Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a foundation year two doctor working in Emergency Department. Your next patient is called Dragon Dez (16-year-old male) complaining of ear pain. Please take a history and perform a relevant examination.
Patient History:
Your name is Dragon Dez – a 16-year-old male – student.
You noticed since yesterday you developed some pain inside the right ear. This has been gradually getting worse since yesterday. The pain is aching. No radiation. Nothing you know makes it worse. Pain score 5/10. Paracetamol eases the pain just slightly.
You have also noticed there's reduced hearing in the affected ear. You often ask others to repeat themselves, especially in a loud environment. You feel a sense of fullness in the right ear as if someone has put a foreign object in the ear. There's also a ringing/crackling noise on the right, which is more noticeable at night when you sleep. You are unsure if you have any fever or not, but you remember developing flu-like symptoms a week ago, like a cough, running nose with a sore throat. You noticed you are slightly unsteady these days and feel like the world the spinning sometimes. You always feel tired, but you think it's due to your poor sleep yesterday night. You feel unwell and have a poor appetite.
No rash/neck stiffness/ photosensitivity. No recent dental work. No recent trauma. No facial muscle weakness. No neurological symptoms. No headache. No confusion. No discharge from the ear.
Ideas, Concerns, Expectations:
You are not sure what this is, but you heard about the seriousness of meningitis and want to rule this out. You are not sure if you have been vaccinated against meningitis. Because you just started fresher's week, you want to feel well again to go back to partying and doing pre-drinks. You hope to get some antibiotics or some ear drops.
Past Medical History:
Asthma, aplastic anaemia, hayfever, GORD, recurrent sinusitis
Drug History:
Salbutamol Inhaler PRN, previous haemopoietic stem cell transplant
Allergic to penicillin (rash)
Family History:
Hayfever, nasal polyps
Social History:
Smoke 5 cigarettes a day since 6 months ago
Occasional drinker
Just started university to study geography
Live in student accommodation with 4 other people
Examination Findings:
Otoscope shows erythematous, bulged and inflamed right tympanic membrane. No wax can be seen. Presence of effusion and bubbles in the right middle ear. Loss of light reflex in the right ear. No discharge or blood can be seen (tympanic membrane may be perforated +/- discharged noted from the right ear). Right lymphadenopathy.
The left ear is otherwise normal. No keratinising skin / tympanic membrane retraction that may indicate cholesteatoma. Facial movement intact (no weakness). No tenderness of mastoid process.
Differentials:
Acute otitis media + effusion +/- perforation
Rule out Labyrinthitis
Rule out mastoiditis
Rule out cholesteatoma
Rule out meningitis
Investigations:
Bedside:
Clinical diagnosis
Observations (pyrexia, tachycardia, hypotension)
ECG if considering prescribing erythromycin (should be avoided in prolonged QT interval / ventricular cardiac arrhythmia i.e. torsade's de points caused by electrolyte disturbance
Culture if there’s discharge / Ear Swab for culture and sensitivity
Bloods:
Routine blood test indicated if systemically unwell i.e. FBC, CRP, U&Es, LFTs, Bone Profile + blood culture
Imaging:
Consider MRI / CT to exclude ENT complications
Special Test:
Consider audiometry if chronic hearing loss is suspected
Consider pneumatic otoscopy – reduced movement of tympanic membrane in air insufflation
Consider tympanometry (flat b curve confirming the presence of middle ear effusion)
Consider acoustic reflectometry to confirm the presence of middle ear effusion
Management: