Acute Otitis Media

HISTORY:

‍RightLeft ear pain for ‍ ‍hoursdays

‍impaired hearing

‍tinnitus

‍ear discharge

‍fever, up to ‍°, over ‍ ‍hoursdays

‍vertigo

‍irritability

‍pulling at ears

‍loss of appetite

‍sleep disturbances

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍no rash



ASSESSMENT:

‍Acute otitis media ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Saline nasal irrigation

- ‍Antibiotics

- ‍Decongestants

- ‍Nasal Steroids

- ‍Acetaminophen

- ‍Ibuprofen

- Referral to otolaryngologist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms do not improve after 72 hours or before if worse