. Provide pain management with acetaminophen or ibuprofen as needed. Educate the patient and parents on the importance of good oral hygiene and regular dental check-ups for prevention (American Academy of Pediatrics, 2021). Follow-up to monitor resolution of symptoms and ensure proper healing.

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