6-year-old boy is brought in my his mother to the office for evaluation of a 3-day history of irritability, fever, and ear pain. She also says that his older sister has had a cold the past week, but it doesn’t seem to be that bad. He is up to date on his immunizations. She also report she has had an intermittent, non-productive cough, but denies any decrease in eating/drinking, diarrhea, or vomiting.
Vital signs show a BP-117/72, HR-94, RR-16, O2-100%, and T-99.2. Physical exam reveals:
- General – Non-toxic appearing, NAD, WN/WD
- Skin – no rash
- Eye – sclera white, conjunctiva clear
- Ear – (below)
- Throat – OP clear, no erythema or tonsillar swelling
- Neck – no LAD
- Heart – RRR without M/G/R
- Lung – CTA without adventitial sounds
- Abdomen – S/NT/ND
- PV – 2+ pulses throughout, BCR < 2s
- Neuro – No focal deficits
Mother is wanting an antibiotic because the holiday season is here and she can’t afford to have him sick.
Question
- What is your diagnosis?
- What is your treatment?
- What do you tell the mother?
