Patient Profile
Patient: Master Aarav Sharma, 3-year-old male
Chief Complaint: Irritability, fever, and tugging at right ear for 2 days
History & Examination
- Medical history: No prior ear infections; immunizations up to date
- Symptoms: Fever (101.5°F), poor appetite, disturbed sleep
- Physical exam: Bulging, erythematous right tympanic membrane with reduced mobility on pneumatic otoscopy
Investigations
- Clinical diagnosis based on history and otoscopic findings
- No imaging or labs required unless complications suspected
Diagnosis
Acute Otitis Media (AOM) — Right Ear confirmed by middle ear effusion and signs of inflammation.
Management Plan
Pharmacological
- Amoxicillin 80–90 mg/kg/day in divided doses for 7 days
- Paracetamol for fever and pain relief
Supportive Care
- Encourage fluid intake and rest
- Caregiver education on symptom monitoring
- Return precautions for mastoiditis, persistent fever, or hearing concerns
Follow-Up Plan
- 48–72 hours: Reassess if symptoms persist or worsen
- 2–3 weeks: Recheck for resolution and middle ear effusion
Outcome Goals
- Symptom resolution and pain control
- Prevention of recurrent AOM
- Preservation of normal hearing and speech development
Long-Term Considerations
- Risk factors: passive smoking, bottle feeding in supine position
- Consider tympanostomy tubes if recurrent AOM (≥3 episodes in 6 months)
References
- Lieberthal AS et al. The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013;131(3):e964–e999.
- UpToDate: Acute Otitis Media in Children.