Welcome to the ACH PIG Challenge! To answer the questions below please post a comment (which will be sent to us but not published) or email ACHPIGChallenge@gmail.com . We will post answers in March, when the new case is published. You will be placed in a drawing to win an Atlas of Pediatric Physical Diagnosis by Zitelli and Davis every time you participate!!
A 12mo female presents to their PCP’s office with a 2 day history of fever (Tmax 101 F), congestion, runny nose, cough and she seems to be tugging at her left ear. She was a term newborn and has been relatively healthy up until this point. She has never been hospitalized and has no chronic medical condtions. She has never been on antibiotics.
On exam, she is febrile to 39 C, has clear rhinorrhea, her oropharynx is moist and benign in appearance. She has bilateral small anterior cervical lymphadenopathy that is mobile and nontender. Her tympanic membranes’s (TM) are not able to be visualized due to cerumen impaction bilaterally. The rest of her exam is within normal limits.
1. What is your diagnosis?
Acute Otitis Media
2. Do you need to investigate her ears further? If so, what is the next step?
If you didn’t have your attending’s help, you would definitely need to find out a way to see the TMs. Technically, you could probably trust your attending’s skills…but as an eagar medical student, you should probably take another look. This time, after an ear wash (my personal favorite is warm water and liquid colace…works like a charm) or with an ear curette gently scoop the ear wax out of the way (you must have a VERY good helper to hold the child still)
3. Your attending is able to visualize the TMs and reports the following findings. Erythematous, bulging left sided TM with purulent fluid present. What are the top 3 causes of this infection?
S. pneumoniae, H. influenza, Moraxella are the top 3 bacterial causes of otitis media.
4. What is your treatment plan, including any dosages of medications you might prescribe? What other questions might help you decide on your treatment plan for this patient?
If this is the first ear infection for this patient, most pediatricians would prescribe high dose Amoxicillin @ 80-90mg/kg/day divided BID for 10 days. If the patient has had multiple or resistant ear infections, Augmentin or Omnicef would be great options. Things you might want to ask include if this patient is in daycare, have they had any other ear infections, or if they have any drug allergies. The answers to these questions might influence your choice of antibiotic therapy. While there are a large percentage of otitis media that is viral in etiology and might resolve spontaneously, in this patient with fever and symptoms of pain and pulling at the ear, antibiotic therapy is indicated.
Tylenol (15mg/kg/dose) or Motrin (10mg/kg/dose) are good choices for antipyretics and pain control in this patient. Remember that Infant’s Tylenol and Children’s Tylenol are different suspensions so you might have to help Mom figure out the right amount to give. Also, Motrin is not indicated in children less than 6 months of age.
5. While you are walking out of the exam room, the patient’s Mom stops you to ask another question. She states that the patient has a horrible cough and wonders if there is anything you can prescribe her. She states the patient is not able to get any rest and sometimes coughs so hard that she vomits. What is your response?
If you choose to treat children as part of your medical practice, you will absolutely be confronted with this issue. Sometimes parents want to try over the counter cough and cold medications but beware that these probably will not work and are indeed not indicated in children less than 2 years of age. The risks of using these cough and cold medications usually outweigh the benefits. Reassure Mom that these symptoms will resolve with time and be sympathetic to her situation. Offer to see the child back if the symptoms do not improve over the next few days and give her a list of reasons when she should worry or bring the child back. (signs/symptoms of respiratory distress, dehydration, lethargy, inability to take antibiotics, or continued fever after 48-72hrs, etc)
