Week 1 - Ear pain Flashcards
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).
• 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?
Perform a physical examination on this patient.
- Introduction, explanation, consent, wash hands.
- General inspection: pain, distressed, flushed, crying, congested/sneezing, fatigue, hoarsness, coughing, lymphadenopathy.
3. Vital signs: • HR - tachycardic. • RR - tachypnoeic. • BP • Temp - febrile.
- 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. - Nose:
• Inspection - discharge, deformity, swelling.
• Palpation - feel for any swelling, tenderness, deformity. - Sinuses:
• Frontal, maxillary, transilluminate maxillary sinuses. - Mouth:
• Cyanosis, hydration, signs of infection/inflammation (redness, swelling), redness of pharynx, enlarged tonsils. - Neck:
• Cervical lymph nodes. - 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.
What is your provisional diagnosis and differential diagnoses?
• Provisional diagnosis: Acute otitis media. • DDx: - URTI (viral, bacterial). - Influenza. - Otitis externa. - Mastoiditis. - Cholesteatoma.
What investigations would you carry out on this patient?
- Clinical diagnosis - otoscope
- Viral culture.
- Serology.
What treatment does this patient require?
- 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.
Identify the aetiology of otitis media.
- 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).
