History. Onset and course, other ENT symptoms, and other accompanying symptoms (feeding difficulty, frequent awakening, and occasional diarrhea). General medical history, past history, family history (allergies?). Any predisposing factors (smokers in the household, communal day care settings)?
Physical Examination. Vital signs, general appearance, complete ENT exam (w/ or w/o pneumatic otoscopy), neck, chest.
Lab. Usually not necessary, though tympanometry may be useful in quantifying resolution.
Assess severity, not only of appearance of the middle ear(s) but beyond that how this episode fits in the child's pattern, if any, of recurring infections and currently how ill is the patient. Differential Diagnosis is directed more at the possible infecting pathogen and association with invasive disease. Complications can be local, such as chronic serous effusion, perforation, mastoiditis or systemic, including bacteremia and meningitis.
General Measures. Recommend age/weight appropriate dosing with acetaminophen for pain or fever. Explain to the parents the anatomy and physiology of the middle ear and how it is compromised by this infection and that this is a variable phenomenon. Discuss possible ways to limit these. Emphasize seriousness of this problem and the need for follow-up visits, in particular if recurrent.
If tympanic membrane perforated, give detailed instructions about ear care (keeping water out of canals, gently removing and cleaning discharge and debris from canal opening). Provide Middle Ear Infection instruction sheet.
Specific Measures. Initial oral antibiotic Rx __________________________________________________*(MIS)
or alternative oral antibiotic Rx ______________________________________________*(MIS).
If the child has a pattern of frequent refractory infections or there is a recent family/community history of resistant bacterial strains, then
Consider oral antibiotic ____________________________________________________*(MIS)
or as an alternative Rx ________________________________________________________*(MIS).
If perforation, consider additional topical Rx ______________________________*(MIS).
Consultation. If child is under ______ months or if severely ill. Consider for frequent, refractory or severe episodes or for more than ______ episodes in one year or as indicated.
Referral. Immediate Transfer. May be necessary for the toxic/septic child.
Follow-up Plan. Recheck in ______ days or sooner if worse.
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