Week 1 - Ear pain Flashcards

1
Q

Mum attends a GP surgery in Cairns with D.J. a 3-year-old Aboriginal child who says his ears hurt.

Take a history of this patient.

HPC:
• Pulling at ears, ears hurt. Worse at night.
• Recurrent, more since starting day care (a few weeks ago - exposure to children/infections).
• Fever, sore throat past few days.
• Recurrent “colds and cough”. (Chronic causes - asthma, allergic bronchitis).
• Father asthma (familial tendency may be present), smoker (pollution can give rise to URTI).
• T 38.2˚C, RR 20 bpm, PR 120/min and regular.
• No neck stiffness (meningeal irritation - can start as URTI), bilateral tender cervical lymphadenopathy (supports infective causes - more typical of viral than bacterial).
• Pharynx, tonsils - inflamed but no pus (suggests more of a viral aetiology). Chest clear (rules out pneumonia).

A

• Identify as ATSI?

HPC:
• Site - where is the pain?
• Onset - when did it start?
• Character of pain?
• Localised or radiate?
• Alleviating factors?
• Timing - experienced it before? Constant or intermittent? How long does it last/worse at a particular time?
• Severity?
• Associated symptoms? i.e. fever, sore throat, headache, cough or cold?
• Effect on lifestyle?

• Any vomiting or lethargy?
• Has he been off his food?
• Any discharge from ear?
• Recurrent ear infections? (especially common in ATSI children).
• Injury to ears or heads or serious infection such as meningitis?
• N.B. a child with otitis media can also have serious bacterial infection such as septicaemia or meningitis.
- Neck stiffness?
- Sensitivity to light?
- Rash?
• Any hearing problems?
• Environment - who lives at home - smokers? Daycare? Siblings with the same problems? Anyone sick in the family? Breastfed or formula, supine feeding?

  • Influenza - fever, chills, muscle aches, cough, congestion, runny nose, headaches and fatigue?
  • URTI - usually resolve within 2 weeks and include a scratchy or sore throat, sneezing, stuffy nose, cough?

PMHx:
• Past illnesses?

PSHx:
• Past surgeries?

Medications:
• Any regular medications?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• Vaccinations - tetanus, influenza, pneumococcal, meningococcal?

FHx:
• Family history of any illnesses/conditions?

SHx:
• Background?
• Occupation?
• Education?
• Religion?
• Living arrangements? i.e. overcrowding.
• Smoking?
• Nutrition?
• Alcohol/recreational drugs? 
• Physical activity?

Systems Review:
• General - weight change, fatigue, weakness, fever, chills, night sweats?
• CVS - chest pain, palpitations?
• RS - dyspnoea, cough/sputum, sinusitis, wheezing?
• GI - vomiting, diarrhoea, abdominal pain.
• UG
• CNS - headaches, nausea, difficulty hearing?
• ENDO
• HAEM
• MSK - sore joints/muscles, rash?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Perform a physical examination on this patient.

A
  1. Introduction, explanation, consent, wash hands.
  2. General inspection: pain, distressed, flushed, crying, congested/sneezing, fatigue, hoarsness, coughing, lymphadenopathy.
3. Vital signs:
• HR - tachycardic.
• RR - tachypnoeic.
• BP
• Temp - febrile.
  1. Ears:
    • Inspection - pinna (size, position, shape), scars, swelling, cauliflower ears, erythema, discharge.
    • Palpation - pinna (swellings or nodules), tug test - for tenderness in EAC, pull down pinna gently.
    • Otoscope
    - EAC - discharge/blood/CSF, oedema, erythema, vesicles, foreign body, cerumen impaction.
    - Tympanic membrane (normally pearly grey, ovoid in shape and semi-transparent) - colour, transparency, dilated blood vessels, bulging or retraction of membrane or any perforation. Identify light reflex (cone of light), short process of malleus, handle of malleus, umbo, incus, pars flaccida, pars tensa.
    • Hearing
    - Whisper test.
    - Tuning fork 256/512 Hz, test on patient’s sternum - Weber and Rinne test.
  2. Nose:
    • Inspection - discharge, deformity, swelling.
    • Palpation - feel for any swelling, tenderness, deformity.
  3. Sinuses:
    • Frontal, maxillary, transilluminate maxillary sinuses.
  4. Mouth:
    • Cyanosis, hydration, signs of infection/inflammation (redness, swelling), redness of pharynx, enlarged tonsils.
  5. Neck:
    • Cervical lymph nodes.
  6. CVS/RS
    • Auscultation - murmurs, infection.

*Tympanic membrane may be dull and opaque, bulging/retracted. Colour varies - may be yellow-grey, pink, red, white. TM mobility reduced. Usual middle earmarks not well seen. Dilated blood vessels.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is your provisional diagnosis and differential diagnoses?

A
• Provisional diagnosis: Acute otitis media.
• DDx:
- URTI (viral, bacterial).
- Influenza.
- Otitis externa.
- Mastoiditis.
- Cholesteatoma.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What investigations would you carry out on this patient?

A
  • Clinical diagnosis - otoscope
  • Viral culture.
  • Serology.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What treatment does this patient require?

A
  • Most cases of AOM in children resolve spontaneously.
  • Supportive - rest, hydration.
  • Analgesia e.g. paracetamol.
  • Antibiotics have a limited role - modest benefit must be weighed against potential harms related to antibiotic use, both for the individual patient (adverse effects) and at a population level (resistance pressure).

Need to consider the socioeconomic circumstances of the family:
• Low SES, ATSI - need to worry about secondary bacterial infection.
• Need for treating aggressively due to risk factors?
• Will/can they come back?
• Can they afford antibiotics/medication?
• What antibiotics do you prescribe? i.e. narrow rather then broad spectrum.
• Distance/transport to chemist?
• Small, remote community - admit overnight?
• Need to liase with ATSI health workers to minimise stress on family.

  • Education is important - explain that it is likely a viral infection, days 3-4 are the worst - expect them to feel better in 2 days.
  • Could give antibiotic script and say fill in 2 days if not better - but relying on parents.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Identify the aetiology of otitis media.

A
  • Viral (25%).
  • Streptococcus pneumoniae (35%).
  • Non-typable strains of Haemophilus influenza (25%).
  • Moraxella catarrhalis (15%).
  • Viral - rhinovirus, parainfluenza, RSV, adenovirus, coronavirus, influenza.
  • Strep - can be primary but more commonly secondary infection following viral infection.

• This case most likely viral - 5-7 days, day 3 usually the worst. Come back in 2 days - expect them to improve (eating, drinking).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly