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Case 3.1 Earache

By Mikki Meadows‐Oliver, PhD, RN, FAAN

SUBJECTIVE

Janice, a 3‐year‐old preschool child, presents to the office with a complaint of left ear pain for 2 days. She is accompanied by her mother, Marsha. She has had an intermittent fever and her maximum temperature at home was 101°F (axillary). The pain is worse sometimes when she is lying down. The pain is occasionally relieved with the use of over‐the‐counter pain relievers. Janice has had no vomiting or diarrhea. She has had a slight runny nose, but no cough.

Diet: Janice’s nutrition history reveals that she has a balanced diet with enough dairy, protein, fruits, and vegetables. Her appetite has decreased over the past 2 days since the ear pain began.

Elimination: She is voiding well with no complaints of dysuria.

Sleep: Janice sleeps approximately 10 hours at night and takes one 1‐hour nap at her preschool. She usually has no problems falling or staying asleep but since the ear pain has started, her sleep has been interrupted.

Past medical history: Janice was born via vaginal delivery at 40 weeks’ gestation. Since being discharged at 2 days of age, she has had no emergency department (ED) visits or hospitalizations. Janice has had 2 episodes of otitis media that were cleared with antibiotics. She has had no injuries or illnesses since that time. Janice passed her developmental screening at her last well‐child visit. She currently attends preschool and is doing well, according to Marsha. She has no chronic illnesses and is currently taking no medications.

Social history: Janice lives at home with both parents. Her mother works as a teacher, and her father is a commercial fisherman. The family has a pet cat. Janice’s father smokes, but not in the home.

Family medical history: Janice’s mother (31 years old) and father (30 years old) are healthy and have no history of chronic medical conditions. Her maternal grandmother (age 52 years) has a history of lupus. Her maternal grandfather (54 years of age) has a history of prostate cancer (in remission). Janice’s paternal grandfather (age 59 years) has a history of hypertension. Her paternal grandmother (53 years of age) has a history of asthma.

Medications: Janice is currently taking no prescription or herbal medications. She has been taking over‐the‐counter pain relievers/antipyretics to relieve symptoms associated with ear pain. Janice has an allergy to penicillin. She gets hives when she takes penicillin. Janice has no known allergies to food or the environment. She is up to date on required immunizations.

OBJECTIVE

Janice’s vital signs are taken, and her weight in the office today is 14 kg. Her temperature is slightly elevated at 38°C (temporal). Janice is alert and quiet, sitting in her mother’s lap. She appears well hydrated and well nourished.

Skin: Her skin is clear of lesions and warm to touch. There is no cyanosis of her skin, lips, or nails. There is no diaphoresis noted. Janice has good skin turgor on examination.

HEENT: Janice’s head is normocephalic. Her red reflexes are present bilaterally; and her pupils are equal, round, and reactive to light. There is no ocular discharge noted. Janice’s external ear reveals that the pinnae are normal, and there is no tenderness to touch on the external ear. On otoscopic examination, the right tympanic membrane (TM) is gray, in normal position, with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the TM. The left TM is erythematous and bulging with purulent fluid visible behind the TM. The TM is opaque with no light reflex or bony landmarks present. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Janice’s mucous membranes are noted to be moist. She has 20 teeth present without evidence of caries. There are no lesions present in the oral cavity.

Neck: Janice’s neck is supple and able to move in all directions without resistance. There are shotty anterior cervical nodes present on the left side of the neck. There is no erythema or tenderness of the nodes.

Respiratory: Janice’s respiratory rate is 26 breaths per minute and her lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted.

Cardiovascular: Janice’s heart rate is 102 beats per minute with a regular rhythm. There is no murmur noted upon auscultation.

Abdomen: Normoactive bowel sounds are present throughout. Janice’s abdomen is soft and nontender. There is no evidence of hepatosplenomegaly.

Genitourinary: Genitourinary examination reveals normal female genitalia.

Neuromusculoskeletal: Janice is noted to have good tone in all extremities. She has full range of motion of all extremities. Her extremities are warm and well perfused. Capillary refill is less than 2 seconds, and her spine is straight.

CRITICAL THINKING

1 Are there laboratory tests or diagnostic imaging studies that should be ordered as part of a workup for ear pain?

2 What is the most likely differential diagnosis and why?

3 What is the plan of treatment, referral, and follow‐up care?

4 Does this patient’s psychosocial history affect how you might treat this case?

5 What if the patient lived in a rural setting?

6 Are there any demographic characteristics that might affect this case?