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PATIENT PRESENTATION

Chief Complaint

“Increased irritability and right ear pain.”

History of Present Illness

JL is a 22-month-old female who presents to her primary care provider (PCP) with a 2-day history of rhinorrhea and a 1-day history of increased irritability, fever (to 101.5°F per Mom), and right-ear tugging. Mom denies that JL has had any nausea, vomiting, or diarrhea.

Past Medical History

Full-term birth via spontaneous vaginal delivery. Hospitalized at 9 months of age for respiratory syncytial virus–associated bronchiolitis. Two episodes of acute otitis media (AOM), with last episode about 6 months earlier.

Surgical History

None

Social History

Lives with mother, father, and her 5-year-old brother who attends kindergarten. JL attends daycare 2 d/wk, and stays at home with maternal grandmother 3 d/wk.

Allergies

No known drug allergies

Immunizations

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Immunization

Age Administered

Hepatitis B

Birth

DTap/Hep B/IPV

2 mo, 4 mo, 6 mo

Hib

2 mo, 4 mo, 6 mo, 15 mo

PCV13

2 mo, 4 mo, 6 mo, 12 mo

Influenza

6 mo, 8 mo, 18 mo

MMR

12 mo

Varicella

12 mo

Home Medications

Vitamin D drops 600 IU/d

Physical Examination

Vital Signs (while crying)

Temp 100.7°F, P 140 bpm, RR 35, BP 100/57 mm Hg, Ht 81 cm, Wt 23.7 kg

General

Fussy, but consolable by Mom; well-appearing

HEENT

Normocephalic, atraumatic, moist mucous membranes, normal conjunctiva, clear rhinorrhea, moderate bulging and erythema of right tympanic membrane with middle-ear effusion

Pulmonary

Good air movement throughout, clear breath sounds bilaterally

Cardiovascular

Normal rate and rhythm, no murmur, rub or gallop

Abdomen

Soft, non-distended, non-tender, active bowel sounds

Genitourinary

Normal female genitalia, no dysuria or hematuria

Neurology

Alert and appropriate for age

Extremities

Normal

QUESTIONS

1. Which of the following clinical criteria is not part of the diagnostic evaluation or staging of acute otitis media (AOM) for this patient?

A. Rhinorrhea

B. Fever

C. Otalgia

D. Contour of the tympanic membrane

2. Which of the following is a risk factor for AOM?

...

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