As described by her mother, J.S has been tugging on her right ear for the past 2 days, producing a moderate amount of yellow nasal discharge. Additionally, she has been irritable. Her temperature was 101.8F, which is positive for fever. Appetite is normal with no vomiting or diarrhea. Negative for previous ear infections, congenital syndrome, and prematurity. Her immunizations are up to date and no one is the family has experienced these symptoms. Though no sick contacts are reported, the mother states that the patient started attending day care 2 weeks ago. No use of medications reported or no known allergies to medications. It means that as far as the patient is ware, she is not allergic to any medications.
A review of systems (ROS) indicates that the patient is positive for fever, irritability, and tingling. Negative for change in appetite, vomiting, diarrhea, previous ear infections, congenital syndrome, or prematurity. Likelihood of sick contact since she started attending day care 2 weeks ago.
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Objective assessment indicates temperature of 101.8F and no weight loss. The patient is well-nourished with no signs of acute distress except tugging on the right ear. Moderate amount of yellow nasal drainage observed in the right ear. The right tympanic membrane is erythematous, bulging, and has diminished mobility. The neck is supple with no masses and the right cervical lymph node is palpable, mobile, and non-tender. No murmurs or gallops in the cardiovascular. Clear to auscultation bilaterally in the lungs and no wheezing, rales, or rhonchi. The musculoskeletal is in full range of motion in all the extremities. The abdomen is soft, non-distended, or non-tender. No hepatosplenomegaly and bowel sounds are present in all four quadrants.
The assessment indicates otitis media with effusion. A comparison of the left and right sides of the ear aids in identifying unusual clinical findings. The assessment excludes cholesteotoma, mastoiditis, acute otitis media, and otitis externa. According to the 2013c guidelines of the American Academy of Pediatrics, the information needed for clinical decision making are the duration of otalgia, presence of otorrhea, and sever symptoms such as moderate to severe otalgia exceeding 48 hours and temperature above 39C, which are all present in the current case (Lieberthal, Carroll, & Chonmaitree et al., 2013). Furthermore, smoke exposure is a risk factor for otitis media (Preciado, 2015) . Though the immunizations are up to date, the patient requires a flu shot because annual flu and pneumococcal vaccines lower the risk for otitis media.
Plan for the patient is Rx amoxicillin 90mg/kg/day for 10 days or max 3g/day. Tylenol suspension (160mg/5ml) for q of 4 to 6 hours for fever and pain management (Siddiq & Grainger, 2015). The patient’s symptoms should improve within 24 to 48 hours upon commencement of antibiotic therapy (Harvey & Paterson, 2014). Follow-up should be initiated for lack of progress after 48 hours or due to parental concern for deterioration. However, routine follow-up is unnecessary if the symptoms resolve. Amoxicillin is the first line treatment for otitis media with effusion and pain management is a critical element. Since the patient has no history of ear infections, amoxicillin clavulanate is not used as first line treatment. For children aged between 6 months and 2 years, antibiotics are recommended for the initial treatment of uncomplicated otitis media with effusion if the diagnosis is definite (Lieberthal, Carroll, & Chonmaitree et al., 2013), which is the case in this scenario. The certainty of the diagnosis and the severity of the infection does not warrant an observation period.
References
Harvey, R., & Paterson, S. (2014). Otitis Externa: An Essential Guide to Diagnosis and Treatment. Hoboken: CRC Press.
Lieberthal, A. S., Carroll, A. E., & Chonmaitree, T., et al. (2013). The diagnosis and management of acute otitis media. Pediatrics, doi:10.1542/peds.2012-3488.
Preciado, D. (2015). Otitis media: State of the art concepts and treatment . Cham: Springer.
Siddiq, S., & Grainger, J. (2015). The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013. BMJ Journal, 100 (4).
