AOM

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ear pain on the ‍rightleft

Symptoms include:

‍ear pain

‍impaired hearing

‍tinnitus

‍ear discharge

‍fever, up to ‍°, over ‍ ‍hoursdays

‍vertigo

‍irritability

‍pulling at ears

‍loss of appetite

‍sleep disturbances



Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍exposure to secondhand smoke

‍daycare attendance

no history of: ‍otitis media, ‍upper respiratory infections, ‍allergies, ‍adenoidal hypertrophy

no use of: ‍antibiotics





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍rashlesions on ‍





ASSESSMENT:

‍Acute otitis media ‍likelysuspectedpossible

DDx: acute otitis media, otitis media with effusion, otitis externa, Eustachian tube dysfunction, mastoiditis, foreign body in the ear, dental issues, temporomandibular joint disorder, pharyngitis, sinusitis, upper respiratory infection, allergic rhinitis, barotrauma, neuralgia





PLAN:

Treatments:

- Saline nasal irrigation

- ‍Antibiotics

- ‍Decongestants

- ‍Nasal Steroids

- ‍Acetaminophen

- ‍Ibuprofen

Further care:

- Referral to otolaryngologist

- Follow-up in ‍ ‍daysweeks

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