Otitis Media in child

HISTORY:

‍RightLeft ‍ear painfeverirritability for ‍ ‍hoursdays

‍fever, up to ‍°, over ‍ ‍hoursdays

‍irritability

‍loss of appetite

‍sleep disturbances

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

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

Head: fontanelles ‍soft, ‍normocephalic

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍clear, ‍nasal flaring, discharge ‍clear, ‍

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

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

Extremities: ‍normal, ‍normal pulses, cap refill ‍< 3 sec> 3 sec

Skin: ‍no rash



ASSESSMENT:

‍Acute otitis media ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍CRP

- Audiogram

- ‍Analgesics

- ‍Ibuprofen

- ‍Antibiotics

- ‍Decongestants

- ‍Nasal Steroids

- Referral to otolaryngologist if recurrent episodes

- Follow-up in ‍ ‍daysweeks

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