URI Case (2nd lab lecture)

Patient Presentation
Chief Complaint
Per patient's mom: “I've had it up to my ears with his ear infections!”

HPI

Seth Jacobs is a 16 month old boy who is brought to his pediatrician by his distraught
mother on a Monday morning in early March. Mom describes a 1day history of tugging at
his right ear and crying, and a 2day history of decreased appetite, decreased
playfulness, and difficulty sleeping. Mom states that his temperature last night was
elevated by electronic axial thermometer (39.5°C), so she gave him 5 mL of ibuprofen
every 12 hours × 2 doses.
When Seth is asked if anything hurts, he does not respond. Mom requests all
recommendations be written as prescriptions (even ibuprofen) for day care
administration. She also notes that it is tax season and she needs Seth to be able to
return to day care immediately so she can return to work as an accountant.

PMH

Immunizations are uptodate, including four doses of 13 valent pneumococcal conjugate

vaccination (Prevnar13).
First episode of AOM at age 4 months treated with amoxicillin without adverse effects.
Recurrent AOM × 3 over the past year; most recent episode 2 weeks ago treated with
high dose amoxicillin for 10 days without adverse effects.
Seth was seen approximately 1 month ago for persistent nonproductive cough of 5day
duration. A diagnosis of acute bronchiolitis was made and symptoms improved with
ibuprofen treatment, fluids, and rest.

FH

Both parents in good health. Two siblings, 3 and 6 years old, in good health.

SH
Seth lives at home with his parents and two sisters. Both parents are employed and
work out of the house. Seth and his 3yearold sister attend day care. His elder sister
attends elementary school. There is a pet dog in the home. Seth uses a pacifier regularly
throughout the day. There is no smoking in the house.

Meds

Ibuprofen suspension 100 mg/5 mL, 5 mL Q 12 h × 2 doses in the last 24 hours.

All
NKDA
ROS
Head: no drainage from ears; Ears nontender to the touch; However, per mom, patient
has been tugging them.
Respiratory: (per mom) denies wheezing. Has lingering, mild cough still present, no
sputum production.

Physical Examination

Gen

WDWN Caucasian male, now crying

VS

BP 104/60, HR 130, RR 26, T 39.1°C; Wt 10 kg, Ht 30″

HEENT
Both TMs erythematous (with R > L); right TM is bulging with limited mobility; copious
cerumen and purulent fluid behind TM; left TM landmarks appear normal including the
pars flaccida, the malleus, and the light reflex below the umbo. However, the right TM
landmarks are difficult to visualize and the fluid is obstructing visualization of the umbo.
Throat is erythematous; nares patent.
Neck
Supple
Chest
Mild crackles at bases bilaterally, improved since bronchiolitis visit 1 month ago
CV
RRR, no murmurs
Abd
Soft, nontender
Genit
Tanner stage I
Ext
No CCE; moves all extremities well; warm, pink, no rashes
Neuro
Responsive to stimulation, DTR 2+ no clonus, CN intact
Assessments
Right ear AOM

Clinical Pearl
Streptococcus pneumoniae has been shown to cause 25–50% of childhood AOM cases.
First line treatment remains amoxicillin despite significant resistance because the high
dose used is generally effective against susceptible, intermediate, and often resistant
pneumococci and it is a low-cost, safe, acceptable tasting therapeutic option with a
narrow microbiologic spectrum.