Question

Case: Mark is a 6-year-old boy accompanied to the office by his mom. He is indeed in some distress, holding his ear and crying intermittently. Mom states that he has been complaining of pain in his ear for 3 days and yesterday complained that the pain was worse with movement of his ear or when he is eating. She has noted no discharge from the ear and he has not been running a fever.

Patient has been spending the summer at an urban day camp, swimming in the pool every day and playing T-ball. Mom recalls no exposure to ticks or poison ivy/oak. There is a cat at home, which has been present since Mark was an infant. His appetite is good and he is normally “very energetic.” Both parents are smokers.

Past medical history: Normal childhood development. History of frequent middle ear infections as well as exertional asthma. History of mild seasonal allergies.

Medications: Occasional oral antibiotic for otitis media in the past year and intermittent use of an asthma inhaler. Mom has been giving him baby aspirin for the past few days for pain relief.

Physical Examination: Afebrile fit young boy in obvious distress.
Ears: Canal is red and swollen. There is reproducible pain and traction of the pinna and tragus. No fluid or discharge noted. On visual exam, no pus or debris is present in the canal. Eardrum appears intact and not erythematous.  

How would you proceed?
    


What points related to assessment & history are important?
What is your differential diagnoses? Please include 3.
What patient factors will affect your antibiotic selection? (have a discussion here about options)
What clinical guidelines will you use?
How will you write the antibiotic Rx?       
How long will you treat the child?
What will you say to the mom related to education and follow up?

Answer 1

•Treatment will proceed based on symptoms.

• Important points are, the boy is suffering from ear pain without discharge, without fever. The boy was suffering from otitis media, asthma, seasonal allergies related to assessment and history.

• Diagnosis.

1) Acute pain in ear related to ear problem as evidenced by patient's facial expression.

2) Disturbed sensory perception related to ear pain.

3) Anxiety related to disease prognosis as evidenced by boy is suffering from distress.

• Patient's ear canal is red and swollen. It is the sign of infection which affects for antibiotic selection.

• Clinical guidelines.

a. Oral antibiotics.

b. Local antibiotic ear drops.

c. Ear wicking.

d. Dry mopping.

• Antibiotic Rx is written ata first composition of the medicine, dose, frequency, time. For example-

1)Rx

Amoxicillin 50mg BID for 5days.

• The child should be treated at least for 5days. If prognosis is not well, then treat the child for 10days.

• Education.

1) Hand hygiene should be maintained.

2) Don't clean the ear through cotton bud. Clean the ear through soft cloths.

3) Avoid the child from smoking exposure.

4) Cold drinks, ice cream should be restricted.