A 5-month-old boy is brought to the clinic due to fever and irritability. Over the past 48 hours, the patient has been less interested in drinking formula, although he still produces an adequate number of wet diapers each day. He woke up crying several times last night and developed a fever this morning. The patient was born at term following an uncomplicated pregnancy and has met all developmental milestones. Temperature is 38.3 C (100.9 F), blood pressure is 89/50 mm Hg, pulse is 135/min, and respiratory rate is 28/min. On examination, the patient is fussy but consolable in his parent's arms. Heart and lung examinations are unremarkable. There is clear rhinorrhea from the nares bilaterally. Otoscopic examination shows erythematous, bulging tympanic membranes bilaterally. Which of the following pieces of additional history is most relevant to this patient's condition?

Question

A 5-month-old boy is brought to the clinic due to fever and irritability.  Over the past 48 hours, the patient has been less interested in drinking formula, although he still produces an adequate number of wet diapers each day.  He woke up crying several times last night and developed a fever this morning.  The patient was born at term following an uncomplicated pregnancy and has met all developmental milestones.  Temperature is 38.3 C (100.9 F), blood pressure is 89/50 mm Hg, pulse is 135/min, and respiratory rate is 28/min.  On examination, the patient is fussy but consolable in his parent's arms.  Heart and lung examinations are unremarkable.  There is clear rhinorrhea from the nares bilaterally.  Otoscopic examination shows erythematous, bulging tympanic membranes bilaterally.  Which of the following pieces of additional history is most relevant to this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d6cb_3108_bc81_77f5dbef853a_MD0003_00 This patient has erythematous, bulging tympanic membranes (TMs) consistent with acute otitis media (AOM), or middle ear infection. AOM is most commonly caused by infection with Streptococcus pneumoniae, nontypeable Haemophilus influenzae, or Moraxella catarrhalis. Presentation can include otalgia, fever, irritability, difficulty sleeping, and poor feeding. Diagnosis is confirmed by the presence of middle ear effusion and inflammation on otoscopy. The most significant risk factor for AOM is young age, particularly 6-18 months, because the eustachian tubes are straight and narrow and drain poorly in young children. Modifiable risk factors include lack of breastfeeding, day care attendance, and cigarette smoke exposure. Passive smoke exposure is associated with recurrent AOM, likely due to increased bacterial colonization of the nasopharynx. Obtaining a history of relevant risk factors is important for counseling patients and families on ways to decrease the risk of recurrent infection. eustachian tubes (Choice A) Compared with newborns delivered vaginally, those delivered via caesarean section have differing gut bacterial colonization due to lack of exposure to maternal vaginal flora. However, the mode of delivery does not alter the risk of AOM. (Choice B) In contrast to formula feeding, breastfeeding plays a protective role against AOM, likely due to decreased bacterial colonization of the nasopharynx. However, formula preparation (eg, powder, concentrated liquid) is not related to AOM. (Choice C) Catscratch disease is most common in children and young adults and can present with prolonged fever and a papular lesion at the site of a cat scratch. This patient has a fever due to a known source, and pet exposure does not increase the risk of AOM. (Choice E) Pressure changes during ascent and descent while flying can lead to barotrauma, including hemotympanum and TM perforation. Symptoms may include ear pain, ear discharge, hearing loss, and tinnitus. The incidence of AOM is not increased after flying. Educational objective: Risk factors for developing acute otitis media include young age (6-18 months), lack of breastfeeding, day care attendance, and passive smoke exposure. References: Acute otitis media during infancy: parent-reported incidence and modifiable risk factors. (http://www.ncbi.nlm.nih.gov/pubmed/27870813) Recurrent acute otitis media: what are the options for treatment and prevention? (http://www.ncbi.nlm.nih.gov/pubmed/28616364)

A 5-Month-Old Boy Is Brought to the Clinic Due to Fever