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S: Subjective
A 3-year-old boy is brought in by his mother with one day of pulling at his left ear, fussiness and poor sleep, following four days of nasal congestion. His highest temperature at home was 38.4 °C (101.1 °F), treated with acetaminophen. He is eating less than usual but drinking and urinating normally. No vomiting, rash or ear drainage. No antibiotics in the past 30 days and no known drug allergies. Immunizations are up to date, including pneumococcal conjugate vaccine. He attends daycare.
O: Objective
Weight 15 kg. Temperature 38.2 °C, heart rate 118, respiratory rate 24. Alert and consolable. Left tympanic membrane: moderate bulging, erythematous and opaque, with reduced mobility on pneumatic otoscopy. Right tympanic membrane: pearly gray with normal landmarks and mobility. Clear rhinorrhea, no conjunctivitis. Neck supple; lungs clear.
A: Assessment
Acute otitis media (AOM), left ear, non-severe. Moderate bulging of the tympanic membrane meets the diagnostic criteria of the American Academy of Pediatrics guideline. The episode is non-severe because the ear pain is mild, has lasted less than 48 hours and the temperature is below 39 °C (Lieberthal et al., 2013).
Differential diagnoses: otitis media with effusion (excluded by the bulging and acute symptoms), otitis externa (no canal edema or tragal tenderness), and a viral upper respiratory infection alone.
P: Plan
- Pain relief: ibuprofen 150 mg (10 mg/kg) every 6 to 8 hours, or acetaminophen 225 mg (15 mg/kg) every 4 to 6 hours, as needed.
- Antibiotic decision: for children aged 24 months or older with non-severe AOM, the guideline allows either antibiotics or observation with close follow-up, chosen with the family (Lieberthal et al., 2013). After discussion, the mother chose observation.
- Safety-net prescription: amoxicillin 90 mg/kg/day in two divided doses (675 mg, or 8.4 mL of the 400 mg/5 mL suspension, twice daily) for 7 days, to start only if symptoms worsen or don't improve within 48 to 72 hours.
- Education: the expected course, fever care, and signs that need prompt review: high fever, ear drainage, swelling behind the ear or unusual drowsiness.
- Follow-up: phone check in 48 to 72 hours, and a clinic visit if symptoms persist.
Reference
Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., Joffe, M. D., Miller, D. T., Rosenfeld, R. M., Sevilla, X. D., Schwartz, R. H., Thomas, P. A., & Tunkel, D. E. (2013). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964–e999. https://doi.org/10.1542/peds.2012-3488
