After studying Module 6: Lecture Materials & Resources, discuss the following:
You see a 3-year-old with hypertension (documented on three different visits) in your primary care clinic.
Describe the workup, differential diagnoses, assessment, and management.
How would your plan of care be different if the child were 10 years old?
What risk factor counseling and advice would you include?
Patient: A.J., 7-year-old male.
Chief Complaint: Left ear pain and fever for 2 days.
Subjective: Reports feeling "stuffy." Ear pain (otalgia) is rated 6/10, constant, and worse when lying down. Reports intermittent fever, last documented at 101.5°F (38.6°C) this morning. No vomiting or diarrhea. Denies sore throat or cough.
Objective: Tympanic Temperature: 100.8°F (38.2°C). Left Tympanic Membrane (TM): Full, bulging, erythematous, with decreased mobility observed on pneumatic otoscopy. Right TM: Clear, mobile, and pink. Remaining physical exam is unremarkable.
Diagnosis: Acute Otitis Media (AOM), Left Ear (J09.3)
Medication: Initiate Amoxicillin at 80-90 mg/kg/day divided twice daily for 10 days, based on patient weight and community resistance patterns. Discuss importance of finishing the entire course.
Symptom Management: Recommend Ibuprofen or Acetaminophen for pain and fever management. Apply warm compress externally.
Follow-up: Schedule a follow-up appointment in 10-14 days for a repeat otoscopy to ensure clearance of the middle ear effusion (MEE). Instruct parents to return sooner for worsening pain or facial swelling.
| Possible DDx | Rationale |
|---|---|
| 1. Otitis Media with Effusion (OME) | Presents with fluid (effusion) and decreased TM mobility, but lacks the acute S&S of infection (fever, severe pain, and bulging/erythema). AOM is distinguished by the bulging and acute inflammation. |
| 2. Otitis Externa (OE) / Swimmer's Ear | Presents with ear pain, but the pain is typically worse with manipulation of the tragus or pinna. OE is an infection of the ear canal, and the TM usually appears normal or mildly erythematous, not bulging. |
| 3. Referred Pain from Pharyngitis/Dental Abscess | Otalgia can be caused by irritation of the cranial nerves shared with the throat or jaw. However, A.J. denies sore throat/dental pain, and the direct observation of a bulging TM confirms the ear is the primary source of the problem. |
The primary health promotion intervention for A.J. and his family relates to otitis prevention and medication safety.
Otitis Prevention: Educate parents on the link between secondhand smoke exposure and increased risk of recurrent AOM. Encourage smoke-free zones in the home and car. Ensure A.J. is up-to-date on all immunizations, especially the pneumococcal vaccine (PCV13) and annual influenza vaccine, as these reduce the bacterial and viral etiologies of AOM.
Medication Safety: Review the proper technique for administering liquid medication, highlighting the use of the appropriate measuring device (syringe/dosing spoon) to ensure the exact prescribed dose is given, preventing under-dosing and potential resistance.
The most valuable lesson learned this week was the importance of systematic clinical reasoning under pressure and the difference between academic knowledge and practical application of clinical guidelines.