Ear👂🏻 Flashcards
As the pharmacist prescriber, what is your diagnosis of JCs condition. Justify the decision with reference to the NICE guidelines.
Acute otitis media(AOM)
Acute otitis media(AOM)
NICE:
Acute onset of symptoms, including:
In older children and adults — earache.
In younger children — holding, tugging, or rubbing of the ear, or non-specific symptoms such as fever, crying, poor feeding, restlessness, behavioural changes, cough, or rhinorrhoea. Note that these non-specific symptoms do not help differentiate AOM from upper respiratory tract infection.
On otoscopic examination:
A distinctly red, yellow, or cloudy tympanic membrane.
Moderate to severe bulging of the tympanic membrane, with loss of normal landmarks and an air-fluid level behind the tympanic membrane (indicates a middle ear effusion).
Perforation of the tympanic membrane and/or discharge in the external auditory canal.
JC observations:
5 days ago:
Observation with the otoscope shows mild redness and swelling within the auditory canal. The tympanic membrane is bulging and red but intact, and the cone of light is still visible.
Body temperature:37.8°C
Today:
Observation with the otoscope in left ear shows severe redness and swelling within the auditory canal. The tympanic membrane is bulging and red but intact, and the cone of light is significantly diminished. (distortions in the cone of light can be a sign of increased middle ear pressure or otitis media)
Body temperature: 38.6°C
As the pharmacist prescriber, what is your decision in relation to prescribing an antibiotic for JC. Justify your answer with reference to NICE guidelines
Passed 7 day mark
Significant feve4
Lethargic
Prescribing an antibiotic would be necessary. NICE guidelines for acute otitis media: ‘Symptoms last for about 3 days, but can last for up to one week’. JC’s symptoms have lasted for 8 days and the patient’s mum was instructed to return if they persisted over a week. NICE guidelines also highlight to review the treatment after the week and JC has already been on ibuprofen for a week. Patient’s symptoms are also described as getting worse. High fever (38.5). Bacterial systemic infection indicated.
Feel sick
Clarithromycin (penicillin allergy)
Otherwise would prescribe amoxicillin
Has the management of JCs condition followed guidelines before seeing the pharmacist prescriber today? Explain why the pharmacist in the community pharmacy and the GP took those actions with regards to JCs condition.
Initial management by community pharmacy:
Community pharmacist said to use ibuprofen and if it is not better after 3 days to see the GP.
According to NICE guidelines, paracetamol or ibuprofen are the first-line choices for AOM pain. The 3 day follow-up recommendation was also in line with NICE.
Swimming should be avoided if evidence of tympanic membrane
Reason:
JC had no red flag symptoms suggesting complications of AOM, such as meningitis, mastoiditis, intracranial abscess, sinus thrombosis, or facial nerve paralysis.
JC had no sign of severe systemic infection (e.g. fever, nausea, vomitting)
Both viral and bacterial infections causing acute otitis media are usually self-limiting and do not routinely require antibiotics.
→ ibuprofen alone was an appropriate for symptom control at that stage
And the pharmacist also adivised to follow up with GP if the symptoms persisted or worsen after 3 days, which may need antibiotics for further treatment.
Management by GP (5 days ago)
The GP examined the ear and said to carry on with ibuprofen and that it could last for 7 days, if it’s still not better after 7 days to come back.
According to NICE, the usual course of AOM is about 3 days, but can be up to a week. So it is line with the guidelines to keep taking ibuprofen for another 4 days for JC.
And for children with mild to moderate AOM symptoms, antibiotics are typically not prescribed immediately, unless for children younger than two years of age with bilateral AOM, or of any age with both AOM and ear discharge.
Reason:
JC’s symptoms are moderate at that stage, and the AOM can be self-limiting in 7 days.
JC had no other high-risk factors or severe signs of complications.
→ watchful waiting was appropriate for JC at that stage.
While the dose adjustment can be considered.
As the pharmacist prescriber, write an appropriate prescription for JC using the form below. You must select the number of days of treatment and justify your selection.
Clarithromycin 125mg / 5ml oral suspension
70ml
5ml twice daily
5-7days
(Based on weight of child)
(If taken for 5 days discard the rest. Store in the fridge.)
