Fever and Ear Pain

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of fever and ‍rightleft ear pain

Ear pain rated at ‍012345678910 / 10 ‍

Described as ‍dullaching

Peak temperature recorded: ‍° ‍not measured

Pattern of fever: ‍persistentintermittent

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍runny nose, ‍clearcolored

‍sore throat

‍shortness of breath

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍body ache

‍joint pain

‍night sweats

‍fatigue

‍rash

‍loss of appetite

‍decreased fluid intake

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍diarrhea, ‍ episodes ‍per day, ‍

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍dysuria

‍frequency

‍flank pain

‍ear discharge

‍hearing loss



Contributing factors:

‍recent travel

‍similar symptoms in close contacts

‍insect bites

‍unprotected sex

‍risk factors for STIs

no history of: ‍otitis media, ‍otitis externa, ‍temporomandibular joint syndrome, ‍ear surgery, ‍diabetes, ‍immunodeficiency

no use of: ‍antibiotics, ‍immunosuppressants





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

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, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM





ASSESSMENT:

‍Acute otitis media ‍likelysuspectedpossible

DDx: acute otitis media, URI with referred ear pain, otitis externa with systemic symptoms, pharyngitis with referred ear pain, mastoiditis, dental abscess, cervical lymphadenopathy with referred ear pain, malignant otitis externa





PLAN:

Investigations:

- Chest X-ray

- Covid test, Influenza test

- Throat swab

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍CRP, ‍blood culture

- Ear swab for culture

Treatments:

- ‍Acetaminophen as needed

- ‍Ibuprofen as needed

- ‍Topical antibiotics

- ‍Antibiotics

- Over-the-counter cold and flu remedies

- Encourage hydration

- Avoid contact with others

Further care:

- Referral to otolaryngologist

- Follow-up in ‍ ‍hoursdays

- Return if fever persists for more than 3 days, if new symptoms develop, or if condition worsens

- Referral to ER if severe headache, stiff neck, or other signs of serious illness occur